Comparative Immunohistochemical Assessment of Craniopharyngioma and Related Lesions

Craniopharyngiomas (CP), Rathke’s cleft cysts (RCC), and sellar xanthogranulomas (XG) are closely related lesions. As expression of cytokeratins 8 (CK8) and 20 (CK20) was reported in RCC but not in CP, the present study investigates the reproducibility of immunohistochemical distinction between CP and RCC, attempting to identify the relationship of XG to these lesions. A comparative study of 55 patient specimens (25 CP, 28 RCC, and 2 XG) was analyzed for the histological features of xanthomatous changes and squamous metaplasia, and expression of CK8 and CK20. In the 25 CP cases, xanthomatous changes were seen in 5 (20%), with CK8 reactivity demonstrated in all 25 cases. A prominent xanthomatous component was identified in 13 of 28 RCC (46%), and squamous metaplasia was seen in 11 (39%), 9 of which also contained xanthomatous features. CK8 reactivity was demonstrated in all 28 RCC cases, whereas CK20 was seen only in 9 cases (32%). Of the two cases diagnosed as XG, none contained epithelium, and immunohistochemistry for cytokeratins was not observed. Overall, differential expression of cytokeratins cannot reliably distinguish CP from RCC. Furthermore, expression of CK20 in RCC is generally seen within a background of prominent squamous metaplasia and reactive xanthomatous changes.     

Pituitary Adenoma with Cholesterol Clefts

Histologically, cholesterol clefts are often observed in craniopharyngioma, Rathke’s cleft cyst, and various granulomas. However, pituitary adenomas with cholesterol clefts are rare. A 46-year-old woman developed visual field disturbance. She had no history of severe headache that would suggest pituitary apoplexy. She presented with homonymous bitemporal hemianopsia and galactorrhea. Blood prolactin level was 63.1 ng/mL. Other hypophysial hormone levels were within normal range. Magnetic resonance imaging revealed a pituitary tumor with intratumoral cyst. The cyst showed high intensity on T1- and T2-weighted images. The tumor was demonstrated with iso intensity on T1-weighted image and with high intensity on T2-weighted image. She underwent trans-sphenoidal surgery. The tumor was soft, with yellowish, oily fluid, probably the cyst content. By light microscopy with hematoxylin and eosin staining, a typical chromophobic adenoma of the pituitary was identified. Immunostaining revealed immunoreactivity for ACTH in several cells. Many cholesterol clefts and several hemosiderin pigment containing macrophages were observed. Electron microscopy demonstrated a pituitary adenoma with sparse and small secretory granules and numerous lysosomes. The cyst was most likely caused by focal hemorrhagic infarction, followed by the formation of cholesterol crystals, the appearance of hemosiderin containing macrophages, foreign body product cells, and accumulation of lysosomes.     

Spectrum of different types of hypophysitis: a clinicopathologic study of hypophysitis in 31 cases

Hypophysitis has been histologically classified into five types: lymphocytic hypophysitis (LYH), granulomatous hypophysitis (GRH), xanthogranulomatous hypophysitis (XGH), xanthomatous hypophysitis (XH), and necrotizing hypophysitis. The present study evaluated 31 cases of hypophysitis to clarify their characteristic clinicopathologic features. The lesions were histologically classified into four groups: LYH (22 cases) including lymphocytic adenohypophysitis (LAH) (19 cases) and lymphocytic infundibuloneurohypophysitis (LINH) (3 cases), GRH (5 cases), XGH (2 cases), and XH (2 cases). In each group, the pituitary gland showed lymphocytic infiltration associated with focal or diffuse hypophysial destruction of variable severity and fibrosis. Histologic and clinical overlap among different types of hypophysitis, especially between LAH and LINH, suggest that these entities may have similar etiologic background and/or represent different stages of the same lesion. Considering the sampling sites and clinical manifestations, LAH may not usually involve the neurohypophysis, but LINH may often extend to the adenohypophysitis. A selective loss of adrenocorticotropic hormone-positive cells was seen in two patients with LAH despite only very slight lymphoplasmacytic infiltration. This suggests that there may be at least two causative mechanisms for hypopituitarism in hypophysitis: nonspecific destruction of all types of adenohypophysical cells by severe inflammation and selective destruction of specific adenohypophysial cells.     

Xanthogranulomatous endometritis associated with endometrial carcinoma

We studied a case of xanthogranulomatous (XG) endometritis associated with endometrial adenocarcinoma. Isolated XG endometritis is a rare entity that may mimic carcinoma as a consequence of the replacement of the endometrium and the invasion of the myometrium by friable yellowish tissue composed of foamy histiocytes. To our knowledge, it has not previously been described as coexisting with a carcinoma. The XG reaction is characterized by pigment-laden foamy cells. Electron microscopy demonstrated that the foamy cells belong to the macrophage/histiocyte series and are not endometrial stromal cells. Histochemical studies revealed the pigment to be composed of hemosiderin and lipofuscin. The absence of calcispherites or a uniform immunoperoxidase staining reaction for alpha 1-antitrypsin excluded the diagnosis of malacoplakia. We have postulated that XG endometritis has a similar etiopathogenesis to XG pyelonephritis and XG cholecystitis. It is a rare morphologic expression of the clinical syndrome of benign senile pyometrium.     

December 1998--16 year old female with headaches, lethargy and a sellar/suprasellar mass

A 16 year female with a history of developmental delay and shunted hydrocephalus presented with two months of progressive headaches, lethargy and visual disturbances. An MRI of the brain revealed a sellar and suprasellar cystic mass which was absent on a previous MRI six years earlier. The pre-operative clinical diagnosis was pituitary adenoma vs. craniopharyngioma. Histologically, the fibrous wall of the ciliated epithelial-lined cyst was thickened by non-caseating granulomatous inflammation, hemorrhage, hemosiderin, and cholesterol clefts, consistent with cyst rupture. Rathke's cleft cysts are uncommon symptomatic lesions in young people, and must be distinguished from craniopharyngioma.     

Xanthogranulomatous endometritis. Report of six cases and a proposed mechanism of development

Xanthogranulomatous endometritis is a rare pathologic finding with only five cases reported in the literature. On review of our files over the past 12 years, we found six cases of xanthogranulomatous endometritis, all associated with endometrial adenocarcinoma that had been irradiated by external beam and/or intracavitary implants prior to surgery. Histologically, these cases were characterized by foamy histiocytes with variable amounts of associated multinucleated giant cells, other chronic inflammatory cells, necrosis, calcium, cholesterol clefts, and hemosiderin. Xanthogranulomatous features were not present in the pretreatment endometrial biopsy specimens from any of the six patients. Contributory factors to the development of xanthogranulomatous endometritis such as necrosis, hemorrhage, obstruction, tumor bulk, or delay in treatment were identified. The mechanism of development of xanthogranulomatous endometritis may involve a complex interaction of elements common to the development of xanthogranulomatous change in other organs (obstruction, inflammation, and a lipid source) as well as elements unique to irradiated tissue (generation of free radicals and lipid peroxidation). These cases indicate that radiation injury in the setting of endometrial adenocarcinoma is an additional etiopathologic finding ofulomatous endometritis.     

Abundant intracytoplasmic hemosiderin in both histiocytes and neoplastic cells: A diagnostic pitfall in fine-needle aspiration of cystic papillary renal-cell carcinoma

Benign renal tubular cells and renal-cell carcinomas (RCC) may have intracytoplasmic hemosiderin (ICH). The RCC subtype most commonly reported to contain ICH is papillary carcinoma (PRCC). PRCC, usually a low-grade neoplasm, may be associated with cystic degeneration, hemorrhage, and presence of abundant hemosiderin-laden macrophages (HLM). We report a case of PRCC with massive ICH and HLM that created a diagnostic challenge to differentiate from a hemorrhagic cyst. Review of 14 additional nephrectomy specimens with PRCC disclosed ICH in 3 cases. All had coexisting cystic change and hemorrhage. Preoperative FNA had been performed in one of these cases, and both ICH and HLM were found. Papillary epithelial cell features, however, were well-defined in this case. PRCC should be considered in the differential diagnosis of cystic renal lesions with hemosiderin-laden cells. Differentiation of HLM from neoplastic cells with massive ICH may be difficult, especially when epithelial fragments are scanty.     

Intranodal palisaded myofibroblastoma – a rare case report and literature review

Intranodal palisaded myofibroblastoma (IPM) is a benign mesenchymal neoplasm originating from smooth muscle cells and myofibroblasts. The inguinal region is the most common site of this rare tumor. As there are only about 89 such cases reported in the literature, the precise etiology and pathogenesis have yet to be explained adequately. It is characterized by spindle cells, amianthoid fibers, and by the proliferation of hemosiderin‐containing histiocytes in the lymph node. A nodular lesion was excised from the inguinal region of a 47‐year‐old female patient with the clinical diagnosis of lymphoma and/or metastase. Macroscopic examination of a section of the lesion demonstrated a solid appearance. Microscopic examination revealed spindle‐cell proliferation, amianthoid fibers, hemosiderin pigment, and extravasated erythrocytes. Nuclei of the spindle cells displayed a palisaded appearance. Compressed lymphoid tissue was observed around the lesion. Neoplastic cells were identified by the presence of vimentin, SMA, Cyclin D1, and beta‐catenin. The Ki67 index was less than 1%. Histological examination confirmed the diagnosis of IPM. Although IPM is benign, it is frequently confused with metastatic lesions and lymphomas.     

Raumfordernde Prozesse der Sellaregion unter besonderer Berücksichtigung tumorähnlicher Läsionen

Most space occupying lesions of the sellar region are tumors (e.g., pituitary adenomas, craniopharyngiomas, but also meningiomas). In approximately 8% of patients with sellar mass lesions, non-neoplastic disorders (e.g., inflammations, cysts, hyperplasia) are causal. Cystic lesions of the pituitary region are classified as Rathke's cysts, colloid cysts, arachnoidal cysts and epidermoid cysts. These have to be differentiated from cystic craniopharyngeomas or cystic pituitary adenomas. Autochthonous inflammations (lymphocyctic hypophysitis, idiopathic granulomatous hypophysitis, xanthomatous and peritumorous hypophysitis) have to be distinguished from generalized diseases involving the pituitary (e.g., sarcoidosis, tuberculosis). Hyperplasia can result in a doubling of pituitary size. Lactotroph and corticotroph hyperplasia are the most common and may be of a diffuse and nodular type. The nodular form of pituitary hyperplasia may show transition into adenoma. Other hyperplasias may be found adjacent to adenomas or other tumours. Furthermore, vascular (aneurysms) and bony lesions (especially fibrous dysplasia) can appear as space occupying lesions of the sellar region.     

Small Bowel Pseudomelanosis Associated with Oral Iron Therapy

An accumulation of pigment deposits on mucosa, called melanosis or pseudomelanosis, of the small bowel is observed infrequently during endoscopic examination. We describe 6 cases of small bowel pseudomelanosis; the possible etiology of which was chronic iron intake. We observed numerous brown spots in duodenum, jejunum, and terminal ileum during upper and lower endoscopy. Interestingly, all patients have been taking oral iron for several years. Histology showed pigment depositions within macrophages of the lamina propria and a positive Prussian blue stain indicating hemosiderin deposition. Herein, we demonstrate that long term iron therapy may result in pseudomelanosis of small bowel, such as duodenum, jejunum, and ileum.     

Cementum-like matrix in solitary bone cysts: a unique and characteristic but yet underrecognized feature of promising diagnostic utility

Solitary bone cysts (SBCs) are benign, intraosseus, cystic lesions, which generally involve metaphysis of long bones during the period of skeletal immaturity. Histologic features are nonspecific, but identification of amorphous cementum-like material provides a significant diagnostic clue. This material is unique to SBC with reported frequency of 10% to 70% and has been described as an immature form of bone. We retrieved and reviewed 41 cases of SBC reported in the last 10 years. The ages of patients ranged from 4 to 64 years (mean, 16 years), with a male-to-female ratio of 3:1. Humerus and femur were the most common sites. Cementum-like matrix was observed in 26 cases (63.4%). This material was seen in different phases of deposition and progression, ultimately transforming into mature bone as seen in 4 cases. Cyst wall lining was observed in 70.7% of cases along with several other nonspecific histologic features including reactive bone formation, hemosiderin macrophages, hemorrhage, multinucleated giant cells, foamy macrophages, fibrin, cholesterol clefts, and granulation tissue. Cementum-like material in the wall of SBCs is a specific and fairly consistent finding of diagnostic significance in cases where cyst wall lining is deficient. We also histologically demonstrate, for the first time, transformation of cementum-like material into reactive and mature bone, which further validates the immature osteoid nature and finding of other authors.     

Cytologic features of pigmented atypical meningioma mimicking melanoma on intraoperative crush preparations

Pigmented tumors rarely arise in the meninges, and when they do, these are mainly melanocytomas or melanomas. We describe the cytologic findings of atypical meningioma with intratumoral hemosiderin pigment mistaken for spindle cell melanoma in a 33‐year‐old male patient during intraoperative consultation. Preoperative radiologic images revealed a cystic meningeal mass with intratumoral hemorrhage. The crush preparation demonstrated cellular smears of syncytial clusters as well as fascicles of large pleomorphic spindle cells with discrete cytoplasmic brown pigment. Detection of cytoplasmic brown pigment and a preponderance of large spindle cells with nuclear pleomorphism led to a diagnosis of spindle cell melanoma on intraoperative cytology. Histopathologic examination displayed high cellularity, nuclear pleomorphism with prominent nucleoli, and foci of spontaneous necrosis. In addition, there were areas showing classic meningotheliomatous meningioma features. Altogether, the histologic findings were consistent with atypical meningioma. The cytoplasmic pigment in the tumor cells was confirmed to be hemosiderin using special stains and immunohistochemistry. To the best of our knowledge, this is the first case report describing cytomorphology of atypical pigmented meningioma. We discuss the differential diagnosis in intraoperative cytology and a possible mechanism related to intratumoral hemosiderin deposition in meningiomas. Diagn. Cytopathol. 2015;43:149–152. © 2014 Wiley Periodicals, Inc.     

Sinusoidal dilatation of the liver as a paraneoplastic manifestation of renal cell carcinoma

Prominent sinusoidal dilatation of the liver, spleen, and adrenals has been observed in nude mice with transplanted human renal cell carcinoma (RCC). To confirm whether this is a paraneoplastic manifestations specific for patients with RCC, 145 human autopsy specimens of RCC, transitional cell carcinoma (TCC) and cerebral hemorrhage (CH) were studied histologically. Sinusoidal dilatation of the liver was found in nine of 45 RCC cases. That incidence rate was significantly high when compared with three of 50 TCC cases (P less than .05) and with none of 50 CH cases (P less than .005) in which sinusoidal dilatation of the liver was found. There were no significant differences among the RCC, TCC, and CH groups in the incidence of sinusoidal dilatation in the spleen and adrenals. The sinusoidal dilatation of the liver associated with RCC was unique in that it occurred focally in the mid-zone of the hepatic lobules without any findings related to passive congestion of the central vein, endothelial damage, or hepatocellular necrosis. This change was not necessarily accompanied by abnormal liver function, although sinusoidal dilatation has been reported as one of the histologic manifestations of the nonmetastatic liver dysfunction syndrome of RCC known as the Stauffer syndrome. Sinusoidal dilatation is thought to be one of the tumor-specific manifestations and the influence of some tumor products is suggested, although the exact etiology remains unclear.     

神经内镜经蝶窦入路的解剖标志研究及其临床应用

目的:探讨神经内镜下经鼻蝶窦入路的解剖标志,并将其应用于神经内镜经蝶垂体瘤手术.方法:8具成人尸头标本,模拟内镜下经鼻蝶窦入路,鼻腔、蝶窦和鞍底分阶段观察并测量解剖标志;指导临床实施内镜下经鼻蝶窦垂体瘤手术10例.结果:内镜下经蝶入路可清晰显露各阶段解剖标志,蝶窦开口下缘距后鼻孔上缘为(15.4±1.8)mm;蝶窦开口中心点至鞍底中心点相距(13.4±2.1)mm;双侧视神经颈内动脉隐窝(OCR)连线中点至鞍底中心点距离(11.0±2.8)mm;鞍底均位于中线部位,以鞍底为中心,可看到鞍底前外方的视神经隆突,侧下方的颈内动脉隆突,前上方可见鞍结节,后方可见斜坡凹陷.10例内镜经蝶垂体瘤手术患者,肿瘤全切除7例(70%),次全切除3例(30%);术后患者临床症状都得到明显改善.结论:熟悉蝶鞍区结构的内镜下解剖关系有助于手术中准确定位,避免损伤重要的神经、血管结构,以提高手术成功率,减少并发症的发生.     

The sperm-mucus interface: patterns of disorder in the diagnosis of specific causes of penetration failure causing infertility

In 94 infertile couples with negative postcoital tests (PCTs) the results of an in-vitro sperm-mucus invasion test (SMIT) were compared with seminal analysis (excluding sperm density less than 1 x 10(6)/ml) and agglutination assays for antisperm antibodies in semen (MAR, TAT) and in mucus (TAT). Abnormalities at the sperm-mucus interface were classed into three types. (i) Failure to form semen clefts and of spermatozoa to colonize the clefts was closely correlated with oligo-asthenoteratozoospermia, and vice versa, the two tests agreeing in 90% of cases (P less than 0.001). Most of the discrepancies, in which sperm-dense clefts developed despite low sperm counts, were due to antisperm antibodies in semen. (ii) Failure of spermatozoa to invade mucus, despite normal sperm colonization of clefts, was closely correlated with the presence of antisperm antibodies in semen (positive MAR or TAT), and vice versa, the tests agreeing in 81% of cases (P less than 0.001). (iii) Failure of sperm survival after normal invasion of mucus could not be correlated significantly with the TAT results on mucus, but more extensive study of this question is needed. Finally a normal SMIT result was associated with a significantly improved chance of conception (39 versus 10% at 12 months), particularly with artificial insemination, suggesting undisclosed coital failure as the cause of the negative PCT. In conclusion, the invasion test, when assessed in the foregoing detail, offers a reliable and simple substitute for laboratory assessment of both seminal quality and the presence of antisperm antibodies in semen, and would be applicable in general infertility practice everywhere.     

Xanthomatous meningioma: a case report with review of the literature

Xanthomatous meningioma is an extremely rare variant of meningioma that is characterized histopathologically by the presence of tumor cells with lipid-filled vacuolated cytoplasm. In this report, we describe the fifth documented case of xanthomatous meningioma and review its clinicopathological features. A 76-year-old Japanese male presented with dizziness. Magnetic resonance imaging demonstrated a well-circumscribed tumor in the left parasagittal to frontal region with attachment of the dura mater. Histopathological examination of the resected specimen revealed proliferation of polygonal to spindle cells with eosinophilic cytoplasm and bland round to oval nuclei. Whorl formation and psammomas were scattered, and mitotic figures were rarely seen. A peculiar finding was the presence of extensive xanthomatous change continuing to the above-mentioned typical meningothelial meningioma. These tumor cells had clear vacuolated cytoplasm and bland round to oval nuclei. Immunohistochemically, xanthomatous cells were positive for epithelial membrane antigen. Accordingly, an ultimate diagnosis of xanthomatous meningioma was made. Our clinicopathological analysis revealed that xanthomatous meningioma affects children to young persons or the elderly, and four of five cases were located in the supratentorial region. Although the detailed mechanism underlying the xanthomatous change has not been clarified, this change is thought to result from a metabolic abnormality of the neoplastic meningothelial cells. Further, xanthomatous change has also been reported in atypical and anaplastic meningiomas. Therefore, it is important to recognize that xanthomatous change can occur in meningiomas, and to avoid misidentifying these cells as macrophages.     

鞍区动脉三维可视模型的建立及其解剖结构分析*

背景：正确掌握鞍区动脉的解剖结构是脑血管疾病诊断和手术的关键,鞍区动脉可视模型对医生详细了解鞍区动脉的复杂结构非常重要。 目的：建立鞍区动脉三维可视模型观察鞍区动脉的相关解剖结构。 方法：依据1例患者头颅CT 扫描数据,利用Mimics软件构建三维数字模型,观察鞍区动脉相关解剖结构。 结果与结论：成功构建鞍区动脉三维可视模型。该模型可以从不同角度和层面观察到鞍区的动脉分布和分支,还可显示和了解个性化解剖结构特征。医生可与模型进行相互作用并任意操作模型,可观察特定视野内解剖结构及了解个性化解剖结构。结果表明,Mimics软件构建三维数字模型方法简单可行。 关键词：鞍区动脉;可视化;三维重建;解剖结构;Mimics软件 doi:10.3969/j.issn.1673-8225.2012.13.017     

Pathologic approach to pulmonary hemorrhage

The pathologist's approach to pulmonary hemorrhage is outlined. Most cases fall into those examples of pulmonary hemorrhage caused by localized sites of bleeding, and those examples that fall within the spectrum of diffuse alveolar hemorrhage. The histologic evaluation of pulmonary hemorrhage is outlined including assessment of fresh hemorrhage in alveolar spaces (including exclusion of traumatic hemorrhage related to the procedure) and the presence of hemosiderin and its various causes. The most common causes of diffuse alveolar hemorrhage and clues to their clinically pathologic diagnosis are discussed.     

Pigments of the Gastrointestinal Tract: A Comparison of Light Microscopic and Electron Microscopic Findings

It is now apparent that light microscopy and histochemistry failed to identify correctly the nature and composition of pigments in various gastrointestinal tract melanoses. In most instances it was thought that the pigment was melanin or a melanin-like substance. Electron microscopy (EM) and electron-probe energy dispersive x-ray analysis have rectified these errors and have shown the following: in melanosis coli the pigment granules contain lipofuscin; in melanoses ilei the pigment granules may contain either silicates and titanium or hemosiderin; and in melanosis duodeni the pigment granules contain iron sulfide. In melanosis esophagi it is not clear what the pigment is; it could be melanin or lipofuscin.     

鞍区肿瘤术后常见并发症的观察及护理

目的探讨鞍区肿瘤术后常见并发症的观察及护理。方法对106例鞍区肿瘤术后常见的并发症进行回顾性分析总结护理要点。结果尿崩症、电解质紊乱、中枢性高热、视神经功能障碍、消化道出血是鞍区肿瘤术后常见的并发症。结论严密细致地观察病情、及早发现、及时治疗,是处理术后并发症的关键环节。