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Primary aneurysmal cyst of soft tissue: Serial magnetic resonance imaging study
HUMANPATHOLOGY Volume29, No. 6 (June 1998)
PRODUCT REVIEW Microscopy-Tutor, Version 1. University of Washington Department of Laboratory Medicine, Philadelphia, PA, Lippincott-Raven, 1997, CD-ROM, $195.00. "Microscopy-Tutor" is a program that provides a basic understanding of the microscope; its use, physical structure, and components. It then explores the concepts of optics such as resolution, magnification, contrast, and so on. It is suitable as an introduction to microscopy and would probably be most useful for upper division college level students a n d / o r as a review of fundamental principles. The texts are simple and straightforward and are easily understood by the beginning student, especially concerning the proper use of the microscope. I assume this program is targeted to that level audience. The "movies" are simple but adequate to re-enforce the verbal descriptions and are well placed. There are many illustrations and they are supportive of the text and well designed. The section on Kohler illumination is a well-thought out "how to" section with well-placed illustrations. There are clear descriptions of contrast versus resolution and the care of lenses and other details for obtaining good images.
The program also includes cleaning, coverslips, and the use of stains (to increase contrast). A reminder of the three dimensional nature of images, a concept often lost by many beginning students, is also included. The "Tutor" also covers the principles of optics, light (physics), lens characteristics, the interface to the eye, and general eye structure. Although this section is interesting, it is a bit detailed for a biology student, although, arguably, it is important for all students using microscopes to have at least a basic understanding these principles. In summary, I found the Microscopy-Tutor to be an enjoyable, well-written and illustrated program. It would be helpful to the beginning student as part of his or her introduction to a microscopy course (especially Kohler illumination setup). Advanced students could use this program for reviewing Kohler illumination and for furthering their understanding of the physics behind the construction of compound microscopes.--RONALD E JENSH, PHD, Department of Patholocy,
Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA.
CORRESPONDENCE Primary Aneurysmal Cyst of Soft Tissue: Serial Magnetic Resonance Imaging Study To the Editor:--We read with great interest the article by Shannon et all appearing in the February 1997 issue of Human Pathology. In that article the authors reported what they claimed to be the first description of magnetic resonance imaging (MRI) and ultrastructural features of an aneurysmal cyst of soft tissues (ACST). This entity was originally described in 1994 by our group. 2 In February 1996, 1 year before the Shannon et all article appeared, we published an additional case and described the MRI and ultrastructural features of this lesion for the first timeP The electron microscopic images reported by Shannon et aP are similar to those we described in 1996 s as well as to the classic description of an aneurysmal bone cyst (ABC). Our description also noted the presence of occasional multinucleated giant cells on the surface of bloodfilled cavernous channels, an additional observation reported in neither the ABC nor in the Shannon et all article. Based on histopathologic and MRI features, Shannon et al l initially considered their tumor a solid lesion, although their report does not give the size of the open biopsy. Because ABCs can contain small solid areas where cavernous channels are not evident4 a lesion can not be classified as solid variant on the basis of a small sample; the complete lesion must be examined. Although they I do not mention the MRI sequences performed or the use of contrast injection (Gd-DPTA), their first MRI shows a tumor with a solid appearance and homogeneous signal intensity. These features are similar to those reported in our article, 3 and different from those of a classic
656
ABC. Moreover, our case was surgically resected, without previous biopsy, 1 month after MRI was performed. Grossly and microscopically, our lesion was mainly cystic and composed of multiple anastomosing cavernous blood channels. Thus, ACST may be considered a solid lesion on MRI although it histologically consists, from the beginning, of multiple cystic blood channels. The areas of increased signal intensity on the T2-weighted images observed by S h a n n o n et aP in the second MRI, performed 5 months after the first radiological study and interpreted as cystic changes, may actually only be alterations provoked by the previous biopsy. FERNANDO LOPEz-BAREA D e p a r t m e n t of Pathology La Paz H o s p i t a l Madrid, Spain JOSE L. RODVdGUEZ-PERALTO D e p a r t m e n t of P a t h o l o g y 12 de O c t u b r e H o s p i t a l Madrid, Spain JUAN ALVAREz-LINERA D e p a r t m e n t of Radiology R u b e r I n t e r n a c i o n a l Hospital Madrid, Spain 1. ShannonP,B~dardY,BellR, et al: Primaryaneurysmalcystof soft tissue: Report of a case with serial magnetic resonance imagingand biopsy. HuM PATHOL28:255-257,1997
CORRESPONDENCE 2. Rodriguez-PeraltoJL, L6pez-BareaF, Sfinchez-HerreraS, et al: Primary aneurysmal cystof soft tissues (Extraosseousaneurysmal cyst). AmJ Surg Pathol 18:632-636, 1994 3. L6pez-BareaF, Rodriguez-PeraltoJL, Burgos-LizaldezE, et al: Primary aneurysmal cyst of soft tissue. Report of a case with uhrastructural and MRI studies. VirchowsArch 428:125-129. 1996 4. Bertoni F. Bacchini P, Capanna R, et al: Solidvariant of aneurysmal bone cyst. Cancer 71:729-734, 1993
Reply To the Editor:--We appreciate the interest of Dr. L6pezBarea a n d colleagues in o u r r e p o r t o f " P r i m a r y Aneurysmal Cyst of Soft Tissue with Serial Magnetic Resonance I m a g i n g and Biopsy. ''1 We would like to r e s p o n d to s o m e of their comments. In our article we do not claim to be the first to describe the magnetic resonance imaging (MRI) a p p e a r a n c e of this lesion b u t the first to r e p o r t a serial MRI study. Similarly, we did n o t claim that this was the first ultrastructural description but that it was the first to r e p o r t b o t h immunohistochemical and ultrastructural features together. Because the lesion was solid radiologically and was sampled by an o p e n biopsy and n o t a n e e d l e biopsy, we i n t e r p r e t e d this as evidence that the lesion was n o t cystic originally. T h e p o i n t raised that the cystic change may be due to the previous biopsy was emphasized in our report. We regret that we did n o t reference the most recent case report by L6pez-Barea et al in o u r article. 2 T h e i r r e p o r t h a d not b e e n received in our library at the time the manuscript was written. However, it does emphasize the value of d o i n g a final literature search on receipt of the galley proofs.
Y.C. BEDARD, M D R. KANDEL, M D R SHANNON, M D Pathology and Laboratory Medicine Mount Sinai Hospital Toronto, Ontario, Canada 1. Shannon P, B~dardY, Bell R, et al: Aneurysmalcyst of soft tissue: Report of a case with serial magnetic resonance imaging and biopsy. HUM PATHOL 28:255-257, 1997 2. L6pez-BareaE Rodriguez-PeraltoJL, Burgos-LizaldezE, et al: Primary aneurysmal cystof soft tissue. VirchowsArch 428:125-129, 1996
Malignant Mesothelioma Presenting as Colonic Tumor
T h e t u m o r cells involved the serosa and the muscular wall; this m o r p h o l o g y was interpreted as incompletely excised "carcin o i d tumor." T h e patient b e c a m e progressively ill, d e v e l o p e d vomiting and significant weight loss, and died 5 m o n t h s after surgery. At autopsy, approximately 1 L ascites and 0.5 L effusion were present in each pleural cavity. No significant disease was f o u n d in respiratory, cardiovascular, hepatobiliary, and genitourinary systems. T h e esophagus and stomach were u n r e m a r k able. However, the serosa of small and large bowels was studded with gray-white nodules, m e a s u r i n g up to 0.5 cm in diameter. Larger t u m o r nodules, up to 1 cm across, involved the mesentery. A l t h o u g h the small-bowel mucosa was free of tumors, the mucosa o f the entire colon c o n t a i n e d i n n u m e r able brownish n o n u l c e r a t e d tumors, averaging 0.5 cm in diameter. Histological examination of t u m o r tissues revealed mesothelial malignant m e s o t h e l i o m a of the p e r i t o n e u m involving all layers of small and large intestines. Immunocytochemically, the t u m o r cells were expressive for cytokeratin 1A and epithelial m e m b r a n e antigen; and nonreactive for carcino-embryonic antigen (CEA), vimentin, S-100, B 72.3, Leu M 1, actin, collagen IV, and HMB 45. T h e results were consistent with malignant mesothelioma. The unusual presentation with diarrhea and rectal bleeding and especially the detection of a concomitant colonic adenocardn o m a resulted in late recognition of the disease. At the time of laparotomy, the relatively unremarkable appearance of serosal surfaces belied the underlying disease, which affected initially and mainly the submucosa and muscular wall and terminally involved extensively also the serosa and mesentery. We agree with the conclusions of Masangkay et aP that MM should be considered in the differential diagnosis o f colonic polyps and f o r e m o s t of the undifferentiated tumors with unclear m o r p h o l o g y on routine examination. IFAT A. SHAH, M D AMPORN SOMSIN, M D SHEILA X. WONG, M D OSAMA S. GANI, M D Department of Pathology and Laboratory Medicine V e t e r a n s Affairs M e d i c a l C e n t e r Phoenix, AZ DOUGLAS D. CHAUSOW, M D Oak Green Pathologists, Ltd Cottonwood, AZ
To theEditor:--We read with interest the recent r e p o r t and the u n i q u e presentation of peritoneal m a l i g n a n t mesothelioma (MM) as a colonic t u m o r / p o l y p . 1 We briefly d o c u m e n t a similar case. A 72-year-old healthy white m a n (a World War II veteran) presented with recent onset of f u l m i n a n t d i a r r h e a a n d rectal bleeding. T h e patient s m o k e d cigarettes but had no history of asbestos exposure. O n endoscopy in O c t o b e r 1990, he h a d a fungating semicircular n o n o b s t r u c t i n g t u m o r in the lower sigmoid colon. T h e biopsy s p e c i m e n was i n t e r p r e t e d at an outside hospital as an ulcerated poorly differentiated adenocarcin0ma. At laparotomy, n o peritoneal tumors were present, the bowel loops were mildly a d h e r e n t to o n e a n o t h e r and the serosal surface easily bled on palpation. T h e e x a m i n a t i o n of the 12-cm l o n g sigmoidectomy s p e c i m e n revealed two distinct tumors: (1) close to distal resection margin, approximately 3 cm in diameter, semicircular, ulcerated, well-differentiated adenocarcinoma, p e n e t r a t i n g the muscular wall and i n v o M n g the serosa, but n o t metastasizing to regional lymph nodes; and (2) i n v o M n g the resection margin adjacent to the main minor, a submucosal neoplastic process c o m p o s e d of sheets and clusters of cuboidal cells with abortive gland formation.
1. MasangkayAV, Susin M, Baker R, et al: Metastatic malignant mesothelioma presenting as colonic polyps. HUMPATHOL28:993-995, 1997
Bronchiolitis Obliterans, Castleman's Disease, and a Bullous Disease: Pemphigus Vulgaris or Paraneoplastic Pemphigus? To the Editor: We read with great interest the article by Saito et aP entitled "Bronchiolitis Obliterans With Pemphigus Vulgaris and Castleman's Disease of Hyaline-Vascular Type: An Autopsy Case Analyzed by Computer-Aided 3-D Reconstruction of the Airway Lesions." T h e authors diagnosed p e m p h i gus vulgaris (PV) in the patient based on clinical presentation (erosions in the t o n g u e a n d oral mucosa) and i m m u n o l o g i c a l findings (positive p e m p h i g u s autoantibodies by i m m u n o f l u o rescence testing). To explain the possible relationship between bronchiolitis obliterans (BO) and PV, Saito et al 1 argue that at a very acute stage of PV epithelial injuries m i g h t have taken place also in the airways and that it m i g h t lead to
657
PRODUCT REVIEW Microscopy-Tutor, Version 1. University of Washington Department of Laboratory Medicine, Philadelphia, PA, Lippincott-Raven, 1997, CD-ROM, $195.00. "Microscopy-Tutor" is a program that provides a basic understanding of the microscope; its use, physical structure, and components. It then explores the concepts of optics such as resolution, magnification, contrast, and so on. It is suitable as an introduction to microscopy and would probably be most useful for upper division college level students a n d / o r as a review of fundamental principles. The texts are simple and straightforward and are easily understood by the beginning student, especially concerning the proper use of the microscope. I assume this program is targeted to that level audience. The "movies" are simple but adequate to re-enforce the verbal descriptions and are well placed. There are many illustrations and they are supportive of the text and well designed. The section on Kohler illumination is a well-thought out "how to" section with well-placed illustrations. There are clear descriptions of contrast versus resolution and the care of lenses and other details for obtaining good images.
The program also includes cleaning, coverslips, and the use of stains (to increase contrast). A reminder of the three dimensional nature of images, a concept often lost by many beginning students, is also included. The "Tutor" also covers the principles of optics, light (physics), lens characteristics, the interface to the eye, and general eye structure. Although this section is interesting, it is a bit detailed for a biology student, although, arguably, it is important for all students using microscopes to have at least a basic understanding these principles. In summary, I found the Microscopy-Tutor to be an enjoyable, well-written and illustrated program. It would be helpful to the beginning student as part of his or her introduction to a microscopy course (especially Kohler illumination setup). Advanced students could use this program for reviewing Kohler illumination and for furthering their understanding of the physics behind the construction of compound microscopes.--RONALD E JENSH, PHD, Department of Patholocy,
Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, PA.
CORRESPONDENCE Primary Aneurysmal Cyst of Soft Tissue: Serial Magnetic Resonance Imaging Study To the Editor:--We read with great interest the article by Shannon et all appearing in the February 1997 issue of Human Pathology. In that article the authors reported what they claimed to be the first description of magnetic resonance imaging (MRI) and ultrastructural features of an aneurysmal cyst of soft tissues (ACST). This entity was originally described in 1994 by our group. 2 In February 1996, 1 year before the Shannon et all article appeared, we published an additional case and described the MRI and ultrastructural features of this lesion for the first timeP The electron microscopic images reported by Shannon et aP are similar to those we described in 1996 s as well as to the classic description of an aneurysmal bone cyst (ABC). Our description also noted the presence of occasional multinucleated giant cells on the surface of bloodfilled cavernous channels, an additional observation reported in neither the ABC nor in the Shannon et all article. Based on histopathologic and MRI features, Shannon et al l initially considered their tumor a solid lesion, although their report does not give the size of the open biopsy. Because ABCs can contain small solid areas where cavernous channels are not evident4 a lesion can not be classified as solid variant on the basis of a small sample; the complete lesion must be examined. Although they I do not mention the MRI sequences performed or the use of contrast injection (Gd-DPTA), their first MRI shows a tumor with a solid appearance and homogeneous signal intensity. These features are similar to those reported in our article, 3 and different from those of a classic
656
ABC. Moreover, our case was surgically resected, without previous biopsy, 1 month after MRI was performed. Grossly and microscopically, our lesion was mainly cystic and composed of multiple anastomosing cavernous blood channels. Thus, ACST may be considered a solid lesion on MRI although it histologically consists, from the beginning, of multiple cystic blood channels. The areas of increased signal intensity on the T2-weighted images observed by S h a n n o n et aP in the second MRI, performed 5 months after the first radiological study and interpreted as cystic changes, may actually only be alterations provoked by the previous biopsy. FERNANDO LOPEz-BAREA D e p a r t m e n t of Pathology La Paz H o s p i t a l Madrid, Spain JOSE L. RODVdGUEZ-PERALTO D e p a r t m e n t of P a t h o l o g y 12 de O c t u b r e H o s p i t a l Madrid, Spain JUAN ALVAREz-LINERA D e p a r t m e n t of Radiology R u b e r I n t e r n a c i o n a l Hospital Madrid, Spain 1. ShannonP,B~dardY,BellR, et al: Primaryaneurysmalcystof soft tissue: Report of a case with serial magnetic resonance imagingand biopsy. HuM PATHOL28:255-257,1997
CORRESPONDENCE 2. Rodriguez-PeraltoJL, L6pez-BareaF, Sfinchez-HerreraS, et al: Primary aneurysmal cystof soft tissues (Extraosseousaneurysmal cyst). AmJ Surg Pathol 18:632-636, 1994 3. L6pez-BareaF, Rodriguez-PeraltoJL, Burgos-LizaldezE, et al: Primary aneurysmal cyst of soft tissue. Report of a case with uhrastructural and MRI studies. VirchowsArch 428:125-129. 1996 4. Bertoni F. Bacchini P, Capanna R, et al: Solidvariant of aneurysmal bone cyst. Cancer 71:729-734, 1993
Reply To the Editor:--We appreciate the interest of Dr. L6pezBarea a n d colleagues in o u r r e p o r t o f " P r i m a r y Aneurysmal Cyst of Soft Tissue with Serial Magnetic Resonance I m a g i n g and Biopsy. ''1 We would like to r e s p o n d to s o m e of their comments. In our article we do not claim to be the first to describe the magnetic resonance imaging (MRI) a p p e a r a n c e of this lesion b u t the first to r e p o r t a serial MRI study. Similarly, we did n o t claim that this was the first ultrastructural description but that it was the first to r e p o r t b o t h immunohistochemical and ultrastructural features together. Because the lesion was solid radiologically and was sampled by an o p e n biopsy and n o t a n e e d l e biopsy, we i n t e r p r e t e d this as evidence that the lesion was n o t cystic originally. T h e p o i n t raised that the cystic change may be due to the previous biopsy was emphasized in our report. We regret that we did n o t reference the most recent case report by L6pez-Barea et al in o u r article. 2 T h e i r r e p o r t h a d not b e e n received in our library at the time the manuscript was written. However, it does emphasize the value of d o i n g a final literature search on receipt of the galley proofs.
Y.C. BEDARD, M D R. KANDEL, M D R SHANNON, M D Pathology and Laboratory Medicine Mount Sinai Hospital Toronto, Ontario, Canada 1. Shannon P, B~dardY, Bell R, et al: Aneurysmalcyst of soft tissue: Report of a case with serial magnetic resonance imaging and biopsy. HUM PATHOL 28:255-257, 1997 2. L6pez-BareaE Rodriguez-PeraltoJL, Burgos-LizaldezE, et al: Primary aneurysmal cystof soft tissue. VirchowsArch 428:125-129, 1996
Malignant Mesothelioma Presenting as Colonic Tumor
T h e t u m o r cells involved the serosa and the muscular wall; this m o r p h o l o g y was interpreted as incompletely excised "carcin o i d tumor." T h e patient b e c a m e progressively ill, d e v e l o p e d vomiting and significant weight loss, and died 5 m o n t h s after surgery. At autopsy, approximately 1 L ascites and 0.5 L effusion were present in each pleural cavity. No significant disease was f o u n d in respiratory, cardiovascular, hepatobiliary, and genitourinary systems. T h e esophagus and stomach were u n r e m a r k able. However, the serosa of small and large bowels was studded with gray-white nodules, m e a s u r i n g up to 0.5 cm in diameter. Larger t u m o r nodules, up to 1 cm across, involved the mesentery. A l t h o u g h the small-bowel mucosa was free of tumors, the mucosa o f the entire colon c o n t a i n e d i n n u m e r able brownish n o n u l c e r a t e d tumors, averaging 0.5 cm in diameter. Histological examination of t u m o r tissues revealed mesothelial malignant m e s o t h e l i o m a of the p e r i t o n e u m involving all layers of small and large intestines. Immunocytochemically, the t u m o r cells were expressive for cytokeratin 1A and epithelial m e m b r a n e antigen; and nonreactive for carcino-embryonic antigen (CEA), vimentin, S-100, B 72.3, Leu M 1, actin, collagen IV, and HMB 45. T h e results were consistent with malignant mesothelioma. The unusual presentation with diarrhea and rectal bleeding and especially the detection of a concomitant colonic adenocardn o m a resulted in late recognition of the disease. At the time of laparotomy, the relatively unremarkable appearance of serosal surfaces belied the underlying disease, which affected initially and mainly the submucosa and muscular wall and terminally involved extensively also the serosa and mesentery. We agree with the conclusions of Masangkay et aP that MM should be considered in the differential diagnosis o f colonic polyps and f o r e m o s t of the undifferentiated tumors with unclear m o r p h o l o g y on routine examination. IFAT A. SHAH, M D AMPORN SOMSIN, M D SHEILA X. WONG, M D OSAMA S. GANI, M D Department of Pathology and Laboratory Medicine V e t e r a n s Affairs M e d i c a l C e n t e r Phoenix, AZ DOUGLAS D. CHAUSOW, M D Oak Green Pathologists, Ltd Cottonwood, AZ
To theEditor:--We read with interest the recent r e p o r t and the u n i q u e presentation of peritoneal m a l i g n a n t mesothelioma (MM) as a colonic t u m o r / p o l y p . 1 We briefly d o c u m e n t a similar case. A 72-year-old healthy white m a n (a World War II veteran) presented with recent onset of f u l m i n a n t d i a r r h e a a n d rectal bleeding. T h e patient s m o k e d cigarettes but had no history of asbestos exposure. O n endoscopy in O c t o b e r 1990, he h a d a fungating semicircular n o n o b s t r u c t i n g t u m o r in the lower sigmoid colon. T h e biopsy s p e c i m e n was i n t e r p r e t e d at an outside hospital as an ulcerated poorly differentiated adenocarcin0ma. At laparotomy, n o peritoneal tumors were present, the bowel loops were mildly a d h e r e n t to o n e a n o t h e r and the serosal surface easily bled on palpation. T h e e x a m i n a t i o n of the 12-cm l o n g sigmoidectomy s p e c i m e n revealed two distinct tumors: (1) close to distal resection margin, approximately 3 cm in diameter, semicircular, ulcerated, well-differentiated adenocarcinoma, p e n e t r a t i n g the muscular wall and i n v o M n g the serosa, but n o t metastasizing to regional lymph nodes; and (2) i n v o M n g the resection margin adjacent to the main minor, a submucosal neoplastic process c o m p o s e d of sheets and clusters of cuboidal cells with abortive gland formation.
1. MasangkayAV, Susin M, Baker R, et al: Metastatic malignant mesothelioma presenting as colonic polyps. HUMPATHOL28:993-995, 1997
Bronchiolitis Obliterans, Castleman's Disease, and a Bullous Disease: Pemphigus Vulgaris or Paraneoplastic Pemphigus? To the Editor: We read with great interest the article by Saito et aP entitled "Bronchiolitis Obliterans With Pemphigus Vulgaris and Castleman's Disease of Hyaline-Vascular Type: An Autopsy Case Analyzed by Computer-Aided 3-D Reconstruction of the Airway Lesions." T h e authors diagnosed p e m p h i gus vulgaris (PV) in the patient based on clinical presentation (erosions in the t o n g u e a n d oral mucosa) and i m m u n o l o g i c a l findings (positive p e m p h i g u s autoantibodies by i m m u n o f l u o rescence testing). To explain the possible relationship between bronchiolitis obliterans (BO) and PV, Saito et al 1 argue that at a very acute stage of PV epithelial injuries m i g h t have taken place also in the airways and that it m i g h t lead to
657