- Email: [email protected]
Surgical management of soft tissue sarcoma
BOOK REWWS In cases in which Snover’s diagnostic triad is found to be present, the diagnosis of acute rejection may be established in biopsy material with comparatively high reliability. However, in accord with Ray et al,’ we also propose the hypothesis that even the incomplete presence of Snover’s triad, ie, without endothelialitis, may be an indicator of therapyrequiring acute rejection in cases in which other clinical and laboratory Iparameters are present. Conversely, our preliminary clmicupathologic analyses” have shown that, in biopsy specimens taken from cases of suspected rejection as well as routinely WI the seventh day postoperatively, histologic signs of rejection. with complete Snover’s triad, are detectahle in a pproximately 80% of all liver transplant patients. In orfly 60% of these patients was the diagnosis of therapyrequrrrng acute rejection definitely established after taking into consideration all clinical and laboratory findings. The other 3% uf patients with histologic signs of acute rejection showed spontaneous remission in all cases, provided that clinical signs of‘ rejection were absent. In contrast to this, most patients displaying both histologic and clinical signs of rejection showed progress, unless anti-rejection therapy was administered. Likewise, patients with infection, which is considered a contraindication for anti-rejection therapy, showed spontaneous remission in some cases. In summary, these facts provide evidence that a spontaneously reversible form of rejection in the orthotopic liver allograft actually does exist. Its distinction from the therapy-requiring form, however, is probably possible only by contrasting the histopathologic findings with all clinical parameters. With respect to this finding, the differential-diagnostic value of the liver biopsy is increased by specifying more precisely the other changes (which are not directly related to rejection), as discussed in the report of Ray et al.’ JOSEF KEMNI,L.Z, MD,
PHD
GUNDOLF GUBERNATIS,
MD
TAIJANA
MD
R. COHNERT,
AXEL C;EORGII.
MD Institute of Pathology Hannover Medical School Lower Saxony. FRC
To the Editor-:-Kemnitz et al have raised important points in their letter and in subsequent publications’.” concerning the specificity of the classic triad of acute liver transplant rejection (mixed portal inflammatory infiltrate, bile duct epithelial injury, and endothelialitis). They report the presence of all three features in the majority of liver transplant patients when biopsies are taken according to a routine protocol; however, only a portion of these patients show clinical signs of rejection and require therapy. This suggests that many patients undergo a transient form of mild rejection that will spontaneously resolve. In addition, they note, as did we, that some patients experience clinically significant rejection even in the absence of the complete histologic triad (eg, no endothelialitis). These are important observations, emphasizing the need to correlate the histology with the clinical picture in developing the appropriate criteria for when to act on histologic findings. The results reported in our study were completed early in the transplantation program, prior to implementing routine protocol biopsies at specified intervals. Instead, the biopsies were mainly performed during episodes of clinically significant liver dysfunction; consequently, patients with histologic evidence of rejection were uniformly treated. Those patients with clinically very mild episodes did not undergo biopsy procedures. so the baseline changes in the transplants could not be commented on. ‘There was one case of an incidental liver biopsy performed during a laporatomy for persistent bleeding in an otherwise asymptomatic patient. This biopsy did show the triad of changes, suggesting rejection without clinical confirmation. This patient received no increased immunosuppression and did well, suggesting the existence of a clinicallv silent form of mild “histologic” rejection. While these cases demonstrate the importance of the clinical background in interpreting histologic findings, further quantitative analyses of the severity and frequency of specific histologic findings may provide additional information concerning their clinical significance and help identify subgroups within the broad category of “rejection” that will generally require therapeutic intervention. Kemnitz et al have already begun such analyses,’ allowing for a more standardized and clinically helpful approach to biopsy interpretation. RICHARD RAY,
MD MD LCLA Medical Center Los Angeles KLAUS LEWIN.
3. Kcnmltz J, C;ul)ernati\ G. Bunzrndahl H, ct al: Criterld tclr the histopathologi< classitication of liver allograft r$xtion and their clinical rele\.incv. TlY~“~pla”r 1’10~ (in pl-e\s)
The
of the
BOOK REVIEWS Surgical
Management
of Soft Tissue
Shiu, Murray F. Rrennan. l989, 297 pages, $58.
Philadelphia,
Sarcoma.
Man H. Lea and Febiger,
For the bulk of the 20th century, Memorial SloanKettering Cancer Center in New York City has been a bea(-011 for O~UIunderstanding of the pathology and therapy of
1. Kenlnitz J, C;ubernatis G, Bunzendahl H. et al: Criteria for the histopathological classification of liver allograft qection ;and their clinical relevance. Transplant Proc 21:2208. 198Y 2. Kemnitz J. Ringe B, Cohnert I‘. et al: Bile duct injury as a part of diagtwstk criteria for allograft rejection. HUM PA-THOI “0: 132”~ I989
malignant tumors, particularly soft tissue sarcomas. Examples of this leadership include the first descriptions of Ewing’s sarcoma, postmastectomy lymphangiosarcoma, and alveolar soft part sarcoma. With this book, the surgeons at Memorial Hospital who have been involved in the therapy of these neoplasms have been given the opportunity to expound on their experience covering a multitude of patients and a wide span of years, with emphasis being given to recent developments in surgical and adjuvant techniques.
1031
HUMAN PATHOLOGY
Volume 20, No, 10 [October 1989)
As such, this book is eminently readable by all individuals with an interest in soft tissue neoplasms. particularly those pathologists who would like a succinct description of the surgical techniques involved in the production of the complicated gross specimens that arrive in the grossing room as a result of these procedures and that require detailed pathologic dissection. The book is divided into three sections: the first covers the concepts and principles involved in the therapy of soft tissue sarcomas; the second outlines in a more detailed fashion the clinical features, therapy, and outcome of sarcomas in specific anatomic sites; and the third, which is relatively brief, covers multidisciplinary treatment of sarcomas. The first section contains chapters on the pathology, clinical features, staging, and biopsy principles of sarcomas. The chapter on pathology is written by Dr Hadju and is a brief synopsis of the microscopic features of sarcomas that are covered in far greater detail in his own textbook. Other topics covered in the first section of particular interest are a SLICcinct description of the radiologic features of sarcomas, including computerized tomographic and magnetic resonance imaging features, and the principles involved in determining what types of biopsy and excision are indicated in a particular patient. It was heartening to read that an emphasis was placed on obtaining ample amounts of viable tumor tissue for the pathologist. The second section, concerning sarcomas at specific sites, comprised the heart of the book and was authored by a number of surgeons from the various services at Memorial Hospital. These chapters covered the extremities, chest wall, abdominal wall, retroperitoneum, gastrointestinal tract, genitourinary tract, uterus, breast, pulmonary metastases, and childhood sarcomas. I found these chapters instructive because they not only supplied readable descriptions of the principles of surgical excision at these sites but also reviewed the clinical and pathologic features affecting prognosis. Particularly instructive were the chapters on the extremities, gastrointestinal tract, breast, and childhood sarcomas. Although the emphasis was on surgical therapy in these chapters, up-to-date coverage of adjuvant chemotherapy and radiotherapy was also given. The book is lavishly illustrated with gross photographs, radiographs, and surgical illustrations. Although at a first glance at the title, the book does not seem pertinent, it is of interest to all surgical pathologists, particularly those with an interest in soft tissue neoplasms. It gives an understanding not only of the surgical techniques, but also the pathologic and clinical features important in the treatment of these tumors, and it is to be recommended to all with even a peripheral involvement with patients afflicted with them.-DAVID M. PARHAM. MD, Associate Member, Department of Pathology. St Jude Children’s Research Hospital. Gastrointestinal Pathology: An Atlas and Text. Cecilia M. Fenoglio-Preiser, Patrick E. Lantz, Margaret B. Listrom, et al. New York, Raven, 906 pages, $225. There was a time when reference books exclusively devoted to gastrointestinal pathology were very few. Professor Morson’s book once stood almost alone. The need to interpret mucosal biopsies from many sites in the gastrointestinal tract gave rise to more monographs and texts. As more refined techniques in flexible endoscopy and cytopathologic examination evolved, the number of treatises on gastrointestinal pathology grew to rival that of books concerning renal biopsy pathology. This latest work, prepared at
the University of New Mexico by Dr Fenoglio-Preiser and her colleagues and with the close collaboration of Dr Rilke in Milan, Italy, is a very ambitious undertaking. If two words can describe the outcome, they are “It succeeds.” The book covers diseases of the alimentary canal from the esophagus to the anus. It excludes the mouth and pharynx and the solid organs associated with digestion. Insofar as it contains over 2,000 illustrations, many of them in color, it is an atlas. The text, however, is not merely a description of the illustrations. It is a well-written, up-to-date narrative of gastrointestinal diseases. Thus, the book is more a superbly illustrated textbook than an atlas through which one thumbs to find a picture to match a microscopic field. Its coverage includes descriptions of biopsy specimens as well as large and small resection specimens. One of its strongest features is the correlation of morphologic features with radiologic and endoscopic methods of diagnosis and with other pertinent clinical data. As such, it is a book that helps the pathologist converse with radiologists, endoscopists, gastroenterologists. and surgeons, as part of a health care team. Numerous radiologic studies are paired with gross and microscopic illustrations to provide the correlation that would exist in a good radiology-pathology conference. A number of endoscopic images are also paired with appropriate photomicrographs. These, however, are not as numerous as the x-ray studies, and might be increased if future additions of this book appear. The general organization of the book logically divides the alimentary canal into esophagus, stomach, small intestine, large intestine, and anus. In general, each of these areas is approached by describing the normal anatomy in the initial section, nonneoplastic diseases in a second section, and neoplastic diseases in a third section. LJsing titles such as “The Non-neoplastic Anus” and “The Neoplastic Anus” seems to be a bit of unnecessary.jargon that evokes some unpleasant images. That is a minor point, however, and not as serious as some of the difficulties encountered in trying to adhere to that approach. For example, data on carcinoma in Barrett’s esophagus must be synthesized from statements made in the chapter on nonneoplastic diseases of the esophagus and in several areas describing carcinoma and dysplasia in the neoplastic esophagus section. The same is true to some degree for carcinoma associated with inflammatory bowel disease. Discussions of dysplasia and malignancy in IBD precede the chapter concerning neoplastic diseases of the large intestine. The authors deviate from their initial organization between the ileocecal valve and the peritoneal reflection. Here, instead of continuing the format with the nonneoplastic large intestine and the neoplastic large intestine, they insert several chapters on the vermiform appendix, inflammatory bowel disease, polyposis, endocrine disorders, mesenchymal tumors, and lymphomas. With the exception of the chapter concerning vermiform appendix, which deserves to be treated separately, this deviation produces some areas of awkwardness. The discussion of polyposis syndromes appears several chapters before detailed discussions of common epithelial polyps of the colon. Dysplasia in inflammatory bowel disease is isolated from the concept of dysplasia in the more common adenomas. This is in contrast to the treatment of dysplasia of the gastric mucosa which appears in the context of gastric neoplasia in general. Discussions of mesenchymal tumors appear both in the chapter on neoplastic diseases of the small intestine and in the chapter on mesenchymal tumors. Despite these shortcomings and repetitions, each subject is more than adequately covered in the text and illustrations. Devoting a separate chapter to disorders of the
1032
PHD
GUNDOLF GUBERNATIS,
MD
TAIJANA
MD
R. COHNERT,
AXEL C;EORGII.
MD Institute of Pathology Hannover Medical School Lower Saxony. FRC
To the Editor-:-Kemnitz et al have raised important points in their letter and in subsequent publications’.” concerning the specificity of the classic triad of acute liver transplant rejection (mixed portal inflammatory infiltrate, bile duct epithelial injury, and endothelialitis). They report the presence of all three features in the majority of liver transplant patients when biopsies are taken according to a routine protocol; however, only a portion of these patients show clinical signs of rejection and require therapy. This suggests that many patients undergo a transient form of mild rejection that will spontaneously resolve. In addition, they note, as did we, that some patients experience clinically significant rejection even in the absence of the complete histologic triad (eg, no endothelialitis). These are important observations, emphasizing the need to correlate the histology with the clinical picture in developing the appropriate criteria for when to act on histologic findings. The results reported in our study were completed early in the transplantation program, prior to implementing routine protocol biopsies at specified intervals. Instead, the biopsies were mainly performed during episodes of clinically significant liver dysfunction; consequently, patients with histologic evidence of rejection were uniformly treated. Those patients with clinically very mild episodes did not undergo biopsy procedures. so the baseline changes in the transplants could not be commented on. ‘There was one case of an incidental liver biopsy performed during a laporatomy for persistent bleeding in an otherwise asymptomatic patient. This biopsy did show the triad of changes, suggesting rejection without clinical confirmation. This patient received no increased immunosuppression and did well, suggesting the existence of a clinicallv silent form of mild “histologic” rejection. While these cases demonstrate the importance of the clinical background in interpreting histologic findings, further quantitative analyses of the severity and frequency of specific histologic findings may provide additional information concerning their clinical significance and help identify subgroups within the broad category of “rejection” that will generally require therapeutic intervention. Kemnitz et al have already begun such analyses,’ allowing for a more standardized and clinically helpful approach to biopsy interpretation. RICHARD RAY,
MD MD LCLA Medical Center Los Angeles KLAUS LEWIN.
3. Kcnmltz J, C;ul)ernati\ G. Bunzrndahl H, ct al: Criterld tclr the histopathologi< classitication of liver allograft r$xtion and their clinical rele\.incv. TlY~“~pla”r 1’10~ (in pl-e\s)
The
of the
BOOK REVIEWS Surgical
Management
of Soft Tissue
Shiu, Murray F. Rrennan. l989, 297 pages, $58.
Philadelphia,
Sarcoma.
Man H. Lea and Febiger,
For the bulk of the 20th century, Memorial SloanKettering Cancer Center in New York City has been a bea(-011 for O~UIunderstanding of the pathology and therapy of
1. Kenlnitz J, C;ubernatis G, Bunzendahl H. et al: Criteria for the histopathological classification of liver allograft qection ;and their clinical relevance. Transplant Proc 21:2208. 198Y 2. Kemnitz J. Ringe B, Cohnert I‘. et al: Bile duct injury as a part of diagtwstk criteria for allograft rejection. HUM PA-THOI “0: 132”~ I989
malignant tumors, particularly soft tissue sarcomas. Examples of this leadership include the first descriptions of Ewing’s sarcoma, postmastectomy lymphangiosarcoma, and alveolar soft part sarcoma. With this book, the surgeons at Memorial Hospital who have been involved in the therapy of these neoplasms have been given the opportunity to expound on their experience covering a multitude of patients and a wide span of years, with emphasis being given to recent developments in surgical and adjuvant techniques.
1031
HUMAN PATHOLOGY
Volume 20, No, 10 [October 1989)
As such, this book is eminently readable by all individuals with an interest in soft tissue neoplasms. particularly those pathologists who would like a succinct description of the surgical techniques involved in the production of the complicated gross specimens that arrive in the grossing room as a result of these procedures and that require detailed pathologic dissection. The book is divided into three sections: the first covers the concepts and principles involved in the therapy of soft tissue sarcomas; the second outlines in a more detailed fashion the clinical features, therapy, and outcome of sarcomas in specific anatomic sites; and the third, which is relatively brief, covers multidisciplinary treatment of sarcomas. The first section contains chapters on the pathology, clinical features, staging, and biopsy principles of sarcomas. The chapter on pathology is written by Dr Hadju and is a brief synopsis of the microscopic features of sarcomas that are covered in far greater detail in his own textbook. Other topics covered in the first section of particular interest are a SLICcinct description of the radiologic features of sarcomas, including computerized tomographic and magnetic resonance imaging features, and the principles involved in determining what types of biopsy and excision are indicated in a particular patient. It was heartening to read that an emphasis was placed on obtaining ample amounts of viable tumor tissue for the pathologist. The second section, concerning sarcomas at specific sites, comprised the heart of the book and was authored by a number of surgeons from the various services at Memorial Hospital. These chapters covered the extremities, chest wall, abdominal wall, retroperitoneum, gastrointestinal tract, genitourinary tract, uterus, breast, pulmonary metastases, and childhood sarcomas. I found these chapters instructive because they not only supplied readable descriptions of the principles of surgical excision at these sites but also reviewed the clinical and pathologic features affecting prognosis. Particularly instructive were the chapters on the extremities, gastrointestinal tract, breast, and childhood sarcomas. Although the emphasis was on surgical therapy in these chapters, up-to-date coverage of adjuvant chemotherapy and radiotherapy was also given. The book is lavishly illustrated with gross photographs, radiographs, and surgical illustrations. Although at a first glance at the title, the book does not seem pertinent, it is of interest to all surgical pathologists, particularly those with an interest in soft tissue neoplasms. It gives an understanding not only of the surgical techniques, but also the pathologic and clinical features important in the treatment of these tumors, and it is to be recommended to all with even a peripheral involvement with patients afflicted with them.-DAVID M. PARHAM. MD, Associate Member, Department of Pathology. St Jude Children’s Research Hospital. Gastrointestinal Pathology: An Atlas and Text. Cecilia M. Fenoglio-Preiser, Patrick E. Lantz, Margaret B. Listrom, et al. New York, Raven, 906 pages, $225. There was a time when reference books exclusively devoted to gastrointestinal pathology were very few. Professor Morson’s book once stood almost alone. The need to interpret mucosal biopsies from many sites in the gastrointestinal tract gave rise to more monographs and texts. As more refined techniques in flexible endoscopy and cytopathologic examination evolved, the number of treatises on gastrointestinal pathology grew to rival that of books concerning renal biopsy pathology. This latest work, prepared at
the University of New Mexico by Dr Fenoglio-Preiser and her colleagues and with the close collaboration of Dr Rilke in Milan, Italy, is a very ambitious undertaking. If two words can describe the outcome, they are “It succeeds.” The book covers diseases of the alimentary canal from the esophagus to the anus. It excludes the mouth and pharynx and the solid organs associated with digestion. Insofar as it contains over 2,000 illustrations, many of them in color, it is an atlas. The text, however, is not merely a description of the illustrations. It is a well-written, up-to-date narrative of gastrointestinal diseases. Thus, the book is more a superbly illustrated textbook than an atlas through which one thumbs to find a picture to match a microscopic field. Its coverage includes descriptions of biopsy specimens as well as large and small resection specimens. One of its strongest features is the correlation of morphologic features with radiologic and endoscopic methods of diagnosis and with other pertinent clinical data. As such, it is a book that helps the pathologist converse with radiologists, endoscopists, gastroenterologists. and surgeons, as part of a health care team. Numerous radiologic studies are paired with gross and microscopic illustrations to provide the correlation that would exist in a good radiology-pathology conference. A number of endoscopic images are also paired with appropriate photomicrographs. These, however, are not as numerous as the x-ray studies, and might be increased if future additions of this book appear. The general organization of the book logically divides the alimentary canal into esophagus, stomach, small intestine, large intestine, and anus. In general, each of these areas is approached by describing the normal anatomy in the initial section, nonneoplastic diseases in a second section, and neoplastic diseases in a third section. LJsing titles such as “The Non-neoplastic Anus” and “The Neoplastic Anus” seems to be a bit of unnecessary.jargon that evokes some unpleasant images. That is a minor point, however, and not as serious as some of the difficulties encountered in trying to adhere to that approach. For example, data on carcinoma in Barrett’s esophagus must be synthesized from statements made in the chapter on nonneoplastic diseases of the esophagus and in several areas describing carcinoma and dysplasia in the neoplastic esophagus section. The same is true to some degree for carcinoma associated with inflammatory bowel disease. Discussions of dysplasia and malignancy in IBD precede the chapter concerning neoplastic diseases of the large intestine. The authors deviate from their initial organization between the ileocecal valve and the peritoneal reflection. Here, instead of continuing the format with the nonneoplastic large intestine and the neoplastic large intestine, they insert several chapters on the vermiform appendix, inflammatory bowel disease, polyposis, endocrine disorders, mesenchymal tumors, and lymphomas. With the exception of the chapter concerning vermiform appendix, which deserves to be treated separately, this deviation produces some areas of awkwardness. The discussion of polyposis syndromes appears several chapters before detailed discussions of common epithelial polyps of the colon. Dysplasia in inflammatory bowel disease is isolated from the concept of dysplasia in the more common adenomas. This is in contrast to the treatment of dysplasia of the gastric mucosa which appears in the context of gastric neoplasia in general. Discussions of mesenchymal tumors appear both in the chapter on neoplastic diseases of the small intestine and in the chapter on mesenchymal tumors. Despite these shortcomings and repetitions, each subject is more than adequately covered in the text and illustrations. Devoting a separate chapter to disorders of the
1032