Patients undergoing radical surgical treatment for Stage IB and IIA cervical carcinoma are at high risk of developing local recurrence and/or distant metastases when one or more of the following factors are present: presence of metastatic pelvic lymph nodes, a large primary growth, full-thickness tumor invasion of the cervix, clinically undetected parametrial extension, and lymphatic/vascular channel permeation in the cervix by tumor cells. Carcinoma of the cervix appears to be behaving like a systemic disease. Therefore, systemic measures should be considered in its therapy. The authors report the initial experience with the use of mitomycin C as a single agent adjuvant in 16 patients with Stage IB carcinoma of the cervix who had undergone Wertheim radical hysterectomy and were thought to be in this high-risk group. Fourteen of the patients are alive and free of disease after durations of follow-up ranging from 16 to 38 months, the disease-free survival at a median follow-up of 29 months being 87.5%. One patient required discontinuation of adjuvant chemotherapy because of severe marrow toxicity; however, in view of the presence of a multiple risk factors, pelvic irradiation was given instead. She died 13 months later from disseminated disease. A second patient died 6 months later from congestive cardiac failure.
Three cases of progressive dyspnoea in young female adults due to pulmonary lymphangitic carcinomatosis are reported. The underlying primary neoplasm was gastric carcinoma in all 3 cases. The diagnosis was not suspected in 2 patients because of their young age.
Mucoepidermoid tumours of the minor salivary glands of the tongue are rarely encountered. A case of a high-grade malignant type is reported here. Merits of subdivision of the mucoepidermoid tumour on the basis of its malignant potential are outlined, and variations of histological presentation of the present tumour at its primary and nodal sites are discussed.
Histopathological features in 89 cases of Stage 1B and early 2A invasive carcinoma of the cervix who underwent Wertheim radical hysterectomy and pelvic lymphadenectomy were studied. Depth of tumour invasion and lymphatic/vascular space permeation by tumour cells were significantly associated with lymph node metastases. The other features such as tumour type, and stromal leucocytic reaction showed no significant relationship to the presence of lymph node metastases.
To assess the importance of Computed Tomography(CT) in the evaluation of retinoblastoma, we reviewed thirteen cases of retinoblastoma which presented at Hospital University Sains Malaysia, Kelantan, Malaysia, from August 1986 to June 1991. High resolution computed tomography of the orbits was performed in all patients prior to therapy. Nine patients (69%) had unilateral and four (31%) had bilateral retinoblastoma. The interesting features were the remarkably high incidence in the right eye (89%) as compared to the left eye (11%) in unilateral retinoblastoma, and overall predominance of the male population (male to female ratio was 2:1). Computed tomography detected intraocular calcification in 82% of the tumourous eyes. All patients presented at late stages when tumours were of large size. The presence of calcification was not related to the size of the tumour. CT detected calcification in a suspected retinoblastoma with a high degree of accuracy. Computed tomographic evidence of intraocular calcification in children under 3 years of age is highly suggestive of retinoblastoma.
The case of a minor salivary gland tumour, arising from the tongue, with nodal metastasis is presented. Biopsy of the tumour and fine-needle aspiration cytology of the neck swelling showed the presence of a clear cell carcinoma with evidence of nodal metastases. A commando operation was performed and the defect was reconstructed using a local tongue flap. The literature review indicated that the neoplasm was rare and its site of occurrence rather unusual.
A 60-year-old Chinese lady presented with a left flank mass and weight loss. Plain films showed a sclerotic L1 vertebral body, osteopenic L2 and L3 vertebral bodies and loss of left psoas outline. However initially unrevealed history of previous carcinoma of the cervix caused confusion as to the aetiology of a sclerotic vertebral body associated with an left flank collection. Psoas abscess with adjacent bony osteomyelitis was initially suspected. The left flank mass turned out to be an infected necrotic large metastatic lymph node compressing the lower pole of the left kidney. The sclerotic and osteopenic vertebral bodies represented an unusual presentation of bony cervical carcinoma metastases.
Overall survival of nasopharyngeal carcinoma (NPC) at UICC stage IV still remains unsatisfactory even with combination chemotherapy (CT) and radio-therapy (RT). In view of the association of reactivation of Epstein-Barr virus (EBV) with the development and recurrence of NPC, immunotherapy in the form of transfer factor (TF) with specific activity against EBV (TF-B1) was suggested as an adjuvant to a combination of CT and RT in order to improve survival. In the present study, 6 UICC stage IV patients received TF-B1 and another 6 patients matched for disease stage were given TF prepared from peripheral blood leucocytes (TF-PBL). Results were compared with another 18 patients matched by age, sex, and stage of disease who received standard therapy without TF during the same period (C group). After a median follow up of 47.5 months, the survival for the TF-B1 group was found to be significantly better (P = < 0.05) than the PBL and C group. While the 8 patients with distant metastasis (DM), not treated with TF-B1 (6 in the control and 2 in the PBL group), died due to progressive disease (average survival being 14.3 months), both patients with DM in the TF-B1 group had complete remission: one died of tuberculosis after surviving for 3.5 years and another is still alive, disease free, after 4.2 years. Although the series involved a small number of cases, the apparent effect of adjuvant immunotherapy in the form of TF with anti-EBV activity is of considerable interest.
We studied the clinical patterns and outcome of patients with FIGO (1985) Stage 1b cervical cancer. In particular, looking at the clinico-pathological characteristics in relation with disease recurrence.
BACKGROUND/AIMS: Recently an increasing number of young colorectal carcinoma patients attending the University Hospital, Kuala Lumpur were noted. This report represents our experience with patients suffering from colorectal cancer aged 30 years or younger.
MATERIALS AND METHODS: All cases of primary carcinoma of the colon and rectum admitted to the University Hospital during 1990 to 1994 were respectively reviewed. Inclusion criteria was that the patient had been 30 years or younger. Data collected included age, gender, race, site of tumour, presenting symptomatology, duration of symptoms, histology, extension of tumour and nodal involvement predisposing factors, treatment and follow-up.
RESULTS: 21 patients were included, 5 patients (24%) were 30 years old at diagnosis, 12 (57%) patients were aged 20-29 years and 4 patients (19%) were less than 20 years old. Thirteen of the 21 patients were female, and 8 (38%) were male, 6 of the 21 patients (29%) were Malaysian, while 1 was Indian (4%). The remainder were Chinese, 14 patients (67%). Six patients (29%) had their primary tumour located in the rectosigmoid, 4 (19%) in the left colon, 1 (4%) in the splenic flexure, 2 in the transverse colon (9%), 1 in the hepatic flexure (4%) and 5 in the caecum 24(%). One patient had a tumour too diffuse to detect a primary site at the time of operation. One patient with a family history of polyps had his entire colon removed at age 14. He had 3 separate foci of tumour. The 5-year survival rate was 25%.
DISCUSSION: Most patients with extensive disease and mucinous histology. Lesions are commonly seen beyond the transverse colon (57%). Presentation included most commonly abdominal pain, haematochezia or haemoccult positive stools.
CONCLUSION: The symptoms above should alert surgeons to colorectal carcinoma as a differential diagnosis
Over a 32-month period at the University Hospital, Kuala Lumpur, we were able to study the cytological appearance of metastatic nasopharyngeal carcinoma (NPC) in 17 cases. This comprised 14 males and three females of which 13 were Chinese, three were Malay, and one was Indian. Their ages ranged from 27 to 64 years. Histological correlation was available in all the patients in the form of nasopharyngeal biopsies, and they were classified as per the World Health Organization classification into types I, II, and III NPC. Smears from type II NPC showed good cellularity with mainly clustered and occasionally dissociated cells, with focal columnar appearance, vesicular nuclei, prominent nucleoli, and variable amounts of cytoplasm. Clusters of malignant cell closely associated with lymphoid cells and dissociation of malignant cells were more characteristic of type III NPC. FNA cytology is now applied extensively to the diagnosis of head and neck tumours and knowledge of the cytomorphology of NPC would greatly aid in pinpointing the primary of this tumour which is notorious for presenting with early nodal metastasis.
Expression of p53 protein was investigated by immunohistochemical techniques in archival cases of 134 primary breast carcinomas comprising 13 comedo ductal carcinoma in situ (DCIS), 105 invasive ductal carcinomas, 7 contained the comedo DCIS component adjacent to the invasive ductal component, 5 invasive lobular carcinomas, three colloid carcinomas and one medullary carcinoma. Overexpression of p53 gene product was studied to determine the association with clinico-pathological parameters and also its relationship to c-erbB2. Overexpression of p53 protein was observed in 31% (4/13) of comedo DCIS, 37% (39/105) of invasive ductal carcinomas, 57% (4/7) of carcinomas containing both the in situ and invasive lesions and all medullary carcinomas. A significant relationship (p < 0.05) was observed between strong immunoreactivity of p53 protein and absence of estrogen receptor, histological grade and c-erbB2 but not with lymph node metastases or age of patient. These observations suggest that overexpression of p53 protein may play an important role in tumor progression from noninvasive to invasive in some breast carcinomas and may have potential as an indicator for poorer prognosis.
Lymph node excision biopsy is commonly carried out for the investigation of lymphadenopathy. The objective of this study is to elucidate the pattern of nodal pathology seen in a private pathology practice. A total of 137 nodal biopsies for primary investigation of nodal enlargement were retrieved from the files in a private diagnostic pathology laboratory in the year 1997. Lymph nodes excised for cancer staging were excluded from this study. The histology was reviewed based on H&E stained sections, and with additional histochemical and immunoperoxidase stains when deemed necessary. Cases of malignant lymphomas were sub-classified with the aid of further immunophenotyping using a panel of monoclonal and polyclonal lymphoid antibodies. One case was excluded from this study due to inadequate tissue for further assessment. There were 58 males and 78 females, giving a ratio of 1:1.3 in the remaining 136 cases. They consisted of 13 Malays (M), 108 Chinese (C), 14 Indians (I) and 1 other ethnic group (O). The ratio of M:C:I:O was 1:8.3:1.1:0.1. The majority of the cases were in the age range of 20 to 50 years. The pathology consisted of 17 (12.5%) malignant lymphomas [6 Hodgkin's lymphoma, 11 non-Hodgkin's lymphoma], 35 (25.7%) metastatic carcinomas, 45 (33.1%) reactive hyperplasia, 19 (13.9%) tuberculosis, 11 (8.2%) Kikuchi's disease and 9 (6.6%) others (Castleman's disease 2, cat scratch disease 2, Kimura's disease 1, sarcoidosis 1, non-specific lymphadenitis 3). All categories of nodal disease showed approximately similar ratio of ethnic and gender distribution as above, except for Kikuchi's disease, for which 100% of the patients were female. The most common site of biopsy was from the head and neck region, particularly the cervical group of nodes. The most common nodal pathology seen in the private laboratory was reactive hyperplasia, followed by metastatic carcinoma. Malignant lymphoma constituted only 12.5% of the cases.
An 86-year-old man presented with a painless, pea-sized growth over the left angle of his jaw, which had been gradually enlarging over two years. A clinical diagnosis of pilar cyst was made. Histopathological examination of the mass revealed a malignant proliferating trichilemmal tumour. During follow-up 4 months later, a palpable small upper jugular lymph node was noted at the left side of the neck. Biopsy revealed a metastatic malignant trichilemmal tumour. This case illustrates a rare malignant tumour which is a challenge to clinical diagnosis.
Tumor cytogenetic analysis from 27 patients with breast cancer diagnosed at the Singapore General Hospital revealed complex karyotypic aberrations in 12 cases. The study group comprised 25 women and 2 men, ranging in age from 33 to 78 years (median 52 years). Ethnic distribution consisted of 22 Chinese, 3 Malaysian, and 2 Indian patients. Pathologic assessment disclosed 24 invasive ductal, 2 invasive mucinous, and 1 mixed invasive mucinous and ductal carcinomas. Histologic grading showed 3 grade 1, 10 grade 2, and 12 grade 3 tumors; 2 cancers were not graded, because they had been subjected to prior chemotherapy. Tumor sizes ranged from 1.5 to 10 cm (median 3 cm). Eleven cases were axillary node negative, whereas the remaining 16 node-positive cancers affected as many as 3 nodes in 8 cases and 4 or more nodes in another 8. Twenty cases demonstrated estrogen-receptor positivity, and 8 cases progesterone-receptor positivity. The spectrum of cytogenetic abnormalities involved chromosomes 1, 3, 6, 7, 8, 11, 16, and 17 and ranged from gains and deletions of both long and short arms, trisomy, monosomy, and other rearrangements. There was a trend toward the presence of karyotypic abnormalities in tumors of higher grade.
BACKGROUND: Teratoma of the thyroid in adults is extremely rare, and most are malignant. Only nine cases have been adequately documented in the English-language literature, and there are no reports detailing the fine needle aspiration (FNA) cytologic characteristics.
CASE: A 32-year-old female presented with a left-sided nodular thyroid mass with left cervical lymphadenopathy. FNA cytology of the thyroid and lymph nodes was done. The cytologic and immunocytochemical features were that of a small round cell tumor with neuroepithelial (NE) differentiation, metastasizing to the cervical nodes. Microscopic study of the thyroidectomy specimen showed a tumor showing an NE pattern with occasional islands of squamous and cuboidal epithelium, leading to a diagnosis of malignant teratoma.
CONCLUSION: Knowledge of FNA cytologic features of rare but highly malignant lesions like thyroid teratomas allow early recognition so that suitable and possibly aggressive treatment protocols can be adopted in the hope of prolonging survival.
This investigation was carried out to gain insight into the prevalence of pS2 expression in invasive ductal breast carcinoma in the Malaysian population and its correlation with oestrogen receptor (ER) protein expression and tumour aggressiveness. Seventy consecutive infiltrating ductal breast carcinomas treated with mastectomy and axillary lymph node clearance were investigated, using the standard avidin-biotin complex immunoperoxidase method with microwave antigen retrieval and commercial monoclonal antibodies (Dako), for expression of pS2 and human ER. This was correlated against histological grade (modified Bloom and Richardson) and the presence of axillary lymph node metastasis of these carcinomas. Four (5.7%) were grade 1, 40 (57.1%) grade 2 and 26 (37.1%) grade 3 tumours. A total of 45 (64%) showed histological evidence of axillary lymph node metastasis. Forty (57%) were ER-positive, while 31 (44%) were pS2-positive. There was a statistically significant correlation between pS2 and ER expressions (chi2-test with Yates correction: P<0.005). There was no correlation between pS2 expression and histological grade (P>0.1) and the presence of lymph node metastasis (P>0.1). Our findings support the views that pS2 may be a co-marker of endocrine responsiveness in invasive breast cancer and that it does not influence breast cancer biology in terms of potential for metastatic spread.
BACKGROUND: Carcinosarcoma (sarcomatoid carcinoma) is a rare tumor with a high predilection for the aerodigestive tract. Cytologic diagnosis of metastatic carcinosarcoma has been reported in very few cases.
CASE: An 84-year-old woman presented with a 2-cm-diameter, right cervical lymph node that was referred for fine needle aspiration cytology (FNAC). She had received radiotherapy for a palatal squamous cell carcinoma 2 years earlier. The FNAC smears had a sarcomatoid appearance. Repeat fine needle aspiration was performed, with cytologic and immunocytochemical staining. Careful consideration of the cytologic and immunophenotypic features led to an impression of carcinosarcoma. Histologic sections of the palatal biopsy that had been previously diagnosed as squamous cell carcinoma were reviewed, and a final diagnosis of carcinosarcoma was established.
CONCLUSION: Metastasis of rare lesions, such as carcinosarcoma may be confusing and difficult to diagnose on FNAC, especially when the cytologic sample shows a predominantly sarcomatoid component. The difficulty is compounded when the sarcomatoid component happens to have been overlooked on the initial histologic assessment. With representative cytologic sampling, immunocytochemical staining and review of the histologic material, the correct diagnosis was achieved in this case.