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BACKGROUND: The purpose of this study was to examine the association between Internet overuse and aggression. METHODS: A total of 2,336 (boys, 57.5%; girls, 42.5%) high school students in South Korea completed the structured questionnaire. The severity of Internet overuse was evaluated using Young's Internet Addiction Test. Aggression was measured using the Aggression Questionnaire, a modified hostility inventory by Buss and Perry. RESULTS: The proportions of boys who were classified as severe addicts and moderate addicts were 2.5% and 53.7%, respectively. For girls, the corresponding proportions were 1.9% and 38.9%, respectively. MANOVA results for univariate analysis showed that gender, duration of Internet use, most frequently used Internet activities, level of Internet addiction, smoking, alcohol, and caffeine were significantly associated with aggression scores. From multivariate analysis, it was found that smoking, alcohol, and level of Internet addiction were independently associated with all aggressive characteristics. Internet addiction scores were also significantly associated with all aggression scores from simple and multiple linear regression analyses (parameter estimate = 0.54∼0.58 for total aggression). Pearson correlation results showed that Internet addiction scores revealed the highest correlation coefficients with aggression among internet-related factors, age, and gender. Severe Internet-addicted boys showed higher scores in all aggression characteristics than severe Internet-addicted girls, even though it was not statistically significant in every characteristic. However, there was no gender effect on the association between internet overuse and aggression. CONCLUSION: This study shows that Internet overuse is strongly associated with aggression in adolescents. Language: en

Oncogenes, tumor suppressor genes, and growth factors are being explored as to their role in the initiation and progression of most neoplasms, but little information exists on the expression of oncoproteins or growth factors in adenocarcinoma of the duodenum or ampulla of Vater. This report covers expressions of p53, c-neu, TGF-alpha, CEA, and EMA in duodenal adenocarcinoma and ampullary adenocarcinoma, as well as correlations between expressions and tumor stage, histological grade and patient survival. The expression of p53, c-neu, TGF-alpha, CEA, and EMA has been studied in 15 duodenal adenocarcinomas and in eight ampullary adenocarcinomas by avidin-biotin-peroxidase complex indirect immunoperoxidase technique. The positive reaction for p53, c-neu, TGF-alpha, CEA, and EMA in duodenal adenocarcinoma was 20%, 60%, 60%, 73%, and 100%, respectively, and in ampullary adenocarcinoma, 13%, 100%, 50%, 63%, and 100%. Among the duodenal tumors, C-neu and p53 expression was noted more frequently in groups with high histological grades. Patients with c-neu positive duodenal adenocarcinoma had a shorter survival than the patients with c-neu negative duodenal adenocarcinoma (P < 0.01). C-neu product may serve as an unfavorable prognostic indicator in duodenal adenocarcinoma. No statistically significant correlation was found between the expressions of CEA, EMA, p53, and TGF-alpha and patient survival, tumor stage, or histological grade in either duodenal or ampullary adenocarcinomas.

Image analysis of tissue biopsies for determination of DNA content as an early marker of neoplasia is hampered by the complexity of corrections necessary to deal with nuclear truncation and overlap in thin sections. The use of confocal laser scanning microscopy (CLSM) for measurement of cellular DNA content on whole cells within thick tissue sections offers the advantage of preservation of cellular architecture, capacity for 3-dimensional analysis, and absence of sectioning artifacts. We have applied this technique to pararosaniline-Feulgen stained human cervical tissues graded from normal to cervical intraepithelial neoplasia (CIN) III. For the purpose of comparison, 15 μm sections were stained and mapped so that the same cell population could be analyzed by both integrated optical density and fluorescence intensity. Distribution of DNA content from normal cervical epithelial cells 2–3 layers out from the basal cell layer measured by both methodologies showed a stable G0/G1 population with no observable S-phase or G2 cells. Cells measured from areas of increasing CIN grade showed progressively higher DNA content values that were not observable in normal tissue. Although these data are preliminary they suggest that CLSM can be used to identify aneuploid states within defined structural areas of pre-invasive neoplasia. J. Cell. Biochem. 25S:49–56. © 1997 Wiley-Liss, Inc.

Two-dimensional gel electrophoresis was used to comprehensively scan the whole genome of 6 cervical intraepithelial neoplasia (CIN) lesions, 7 cervical squamous cell carcinomas, 1 cervical adenosquamous cell carcinoma, and 2 cervical adenocarcinomas for multiple genetic alterations, such as DNA amplification, chromosome deletion, loss of heterozygosity, and chromosome translocation, as compared with the paired normal tissues. DNA spot analysis of the genomic 2-dimensional gels was performed by a computer color overlay system and by spot recognition software allowing for objective spot comparison and quantitation. Nine spots were found to be amplified in the cervical carcinomas while two amplified spots were detected in the CIN III lesions. Fourteen DNA spots were either reduced in their intensity or absent in cervical carcinomas as compared to their normal paired tissues. Reduction of intensity in 6 spots was observed in the 5 CIN III lesions. These genetic alterations may represent changes in cancer genes that are associated with human cervical carcinogenesis. Further characterization of these alterations may be significant to the understanding of cervical tumorigenesis and to the development of biomarkers for clinical trials in cancer chemoprevention.

Background. The papillary cystic and solid tumor of the pancreas is rare. It occurs predominantly in young women, and most present a benign behavior. The pathogenesis of this tumor has attracted a number of investigations but remains unclear. Methods. We present three patients with this tumor and a review of 289 others from the world's literature, a total of 292 cases. On the basis of the analyses of the clinical and pathologic features from the reported cases, the pathogenesis of this unusual tumor has been further explored. Results. Ninety percent of the patients were female, with a mean age of 23.9 years. The tumors were usually quite large with a mean diameter of 10.3 cm. Ninety-two percent of these tumors were totally or partially cystic. Rupture of the capsule resulted in hemoperitoneum in eight cases, five of which were without any identifiable cause. Forty-three tumors (14.7%) have been recognized as malignant. The overall prognosis has been excellent and an aggressive approach to resection is indicated. Conclusions. The results of immunohistochemical staining and electromicroscopy were rather diverse, but most, including the current cases, support the hypothesis that the tumor originates from pleuripotential embryonic stem cells. Thus the term pancreatic embryonic tumors seems preferable to papillary cystic and solid tumor of the pancreas to delineate the origin of the tumor and to reflect some of its biologic characteristics.

Aim: The purpose of this study was to examine the association of Internet overuse with excessive daytime sleepiness (EDS). Methods: A total of 2336 high school students in South Korea (boys, 57.5%; girls, 42.5%) completed the structured questionnaire. The severity of Internet addiction was evaluated using Young's Internet addiction test. Results: The proportions of boys who were classified as Internet addicts and possible Internet addicts were 2.5% and 53.7%, respectively. For girls, the corresponding proportions were 1.9% and 38.9%, respectively. The prevalence of EDS was 11.2% (boys, 11.2%; girls, 11.1%). When Internet addicts were compared with non-addicts, they consisted of more boys, drank alcohol more, and considered their own health condition as poor. But smoking was not related with Internet addiction. The prevalence rate of EDS for Internet addicts was 37.7%, whereas that for possible Internet addicts and non-addicts was 13.9% and 7.4%, respectively. The prevalence of insomnia, witnessed snoring, apnea, teeth grinding, and nightmares was highest in Internet addicts, middle in possible addicts, and lowest in non-addicts. With adjustment for duration of Internet use, duration of sleep time, age, gender, smoking, taking painkillers due to headache, insomnia symptoms, witnessed apnea, and nightmares, the odds of EDS were 5.2-fold greater (95% confidence interval [CI]: 2.7–10.2) in Internet addicts and 1.9-fold greater (95%CI: 1.4–2.6) in possible Internet addicts compared to non-addicts. Conclusion: Internet addiction is strongly associated with EDS in adolescents. Clinicians should consider examining Internet addiction in adolescent cases of EDS.

Direct hepatic arterial infusion of floxuridine (FUDR) (Roche Laboratories, Division of Hoffman-LaRoche Inc., Nutley, NJ, U.S.A.) has been used extensively in the treatment of metastases of colorectal tumors to the liver. The effectiveness of infusion and tolerance of the chemotherapy has been improved utilizing a totally implantable infusion pump delivery system. However, unequal distribution of drug infusion may occur to different parts of the liver parenchyma as demonstrated by hepatic arterial infusion scintigraphy (HAPS). We present a case of such unequal perfusion in which fatty metamorphosis of the liver occurred in the overperfused liver segment after FUDR therapy. The liver parenchymal changes were followed by serial computerized tomography scans and proven by biopsy during a minilaparotomy. Serial HAPS examinations show redirection of subsequent infusion to the opposite liver lobe due to parenchymal damage and vascular sclerosis. The importance of uniform liver perfusion and a rare dose-related effect of FUDR on liver parenchyma are thereby demonstrated.

The diagnosis of a pancreatic carcinoid should be based on the measurement of serotonin in serum or its demonstration in the tumor and/or by the measurement of its derivative (5-HIAA) in urine. Carcinoid of the pancreas is a rare but definite entity; usually having metastasized by the time of diagnosis. The term "serotonin-producing tumor of the pancreas" has been suggested as an alternative designation for "pancreatic carcinoid."The literature on carcinoid tumors of the pancreas is confusing because much of it preceded the development of the more specific immunological, chemical and staining techniques currently available.43 case reports were collected from the world's literature, based on a demonstrable pancreatic neuroendocrine tumor plus a positive finding of at least one of the following without another dominant hormone being demonstrated: elevation of 5-Hydroxytryptamine (5-HT) (serotonin) in the serum or detected in tumor tissue, and/or elevation of 5-Hydroxyindole acetic acid (5-HIAA) in the urine. In addition to these two hormone-specific assays, information was collected on the silver-staining properties of the tumor; properties which have traditionally been associated with carcinoid tumors. Positive silver staining in tumor cells (argyrophilic and/or argentaffin reaction) is strongly indicative of the carcinoid tumor but the findings are less specific than the hormone assays and immunohistologic stains.In this review of 43 cases, including two current ones, the pancreatic carcinoid tumor has the following important features: 1. It is a rare tumor that is usually diagnosed late when the tumor is large and has metastasized. Thirty-eight (88.4%) have been malignant. They are, therefore, associated with a high incidence of the "carcinoid syndrome." 2. To date, prognosis in therapy is poor, based on delayed diagnosis, a resultant low incidence of resectability, and an uncertain duration of survival after resection. 3. Pancreatic carcinoid tumors remain difficult to differentiate from other endocrine tumors. The measurement of urinary 5-HIAA excretion or the demonstration of elevated serotonin level in the tumor or in serum is essential to its distinction. Silver staining of the tumor, although of historic importance, has been superceded by the hormone-specific studies. 4. To distinguish it from other endocrine tumors of the pancreas, the terms "pancreatic serotoninoma" or "serotonin-producing tumor of the pancreas" have been suggested as possible alternatives. Its growth characteristics may be related more to its cell of origin than to its extent of hormone secretion. Not all of the tumors result in recognizable hyperserotoninemia.

BACKGROUND Myelopathy in Klippel-Trenaunay-Weber syndrome is uncommon but has been reported secondary to spinal vascular malformations. REPORT A patient with Klippel-Trenaunay-Weber syndrome who presented with spinal cord compression from a spinal extradural mass lesion (angiomyolipoma) is described. DISCUSSION This association has not been reported previously but is consistent with the segmental vascular abnormalities observed in Klippel-Trenaunay-Weber syndrome.

For the purpose of determining the prognostic significance of HER2/neu oncogene in pancreatic and ampullary cancers, 21 pancreatic cancers of ductal origin and six cancers of the ampulla of Vater were studied immunohistochemically using the monoclonal antibody (MAb) CB11, specifically reactive with HER2/neu product. Staining of the epithelium of the normal duct and acini was negative or weakly positive. Moderately and strongly positive reactions indicated the overexpression of this gene, and were found in 10 of 21 (47.6%) pancreatic cancers of ductal origin and in 2 of 6 (33.3%) ampullary adenocarcinomas. Overexpression of HER2/neu was closely and inversely related to the survival of the patients with pancreatic cancer of ductal origin: 19.1 +/- 11.7 mo for those not overexpressing vs 7.3 +/- 3.8 mo for the overexpressors (p0.01). Among the pancreatic cancer group, 11 patients underwent cancer resection. The average survival for the 7 with nonoverexpressing cancer was 21.4 +/- 14.3 mo vs 10.5 +/- 3.6 mo for those with overexpressing tumor. Among those not undergoing resection, the average survival for the 4 with nonoverexpressing cancer was 15.0 +/- 3.8 mo as contrasted to 5.2 +/- 2.1 mo for the overexpressors (p0.01). Although the number of patients is small, these findings suggest that the overexpression of HER2/neu gene product may be frequently found in pancreatic cancer of ductal origin and may be one of the useful prognostic biomarkers for this cancer.

Background. Three cases of islet cell tumors of the pancreas with hypercalcemia were studied, and 16 similar cases have been found in a 25-year review of the English-language literature. The purpose of the study was to review the cause of the hypercalcemia and the clinical characteristics of the tumors. Methods. Tumor tissue retrieved from paraffin-embedded blocks was studied immunohistochemically for both parathyroid hormone (PTH) and PTH-related protein (PTHrP). PTH was measured in the serum in each patient and the serum PTHrP was measured by immunoassay in one patient. Results. One of our patients had a fatal serum calcium level of 26.4 mg/dl. PTHrP stains were positive in two of our tumors, and one patient had an elevated PTHrP serum level. Serum PTH levels were normal or low in each patient. All three tumors were malignant and extremely vascular. The total group of 19 patients have in common hypercalcemia associated with a normal or low serum PTH level. Although the cause of hypercalcemia has not been proved, the tumors apparently produce PTHrP, because seven of eight tumors stained positive for PTHrP and each of the four patients tested had an elevated PTHrP serum titer. The tumors are extremely vascular, are usually malignant (17 of 18), and become large, but they are compatible with a relatively long patient survival time. Conclusions. These neuroendocrine tumors associated with hypercalcemia share several characteristics, but a claim that they represent another type of “functioning islet cell tumor” should await a clearer delineation of the cause of the hypercalcemia.

There are three distinct pairs of major salivary glands: parotid, submandibular, and sublingual. Minor salivary glands are scattered in the lips, buccal mucosa, palate, and tongue. The major salivary glands are lobulated structures comprising lobules separated by fibrous connective tissue (Fig. 3.1 A).

Only neoplasms of the small intestine will be reviewed in this chapter. Approximately 5% of all gastrointestinal neoplasms arise in the small intestine. In descending order of frequency, the common benign neoplasms arising in the small intestine are leiomyoma, lipoma, adenoma, adenomatous polyp, angioma, and fibroma.1

Interstitial cystitis usually occurs in elderly women, who present with lower abdominal or perineal pain and urinary frequency. The lesion can involve anywhere in the bladder. Histologically, the lesion is a mucosal ulceration covered by fibrin and necrotic material. The underlying lamina propria and muscularis show edema, hemorrhage, granulation tissue, and a mononuclear cell infiltrate. Mast cells are frequently observed (Fig. 14.1).

Fifty-six lymph nodes excised from 11 patients with pancreatic adenocarcinoma were studied for evidence of metastasis by standard light microscopy and immunohistochemistry using an anticytokeratin monoclonal antibody. Eight of 56 nodes contained metastatic carcinoma as demonstrated by conventional techniques. By immunohistochemistry, positive-staining cells were easily identified. In 10 of 56 nodes, the positive staining was accompanied by cytologic atypia, changes consistent with malignancy. In seven additional nodes, positive-staining cells were present, but cytologic atypia was lacking. The use of immunohistochemistry facilitated recognition of malignant cells and raised questions that single-cell metastasis may be present. Positive staining for cytokeratin should prompt a close examination of cells to determine if morphologic features of malignancy are present.

Many widely different esophageal lesions are clinically manifested by dysphagia, heartburn, or hematemesis. Inflammatory disease and carcinoma of the esophagus will be reviewed.

Although the incidence of ovarian cancer is lower than that of cervical and endometrial cancers, its mortality rate is higher than that of cancers of the cervix and endometrium combined, indicating its lethal biologic behavior. The diagnostic yield by cervical cytology of ovarian and fallopian tube neoplasms is poor. Since most adnexal masses need to be resected or debulked for diagnosis or treatment, percutaneous fine needle aspiration (FNA) is not the primary diagnostic approach except for advanced neoplasms beyond exploration.

In this chapter neoplasms will be discussed, with particular emphasis on fine needle aspiration (FNA). Epidemiologic data indicate that incidence and mortality rates of carcinoma of the pancreas steadily increased until 1970, and has since then plateaued.1 The epidemiology of pancreatic cancer has been controversial. Most consistently documented etiologic factors are cigarette smoking, a high fat diet, diabetes mellitus, and an industrial carcinogenic exposure.2–5 Most pancreatic cancers are duct cell adenocarcinoma and 65% occur in the head of the pancreas, resulting in jaundice. The remaining cases occur in the body and tail and are at an advanced stage at the time of diagnosis.

This chapter focuses on bone lesions that clinically and radio-logically are suspicious of being neoplasm and that require biopsy for diagnosis. The pathologic diagnosis of bone lesions, either by open biopsy or fine needle aspiration (FNA), requires a thorough knowledge of clinical and radiological data. Lesions in bone suitable for diagnosis by FN A are metastatic neoplasms, which are common. Primary tumors of bone are comparatively rare, although in some circumstances FN A may provide the diagnosis, an advantage in terms of cost effectiveness and optimal management.

A number of infectious diseases involve the female genital tract, most of them being identified by culture. Some infectious diseases that may be diagnosed or at least suspected by cytology or histopathology will be reviewed.

Cytopathology and histopathology supplement and complement each other. Cytologic evaluation should identify altered cells and from these cells one may be able to recognize a disease process. In fact, from this evaluation one may be able to synthesize the histopathologic picture.

Cytologic examination of spontaneously occurring serous effusions is widely performed, especially with a view to detecting cancer cells in the fluid. The finding of cancer cells in such a fluid is of the gravest prognostic significance, denoting that the patient has cancer that is not only advanced but which is almost certainly incurable. Apart from cancer cells, examination of a serous fluid may reveal inflammatory changes, usually nonspecific, but which may be specific for certain diseases. Cytologic examination of serous fluids may also reveal infection with bacteria, fungi, parasites, or viruses. It may also reveal the presence of a fistulous connection with a serous cavity.

Since almost all space-occupying intracranial lesions are operated on for diagnosis, the least traumatic and most cost effective diagnostic procedure is highly desirable.

Enlargement of the thyroid gland (goiter) is a common clinical problem, with most goiters being of nodular pattern type. Radionuclide or ultrasound imaging of the thyroid are sufficiently accurate to eliminate the need for surgical exploration in most cases. Since the mid-1970s, fine needle aspiration (FNA) has become a highly cost-effective diagnostic test for thyroid nodules.1 Solitary nonfunctioning “cold” nodules raise a high suspicion of cancer.

During the reproductive years, the size and weight of a normal uterus vary according to parity. Nulliparous uteri weigh 40 to 100 g and measure about 8 cm in length, 5 cm in width at the fundus, and 2.5 cm in anteroposterior thickness. Muciparous uteri weigh up to 250 g and measure 12 cm × 5–7 cm × 3.5 cm.

Three patients with pancreatic adenocarcinoma are studied who had a prior history of malignant lymphoma. No common predisposing factors for the development of pancreatic adenocarcinoma were identified. We conclude that patients with malignant lymphoma who have new or persistent pancreatic masses must be evaluated for the possibility of a second primary neoplasm.

Transcutaneous fine-needle aspiration (FNA) biopsies were performed on 30 patients with space-occupying lesions in the pancreas. Patient selection for FNA was based on pancreatic lesions suspected of malignancy by clinical and/or radiologic imaging methods. Patients with obstructive jaundice were excluded because of the necessity of laparotomy to relieve biliary obstruction. Of these 30 cases, 15 cases were positive for malignant cells. Of these 15 positive cases, 11 were adenocarcinomas of duct cell origin, one cystadenocarcinoma, one islet cell tumor, one lymphoma, and one metastatic malignant melanoma. The remaining 15 cases, negative for malignant cells, were ultimately shown to have the following lesions: five adenocarcinomas of the pancreas, one metastatic carcinoma from the breast, and nine nonneoplastic disease. Overall diagnostic accuracy was 80%. The sensitivity, specificity, and predictivity for positive FNA biopsy of pancreatic malignancy were 79, 100, and 100%, respectively. Cytologic features with corresponding histologic types were presented. Immunocytochemical and electron microscopic studies were performed on some cases. Only one complication that was possibly related to FNA biopsy occurred. In conclusion, transcutaneous FNA biopsy of pancreatic malignancy is highly valuable in patient management.

DNA content measurements were performed by flow cytometry on eight ductal-type pancreatic adenocarcinomas. The majority of the neoplasms contained an aneuploid DNA content, with hyperdiploid DNA content being the most common abnormality. Two neoplasms had a diploid DNA content. These latter two patients are alive at 11 mo and 3 mo. The data suggest that a large percentage of pancreatic adenocarcinomas have an aneuploid DNA content. Further study is needed to evaluate the relationship between aneuploid DNA content and survival.

We retrospectively evaluated 664 specimens submitted for intraoperative frozen-section analysis for which cytologic imprints or smears were also prepared; 238 (36%) were malignant neoplasms. These preparations were retrospectively evaluated independently by three reviewers of varied experience in the detection of malignancy. The number of false-positive and false-negative results were recorded, and various assessment parameters (sensitivity, specificity, efficiency, and predictive value) were calculated. The imprint was of chief value as an adjunct to the frozen section, particularly in avoiding false-positive and, to a lesser extent, false-negative interpretations. Experience with the use of intraoperative cytology demonstrated the technique to be of value in providing abbreviated preparation time (3-5 min); supportive diagnostic information when frozen section was equivocal: diagnostic information when frozen-section evaluation could not be done (e.g., excessively small sample); contributory information for final diagnosis on difficult cases; and excellent teaching material for cytopathology.

An exhaustive discussion of the pathologic features of neoplasms of the alimentary tract would require a text twice the size of this entire volume. The organs of the alimentary tract are among the most frequent site of origin of malignancies in the human body (SILVERBERG 1985; ROSAI 1981). Thus, the diversity of malignant new growths found in this systemis great, and virtually every type of neoplasm that has been identified has been described as arising from the alimentary tract, or involving it secondarily. For this reason, we will discuss only the most important malignancies below, and the lesser ones will be mentioned only cursorily for completeness. While there may be reasons to disagree with any classification, we have generally organized the discussion to follow that of the Histological Classification of Tumours of the World Health Organization (OOTA and SOBIN 1977; MORSON and SOBIN 1976; GIBSON and SOBIN 1978). In keeping with the remainder of this volume, we have left out discussion of tumors of the mouth, oropharynx, and salivary glands, but have included discussion of important tumors of the liver and biliary tree and those of the exocrine and endocrine pancreas.

To improve our future care of the patient with exocrine pancreatic cancer by seeking, within the limitations of our present approaches, additional information on the growth and spread of the cancer and its influences on the patient.Consecutive autopsies of all patients with exocrine pancreatic cancer were reviewed retrospectively by two surgeons and three pathologists.Three teaching hospitals of the Medical College of Ohio, Toledo.One hundred fifty-four consecutive autopsies of patients with exocrine pancreatic cancer during the period between 1952 and 1992.Intrapancreatic metastases or multicentric cancers were found in 12 patients. In 32 patients, pancreatic cancer skipped the lymph nodes, primarily draining the respective areas of the pancreas to metastasize to the secondary chain of nodes. In 13 patients, pulmonary metastases occurred without hepatic metastasis. Intrapancreatic contiguous extension was identified in 34 patients. Carcinoma of the body and/or tail of the pancreas was characterized by transperitoneal as well as hematogenous dissemination to a greater extent than was carcinoma of the head of the pancreas. Seven of 11 small tumors (2 cm in diameter) were associated with remote metastases. Relatively severe chronic obstructive pancreatitis was found to have resulted from pancreatic carcinoma in 18 cases, whereas in seven patients, pancreatic carcinoma probably developed in preexisting chronic pancreatitis. Thromboembolic disease was found in 30 patients, more frequently in the patients with the mucin-producing tumors of the pancreatic body and tail. In 21 patients, the amount of ascites was not proportional to the severity of peritoneal dissemination, vessel invasion, or recognizable hepatic dysfunction. Thromboembolic disease, severe infection, stress ulcer, and acute hemorrhagic erosive gastroenteritis were frequent systemic complications contributing to death. Malnutrition in the form of cachexia was undoubtedly a major, even dominant, feature in many patients that could not be quantitated from this data.Metastasizing cells frequently bypass the initial filters in lymph nodes, liver, or lung to become established in secondary or tertiary sites. Intrapancreatic metastases or multicentric tumors also may develop more frequently than generally has been recognized. Small cancers (2 cm in diameter) are often associated at autopsy with remote metastases. These facts would appear to limit the usefulness of the current staging of resected cancers of the pancreas. Cancers of the body or tail are characterized by transperitoneal and hematogenous spread to a greater extent than are those of the head. Anatomical studies often do not explain the cause or the extent of ascites associated with pancreatic adenocarcinoma. As previously indicated, chronic pancreatitis appears to be further confirmed as a precursor of pancreatic cancer.

Objective: To delineate the frequency and significance of free cancer cells in the peritoneal cavity of patients with pancreatic exocrine adenocarcinoma. Design: Randomly selected patients with pancreatic cancer had peritoneal washings performed at the beginning and conclusion of laparotomy. Results of cytologic studies were correlated with the clinical findings, size, spread, and resectability of the tumor and with the survival time of the patient. All patients were followed up until the present or until their deaths. Setting: Tertiary care, referral hospitals in Toledo, Ohio. Patients: Only patients with biopsy-proven adenocarcinoma of the pancreas were included. Thirty-six patients, yielding 62 specimens for cytologic study, were included. Intervention: Peritoneal washings were performed at the beginning and completion of laparotomy. Each washing was evaluated independently by two skilled cytologists. If present, ascites was quantitated and studied cytologically. Biopsy specimens were obtained in each patient at the time of the study. Main Outcome Measurements: Presence or absence of malignant cells in peritoneal fluid; maximal diameter, grade, and spread of cancer; presence and volume of ascitic fluid; resectability of cancer; and length of survival of the patient. Result: Of the 36 patients studied, three had positive cytologic findings. All three had peritoneal carcinomatosis. Of 11 patients with ascites, only one had positive cytologic findings. Conclusions: Results of cytologic studies of peritoneal washings or of ascitic fluid are seldom positive with pancreatic exocrine carcinoma. When positive, they denote a very grave prognosis. (Arch Surg. 1994;129:639-642)

The cytologic features of familial hemophagocytic lymphohistiocytosis in two infant siblings were reviewed and compared to the histopathologic features in the same cases. The cytologic features of familial hemophagocytic lymphohistiocytosis in imprint smears from the spleen, lymph nodes, and liver were distinct, with proliferation of benign histiocytes engulfing erythrocytes and platelets. Hemophagocytic activity was more readily identifiable in imprint smears than in paraffin-embedded histologic sections. The differential diagnosis of histiocytic proliferative syndromes is also discussed.

Myelolipoma is a benign nonepithelial neoplasm composed of mature marrow elements and fat cells. This rare neoplasm is usually discovered by pathologists incidentally at autopsy, and, with rare exceptions, usually occurs in the adrenal glands. One of these exceptional anatomic sites is the mediastinum, and only three cases of primary mediastinal myelolipomas have been documented in the English-language literature (1-3). We are presenting a primary myelolipoma involving the posterior mediastinum that was discovered on routine chest radiographs and successfully resected. Computed tomography (CT) scan findings of this rare mediastinal tumor are also presented. This is the first case report in the English language of primary myelolipoma in the mediastinum that was detected clinically and resected successfully.

Data on squamous carcinoma of the cervix from a 20 year study period (1955 to 1974) in metropolitan Toledo revealed a 66% reduction of the average annual age-adjusted incidence rate and a 61% reduction in death rate of cervical squamous carcinoma when the first time period (1955 to 1958) was compared with the last time period (1971 to 1974). The decrease for both morbidity and mortality rates was more pronounced in women age 50 years and younger. The age-adjusted death rate during this study period revealed 15.5/100,000 for black women and 8.7/100,000 for white women. The reduction in death rate of 83% in black women is more prominent than 54.5% in white women. The decrease in both morbidity and mortality for cervical squamous carcinoma has a close relation to cytologic screening activity. The factors of age and race, probably related to socioeconomic status, are two known determinants of risk for cervical squamous carcinoma. Data for endometrial carcinoma during this study period revealed 15.5/100,000 women in the average age-adjusted incidence and an increase of 13.8% in average yearly rates when the first time period (1955 to 1958) were compared with the last time period (1971 to 1974). The peak age was 60 to 64 years old in the first time period and shifted to 70 to 74 years old in the last time period. The trend in metropolitan Toledo is comparable to that of Louisville, Kentucky. The mass cytologic screening program which contributed to a remarkable reduction in morbidity and mortality for the cervical squamous carcinoma, did not have any beneficial effect on endometrial carcinoma. Cancer 42:2439–2449, 1978.

Pulmonary carcinoid tumors presenting as peripheral or coin lesions are rare and radiologically may resemble other primary or metastatic neoplasms in the lung. This study consisted of the cytologic evaluation of fine-needle aspirates from five peripheral carcinoid tumors of the lung with particular reference to the differences between the cytologic manifestations of this neoplasm and of small-cell carcinoma and well-differentiated adenocarcinoma. Aspirates of typical carcinoid tumors are characterized by (1) isolated cells and loose aggregates of cells; (2) spindle- and oval-shaped cells of uniform size with scanty, pale eosinophilic cytoplasm; and (3) nuclei with evenly dispersed finely granular chromatin and usually prominent single micronucleoli with occasional macronucleoli. In contrast, the cells of small-cell carcinoma are pleomorphic and arranged in noncohesive loose aggregates, their cytoplasm is scanty, and they show nuclear molding. Their nuclei are hyperchromatic with fine to coarsely granular chromatin. The cells of well-differentiated adenocarcinoma are arranged in three-dimensional clusters or loose aggregates of relatively uniform cells with a columnar configuration. The nuclei are uniformly round and hyperchromatic with finely granular chromatin. Macronucleoli are usually prominent. This study demonstrates that cytologic analysis of fine-needle aspirates can play a significant role in the evaluation and management of peripheral lung tumors. Diagn Cytopathol 1986;2:343–346.

An 81-year-old woman was hospitalized because of dyspnea and edema. At age 59 years (in 1961), she underwent pericardial abrasion for relief of chest pain. When the surgeon passed a ligature around the coronary sinus, this structure was torn and temporary bleeding occurred. The coronary sinus was narrowed to 3 mm in diameter. Powdered asbestos was sprinkled over the epicardium. Fat was brought into contact with the heart as a graft. The patient recovered from the operation and had relief of chest pain. Ten years later, at age 69 years, she noted exertional dyspnea and edema. By age 80 she was completely incapacitated because of dyspnea and edema. At hospital admission, at age 81 years, she was dyspneic, cyanotic and had anasarca. The precordium was quiet. Marked jugular venous distention and Kussmaul's sign were present. The first heart sound varied in intensity (due to atrial fibrillation). There was a grade 3/6 holosystolic murmur and an $3 gallop at the cardiac apex. There were no rubs. At cardiac catheterization, she had characteristic features of pericardial constriction. Right atrial mean and right ventricular diastolic pressures were 24 mm Hg. A V wave of 51 mm Hg was present in the pulmonary-capillary wedge tracing. Left ventriculography revealed calcium in the mitral anulus, mild hypokinesia of the left ventricle, mitral valve

A case of primary pineal germinoma with widespread extracranial metastasis in a 36-year-old man is presented. A clinical work-up revealed bilateral pleural effusions, ascites, and metastatic lesions involving the lung. Cytology and electron microscopic study of the pleural and ascitic fluid and of the fine needle aspiration material revealed metastatic germinoma. Although the cytologic features were not distinct from those of anaplastic carcinoma, they were distinguishable from those of glial neoplasms, lymphoma, and sarcoma. The computed tomography findings, elevated human chorionic gonadotropin level, and electron microscopic features contributed significantly to the diagnosis of extracranial metastasis of the pineal germinoma. Metastatic spread most likely occurred via the ventriculoperitoneal shunt.

A 37-year-old woman with documented primary aldosteronism died of a cerebral hemorrhage. At postmortem examination she was found to have bilateral, adrenal hyperplasia and nodular basophilic hyperplasia of the anterior and intermediate lobe of the pituitary. Based on these findings and experimental evidence suggesting the existence of a pituitary factor that stimulates aldosterone secretion, we postulate that idiopathic aldosteronism is caused by an abnormality of the intermediate lobe of the pituitary gland leading to overproduction of non-adrenocorticotropic hormone peptides derived from pro-opiomelanocortin that increase aldosterone production and cause hyperplasia of the adrenal glands. ( JAMA 1984;251:2555-2558)

A case of lung carcinoma extending into left atrium through a pulmonary vein and mimicking left atrial myxoma is presented. The localized enlargement of a pulmonary vein is seen as a possible CT sign of pulmonary vein tumor thrombosis. Computed tomography (CT) and echocardiography are complementary in the correct diagnosis of this condition.

Two patients with essential cryoglobulinemia, an immune complex disease, developed an intense, chronic, monoarticular knee synovitis. In each patient, synovial fluid findings (high white count and left shift) suggested a pyrogenic or crystalline etiology. A synovectomy was eventually performed in both patients to control their synovitis, which was refractory to medical management. The histologic and immunofluorescent synovial changes in the arthropathy of essential cryoglobulinemia, which was not previously been characterized, are marked by diffuse eosinophilic infiltration and edema. In both patients, synovial specimens suggested an immune complex process; immunofluorescent studies revealed immunoglobulin IgG in one patient, and IgG, IgA, and immune complexes (C1q) deposits in the other patients. Both patients, subsequently treated with D-penicillamine and chloroquine, or chloroquine alone, were followed for two years and had a slow but definite fall in their cryoglobulin levels, despite the persistence of monoarticular synovitis in one patient.

The clinical and autopsy findings in a case of histologically benign teratoma of the mediastinum in a 19-year-old man with Klinefelter's syndrome are presented. A rough statistical analysis based on a review of the literature revealed that the incidence rate of Klinefelter's syndrome among the patients with mediastinal germ cell tumor is 30 to 40 times that of Klinefelter's syndrome among the general control population. The pathogenesis of this neoplasm appears to be related to the genetic abnormality in Klinefelter's syndrome, and this seems to predispose to the development of extragonadal mediastinal germ cell neoplasms.

To the Editor.— Kaposi's sarcoma of the gastrointestinal tract in patients with acquired immunodeficiency syndrome (AIDS) is usually asymptomatic. 1 In contrast, we describe two patients with unusual clinical manifestations of this tumor. Top, Portion of intestinal perforation in right upper corner and focus of Kaposi's sarcoma in center (hematoxylin-eosin, ×30). Bottom, Irregular slitlike vascular channels separated by fibroblastic stroma characteristic of Kaposi's sarcoma (hematoxylin-eosin, ×320). Report of Cases.—Case 1.— A 34-year-old homosexual man presented with AIDS manifested by oral and cutaneous Kaposi's sarcoma. He was treated initially with interleukin-2 with progression of his skin lesions. Bronchoscopy performed eight months after presentation revealed pulmonary involvement with Kaposi's sarcoma. Therapy with bleomycin sulfate and vincristine sulfate was initiated with partial response. Five months after initiation of chemotherapy, the patient entered the hospital with sepsis secondary to ileal perforation. He underwent emergency laparotomy and small-bowel resection. The resected segment of small intestine