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A 26-year-old man with lymphomatoid granulomatosis (LYG) was found at postmortem examination to have an immunoblastic sarcoma involving the central nervous system. Residual evidence of LYG was present only in the lungs at autopsy. Studies for intracellular immunoglobulin utilizing the immunoperoxidase technique showed a marked polyclonal reaction in sections of lymph nodes and occasional cells in the cellular central nervous system tumor that stained for intracellular immunoglobulins (IgG, IgM and both kappa and lambda). This case may represent another example of immunoblastic sarcoma occurring in the presence of an abnormal immune state or proliferation.

Fistulas between the tracheobronchial tree and the esophagus (TE fistula) caused by tuberculosis are rare; usually they are associated with readily apparent pulmonary and/or mediastinal infection, and require surgical management. The patient we describe presented with a TE fistula as the only manifestation of active tuberculosis. This case represents the first report of successful nonsurgical treatment of tuberculous TE fistulas.

To investigate the nature of non-endemic Burkitt's lymphoma, we examined neoplastic cells from eight American patients for receptors for sheep erythrocytes (E), complement (EAC), and Fc fragment of lgG (igGEA), and for surface immunoglobulins (Slg) and hydrolytic enzymes. In addition, we reviewed 47 biopsies and 17 autopsies from American patients to ascertain patterns of involvement by tumor in lymph nodes, spleens and Peyer's patches. Neoplastic cells in all cases studies bore monoclonal surface immunoglobulins of the igM class. Receptors for EAC and igGEA were identified on a minority of the cells. Little or no hydrolytic enzyme activity was demonstrable. These results indicate that, like Burkitt's lymphoma in Africans, this histologically identical tumor in American patients consists of B lymphocytes. In 10 biopsies and two autopsies, germinal centers were selectively involved by tumor, suggesting that these neoplastic cells may be related to some B lymphocytes of normal germinal centers.

A 72-year-old man who had been taking rifampin daily for several months was concurrently administered warfarin daily for ten weeks. During this period, the prothrombin time (PT) rose remarkably little as the dosage of warfarin was increased. With difficulty, satisfactory anticoagulation was achieved by giving warfarin 20 mg daily. On discontinuation of rifampin therapy, the PT increased significantly, and subsequent stabilization of the PT within therapeutic range required treatment with warfarin 7.5 mg daily.

Metastatic carcinoma to the testis is unusual. There are only seven previously reported cases in which a testicular mass was the first clinical manifestation of an underlying malignancy. The authors review 127 cases in which the testis was involved by metastatic carcinoma, and describe an additional two patients in whom a malignant testicular mass was the presenting sign of an underlying nontesticular carcinoma. The tumors most commonly reported to metastasize to the testis are: prostate (45 cases), lung (25 cases), melanoma (12 cases), colon (11 cases), kidney (10 cases), stomach (6 cases), and pancreas (5 cases). Neuroblastoma, retinoblastoma, carcinoid tumor, and cancers of the bile duct, ureter, bladder, salivary gland, and thyroid have also involved the testis secondarily. Nineteen patients (15%) had bilateral testicular metastases. Patients with secondary testicular neoplasms were older in general than those with germ cell tumors (mean, 55 years; median, 57 years). Histologically, the presence of extensive lymphatic and vascular invasion and an interstitial pattern, in which the seminiferous tubules are spared, is suggestive of a metastasis. In four of the nine cases (44%) in which testicular enlargement was the first manifestation of an underlying carcinoma the correct pathologic diagnosis was initially missed. Serum alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG) are occasionally elevated in patients with nontesticular primary tumors, but markedly elevated levels in young patients suggest a nonseminomatous germ cell tumor, as does positive immunoperoxidase staining for AFP and HCG.

Spleens from 42 patients with polycythemia vera were studied with immunohistologic technics to assess the degree of hematopoietic cellularity in an attempt to clarify the pathogenesis of the splenomegaly characteristic of this disorder. The 22 spleens obtained in the erythrocytotic phase showed striking congestion with mature erythrocytes but no significant extramedullary hematopoiesis. However, the 20 spleens obtained in the spent phase showed prominent trilinear extramedullary hematopoiesis. Increasing splenomegaly with extramedullary hematopoiesis correlated with the development of increased medullary reticulin and peripheral blood leukoerythroblastosis. Splenic myeloid metaplasia is not a feature of uncomplicated polycythemia vera, and its presence indicates progression to the spent phase, or postpolycythemic myeloid metaplasia. The authors' findings indicate that the presence of hematopoietic precursors in the spleen in the spent phase of polycythemia vera and in agnogenic myeloid metaplasia is a result of their filtration from the peripheral blood.

Eight patients with intraocular lymphoma were studied; all were middle-aged or elderly, usually presenting with a unilateral visual deficit. All patients also had an extraocular lymphoma with either systemic (2) or isolated central nervous system (CNS) involvement (6). When ocular symptoms preceded CNS symptoms, they presented from 11 months to 10 years earlier. Intraocular lymphoma tended to affect the eye ipsilateral to the CNS tumor either exclusively or initially, and to the greatest degree histologically. Histologic examination of intervening optic pathways revealed extension of intraocular tumor across the optic nerve into orbital leptomeninges in 3 cases. Corresponding CNS tumors showed prominent leptomeningeal involvement. All intraocular and extraocular tumors showed diffuse growth patterns with histiocytic (large cell), poorly differentiated lymphocytic or mixed lymphocytic-histiocytic subtypes. CNS tumors were detected only after onset of neurologic symptoms, and were almost always fatal, although CNS irradiation prolonged survival for years in some cases. Our data suggest that the peculiar link between intraocular and CNS lymphomas may reflect both multicentric and metastatic disease processes. The prompt recognition of intraocular lymphomas as a harbinger of extraocular tumor may prove valuable in earlier recognition and treatment of the disease.