Biomedical subjects
R E Fechner
Publications and source records attributed to R E Fechner.
Spindle cell carcinoma of the larynx.
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Chondrometaplasia of the larynx.
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Radiotherapeutic alternatives to standard management of adenocarcinoma of the endometrium.
Primary radiotherapy as an alternative management for adenocarcinoma of the endometrium was chosen for 117 patients treated at the University of Michigan Medical Center and University of Virginia Medical Center. Cases were selected for radiation because of contraindications to surgery (52.2%) or by protocol for disease outside the endometrium (47.8%). An overall 5-year actuarial survival rate of 49.6% was attained for all stages, with 55% 5-year survival for disease limited to the uterus or cervix. Stage and grade were the most significant risk factors. The addition of external-beam irradiation did not improve local failure rates or survival. Heyman's uterine packing technique was slightly more successful than uterine "line sources" in controlling local disease (P = 0.08). Treatment-related mortality (0.8%) and morbidity (6.8%) were minimal. Surgery, whenever possible, remains the "best standard therapy" but the radiotherapeutic alternative is of significant benefit for those deemed nonsurgical candidates.
Pilomatricoma-like changes in the epidermal cysts of Gardner's syndrome.
We studied fifty-seven cutaneous cysts from seven members of a kindred with Gardner's syndrome. All of the cysts had large areas indistinguishable from ordinary epidermal cysts. In addition, twenty-one (37%) contained columns of shadow cells, similar to those of pilomatricoma, that projected into the lumina. The cells at the point of attachment of the columns to the cyst lining were often indistinguishable from the hair matrix-like, basophilic cells of pilomatricoma. In twenty-nine cysts (51%), masses of shadow cells were free within lumina, unattached to the epithelial lining. Deposits of shadow cells, associated with a giant cell reaction and often calcified, were present in the pericystic connective tissue of twenty cysts (35%). Thirty-six of the fifty-seven cysts (63%) had one or more of the foregoing features, and the changes were observed in cysts from six of the seven patients studied. Our observations and similar findings recorded in the literature suggest that pilomatricoma-like changes may be a characteristic of the epidermal cysts of an undetermined number of kindreds with Gardner's syndrome.
Epithelial polyps of the prostatic urethra. A light-microscopic and immunohistochemical study.
Epithelial polyps of the prostatic urethra are an uncommon and histologically heterogeneous group of lesions. We review the clinical and histologic features of a series of seven such polyps. Six were composed of prostatic-type epithelium. In five instances the epithelium was entirely histologically identical to that of normal prostate. One case contained foci of stratified, mitotically active cells, suggesting adenomatous transformation. All six stained intensely for both prostatic acid phosphatase and prostatic specific antigen. The seventh polyp was cytologically different. It was composed of flattened to cuboidal cells that did not stain for either antigen. All patients were treated by transurethral excision, and none of the six with follow-up developed a recurrence.
Hepatopedal flow restoration in patients intolerant of total portal diversion.
This report describes an experience with operative restoration of hepatopedal portal blood flow in five patients intolerant of total splanchnic shunting. Portal flow was reestablished by takedown of the total shunt and construction of a selective, distal splenorenal shunt, or by isolation and arterialization of the hepatic limb of the shunted portal vein. In two patients, shunt revision was undertaken electively for chronic encephalopathy, which had been unresponsive to low-protein diet, intestinal antibiosis and oral lactulose. Eighteen and 48 months after operation, both patients have had no encephalopathy on an unrestricted protein intake, and work actively as homemakers. Needle liver biopsies showed enhanced mitotic activity in the early postoperative period, suggesting hepatocyte regeneration. In three patients, shunt conversion or arterialization was undertaken in desperate circumstances, characterized by liver failure (bilirubin greater than 10 mg/dl, albumin less than 2.5 g/dl, prothrombin time greater than 16 sec), coma, and respirator dependency. Although the patients showed immediate, marked improvement in mentation, all three died of intraabdominal hemorrhage in the first few postoperative days, in spite of maximum blood product support. Two conclusions can be drawn from this limited experience: (1) at a time of election, restoration of hepatopedal portal flow can be accomplished with considerable benefit in patients with side-to-side portacaval or hemodynamically equivalent shunts, and (2) similar procedures in patients with fulminant liver failure are unlikely to succeed.
Giant-cell reparative granuloma of the hands and feet.
Giant-cell reparative granuloma occurring outside the jaw is unusual, being seen predominantly in the tubular bones of the hands and feet. It produces a lucent, expansile lesion in the metacarpals, metatarsals, or phalanges. The authors describe the radiographic and pathological features of 5 cases and review the literature.
Adenoma of the middle ear.
Benign adenoma of the middle ear emerged as a distinct entity following a review of 20 cases as reported from the Armed Forces Institute of Pathology in 1976. We report 4 additional cases and note that the pathologic diagnosis is not so clear cut. Benign primary adenoma may be confused with adenocarcinoma, ceruminoma, and glomus tumor. The otologic surgeon must take a hard look at the clinical signs and symptoms to determine if they are compatible with the diagnosis of primary middle ear adenoma. While middle ear adenoma has recently been implicated as a cause of facial paralysis (including a case herein), bone destruction should never be found in concert with this neoplasm.
Pathologic quiz case 1. Fibrous dysplasia of bone and ossifying fibroma.
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Carcinoma of the gallbladder and cholecystostomy.
Seven cases of carcinoma of the gallbladder after cholecystostomy were seen at the University of Virginia Medical Center, Charlottesville, between 1926 and 1979. These cases represented 6.7% of all cases of carcinoma of the gallbladder treated at that institution during that period. The interval between cholecystostomy and diagnosis of carcinoma ranged from three months to 40 years. Five patients had "gallbladder" symptoms intermittently during the interval, and two patients did not. One of the patients had a confirmed calcified or porcelain gallbladder five years before the development of carcinoma. At operation, none was found to have localized disease, and most had extensive metastatic disease. There were no survivors. Primary carcinoma of the gallbladder is an aggressive disease and difficult to diagnose. Few specific characteristics are available to the clinician and surgeon to detect this disease in its early stages. Patients who undergo cholecystostomy or have undergone cholecystostomy, with or without symptoms, should have elective cholecystectomy if they are acceptable operative risks. Such a policy would prevent a small, but substantial, number of cases of carcinoma of the gallbladder.
A solitary juvenile polyp with hyperplastic and adenomatous glands.
This report describes a 21-year-old man with chronic rectal bleeding, who was found to have a solitary juvenile polyp containing hyperplastic and adenomatous glands. This admixture of glandular elements has not been clearly recognized previously. The significance of this finding is uncertain at this time. Since adenomatous polyps are considered premalignant lesions, and juvenile polyps have been associated with colon cancer, we recommend that juvenile polyps with adenomatous glands also be regarded as premalignant lesions.
Necrotizing sialometaplasia of the larynx secondary to atheromatous embolization.
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Unusual adenomatous polyps in juvenile polyposis coli.
A 14-year-old boy had an ileocolectomy for juvenile polyposis coli. Twenty-five years later he developed peculiar adenomatous polyps in his rectum. The polyps had irregularly shaped glands lined by cells with stratified, atypical nuclei. Some glands were distended with mucus, but otherwise the polyps did not resemble juvenile polyps. Two other types of polyps associated with juvenile polyposis coli and often designated as adenomatous polyps are illustrated. A solitary juvenile polyp with foci of hyperplastic and adenomatous change is also depicted, and the association of juvenile polyps with colonic neoplasia is reviewed.
Aggressive sinonasal lesion resembling normal intestinal mucosa.
A 30-year-old male chemical plant worker had an unusual sinonasal lesion characterized by well-formed villi lined by resorptive, Paneth, argentaffin and goblet cells. The villi were underlain by smooth muscle resembling muscularis mucosa. In other areas, the pattern was more disorganized. Using criteria applied to analogous intestinal lesions, these foci were adenomatous, but cytologically benign. Nonetheless, both the villi and the adenomatous component invaded bone, and recurred multiple times. The cytologic blandness and well-organized architecture of this lesion are deceptive; they belie a lesion that is highly aggressive locally. Our patient died of disease 8 years after initial diagnosis.
Is carcinoma of the gallbladder a curable lesion?
Carcinoma of the gallbladder is an uncommon, but not rare tumor that is associated with a 5% five-year survival rate after resection and this rate has not appreciably improved over the last decades in most series. Nevin et al.(20) however have reported that favorably staged gallbladder cancers (according to histologic grade and depth of invasion) have a relatively good prognosis. They quoted an overall five-year survival of 21% in 66 patients. Most of the surviving patients (11) were in the favorably staged category: Stage I (intramucosal cancer) and Stage II (invasion of mucosa and muscularis). The remaining few were in Stage III (invasion of all layers), Stage IV (cystic node metastases), or Stage V (extension of metastases to the liver or distant sites). Our data has been analyzed to determine whether microstaging of the primary cancer will select out a subgroup with a favorable prognosis, and whether there are survival benefits according to the type of surgical resection. A clinical and pathologic review was done of 100 patients treated at the University of Virginia Hospital from 1930 to 1978. There were 77 women and 23 men, with an average age of 65 years (range 21-89). Gallstones were described in 78% of the patients. Surgical procedures included cholecystectomy alone (23 patients), cholecystectomy with biliary drainage (17 patients), cholecystectomy and resection of the hepatic bed (8 patients), and exploration with biopsy or bypass (44 patients). Autopsy only was done in eight patients. There were only three long-term survivors (6 years, 11 years, and 24 years). Median survival was six months with cholecystectomy alone, five months with cholecystectomy and bypass, 14 months after partial liver resection, and 2.0 months after laparotomy/bypass/biopsy. The five-year survival rate was 5% after cholecystectomy alone or with bypass, and 13% (1/8) after cholecystectomy and partial liver resection (p = 0.07). Microstaging of the primary cancers showed no prognostically favorable subgroup. Of 46 patients with microstaged lesions, only 13% were in the very favorable Stage I and II groups (only one of six survived), 46% were Stage III (1/21 survived), and the remaining 41% were in the highly unfavorable Stage IV and V groups (1/19 survived). Most patients showed progression of disease either primarily or secondarily that was locoregional (liver and nodes). Although longterm survival may accompany cholecystectomy alone for a favorable early-staged cancer, this is still uncommon. There may be theoretical, although not proven, merit for resection of the hepatic bed and regional node dissection in the selected patient, possibly complimented by adjuvant therapy. Future advances in chemotherapy and radiation will be needed to augment the current poor cure rate of this disease.
Expansile subchondral bone cyst.
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