No abstract

Upper tract pressure flow studies in four clinically unobstructed ureters with double J stents in situ indicated that urinary flow occurred mainly around the stent and that there was significant vesicorenal pressure transmission. This study examined the dynamics of ureteric urinary flow and morphological effects consequent upon stenting a ureter in vivo. In a porcine model, ureteric intubation caused a rise in intrapelvic pressures, hydroureter, vesicorenal reflux and generalised thickening of the ureteric wall with characteristic histological changes in the urothelium. These findings suggest that double J stents may compromise urinary drainage when ureteric obstruction is not present, urging caution in their use in the damaged, unobstructed upper urinary tract.

The plasma cell variant of Castleman's disease (angiofollicular hyperplasia) is an uncommon and poorly understood lymphoproliferative disorder which may be associated with a wide variety of systemic features. The clinical, pathological, immunophenotypic and genotypic features of a series of five cases are presented. The clinical manifestations were variable but systemic features were present in four cases. Histologically, all five cases were similar. The characteristic follicle-like structures are composed of concentric rings of B-lymphocytes with a mantle zone phenotype, surrounding an inner core of dendritic reticulum cells. The central regions are composed of plump cells that express Factor VIII related antigen, stain with Ulex europaeus I and are associated with laminin immunoreactivity. Many of these cells stain with Ki67 indicating cellular proliferation. Between these 'follicles', plasma cells are present interspersed between high endothelial venules. Using immunohistochemical techniques two cases were polyclonal, whilst in two others unequivocal lambda/IgA restriction was present; in the other case an intermediate picture of lambda/IgA predominance was apparent. Genotypic studies in three cases indicated immunoglobulin gene rearrangements but germ line T-cell receptor genes. The significance of the apparent clonal proliferation of plasma cells is discussed and a unifying model of Castleman's disease is proposed.

SUMMARY Carcinoma of the larynx was treated by irradiation followed by laryngectomy in a man who had been receiving regular haemodialysis for two years. At least one, and probably two, parathyroid glands were removed at this time, and the remaining two were removed three years later for tertiary hyperparathyroidism. A portion of one gland was implanted into the forearm. The forearm implant was resected the following year for recurrent hypercalcaemia. Six years later, again with recurrent hypercalcaemia, he died of bronchopneumonia. Metastatic parathyroid carcinoma was found in the apex of the left lung. The source of this parathyroid tissue and the possible role of irradiation in the pathogenesis of parathyroid cancer in this patient were investigated.Parathyroid carcinoma may present diagnostic difficulty to both clinicians and histopathologists. We describe a man with tertiary hyperparathyroidism and systemic sarcoidosis who had previously received radiotherapy to the neck for laryngeal carcinoma and was receiving regular haemodialysis, in whom the diagnosis of parathyroid carcinoma was made only at necropsy. This case illustrates the diagnostic difficulties sometimes presented by the condition and raises the question of the possible role of radiation in inducing malignant change in parathyroid tissue already stimulated as a result of longstanding renal failure. CASE REPORTA 34 year old man began regular haemodialysis for chronic renal failure resulting from congenital hypoplasia of a solitary right kidney in 1972. Two years later a squamous carcinoma of the larynx was treated with radiotherapy (total dose 3250 cGy divided into six doses over 18 days: source, Co II, field 7 x 7 cm). His chest was screened during radiation. The carcinoma was not cured, and total laryngectomy, which included removal of the left lobe of the thyroid and at least one, but probably both, left parathyroids, was carried out four months later. Serum calcium concentration was 2-76 mmolI (11 mg/ 100 ml) (corrected to a serum albumin concentration of 41 g/l, as described by Tomlinson and Accepted for publication 17 June 1985 O'Riordan'; normal range 2-20-2-70 mmoVI (8.8-10-8 mg/100 ml)) and alkaline phosphatase 58 IU/I (normal range 25-100). Fig. 1 shows the serial calcium measurements recorded. Hilar lymphadenopathy and miliary mottling were noted on a chest radiograph.By 1977 he had developed symptomatic hypercalcaemia (serum calcium concentration 3 07 mmol/l (1 2 3 mg/ 100 ml) and alkaline phosphatase 169 IU/ 1). Serum parathyroid hormone concentration (N terminal assay2) was raised at 1-43 ,ug/l (normal <0-73,ug/l). Digital subperiosteal erosions were visible on radiography. Hydrocortisone 40 mg was given thrice daily for 30 days: no change in serum calcium concentration occurred, suggesting that hyperparathyroidism was the cause of the hypercalcaemia. At an exploration of the neck in July 1977 both right parathyroid glands were enlarged (see below) and were excised intact. About one third of the superior parathyroid (0.3 x 1 0 ...

Ten cases of malignant lymphoma of the colon and rectum complicating chronic inflammatory bowel disease are presented. Seven patients had chronic ulcerative colitis with a history varying from 6 to 20 years. There was extensive colitis in six of these patients and left-sided colitis in one. All seven lymphomas showed the pathological and immunohistological features of primary B-cell tumours of the gastrointestinal tract with a predominance of high-grade tumours. Three patients had Crohn's disease of the large intestine complicated by malignant lymphoma of the sigmoid colon or rectum. The history of Crohn's disease varied from 30 months to 20 years and in each case there was fissuring and fistulae. There was extensive anal involvement in two cases. Histologically the three lymphomas were heterogeneous: one was of 'granulomatous' T-cell type and the other two were markedly polymorphic and of equivocal phenotype. They were also characterized by numerous multinucleate tumour giant cells. Primary colorectal malignant lymphoma should be regarded as a rare, but significant, complication of ulcerative colitis. Immunosuppression may be an additional factor in the genesis of intestinal lymphoma in Crohn's disease. The prognosis appears to be dependent on factors already known to be of prognostic significance in primary gut lymphomas: a predominance of high-grade tumours suggests that the outlook is generally worse than that for idiopathic primary large intestinal lymphoma.