Continuing its commitment to patient care quality, the American Nurses Association appointed a committee in 1997 to expand nursing-sensitive quality indicators beyond acute care. This article is the ...final report describing the processes used to identify a core set of community-based quality indicators relevant to nurses across the care continuum and identifies next steps. The indicator categories are (a) change in symptom severity, (b) strength of the therapeutic alliance, (c) utilization of services, (d) client satisfaction, (e) risk reduction, (f) increase in protective factors, and (g) level of function/functional status. Potential indicators requiring further research and development are also described.
We prospectively studied the utility of fine needle aspiration (FNA) to diagnose non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD) in patients with human immunodeficiency virus (HIV) infection ...and lymphadenopathy. Twenty-one patients with a clinical evidence of lymphoma underwent 24 FNA and site-specific tissue biopsies. Twenty-two of the 24 biopsy results were consistent with a malignant lymphoproliferative neoplasm: NHL (19 cases), HD (two cases), and T-cell lymphoma (one case). Two biopsies showed reactive lymphoid hyperplasia consistent with a clinical diagnosis of persistent generalized lymphadenopathy. There was an 87% correlation (21 of 24) between FNA and biopsy diagnoses. Eighteen of the 19 biopsy-confirmed NHL cases were diagnosed with FNA. Both cases of HD and the one T-cell lymphoma were also diagnosed with aspirate material. In conclusion, the FNA in HIV-infected individuals with suspected malignant lymphadenopathy is highly sensitive (95%). The FNA, when used in conjunction with the clinical appearance, is a useful tool in the management of HIV infection and lymphadenopathy.
The pathologic, immunologic, and clinical features of 25 cases of interfollicular (IF) small lymphocytic lymphoma (SLL) characterized by pseudofollicles (PFs) in the IF region of the lymph nodes and ...by multiple reactive follicles (RFs) were examined. IFSLL is characterized morphologically by variable numbers and sizes of prolymphocytes (nuclei showing one centrally located prominent nucleolus) in the PFs and by small round lymphocytes in the IF region. The lymph nodes in our cases had multiple RFs (100%) and patent or partially patent sinuses (72%), with moderate expansion of the IF region (48%) and typically absent or minimal perinodal infiltration (48%). In 48% of the cases, the PFs surrounded the RFs, producing a pseudo-mantle zone pattern. Immunologic study showed the medium and large prolymphocytes to be mildly LN 1- and LN 2-positive, whereas the small prolymphocytes and lymphocytes were LN 1-negative and moderately LN 2-positive. Few cells in the IF region stained with UCHL-1 antibody. These data indicate the marked preponderance of the non-follicular center cell type of B cells in the IF areas. In all 11 cases tested, a monoclonal B cell population was found. The mean age of the patients was 62 years, with a male to female ratio of 1:1.7. B symptoms were present in 20% of the patients. Nineteen percent of the patients had clinical stage I or II disease, whereas 81% had stage IV disease. The median absolute lymphocyte count was 3,239 X 10(6), with a range of 767 to 13,770 X 10(6) cells/L. In six cases, the lymphocyte count was above 4,000 X 10(6), and in no case was it more than 15,000 X 10(6). It was difficult to distinguish these cases of IFSLL from lymphadenitis and other non-Hodgkin's lymphomas because it was difficult to recognize the subtle PF pattern in the presence of a partially preserved lymph node architecture. Because of the partially retained lymph node architecture and the expansion of the IF region by PFs, this lymphoma is thought to originate from the IF small B lymphocytes, which displayed an in situ growth pattern. Moreover, because of the predominant disease in the lymph nodes and the similarity of features in PFs and follicles, we conclude that IFSLL is a disease that is primary to the lymph nodes. IFSLL should be distinguished from mantle zone lymphoma and chronic lymphocytic leukemia.
Small‐cell osteosarcoma Martin, Sue Ellen; Dwyer, Andrew; Kissane, John M. ...
Cancer,
1 September 1982, Volume:
50, Issue:
5
Journal Article
Peer reviewed
Six cases of small‐cell osteosarcoma, a tumor that resembles Ewing's sarcoma but produces osteoid matrix, are presented. The patients were young (6–31 years of age) and presented with symptoms of ...pain and/or swelling of 1–10 months duration. The lesions demonstrated a wide variation in radiographic appearance. Histologically, the tumors were composed of small, round cells that produced variable amounts of osteoid. In three cases chondroid was also present. Two of the six patients were treated with surgery alone and four received radiation and either single‐ or multiple‐agent adjuvant chemotherapy. The two patients who received radiation and multiple‐agent adjuvant chemotherapy have no evidence of disease at four and ten years after diagnosis. Recognition of this tumor as distinct from Ewing's sarcoma and from other forms of osteosarcoma is important to determine the incidence, clinical features, and optimal therapy for this tumor.
The immunoreactivity of alcohol-fixed cell blocks from 15 fine-needle aspiration (FNA) specimens of malignant melanoma was investigated using monoclonal antibodies to keratin and vimentin ...intermediate filaments, melanoma cytoplasmic antigen (HMB-45), and S-100, as well as polyclonal antibodies to S-100. The results were compared with the immunoprofiles obtained using formalin-fixed surgical specimens from 10 of the same patients. In all cases, immunostaining for keratin was negative and immunostaining for vimentin was positive. Immunostaining for HMB-45 was positive in 13/15 aspirates and in 9/10 surgical specimens. Immunostaining for S-100 protein showed the greatest variability in staining, with 5/15 fine needle aspiration biopsies and 9/10 surgical specimens being positive using the polyclonal antibody and only 1/15 FNA specimens and 7/10 surgical specimens being positive using the monoclonal S-100 reagent. Our findings indicate that immunocytochemical studies can be very useful as an adjunct in the FNA diagnosis of melanoma. Also included in our series is an unusual variant of malignant melanoma, the so-called signet ring melanoma. Given the location of the anal verge, the use of immunocytochemical markers was essential in establishing the correct diagnosis in this case. While S-100 protein is of limited value as a marker of melanoma in alcohol-fixed FNA specimens, a definitive diagnosis of malignant melanoma can be made using a panel of antibodies including keratin, vimentin, and HMB-45.
Immunohistochemical analysis of 40 formalin-fixed, paraffin-embedded malignant melanomas (12 primary mucosal, 16 primary cutaneous, and 12 metastatic cutaneous) was performed to study the possible ...differences in immunostaining profiles according to location. The majority of melanomas were reactive with a polyclonal antibody to S100 protein (P-S100; 85%), a monoclonal melanoma-specific antibody (HMB-45; 88%), and a monoclonal antibody to vimentin (90%), and there were no differences in staining profiles for these antibodies by anatomic location. In contrast, while 13 of 16 cutaneous melanomas (81%) and ten of 12 metastatic melanomas (83%) were reactive with a monoclonal antibody to S100 protein (MoAb-079), only five of 12 mucosal tumors (42%) showed positive staining for MoAb-079. Similarly, 14 cutaneous melanomas (88%) and 11 metastatic melanomas (92%) showed positive staining for neuron specific enolase (NSE), while only four mucosal melanomas (33%) were NSE-positive. Of the 40 melanomas, all but two were reactive with either P-S100, MoAb-079, or HMB-45. These findings suggest that MoAb-079 and NSE may be less sensitive markers than P-S100 and HMB-45 for routinely processed mucosal melanomas as compared with cutaneous and metastatic tumors.
High‐grade mantle zone lymphoma Ellison, Douglas J.; Turner, Roderick R.; van Antwerp, Randy ...
Cancer,
1 December 1987, Volume:
60, Issue:
11
Journal Article
Peer reviewed
A 66‐year‐old man with a 6‐month history of sweating at night, generalized lymphadenopathy, hepatosplenomegaly, and paraproteinemia was diagnosed to have a Stage IV mantle zone lymphoma (MZL), which ...behaved aggressively. The neoplasm rapidly disseminated to extranodal sites—the skin, lungs, pleural cavity, and the central nervous system. The neoplasm did not respond to initial double‐agent chemotherapy, but it did partially respond to multi‐agent chemotherapy. In addition, the neoplasm had histopathologic features not reported previously in MZL—vascular invasion, massive extranodal infiltration, high mitotic count, and convoluted nuclei.
A case of mucoepidermoid carcinoma of the bronchus with low grade histologic features exhibited an aggressive biological behavior. All gross, microscopic, and ultrastructural features were those of a ...morphologically low grade mucoepidermoid carcinoma. Grossly, the lesion was an exophytic endobronchial mass; microscopically, it contained sheets of monomorphic cells with well‐formed mucus glands, no mitoses, and no necrosis; and ultrastructurally, it consisted of numerous goblet cells and mitochondria‐ and glycogen‐rich cells with well‐formed microvilli. However, the patient developed widespread metastases to skin, subcutaneous tissue, femur, vertebral column, and pericardium and died two months after the primary endobronchial tumor was excised. The metastases, like the primary tumor, had the appearance of “low grade” mucoepidermoid carcinoma. Explants of the original tumor grown in nude mice for three months showed persistence of the low‐grade morphologic pattern. Although metastases are known to occur frequently from high‐grade lesions, widespread metastases from histologically low‐grade lesions have not previously been reported. Low‐grade histologic features of mucoepidermoid carcinoma are not necessarily then indicative of low‐grade biological behavior.
The cytologic diagnosis of malignant lymphoma can be extremely difficult because the cytologic features of the malignant cells in small cell and mixed small and large cell lymphomas may be ...indistinguishable from those of reactive lymphoid cells. In addition, large cell lymphoma can be difficult to distinguish from undifferentiated carcinoma in cytologic specimens. Using the avidin-biotin immunoperoxidase technic and antibodies to the B-cell markers alpha, gamma, and mu heavy chains and kappa and lambda light chains, to the T-cell markers Leu-1, Leu-2a, and Leu-3a, to the lymphoid marker T200, to TdT, and to Leu-M3, the authors studied 35 cytologic specimens including pleural, cerebrospinal, and ascites fluids and fine-needle aspirations. Immunologic staining allowed them to make a definitive diagnosis of lymphoma or reactive effusion in every case studied and resulted in a significant modification of the morphologic diagnosis in over 50% of cases. In 16 cases the lymphoid cells were monoclonal B-cells: ten expressing IgM kappa; four expressing IgM lambda; one expressing IgA kappa; and one expressing kappa without demonstrable heavy chain expression. Although there are no good markers of monoclonality for T-cells, the authors were able to make a positive diagnosis in two cases of T-cell lymphoid malignancies by the expression of an aberrant phenotype on the malignant cells. The expression of TdT confirmed the diagnosis in one case of common ALL and one lymphoblastic lymphoma. In a patient with a "null cell" large cell lymphoma, the expression of T200 on the malignant cells ruled out the possibility of carcinoma. In 15 cases the marker studies indicated a reactive lymphoid proliferation. The authors conclude that immunologic markers are very useful in the cytologic diagnosis of lymphoma.
Patients infected with the human immunodeficiency virus (HIV) are subject to infections and neoplasms, which frequently result in palpable or radiologically identified masses. Fine-needle aspiration ...(FNA) offers a rapid, simple, and cost effective approach for diagnosis of these masses. During a 2-yr period, 396 aspirates were performed on 362 HIV-infected patients within the LAC-USC Medical Center. Adequate material was obtained from 84% of the FNA, allowing the etiology of the mass to be determined in 90% of the cases by means of a combination of cytologic, microbiologic, and immunocytochemical procedures. Significant pathologic processes identified in these patients by means of FNA included reactive lymphoid proliferations (35%), abnormal lymphoid proliferations (12%), infections (12.5%), cystic (5.5%) and inflammatory processes (5%), nonlymphoid malignancies (4%), and salivary gland pathology (1%). We conclude that FNA is an appropriate initial diagnostic procedure in HIV positive patients presenting with mass lesions.
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