Mammary "comedo"-DCIS: apoptosis, oncosis, and necrosis: an electron microscopic examination of 8 cases

The terms apoptosis and necrosis are commonly used to imply two distinct types of cell death. Apoptosis reflects a genetically mediated. ATP-dependent form of cell death. A passive form of cell death (oncosis) also occurs, often in response to some form of injury. Both pathways can lead to necrosis (postmortem autolytic cell changes). The nature of intraluminal necrosis in mammary ductal carcinoma in situ (DCIS) was evaluated using ultrastructural analysis on paraffin-embedded material of 8 cases with "comedo"-DCIS. In each case, intraepithelial proliferation zones and intraluminal zones (peripheral and central luminal zones) were examined. All cases with "comedo"-DCIS revealed abundant apoptosis, characterized by apoptotic cells showing chromatin condensation and margination with sharply circumscribed, uniformly dense crescents, as well as cytoplasmic condensation. Numerous membrane-bound apoptotic bodies with condensed cytoplasm (with or without nuclear fragments) were also observed. The central luminal zones of "comedo"-DCIS, however, revealed necrotic debris characterized by severe degradative changes, largely devoid of recognizable cell structures. In addition, two cases displayed features of oncosis, characterized by nuclear and cytoplasmic swelling, vacuolization of cytoplasm, and mitochondrial swelling with occasional dense bodies. The results indicate that necrosis (postmortem, secondary degradative cell changes) in "comedo"-DCIS is the end result of either apoptosis (programmed cell death) alone or a combination of apoptosis and oncosis (passive or "accidental" cell death).

Primary vulvar and vaginal extraosseous Ewing's sarcoma/peripheral neuroectodermal tumor: diagnostic confirmation with CD99 immunostaining and reverse transcriptase-polymerase chain reaction

Two cases of extraosseous Ewing's sarcoma/peripheral neuroectodermal tumor arising in unusual, superficial sites are reported. One tumor involved the vaginal wall of a 35-year-old woman, and the other neoplasm arose in the dermis of the vulva in a 28-year-old woman. The tumors showed characteristic microscopic features of Ewing's sarcoma/peripheral neuroectodermal tumor with nodular monotonous proliferations of undifferentiated, small, round, hyperchromatic cells with a low mitotic index. Rare rosette-like formations were apparent only in the vulvar neoplasm. The tumors displayed intense immunoreactivity in a membranous pattern for CD99, the cell surface glycoprotein encoded by the MIC2 gene. Genetically, the tumors expressed the EWS/FLI-1 chimeric transcript, derived from the t(11;22)(q24;q12) chromosomal translocation. Both patients had localized disease treated with wide local excision; one received postoperative chemotherapy, and the other received chemotherapy and radiotherapy. To date, 18 and 19 months after diagnosis, neither patient has had clinical evidence of local recurrence or metastasis. To our knowledge, these are the first reported cases of vaginal and vulvar Ewing's sarcoma/peripheral neuroectodermal tumor, confirmed with molecular genetic analysis, in the English literature.

The mammary pathology of genetically engineered mice: the consensus report and recommendations from the Annapolis meeting

NIH sponsored a meeting of medical and veterinary pathologists with mammary gland expertise in Annapolis in March 1999. Rapid development of mouse mammary models has accentuated the need for definitions of the mammary lesions in genetically engineered mice (GEM) and to assess their usefulness as models of human breast disease. The panel of nine pathologists independently reviewed material representing over 90% of the published systems. The GEM tumors were found to have: (1) phenotypes similar to those of non-GEM; (2) signature phenotypes specific to the transgene; and (3) some morphological similarities to the human disease. The current mouse mammary and human breast tumor classifications describe the majority of GEM lesions but unique morphologic lesions are found in many GEM. Since little information is available on the natural history of GEM lesions, a simple morphologic nomenclature is proposed that allows direct comparisons between models. Future progress requires rigorous application of guidelines covering pathologic examination of the mammary gland and the whole animal. Since the phenotype of the lesions is an essential component of their molecular pathology, funding agencies should adopt policies ensuring careful morphological evaluation of any funded research involving animal models. A pathologist should be part of each research team.

Ossifying well-differentiated Sertoli-Leydig cell tumor of the ovary

A unique case of an ovarian sex cord-stromal tumor occurring in a pregnant 20-year-old is described. The tumor showed central ossification on macroscopic examination. Microscopically, cords and nests of Sertoli cells were identified, mostly away from the abundant central hyalinization, calcification, and ossification. A small number of Leydig cells were present, with isolated Reinke crystals. The presence of these cells could reflect luteinized stromal cells secondary to pregnancy. The Sertoli cells were dominant and the calcified/ossified areas were at the center of a dominant Sertoli nodule. This degree of ossification has never been reported in either ovarian Sertoli tumors or well-differentiated Sertoli-Leydig tumors. Calcifying Sertoli cells neoplasms have been described in the testis, but this case appears to be the first description of a case with similar features in the ovary.

Fibromatosis of the breast: age-correlated morphofunctional features of 33 cases

OBJECTIVE

To predict if antiestrogenic agents are useful in the treatment of breast fibromatoses, we undertook an immunohistochemical study of sex steroid hormone receptors (estrogen receptor, progesterone receptor, and androgen receptor) and protein pS2 in 33 cases.

METHODS

The morphologic and immunohistochemical findings were correlated to patient menstrual status, which was categorized as childbearing age (n = 15), perimenopausal (n = 8), and postmenopausal (n = 10).

RESULTS

Fibromatoses in women of childbearing age were more cellular, more mitotically active, and displayed a larger proportion of cells with mild atypia than those in perimenopausal and postmenopausal women. The hormonal status of these 3 groups does not explain the morphologic variations observed in these groups, inasmuch as no immunostaining for any of the hormone receptors was detected in the tumors.

CONCLUSIONS

The absence of estrogen receptor and pS2 in breast fibromatoses suggests that antiestrogenic agents are unlikely to be beneficial in the management of these tumors. Assessment of the hormone receptor profile is a useful adjunct in the diagnosis of spindle cell lesions of the breast. Although most spindle cell carcinomas as well as fibromatoses of the breast do not express estrogen or progesterone receptors, the absence of androgen receptor reactivity would favor a diagnosis of fibromatosis over that of myofibroblastoma.

Teratomatous genotype detected in malignancies of a non-germ cell phenotype

Originating from post-meiotic germ cells, mature ovarian teratomas (MOT) are genetically homozygous tumors within heterozygous hosts. MOT may be associated with malignant tumors of a non-germ cell phenotype (so-called malignant transformation). Based on the presence of in situ changes, some cases have been hypothesized to arise from teratomatous tissue. However, other malignancies associated with mature teratomas, such as sarcomas, may originate from either teratomatous elements or preexisting somatic ovarian tissue. Eight cases of MOT containing various histologic types of malignancy, including four squamous cell carcinomas, two sarcomas, one thyroid carcinoma, and one carcinoid tumor, were selected for study. Using selective tissue microdissection and PCR-based analysis of the extracted DNA, we compared the genotypic pattern of the mature teratomatous components to the associated malignant neoplasm with a random panel of highly informative genetic markers for different chromosomes. In all eight cases, genetic analysis of the malignant component revealed a homozygous genotype. In seven cases, the genetic profiles of mature teratomas and the associated malignant tumors were identical, suggesting a direct pathogenetic relationship between these lesions. In one case, the malignant component revealed homozygosity of different alleles compared with mature teratoma, suggesting independent teratomatous growth processes. This finding indicates that some ovarian malignancies of the non-germ cell phenotype arise in teratoma and fall into the spectrum of germ cell tumors.

Loss of heterozygosity is detected at chromosomes 1p35-36 (NB), 3p25 (VHL), 16p13 (TSC2/PKD1), and 17p13 (TP53) in microdissected apocrine carcinomas of the breast

INTRODUCTION

Apocrine carcinomas of the breast are an unusual special category of predominantly AR+, ER-, and PR- breast cancer, characterized by cells with abundant, eosinophilic cytoplasm and nuclei with often prominent nucleoli. To further investigate these lesions, loss of heterozygosity (LOH) was evaluated at multiple chromosomal loci, including loci frequently mutated in breast cancer.

MATERIALS AND METHODS

Twenty-five intraductal apocrine carcinomas, 11 invasive apocrine carcinomas, and six apocrine hyperplasias were retrieved from the files of the Armed Forces Institute of Pathology (Washington, DC) and Fairfax Hospital (Fairfax, VA). Cells from lesional as well as normal tissues were microdissected. LOH was performed at a number of chromosomal loci, including loci commonly altered in breast cancer: 1p35-36 (NB), 3p25.5 (VHL), 8p12 (D8S136), 9p21 (p16), 11p13 (D11S904), 11q13 (INT-2 and PYGM), 16p13.3 (TSC2/PKD1 gene region), 17p13 (TP53), 17q13 (NM23), and 22q12 (D22S683).

RESULTS

Among informative in situ and invasive apocrine carcinomas, LOH was present in 33% of 15 cases for 17p13 (TP53), as well as 36% of 14 cases for 3p25 (VHL), 30% of 10 cases for 1p35-36 (NB), and 27% of 11 cases for 16p13.3 (TSC2/PKD1). A higher frequency of LOH was noted among invasive apocrine carcinomas (30 to 50%) compared with in situ apocrine carcinomas (23 to 33%) at these loci. LOH was present simultaneously for TP53 and either VHL or NB in five cases. Infrequent (< or =12%) or absent LOH was detected at the remaining loci, including several loci commonly mutated in breast cancer (i.e., INT2, PYGM, and NM23). LOH was not detected in any of the six apocrine hyperplasias.

CONCLUSION

An intermediate frequency of allelic loss was detected at multiple tumor suppressor gene loci, including 17p13 (TP53), as well as 1p35-336 (NB), 3p25 (VHL), and 16p13 (PKD1/ TSC2), in apocrine carcinomas of the breast, with a higher overall frequency of LOH noted among invasive tumors compared with in situ tumors. Aside from LOH at p53, LOH was infrequent or absent at several other loci commonly mutated in breast cancer. This preliminary molecular evidence supports immunohistochemical data that apocrine carcinomas of the breast may possess unique mechanisms of carcinogenesis, compared with ordinary ductal carcinomas. However, further study is needed to support this assertion and to determine if the LOH detected is truly etiologic or if it is the result of genetic progression.

Evidence that Leydig cells in Sertoli-Leydig cell tumors have a reactive rather than a neoplastic profile

BACKGROUND

Leydig cells are a variable and an inconstant feature of Sertoli-Leydig cell tumors (SLCT). Controversy exists regarding their neoplastic versus reactive nature, and their molecular biologic profile is unknown.

METHODS

Six SLCT and one pure Leydig cell tumor were studied. Mitotic counts and immunohistochemistry for Ki-67 were performed in all cases. Leydig cells, neoplastic tissues, and normal nonneoplastic tissues were microdissected. DNA extracts of these samples were assessed for loss of heterozygosity (LOH) by polymerase chain reaction amplification with ten polymorphic DNA markers that have shown high rates of LOH in a variety of human tumors. Three SLCT and the Leydig cell tumor were assessed for clonality by examining the DNA methylation pattern at a polymorphic site on the androgen receptor gene.

RESULTS

Leydig cells in SLCT had a low mitotic count (0-1/50 high-power fields [HPF]) compared with the neoplastic stroma (median, 40/50 HPF). Ki-67 was positive in < 2% of Leydig cells in all SLCT, compared with a median of 7% in the neoplastic stroma. Clonality analysis confirmed the monoclonality of the neoplastic cells in the Leydig cell tumor. However, the Leydig cells from three SLCT were polyclonal, whereas the monoclonal nature of the neoplastic Sertoli tubules was confirmed in one of these cases and that of mucinous heterologous elements in another case. The Leydig cell tumor showed LOH at four of the eight loci evaluated. Leydig cells from five SLCT were evaluated: one showed LOH at one locus, two showed LOH at two loci, and the remaining two showed no LOH.

CONCLUSIONS

The demonstration that Leydig cells from SLCT are polyclonal strongly suggests that they are nonneoplastic in nature. This is supported by a low proliferation fraction and a lower fraction of LOH compared with the truly neoplastic Leydig cells.

Molecular abnormalities associated with secretory carcinomas of the breast

Secretory carcinomas (SCAs) represent a unique histological variant of invasive breast carcinomas, occurring predominantly in patients younger than 30 years of age. Data from limited series have shown SCAs to have a favorable prognosis in patients younger than 20 years of age, whereas the clinical course tends to parallel the more common in filtrating ductal carcinomas (IDCs) in patients older than 20 years. There are no reports on the molecular abnormalities associated with this unusual tumor. Microdissected archival formalin-fixed tissue from 10 SCAs collected from 2 institutions were used to determine the frequencies of allelic loss at 13 chromosomal regions with 19 microsatellite markers, using multiplex polymerase chain reaction (PCR)-based techniques. The results of loss of heterozygosity (LOH) and microsatellite alterations (MAs) analyses were compared with 20 cases of IDCs. P53 gene mutation analysis was also performed on the 10 SCAs using single-strand conformation polymorphism (SSCP) analysis, followed by sequencing of abnormal bands. LOH at multiple regions of chromosome 3p were the most common abnormality in both SCAs (55%) and IDCs (50%), followed by LOH at 17q21 (BRCA1 locus), 13q14 (retinoblastoma gene locus), and 8p21-23. No significant differences were seen in the frequencies of LOH at any chromosomal region except for 17p13 (p53 gene locus), where allelic losses were absent in SCAs, but evident in 46% of IDCs (P < .05). The 2 histological entities were similar in the fractional regional loss (FRL) index (0.26 v 0.24), fractional allelic loss (FAL) index (0.23 v 0.27), as well as in the frequency of MAs (0.015 v 0.005), P > .05. P53 gene missense mutation (G:C::A:T) was detected in 1 of 10(10%) SCAs. Based on the considerable similarities in the molecular abnormalities associated with both tumors, the formation of secondary lumina in both the in situ and the invasive components, as well as suggestions from limited series that the clinical behavior in adult patients parallels that of IDCs, SCA most likely reflects a secretory variant of IDCs.

Sertoliform endometrioid carcinomas of the ovary: a clinicopathologic and immunohistochemical study of 13 cases

Ovarian endometrioid carcinomas with sertoliform features (SECs) are infrequent and often misinterpreted as sex cord-stromal tumors. The clinicopathologic features and immunohistochemical expression of keratin, epithelial membrane antigen (EMA), inhibin, and estrogen and progesterone receptors were evaluated in 13 cases of SEC. The women were 41 to 89 years of age (mean, 60 yr) with abdominal enlargement secondary to a unilateral ovarian mass as the most frequent clinical presentation. One patient displayed virilization. At presentation, 10 patients were Stage I, one was Stage II and two were Stage III. The tumors were composed of compact anastomosing cords and small tubules embedded within a fibrous stroma. Nuclear features were Grade 1 or 2 in all but one tumor. Areas of conventional endometrioid carcinoma were observed in 12 cases. An adenofibromatous component comprising 5 to 60% of the lesion was present in seven cases. All 12 cases examined immunohistochemically were positive for keratin and EMA and negative for inhibin with focal, luteinized stromal cells positive for inhibin in 10 cases. Estrogen and progesterone receptors were positive in 10 and 11 cases, respectively. Follow-up on 6 of 10 patients with Stage I and the one patient with Stage II disease displayed no evidence of disease 10 to 120 months (mean, 57 mo). Progressive disease and death occurred at 12 and 72 months only in the two women with Stage III disease, one of which had an associated serous carcinoma in the contralateral ovary. Adequate sampling, a careful search for areas of conventional endometrioid carcinoma, and immunohistochemical studies (including EMA, keratin, and inhibin) are helpful in the evaluation of ovarian tumors with sex cord-stromal features. SEC should be considered a well-differentiated endometrioid carcinoma despite the presence of a solid, sex cord-like proliferation, with a good prognosis when confined to the ovary.

Use of keratin 35betaE12 as an adjunct in the diagnosis of mammary intraepithelial neoplasia-ductal type--benign and malignant intraductal proliferations

A variety of studies have investigated the role of low molecular weight (LMW) and high molecular weight (HMW) cytokeratin (CK) expression in the normal breast and invasive breast carcinomas. A few studies with small numbers of cases have addressed this issue in intraductal proliferations of the breast. This study investigates the expression of these CKs in a large series of ductal intraepithelial neoplasias of the breast. We examined 150 ductal carcinomas in situ (DCIS), 35 cases of intraductal hyperplasia (IDH), and 15 cases of atypical intraductal hyperplasia (AIDH). Immunohistochemistry was performed using monoclonal antibodies against CK-34betaE12 (HMW CK), CK-8, and CK-19 (LMW CK) on formalin-fixed, paraffin-embedded tissue. The intensity (0, +1, +2, +3) and percentage of positive intraductal cells (0-100%) were multiplied to obtain a score from 0 to 300. The immunoprofiles of IDH, AIDH, and DCIS were categorized into four groups showing negative or low (0-60), moderate (61-100), high (101-200), and very high (201-300) scores. All cases of IDH showed an intensely positive reaction (high to very high scores) for CK-34betaE12. In contrast, 90% of the DCIS showed a negative or only focal and weak reaction (negative or low score) for this antigen. The remaining 10% of DCIS showed a positive immunoreaction for CK-34betaE12 with moderate to high scores. All cases of florid IDH and 96% of cases of DCIS expressed CK-8 intensely with high to very high scores. Although CK-19 was strongly expressed in 97% of cases of IDH (high to very high scores), a very high score was also found in 80% of cases of DCIS that were positive for CK-19. Of the 15 AIDHs, 80% had a negative or only focal reaction (negative or low score) for CK-34betaE12 and the remaining 20% had a moderate to high score for this antigen. Although CK-8 was strongly positive in 87% of cases of AIDH (high to very high scores), only 53.5% of AIDHs showed intense positivity for CK-19. The present study clearly shows that the immunoprofile of IDH is different from DCIS as far as HMW CK is concerned. Although florid IDH is characterized by a diffuse and intense immunoreaction for HMW CK, the lack of or only weak positivity for HMW CK (CK-34betaE12) is, in most cases, a hallmark of ductal carcinoma in situ. The immunoprofile of AIDH is very similar to that of DCIS. The expression of CK-8 and CK-19 is not useful in separating the various categories of ductal intraepithelial proliferations of the breast. We recommend the use of CK-34betaE12 as an adjunct in the diagnosis of a variety of problematic intraductal proliferations of the breast.

Wolffian adnexal tumor, so-called female adnexal tumor of probable Wolffian origin (FATWO): immunohistochemical evidence in support of a Wolffian origin

Wolffian adnexal tumor (WAT) is a rare neoplasm believed to originate from wolffian remnants on the basis of its location in areas where these remnants are abundant. To study its histogenesis, the immunoprofile of 25 WATs was compared with that of 10 cervical and vaginal mesonephric remnants and 12 rete ovarii. WATs were unilaterally located in the broad ligament (n = 10), mesosalpinx (n = 9), ovarian hilus (n = 5), and pelvis, not otherwise specified (n = 1). They showed varying morphologies with solid (spindle cells), tubular (lined by columnar cells), retiform and multicystic (spaces lined by cuboidal and attenuated cells) patterns. WATs were immunoreactive for pan-cytokeratin (AE1/3, CK1) (100%), CAM 5.2 (100%), cytokeratin 7 (CK7) (88%, focal staining), keratin 903 (17%), epithelial membrane antigen (EMA) (12%), estrogen receptor (28%), progesterone receptor (24%), androgen receptor (78%), inhibin (68%), calretinin (91%), and vimentin (100%). No immunostaining was detected with monoclonal carcinoembryonic antigen and cytokeratin 20. The pattern of staining was nearly identical to that of the rete ovarii and differed somewhat from mesonephric remnants, which were diffusely immunoreactive for CK7, immunopositive for EMA (apical staining), and nonreactive for inhibin. Our findings provide immunohistochemical support for the derivation of WATs from wolffian remnants, in particular from the rete ovarii. Because of immunoreactivity for inhibin and calretinin in a significant number of WATs, our results further show that these immunostains alone do not allow absolute distinction of WATs from sex cord-stromal tumors and adenomatoid tumors, respectively, with which they may be confused.

Osteosarcomatous differentiation in phyllodes tumors

Osteosarcomatous differentiation in phyllodes tumors is uncommon. The clinicopathologic features of 22 such cases in our files were retrospectively reviewed to evaluate the prognostic significance of this rare neoplasm. All patients were women between 40 and 83 years of age (mean, 60 years). Most (73%) presented with a palpable mass. None had prior irradiation to the breast or chest region. Patients were treated with excisional biopsy (N = 4), partial mastectomy (N = 1), or mastectomy (N = 17). All axillary nodes, dissected in 11 patients, were free of tumor. Two patients had extramammary spread at diagnosis. The neoplasms measured 1.9-15 cm (mean, 6.4 cm); 54% were grossly circumscribed or multilobulated. The osteosarcomatous component was classified as fibroblastic (N = 11), osteoclastic (N = 6), or osteoblastic (N = 5) and occupied a variable percentage of the phyllodes' stroma ranging from -25% to essentially 100% of the neoplasm. Of 21 patients with available follow-up, 11 (52%) were alive at a median follow-up of 44 months. Nine patients (43%) developed locally recurrent (N = 1) or metastatic (N = 8) disease. Metastases were clinically apparent within 1 year of diagnosis in all eight patients; seven died within 12 months of detection of initial metastasis. By univariate analysis, gross tumor size and osteosarcoma subtype significantly correlated with prognosis. In a multivariate analysis, neither of these factors were independent prognosticators. Phyllodes tumors with an osteosarcomatous component are potentially aggressive neoplasms, particularly when large (>5 cm) or associated with an osteoclastic or osteoblastic osteosarcoma. Complete excision without axillary dissection is advised.

Spherulosis of the breast. A spectrum of municous and collagenous lesions

OBJECTIVE

Collagenous spherulosis of the breast is an uncommon localized pattern of basement membrane material deposition that may be mistaken for atypical proliferations or carcinoma. This report describes 9 cases in which the predominant or exclusive appearance of the spherules was basophilic instead of eosinophilic.

DESIGN

The files of all cases of collagenous spherulosis diagnosed at the Armed Forces Institute of Pathology were reviewed to ascertain the frequency of diagnosis.

RESULTS

Spherulosis with a predominantly basophilic pattern had a histochemical and immunohistochemical profile similar to collagenous spherulosis and was associated with more collagenous-appearing forms in 7 of 9 cases. Review of 81 cases showed that collagenous spherulosis was correctly diagnosed in 15% of referrals and was mistaken for intraductal or invasive carcinoma in 11% of cases.

CONCLUSIONS

Mucinous and collagenous patterns appear to be related forms of spherulosis. They are underrecognized by pathologists and maybe mistaken for atypia or malignancy.

Hepatocytic differentiation in retiform Sertoli-Leydig cell tumors: distinguishing a heterologous element from Leydig cells

Sertoli-Leydig cell tumors (SLCT) of the ovary are rare sex cord-stromal neoplasms. A minority of SLCT are characterized by a pattern resembling that of the rete ovarii and frequently have a range of homologous and heterologous tissues. Approximately 20 cases of SLCT have been reported to have elevation of serum alpha-fetoprotein (AFP) levels, or tissue immunoreactivity for AFP, a protein usually associated with germ cell neoplasms, especially yolk sac tumor. We identified hepatocytic differentiation in five cases of retiform SLCT (RSLCT), and confirmed immunohistochemically that these cells are hepatocytes rather than Leydig cells. Hepatocytes are positive for keratins (AE1/3 and Cam 5.2), AFP, and ferritin, negative for vimentin, and show weak to moderate staining for inhibin. Leydig cells are negative for keratins, positive for vimentin, and intensely positive for inhibin. Immunohistochemistry is needed to distinguish hepatocytic differentiation from Leydig cells with certainty. Including the cases in this report, hepatocytic differentiation has been associated with a retiform pattern in SLCT in 14 of 25 cases (56%). The association of these two patterns appears to be characteristic of a relatively primitive sex cord-stromal neoplasm.

Ovarian hepatoid yolk sac tumours: morphological, immunohistochemical and ultrastructural features

AIM

The clinicopathological, immunohistochemical and ultrastructural features of two ovarian hepatoid yolk sac tumours (H-YST) from our files are reviewed.

METHODS AND RESULTS

Using avidin-biotin-peroxidase complex technique, the immunoprofile of these tumours was compared to that of a classic yolk sac tumour and to that previously reported for hepatocellular carcinomas. The clinicopathological and morphological features of our cases are similar to the seven previously reported ovarian cases. This rare germ cell tumour occurs in young females (mean age = 17.6 years) and presents most commonly with abdominal pain and a large ovarian mass (average size = 140 mm). Histologically, the tumours display a striking resemblance to hepatocellular carcinoma. The absence of an associated typical pattern of yolk sac tumour or other germ cell neoplasm may make it difficult to recognize the germ cell origin of this lesion. Our cases demonstrated positive staining for alpha-fetoprotein and alpha-1-antitrypsin. In addition, there was immunoreactivity with polyclonal carcinoembryonic antigen (CEA) antiserum in a canalicular pattern, focal staining for inhibin, oestrogen and progesterone receptors and absence of immunoreactivity for CK7 that contrasts with the immunophenotype of a usual yolk sac tumour.

CONCLUSIONS

Ovarian H-YST and hepatocellular carcinoma share a similar immunoprofile. Ovarian H-YST is a highly aggressive tumour, most patients exhibit recurrence or die of disease within 2 years of diagnosis.

Papillary transitional cell carcinoma of the breast: a report of five cases with distinction from eccrine acrospiroma

Papillary carcinomas of the female breast exhibit a spectrum of morphologic appearances and might be mistaken for benign intraductal papillary lesions or papillary adnexal neoplasms. We report herein five cases of papillary carcinoma in which the epithelium closely resembled transitional cells of the urinary bladder. Grossly, the tumors had a nodular or papillary appearance, white, tan, or red in color. The microscopic features were those of an intraductal papillary proliferation of solid layers of epithelial cells overlying fibrovascular cores. The proliferating cells assumed a whorled or streaming growth pattern, with flattening of superficial cells. One case showed microinvasion. Comparison with a similar number of cases of the solid variant of papillary carcinoma of the breast showed a greater range of nuclear pleomorphism, mitotic counts, and a more varied immunohistochemical profile in the papillary carcinomas with transitional cell features. Eight cases of eccrine acrospiroma occurring in the female breast also displayed a solid or solid papillary pattern, with flattened superficial cells. These occurred in a younger age group, were located in the dermis or subcutis, and usually had zones of clear cells visible at low magnification. No evidence of recurrent or metastatic disease was found in the four patients for whom follow-up was available; the length of follow-up ranged from 18 months to 11 years. The stimulus for the development of this unusual phenotype is unclear, but the transitional-like variant seems to behave in a fashion similar to that of other types of papillary carcinoma of the breast. Distinction of this malignant lesion from various benign lesions that occur in the same region is mandatory.

Breast tumors with myofibroblastic differentiation: clinico-pathological observations in myofibroblastoma and myofibrosarcoma

This report describes the clinico-pathological features of myofibroblastic tumors of the breast in six patients. Four women and one man presented with a benign myofibroblastoma. The sixth patient was a woman with myofibrosarcoma. All myofibroblastomas were composed of a fascicular arrangement of spindle cells embedded in dense bundles of collagen. Tumors differed with respect to their proportion of neoplastic cells and collagenous stroma as well as cellular pleomorphism. Based on this variation, the tumors could be subclassified as classic, collagenized, epithelioid and cellular myofibroblastoma. Immunohistological staining confirmed myofibroblastic differentiation by strong expression of either desmin or smooth muscle actin with coexpression of vimentin. In addition, numerous cells reacted with antibodies to CD68. Proliferative activity was rather low in the myofibroblastoma with an average of 0-2 mitotic figures per 10 HPF. DNA cytometric analysis was performed in two cases and showed diploid stem lines with minor S-phase fractions (1% and 3%). In the myofibrosarcoma, cells contained pleomorphic nuclei with some giant cells and numerous mitotic figures (6-7/10 HPF) and had infiltrating margins that were apparent even grossly. Immunohistochemically, tumor cells strongly expressed vimentin, smooth muscle actin and fibronectin. Ultrastructurally, neoplastic cells met the criteria of myofibroblasts, i.e. contained abundant intermediate filaments and myofilament bundles with focal densities as well as fibronexus junctions. DNA cytometric analysis exhibited again a diploid stemline but marked proliferative activity was present as indicated by an S-phase fraction of 20%. In conclusion, in benign myofibroblastoma there may be some cellular pleomorphism but mitotic activity is always low. The malignant counterpart, myofibrosarcoma, is characterized by marked cellular pleomorphism, infiltrating margins and high mitotic rate.

Oncocytic metaplasia and carcinoma of the endometrium: an immunohistochemical and ultrastructural study

Endometrial oncocytic carcinoma is an unusual neoplasm, with few cases reported. Endometrial curettage specimens coded as prominent oxyphilic metaplasia (N = 5) and oxyphilic or oncocytic carcinoma (N = 4) were reviewed, and hysterectomy slides from the four carcinomas were also examined. Immunohistochemical and ultrastructural analyses were performed in three of five metaplasias and in all four carcinomas. Most patients (89%) with oncocytic metaplasia and carcinoma had vaginal bleeding. Oncocytic metaplasia was characterized by a single layer of cells with abundant eosinophilic, granular cytoplasm, minimal pleomorphism, and rare mitotic activity. Carcinoma was diagnosed on the basis of an altered stroma (n = 2) and/or a confluent growth pattern (n = 4) and had a papillary (n = 4), glandular (n = 2), or solid (n = 1) morphology. Carcinomas showed a similar population of oncocytic cells as metaplasias, but with occasional nuclear stratification and greater pleomorphism and mitotic activity. Tumors were International Federation of Gynecology and Obstetrics (FIGO) grade 1 (n = 2) or 2 (n = 2) and FIGO stage Ib, Ic, IIb, and IIIc. Omental metastases developed in the patient with the stage III tumor at 13 months; the two patients with stage I tumors were alive with no evidence of disease at a mean of 29 months. All carcinomas expressed p53 and 75% and 100% were estrogen receptor (ER)- and progesterone receptor (PR)-negative, respectively, whereas all metaplasias were p53 negative- and ER- and PR-positive. Ki-67 labeling index was 1 to 3% in metaplasias and 14 to 33% in carcinomas. Oncocytic metaplasias and carcinomas contained abundant mitochondria and free ribosomes, accounting for the oncocytic appearance. Because oncocytic carcinomas frequently show deep myometrial invasion and require surgical staging, it is important to distinguish oncocytic metaplasia from carcinoma on biopsy material. Ki-67, p53, and ER and PR immunostains may assist in this potentially difficult differential.

Comparison of loss heterozygosity in primary and recurrent ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) of the breast is often an indolent disease, although some cases are reported to recur many years after a limited surgical resection. It is not known whether these recurrences reflect a resurgence of residual disease or an independent development of a second tumor in susceptible individuals. Therefore, we conducted a longitudinal molecular study of four women with reappearance of DCIS 2 to 15 years after an initial conservative resection. Loss of heterozygosity (LOH) was characterized in both tumors in each case, using several polymerase chain reaction-amplified microsatellite markers on five chromosomal arms commonly affected in breast cancer. In three cases with ipsilateral recurrent disease, all of the allelic losses seen in the initial tumors were also seen in the recurrent lesions, suggesting a common genetic pathway for the development of both lesions and continuous proliferation of residual disease. The presence of at least one additional LOH in all of the three recurrent tumors, however, suggests that the recurrent tumors developed after genetic progression. In contrast, in one case of DCIS that was followed by the development of DCIS in the contralateral breast 7 years later (a case of bilateral DCIS), unrelated LOH patterns were present in the two lesions. These findings suggest that the reappearance of DCIS in the same breast is most commonly the result of a tumor derived from (but not identical to) the original lesion, with acquisition of additional genetic changes, even when the recurrent lesion manifested itself many years (15 years, in one case) after the initial presentation. Furthermore, genetic progression could be detected in tumors recurring in as little as 2 years after the initial resection.

Ductal carcinoma in situ (DCIS) in the male breast: a morphologic study of 84 cases of pure DCIS and 30 cases of DCIS associated with invasive carcinoma--a preliminary report

BACKGROUND

Ductal carcinoma in situ (DCIS) in the male breast is a rare disease that to the authors' knowledge has been investigated to date only in small numbers. Compared with DCIS in the female breast, distinct clinical and morphologic differences have been suggested.

METHODS

The files of the Armed Forces Institute of Pathology (AFIP) were searched for cases of pure DCIS and DCIS associated with invasive carcinoma (DCISAIC) in male patients. A total of 280 cases of pure DCIS and 759 invasive mammary tumors were identified; 114 cases (including 84 pure DCIS and 30 DCISAIC) were studied for this preliminary report. All cases were reviewed and classified according to specific subtypes (papillary, cribriform, solid, micropapillary, and comedo) and grades of DCIS. Basic clinical data were extracted from the patients' charts.

RESULTS

Men with pure DCIS presented at a median age of 65 years, with a typically nodular, retroareolar, partially cystic mass that frequently was associated with a nipple discharge. The median duration of symptoms was 2 months for patients with pure DCIS and 6 months for patients with DCISAIC. Histologically, the predominant appearance of DCIS (in 74% of cases) was that of a papillary carcinoma often with a superimposed cribriform pattern. Intraductal extension beyond the main papillary lesion was common. It is interesting to note that the pure DCIS cases in this series were uniformly of either low or intermediate grade; high grade or comedocarcinomas were only observed within the group of DCISAIC. No significant morphologic differences between pure DCIS and DCISAIC were encountered, although DCISAIC did show relatively more cellular atypia with more frequent necrosis compared with pure DCIS.

CONCLUSIONS

DCIS in the male breast is a distinct lesion that occurs at an older age and displays a significantly different distribution of morphologic subtypes compared with its female counterpart. It presents most frequently as an intraductal papillary carcinoma, and less commonly as a nonpapillary cribriform, solid, or micropapillary DCIS. In the current study the majority of pure DCIS cases were low grade (AFIP Grade 1) with occasional cases displaying necrosis (AFIP Grade 2); high grade pure DCIS appears to be a rare lesion in the male breast. In contrast, DCIS associated with invasive carcinoma more frequently is of higher grade.

Endocrine tumors of the cervix: morphologic assessment, expression of human papillomavirus, and evaluation for loss of heterozygosity on 1p,3p, 11q, and 17p

BACKGROUND

Cervical endocrine tumors are rare lesions, with a varied diagnostic nomenclature. A recent consensus meeting proposed a standardized terminology. This study evaluated: 1) applicability of histopathologic guidelines; 2) evidence of loss of heterozygosity (LOH) at selected sites; and 3) the presence of human papillomavirus (HPV) detected by nonisotopic in situ hybridization (ISH).

METHODS

Thirty-eight cases (patient age range, 19-88 years; mean, 48 years) were retrieved. Outcome data were available for 32 patients. Classification was based on architectural and cytologic features. Tissue was available from 15 cases for LOH analysis with D3S1234(3p14), D3S1289(3p21), THRB(3p24), TP53(17p13), D1S468(1p36), and INT-2(11q13). In ten cases, tissue was analyzed by nonisotopic ISH with HPV probes for types 6/11, 16/18, and 31/33.

RESULTS

Tumors were divided into four groups: small cell carcinoma (SCC) (n=25); large cell neuroendocrine carcinoma (LCNC) (n=5); SCC with focal LCNC differentiation (n=3), and carcinoid tumor (n=5). Tumors defined as exclusively or predominantly SCC had a particularly poor prognosis, with 20 patients dead of disease (<6 years after diagnosis) and 6 alive with disease (after <3 years of follow-up). LOH at various 3p loci (3p14, 3p21, and 3p24) was observed in eight cases. One patient demonstrated LOH on 17p(TP53). Eight of ten cases assessed by ISH showed nuclear staining using a combined HPV-16/18 probe.

CONCLUSIONS

Cervical endocrine tumors are highly aggressive and can be subdivided into definable categories. LOH at 3p loci is a frequent finding, as is nuclear staining with a combined HPV-16/18 probe. LOH at 17p(TP53 locus) appears to be relatively uncommon, suggesting that p53 mutations may not be developmentally significant.

Nodular hyperplasia, adenoma, and adenomyoma of Bartholin's gland

Inflammatory lesions and cysts are by far the most common causes of swelling or enlargement of Bartholin's glands, and carcinomas, though rare, are the most frequent solid lesions that arise at this site. There have been very few reports of benign solid lesions of Bartholin's gland, and, among these lesions, the distinction between adenoma (AD) and hyperplasia has not been well defined. All cases diagnosed as either Bartholin's gland adenoma or hyperplasia in the Armed Forces Institute of Pathology files were reviewed. Using specific criteria, 17 qualified as nodular hyperplasia (NH), 1 as AD, and 1 as adenomyoma (AM). Five NHs, the AD, and the AM were studied with immunohistochemical stains for estrogen receptor (ER), progesterone receptor (PR), MIB-1, and p53. The average age of the patients with NH was 35 years (range, 19 to 56). These lesions were solid or solid and cystic, had a mean maximal dimension of 2.3 cm, and were frequently thought to be Bartholin's cysts on clinical examination. Microscopically, the NHs had an irregular or lobulated contour and were composed of a proliferation of cytologically bland mucinous acini with maintenance of the normal duct-to-acinar relationship. Varying degrees of inflammation and squamous metaplasia of the ducts were common in NH. The patient with the AD was 45 years old and the patient with AM was 65. Both were well-circumscribed, solid lesions, 2.2 and 2.5 cm in maximal dimension, respectively, and composed of a haphazard proliferation of acini and tubules. A small adenoid cystic carcinoma (ACC) arose from the periphery of the AD. p53 positivity was evident in up to 40% of the ACC cells; the cells in the adjacent AD were negative for p53. Only occasional cells were MIB-1 positive (< 5%) in some cases, and ER and PR were absent in the epithelial elements in all 7 cases tested but were focally present in the stromal cells of 3 of the 5 NHs and the fibromuscular stroma of the AM. The patient with the AM and the one with the AD are alive without evidence of recurrent or metastatic disease after 4 months and 19.8 years, respectively. NH, AD, and AM of the Bartholin's gland, as defined in this study, are extremely rare lesions. NH occurs in younger patients and is often associated with inflammation or obstruction of Bartholin's duct.

Endometrial adenocarcinoma associated with intrauterine pregnancy. A report of five cases and a review of the literature

Endometrial adenocarcinoma associated with pregnancy is a rare lesion; only 14 acceptable examples have been reported in the literature. This study describes five additional examples with a critical review of the previously published cases. Four of the five women were nulliparous and three had sought medical intervention for infertility. The tumors were all well-differentiated endometrioid adenocarcinomas; three had a focal to extensive papillary pattern and three had focal to extensive squamous differentiation. Four were diagnosed at the time of dilatation and curettage and one at the time of cesarean section for a 28-week, live infant. Follow-up was available for four of the five women. Two women underwent hysterectomy with bilateral oophorectomy and were alive and well 12 and 48 months after diagnosis. The woman who had the live birth and the remaining woman were treated by repeat curettage with or without progesterone therapy, and each woman has had two subsequent full-term pregnancies with live births. These women are alive and well 57 and 58 months after diagnosis. Women with focal, well-differentiated carcinomas can successfully maintain their fertility if followed by repeat curettage with or without progesterone therapy.