LOH at 16p13 is a novel chromosomal alteration detected in benign and malignant microdissected papillary neoplasms of the breast

Papillary carcinoma of the breast is a variant of predominantly intraductal carcinoma characterized by a papillary growth pattern with fibrovascular support. Loss of heterozygosity (LOH) was evaluated at multiple chromosomal loci (including loci reported to show frequent genetic alterations in breast cancer) to determine the frequency of genetic mutations in these tumors and their precursors. Thirty-three papillary lesions of the breast (6 papillary carcinomas, 12 carcinomas arising in a papilloma, and 15 intraductal papillomas with florid epithelial hyperplasia) were retrieved from the files of the Armed Forces Institute of Pathology (AFIP). Tumor cells and normal tissue were microdissected in each case and screened for LOH at INT-2 and p53 as well as several loci on chromosome 16p13 in the TSC2/PKD1 gene region (D16S423, D16S663, D16S665). LOH on chromosome 16p13 was present in 10 of 16 (63%) informative cases of either papillary carcinoma or carcinoma arising in a papilloma as well as in 6 of 10 (60%) informative cases of intraductal papilloma with florid epithelial hyperplasia (IDH). One case showed simultaneous LOH in both the florid IDH and carcinoma components of a papilloma. LOH was not observed at either INT-2 or p53 in any of the papillary carcinomas or papillomas with florid IDH. In conclusion, a high frequency of LOH at chromosome 16p13 (the TSC2/PKD1 gene region) is in both papillary carcinomas of the breast as well as in papillomas with florid IDH, including a case with LOH present simultaneously in both components. These findings suggest that chromosome 16p contains a tumor suppressor gene that frequently is mutated early in papillary neoplasia.

Human papillomavirus type 16 is detected in transitional cell carcinomas and squamotransitional cell carcinomas of the cervix and endometrium

BACKGROUND

The etiologic role of human papillomavirus (HPV) in a variety of squamous neoplasms, including malignant and premalignant lesions of the cervix, is well established. The presence of HPV, predominantly HPV types 16 and 18, in adenocarcinomas of the endometrium has also been reported, although less commonly. Although rare, transitional cell carcinoma (TCC) in the female genital tract, including such sites as the cervix, endometrium, and ovary, has been described. HPV, however, has not been previously studied in TCC of the female genital tract, the etiology of which is uncertain.

METHODS

Eight cases of primary TCC of the endometrium and six cases of primary TCC of the cervix were retrieved from the files of the Armed Forces Institute of Pathology and the University of Texas Southwestern Medical Center. Slides stained with hematoxylin and eosin were reviewed, and tumor tissue was obtained and analyzed for the presence of HPV types 6, 11, 16, 18, 31, and 33 by polymerase chain reaction (PCR).

RESULTS

HPV was detected by PCR in 4 of 6 TCCs of the cervix (67%) and in 2 of 8 TCCs of the endometrium (25%), using HPV general primers and specific primers to HPV type 16. PCR for HPV using specific primers to HPV types 6 and 11, 18, 31, and 33 were negative in all cases.

CONCLUSIONS

The results of this study demonstrated that HPV type 16 was present in a proportion of primary TCCs of the cervix and endometrium. These findings support the hypothesis that these rare neoplasms are similar, with regard to risk factors, to the more commonly occurring squamous cell carcinomas of the cervix, and suggest that HPV may play an etiologic role in at least a proportion of these tumors.

Primary osteogenic sarcoma of the breast: a clinicopathologic analysis of 50 cases

Extraskeletal osteosarcomas are rare. Few primary mammary osteosarcomas have been reported; many of these have been described in association with a biphasic tumor. Fifty pure osteosarcomas of the breast, diagnosed between 1957 and 1995, were reviewed after excluding those of biphasic origin. The absence of epithelial differentiation was confirmed using a panel of immunohistochemical markers in 32 cases and using ultrastructural evaluation in an additional four cases. Tumors occurred in 49 women and one man; age ranged from 27 to 89 years (median, 64.5 years). One patient received radiotherapy for ipsilateral breast carcinoma 9 years before presentation. Patients were treated by excisional biopsy (n = 13), tylectomy (n = 5) or mastectomy (n = 32). All axillary nodes, dissected in 20 patients, were free of tumor. One patient had extramammary spread at diagnosis. The neoplasms were 1.4 cm to 13.0 cm (mean, 4.6 cm), and 60% were grossly circumscribed. Tumors were classified as fibroblastic (n = 28), osteoclastic (n = 14), or osteoblastic (n = 8). Of 39 patients with available follow-up information, locally recurrent (n = 11) and metastatic (n = 15) disease developed in 23 (59%) at a mean of 10.5 and 14.5 months from diagnosis. Eight (73%) patients in whom local recurrence developed were treated with excisional biopsy or tylectomy; of these, seven had a positive margin. Sixteen (41%) patients died of disease at a mean of 17.1 months, within 20 months of onset of metastases, most commonly to the lung. Mammary osteosarcomas are aggressive tumors with a propensity for blood-borne rather than lymphatic spread. Total excision without axillary dissection is advised.

Mammary ductal carcinoma in situ with microinvasion

BACKGROUND

The natural history of patients with intraductal carcinoma (DCIS) and microinvasion is poorly defined, and the clinical management of these patients, with particular reference to management of the axilla, has been controversial. Previous studies of this lesion have used varied and/or arbitrary criteria for the evaluation of microinvasion.

METHODS

Thirty-eight DCIS lesions with microinvasion (n=29) or probable microinvasion (n=9), diagnosed during the period 1980-1996, were retrospectively analyzed after cases not treated with mastectomy and axillary lymph node dissection were excluded. Microinvasion was defined as a single focus of invasive carcinoma < or = 2 mm or up to 3 foci of invasion, each < or =1 mm in greatest dimension.

RESULTS

The patients were all females with a mean age of 56.4 years. DCIS was of comedo (n=31) or papillary (n=7) subtype. Microinvasion was often associated with an altered, desmoplastic stroma (55%) or a lymphocytic infiltrate (39%). The foci of microinvasion ranged from 0.25 to 1.75 mm (mean, 0.6 mm), with an aggregate mean size of 1.1 mm (range, 0.25-2.25 mm). Foci of microinvasion, ranging from 1 to 3 (mean, 1.7), were adjacent to DCIS in 95.3% of cases. The extent of DCIS did not correlate with the number of foci of microinvasion. Axillary lymph node dissections yielded a mean of 19.3 lymph nodes (range, 7-38), and all lymph nodes were negative for metastasis. None of 33 patients, followed for a mean of 7.5 years (range, 1.0-14.4 years), developed local recurrence or metastasis.

CONCLUSIONS

The cases of microinvasive carcinoma examined in this study, as defined above, were not associated with axillary lymph node metastases and appeared to be associated with an excellent prognosis. Further study is indicated to determine the appropriate management and long term prognosis of patients with this lesion.

Mucinous cystadenocarcinoma of the breast

Four unusual cases of primary mammary mucinous cystadenocarcinoma composed predominantly of tall columnar cells with abundant intracytoplasmic mucin are reported; they were multicystic and appeared virtually identical to mucinous cystadenocarcinomas of the ovary and pancreas. Three of the women were white and one was black, they ranged in age from 49 to 67 years (average 58), and they had tumors that ranged from 0.8 to 19 cm in diameter. Microscopically, the tumors were characterized by cystic spaces lined by predominantly bland-appearing columnar mucinous cells with stratification, tufting, and papillary formations. Varying degrees of cytologic atypia were focally evident, with gradual loss of the intracytoplasmic mucin and transformation to an eosinophilic squamoid cell population. Multifocal invasion generally emanated from these eosinophilic, squamoid areas in all cases. All four tumors displayed immunoreactivity for MIB-1 (Ki-67) in a relatively high percentage of cells and failed to show immunoreactivity for estrogen receptors and progesterone receptors. All four stained positively with cytokeratin 7 (CK7) but were negative with cytokeratin 20 (CK20). Mastectomy and axillary lymph node dissection were performed in three cases and lumpectomy with lymph node dissection in the remaining case. Lymph node metastases, identified in only one patient, retained the distinctive morphology. Three of the patients are alive without evidence of disease 11, 22, and 24 months after the diagnosis; the fourth is a recent case. These tumors are a rare, clinicopathologically distinct type of primary breast carcinoma that should be distinguished from typical mucinous (colloid) carcinomas of the breast and, more importantly, metastases from other sites.

Uterine angiosarcomas: a morphologic and immunohistochemical study of four cases

The clinical, gross, microscopic, and immunohistochemical features of four examples of exceedingly rare uterine angiosarcomas reviewed at the Armed Forces Institute of Pathology between 1970 and 1997 are presented. One of the cases described has been reported previously. Based on our findings and a review of the literature, uterine angiosarcomas are aggressive lesions that occur predominately in peri- and postmenopausal women with uterine bleeding and anemia. Grossly, the lesions are of large size at initial presentation with deep myometrial extension. Histologically, the lesions demonstrate characteristic features of angiosarcoma and, when associated with a benign smooth muscle proliferation within the uterus, tend to demonstrate an epithelioid morphology. The immunohistochemical reactivity with CD31, factor VIII, and CD34 and lack of reactivity with smooth muscle actin, keratin, and estrogen receptor confirm the vascular nature of these lesions and exclude the differential diagnostic considerations of carcinosarcoma (MMMT), leiomyosarcoma, adenosarcoma, and hemangiopericytoma. The overall survival of these lesions is poor; the majority of women die of disease within 1 year of diagnosis.

Ductal carcinoma in situ: introduction of the concept of ductal intraepithelial neoplasia

The current definition, diagnostic criteria, grading, and approach to assessment of extent of ductal carcinoma in situ (DCIS) are presented. The problem areas, particularly the difficulties in separating low-grade DCIS from atypical intraductal hyperplasia (AIDH), accurate assessment of size and/or extent of DCIS, and their impact on patient management are critically reviewed. On the basis of the route of progression of DCIS, recently confirmed by three-dimensional reconstructed models, an optimal and simple approach to uniform excision, orientation, and processing of biopsy samples is presented. Emphasis is placed on the role of intraductal proliferative lesions (IDH, AIDH, and DCIS) as risk factors of variable magnitude in subsequent development of invasive breast carcinoma. It is proposed that these proliferations should be classified as "mammary intraepithelial neoplasia, ductal type" or as "ductal intraepithelial neoplasia" (DIN); the rational for the application of this classification system is provided. This approach obviates the current separation of AIDH and low-grade DCIS into two very drastically different categories of cancer and non-cancer without interfering with appropriate management of the various lesions. The DIN classification is presented in a simple translational table, along with the current terminology for various lesions.

Pure pleomorphic rhabdomyosarcomas of the uterus

Pure rhabdomyosarcoma arising in the uterus is a rare tumor currently classified by the World Health Organization (WHO) as a uterine sarcoma. The records of eight women with uterine rhabdomyosarcomas were retrieved from the files of the Armed Forces Institute of Pathology (AFIP). The eight women presented with vaginal bleeding, abdominal enlargement, or acute abdomen. The mean age of the patients was 64.6 years (range 35-87). Macroscopically, 4 tumors were polypoid endometrial masses, 2 were intramyometrial, 1 was located in the cervix, and 1 was a 15-cm mass involving the endometrium and myometrium with direct extension into the small intestine. Microscopically, the tumors consisted of a variable proportion of large rhabdomyoblasts admixed with smaller round, polygonal, and spindle-shaped cells. No epithelial elements were identified on light microscopy. Tissue from the extrauterine and metastatic lesions was available for review in four cases and also showed pure rhabdomyosarcoma. Immunohistochemical assessment of seven tumors supported the sarcomatous nature of the neoplastic cells. Six patients died of disease within 15 months of initial diagnosis and 1 patient died of a pulmonary embolus. The patient whose 15-cm tumor had extended into the small intestine survived 6 years; she died of a presumed pancreatic carcinoma. Presenting mainly in elderly women, uterine pleomorphic rhabdomyosarcomas are rare, highly malignant tumors with frequent extrauterine spread at presentation. Patients rarely survive beyond 15 months.

Superficial angiomyxoma (cutaneous myxoma): a clinicopathologic study of 17 cases arising in the genital region

Seventeen cases of superficial angiomyxoma (cutaneous myxoma) of the genital region are reported. Thirteen patients were female (age range: 15-33 years; mean: 21 years) and four were male (age range: 18-55 years; mean: 39 years). The sites of involvement in females were the labium majus or labium, not otherwise specified (n = 6), vulva (n = 4), groin (n = 2), and mons pubis (n = 1). All lesions in male patients involved the scrotum. The tumors were present from 2 months to 4 years before resection and ranged from 0.9 to 6 centimeters in maximal dimension; 10 tumors were 3 centimeters or less in size. The predominant reason for seeking medical attention was a slow growing painless mass. All lesions were locally excised. Follow-up was obtained for 9 patients with a mean and median follow-up interval of 135 and 95 months, respectively. A recurrence developed in three patients at 8 months, 7 years 11 months, and 20 years. No patient has been shown to have Carney's complex. The tumors were immunoreactive for vimentin (11/11), CD34 (11/11), muscle-specific actin (8/12), smooth muscle actin (9/11), S100 protein (5/13), and Factor XIIIa (5/9). No immunoreactivity was present for desmin (DE-R- 11), glial fibrillary acidic protein, estrogen receptor or progesterone receptor. Superficial angiomyxomas are probably derived from fibroblast-like cells capable of antigen modulation.

Angiomyofibroblastoma of the female genital tract: analysis of 17 cases including a lipomatous variant

The clinicopathological and immunohistochemical profile of 17 cases of angiomyofibroblastoma (AMF) arising in the genital tract of females is reported. The lesions usually presented as painless masses and were located in the superficial vulvar region (15 cases), canal of Nuck (one case), and perineum (one case) in women ranging in age from 38 to 60 years (median, 46 years). The tumors were well delineated and ranged in size from 2 to 8 cm in greatest dimension. Microscopically, they were composed of spindled and epithelioid mesenchymal cells arranged in cords and nests preferentially arrayed around numerous small to medium-sized vessels. Mitotic activity ranged from 0 to 7 mitoses per 50 high-power fields (HPF) with no abnormal mitotic figures. Minimal nuclear atypia was appreciated. Intralesional fat was present in 12 cases and in two of these cases constituted most of the tumor (lipomatous variant of AMF). Tumor cells expressed vimentin (five of five cases), estrogen receptor protein (six of six cases), progesterone receptor protein (five of six cases), desmin (six of eight cases), CD34 (one of six cases), and smooth muscle actin (one of seven cases). None of the eight women with follow-up of up to 25 years (mean, 7.8 years) after simple excision developed a recurrence. This study confirms the benign nature of AMF, broadens its morphological spectrum to include a lipomatous variant, and proposes an origin from a perivascular stem cell that is capable of myofibroblastic and fatty differentiation.

Papillary squamotransitional cell carcinoma of the cervix: a report of 32 cases

Papillary carcinomas of the uterine cervix with transitional or squamous differentiation are rare tumors that often resemble transitional cell carcinomas of the urinary tract. We reviewed 32 such cases of papillary cervical carcinoma and divided them into three groups: 1) predominantly (> 90%) squamous (nine cases), 2) mixed squamous and transitional (16 cases), and 3) predominantly transitional (seven cases). Overall, the patients ranged in age from 22 to 93 years (mean 50), and the most common clinical presentation was abnormal bleeding (15 patients) and an abnormal Papanicolaou smear (nine patients). The tumors ranged in size from 0.7 to 6.0 cm (mean 3.0). All cases demonstrated a papillary architecture with fibrovascular cores lined by a multilayered, atypical epithelium resembling a high-grade squamous intraepithelial lesion of the cervix. Underlying superficial to deep stromal invasion was seen in 18 of 20 cases (90%); in the remaining 12 cases, the specimen was too superficial to assess invasion. Eighteen (86%) of the 21 cases examined immunohistochemically demonstrated immunoreactivity for cytokeratin 7, whereas only two of the 21 (9.5%) showed positivity for cytokeratin 20. Of the 12 women for whom follow-up information was available, three were treated by simple hysterectomy, two underwent radical hysterectomy, one was treated with radiation alone, and one with combination chemotherapy and radiotherapy. Three patients died of disease (two in the squamous group and one transitional) within an average of 13 months after diagnosis. Local recurrence developed in two women, and one of these, a vaginal recurrence, occurred 12 years after the original diagnosis. Based on the above findings, we believe that these tumors are a clinicopathologically distinct, homogeneous group that display a morphologic spectrum. Nevertheless, because some tumors may show a purely squamous or purely transitional appearance, we propose retaining the above three separate designations for these tumors with the understanding that there is often a substantial degree of subjectivity in deciding whether a tumor is squamous or transitional. The most distinctive, objective, and easily recognizable feature of these tumors is their surface papillary architecture rather than their superficial resemblance to transitional cell carcinomas of the urinary tract, and we emphasize the need to distinguish these potentially aggressive malignant tumors from the far more common and benign papillary lesions of the cervix.

Transitional cell carcinoma of the endometrium and endometrial carcinoma with transitional cell differentiation

BACKGROUND

Transitional cell carcinoma (TCC) is rare in the female genital tract. Although it is most common in the ovary, small series of cases in the cervix have been reported, with isolated cases described in the fallopian tube, adnexa uteri, and endometrium.

METHODS

Eight cases of primary TCC involving the endometrium and 1 case of ovarian TCC metastatic to the endometrium were retrieved from the files of the Armed Forces Institute of Pathology and the University of Texas Southwestern Medical Center. Cases were selected based on the presence of endometrial TCC, whether pure or combined with other patterns, and regardless of the relative amount. Immunostaining for cytokeratins 7 and 20 was performed.

RESULTS

Among the 8 women with primary endometrial tumors, the mean age was 61.6 years (range, 41-83 years). Uterine bleeding was the presenting symptom in 7 women. Macroscopically, the tumors were polypoid, and infiltrated the myometrium, although the extent of infiltration varied. Seven endometrial tumors showed a papillary component. TCC was always admixed with other patterns (predominantly squamous, but also endometrioid, papillary, and serous patterns), with the proportion of the TCC component ranging from 5% to 95% (mean, 63.8%). TCC was the main invasive pattern observed in all three of the cases that had deep myometrial invasion; these cases also had vascular invasion. Seven tumors were confined to the uterus; one was metastatic to the ovary. The ovarian TCC metastatic to the endometrium had a pure TCC pattern. Five of 7 cases of TCC had cytokeratin 7+/20- immunoreactivity; 2 cases were cytokeratin 7-/20-. Treatment of primary endometrial tumors was mainly surgical, with adjuvant radiation therapy in 4 cases or chemotherapy in 1 case. Survival ranged from 3 months to 12.9 years (mean, 5.1 years). Of five women for whom follow-up was available, three were alive with no evidence of disease, one was alive with a local recurrence, and one died of unrelated disease.

CONCLUSIONS

TCC is a rare, distinct subtype of endometrial carcinoma with morphologic features of urothelial differentiation, but retention of a mullerian immunoprofile. While the overall prognosis does not appear to be worse than what might be anticipated for the stage of tumor present, TCC appears to be the more aggressive histologic subtype among the patterns with which it is admixed.

Use of monoclonal antibody against human inhibin as a marker for sex cord-stromal tumors of the ovary

Inhibin is a glycoprotein hormone produced by normal ovarian granulosa cells and testicular sertoli cells. In the ovary, it inhibits the secretion of follicle-stimulating hormone. Patients with granulosa cell tumors (GCT) have elevated serum levels of inhibin and this finding has been used to detect recurrent tumor. This study attempts to determine whether inhibin antibody (IAB) can preferentially mark GCT and Sertoli-cell or Sertoli-Leydig cell tumors (SCT) in paraffin-embedded tissues and facilitate distinction of GCT from small cell carcinoma of hypercalcemic type (SCC), SCT from Sertoliform endometrioid carcinoma (SEC), and primitive gonadal-stromal tumors from a variety of poorly differentiated neoplasms. Applying microwave-enhanced immunohistochemistry, a total of 126 paraffin-embedded and microwave-enhanced archival ovarian tumors and tissues were studied by using monoclonal IAB. The tumors included 32 adult GCT, 7 juvenile GCT, 4 metastatic GCT, 8 SCT, 7 SCC, 6 primitive gonadal stromal tumors (PGST), 5 fibrothecomas, 6 lipid cell tumors (LCT), 5 extrauterine endometrial stromal sarcomas (ESS), 5 hemangiopericytomas (HPC), 1 metastatic malignant melanoma, 1 metastatic malignant lymphoma, and 27 epithelial tumors including 8 SEC, 5 mucinous tumors, and 4 Brenner tumors. Seven pregnancy luteomas (nodular theca lutein hyperplasia of pregnancy), 3 corpora lutea and 2 ovarian follicles were also studied. The intensity of immunostaining was scored from one to three and the percentage of the immunoreactive tumor cells was determined and expressed in 10% increments. Among 32 adult GCT, 31 (97%) tumors reacted positively with IAB. The percent of positive cells ranged from 30% to 100% (average 80%). Similarly, all four metastatic GCT, 7 juvenile GCT and 4 of 5 fibrothecomas were immunoreactive with monoclonal IAB. Seven of 8 (88%) SCT, 5 of 6 (83%) PGST, all 6 LCT, 7 pregnancy luteomas, 3 corpora lutea and the 2 ovarian follicles were also positive with IAB. The most intense positivity was observed in luteinized stromal cells regardless of tumor type. No immunoreactivity was observed in any of the 7 SCC, 5 ESS, 5 HPC, 1 metastatic malignant melanoma, 1 metastatic malignant lymphoma and the epithelial component of all 27 epithelial tumors including 8 SEC. Among the mucinous tumors of the ovary, however, 3 tumors with luteinized stromal cells showed immunoreactivity in these cells, but no positivity was seen in the mucinous epithelium. We conclude that IAB is an excellent marker for sex cord differentiation in ovarian tumors. It can be used effectively in the diagnosis of GCT and its distinction from epithelial neoplasms particularly SCC. The IAB may also be helpful in differentiating LCT from epithelial malignancies. However, it cannot be used to distinguish GCT from SCT.

Identical clonality of both components of mammary carcinosarcoma with differential loss of heterozygosity

The histogenesis of carcinosarcomas is controversial, specifically with respect to clonality and cell of origin. To answer these questions, tumor cells from both epithelial and spindle-cell components were microdissected from three cases each of mammary carcinosarcoma and its postulated precursor, carcinoma with spindle-cell metaplasia. Clonality was assessed using the principle of X chromosome inactivation. Loss of heterozygosity (LOH) was evaluated at seven chromosomal loci to assess shared and distinctive genetic alterations for the two components in each tumor. All of the six cases demonstrated identical clonality of the carcinomatous and spindle-cell components, identical to a focus of ductal carcinoma in situ present in one case. LOH for NM23 was detected in both components in one carcinosarcoma, whereas LOH for INT-2 was detected in both components in one metaplastic carcinoma. Differential LOH for D11S904 was present in only the mesenchymal components of these two cases. We conclude that the two components of carcinosarcoma and its precursor are clonal and that the sarcomatous and spindle-cell components arise from mutation of the carcinoma. Presence of differential LOH at D11S904 in only the spindle-cell components suggests that this mutation might be critical to the development of this second phenotype.

The influence of endogenous and exogenous reproductive hormones on the mammary glands with emphasis on experimental studies in rhesus monkeys

Endogenous and exogenous reproductive hormones have long been recognized as a risk factor for breast carcinoma. These hormones are thought to exert their influence by altering the kinetics of cell proliferation, differentiation or atrophy resulting in an increased population of susceptible cells. Prolonged exposure to endogenous hormones (predominantly estrogens and progestins) resulting from either early menarche, late menopause, and absent or reduced ovarian cyclic functions due to parity are associated with an increased risk. Oophorectomy, in contrast, provides a protection inversely related to age at ablation. The influence of exogenous hormones (birth control pills, hormone replacement therapy, etc.) on mammary carcinogenesis remains a controversial issue. The various viewpoints will be discussed. Among rhesus monkeys in captivity, experimental exposure to a variety of synthetic oral contraceptive steroids has resulted in a variety of proliferative changes including atypical hyperplasia and carcinoma in the mammary duct system. A much higher proportion of severe atypias and carcinoma was observed among those receiving progestational hormones in pure form or in combination with estrogens. Pure estrogenic compounds did not cause as severe a proliferation or atypia in as high a proportion as observed when progestational hormones were used in pure or combined form. In view of this finding it is important to use caution when considering addition of progestins to hormone replacement therapy in an effort to prevent endometrial carcinomas. This is particularly important if the patient has other risk factors for breast carcinoma.

The pathology of vulvar neoplasia

Current literature on the pathology of vulvar disease continues to focus on vulvar intraepithelial neoplasia, the role of human papillomavirus in vulvar neoplasia, and Paget's disease of the vulva. Of particular concern is an increasing incidence of vulvar intraepithelial neoplasia noted over the past several decades, specifically among younger women. Human papillomavirus has emerged as a major factor in this trend. Furthermore, a more aggressive course may ensue in these young women, requiring diligent follow-up.

Genetic analysis of synchronous mucinous tumors of the ovary and appendix

The coexistence of mucinous ovarian and appendiceal tumors in association with pseudomyxoma peritonei (PP) is well established. However, it has not been determined whether they represent independent or metastatic neoplasms. The authors analyzed microsatellites on chromosome 17q 21.3-22 (nm23), 3p 25-26 (von Hippel Lindau disease [VHL] gene), and 5q 21-22 (D5S346 locus) in 12 synchronous ovarian and appendiceal mucinous lesions. Loss of heterozygosity (LOH) at the nm23 locus has been shown previously in ovarian carcinomas, and genetic alterations at both the 3p and 5q loci have been reported in colorectal carcinomas. The ovarian lesions consisted of nine mucinous tumors of low malignant potential and three invasive adenocarcinomas, and the appendiceal lesions consisted of eight carcinomas without invasion, two invasive carcinomas, and two mucosal hyperplasias. DNA was extracted from microdissected cells obtained from formalin-fixed, paraffin-embedded tissue sections and amplified by polymerase chain reaction. In three specimens, genetic alterations occurred at 17q 21.3-22 in only the ovarian tumors. One of these cases showed LOH on chromosome 5q 21-22 in only the appendiceal tumor. In three other specimens, LOH at the same locus was found in both tumors. Six specimens did not show LOH at any locus. These results suggest that a subset of synchronous mucinos ovarian and appendiceal lesions showing different LOH patterns in both sites most likely represent patients with two separate primary lesions. Another group of specimens with the same allelic loss in both tumors most likely represent patients with a single primary and metastatic spread. Thus, genetic analysis of these lesions may be useful in investigating the origin of histologically similar synchronous tumors.

Primary diffuse large B-cell lymphoma of the breast. A clinicopathologic study of 31 cases

Primary non-Hodgkin's lymphoma of the breast is a rare neoplasm for which survival data vary among the reported studies. Thirty-one cases of diffuse large B-cell lymphoma of the breast, which had been seen in consultation from 1973 to 1985 at our institution, were reviewed. This represents the largest number of lymphomas of this histologic subtype reported to date in the English literature. Histologic examination and immunophenotypic analysis were performed and the results were correlated with clinicopathologic data. The patient population consisted of 29 females and 2 males with a mean patient age of 58.2 years. At the time of diagnosis, 26 patients had unilateral involvement (16 left, 10 right), and 5 had bilateral disease. Mean tumor size was 3.8 cm. Histologically, all cases showed a diffuse large B-cell lymphoma as classified by the Revised European-American Classification of Lymphoid Neoplasms (R.E.A.L Classification). Immunophenotypic studies on paraffin sections confirmed a B-cell lineage in every case. The majority of patients received chemotherapy and/or radiation therapy. The median survival was 36 months, confirming that this neoplasm has a poor prognosis.

Mesonephric hyperplasia of the uterine cervix: a clinicopathologic study of 51 cases

Lesions derived from remnants of the mesonephric (Wolffian) duct frequently occur in the wall of the uterine cervix and often cause diagnostic problems. Fifty-one cervical mesonephric lesions were studied. There were 40 lobular mesonephric hyperplasias and 11 diffuse mesonephric hyperplasias. Lobular hyperplasia was characterized by a distinctive clustering of mesonephric tubules, while diffuse hyperplasia was nonclustered. Fifteen patients with hyperplasia followed for a mean of 6.3 years were alive and well at last contact. In addition to morphologic differences between lobular and diffuse hyperplasia, there were statistically significant differences in patient age (means of 35 and 46 years, respectively) and lesion size (means of 11.8 and 15.7 mm, respectively), and less pronounced differences in proximity to surface epithelium and age-size correlations. Evidence suggests that the two types of mesonephric hyperplasias may be distinct entities. The morphologic appearances of the diffuse hyperplasias are emphasized to prevent their misinterpretation as variants of minimal deviation adenocarcinoma.

Pathology of advanced primary breast carcinoma

For a majority of women with breast carcinoma, the clinical course of the disease is determined by tumor size and axillary node metastases. Tumor type and grade are also important prognostic factors. Estrogen and progesterone receptor statuses are good predictors of the likelihood of response to hormone therapy and survival. Patients with high S-phase fraction are at increased risk for early relapse. As far as other markers are concerned, sufficient information is not available currently to make definitive decisions regarding inclusion of their assessment in the routine evaluation of breast carcinomas.

A comparison of two commercially available in vitro chemosensitivity assays

In vitro chemosensitivity assays (IVCAs) are expensive laboratory tests utilized to assist oncologists in the selection of chemotherapeutic regimens. Their utility is disputed; yet, these assays continue to be requested because of the importance of the information they can provide and their scientifically logical approach. Therefore, we compared the results of two assays offered to clinicians at our hospital; the extreme drug resistance assay performed by Oncotech (OT) and the fluorescent cytoprint assays performed by Analytical Biosystems (AB). The two techniques used and the expression of assay results by the two companies are discussed. Twenty neoplasms, all at least 3 cm in diameter and predominantly of breast and ovarian origin, were compared. OT performed 74 drug assays on 17 tumors, while AB performed 194 assays on the corresponding neoplasms; 3 neoplasms were insufficient for comparison. Evaluation of the results revealed apparent disagreement on at least 44 drug assays with complete disagreement on at least 2 of the drugs tested in 12 of 17 cases. In conclusion, based on available information, comparisons between IVCAs show great variation in results; prospective studies are needed to evaluate commercially available assays for correlation with clinical outcome, and results should be expressed so comparisons can be readily made. Though utility may be limited to tumors resistant to standard therapy, cost and benefit to the patient will ultimately determine the fate of these tests.

Coexistence of nipple duct adenoma and breast carcinoma: a clinicopathologic study of five cases and review of the literature

The simultaneous occurrence of nipple duct adenoma (NDA) and carcinoma in the same breast is rare and generally considered an incidental finding. Five examples of such concurrent lesions are reported. The patients ranged in age from 48 to 70 y, and they all presented with a palpable mass that was subareolar in three and in the lower inner quadrant in two women. The presence of distorted nipple with discharge in two patients and nipple erosion in another had raised the possibility of Paget's disease clinically. Microscopically, an infiltrating duct carcinoma was present in four women and an intraductal carcinoma in the fifth--all along with a NDA. Two of the invasive carcinomas were adjacent to the NDA and immediately beneath the surface epithelium of the nipple; the NDA in one of these had atypical intraductal hyperplasia. Three women had mastectomy and axillary node dissection, two had excisional biopsy only. Follow-up was available in four women and ranged from 1.5 to 8 y. One of these women developed metastasis and died 8 y postdiagnosis; the remaining three are alive and well. In at least three cases, the invasive carcinoma was not suspected clinically, and the initial procedure was done because of symptomatology secondary to the NDA.

Pseudoinvasion in intraductal carcinoma

Fine-needle aspiration, stereotactic biopsies, and guide wire localization have introduced an element of pre-excision trauma to mammary lesions. Dislodgement of tumor cells may result in diagnostic difficulties and misinterpretation of a tissue artifact as an invasive carcinoma. Eight breast biopsy specimens with intraductal carcinoma (ranging from cribriform to comedo types) displayed changes suggestive of an invasive carcinoma. Three of the patients had a prior history of needle aspiration; the remaining five women had undergone needle localization to guide the biopsy. In all cases, two or more dislodged tumor cell clusters were found in the stroma or adipose tissue either immediately adjacent to a disrupted duct with intraductal carcinoma or in the nearby stroma. Those cases with prior needle aspiration were associated with significant hemorrhage and reactive changes with small, rounded clusters of tumor cells within pools of blood. The needle localization specimens had minimal tissue reaction with larger fragments of detached cell clusters. Breast trauma by a puncturing instrument (needle or guide wire) can disrupt mammary ducts with intraductal carcinoma and dislodge the proliferating cells into the surrounding stroma. The dislodged cells simulate invasion. To minimize damage to the architectural integrity of the lesion under investigation, limits should be imposed on the number of needle passes.