Pathology of transitional cell carcinoma of the bladder and its clinical implications

Transitional cell carcinomas are divided into superficial and muscle-invasive tumors. Most of them are superficial tumors, and approximately 15-20% are muscle-invasive carcinomas. Pathologists play a significant role in diagnosing bladder tumors and in reporting features important for determining prognosis. We will review the cytologic and histopathologic features that help determine prognosis, including depth of invasion, tumor grade, multicentricity, tumor size, and the presence of vascular/lymphatic invasion, blood group antigen expression, proliferative indices, and molecular markers. Brief mention will be made of specimen handling, interpretation, reporting, and histologic variants of transitional cell carcinoma.

Histologic variants of adenocarcinoma and other carcinomas of prostate: pathologic criteria and clinical significance

Most cases of carcinoma involving the prostate gland show characteristic acinar histologic features. The term variant is used to describe a distinctly different histomorphologic phenotype of a certain type of neoplasm. The recognition of histologic variants of prostate carcinoma is important because some types are associated with a different clinical outcome and might have a different therapeutic approach, and because awareness of the unusual pattern might be critical in avoiding diagnostic misinterpretations. In this article, we review the subject of histologic variants of prostatic adenocarcinoma with a focus on histologic criteria and clinical significance. We discuss small cell carcinoma, ductal (endometroid) carcinoma, sarcomatoid carcinoma, signet ring cell carcinoma, mucinous carcinoma, lymphoepithelioma-like carcinoma, adenosquamous carcinoma of the prostate, squamous carcinoma, adenoid cystic carcinoma, and transitional cell carcinoma involving the prostate.

Vascular adrenal cysts: a clinicopathologic and immunohistochemical study of six cases and a review of the literature

The clinical, histologic, and immunohistochemical features of six cases of hemorrhagic adrenal pseudocysts are reported together, with a review of the English literature on this topic since 1950. The mean age at presentation was 57 years (range, 30-72 yr). There were four men and 2 women. The average cyst size was 9.2 cm (range, 6-16 cm). In four patients, the hemorrhagic adrenal pseudocysts were incidental findings. The remaining two patients presented with an abdominal mass and hypertension, respectively. The hemorrhagic pseudocysts were unilocular cystic masses surrounded by a fibrous capsule and containing abundant amorphous material, blood, and fibrin. Numerous dilated, thin-walled, vascular channels that stained strongly for Factor VIII-related antigen, collagen IV, laminin, Ulex europaeus agglutinin I lectin, and CD34 were present within the fibrous capsule, cyst contents, and surrounding residual adrenal gland. These findings support a vascular origin for these lesions, and they are thought, therefore, to be related to endothelial adrenal cysts. The literature review of 111 vascular adrenal cysts (85 hemorrhagic pseudocystic type and 26 endothelial type) showed similar clinical features. The mean age at presentation was 44.5 years (range, 5 d-95 yr), with a female predominance (62%). The most common clinical presentation was abdominal pain (35%), followed by incidental findings (32%). There were no significant clinical differences between hemorrhagic and endothelial type cysts. In some cases, the presence of intracystic islands of cortical cells can cause diagnostic confusion with adrenal cortical tumors. The presence, however, of a rich intracystic and capsular vascular network, normal-appearing islands of cortical cells, and abundant thrombotic fibrinous material, rather than necrotic tumor cells, should rule out the possibility of a degenerating adrenal cortical neoplasm.

Intraluminal crystalloids in breast carcinoma. Immunohistochemical, ultrastructural, and energy-dispersive x-ray element analysis in four cases

OBJECTIVE

Intraluminal crystalloids have been described in the prostate, salivary gland, and ovary, but have not yet been reported in the breast. We report four cases of breast carcinoma in which these crystalloids were found in ducts with intraductal carcinoma or atypical hyperplasia. The presence of intraluminal crystalloids may be a useful adjunct in making a diagnosis of carcinoma or may be a feature to look for as a marker for the presence of carcinoma.

DESIGN

Four cases of breast carcinoma containing intraluminal crystalloids were identified among 6900 surgical breast specimens between January 1990 and June 1995 at M. D. Anderson Cancer Center, Houston, Tex. Those sections with crystalloids identified by hematoxylin-eosin stain were stained with periodic acid-Schiff, Alcian blue, and mucicarmine stains. Immunohistochemical and ultrastructural studies and energy-dispersive x-ray analysis were also performed on these sections.

RESULTS

The intraluminal crystalloids were eosinophilic, varied in shape and size, and did not exhibit birefringence under polarized light. Immunohistochemically, the crystalloids were negative for keratin, muscle-specific actin, and kappa and lambda light chains, but the surfaces stained positively for epithelial membrane antigen. By electron microscopy, the crystalloids had no limiting membrane and were composed of an electron-dense material with no discernible periodicity. By energy-dispersive x-ray element analysis, the crystalloids had no mineral content; however, sulfur was found, indicating a protein content.

CONCLUSIONS

The pathogenesis and constituents of these intraluminal crystalloids remain to be determined. Inasmuch as intraluminal crystalloids have not been found in normal ducts or acini, or in ductal hyperplasia without atypia, their presence may serve as a marker for breast carcinoma.

Expression of plasminogen activators and plasminogen activator inhibitor 1 in dedifferentiated chondrosarcoma

BACKGROUND

The plasminogen activator system plays an important role in different malignant tumors. These enzymes participate in the destruction of intercellular matrices and basement membranes and/or can modulate the growth potency of tumor cells and may even promote metastases. In this study, the expression of three glycoproteins that play a role in the plasminogen activator system as activators of proteolysis-urokinase type plasminogen activator (u-PA), tissue type plasminogen activator (t-PA), and plasminogen activator inhibitor type 1 (PAI-1) were studied in various components of dedifferentiated chondrosarcomas of bone.

METHODS

The expression of u-PA, t-PA, and PAI-1 was investigated in 10 dedifferentiated chondrosarcomas and 14 conventional chondrosarcomas. The plasminogen activator/inhibitor glycoproteins were visualized immunohistochemically on paraffin sections and the levels of expression were assessed semiquantitatively.

RESULTS

In dedifferentiated chondrosarcoma, high grade dedifferentiated components displayed strong, diffuse coexpression of u-PA, t-PA, and PAI-1. For all glycoproteins studied, the immunoreactivity was significantly increased compared with the reactions in the low grade cartilaginous component of the same tumor and conventional chondrosarcoma. In the latter, u-PA, t-PA, and PAI-1 expression was found to be enhanced at invasive foci and in regions of endochondral ossification.

CONCLUSIONS

The current study documents the overexpression of u-PA, t-PA, and PAI-1 in dedifferentiated chondrosarcoma and suggests involvement of the plasminogen activator system in the biology of these tumors.

Conventional and dedifferentiated parosteal osteosarcoma. Diagnosis, treatment, and outcome

BACKGROUND

Dedifferentiated parosteal osteosarcoma (dd-POS) designates high grade transformation, of conventional low grade parosteal osteosarcoma (c-POS). The paradigm of preoperative diagnosis, neoadjuvant chemotherapy, and wide local excision has not been adequately evaluated for dd-POS, as it has been for conventional high grade intramedullary osteosarcoma.

METHODS

A retrospective review was conducted of 28 patients treated at the authors' institution between January 1980 and December 1992 for an osteosarcoma arising on the surface of the bone diagnosed as either c-POS or dd-POS. The clinicopathologic features, diagnosis, treatment, and patient outcome were analyzed.

RESULTS

A dedifferentiated component was identified in 12 of 28 tumors (43%). Neither the presence of radiolucencies (77% in c-POS and 100% in dd-POS, P = 0.06) nor medullary invasion (42% in c-POS and 50% in dd-POS, P = 0.28) distinguished dd-POS from c-POS. However, all patients who presented with focal hypervascularity on an arteriogram defined the high grade component of dd-POS that was confirmed by selective needle biopsy. This differed significantly (P = 0.00003) from c-POS. None of the patients with c-POS died of the disease (median survival duration, 77 months; range, 16-152 months). Six patients (35%) developed a local recurrence, but five were treated successfully with further surgery. In the dd-POS group, 7 of the 12 patients died of the disease. Ten patients with dd-POS received preoperative chemotherapy (IA cis-diamminedichloroplatinum, IV doxorubicin), and a good response (> 90% necrosis of high grade component) was observed in four. Among patients whose disease was localized, continuous disease free survival was prolonged significantly (P = 0.03) in patients with a good response (median, 75 months) compared with those who responded poorly (median, 13 months). Five patients remained continuously disease free (median, 66 months, range, 29-95 months).

CONCLUSIONS

Wide surgical excision alone is adequate treatment for patients with c-POS. Recognition of dedifferentiated areas with angiography and percutaneous biopsy of hypervascular areas should prompt the administration of chemotherapy and wide local excision to optimize patient outcome.

Chondromyxoid fibroma of paranasal sinuses: report of two cases presenting with nasal obstruction

Chondromyxoid fibroma (CMF) is a rare, benign cartilaginous tumor that often occurs in the metaphyses of long bones. Tumors of the craniofacial bones are extremely rare and most often involve the mandible and the maxilla. This report presents the clinicopathological and radiological features of two unusual cases of CMF arising in the paranasal sinuses that presented with nasal obstruction. The tumors arose in the sphenoid and ethmoid sinuses and were treated by curettage and resection, respectively. One of the two patients was 20 days old, suggesting a possible congenital origin.

Intraabdominal desmoplastic small cell tumor. Report and discussion of five cases

BACKGROUND

Intraabdominal desmoplastic small cell tumor is a rare malignancy that has only recently been described. In the adult population, it is usually seen in young males. The tumor appears to arise as a dominant mass or masses in the abdominal cavity, particularly in the pelvic region, without a clear visceral origin. Multiple small tumor nodules may be found attached to the peritoneal surface. Visceral metastases occur late in the clinical course, ultimately leading to the patient's death. Five young adults with intraabdominal desmoplastic small cell tumors were treated with aggressive chemotherapy.

METHODS

Charts of five patients treated between 1990 and 1995 were reviewed. The diagnosis of desmoplastic small cell tumor was made on the basis of typical clinical and radiographic findings, light microscopy showing hyperchromatic cells surrounded by a desmoplastic stroma, and immunohistochemistry demonstrating markers of epithelial and mesenchymal differentiation. Patients were treated with aggressive combination chemotherapy consisting of alternating regimens similar to those used as testis cancer salvage therapy.

RESULTS

Four of the five patients demonstrated a partial response to chemotherapy. Two of the responding patients had surgery with the intent of removing all residual disease, but this was successful in only one case. All patients have died from their cancer.

CONCLUSIONS

Intraabdominal desmoplastic small cell tumors are sensitive to combination chemotherapy. It appears that treatment offers good palliation and may prolong survival in isolated cases. However, even the patients managed with the most aggressive medical and surgical approaches are not cured and ultimately die of their disease.

Chondrosarcoma of the pelvis. Prognostic factors for 67 patients treated with definitive surgery

BACKGROUND

Chondrosarcoma (CS) most commonly involves the pelvis. Local and systemic failures often result in poor outcome. Prognostic factors that determine patient outcome remain ill-defined.

METHODS

We retrospectively analyzed 67 patients with CS of the pelvis treated by definitive surgery from January 1970 to December 1992. All patients had localized disease including Grade 1 (19 patients), Grade 2 (18 patients), Grade 3 (17 patients), and dedifferentiated (13 patients) tumors. Thirty-two patients underwent a limb-sparing surgical resection and 35 patients underwent hemipelvectomy. Follow-up was available for all patients. The median duration of follow-up for the survivors was 115 months (range, 24-288 months).

RESULTS

At last follow-up, 52% of the patients were disease free, 8% were alive with disease, 36% died of disease, and 4% died of other causes. Nineteen patients (28%) had developed a local recurrence (LR). The median time to LR was 23 months (range, 1-111 months). Independent variables in a multivariate analysis associated with increased risk of LR included inadequate surgical margin, tumor epicenter in the pubis, and high grade histology. LR did not influence overall patient survival. Twenty-three patients (36%) developed distant metastases at a median time of 9 months (range, 1-111 months) postoperatively. Metastases developed in 0% of the patients with Grade 1, 20% of the patients with Grade 2 60% of the patients with Grade 3 and 75% of patients with dedifferentiated CS. On multivariate analysis, histologic high grade was the only significant predictive variable for distant relapse (P = 0.005).

CONCLUSIONS

The critical issue for a favorable outcome in low grade CS of the pelvis is adequate surgical excision (i.e., negative surgical margin). The high rate of systemic failure in high grade and dedifferentiated CS, despite adequate surgery, emphasizes the need for more effective systemic therapy.

Allergic fungal sinusitis: a clinicopathologic study of 16 cases

Allergic fungal sinusitis (AFS) has been clinicopathologically defined as a noninvasive form of fungal infection. Etiologically, most reported cases have been attributed to pigmented dematiaceous fungi. The authors report 16 cases of AFS from our institution, along with a review of cases from the literature. The patients' age ranged from 8 to 71 years, with a mean age of 25 years. All patients were immunocompetent, although six had a strong history of atopy. Multiple sinuses were affected in all cases; nine patients had bilateral involvement, and seven patients manifested unilateral involvement. Histopathologically, all cases were characterized by the presence of "allergic mucin," with scattered fungal organisms without invasion of mucosa or bone. Fontana-Masson stain identified fungi in all but one case and assisted in distinguishing the pigmented dematiaceous organisms from other septated fungal forms. Accordingly, Fontana-Masson stain can be useful in confirming the diagnosis of AFS in the lack of tissue culture results. Fungal cultures performed on six cases grew Exserohilum (three cases), Bipolaris (one case), Drechslera (Bipolaris) (one case), and Curvularia (one case). All patients were treated with surgical debridement and sinus aeration. Follow-up of at least 6 months was obtained in six cases, of which four showed recurrent disease between 8 months and 4 years after the initial surgical procedure. A literature review showed that the most common etiologic agents were members of the dematiaceous family (81%), with the most common genus being Bipolaris (42%), followed by Curvularia (21.3%). It is believed that type I and III hypersensitivity reactions underlie the pathogenesis of this disease.

Avulsion fracture of the anterior inferior iliac spine with abundant reactive ossification in the soft tissue

Patients who have sustained an avulsion fracture and present clinically during the healing phase of the injury may manifest a mass that clinically and radiographically mimics a malignant neoplasm. A 15-year-old male soccer goalkeeper presented with a large ossified mass in the soft tissues overlying the right hip 6 months after experiencing a popping sensation in his hip joint during a game. Although an osteosarcoma was suspected clinically and radiographically, a Tru-Cut needle biopsy of the lesion revealed reactive bone formation. Correlation of the clinical, radiographic, and pathologic findings indicated an avulsion fracture of the anterior inferior iliac spine with abundant reactive ossification in the soft tissues. The healing phase of an avulsion fracture may clinically and radiographically be mistaken for neoplasia. In such cases, a Tru-Cut needle biopsy may reveal the reactive nature of the process.

Endocervical type glands in urinary bladder: a clinicopathologic study of six cases

The authors report six cases of glandular lesions made up of endocervical type glands in the urinary bladders of women aged 34 to 65 years (mean, 39 years). Two patients presented with dysuria, one with painless hematuria, one with complaints of pelvic discomfort and hematuria, and one with vaginal discharge. The sixth patient was asymptomatic, but on a routine gynecologic examination, a pelvic mass was found. On physical examination, three women had masses between the bladder and uterus. Four lesions were located in the posterior wall of the urinary bladder, one in the dome, and one in the trigone. Four patients underwent biopsy of the bladder lesion. One of these patients had undergone a hysterectomy 10 years earlier. One woman with a pelvic mass between the bladder and uterus underwent a hysterectomy, bilateral salpingo-oophorectomy, and partial cystectomy. The sixth patient had a transurethral resection of the bladder tumor and left oophorectomy. Histologically, all cases showed intermediate to large-sized irregularly shaped endocervical type glands in the muscularis propria of the urinary bladder. Some glands exhibited cystic dilatation and contained mucinous secretions. The glands elicited no desmoplastic tissue reaction. The intraluminal mucin frequently contained polymorphonuclear leukocytes. In all cases, the glands were lined by mucinous, tall, columnar cells and less commonly by flattened to cuboidal cells. Rare admixed ciliated cells were also observed. The lining epithelium was bland in five cases, but moderate nuclear atypia was seen in one case. Mitoses were not observed in any case. Associated lesions included endometrial type glands surrounded by elastotic stroma in one case, exuberant cystitis glandularis in one case, and a pseudodiverticulum of the bladder in one case. Review of the slides from the patient who had had a hysterectomy 10 years previously revealed endocervical adenocarcinoma in situ. Follow-up (mean = 30 months; range = 6 to 60 months) shows that all patients are alive and well, suggesting that the lesion is benign.

Spermatic cord contamination in testicular cancer

It is not uncommon to find testicular germ-cell tumors in the spermatic cord. This may represent contamination or true involvement (vascular invasion or direct tumoral extension into the cord). A correct identification of the process has important clinical implications. In a review of 326 testicular germ-cell tumors, 79 (24.2%) revealed tumor in the spermatic cord. Of these 79, contamination was found in 57 (72.1%), true involvement in 15 (19%), and true involvement and contamination in 7 (8.9%). Spermatic cord contamination was seen most frequently with seminomas: 34 (24.1%) of 141 seminomas and 20 (15.4%) of 130 mixed germ-cell tumors. Eighteen of the 20 mixed germ-cell tumors contained an embryonal carcinoma component. True involvement was seen most frequently in embryonal carcinoma. Six (15.4%) of 39 pure embryonal carcinomas demonstrated true cord involvement. Six mixed germ-cell tumors with true cord involvement contained an embryonal carcinoma component. Distinguishing between true involvement of the spermatic cord and contamination can occasionally be problematic. Because true involvement, especially at the spermatic cord resection margin, identifies patients at a high risk for relapse, the problem of contamination caused by inadequate precautionary measures can be avoided by meticulous handling and processing of the specimens.

Anaplastic variant of spermatocytic seminoma

Four examples of spermatocytic seminoma with a predominant anaplastic component occurred in men 33 to 43 years of age, without histories of cyptorchidism. The seminomas presented with painless testicular masses recognized 3 to 18 months before orchiectomy. Preoperative serum measurements of human chorionic gonadotropin and alpha-fetoprotein were negative. All tumors contained areas (10% to 30% of the tumor) in which the three cell types characteristic of conventional spermatocytic seminoma could be identified under light microscopy. The predominant anaplastic component also contained the three cell types, but the nuclei had prominent nucleoli with granular and filamentous chromatin. In addition, sheets of cells with vesicular nuclei and prominent nucleoli superficially resembling embryonal carcinoma were found. There were numerous large mononuclear and multinucleated giant cells with bizarre nuclei and prominent nucleoli, but no sarcomatous elements. Many normal and abnormal mitotic figures were present. Tunical and vascular invasion and extensive necrosis were constant features. Immunohistochemistry documented p53 protein overexpression in two tumors, but neoplastic cells were negative with immunostains for placenta-like alkaline phosphatase, leukocyte common antigen, neuron-specific enolase, alpha-fetoprotein, human chorionic gonadotropin, vimentin, and cytokeratins. Ultrastructural examination of the anaplastic component showed large rope-like nucleoli, but the cytoplasmic features were similar to those of conventional spermatocytic seminoma. Despite the presence of a major anaplastic component, no patient has developed metastasis. Larger series and longer follow-up are needed to understand the natural history of these neoplasms.

What does the pathology report really mean?

The correct histological diagnosis, the extent of the tumor, and the histological variables that affect prognosis are important in selecting the initial treatment and determining the need for and type of additional therapy. Therefore, a pathology report should include the following information: (1) histological classification, seminoma versus nonseminomatous germ cell tumor, including the percentage of germ cell components for the latter; (2) presence of vascular and/or lymphatic invasion; (3) involvement of spermatic cord or epididymis; (4) status of cord margin of resection; and (5) a statement about whether viable carcinoma or teratomatous elements are present in the metastatic specimen after chemotherapy. For nonseminomatous germ cell tumors, the pathology report should include a statement about whether the tumor is pure or mixed, and if the latter, the relative amount of each component.

Epstein-Barr virus is detected in undifferentiated nasopharyngeal carcinoma but not in lymphoepithelioma-like carcinoma of the urinary bladder

The Epstein-Barr virus (EBV) is associated with nasopharyngeal carcinoma (NPC) and with lymphoepithelioma-like carcinomas developing in certain anatomic sites. In this study, an in situ hybridization was used to identify EBV-encoded ribonucleic acid (RNA) (EBER1) transcripts in 32 of 45 cases of NPC but not in any of the 11 lymphoepithelioma-like carcinomas developing in the urinary bladder. EBER1 was most commonly detected in those NPCs having undifferentiated or nonkeratinizing squamous histology rather than the keratinizing squamous cell subtype of NPC. The EBV-encoded latent membrane protein 1 (LMP1) was expressed focally in only seven of 21 EBER1-positive NPCs by an immunohistochemical technique. These findings imply that EBER1 hybridization is more sensitive than LMP1 immunohistochemistry on paraffin sections in detecting carcinoma-associated virus. Previous in vitro studies have suggested that LMP1 expression might be a function of differentiation, but this study of naturally infected NPCs showed no strong correlation between LMP1 positivity and degree of tumor differentiation, albeit a limited spectrum of differentiation that could be examined. In two cases in which frozen tissue was available, the NPCs were monoclonal with respect to viral DNA structure, implying that the virus was present before malignant transformation. Unlike NPCs, the lymphoepithelioma-like carcinomas of the bladder were uniformly EBV negative, lending further evidence to the growing body of literature linking EBV with lymphoepithelial carcinomas of foregut-derived tissues but not with similar-appearing tumors developing in other anatomic sites.

Nodular spindle-cell vascular transformation of lymph nodes. A benign process occurring predominantly in retroperitoneal lymph nodes draining carcinomas that can simulate Kaposi's sarcoma or metastatic tumor

We describe a vasoproliferative nodular spindle-cell lesion representing a variant of vascular transformation of lymph-node sinuses and designated a nodular spindle-cell vascular transformation of lymph nodes. The lesion is most frequently identified in retroperitoneal lymph nodes excised in association with radical nephrectomies for renal cell carcinoma, but it can also be present in association with other malignant tumors. Occasionally it is seen in superficial lymph nodes in patients with no history of malignant neoplasms. This lesion can be confused with Kaposi's sarcoma or with a metastatic sarcomatoid carcinoma because of its spindle-cell composition, cellularity, occasional high mitotic activity, and frequent occurrence in the regional lymphatic drainage of a known malignancy.

Osteosarcoma. Specimen management following primary chemotherapy

The use of preoperative (i.e., primary) chemotherapy has been shown to be of direct and significant benefit to the osteosarcoma patient. There is virtually an immediate palliation of symptoms. Increasing numbers of patients with osteosarcoma involving bones of the appendicular skeleton are eligible for limb-salvage procedures secondary to the local effects of chemotherapy that result in a decrease in size and compaction (i.e., down-staging) of the tumors.

p53 expression in dedifferentiated chondrosarcoma

BACKGROUND

p53 acts as a tumor suppressor gene because of to its negative control of the cell cycle and its central role in programmed cell death. It frequently is mutated, as observed in a variety of human neoplasms. The mutations inhibit tumor-suppressor activities of p53, which may gain a new function of tumor promotion. In this study, p53 was investigated in various components of dedifferentiated chondrosarcoma and correlated with their proliferative activities.

METHODS

Immunohistochemical assays for p53, Ki-67, and proliferating cell nuclear antigen (PCNA) were used in a series of eight dedifferentiated chondrosarcomas of bone. The cartilaginous component was low grade (Grade I-II) in five cases. It was predominantly low grade with foci of a high grade (Grade III) chondrosarcoma in the remaining three cases. The noncartilaginous (dedifferentiated) high grade component consisted of malignant fibrous histiocytoma in five cases and osteosarcoma in three.

RESULTS

Regardless of the histological type, diffuse strong nuclear staining for p53 occurred in the high grade noncartilaginous component of all eight of the tumors. The low grade cartilaginous component of six cases was negative for p53, with focal weak staining in the two remaining cases. The high grade cartilaginous component showed strong positive staining for this protein in all three cases. Ki-67 and PCNA expression were similar to that of p53.

CONCLUSIONS

The percentage of p53 positive staining roughly was parallel to the proliferating fraction of cells in various components of dedifferentiated chondrosarcoma. Moreover, p53 overexpression was consistently present in the high grade noncartilaginous (dedifferentiated) component of the tumor and was accompanied by increased proliferative activity.