Parachordoma

Parachordoma is a soft tissue tumor that has a light microscopic appearance similar to that of chordoma, and the immunostaining properties of the two tumors are alike. The clinical findings and light microscopy of one case of parachordoma are presented together with ultrastructural observations on this tumor and parachordomas from five additional patients.

Mesenchymal hamartoma of the chest wall in infants and children: a clinicopathological study of five patients

Mesenchymal hamartoma of chest-wall is a rare benign lesion that has varied histological characteristics and usually occurs during early infancy. We report the histological characteristics of mesenchymal hamartoma found in five patients aged respectively 25 days, 5 months, 8 months, and 4 and 8 years at presentation. Two patients presented with respiratory distress, two with an asymptomatic chest-wall mass, and one with a deformity of the left chest wall. Surgical resection was performed on four patients and a biopsy only in one patient. Overall, the tumors were well delineated, lobulated, tan to reddish in color, and on section showed blood-filled cystic spaces with interspersed small islands of cartilage and fibrous tissue. Histological analyses demonstrated mixtures of bone trabeculae with spindle-cell stroma, chondroblast-like proliferation, mature and immature hyaline cartilage, and aneurysmal bone cyst formation. All patients are alive and well without evidence of disease. Despite the alarming clinical and histologic presentation, mesenchymal hamartoma of the chest wall is a non-neoplastic benign lesion.

Pseudosarcomatous fibromyxoid tumor of the urinary bladder and prostate: immunohistochemical, ultrastructural, and DNA flow cytometric analyses of nine cases

Pseudosarcomatous fibromyxoid tumor of the genitourinary tract is a rare pathologic entity of hitherto unknown etiology that, because of the cellular pleomorphism and the infiltrative nature of the lesion, may be mistakenly diagnosed as sarcomatoid carcinoma or sarcoma. We retrospectively studied nine pseudosarcomatous fibromyxoid tumors involving the bladder and prostate to define characteristic parameters that may allow for accurate diagnosis. The study patients included four men and five women with a mean age of 48.7 years. Histologic analysis revealed myxoid lesions with a proliferation of spindle fibroblastic cells in a background of granulation tissue-type vascularity and inflammatory cells. Mitoses were infrequent and no atypical forms were found. Immunostaining was positive for vimentin and smooth muscle actin, and negative for S-100 protein, desmin, myoglobin, and keratin. Ultrastructurally, the lesion displayed fibroblastic and myofibroblastic cell features. Flow cytometric DNA content analysis revealed uniform DNA diploidy and a low S-phase fraction. All patients were alive and well with no evidence of disease after a mean follow-up of 4.8 years. In contrast, the sarcomatoid carcinomas and sarcomas of the urinary bladder and prostate that were used as controls occurred in older patients and had more frequent mitoses with atypical forms, tumor-type necrosis, and different immunostaining profiles; they were preponderantly aneuploid or diploid with high S-phase fraction. Awareness of the clinicopathologic and biologic characteristics of these lesions is necessary to ensure their accurate diagnosis and to prevent unnecessary radical therapy.

Primary carcinoid of the kidney. Immunohistochemical and ultrastructural studies of five patients

BACKGROUND

Primary carcinoid tumor of the kidney is rare; only 18 patients have been reported. Because of the rarity of the lesion, its prognosis and clinicopathologic features are not well characterized, and its histogenesis is unknown.

METHODS

Clinicopathologic, immunohistochemical, and ultrastructural studies were performed on five patients with primary carcinoid tumor of the kidney.

RESULTS

Age of the patients ranged from 42 to 63 years, with a mean of 53.2 years. Only one patient had a carcinoid syndrome. Three were men, and two were women. In each patient, the tumor was solitary and confined to the kidney. All tumors had histologic features identical to those of carcinoid tumors affecting other sites. The cytoplasmic granules of the tumor cells were reactive with Grimelius stain in all patients. All tumors also were immunoreactive for keratin, neuron-specific enolase, and chromogranin, but only two patients had tumors that reacted for serotonin, pancreatic polypeptide, and vasoactive intestinal polypeptide. Ultrastructural studies showed numerous intracytoplasmic neuroendocrine granules in four tumors. One patient had Robson Stage I cancer, and two each had Stage II and IV cancer. The two patients with Stage IV tumor died of disease at 36 months and 28 months after diagnosis; one patient with Stage II carcinoid is alive without clinical evidence of residual disease 8 years after control of metastases; the other patient with Stage II and the patient with Stage I cancer are alive and well without evidence of disease at 36 months, and 2 months, respectively.

CONCLUSION

Tumor stage at presentation appears to be the most important factor in determining outcome. The number of mitoses and degree of cellular atypia appear to be important pathologic parameters in predicting prognosis, despite the limited number of patients reported in this report.

Granulosa cell tumor of the adult testis: a clinicopathologic study of seven cases and a review of the literature

We report a study of seven men, aged 16 to 76 years (average age, 47.4 years) with granulosa cell tumor (GCT) of the testis. Three patients presented with testicular enlargement of several years' duration and a fourth presented with a testicular enlargement of unknown duration. The tumors in three patients were detected during routine physical examination. None of the patients had endocrine-related symptoms. All tumors were well circumscribed and showed the solid, cystic, microfollicular, gyriform, insular, and trabecular patterns typical of GCT of the ovary. Call-Exner bodies were present in three tumors and two tumors had a focal spindle-cell component. In one case the surrounding testicular parenchyma showed Leydig's cell hyperplasia and a Sertoli cell nodule. The tumor cells revealed strong immunoreactivity for vimentin but showed no expression for keratin or epithelial membrane antigen. One patient developed liver and retroperitoneal lymph node metastases 121 months after initial diagnosis and died 13 months later. Another patient initially presented with retroperitoneal lymph node metastasis and developed metastasis to the inguinal lymph nodes 12 months later. Three patients are alive at 1, 4, and 37 months with no evidence of disease. Another patient died of an unrelated condition. Follow-up information was not available for the seventh patient. Twelve cases of GCT of the adult testis have been reported in the literature, with metastases occurring in two: one of these two patients had a tumor for 8 years and died of disease 5 months after diagnosis with multiple metastases and the other had metastasis at the time of diagnosis, but was free of disease for 14 years. Our findings and a review of the literature indicate that GCT of the adult testis is a rare and slow-growing neoplasm with the potential to form distant metastases. Because recurrence or distant metastasis may occur late in the clinical course, long-term follow-up of these patients is recommended.

Sarcomatoid collecting duct carcinoma: a clinicopathologic and immunohistochemical study of five cases

Sarcomatoid renal cell carcinoma is a well-known entity, but sarcomatoid collecting duct carcinoma has not been reported. We recently encountered five cases. The patients were men whose ages ranged from 59 to 82 years (mean age, 68 years). All presented with gross hematuria and three had abdominal fullness. Tumor size ranged from 6 to 9 cm in greatest dimension. The Fuhrman's nuclear grade of the carcinomatous components was 3 in three cases and 4 in two. The sarcomatoid areas were composed of pleomorphic spindle cells forming a malignant fibrous histiocytomatous pattern in four cases and a fibrosarcomatous pattern in one. The immunohistochemical findings in the carcinomatous and sarcomatoid components were identical. Wide-spectrum anti-cytokeratin cocktail, epithelial membrane antigen, and vimentin antibodies demonstrated immunoreactivity, while Leu-M1 did not react in all five cases. Three of the five tumors were positive for Ulex europaeus agglutinin I lectin. One sarcomatoid carcinoma reacted with monoclonal antibody to high molecular weight keratins, and all five tumors reacted with a monoclonal antibody to low molecular weight keratins. Two patients died at 5 months and 13 months after diagnosis, two are alive with metastatic disease at 1 and 14 months, and one is alive with no evidence of disease at 36 months.

Prognostic factors in prostate cancer. Analysis of 874 patients treated with radiation therapy

BACKGROUND

The outcome of radiation therapy for localized prostate cancer depends on many pretreatment variables that are interrelated in complex ways. A multivariate analysis of 874 cases of prostate cancer treated between 1966 and 1988 was conducted. The median length of the follow-up period after radiation therapy was 6.7 years.

METHODS

The disease outcome and rate of survival was analyzed with the proportional hazards model for patients with stage A2 (104), stage B (168), or stage C (602) prostate cancer treated with radiation therapy as the only primary treatment.

RESULTS

Local recurrence rates were 12%, 24%, and 33% at 5, 10, and 15 years, respectively. In multivariate analysis, stage (A2 vs. B+C) and pathologic grade (1 + 2 vs 3 + 4) were independently related to local recurrence. At 10 years local control had been achieved in 79% of favorable cases (stage A2 or stage B/C, grade 1), but in only 62% of unfavorable cases (stage B/C, grade 4). Metastatic relapse rates were 25%, 38%, and 47% at 5, 10, and 15 years, respectively. Factors that independently correlated with metastasis were high pathologic grade, transurethral resection in stage C, elevated acid phosphatase levels, and being 60 years of age or younger. A favorable group of cases (stage A2/B, grade 1 or stage C, grade 1, no transurethral resection, older than 60 years of age) had a metastatic rate of only 10% after 10 years, whereas an unfavorable group (largely stage C, grades 3/4) had a metastatic rate approaching 70%. The overall survival rate was 77%, 49%, and 32% at 5, 10, and 15 years, respectively. Pathologic grade (1 vs 2 + 3 vs 4) and transurethral resection in stage C correlated with survival. A favorable group of patients (stage A2/B or stage C and grade 1) had a normal survival expectation of 15 years. An unfavorable group consisting of grade 4 tumors had a survival rate of less than 20% at 10 years.

CONCLUSIONS

The complexity and long natural history of prostate cancer demand careful stratification and follow-up examination to evaluate treatment results. The study of adjuvants to improve the local effectiveness of radiation and to mitigate the high metastatic rates in unfavorable local disease are urgent priorities.

Primary carcinoid tumor of testis. Immunohistochemical, ultrastructural, and DNA flow cytometric study of three cases with a review of the literature

The cases of three patients with primary carcinoid tumor of the testis were reported. The patients were 41, 44, and 83 years of age. At initial examination, all three had testicular masses with or without associated pain, and none had the carcinoid syndrome. The tumors measured 4.3 cm, 3.0 cm, and 6.5 cm in dimension. All three tumors manifested classic histologic features of carcinoid tumors. The neoplastic cells exhibited argyrophilia, and all were immunoreactive to chromogranin, serotonin, neuron-specific enolase, and cytokeratin. Two tumors had positive test results for gastrin and one had positive test results for substance P and vasoactive intestinal polypeptide. No tumors reacted with somatostatin, insulin, pancreatic polypeptide, or placental alkaline phosphatase. Intracytoplasmic, membrane-bound, round-to-elliptical pleomorphic granules were identified by ultrastructural analysis in all cases. DNA flow cytometric analysis revealed a low degree (near-diploid) DNA aneuploidy in all cases, with a DNA index of 1.15 in two tumors and 1.3 in the third tumor. The three patients are alive and well 11 years, 7 years, and 6 months, respectively, after diagnosis. A total of 57 cases of this entity, including the 3 reported here, have been reported. Of these, 43 were pure carcinoid, and 14 were associated with teratoma; 6 (11.6%) patients developed metastases. Tumor size and the presence of carcinoid syndrome have been found to correlate with metastatic potential. Neither tumor necrosis nor local tumor invasion (into vessels, tunica albuginea, etc.) correlated with adverse prognosis. Carcinoid tumor of the testis is a rare indolent neoplasm with potential for distant metastases.

Case report 798: Recurrent chondromyxoid fibroma in connective tissue of leg

In summary, this is a case of recurrent CMF in soft tissue, 17 years after the diagnosis of the initial lesion. The literature concerning this entity is reviewed and the histological and radiological patterns are considered. The causative factors are evaluated and the prognosis is discussed.

Dedifferentiation of locally recurrent prostate cancer after radiation therapy. Evidence for tumor progression

BACKGROUND

Untreated or unsuccessfully treated prostatic adenocarcinoma may develop more malignant characteristics as time passes--the phenomenon of tumor progression. Whether this occurs after unsuccessful radiation therapy has not been answered. This study was designed to address that issue.

METHODS

The histologic grades at initial diagnosis and at local recurrence were compared in 49 patients who experienced local recurrence after external beam radiation therapy.

RESULTS

Tumor grades were assigned using the M. D. Anderson grading system. At the initial diagnosis, the grades were distributed as follows: Grade 1, 18 (37%), Grade 2, 22 (45%); Grade 3, 8 (16%); and Grade 4, 1 (2%). At recurrence, the grades were: Grade 1, 3 (6%); Grade 2, 14 (29%); Grade 3, 14 (29%); and Grade 4, 18 (37%). The shift to higher grades at recurrence was highly significant (P < 0.001). This dedifferentiation could not be accounted for by possible tissue sampling variability, and stepwise multiple variable logistic regression revealed that the only factor predicting for dedifferentiation was the time since treatment. The tumors that recurred later had a significantly higher likelihood to be dedifferentiated than those that recurred early. Patients whose tumors dedifferentiated had a poorer survival than those whose tumors retained their original grade.

CONCLUSIONS

The possibilities were considered that the dedifferentiation could arise by tissue sampling error, by persistence and regrowth of high-grade components, by the development of new tumors, or by radiation-induced transformation. None of these mechanisms appeared to explain the data adequately, and it was concluded that the observed dedifferentiation was indeed a manifestation of time-dependent tumor progression. Eradication of the primary tumor is therefore important, not only to allay local symptoms, but also to prevent the emergence of more virulent and potentially lethal tumors.

MRI of extraskeletal osteosarcoma

We report four cases of extraskeletal osteosarcoma of the thigh to illustrate MRI findings of this rare neoplasm. Calcifications or osteoid material were not discernible in these tumors on MRI or conventional radiography. Three tumors were well demarcated on MRI and corresponded to pseudoencapsulation on radiologic-pathologic correlation. These three tumors were heterogeneous in appearance and were hyperintense to muscle on T1-weighted imaging and demonstrated high signal intensity on T2-weighted imaging. In the fourth tumor, which occupied almost the entire thigh, MRI before and after intravenous gadopentetate dimeglumine administration revealed cystic, hemorrhagic, and solid components. Pathological examination revealed a cystic hemorrhagic cavity containing necrotic and viable tumor and a large solid tumor component. The MRI findings in extraskeletal osteosarcoma are non-specific. However, in the appropriate age group the differential diagnosis of a soft-tissue mass in the thigh should include extraskeletal osteosarcoma, even in the absence of radiographically discernible calcifications or osteoid material within the soft-tissue mass.

Extraskeletal myxoid chondrosarcoma. A clinicopathologic study of ten patients with long-term follow-up

Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft tissue sarcoma that has been reported to have a relatively good prognosis. The authors report ten patients with EMC on whom there was a minimum follow-up of 10 years. The patients' ages ranged from 31 to 72 years (mean, 57 years); there were six men and four women (seven white, three black). The tumor locations included the knee area and thigh (three patients each), the shoulder (two patients), and the leg and foot (one patient each). The tumors ranged from 3.5 to 18 cm in greatest dimension (median, 11.5 cm). All cases had typical histologic features. Lung metastases developed in all patients but one, and three patients had extrathoracic metastases (one in regional lymph nodes; one in subcutis; and one widespread). Four of the patients who had metastases also had local recurrence, as did the only patient without known metastases. Seven patients died of tumor at 4, 5, 8, 10, 15, 16, and 17 years, respectively, and the three remaining patients were alive with metastatic disease at latest follow-up of 13, 14, and 16 years. The authors' results are distinctly different from those previously reported in series with shorter follow-up times. The authors conclude that extraskeletal myxoid chondrosarcomas are indolent but resilient and capricious tumors with a high potential for metastasis, especially to the lungs, over the long-term.

Diagnosis of eosinophilic granuloma of bone by fine-needle aspiration with concurrent institution of therapy: a cytologic, histologic, clinical, and radiologic study of 27 cases

Twenty-seven patients with eosinophilic granuloma (EG) of bone seen at our institution between 1979 and 1991 underwent fine-needle aspiration (FNA) with or without concurrent Tru-Cut biopsy. The 16 males and 11 females ranged in age from 2 1/2 to 61 years (median, 10 yr). Twenty-four patients had monostotic lesions. The clinicoradiologic differential diagnosis included osteomyelitis and Ewing's sarcoma (young patients) and primary and metastatic malignancies (older patients). Twenty-four of 28 FNAs (one patient had two FNAs) were diagnostic of EG, and 10 cases were diagnosed by FNA alone. Smears in these cases showed histiocytes, often with grooved or infolded nuclei, and abundant eosinophils. Multinucleated giant cells, foamy histiocytes, neutrophils, lymphocytes, and plasma cells were present in variable numbers. Four FNAs were misdiagnosed: two as osteomyelitis where smears contained abundant neutrophils, sparse eosinophils, and histiocytes misinterpreted as foamy histiocytes, and two as metastatic carcinoma (in adults) where histiocytes in a scant specimen (one case) and skin appendiceal structures without lesional tissue (one case) were misinterpreted. These cases were correctly diagnosed on repeat FNA (one case), Tru-Cut (two cases), or excisional biopsy (one case); however, three cases diagnosed by FNA had nondiagnostic concurrent Tru-Cut biopsies. Treatment consisted of intralesional injection of 125 mg of methylprednisolone (22 cases). Progressive or complete healing of all lesions occurred. FNA is a rapid and useful technique for the immediate diagnosis of EG that allows concurrent institution of therapy.

Extraskeletal myxoid chondrosarcoma. A clinicopathologic study of ten patients with long-term follow-up

Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft tissue sarcoma that has been reported to have a relatively good prognosis. The authors report ten patients with EMC on whom there was a minimum follow-up of 10 years. The patients' ages ranged from 31 to 72 years (mean, 57 years); there were six men and four women (seven white, three black). The tumor locations included the knee area and thigh (three patients each), the shoulder (two patients), and the leg and foot (one patient each). The tumors ranged from 3.5 to 18 cm in greatest dimension (median, 11.5 cm). All cases had typical histologic features. Lung metastases developed in all patients but one, and three patients had extrathoracic metastases (one in regional lymph nodes; one in subcutis; and one widespread). Four of the patients who had metastases also had local recurrence, as did the only patient without known metastases. Seven patients died of tumor at 4, 5, 8, 10, 15, 16, and 17 years, respectively, and the three remaining patients were alive with metastatic disease at latest follow-up of 13, 14, and 16 years. The authors' results are distinctly different from those previously reported in series with shorter follow-up times. The authors conclude that extraskeletal myxoid chondrosarcomas are indolent but resilient and capricious tumors with a high potential for metastasis, especially to the lungs, over the long-term.

Renal oncocytoma and granular renal cell carcinoma. A comparative clinicopathologic and DNA flow cytometric study

Twenty-three renal oncocytomas and 18 granular renal cell carcinomas (GRCC) were comparatively studied clinicopathologically and by DNA flow cytometry to delineate their differences. Of the patients with renal oncocytomas, 15 were men and 8 were women, and their ages ranged from 42 to 81 years (mean, 64 years). The gross appearance of renal oncocytomas was characteristically homogeneous tan-brown, with variable scarring, without areas of large hemorrhage, and with no apparent necrosis. Twenty-two renal oncocytomas were confined within the kidney (Robson stage I) and one tumor extended into the renal vein (stage IIIa). Twenty-two renal oncocytomas, including the stage IIIa tumor, manifested diploid DNA content and only one neoplasm showed a feature suggestive of near-diploid DNA aneuploidy. Of the 17 patients with renal oncocytomas who had adequate follow-up, none developed metastasis or died of disease. Of the patients with GRCC, 13 were men and 5 were women, and their ages ranged from 30 to 73 years (mean, 53 years). The gross appearance of GRCC was variegated, yellow to tan, and punctuated with geographic areas of necrosis. Eleven patients with GRCC were stage I, 4 were stage II, 2 were stage IIIa, and 1 patient had metastases at initial examination (stage IV). Seven GRCCs were DNA diploid, one was DNA tetraploid, and 10 tumors were DNA aneuploid. Twelve patients were alive with no evidence of disease (12 to 36 months; median, 26 months). All patients with DNA diploid neoplasm pursued benign clinical courses. One patient was alive with metastatic disease and two patients developed metastases and died of their disease; all three patients had DNA aneuploid tumors. Two patients died of other causes and one patient was lost to follow-up. Our data indicate that renal oncocytoma is a distinct clinicopathologic disease with characteristic gross, histologic, DNA flow cytometric, and biologic features that are different from GRCC.

Metastatic prostatic carcinoma presenting as an oncocytic tumor

We discuss a 63-year-old man who presented with a metastatic tumor in an inguinal lymph node. By light microscopy, the tumor cells were characterized by a finely granular eosinophilic cytoplasm. A diagnosis of metastatic oncocytic carcinoma was made based on the results of an ultrastructural examination, which showed the cytoplasm of the tumor cells to be filled with mitochondria. Results of immunocytochemical studies showed positive reactivity for prostatic acid phosphatase and prostate-specific antigen. A transurethral resection of the prostate showed an oncocytic adenocarcinoma of the prostate, apparently the first of its kind, which was demonstrated to be the site of origin of the inguinal lymph node metastasis.

Cytologic and histologic features of superficial bladder cancer

Despite technologic advances in diagnostic skills, cytologic and histologic evaluation is still the standard for the identification of bladder cancer, and these two techniques are critical in therapy selection and post-treatment surveillance. The key to the proper interpretation of cytologic specimens lies in appropriate collection and handling of the sample. Because treatment differs according to the histologic type of a tumor, when a mixture of types is found, all should be listed with their relative proportions. Both pathologists and urologists must be aware of the importance of the muscularis mucosae; a transitional-cell carcinoma may invade this layer without extending into the true muscle.

Chondrosarcoma: MR imaging with pathologic correlation

Magnetic resonance (MR) images of 21 surgically confirmed chondrosarcomas were retrospectively reviewed in conjunction with plain radiographs and computed tomographic scans and correlated with pathologic findings. The tumors appeared lobulated, and signal intensity, as analyzed visually (intermediate on T1-weighted, high on T2-weighted images), was similar for all lesions, regardless of pathologic type. Size of lesion was not an indicator of grade. The appearances of mesenchymal and dedifferentiated chondrosarcomas mimicked that of conventional chondrosarcoma. Extraskeletal chondrosarcoma was visualized as a lobulated soft-tissue mass. In all cases, MR imaging accurately depicted intraosseous and soft-tissue extent of tumor noted at surgery and pathologic examination. Histologic type or grade of chondrosarcoma generally cannot be characterized on the basis of visual analysis of signal intensity noted on routine MR images. However, MR imaging is excellent for exact delineation of tumor extent.

Sarcomatoid carcinoma of the prostate. A clinicopathologic study of 12 patients

Sarcomatoid carcinoma of the prostate is a rare tumor that can be difficult to distinguish from a true sarcoma. The authors report 12 patients in whom the typical light microscopic appearance of prostatic adenocarcinoma was accompanied by the appearance of spindled or pleomorphic sarcomatoid areas within the same specimen or in subsequent accessions. Immunostaining or electron microscopic study demonstrated epithelial differentiation within the sarcomatoid area(s) in 6 of the 11 patients in whom special studies were performed. All nine patients for whom follow-up data were available died of disease within 3 to 48 months (median time until death, 12.0 months) after the appearance of the sarcomatoid carcinoma, and the clinical course in each instance was characterized by aggressive local recurrence. Our experience confirms that sarcomatoid carcinoma of the prostate is an aggressive variant of prostatic adenocarcinoma.