Periacinar retraction clefting in the prostatic needle core biopsies: an important diagnostic criterion or a simple artifact?

The presence of retraction clefts correlates with lymphovascular invasion and lymph node metastasis and predicts poor outcome: Analysis of 2497 breast cancer patients

Some invasive breast carcinomas are surrounded by a clear space that separate the tumor cells from the adjacent stroma, similar to invasive micropapillary carcinoma (IMPC), but lack the thin strands of connective tissue that separate the cells and characteristic "inside-out" growth pattern of IMPC on immunohistochemical stain for EMA. We consider the presence of the retraction clefts a common phenomenon that may present as a precursor stage of IMPC (PSIMPC). In this study, a total of 2497 cases of invasive breast carcinomas were prospectively collected. Among 2497 cases of breast cancer, 949 (38.0 %) cases were PSIMPC, 200 (8.0 %) cases were IMPC and 1348 (54.0 %) cases were IBC-NST. LVI was seen in128 of 200 (64 %) IMPC and 364 of 948 (38.0 %) PSIMPC, in contrast to 246 of 1341 (18 %) IBC-NST (P < 0.001). Lymph node metastasis was seen in 147 of 200 (73.4 %) IMPC and 551 of 949 (58 %) PSIMPC, in contrast to 563 of 1345 (42 %) IBC-NST (P < 0.001). The 5-year disease-free survival (DFS) and overall survival (OS) of PSIMPC were 76.8 % and 87.6 %, compared to 63.2 % and 85.9 % in IMPC, 86.2 % and 93.7 % in IBC-NST. PSIMPC demonstrated a more favorable DFS and OS compared to IMPC, but worse DFS and OS compared to IBC-NST. Cox and logistic regression analysis showed that PSIMPC was an independent predictor of DFS and OS. Our findings suggest that the presence of retraction clefts is a precursor state of IMPC, exhibiting IMPC-like features, such as higher incidence of lymphovascular invasion, lymph node metastasis and more aggressive clinical behavior.

Peritumoral Clefting and Expression of MMP-2 and MMP-9 in Basal Cell Carcinoma of the Skin

BACKGROUND/AIM

Peritumoral clefting is one of the main histologic features of basal cell carcinoma of the skin (BCC). The aim of the study was to analyze the expression of MMP-2 and MMP-9 both in cells of basal cell carcinoma and in the adjacent stroma and to correlate the findings of immunohistochemical analysis with the presence of peritumoral clefting.

PATIENTS AND METHODS

The study was made on archival material comprising 48 cases of BCC. These were scanned for the presence of peritumoral clefts. The results of immunohistochemical staining for MMP-2 and MMP-9 were determined semiquantitatively using immunohistochemical staining index (ISI).

RESULTS

Peritumoral retractions were found in 40 BCC cases. Positive immunohistochemical reaction for MMP-2 in tumor cells was found in 47 cases and in all cases in the adjacent stroma. Positive immunostaining for MMP-9 in BCC tumor cells was observed in 37 cases and in all cases in the adjacent stroma. There was no statistically significant association between peritumoral retractions and expression of MMPs. A statistically significant correlation was found in the expression of both MMP-2 and MMP-9 between the tumor and the stroma.

CONCLUSION

Tumor cells elaborate MMP-2 and -9, but they also produce some other factors that may induce production of MMPs in adjacent stromal cells. The role of MMPs in the development of peritumoral clefts could not be confirmed.

Prostate cancer: diagnostic criteria and role of immunohistochemistry

The diagnosis of prostate cancer is based on microscopic criteria. Presently, prostate needle biopsy interpretation can be a challenge for the pathologist due to the increased number of specimens with limited amount of suspicious glands and minimal atypia. It is critical for the pathologist to have an organized methodical approach when considering the morphological features enabling a definitive diagnosis of prostate cancer. Although several diagnostic criteria and supportive features have been advocated, only few findings are absolutely specific and diagnostic of prostate cancer. The diagnosis of prostate cancer relies on a combination of architectural and cytological features that are reviewed in detail herein. Infiltrative growth pattern, prominent nucleoli and lack of basal cells are the most useful diagnostic criteria. Perineural invasion, glomerulation and mucinous fibroplasia are pathognomonic features of prostate cancer, although uncommon on small prostate cancer foci. The role of immunohistochemistry in establishing a diagnosis of limited prostate is addressed.

The Impact of Peritumoral Retraction Clefting & Intratumoral Eosinophils on Overall Survival in Oral Squamous Carcinoma Patients

This retrospective study aimed to investigate the impact of peritumoral retraction clefts (RC) and tumor-associated tissue eosinophilia (TATE) as predictors of overall survival (OS) in oral squamous cell carcinoma (OSCC) patients. Their relationships with tumor-factors were also examined. Eighty-seven OSCC cases (pTNM: I + II/III + IV; 32/55), post-curative surgery, comprised the study cohort. Three observers independently estimated the percent RC semi-quantitatively in the selected tumor sections. Additionally, stromal eosinophils were counted in ten consecutive high-power fields of intratumoral and peritumoral regions to evaluate the corresponding TATE. The percent RC ranged between 0% -90% (Mean ± SD: 16 ± 24%; Median: 5%). The stromal eosinophils were greater in peritumoral as compared to intratumoral region. The events of death and tumor recurrence were reached in 16 (18.4%) and 36 (41%) cases respectively. The 3-years OS was 69% [Median OS: 1880 days; Mean follow up: 471(Range; 36-1880) days]. Increased percent RC exhibited relationship with pathologic stage (pTNM III&IV), primary tumor (pT III&IV), tumor depth > 4 mm and categorical tumor recurrence. Additionally, peritumoral eosinophilic infiltrates increased with increasing tumor depths and muscle invasion. Kaplan-Meier curves revealed significantly reduced OS in OSCC cases exhibiting: increased percent RC (>2.5%), mild -moderate/absent intratumoral TATE (versus intense TATE) or categorical tumor recurrence. In subsequent multivariate tests, all the three variables retained significance. Additionally, intraclass correlation coefficient demonstrated acceptable internal consistency for the observers who estimated percent RC. In conclusion, RC and intratumoral TATE proved to be independent predictors of OS in our OSCC cohort. Additionally, increased percent RC pointed towards aggressive tumor behaviour.

High Grade T1 Papillary Urothelial Bladder Cancer Shows Prominent Peritumoral Retraction Clefting

Differentiation of noninvasive from invasive papillary urothelial carcinoma can be challenging due to inability of proper orientation and thermal damage of transurethrally obtained material. The aim of this study was to analyze the presence and extent of peritumoral retractions in pT1 compared to pTa papillary urothelial carcinoma. Since peritumoral retractions may result from altered expression profiles of extracellular matrix proteins, we additionally analyzed the expression of matrix metalloproteinase 2 (MMP-2) and interleukin 8 (IL-8) in these tumors. The study comprised 50 noninvasive (pTa) and 50 invasive (pT1) cases of transurethrally obtained primary papillary urothelial carcinomas. The invasive nature of nests showing peritumoral retractions was confirmed immunohistochemically using antibody against collagen IV. Staining for MMP-2 and IL-8 was evaluated semiquantitatively using immunohistochemical staining index, calculated by multiplying the percentage of positive cells and staining intensity. Peritumoral retractions were found in 32% of pT1 carcinomas but in none of the pTa carcinomas. All tumors showing peritumoral retraction were high grade tumors. There was no statistically significant correlation between the expression of MMP-2 or IL-8 and the presence of peritumoral retractions or stage of the tumor (pTa vs. pT1). A statistically significant but weak correlation was found between MMP-2 and IL-8 expression (χ2-test, p=0,015). There was no statistically significant correlation between the presence of peritumoral retractions or MMP-2 expression and tumor recurrence and progression. Our study shows that, in doubtful cases, when differentiating between pTa and pT1 stages of papillary urothelial carcinoma, the presence of peritumoral retractions could favor the diagnosis of invasive neoplasm.

Artefact as the Pathologist’s Friend: Peritumoral Retraction in In Situ and Infiltrating Duct Carcinoma of the Breast

Peritumoral retraction artefact appears in tissue sections as an empty space partially or completely encircling a nest of tumor cells, usually in conformity with the rounded or angular outline of that particular nest. The present study was designed to test this finding in a large series of cases and to quantify the appearance of peritumoral retraction artefact in, in situ and infiltrating duct carcinoma of the breast. We examined 199 cases of infiltrating duct carcinoma (IDC) and 188 cases of ductal carcinoma in situ (DCIS). Of the total of 387 cases, 111 were core needle biopsies, whereas the others were larger resections. In each specimen, retraction was evaluated on hematoxylin and eosin-stained slides as negative, 1+ (1% to 25% of tumor showing retraction), 2+ (26% to 50%), 3+ (51% to 75%), or 4+ (76% to 100%). Overall, peritumoral retraction was noted in 168 of 199 cases (84.4%) of IDC, versus 30 of 188 cases (16%) of DCIS ( P < 0.0001). Peritumoral retraction scored as 2+ or greater (26% to 50%) was seen in only 1 of 188 DCIS specimens, compared with 77 of 199 IDC. Thus, peritumoral retraction artefact appears to be a significant finding seen during the evaluation of hematoxylin and eosin specimens for the diagnosis of carcinoma. We discuss the possibility that this phenomenon might represent true prelymphatic space involvement rather than a fixation artefact.

Correlation of Periacinar Retraction Clefting in Needle Core Biopsies and Corresponding Prostatectomy Specimens of Patients with Prostatic Adenocarcinoma

One of the underemphasized supportive criteria for the diagnosis of prostatic cancer is the presence of retraction clefting around neoplastic glands. We analyzed a series of 152 prostatic cancer cases to determine the frequency, extent, and correlation of periacinar retraction clefting between needle core biopsies (NCB) and corresponding matched radical prostatectomy (RP) specimens. Clefting was significantly more frequent in neoplastic compared to nonneoplastic acini in NBC and RP (p<0.05). There was no significant difference in the frequency of retraction clefting in neoplastic acini between NCB and corresponding RP (p>O.05). We have also found a concordance in matched RP and NCB (Kappa=0.582). We conclude that periacinar retraction clefting appears more frequently in neoplastic acini and could serve as a reliable criterion in the diagnosis of prostatic adenocarcinoma.

Prostate cancer stroma: an important factor in cancer growth and progression

Reactive stromal changes that occur in different human cancers might play a role in local tumor spreading and progression. Studies done on various human cancers have shown activated stromal cell phenotypes, modified extracellular matrix (ECM) composition, and increased microvessel density. Furthermore, they exhibit biological markers consistent with stroma at the site of wound repair. In prostate cancer, stroma is composed of fibroblasts, myofibroblasts, endothelial cells and immune cells. Predominant cells in the tumorous stroma are, however, fibroblasts/myofibroblasts. They are responsible for the synthesis, deposition and remodeling of the ECM. Epithelial tumorous cells, in interaction with stromal cells and with the help of various molecules of ECM, create a microenvironment suitable for cancer cell proliferation, movement, and differentiation. In this review, we discussed the role of different stromal components in prostate cancer as well as their potential prognostic and therapeutic significance.

Periacinar retraction clefting in nonneoplastic and neoplastic prostatic glands: artifact or molecular involvement

A space between neoplastic acini and prostatic stroma is not rare and studies have interpreted this as an artifact, considering the absence of endothelial cells indicating vascular invasion. Thus, the aims of this work were to characterize and correlate the occurrence and extent of retraction clefting with the reactivities of α and β dystroglycan (αDG, βDG), laminin, matrix metalloproteinase 2 (MMP-2), p63, insulin-like growth factor 1(IGF-1), vimentin, and fibroblast growth factor 2 (FGF-2). The study was based on nonneoplastic and neoplastic prostatic tissues obtained from necropsies and retropubic radical prostatectomies. The results showed that periacinar retraction clefting was significantly more frequent in prostatic carcinoma samples than in normal prostatic acini. Most of the neoplastic acini (72.0%) showed retraction clefting of more than 50% of circumference, which were significantly more frequent in Gleason score 7 and 6. Decreased collagen and reticular and elastic fibers were verified in the stroma around neoplastic acini. Weak and discontinuous αDG, βDG, and laminin immunoreactivities and intensified MMP-2, vimentin, IGF-1 and FGF-2 immunoreactivities were verified in the neoplastic acini; p63 immunoreactivity was negative in all carcinomas. Thus, these findings showed that the lack of epithelial basal cells, DGs, and laminin and increased MMP-2, IGF-1, and FGF-7 could be considered important pathways in periacinar retraction occurrence. This study demonstrated the origin of and the biological mechanisms responsible for periacinar retraction clefting in prostatic carcinoma.

Periacinar retraction clefting and d2-40 expression in prostatic adenocarcinoma

Retraction clefting is known to appear in various types of tumors, but it has only recently been recognized as a specific histological phenomenon. Previously, it was considered merely a laboratory procedure artifact, but lately, there have been some assumptions that peritumoral retractions actually represent lymphatic spaces. In our study, we analyzed neoplastic glands in 52 specimens of prostatic adenocarcinoma. Immunohistochemical analysis was performed using D2-40 antibody, to highlight lymphatic endothelium and thereby differentiate actual lymph vessels or lymphovascular invasion from periacinar retractions. Our results showed that the number of lymph vessels was significantly lower in tumorous tissue compared to adjacent normal prostatic tissue. On the other hand, the number of lymph vessels in tumorous tissue was significantly higher than the number of lymph vessels mimicking periacinar retractions. Overall, the number of lymph vessels mimicking periacinar clefts was particularly low. These results are in accordance with our previous studies, which had shown that periacinar clefting appears due to lack of basal cells and stromal changes around tumorous acini. Also, these results support our hypothesis that retractions do not represent lymph vessels but should be considered a distinct entity, which is proven to be helpful both as diagnostic and predictive factor.

Extensive retraction artefact predicts biochemical recurrence-free survival in prostatic carcinoma

AIMS

To determine whether the presence and extent of peritumoral retraction artefact could be used to predict biochemical recurrence-free survival in prostatic carcinoma.

METHODS AND RESULTS

The study included 162 consecutive patients treated by radical retropubic prostatectomy and bilateral lymphadenectomy for clinically localized prostatic carcinoma. A variable degree of retraction artefact was present in all 162 analysed tumours. The extent of retraction artefact in prostatic carcinomas ranged from 5% to 55% with a median value of 15% (interquartile range 10-25%). We found no correlation between the extent of retraction artefact in the tumours and patient's age (P=0.608), preoperative (P=0.362) and postoperative (P=0.279) Gleason score or lymph node metastases (P=0.084). In contrast, the extent of retraction artefact correlated with high preoperative prostate-specific antigen (P<0.001), short follow-up time (P<0.001), seminal vesicle invasion and/or extracapsular extension of the tumour (T3 stage tumours) (P<0.001) and positive surgical margins (P<0.001). Furthermore, extensive retraction artefact was associated with poor biochemical recurrence-free survival in both univariate (P<0.001) and multivariate analyses (P=0.013).

CONCLUSION

The presence of extensive retraction artefact in prostatic carcinoma correlates with tumour characteristics signifying aggressive behaviour and indicates poor biochemical recurrence-free survival.

The presence of micropapillary features and retraction artifact in core needle biopsy material predicts lymph node metastasis in breast carcinoma

Retraction artifact around tumor cell nests is a characteristic feature of invasive micropapillary carcinoma (IMPC), a special type of breast cancer commonly associated with nodal metastasis. We have recently reported that the extent of retraction artifact in usual invasive ductal carcinomas (IDC) is also a strong predictor of nodal metastasis. We examined whether the presence and extent of micropapillary features and retraction artifact in core needle biopsy of breast cancers can predict nodal metastasis in a prospective series of 47 IMPC and 424 IDC. Micropapillary features were present on core needle biopsy in 28 of 47 IMPC cases. Nodal metastases were found in 21 of 28 and 14 of 19 IMPC cases with and without micropapillary features present on core needle biopsy, respectively. Lymph node metastasis was significantly associated with the presence of micropapillary features, but not with its extent within these tumors. The presence of extensive retraction artifact in core needle biopsy samples of IDC also showed a significant association with nodal metastasis. Our results indicate that the presence of micropapillary features or extensive retraction artifact on core needle biopsy of breast carcinoma can predict nodal metastasis. Our results support the notion that the characteristic clear spaces separating the tumor cells from the stroma in IMPC and IDC of the breast are not a random artifactual phenomenon simply resulting from tissue fixation and processing, but rather they are likely related to altered tumor-stromal interactions, which might have an important role in lymphatic tumor spread.

Periacinar retraction clefting in proliferative prostatic atrophy and prostatic adenocarcinoma

AIMS

To evaluate the presence and extent of periacinar retraction clefting in proliferative prostatic atrophy and carcinoma in radical prostatectomy specimens.

METHODS

Atrophic foci and neoplastic glands were analysed in specimens from 50 patients who underwent radical prostatectomy. Analysed atrophic glands were classified in two main groups, proliferative atrophy (PA) and proliferative inflammatory atrophy (PIA); each group was subclassified into simple atrophy (SA) and postatrophic hyperplasia (PAH). According to the presence and extent of periacinar retraction clefting, atrophic and neoplastic glands were classified as: group 1, glands without clefts or with clefts affecting 50% of the circumference in <50% of examined glands; and group 3, glands with clefts that affected >50% of the circumference in >or=50% of examined glands.

RESULTS

Forty-four (88.0%) atrophic foci were without periacinar clefts or clefts were present in less than half of the gland circumference (group 1). In 6 (12.0%), atrophic foci clefts affected >50% of gland circumference (groups 2 and 3). Forty-five (90.0%) carcinomas were with clefts which affected more than 50% of gland circumference (groups 2 and 3); and in five carcinomas only, clefts were not found or affected <50% of gland circumference (group 1).

CONCLUSION

Results indicate that periacinar retraction clefting represents a reliable criterion in differential diagnosis between proliferative atrophy and carcinoma.

Extensive retraction artifact correlates with lymphatic invasion and nodal metastasis and predicts poor outcome in early stage breast carcinoma

Retraction artifact resulting in clear spaces around tumor cell nests is frequently seen in histologic material and may present difficulty in their differentiation from lymphovascular invasion. We noticed that retraction artifact seemed to be more common around groups of breast cancer cells compared with benign acini, and when extensively present, metastasis to axillary lymph nodes was often seen. Thus, we performed a study of 304 cases of stage pT1 and pT2 breast carcinomas to test our hypothesis that extensive retraction artifact in tumors correlates with lymphatic spread and outcome. Tumors were evaluated to determine the presence and extent of retraction artifact around tumor cell nests and the presence of lymphatic invasion. Lymphatic invasion was confirmed by D2-40 immunostaining. The extent of retraction artifact in tumors was correlated with clinicopathologic tumor features and patient outcome. Variable degree of retraction artifact was present in 183 of 304 (60%) invasive carcinomas, with its extent ranging from 0% to 90% (median 5%). The extent of retraction artifact showed a significant correlation with tumor size, histologic type, histologic grade, presence of lymphovascular invasion, and nodal metastasis. Further, extensive retraction artifact was significantly associated with poor overall and disease-free survival in both univariate and multivariate analyses. We propose that the apparent retraction of the stroma from cells of invasive breast carcinoma on routine histologic sections is not a phenomenon merely due to inadequate fixation as currently believed. Rather, it likely signifies important biologic changes that alter tumor-stromal interactions and contribute to lymphatic spread and tumor progression.

Periacinar Clefting and p63 Immunostaining in Prostatic Intraepithelial Neoplasia and Prostatic Carcinoma

The aim of the present study was to correlate the presence and extent of retraction clefting and the expression of p63 in neoplastic glands and glands with prostatic intraepithelial neoplasia (PIN) in needle core biopsies. We analyzed needle core biopsies from 28 patients with PIN and 41 patients with adenocarcinoma. Neoplastic glands and those with PIN were analyzed on high power field (400x) and classified in three groups according to the extent of clefting. Immunohistochemical staining was performed following Microwave Streptavidin ImmunoPeroxidase (MSIP) protocol on DAKO TechMate Horizon automated immunostainer. Periacinar retraction clefting was significantly more prominent in prostatic carcinoma compared to PIN (p<0.0001) and nonneoplastic glands (p<0.0001). There was no difference between normal glands and PIN regarding clefting (p=0.8064). p63 was positive around the whole circumference in 12 out of 28 cases with PIN, and discontinuously positive in remaining 16 PIN cases suggesting initial disruption of the basal cell layer. p63 immunostaining was also positive in all nonneoplastic glands, and negative in all carcinomas. We conclude that retraction clefting was associated with cancer and lack of basal cells, but not with PIN. The relationship between clefting and p63 immunostaining in prostatic cancer should be further analyzed.

The potential value of (Myo)fibroblastic stromal reaction in the diagnosis of prostatic adenocarcinoma

BACKGROUND

Reactive stromal changes that occur in different human cancers probably are involved in local tumor spreading. The aim of this study was to analyze changes of the stroma in prostatic carcinoma and to establish their possible diagnostic significance.

METHODS

For the definition of reactive stroma in prostate cancer Mallory trichrome method and immunohistochemical analysis of vimentin, alpha-smooth muscle actin, and desmin were performed.

RESULTS

Compared with adjacent peritumoral tissue and stroma in benign prostatic hyperplasia, reactive stroma in prostate cancer showed increased vimentin expression, and decreased desmin expression (P < 0.05). Mallory method also showed more pronounced desmoplastic reaction in stroma of prostatic adenocarcinoma (P < 0.05).

CONCLUSIONS

Our study indicates that a reactive stroma, which occurs in prostatic carcinoma, could be clearly shown by Mallory method and confirmed by immunohistochemistry. We suggest that Mallory trichrome method may be used as a helpful additional diagnostic tool in the diagnosis of suspicious cases of prostatic adenocarcinoma.