Axillary node staging by ultrasonography and fine-needle aspiration cytology in patients with breast cancer

Background

This study evaluated the role of axillary ultrasonography (AUS) and fine-needle aspiration cytology (FNAC) in preoperative staging of the axilla in patients with invasive breast cancer.

Methods

Between October 2006 and March 2009, 502 patients scheduled to undergo surgery for invasive breast cancer had preoperative AUS. All patients with suspicious nodes on ultrasonography underwent FNAC, and those with positive cytology proceeded directly to axillary node clearance. Patients with normal findings on AUS or negative cytology underwent sentinel node biopsy (SNB).

Results

A total of 137 (27·3 per cent) of 502 patients had axillary node metastases on final histology. Thirty-nine (28·5 per cent) node-positive patients were identified by AUS–FNAC and spared unnecessary SNB. AUS–FNAC had a sensitivity of 28·5 per cent and a specificity of 100 per cent for detecting axillary nodal metastases. AUS–FNAC findings were normal in all 15 patients with nodal micrometastases and in 11 patients with isolated tumour cells on histopathology. The sensitivity of AUS–FNAC had a positive correlation with invasive tumour size (odds ratio 1·03) and grade (odds ratio 2·80).

Conclusion

Preoperative AUS–FNAC avoided unnecessary SNB in 28·5 per cent of node-positive patients and in 7·8 per cent of patients overall.

Intraoperative evaluation of axillary sentinel lymph nodes using touch imprint cytology and immunohistochemistry. Part II. Results

AIM

In order to operate selectively on positive axillae during the initial operative session for early breast cancer, an accurate and rapid intraoperative method to examine an axillary node sample (ANS) or a sentinel node biopsy (SNB) is required. The aim of this study was to determine the feasibility and accuracy of Immunohistochemistry (IHC)-stained touch imprints in detecting metastatic axillary nodes intraoperatively.

MATERIAL AND METHODS

Four hundred and thirty-two axillary nodes from 52 patients (23 axillary node clearance (ANC), 15 ANS and 14 SNB) were bisected, imprinted and stained with anti-cytokeratin 19 IHC. Results were compared with those of routine haematoxylin and eosin (H&E)-stained sections.

RESULTS

IHC imprints detected 32 positive nodes from 12 patients. H&E sections detected 31 positive nodes from 11 patients. IHC imprints missed metastases in three nodes and missed the diagnosis of positive axillae in two patients. H&E missed metastases in four nodes and missed the diagnosis of positive axillae in 3 patients. On a node-basis, sensitivities were 91.4 and 88.5%, negative predictive values (NPV) were 99.2 and 99.0% and overall accuracies were 99.3 and 99.1% for IHC imprints and H&E sections, respectively. On a patient-basis, sensitivities were 85.7 and 78.5%, NPVs were 95.2 and 93.1% and overall accuracies were 96.1 and 94.2% for IHC imprints and H&E sections respectively. There were no false positives. Interpretation of the results by a non-histopathologist was concordant with that of a histopathologist. Results might be obtained within 30-45 min depending on the number of examined nodes.

CONCLUSION

Intraoperative IHC staining of touch imprints of axillary sentinel nodes is feasible and is a reliable method for evaluating axillary nodes. Slides can be reliably interpreted by a trained non-histopathologist.

Immunohistochemistry increases the accuracy of diagnosis of benign papillary lesions in breast core needle biopsy specimens

AIMS

Recent studies have suggested that benign papillary lesions without atypia [benign papilloma (BP)] diagnosed on breast core needle biopsy (CNB) may not require excision. However, most have studied only small numbers of cases and scant data are available on the utility of immunohistochemistry in the categorization of papillary lesions on CNB. In the largest published series of BP identified on CNB, we studied the impact of immunohistochemistry on the accuracy of a CNB diagnosis of BP.

METHODS AND RESULTS

Breast CNBs (n = 129) with a diagnosis of papillary lesion were immunostained for calponin, p63 and cytokeratin 5/6. Haematoxylin and eosin and immunostained slides were independently reviewed by four breast pathologists. BP was the final excision diagnosis in 35 cases. With the use of immunohistochemistry, the positive predictive value (PPV) of BP diagnosis by the four individual pathologists increased from 72.7-83.3% (mean 79.2%) to 77.8-87.5% (82.1%), the negative predictive value (NPV) increased from 77.8-98.5% (88.6%) to 100% for all four participants and overall accuracy increased from 78.7-92.6% (84.7%) to 90.7-95.4% (92.8%). No case of invasive carcinoma was diagnosed as BP on CNB by any participant. The frequency of ductal carcinoma in situ following a BP diagnosis on CNB ranged from 2.5% to 4.8% (4%) but was only 0-3% (2.3%) after excluding cases that were radiologically suspicious for malignancy.

CONCLUSIONS

Immunohistochemistry increases accuracy of BP diagnosis in CNB specimens. Benign papillary lesions diagnosed on CNB do not require excision in the absence of suspicious clinical/radiological findings.

Radial intratumoral increase and correlation of microvessels and proliferation in solid breast carcinoma

AIMS

To compare correlations between different morphometrically assessed measurements of tumour microvasculature and to identify those which show closest correlation with Ki67 and to examine radial intratumoral distribution of microvessels and proliferation.

METHODS AND RESULTS

Immunohistochemically defined microvessels and Ki67+ cells were quantified in sequential fields of 0.12 mm2 (x600) in four transects in each of five tumours. The total number of vessels (TNV) correlated more closely with proliferative activity than the numbers of vessels with a discernible lumen (TLV) and TNV decreased towards the centre of the tumour whereas TLV did not. A higher proliferative index (PI) was found at the periphery of the tumours. Comparison between transects through subjectively identified microvessel hot-spots and non-hot-spot transects showed similar mean, median and peak vessel counts but showed a different distribution on chi2 analysis.

CONCLUSIONS

TNV correlates most closely with PI in breast carcinomas. There is marked variation in microvessel density and PI between fields of 0.12 mm2 but there is a significant radial reduction in both from the edge towards the centre of tumours.

Intraoperative evaluation of axillary sentinel lymph nodes using touch imprint cytology and immunohistochemistry: I. Protocol of rapid immunostaining of touch imprints

AIMS

Sentinel Node Biopsy (SNB) is considered an accurate method of detecting axillary lymph node status in patients with small breast cancer. Combined with an accurate and rapid histopathology tool, it could spare this group of patients unnecessary Axillary Node Clearance (ANC) with its associated hazards. Intraoperative examination of SNB for cancer cells has been investigated using both Frozen Sections (FS) and Imprint Cytology (IC) stained with different stains. This study is devoted to establish a reliable and rapid protocol for immunostaining of touch imprints from SNB.

METHODS

We investigated two different EPOS (Enhanced Polymer One-Step staining--DAKO) anticytokeratin antibodies, five different tissue fixatives and different incubation periods and temperatures with both positive and negative controls.

RESULTS

We have developed a protocol, which produced good and consistent immunostaining of touch imprints. The initial results using this protocol are concordant with those of permanent Haematoxylin and Eosin (H&E) sections.

CONCLUSIONS

We propose this protocol for rapid immunostaining of touch imprints of SNB.

Evaluation of axillary lymph nodes using touch imprint cytology and immunohistochemistry

BACKGROUND

The success of sentinel node biopsy in determining axillary lymph node status necessitates an accurate and rapid method for intraoperative examination of the nodes. The aim was to determine the feasibility and accuracy of immunohistochemistry (IHC) of touch imprints in detecting axillary nodal metastases intraoperatively.

METHODS

Some 344 axillary nodes from 30 patients with early breast cancer were bisected, imprinted and subjected to IHC. Results were compared with those of routine haematoxylin and eosin examination of the same nodes.

RESULTS

Using IHC, 29 nodes from nine patients were positive for metastases. Using haematoxylin and eosin, 28 nodes from eight patients were positive. On a patient basis, the sensitivities of IHC and haematoxylin and eosin were 100 and 88.9 per cent, and negative predictive values (NPVs) were 100 and 95.5 per cent, respectively. On a node basis, the sensitivities were 96.7 and 93.3 per cent, and NPVs were 99.7 and 99.3 per cent, respectively. There were no false positives. The results were obtained within 30-45 min, depending on the number of nodes examined.

CONCLUSION

IHC of touch imprints can provide a fast and sensitive method for detecting metastases in axillary nodes during breast cancer surgery.

Diagnostic difficulty arising from displaced epithelium after core biopsy in intracystic papillary lesions of the breast

This study reports two cases of intracystic papillary carcinoma of the breast, which had been biopsied preoperatively using a 14 gauge (14G) core biopsy needle. In each case, a needle tract containing groups of epithelial cells within granulation tissue could be identified on histology of the excised specimen. Both cases showed extracapsular tumour, which was interpreted as displacement of epithelium related to preoperative core biopsy. Subsequent axillary lymph node sampling showed no evidence of metastasis. In one case, extracapsular tumour appeared to be in blood vessels, but flattened cells lining the spaces containing tumour failed to react with factor 8 related antigen or CD34 on immunohistochemistry. It is likely that intracystic papillary carcinomas are particularly prone to this artefact because friable tumour fragments escape, accompanied by cyst fluid, when the capsule is punctured by a 14G core biopsy needle.

Effect of margins of excision on recurrence after local excision of ductal carcinoma in situ of the breast

AIMS

To determine important factors influencing recurrence after local excision of duct carcinoma in situ (DCIS) of the breast.

MATERIALS AND METHODS

The extent (size) in millimetres, classification (by cytonuclear grade (NHSBSP system), by extent of necrosis, and by the Van Nuys system), and excision margins of 115 cases of screen detected DCIS treated by local excision were measured. A prognostic index was calculated by the addition of the Van Nuys classification (low grade, 1; moderate grade, 2; high grade, 3), margin score (> or = 10 mm, 1; 1-9 mm, 2; < 1 mm, 3), and size score (< or = 15 mm, 1; 16-40 mm, 2; and > or = 41 mm, 3), giving a total score of 3-9.

RESULTS

Classification using cytonuclear grade, extent of necrosis, or the Van Nuys system did not correlate significantly with recurrence. The excision margin (in millimetres) was associated with recurrence (p = 0.027) and if excision margin status was simplified using the scoring system (> or = 10 mm, 1; 1-9 mm, 2; < 1 mm, 3), the margin score was significantly associated with recurrence (p = 0.03). A prognostic index based on the Van Nuys score, margin status, and size was significantly associated with recurrence (p = 0.003).

CONCLUSION

The results support the hypothesis that the margin of excision is the most important factor predicting the recurrence of DCIS after local excision.

The effect of fixation and processing on the sensitivity of oestrogen receptor assay by immunohistochemistry in breast carcinoma

AIMS

To investigate the effect of different fixation and processing regimens on the assessment of oestrogen receptor (ER) by immunohistochemistry (IHC).

METHODS

The ER results for 420 patients from seven different hospitals in which antigen retrieval and IHC were performed centrally were compared. The intensity of ER positivity was assessed semiquantitatively using the Quick score (range 0-7). The scoring profiles of cases from each different source (hospital) were compared to detect differences in the proportion of cases that were negative (Quick score = 0), moderately positive (Quick score = 1-5), and strongly positive (Quick score = 6-7).

RESULTS

There were no significant differences (p = 0.3; kappa(2) test) in the proportion of cases in each category.

CONCLUSIONS

None of the fixation or processing regimens had a significant adverse effect on the sensitivity of the ER assessment performed by automated immunohistochemistry.

Comparison of core oestrogen receptor (ER) assay with excised tumour: intratumoral distribution of ER in breast carcinoma

AIMS

The use of the H score (involving the assessment of intensity and distribution of positivity) on sections stained for the oestrogen receptor (ER) by immunocytochemistry (ICC) allows different samples to be compared and detailed correlations to be made between hormone receptor expression and morphology. This study assessed the reliability of core biopsy in predicting ER expression in the same tumour excised later at treatment. The distribution of ER within excised tumours was investigated.

METHODS

The distribution of ER positivity was investigated in 51 diagnostic core biopsies and across the diameter of 51 subsequently excised tumours in a field by field (magnification, x40; field diameter, 0.4 mm) assessment using the semiquantitive H scoring system.

RESULTS

The ER H score in diagnostic core biopsy was significantly higher (p = 0.05, paired rank test; overall mean, 130; n = 51) than the mean in the corresponding excised tumour (mean, 110; n = 51). There was a significant downward trend in ER positivity from the periphery of tumours towards the centre (p = 0.001). The reduction of ER positivity was 6 H score units (2%)/mm. If core biopsies were orientated with the tumour edge at one end no change in ER positivity with field number along the length of the core could be demonstrated.

CONCLUSIONS

ER estimation in core biopsies correlated well with expression in tumours but ER expression was higher in the core biopsies than in the excised tumours. ER expression was higher at the periphery of tumours than at the centre. The higher ER expression in cores may reflect the higher chance of sampling the peripheral part of a tumour using a needle core.

Combined wide excision and mastopexy/reduction mammoplasty for inframammary hidradenitis: a novel and effective approach

Hidradenitis suppurativa is a rare chronic skin condition involving the apocrine glandular zones, which are found predominantly in the axilla and inguinoperineal regions, but have been described at other sites, including the inframammary fold. Treatment requires complex surgical intervention with wide excision of involved tissue. Inframammary hidradenitis tends to affect young women and can prove resistant even to this radical form of surgery, which often results in marked scarring and breast deformity. We therefore decided to adopt a novel approach by incorporating the wide excision of inframammary skin currently necessary in a reduction mastopexy procedure. This enables primary closure with ptosis correction and should improve cosmesis. The reduction in the depth of the inframammary fold also makes hygiene easier in the long term. During a 6-year period, five patients (mean age 27 years) have been treated by this method. All patients had long-standing hidradenitis (mean 12 years), and had been treated with several courses of antibiotics. A modified Wise pattern reduction incision was used with a minimum amount of breast tissue being removed. In each case histology was consistent with hidradenitis. All wounds healed well and to date there have been no inframammary recurrences. The success of this operation in curing inframammary hidradenitis has had a dramatic affect on the lives of these young women and underlines the need for this rare condition to be treated in a specialist centre.

Conversion to core biopsy in preoperative diagnosis of breast lesions: is it justified by results?

AIMS

In recent years there has been increased use of core biopsy for the preoperative diagnosis of screen detected and symptomatic breast lesions. The aim of this study was to compare the quality assessment parameters for preoperative diagnosis by fine needle aspiration cytology (FNAC) before conversion to core biopsy with those for core biopsy after conversion in screening and symptomatic practice. Accuracy of typing and grading of tumours on core biopsy was assessed.

METHODS

Correlation of FNAC (C1-5) and core biopsy (B1-5) results (total of 1768 cases) with subsequent available resection histology was performed for 473 FNAC samples in 1997/98, 349 core biopsies in 1998/99 performed in symptomatic practice, for 561 FNAC samples in 1997/98, and 385 core biopsies in 1998/99 performed in screening. Quality assessment parameters were calculated using the methodology detailed in the National Health Service Breast Screening Programme guidelines for cytology practice.

RESULTS

Increased absolute and complete specificity, lower inadequate rates, and lower suspicious rates were found for core biopsy compared with FNAC in both symptomatic and screening practice. Typing of tumours was attempted in 86.7% of core biopsies in symptomatic practice and was accurate in 93.6% (132 of 141 where type was stated). Grading of tumours was attempted in 63.5% of invasive carcinomas, with the provisional grade on core biopsy being confirmed on later histology in 75% of grade 1 cases, in 70% of grade 2 cases, and in 86% of grade 3 cases. No case provisionally graded as 1 was subsequently found to be grade 3 and no provisionally grade 3 case was found to be grade 1.

CONCLUSION

Conversion to core biopsy for the preoperative diagnosis of breast lesions increases specificity and reduces inadequate and suspicious rates. Grading and typing of tumours and assessment of oestrogen receptor status by immunocytochemistry is also possible in core biopsy, thereby increasing diagnostic information available when considering treatment options.

Rapidly enlarging lump in the neck: is it a tumour?

A rapidly enlarging lump in the neck of an adolescent, is a cause for concern. Amongst the various clinical differential diagnoses, including lymphoma and other malignant lesions, focal myositis is an unusual cause. To date, only two such cases affecting the sternomastoid have been reported worldwide. We report a further similar case.

Consistency in the observation of features used to classify duct carcinoma in situ (DCIS) of the breast

AIM

To determine interobserver and intra-observer agreement in the assessment of cytological grade and intraduct necrosis in pure duct carcinoma in situ (DCIS) of the breast.

METHODS

Sixty unselected cases with illustrated diagnostic criteria were circulated to 19 practising histopathologists.

RESULTS

Overall agreement was moderate for cytological grade in three categories: 71% agreement; weighted kappa (kappa w), 0.36; intraduct necrosis in three categories (absent, present, extensive): 76% agreement; kappa w, 0.57; and the Van Nuys classification system: 73% agreement; kappa w, 0.48. Agreement was no better among observers participating in the National External Quality Assurance Programme. Intra-observer agreement for cytological assessment (69.6% agreement; kappa w, 0.52) and intraduct necrosis (68.3% agreement; kappa w, 0.48) was moderate, suggesting that individual variation rather than precision of criteria contributes to the lack of agreement.

CONCLUSIONS

Moderate agreement on observations can be achieved by non-specialist pathologists, with better agreement on necrosis than cytological grade. There was evidence of consistent individual bias towards over or under scoring cytological grade, which could be corrected with adequate and prompt feedback.

Spindle cell angiosarcoma of the oropharynx

Angiosarcomas are uncommon malignant tumours of vascular endothelium. In the head and neck, the scalp is the commonest site of origin. A rare case of spindle-cell angiosarcoma of the oropharynx, treated by surgery and post-operative radiotherapy, is reported. We discuss the clinical presentation and histopathological diagnosis of this lesion.

Angiolymphoid hyperplasia with eosinophilia of the parapharyngeal space

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon benign condition characterized by cutaneous nodules with a predeliction for the head and neck region. Extracutaneous involvement is rare. We report a 44-year-old woman who had a large submucosal ALHE tumour in the parapharyngeal space. Our patient is of interest because of the unusual, and as far as we are aware from the literature, unique site and presentation of her lesion.

Evidence of effectiveness of clinical audit in improving histopathology reporting standards of mastectomy specimens

AIM

To assess the effectiveness of clinical audit in improving standards in histopathological reporting of mastectomy specimens.

METHODS

Reports on mastectomy specimens containing tumour issued by non-specialist histopathologists in 1990, 1992, 1994, and 1996 were scored for their information content. There were 10 reports evaluated from each year. Before 1990 no reporting guidelines had been formulated within the department. The audits in 1992 and 1994 were performed after agreed written guidelines (including the establishment of six essential pieces of information), and in 1996 the specimens were reported using a proforma.

RESULTS

There was a significant increase in information after the introduction of written guidelines but there was a reduction in information over time. In 1990 none of the 10 reports included all six pieces of mandatory information; in 1992 four of the reports contained all mandatory information; in 1994 only one report contained all mandatory information. The introduction of a proforma for reporting resulted in further significant improvement with all 10 reports in 1996 containing all mandatory information.

CONCLUSIONS

Successive rounds of audit increases the standard of reporting in histopathology. There is a need for continuing monitoring of standards as these may deteriorate over time. Reporting complex specimens on a proforma has a significant beneficial effect on information content.

The clinical behavior of breast carcinoma is probably determined at the preinvasive stage (ductal carcinoma in situ)

BACKGROUND

Mammography has greatly increased the number of women diagnosed with ductal carcinoma in situ (DCIS) of the breast. New classifications of DCIS recently have been proposed. In this study, these classifications were applied to DCIS associated with invasive tumors and correlated with patient prognosis.

METHODS

Three hundred cases of infiltrating ductal carcinoma of the breast in which there was associated DCIS in the surrounding breast were studied. The DCIS was classified as well, moderately, or poorly differentiated, according to two recently published systems using the cytonuclear features of the malignant cells (Holland classification) and cytology and the presence of necrosis (Van Nuys classification).

RESULTS

The differentiation of DCIS was significantly correlated with the grade of the invasive carcinoma (P < 0.0001), the Nottingham prognostic index (P < 0.0001), and the clinical outcomes of the patients (P < 0.0001).

CONCLUSIONS

These findings indicate that a model in which there is increasing in situ dysplasia before the development of stromal invasion is incorrect for breast carcinoma. Rather, in most cases, well-differentiated DCIS probably gives rise to low grade invasive breast carcinoma with a better long term clinical outcome. These data suggest that many of the important prognostic biologic and genetic characteristics of breast carcinoma are already established in the neoplastic clones of malignant cells at the preinvasive stage of the disease.

Microdissection of stained archival tissue

In many tissues the preinvasive stage of neoplastic progression can be identified histologically as dysplasia or in situ disease. There is much interest in defining the molecular events associated with the early stages of neoplasia. Retrieval of histologically recognisable preinvasive neoplastic tissue uncontaminated by inflammatory or stromal cells is important for genetic studies using polymerase chain reaction (PCR) assay. A novel method for microdissection is described in which 10 microns sections are dewaxed, stained with haematoxylin and eosin, dried, covered with Sellotape, and the tissue cut out using a scalpel blade under direct visual control. The method is quick, eliminates problems of operator tremor, preserves the architecture of the micro-dissected tissue (for photographic documentation) and requires no special equipment. The presence of Sellotape and adhesive in the reaction mixture has no detrimental effect on the ability to extract DNA or to perform PCR.

Immunoreactive p53 and metallothionein expression in duct carcinoma in situ of the breast. No correlation

Immunocytochemically detectable MT and p53 have been found more commonly in comedo DCIS of the breast with high-grade cytology. The aim of this study is to confirm these findings and to investigate the relationship between MT and p53 in a single large series of cases of DCIS of the breast. To this end, 127 cases of DCIS were classified histologically according to architecture, cytonuclear differentiation (grade), presence and extent of intraduct necrosis, and using the Van Nuys system. Sections were immunostained for p53 and MT (E9) using established techniques, and the extent and intensity of staining were assessed semi-quantitively. The results confirmed that there was generally more MT and p53 positivity in poorly differentiated (grade 3) DCIS with extensive necrosis and that MT expression was greater in grade 2 lesions than p53 expression. However, overall there was no statistically significant correlation between p53 and MT staining. The results indicate that MT and p53 overexpression may arise from independent mechanisms in early breast neoplasia.

Loss of E-cadherin expression associated with lymph node metastases in small breast carcinomas

The National Breast Screening Programme affords the opportunity to study breast carcinomas at an early stage in their development. E-cadherin is a calcium-dependent, intercellular adhesion molecule whose loss of expression may facilitate the processes of invasion and metastasis of some human tumours. From a group of screen-detected ductal carcinomas less than or equal to 10 mm in diameter, 16 with lymph node metastasis were identified and matched for grade, size and patient age with node negative tumours. The level of expression of E-cadherin (detected by immunocytochemistry) was compared in the matched pairs using a simple semi-quantitative intensity distribution scoring system. The results showed a significant (P = 0.05 Wilcoxon paired rank test) reduction of E-cadherin expression in tumours with lymph node metastases compared to those without. In the context of the small size of these tumours it is proposed that these results support the hypothesis that reduction in E-cadherin expression is an early event in the development of metastases.

Pathology of R4 spiculated lesions in the breast screening programme

Small spiculated carcinomas are indistinguishable from benign radial scar/complex sclerosing lesions on mammography, leading to a radiological assessment of R4 (suspicious, probably malignant). The cytological and pathological features of 80 screen detected R4 spiculated lesions were reviewed. The analysis showed that there were 46 radial scars, of which 38 were benign and 8 (17%) contained foci of ductal carcinoma in situ (DCIS), and 34 spiculated carcinomas. The majority of radial scars showed some degree of epithelial hyperplasia (assessed semi-quantitively) but the cellularity of the lesion as a whole was not related to the presence of DCIS. In 20 cases no aspiration was attempted for cytology but 40% were inadequate and only one lesion containing DCIS had cytology C4 or C5. Diagnosis of radial scar was made in all cases by localization biopsy. The carcinomas ranged in size between 4 and 15 mm (mean 8.9 mm) and were of grade 1 (21 = 63%) or grade 2 (12 = 37%). There were 16 infiltrating ductal carcinomas of no special type, 12 tubular carcinomas, three lobular carcinomas, two ductal and lobular mixed, and one mucinous carcinoma. Only one patient with carcinoma was node-positive. For the carcinomas, 12 (35%) yielded C5 (malignant) cytology allowing pre-operative diagnosis.

E-cadherin (E-cad) expression in duct carcinoma in situ (DCIS) of the breast

E-cadherin (E-cad) is an epithelial cell-cell adhesion molecule whose loss or reduced expression is associated with a more invasive tumour phenotype. Ninety-six cases of screen detected pure ductal carcinoma in situ (DCIS) were analysed immunocytochemically for expression of E-cad using the HECD-1 mouse monoclonal antibody. The in situ component in each case was classified on the basis of cytonuclear grade, extent of necrosis, Van Nuys classification and a newly devised Cardiff classification. The amount of E-cad expression was assessed semi-quantitatively using an intensity distribution method. There is significantly more expression of E-cad in well-differentiated DCIS when compared with poorly differentiated DCIS and this finding is highly significant (P < 0.001) irrespective of the classification system used. These findings suggest that progressive loss of E-cad expression may occur at an early stage of breast cancer development.

A critical appraisal of six modern classifications of ductal carcinoma in situ of the breast (DCIS): correlation with grade of associated invasive carcinoma

The in-situ component of 180 cases of screen detected infiltrating duct carcinoma of the breast was classified according to six published classifications for ductal carcinoma in situ based on architecture, necrosis and cytology. All cases were assessed independently by two experienced observers to assess inter-observer variation. The differentiation of ductal carcinoma in situ as assessed by all the classification systems correlated with the grade of the associated invasive carcinoma (chi-squared between 50 and 107: P < 0.0001). Disagreements were commonest in the assessment of architecture and least common in the assessment of necrosis. For cytonuclear grade most disagreements (62.2%) involved the distinction between low and intermediate as against 33.9% disagreements for intermediate vs. high. Nuclear grade alone and necrosis alone were correlated with the grade of invasive carcinoma associated with the ductal carcinoma in situ and the Nottingham prognostic index of the patient. The Van Nuys classification of ductal carcinoma in situ is commended because it has a low inter-observer disagreement, is significantly correlated with the grade of the infiltrating carcinoma, uses simple well-defined criteria (with no requirement for percentage estimations), is applicable to small numbers of ducts and, most importantly, appears to correlate with disease-free survival.

Phraseology in pathology reports. A comparative study of interpretation among pathologists and surgeons

This questionnaire based study compared the interpretation, use and preferences, among pathologists and surgeons, of descriptive phrases found in surgical reports. The results show that there is a wide variation in individual interpretation of phrases in both groups. The frequency of usage of phrases by pathologists and preference for phrases by surgeons were also diverse. The adoption of a limited number of descriptive phrases that are mutually understood and acceptable for use by both pathologists and clinicians is recommended to avoid interpretive ambiguity in pathology reports.

The pathogenesis of hidradenitis suppurativa: a closer look at apocrine and apoeccrine glands

We undertook a retrospective pathological study of 118 skin resection specimens from 101 patients with hidradenitis suppurativa. Follicular occlusion was identified in all the specimens, regardless of disease duration (1 month to 18 years), but was not noted in the axillary and inguinal skin of controls. We therefore regard follicular occlusion as an early and important feature in the pathogenesis of the disease. The presence of apoeccrine glands in axillary skin provided an in vivo model to directly observe the effects of follicular occlusion on follicle inflammation and apocrine gland destruction. In the majority of cases, active folliculitis was associated with apocrinitis and apocrine destruction, whereas apoeccrine glands, which drain directly on to the epidermal surface, appeared intact and non-inflamed. These observations provide direct evidence in an in vivo model that follicular occlusion by keratinous material, with subsequent active folliculitis and secondary destruction of the skin adnexae and subcutis, occur as an integral step in the pathogenesis of hidradenitis suppurativa.

Cutaneous infection with Tunga penetrans

A 23-year-old man presented with a small black lesion at the distal margin of the right great toenail. He had returned from the Ivory Coast 1 month previously, having spent 6 weeks there. Histopathological examination of material extruded from the lesion showed a variety of arthropod internal organs, allowing a definitive diagnosis of infection with the ectoparasitic flea Tunga penetrans. Curettage of the lesion revealed a gravid adult female flea.

Methods for assessing splenic macrophage depletion by liposome encapsulated clodronate

Small unilamellar vesicles containing clodronate (SUVc) injected intravenously will deplete splenic macrophages and the degree of histological depletion can be assessed by determining the clearance and uptake of monoclonal antibody coated erythrocytes. Splenic Fc dependent clearance, assessed in decomplemented animals, provides a more sensitive index of the effects of large multilamellar liposome encapsulated clodronate (MLVc) and SUVc than does the clearance of complement coated erythrocytes on macrophage depletion in the spleen. MLVc were more efficient than SUVc in inducing a reduction in the number of red pulp macrophages within the spleen. Receptor specific red cell uptake in the spleen could be used as an alternative to histology when assessing splenic macrophage depletion. Encapsulation of clodronate is crucial to its depleting effect since the free drug in saline does not change splenic macrophage number or function.

Airway obstruction with stridor due to nasal secretions

Two cases of non-fatal airway obstruction by nasal secretions are described. The diagnosis was made after laryngoscopy and the features which suggested this previously undescribed aetiology were: depression of conscious level; poor oral hygiene; and irregular friable mass with mucoid areas obstructing the airway. The diagnosis was confirmed by histological examination of the obstructing material which was composed of laminated fragments of squamous epithelium, keratin debris and mucus. It is suggested that these masses form in the post-nasal space and then become dislodged descending into the larynx, where they cause partial laryngeal obstruction and stridor. In patients whose conscious level is depressed and who have poor oral hygiene, nasal secretions should be considered as a cause of sudden unexplained airway obstruction and stridor.

The effect of free and liposome-encapsulated clodronate on the hepatic mononuclear phagocyte system in the rat

Clodronate, encapsulated within small unilamellar vesicles (SUVc) will deplete hepatic macrophages after intravenous injection. Functional studies, using probes to evaluate hepatic Fc and C3b uptake, showed a close correlation between the inhibition of receptor-mediated uptake and the depletion of hepatic macrophages. Twenty milligrams of clodronate encapsulated within SUVc produced > or = 90% inhibition of uptake and clearance of Fc- and C3b-coated erythrocytes and a comparable reduction of hepatic macrophage numbers. Inhibition of macrophage receptor-mediated uptake of these erythrocytes was closely related to the reduction in macrophage numbers. Repopulation of macrophages within the liver took place over 2 weeks. At 1 week after depletion, although repopulation was taking place, receptor-mediated function remained suppressed. In a preliminary experiment, treatment of rats with adjuvant arthritis with 20 mg clodronate encapsulated in SUV suppressed the inflammation and reversed the course of the disease, while treatment with 20 mg free clodronate in saline or 20 mg clodronate in multilamellar vesicles (MLVc) did not.

Metallothionein expression in duct carcinoma in situ of the breast

In a previous study immunocytochemically detectable metallothionein (MT) expression in tumor cells of invasive duct carcinoma of the breast was shown to be associated with a more aggressive behavior and these findings have been subsequently confirmed by others. The aim of this study was to examine the prevalence and significance of MT positivity in preinvasive duct carcinoma in situ (DCIS). Fifty-five specimens of pure screen-detected DCIS were stained immunocytochemically for MT using the antibody E9. The intensity and distribution of MT staining were assessed using a semiquantitative method resulting in intensity distribution (ID) scores allowing duct by duct analysis in relation to architectural and cytological features of the DCIS. In general, myoepithelial cells around benign and malignant structures stained uniformly strongly for MT. Staining in DCIS was analyzed by architecture irrespective of cytology and by nuclear grade irrespective of architecture. The results showed that MT staining was significantly greater in comedo (ducts with necrosis) DCIS (ID = 97) compared with noncomedo (ducts without necrosis) DCIS (ID = 56) (P = .05 by Mann Whitney U statistic) and that low cytological grade (ID = 50) was associated with less MT staining than was high cytological grade (ID = 92) (P = .05 by Mann Whitney U statistic). These observations thus are consistent with the previously observed association between MT positivity and more aggressive behavior in invasive duct carcinoma of the breast.

Benign lymph node inclusions mimicking metastatic carcinoma

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Role of fine-needle aspiration cytology and needle-core biopsy in the diagnosis of lobular carcinoma of the breast

Fine-needle aspiration cytology (FNAC) plays a key role in the preoperative diagnosis of carcinoma of the breast but is less reliable in the diagnosis of infiltrating lobular carcinoma. The method of diagnosis was reviewed in 56 patients with lobular carcinoma who had attended screening and symptomatic clinics. In 29 patients FNAC results demonstrated malignant cells; 15 of these had palpable disease and the mean tumour size was 21 mm. In 27 patients FNAC failed to demonstrate malignant cells; 13 lesions were palpable and the mean tumour size was 23 mm. Ten patients were diagnosed by needle-core biopsy when FNAC was not diagnostic. FNAC may fail to diagnose even large lobular carcinoma and needle-core biopsy is strongly recommended in this situation.

A dual immunocytochemical assay for oestrogen and epidermal growth factor receptors in tumour cell lines

A new dual immunocytochemical assay for oestrogen receptor (ER) and epidermal growth factor receptor (EGFR) has been developed. It has been tested in a variety of conditions using cell culture lines and the results correlate well with those obtained from single immunocytochemical assays. MCF-7 and A431 cells and a mixture of the two types of cell were assessed immunocytochemically for ER and EGFR. ER showed immunopositivity of 30% in MCF-7 cells, 10% in the mixture and 0% in A431 cells. EGFR demonstrated immunopositivity of 0% in MCF-7 cells, 70% in the mixture and 100% in A431 cells. Dual immunocytochemical assays using anti-ER followed by anti-EGFR monoclonal antibodies on single histological sections showed similar reactivity to the single assays. Three staining patterns were seen in the mixture: ER+/EGFR- (MCF-7 cells), ER-/EGFR- (MCF-7 cells) and ER-/EGFR+ (A431 cells). ZR-75-1 and MDA-MB-231 cells and their retrovirally transfected counterparts ZR/HERc and MDA/HEGO cells were then analysed. The dual assay revealed the fourth phenotype (ER+/EGFR+) in 40% of ZR/HERc cells and in 10% of MDA/HEGO cells. This is the first description of a dual immunocytochemical assay system for ER and EGFR on single 5 microns frozen section samples. Studies are now underway assessing breast carcinoma sections which may allow investigation of the clonality of human breast cancer.

Amyloid, thrombosis, and acute myocardial infarction in association with a bicuspid aortic valve

A 34 year old man presented with an inferior non-Q-wave myocardial infarction. Echocardiography showed a bicuspid aortic valve with aortic outflow obstruction. Left coronary cusp morphology was normal but the right coronary cusp was grossly distorted and replaced by a mobile echodense mass encroaching upon the aortic valve orifice. The aortic valve was replaced and pathological analysis of the excised valve showed primary amyloid infiltration of the right coronary cusp but a normal left coronary cusp. The mass adherent to the right coronary leaflet had the histological appearances of organised thrombus and this was assumed to be the source of coronary embolism. This is the first reported case of primary valvar amyloid presenting with clinical sequelae and it illustrates the need for careful clinical assessment in young patients presenting with acute ischaemic syndromes.

Sarcoid-like granulomas in primary renal cell carcinoma

A case of renal cell carcinoma containing non-caseating epithelioid granulomas is described. These granulomas were indistinguishable from sarcoid granulomas microscopically. There was a clinical suggestion of sarcoidosis thirteen years prior to the excision of the tumour. The pathogenesis and significance of tumour-associated epithelioid granulomas are discussed.

Granulomatous hidradenitis suppurativa and cutaneous Crohn's disease

Three patients with concurrent hidradenitis suppurativa and Crohn's disease are presented. The notable histological feature in each hidradenitis resection was the presence of numerous discrete epithelioid granulomas in areas of non-inflamed dermis. The purpose of the study was to determine the incidence of epithelioid granulomas in 101 hidradenitis patients and their significance in relation to systemic granulomatous disease. Discrete epithelioid granulomas were identified in 8% of the resections (10 patients). One patient had Crohn's disease and one other pulmonary sarcoidosis. Seven patients with granulomatous hidradenitis neither had nor developed any other disease during the 3-year follow-up period. Clinical review identified a further two patients with Crohn's disease but associated with non-granulomatous changes in the skin resections. Foreign body type granulomas were identified in 25% of the resections adjacent to ruptured hair follicles, sinus tracts or nearby degenerate sweat glands. The study shows that, although foreign body type granulomas are a common finding in hidradenitis, the presence of discrete epithelioid granulomas in the dermis away from the site of active inflammation is unusual and should alert the pathologist to the possibility of systemic granulomatous disease such as Crohn's disease or sarcoidosis.

Epithelial--stromal interactions in tumors. A morphologic study of fibroepithelial tumors of the breast

BACKGROUND AND METHODS

The known spatial interaction between normal breast epithelium and its surrounding stroma prompted an investigation of the spatial relationship between stromal mitoses and the epithelial component of fibroepithelial tumors of the breast. The authors applied a novel computerized morphometric technique to routinely processed histologic sections of 23 fibroepithelial tumors (13 fibroadenomas and 10 phyllodes tumors). The proportional area of epithelium in successive concentric annuli surrounding stromal mitoses was measured, and its distribution was compared with that around suitable control points.

RESULTS

The authors found that stromal mitotic activity in these tumors was significantly more likely to occur close to rather than remote from the epithelial component, with a significant excess of epithelium around mitoses compared with control points within a range of 79 microns. Essentially similar findings were obtained when randomly identified fibroblast nuclei were used as control points, thus obviating variations in stromal cell density with distance from epithelium as an explanation for the findings.

CONCLUSIONS

These findings support the hypothesis that stromal growth in fibroepithelial tumors depends, to a variable extent, on the epithelial component. An interaction in the opposite direction (i.e., the stroma providing the growth support to the epithelium) also may occur, but this was not investigated. It is suggested that there is an interdependence of growth between the epithelial and stromal components in these tumors that explains their complex morphology and that stromal dependence on epithelium is lost with increasing malignancy of the stromal elements.

Prediagnostic malakoplakia presenting as a chronic inflammatory mass in the soft tissues of the neck

Malakoplakia presenting in the head and neck is very rare. We present a case of an inflammatory mass in the neck, clinically mimicking actinomycosis in a 67-year-old man. Repeated culture of E. coli and histological and electron microscopic examination of biopsy material showed an infiltration of granular macrophages and intracellular gram negative bacilli, but no classical Michaelis-Gutmann bodies. The clinical and pathological findings and criteria for the diagnosis of malakoplakia are discussed.

Immunocytochemically detectable metallothionein in granulation tissue surrounding mucosal ulceration

Metallothioneins (MTs) are low-molecular-weight heavy metal binding proteins which are effective free oxygen radical scavengers in vitro. Free oxygen radicals have been implicated in the pathogenesis of stress-induced acute gastric mucosal ulceration and ischaemic injury in rat and man. Experimentally, MTs can have a protective role in stress-induced ulceration in rats. The possible cytoprotective role of MTs in chronic mucosal ulceration in man has not been previously studied. Evidence for locally produced MTs in human chronic gastric and small bowel ulcers has been sought by immunocytochemical staining using a monoclonal antibody (E9) to MT. At the base of ulcers MT has been localized to spindle cells (fibroblasts) in granulation tissue. Labelling of macrophages with a pan-macrophage marker KP1, and double labelling with KP1 and E9 showed two distinct populations, and MT appeared to be localized primarily in fibroblast-like cells.

Low recurrence rate after partial hypophysectomy for prolactinoma: the predictive value of dynamic prolactin function tests

OBJECTIVE

To determine the factors influencing the outcome of transethmoidal partial hypophysectomy for suspected prolactinoma and the predictive value of pre and post-operative dynamic PRL function tests.

DESIGN

A retrospective study of patients undergoing surgery for a suspected prolactinoma in Cardiff between 1979 and 1989.

PATIENTS

Eighty-two hyperprolactinaemic patients (75 women, seven men) diagnosed as having a prolactinoma on the basis of dynamic PRL function tests, radiological investigation and exclusion of other causes.

MEASUREMENTS

TSH and PRL responses to domperidone (10 mg i.v.) and TRH (200 micrograms i.v.) measured preoperatively, 2 months post-operatively, and annually thereafter. CT scan performed preoperatively in 58 patients. Operative findings, including adenoma size, documented in each case.

RESULTS

Forty-two patients (51%) had microadenomas (less than 10 mm), 37 (46%) had macroadenomas and in three no tumour was found at operation. Preoperatively, normal responses of both TSH (incremental rise less than 2.0 mU/l) and PRL (greater than 100% rise) to domperidone were observed in two patients only: both had an abnormal vascular supply to the pituitary rather than an adenoma. Serum PRL was normalized in the early post-operative period (less than 72 h; 'early cure') in 65 patients (79%). The highest early cure rate (96%, n = 26) was in patients with adenomas of 5-9 mm, lower rates being achieved for lesions of 10-19 mm (80%, n = 30), less than 5 mm (63%, n = 19) or greater than or equal to 20 mm (57%, n = 7). The early cure rate was strongly correlated with preoperative PRL, ranging from 100% in patients with PRL less than 1000 mU/l (n = 13) to zero in those with PRL greater than 10,000 mU/l. Dopamine agonist therapy of between 5 weeks and 4 years duration prior to surgery was associated with a significantly reduced early cure rate (60 vs 94%, P less than 0.02) in macroadenoma but not microadenoma patients. Recurrent hyperprolactinaemia during mean follow-up of 51.7 months occurred in eight patients (12%), in five cases within 2 months of surgery and in the others at 26, 48 and 50 months. Recurrence could not be predicted from any preoperative parameter, but a serum PRL greater than 150 mU/l 1-3 days following microadenomectomy was associated with early recurrence and probably indicates failed surgery. An abnormal response of TSH to domperidone was documented 2 months post-operatively in 11/60 patients with normal basal PRL, and preceded all three late recurrences. Of four patients with abnormal responses of both PRL and TSH at this time, two have relapsed to date.

CONCLUSIONS

In carefully selected patients, partial hypophysectomy is an acceptable alternative to medical treatment for prolactinoma. Preoperatively, dynamic tests accurately identified those patients whose hyperprolactinaemia was non-adenomatous in origin and, post-operatively, identified a subgroup of patients at increased risk of late recurrence.

Transient epidermal necrosis associated with disseminated intravascular coagulation in a patient with urticaria

A patient with intermittent erythema developed urticaria and a systemic illness associated with the development of disseminated intravascular coagulation and a widespread bullous eruption. A skin biopsy showed intravascular fibrin and epidermal necrosis with no evidence of vasculitis. The patient made a complete recovery following therapy with fresh frozen plasma and platelets and pulsed intravenous methylprednisolone.

Rapidly progressive aortic valve incompetence in a patient with rheumatoid arthritis

A 27-year-old female with seropositive rheumatoid arthritis of onset at age 18 years developed progressive aortic valve incompetence requiring urgent aortic valve replacement. Rheumatoid aortic valve disease may be more rapidly progressive than aortic valve disease from other causes and awareness of this by the monitoring physicians may help to avoid the possible complications.

Killing of Mycobacterium tuberculosis in tissue by microwaves with simultaneous tissue fixation

Guinea-pig liver heavily infected with M. tuberculosis has been sterilised by exposure to microwaves in a standard commercially available domestic oven. Subsequent histology showed good tissue preservation and organisms of normal morphology were identified by Ziehl Neelsen staining. The findings allow the safe use of frozen sections for diagnosis in tissue containing M. tuberculosis.