Biomineralogical signatures of breast microcalcifications

Microcalcifications, primarily biogenic apatite, occur in cancerous and benign breast pathologies and are key mammographic indicators. Outside the clinic, numerous microcalcification compositional metrics (e.g., carbonate and metal content) are linked to malignancy, yet microcalcification formation is dependent on microenvironmental conditions, which are notoriously heterogeneous in breast cancer. We interrogate multiscale heterogeneity in 93 calcifications from 21 breast cancer patients using an omics-inspired approach: For each microcalcification, we define a "biomineralogical signature" combining metrics derived from Raman microscopy and energy-dispersive spectroscopy. We observe that (i) calcifications cluster into physiologically relevant groups reflecting tissue type and local malignancy; (ii) carbonate content exhibits substantial intratumor heterogeneity; (iii) trace metals including zinc, iron, and aluminum are enhanced in malignant-localized calcifications; and (iv) the lipid-to-protein ratio within calcifications is lower in patients with poor composite outcome, suggesting that there is potential clinical value in expanding research on calcification diagnostic metrics to include "mineral-entrapped" organic matrix.

A rare eicosanoid precursor analogue, sciadonic acid (5Z,11Z,14Z-20:3), detected in vivo in hormone positive breast cancer tissue

Numerous genetic alterations of HSA 11q13 are found frequently in several cancer types, including breast cancer (BC). The 11q13 locus harbors FADS2 encoding Δ6 desaturation which is not functional in several cancer cell lines, including hormone positive MCF7 BC cells. In vitro, the non-functional FADS2 activity unmasks 18:2n-6 elongation to 20:2n-6 and Δ5 desaturation by FADS1 to yield 5Z,11Z,14Z-20:3 (sciadonic acid) rather than 5Z,8Z,11Z,14Z-20:4 (arachidonic acid). In this pilot study we aimed to determine whether 5,11,14-20:3 appears in vivo in hormone positive human BC tissue. Fatty acids were profiled in surgically removed human breast tumor and adjacent normal tissue (n = 9). Sciadonic acid was detected in three of nine breast tumor samples and was below detect limits in normal breast tissue. The internal Δ8 double bond of arachidonic acid is required for normal eicosanoid synthesis but is missing in sciadonic acid. This pilot study demonstrates for the first time in vivo sciadonic acid in hormone positive BC tissue, warranting a larger survey study to further evaluate its appearance and the functional implications.

Correlative imaging reveals physiochemical heterogeneity of microcalcifications in human breast carcinomas

Microcalcifications (MCs) are routinely used to detect breast cancer in mammography. Little is known, however, about their materials properties and associated organic matrix, or their correlation to breast cancer prognosis. We combine histopathology, Raman microscopy, and electron microscopy to image MCs within snap-frozen human breast tissue and generate micron-scale resolution correlative maps of crystalline phase, trace metals, particle morphology, and organic matrix chemical signatures within high grade ductal carcinoma in situ (DCIS) and invasive cancer. We reveal the heterogeneity of mineral-matrix pairings, including punctate apatitic particles (<2 µm) with associated trace elements (e.g., F, Na, and unexpectedly Al) distributed within the necrotic cores of DCIS, and both apatite and spheroidal whitlockite particles in invasive cancer within a matrix containing spectroscopic signatures of collagen, non-collagen proteins, cholesterol, carotenoids, and DNA. Among the three DCIS samples, we identify key similarities in MC morphology and distribution, supporting a dystrophic mineralization pathway. This multimodal methodology lays the groundwork for establishing MC heterogeneity in the context of breast cancer biology, and could dramatically improve current prognostic models.

Effectiveness of Toyota process redesign in reducing thyroid gland fine-needle aspiration error

Our objective was to determine whether the Toyota Production System process redesign resulted in diagnostic error reduction for patients who underwent cytologic evaluation of thyroid nodules. In this longitudinal, nonconcurrent cohort study, we compared the diagnostic error frequency of a thyroid aspiration service before and after implementation of error reduction initiatives consisting of adoption of a standardized diagnostic terminology scheme and an immediate interpretation service. A total of 2,424 patients underwent aspiration. Following terminology standardization, the false-negative rate decreased from 41.8% to 19.1% (P = .006), the specimen nondiagnostic rate increased from 5.8% to 19.8% (P < .001), and the sensitivity increased from 70.2% to 90.6% (P < .001). Cases with an immediate interpretation had a lower noninterpretable specimen rate than those without immediate interpretation (P < .001). Toyota process change led to significantly fewer diagnostic errors for patients who underwent thyroid fine-needle aspiration.

Errors in thyroid gland fine-needle aspiration

Scant published data exist on redesigning pathology practice based on error data. In this first step of an Agency for Healthcare Research and Quality patient safety project, we measured the performance metrics of thyroid gland fine-needle aspiration, performed root cause analysis to determine the causes of error, and proposed error-reduction initiatives to address specific errors. Eleven cytologists signed out 1,543 thyroid gland aspirates in 2 years, and surgical pathology follow-up was obtained in 364 patients. Of the 364 patients, 91 (25.0%) had a false-negative diagnosis and 36 (9.9%) a false-positive diagnosis. Root cause analysis showed that major sources of error were pre-analytic (poor specimen quality) and analytic (interpretation of unsatisfactory specimens as nonneoplastic and lack of diagnostic category standardization). We currently are evaluating the effectiveness of error reduction initiatives that target pre-analytic and analytic portions of the diagnostic pathway.

Fine needle aspiration cytology of adult perineal rhabdomyosarcoma: a case report

BACKGROUND

Adult perineal soft tissue sarcomas are rare. Fewer than 30 cases have been reported, and all were diagnosed after surgical resection by histologic examination. Below we report a case in which the diagnosis was established preoperatively by fine needle aspiration (FNA).

CASE

A 27-year-old man presented with a firm, midline, perineal mass. Magnetic resonance imaging showed a 3-cm, enhancing mass that was considered neoplastic. FNA biopsy, followed by cytologic examination, revealed moderately cellular aspirates composed of discohesive, small, blue cells with scant cytoplasm, high nuclear/cytoplasmic ratios and pleomorphic nuclei with irregular nuclear contours; uniform, hyperchromatic chromatin; and occasional mitotic figures. Frequent naked nuclei and scattered cells with more abundant, dense cytoplasm and eccentric nuclei were also noted. The diagnosis of rhabdomyosarcoma was favored on FNA and was corroborated by immunohistochemical stains for desmin, myogenin and CD56. Upon surgical resection, the diagnosis of alveolar rhabdomyosarcoma was confirmed histologically and immunophenotypically.

CONCLUSION

FNA is a useful tool in diagnosing soft tissue lessions of the perineum, including rare primary tumors, such as adult rhabdomyosarcoma. In this case, early identification avoided incisional biopsy and directed appropriate extirpative surgery and reconstruction considerations.

Disseminated nocardiosis diagnosed by fine needle aspiration biopsy: Quick and accurate diagnostic approach

Nocardia is an uncommon pathogen in immunocompetent patients; however, it has been increasingly recognized as a significant opportunistic pathogen in organ transplant patients. Diagnosis of Nocardiosis is usually made by microbiologic culture or cytologic examination of pulmonary specimens including, sputum, and brushing/washings or by histologic evaluation of tissue biopsy material. We report a case of subcutaneous Nocardiosis diagnosed by Fine-needle aspiration biopsy (FNA). The patient is a 66-year-old man with a history of lung transplantation and posttransplant lymphoproliferative disorder who presented with subcutaneous masses in the right upper arm and the left shoulder. FNA was performed in an outpatient clinic setting, with immediate morphologic assessment revealing filamentous branching organisms suspicious for Nocardiosis. Subsequent examination with special stains and microbiologic culture confirmed the diagnosis. The quick and accurate diagnosis by FNA led to emergent and appropriate treatment.

Improving the quality of cytology diagnosis: root cause analysis for errors in bronchial washing and brushing specimens

Detailed root cause analysis to determine causes of pulmonary cytology errors has not been used to design specific practice changes. We performed root cause analysis of all false-negative bronchial brushing and washing specimen errors (n = 32) detected by the cytologic-histologic correlation process in 2002. Medical records and all slides were reviewed. Based on the correlation process, 10 errors were interpretive, 16 sampling, and 6 combined interpretive/sampling. Root cause analysis showed that the lesion was not accessible in 8 cases and tumor was readily identified on the slides in only 1 case. In 11 cases, the malignant cells were few and not recognized, and in 13 cases, obscuring artifacts (eg, cellular crushing and air drying) limited interpretation. Sampling issues had a major role in the misdiagnosis in 31 cases (97%), and recommendations for error reduction include immediate interpretation and the use of transmucosal fine-needle aspiration.

Metastatic balloon cell melanoma: a case report

BACKGROUND

The protean morphology of malignant melanoma is diagnostically challenging. Balloon cell melanoma is a histologic variant composed predominantly or entirely of large cells with abundant, vacuolated cytoplasm. It shares the cytologic features of the other subcategories of malignant melanoma, such as discohesion, nuclear pleomorphism and intranuclear cytoplasmic pseudoinclusions, but generally lacks melanin pigment and, as the name would suggest, is characterized by the presence of numerous cytoplasmic vacuoles.

CASE

A 55-year-old man presented with an enlarged right cervical lymph node. Clinically and radiographically this mass was considered to be metastatic; however, the patient had no known primary neoplasm. Fine needle aspiration biopsy (FNAB) and cytologic examination showed numerous discohesive, variably sized, malignant cells with abundant, vacuolated cytoplasm and pleomorphic nuclei with irregular nuclear contours, macronucleoli and frequent intranuclear cytoplasmic pseudoinclusions. Pigment was not identified. These features, along with strong immunohistochemical positivity for S-100, HMB-45 and Melan-A, suggested the diagnosis of balloon cell melanoma. A right parotidectomy and lymph node dissection were performed, and histologic tissue evaluation confirmed the diagnosis.

CONCLUSION

This case of lymph node balloon cell melanoma metastasis was diagnosed by FNAB.

Development and characterization of efficient xenograft models for benign and malignant human prostate tissue

BACKGROUND

Various research groups have attempted to grow fresh, histologically intact human prostate cancer tissues in immunodeficient mice. Unfortunately, grafting of such tissues to the sub-cutaneous compartment was found to be associated with low engraftment rates. Furthermore, xenografts could only be established using high-grade, advanced stage, but not low- or moderate-grade prostate cancer tissues.

METHODS

This paper describes methods for xenografting both benign and malignant human prostate tissue to severe combined immunodeficient (SCID) mice. We examine the efficiency and histopathologic consequences of grafting to the sub-cutaneous, sub-renal capsule, and prostatic orthotopic sites.

RESULTS

Sub-renal capsule grafting was most efficient in terms of take rate (>90%) for both benign and malignant tissue. Orthotopic grafts consistently exhibited the best histopathologic differentiation, although good differentiation with continued expression of androgen receptors (AR) and PSA was also seen in the sub-renal capsule site. Sub-cutaneous grafting resulted in low take rates and the lowest level of histodifferentiation in surviving grafts. Grafted benign tissues in all sites appropriately expressed AR, PSA, cytokeratins 8, 18, and 14 as well as p63; carcinoma tissues did not express the basal cell markers. Grafting of tissues to castrated hosts did not affect the graft take rates (but was not practical in the case of the orthotopic site). Grafting followed by host castration resulted in epithelial regression with loss PSA and reduced AR expression at all three sites.

CONCLUSIONS

These data suggest that sub-renal capsule and orthotopic grafting of human prostate tissue can be used for many basic scientific and translational studies.

The gene expression signatures of melanoma progression

Because of the paucity of available tissue, little information has previously been available regarding the gene expression profiles of primary melanomas. To understand the molecular basis of melanoma progression, we compared the gene expression profiles of a series of nevi, primary melanomas, and melanoma metastases. We found that metastatic melanomas exhibit two dichotomous patterns of gene expression, which unexpectedly reflect gene expression differences already apparent in comparing laser-capture microdissected radial and vertical phases of a large primary melanoma. Unsupervised hierarchical clustering accurately separated nevi and primary melanomas. Multiclass significance analysis of microarrays comparing normal skin, nevi, primary melanomas, and the two types of metastatic melanoma identified 2,602 transcripts that significantly correlated with sample class. These results suggest that melanoma pathogenesis can be understood as a series of distinct molecular events. The gene expression signatures identified here provide the basis for developing new diagnostics and targeting therapies for patients with malignant melanoma.

Cyclooxygenase-2 expression is related to nuclear grade in ductal carcinoma in situ and is increased in its normal adjacent epithelium

Cyclooxygenase-2 (COX-2) is emerging as an important cancer biomarker and is now an experimental target for solid tumor treatment.However, no study has exclusively focused on COX-2 expression in early lesions such as ductal carcinoma in situ (DCIS). We examined COX-2 expression by immunohistochemistry in 46 cases of women undergoing surgical resection for DCIS. We found that COX-2 expression was detected in 85% of all DCIS specimens, with increased COX-2 staining correlating with higher nuclear grade. Strikingly, COX-2 staining intensity in the normal adjacent epithelium was stronger than in the DCIS lesion itself. Our observations demonstrate that COX-2 is up-regulated in the normal adjacent epithelium and supports the hypothesis that the surrounding epithelial tissue is part of the disease process in DCIS.

Fine needle aspiration cytology of intraoral epithelioid hemangioma. A report of two cases

BACKGROUND

Epithelioid hemangioma (EH) is an uncommon, benign, vascular lesion of unknown etiology. The clinical differential diagnosis is broad and includes both epithelial and vascular neoplasms. In contrast to the histopathology of this lesion, the cytopathology, as obtained by fine needle aspiration biopsy (FNAB), has been described only once before.

CASES

Two cases of EH of the oral cavity were evaluated by FNAB. The first case included histologic follow-up, while the second included immunohistochemical analysis of the aspirate material (cell block). The smear characteristics included cohesive epithelioid cells with moderate cytoplasm, ovoid nuclei and small nucleoli that formed occasional abortive vascular channels as well as spindle cell groups and a few larger cells with pleomorphic nuclei and irregular nuclear contours against a largely bloody background. Immunohistochemical staining for CD34 and factor VIII-related antigen confirmed the endothelial nature of these proliferations.

CONCLUSION

The cytomorphology, an endothelial immunophenotype, and the appropriate clinical presentation should permit diagnostic consideration of EH in the differential diagnosis of an endothelial lesion.

Expression of the coxsackie adenovirus receptor in normal prostate and in primary and metastatic prostate carcinoma: potential relevance to gene therapy

Adenovirus-based gene therapy may provide an alternative mode of treatment for prostate cancer, especially for late-stage and androgen-independent disease for which there is currently no effective treatment. Efficient adenovirus infection of target cells depends upon the presence of the coxsackie adenovirus cell surface receptor, CAR, which is the primary receptor for group C adenoviruses and is important for the attachment of adenovirus to the cell membrane. To evaluate the potential efficacy of adenoviral therapy for prostate cancer, we evaluated CAR expression in normal prostate tissue and in prostate carcinoma of increasing Gleason grades in paraffin-embedded, archival tissues using a polyclonal antibody raised against human CAR. Immunohistochemical analysis of benign prostate epithelia demonstrated intense luminal and lateral cell membrane staining. There was a statistically significant difference in CAR membrane expression with respect to Gleason score. In addition, metastatic prostate specimens demonstrated strong membrane staining for CAR. Adenovirus therapy may, therefore, provide an alternate modality in the treatment of prostate cancer and may be especially efficacious in the treatment of metastatic disease.

Utility of intraoperative frozen section analysis of surgical margins in region of neurovascular bundles at radical prostatectomy

OBJECTIVES

To report our experience with intraoperative frozen section (IFS) analysis in patients who are potential candidates for nerve-sparing surgery. Potency can be maintained in select patients who undergo radical prostatectomy using a nerve-sparing approach. However, extracapsular disease extension in the area of the neurovascular bundles may compromise adequate surgical margins in some patients undergoing such surgery.

METHODS

We reviewed the pathologic results from 101 patients who underwent either unilateral or bilateral nerve-sparing radical prostatectomy in whom IFS analysis was performed. The clinical disease stage was T1 in 20 patients and T2 in 81 patients. The mean serum prostate-specific antigen level before surgery was 7.2 ng/mL. Of the 101 patients, 62, 28, and 11 had a biopsy Gleason score of 2 to 6, 7, and 8 to 10, respectively. IFS analysis was performed on the surgical margin thought to be at risk of tumor involvement as determined by the results of systematic prostate biopsy, transrectal ultrasonography, or intraoperative inspection. If the frozen section was positive, additional tissue, including the neurovascular bundle, was subsequently removed to establish clear surgical margins. IFS results were compared with those on the final, permanent tissue section, as well as with the status of the additionally resected tissue.

RESULTS

The IFS results were identical to those obtained on the final, permanent section in 92 (91%) of the 101 cases. The IFS results showed positive margins in 15 (15%) of 101 patients. Of these cases, 11 demonstrated positive margins on the final permanent sections. Of the 86 patients with negative frozen section diagnosis, 5 had positive surgical margins on permanent sections at the site of the IFS. The positive and negative predictive value for the IFS technique was 73% and 94%, respectively. Of the 15 patients with positive IFS, 12 (80%) had no evidence of tumor in the additionally resected tissue. Prostate-specific antigen recurrence was noted in 7% of the study population. The risk of recurrence in patients with either positive or negative IFS findings was similar.

CONCLUSIONS

IFS at the time of radical prostatectomy can reliably predict the final surgical margin status in most carefully selected high-risk patients when there are concerns about the margin status.

Malignant transformation in a nontumorigenic human prostatic epithelial cell line

The human prostatic epithelial cell line BPH-1 is normally nontumorigenic in nude mice. The present report demonstrates that this cell line can be permanently transformed by its microenvironment to become tumorigenic. The establishment of a series of tumorigenic sublines based on this parental cell line is described. BPH-1 cells were induced to form tumors either by recombination with human prostatic carcinoma-associated fibroblasts (CAFs) or by exposure to carcinogenic doses of testosterone and estradiol (T+E2) after recombination with rat urogenital sinus mesenchyme. Epithelial cells isolated from these tumors were established as cell strains in culture. When regrafted to nude mouse hosts epithelial cells isolated from CAF- or T+E2-induced tumors were found to be consistently tumorigenic even in the absence of CAF or T+E2. The T+E2-induced cell strains have been designated BPH1(TETD)-A and -B and the CAF-induced strains are designated BPH1(CAFTD)-01 through -08. In vitro, the cells had an epithelial morphology with a less well-defined cobblestone pattern than the parental line. They express SV40 large T antigen, confirming their derivation from the parental BPH-1 line. The BPH1(CAFTD) strains formed colonies in soft agar, whereas the parental BPH-1 cells and the BPH1(TETD) sublines did not. There was no immunocytochemically detectable expression of androgen (AR), alpha-estrogen (ERalpha), or progesterone (PR) receptors by the parental BPH-1 cell line or by any of the tumor-derived cell strains. The cells uniformly coexpressed both basal and luminal cell-type cytokeratins and the basal cell marker p63. When grafted beneath the renal capsule of athymic mouse hosts, all of the tumor-derived cell strains consistently formed tumors. These were predominantly poorly or moderately differentiated squamous or adenosquamous tumors, similar in organization to the primary tumors from which the cell strains were derived. The cell strains continued to express both basal- and luminal-type cytokeratins in vivo. Some of the cell strains also coexpressed vimentin. E-cadherin expression was absent from many of the cells, although patches of cells expressing this marker were seen. The cells continued to express SV40T antigen. These cell strains, which are all derived from a common nontumorigenic progenitor, represent a useful resource for examining genetic and phenotypic changes during carcinogenesis.

Mucinous adenocarcinoma of the ovary metastatic to the eye: report of a case with diagnosis by fine needle aspiration biopsy

BACKGROUND

Metastatic malignancy involving the ocular uveal tract is rare. Approximately one-third of patients will present without a known primary site. This is the ninth reported clinically detected case of ovarian carcinoma metastatic to the eye, the second with mucinous differentiation and the first in which the diagnosis was established by fine needle aspiration (FNA).

CASE

A woman developed ovarian mucinous adenocarcinoma metastatic to the choroid layer of the eye.

CONCLUSION

FNA is useful in diagnosing lesions of the eye and orbit, including diagnosis of rare metastatic lesions.

A human prostatic epithelial model of hormonal carcinogenesis

The effects of stromal and hormonal environment on the immortalized but nontumorigenic human prostatic epithelial cell line BPH-1 were investigated in an in vivo model. BPH-1 cells were recombined with rat urogenital sinus mesenchyme (UGM), and the tissue recombinants were grafted to the renal capsule of adult male athymic mouse hosts. BPH-1 + UGM recombinants formed solid branching epithelial cords with a well-defined basement membrane. The cords canalized to form ductal structures. The mesenchymal cells formed thick sheets of well-differentiated smooth muscle surrounding the epithelium, reinforcing the idea that the epithelium dictates the patterning of prostatic stromal cells. When hosts carrying BPH-1 + UGM tissue recombinants were exposed to testosterone propionate and 17-beta-estradiol (T + E2), the tissue recombinants responded by forming invasive carcinomas, demonstrating mixed, predominantly squamous as well as adenocarcinomatous (small acinar and mucinous) differentiation. When either untreated or T + E2-treated hosts were castrated, epithelial apoptosis was observed in the grafts. When tumors were removed and regrafted to fresh hosts they grew rapidly. Tumors were serially regrafted through six generations. Histologically these tumors consisted largely of focally keratinizing squamous cell carcinoma with high-grade malignant cytological features. BPH-1 cells grown in the absence of UGM survived at the graft site but did not form tumors or organized structures. This behavior was not influenced by the presence or absence of T + E2 stimulation. These data show that an immortalized, nontumorigenic human prostatic epithelial cell line can undergo hormonal carcinogenesis in response to T + E2 stimulation. In addition, the data demonstrate that the stromal environment plays an important role in mediating hormonal carcinogenesis.

Docetaxel, estramustine, plus trastuzumab in patients with metastatic androgen-independent prostate cancer

The incidence of human epidermal growth factor receptor 2 (HER2) protein overexpression and its prognostic value are not well characterized in patients with prostate cancer. A phase I study was designed to evaluate docetaxel/estramustine plus trastuzumab, a humanized monoclonal antibody that binds to the HER2 receptor, in patients with metastatic androgen-independent prostate cancer (AIPC). HER2 positivity was not required because safety was the primary endpoint. Patients received oral estramustine 280 mg three times daily (days 1 to 5); docetaxel, 70 mg/m(2) intravenously (day 2); and trastuzumab, 2 mg/kg intravenously (days 2, 9, and 19), every 21 days until the disease progressed or toxicity became unacceptable. This regimen was well tolerated among the first 13 treated patients. Grade 4 neutropenia was seen in 10% of administered cycles. There were two episodes of febrile neutropenia and two thrombembolic events. Of the 13 patients evaluable for prostate-specific antigen (PSA) response, nine (69%) experienced a decrease in PSA level of >50%. Two (33%) of six patients with measurable disease had objective responses, and one complete response was seen on bone scan. Docetaxel/estramustine/trastuzumab appears to be a safe combination when used in the treatment of metastatic AIPC. The response data are too preliminary for speculation about the relative benefits of this 3-drug regimen compared with the combination of only docetaxel and estramustine in this clinical setting.

HER2 protein expression and gene amplification in androgen-independent prostate cancer

The role of the HER2 receptor remains uncertain in the pathogenesis and progression of human prostate cancer. Previous studies have reported widely divergent rates for HER2 expression in primary prostate tumors, probably owing to significant methodologic differences in the studies. Few data exist about the frequency of HER2 protein overexpression and gene amplification in androgen-independent prostate cancer (AIPC), although recent xenograft models suggest HER2 expression may be up-regulated in the transition from androgen-dependent to androgen-independent disease. We studied the role of HER2 protein in AIPC by immunohistochemical and fluorescence in situ hybridization (FISH) analyses on AIPC specimens using well-characterized and validated reagents. Fourteen (36%) of 39 specimens expressed HER2; however, only 2 (5%) had moderate (2+) expression, and 2 (5%) had high-level (3+) expression. Two (6%) of 36 specimens had gene amplification by FISH. These data suggest that HER2 protein overexpression and gene amplification are relatively uncommon in AIPC.

MRI phenotype is associated with response to doxorubicin and cyclophosphamide neoadjuvant chemotherapy in stage III breast cancer

BACKGROUND

The preferred management for women with stage II or locally advanced breast cancer (LABC) is neoadjuvant chemotherapy. Pathologic response to chemotherapy has been shown to be an excellent predictor of outcome. Surrogates that can predict pathologic response and outcome will fuel future changes in management. Magnetic resonance imaging (MRI) demonstrates that patients with LABC have distinct tumor patterns. We investigated whether or not these patterns predict response to therapy.

METHODS

Thirty-three women who received neoadjuvant doxorubicin and cyclophosphamide chemotherapy for 4 cycles and serial breast MRI scans before and after therapy were evaluated for this study. Response to therapy was measured by change in the longest diameter on the MRI.

RESULTS

Five distinct imaging patterns were identified: circumscribed mass, nodular tissue infiltration diffuse tissue infiltration, patchy enhancement, and septal spread. The likelihood of a partial or complete response as measured by change in longest diameter was 77%, 37.5%, 20%, and 25%, respectively.

CONCLUSIONS

MRI affords three-dimensional characterization of tumors and has revealed distinct patterns of tumor presentation that predict response. A multisite trial is being planned to combine imaging and genetic information in an effort to better understand and predict response and, ultimately, to tailor therapy and direct the use of novel agents.

Calcifying aponeurotic fibroma features seen on fine-needle aspiration biopsy: case report and brief review of the literature

Calcifying aponeurotic fibroma is a rare benign soft tissue proliferation, which occurs in the distal extremities in children. We describe a case of calcifying aponeurotic fibroma of the hand in a 9 year-old male diagnosed by FNA. Clinically and radiographically this mass was felt to be suspicious for sarcoma, likely alveolar rhabdomyosarcoma. Cytologic examination revealed benign appearing spindled cells, chondroid cells, multinucleated giant cells and calcific debris. These features recapitulate the classic histologic features of calcifying aponeurotic fibroma. Conservative excision was performed and histologic exam confirmed the diagnosis. To the authors' knowledge, this is the first description of the cytologic features of this entity.

Percutaneous biopsy of a posterior mediastinal mass through an extrapleural window created with dilute contrast

Extrapleural administration of dilute contrast was used to facilitate biopsy of a posterior mediastinal mass.

Ewing's sarcoma masquerading as osteomyelitis

Ewing's sarcoma in the infant and young child is rare, highly malignant, and can be difficult to identify. An erroneous diagnosis of osteomyelitis may be considered first because the presentation may be similar to that of Ewing's sarcoma, and routine laboratory evaluation may not distinguish between these entities. Two such cases are presented, one involving the tibia in a 16-month-old child and another a finger phalanx in a 7-month-old child. In both cases the correct diagnosis of Ewing's sarcoma was delayed because of initial misdiagnosis of osteomyelitis. This diagnostic dilemma is summarized, and the literature reviewed. Special attention is given to recent advances in histochemistry and cytogenetics that assist in tumor identification. The conclusion highlights areas of remaining controversies for which additional study may facilitate distinction between osteomyelitis and Ewing's sarcoma.

Fine needle aspiration cytology of dermatopathic lymphadenitis

OBJECTIVE

Dermatopathic lymphadenitis (DL) can be a nonneoplastic cause of an enlarged lymph node or nodes. Cytologic findings of DL have not been well described. The differential diagnosis includes Langerhans histiocytosis (LH) in children and low grade lymphoma in adults. We present three cases of dermatopathic lymphadenitis with a discussion of cytologic findings and differential diagnosis.

STUDY DESIGN

Fine needle aspiration (FNA) findings of three cases of lymph nodes involved by DL were reviewed. All three were axillary lymph nodes in patients with skin rashes. Immunoperoxidase stains for S-100 and CD1a were performed on a cell block from one case, and flow cytometric analysis was performed on another.

RESULTS

FNA of DL yields cellular smears with abundant histiocytoid cells with moderate cytoplasm and ovoid, vesicular nuclei with longitudinal grooves (interdigitating reticulum cells). These histiocytoid cells are S-100 and CD1a positive. The background cells are mature lymphocytes, scattered eosinophils and plasma cells. Case 1 was originally misinterpreted as consistent with LH. In case 2, flow cytometric analysis of a mixed population of lymphocytes was seen, ruling out lymphoma. In case 3, the diagnosis of DL was based on morphologic features.

CONCLUSION

Interdigitating reticulum cells in dermatopathic lymphadenitis are S-100 and CD1a positive and could be confused with LH in children. In adults, flow cytometry could be used to distinguish them from low grade lymphoma. FNA findings of DL should be interpreted with the clinical history.

Appraisal of intratumoral microvessel density, MIB-1 score, DNA content, and p53 protein expression as prognostic indicators in patients with locally confined renal cell carcinoma

BACKGROUND

The prognostic values of intratumoral microvessel density (iMVD), tumor cell proliferation rate, DNA content (ploidy), and p53 protein expression are controversial or have not been well studied in patients with renal cell carcinoma (RCC) confined to the kidney.

METHODS

A uniform group of 52 clear cell (conventional) RCCs confined to the kidney (classified as T1N0M0 or T2N0M0) were analyzed for iMVD, MIB-1 score, DNA content, S-phase fraction, and p53 protein expression by immunohistochemical methods or flow cytometry. iMVD was evaluated in a single area (X200, 1.15 mm2) representative of the highest MVD (neovascular "hot spot") after independently highlighting endothelial cells with antibodies specific for factor VIII-related antigen (F8/86) and CD31 (JC/70A). The MIB-1 antibody (Ki-67 antigen) score was used as a marker for the tumor cell proliferation rate. DNA content and S-phase fraction were determined by flow cytometry using paraffin embedded tissue. p53 expression was assessed using the D07 antibody.

RESULTS

The median time of clinical follow-up was > 9 years. Eleven patients died of disease; the median time to death was 26 months. iMVD counts using antifactor VIII and anti-CD31 were tightly correlated (correlation coefficient = 0.89). S-phase fraction was higher in aneuploid tumors than in diploid tumors (mean, 12.4% vs. 4.3%; P = 0.01). Using univariate survival analyses, tumor size (stage classification pT1 vs. PT2; P = 0.01) and nuclear grade (P = 0.04) were associated with shortened survival. No statistically significant differences in survival were found for iMVD, MIB-1 score, DNA content, S-phase fraction, or p53 expression. Only two cases strongly expressed p53 protein; both tumors were of high nuclear grade. Using multivariate survival analyses, nuclear grade and tumor size were the only independent prognostic factors (best model P = 0.002).

CONCLUSIONS

In this study, nuclear grade and tumor size were found to be independent predictors of survival in locally confined clear cell (conventional) RCC, as has been shown previously for locally confined RCC in general. MIB-1 score, iMVD counts, DNA content, S-phase fraction, and p53 expression did not contribute additional prognostic information.

Intracortical Osteosarcoma

Intracortical osteosarcoma is the rarest form of osteosarcoma and typically occurs in the young. The authors describe a case of intracortical osteosarcoma arising in the femur of a 44-year-old woman. A diaphyseal location and a typical radiographic appearance, illustrated in this report, distinguish intracortical osteosarcoma from conventional (intramedullary) osteosarcoma, but not from less common forms of osteosarcoma or from several benign bone tumors. This case illustrates the low-grade osteoblastic histology, malignant osteoid formation, and medullary and surrounding soft tissue invasion diagnostic of intracortical osteosarcoma. The authors discuss the diagnostic difficulties presented by intracortical osteosarcoma and the natural history of these tumors. Int.J Surg Pathol 3(3):195-200, 1996