Comprehensive clinicopathological, molecular, and methylation analysis of mesenchymal tumors with NTRK and other kinase gene aberrations

Alterations in kinase genes such as NTRK1/2/3, RET, and BRAF underlie infantile fibrosarcoma (IFS), the emerging entity 'NTRK-rearranged spindle cell neoplasms' included in the latest WHO classification, and a growing set of tumors with overlapping clinical and pathological features. In this study, we conducted a comprehensive clinicopathological and molecular analysis of 22 cases of IFS and other kinase gene-altered spindle cell neoplasms affecting both pediatric and adult patients. Follow-up periods for 16 patients ranged in length from 10 to 130 months (mean 38 months). Six patients were treated with targeted therapy, achieving a partial or complete response in five cases. Overall, three cases recurred and one metastasized. Eight patients were free of disease, five were alive with disease, and two patients died. All cases showed previously reported morphological patterns. Based on the cellularity and level of atypia, cases were divided into three morphological grade groups. S100 protein and CD34 were at least focally positive in 12/22 and 14/22 cases, respectively. Novel PWWP2A::RET, NUMA1::RET, ITSN1::RAF1, and CAPZA2::MET fusions, which we report herein in mesenchymal tumors for the first time, were detected by RNA sequencing. Additionally, the first uterine case with BRAF and EGFR mutations and CD34 and S100 co-expression is described. DNA sequencing performed in 13 cases uncovered very rare additional genetic aberrations. The CNV profiles showed that high-grade tumors demonstrate a significantly higher percentage of copy number gains and losses across the genome compared with low- and intermediate-grade tumors. Unsupervised clustering of the tumors' methylation profiles revealed that in 8/9 cases, the methylation profiles clustered with the IFS methylation class, irrespective of their clinicopathological or molecular features. © 2024 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Poorly differentiated extra-axial extraskeletal chordoma diagnosed by methylation profiling: case report and analysis of brachyury expression in SWI/SNF-deficient tumors

Chordoma is a rare malignant tumor with notochordal differentiation, usually affecting the axial skeleton of young patients. We report a case of a high-grade epithelioid tumor involving the synovium and soft tissues of the knee in a 74-year-old male patient. The preliminary biopsy was inconclusive, but a diagnosis of metastatic clear-cell carcinoma of unknown origin was suggested. However, imaging studies did not reveal any primary lesions. The resection specimen consisted of nests and sheets of oval to polygonal cells with discernible cell borders, clear or lightly amphophilic cytoplasm, and round to oval nuclei with occasional well-visible eosinophilic nucleoli. Rare atypical mitoses, necrotic areas, and bizarre nuclei were noted. The biopsy and resection specimens underwent a wide molecular genetic analysis which included methylation profiling. The DKFZ sarcoma classifier assigned the methylation class chordoma (dedifferentiated) with a calibrated score of 0.96, and additionally, a loss of SMARCB1 locus was noted in the copy number variation plot. To verify these findings, T-brachyury and SMARCB1 immunostaining was performed afterward, showing diffuse nuclear positivity and complete loss in the tumor cells, respectively. To assess the prevalence of T-brachyury immunopositivity among SWI/SNF-deficient tumors and to evaluate its specificity for poorly differentiated chordoma, we analyzed a series of 23 SMARCB1- or SMARCA4-deficient tumors, all of which were negative. After incorporating all the available data, including the absence of any morphological features of conventional chordoma, the case was diagnosed as poorly differentiated chordoma. As illustrated herein, the utilization of methylation profiling in the diagnostic process of some carefully selected unclassifiable soft tissue neoplasms may lead to an increased detection rate of such extremely rare soft tissue tumors and enable their better characterization.

Spindle cell rhabdomyosarcomas: With TFCP2 rearrangements, and novel EWSR1::ZBTB41 and PLOD2::RBM6 gene fusions. A study of five cases and review of the literature

AIMS

Spindle-cell/sclerosing rhabdomyosarcomas (SS-RMS) are clinically and genetically heterogeneous. They include three well-defined molecular subtypes, of which those with EWSR1/FUS::TFCP2 rearrangements were described only recently. This study aimed to evaluate five new cases of SS-RMS and to perform a clinicopathological and statistical analysis of all TFCP2-rearranged SS-RMS described in the English literature to more comprehensively characterize this rare tumour type.

METHODS AND RESULTS

Cases were retrospectively selected and studied by immunohistochemistry, fluorescence in situ hybridization with EWSR1/FUS and TFCP2 break-apart probes, next-generation sequencing (Archer FusionPlex Sarcoma kit and TruSight RNA Pan-Cancer Panel). The PubMed database was searched for relevant peer-reviewed English reports. Five cases of SS-RMS were found. Three cases were TFCP2 rearranged SS-RMS, having FUSex6::TFCP2ex2 gene fusion in two cases and triple gene fusion EWSR1ex5::TFCP2ex2, VAX2ex2::ALKex2 and VAX2intron2::ALKex2 in one case. Two cases showed rhabdomyoblastic differentiation and spindle-round cell/sclerosing morphology, but were characterized by novel genetic fusions including EWSR1ex8::ZBTB41ex7 and PLOD2ex8::RBM6ex7, respectively. In the statistical analysis of all published cases, CDKN2A or ALK alterations, the use of standard chemotherapy and age at presentation in the range of 18-24 years were negatively correlated to overall survival.

CONCLUSION

EWSR1/FUS::TFCP2-rearranged SS-RMS is a rare rhabdomyosarcoma subtype, affecting predominantly young adults with average age at presentation 34 years (median 29.5 years; age range 7-86 years), with a predilection for craniofacial bones, rapid clinical course with frequent bone and lung metastases, and poor prognosis (3-year overall survival rate 28%).

Extraskeletal myxoid chondrosarcoma: A study of 17 cases focusing on the diagnostic utility of INSM1 expression and presenting rare morphological variants associated with non-EWSR1::NR4A3 fusions

Extraskeletal myxoid chondrosarcoma (EMC) is a rare sarcoma of uncertain lineage. Insulinoma-associated protein 1 (INSM1) has recently been described as a highly specific and sensitive immunohistochemical marker for EMC. The goal of this study was to evaluate the diagnostic significance of INSM1 immunohistochemistry in EMC. Furthermore, correlations between molecular and morphological findings were performed. Sixteen of 17 EMC cases were stained with the INSM1 antibody. Tumors with at least 5% INSM1-positive cells and any staining intensity were considered positive. Molecular testing was successfully performed in 12/17 cases. The immunohistochemical analysis detected 13 INSM1-positive (81%) and 3 INSM1-negative tumors (19%). The extent of the staining was classified as 1+ in 7 cases (44%), 2+ in 2 cases (13%), 3+ in 2 cases (13%) and 4+ in 2 cases (13%). Intensity of immunostaining was weak in 5 cases (31%), moderate in 2 cases (13%) and strong in 6 cases (38%). Molecular assays revealed 8 EWSR1::NR4A3 positive tumors (67%), 2 TAF15::NR4A3 positive tumors (17%), 1 TCF12::NR4A3 positive tumor (8%) and 1 NR4A3 positive tumor (8%) in which no other gene alteration was identified. Two of them, namely TCF12 positive and one TAF15 positive tumors, were highly cellular and partially associated with pseudopapillary architecture. Our study found that moderate/strong expression of INSM1 in more than 25% of tumor cells was present in only 31% of cases. Thus, the diagnostic utility of INSM1 is rather low. Two morphologically unique cases of non-EWSR1 rearranged EMC with an extremely rare pseudopapillary growth pattern are also reported.

Dermatofibrosarcoma protuberans with fibrosarcomatous transformation: a case report

Dermatofibrosarcoma protuberans is a quite rare local aggressive tumor of dermis and subcutis, revealing characteristic morphology and chromosomal translocation (17; 22)(q21;q13) with gene fusion COL1A1-PDGFB. The tumour almost never metastasizes and complete excision signs an excellent prognosis. Approximately in 10% of cases, dermatofibrosarcoma undergoes a fibrosarcomatous transformation associated with metastatic disease and worse prognosis. In this paper, we refer a case of a male patient with subcutaneous tumor in back region, in which the small biopsy lead to diagnosis of a spindle cell sarcoma. However, only the histopathological examination of the entire tumor in the material from the radical surgery detected the dermatofibrosarcoma protuberans with fibrosarcomatous transformation. Both components of the tumor showed the characteristic genetic alteration. Identification of fibrosarcomatous component within the DFSP matters in prognosis. Distinction between fibrosarcoma arising within the dermatofibrosarcoma protuberans and fibrosarcoma arising de novo is of therapeutic consequence: the patients with metastatic or inoperable DFSP with fibrosarcomatous transformation may profit form imatinib treatment.

Chondroblastoma-like primary malignant giant cell tumor of the humerus - a case report

35-year-old woman suffered prolonged pain in the left shoulder, where an aggressively growing tumor of the proximal humerus was revealed thereafter. The lesion caused massive osteolysis of the metaepiphysis with cortical disruption, but no soft tissue extension was evident. Given the unsatisfactory effect, the ongoing neoadjuvant chemotherapy was prematurely ceased and the resection 13 cm long segment of bone with modular prosthesis replacement followed. Histologically, clear-cut malignant tumor with both the presence of numerous reactive osteoclast-like giant cells and geographic structural deposition of chondroid matrix bore a close resemblance to chondroblastoma. Dominant cellular composition formed solid mosaic clusters of large, atypical, frequently binucleated cells with voluminous eosinophilic cytoplasm. Impressive nuclear pleomorphism was accentuated by both the grooving and atypical mitotic figures. Thorough sampling disclosed limited, but sharply contrasting parts, where biphasic arrangement of small uniform stromal elements together with regularly distributed, reactive osteoclasts suggested putative precursor giant cell lesion. Except the osteoclasts, all matrical and stromal cells were strongly SOX9 and D2-40 positive; in contrary desmin, SATB2, S100 and p63 yielded completely negative results. Detected H3F3A c.103G>T mutation in exon 2 finally established true nature of that peculiar neoplastic proliferation and lead to descriptive term of primary chondroblastoma-like malignant giant cell tumor. In the setting of all the microscopic variability, histogenesis and complex differential diagnosis of skeletal (malignant) giant cell lesions, there are discussed e.g. aggressive/malignant chondroblastoma, chondroblastoma-like osteosarcoma or giant cell-rich osteosarcoma and practical impact of specific mutational analysis results as well.

Dermatofibrosarcoma protuberans of the breast: A case report

Dermatofibrosarcoma protuberans (DFSP) is a rare malignant tumor of subcutaneous tissue characterized by slow infiltrative growth. The tumor occurs in patients of all ages, with the highest frequency occurring between the second and the fifth decades of age. Genetically, DFSP is characterized by a reciprocal translocation t(17;22)(q22;q13), or more often, as a supernumerary ring chromosome involving chromosomes 17 and 22. Standard treatment of a localized tumor is surgical excision with wide margins. In the present study, a case report of a 43-year-old woman with a growing tumor in the left breast is discussed. The patient underwent breast-conserving surgery. Histological and cytogenetic examinations of the tumor resulted in a diagnosis of DFSP. The clinical and morphological characteristics of the tumor, in addition to the treatment options, were also evaluated.

[What´s new in Ewing-like sarcoma family? Soft tissue and bone sarcomas with CIC/BCOR rearrangement. Review of the literature and first personal experience]

The literature is reviewed regarding of a rare molecularly defined group of sarcomas with rearrangement of both CIC and BCOR genes, which were originally placed into the EWSR1wt Ewing-like category. Personal experience with three cases demonstrating difficulties of this issue is added. Both groups of lesions differ not only by age and topography, but also vary in both the prognostic and the predictive parameters. CIC-rearranged tumors are very aggressive and almost never occur in the skeleton; in contrary, the BCOR-rearranged ones are predominantly bone tumors in young males behaving even better than classical Ewing sarcoma. From the morphologic point of view, it turned out to be a salient finding that these types of neoplasm might leave canonical morphotype of small blue round cell sarcoma. Instead of it, they are not uncommonly characterized as a relatively uniform spindle cell proliferation with prevailing myxoid transformation deserving much broader differential diagnosis. Our three cases reports display difficulties in reaching the correct diagnosis even by implementing sophisticated molecular techniques in routine practice. Notwithstanding of exhaustive molecular assays used, one may still encounter a lesion where original descriptive term Ewing-lie sarcoma remains uncorrected.

[Diffuse tenosynovial giant cell tumor of the cervical spine destroying vertebra C6 - a case report]

Presented is a case of 59-year-old woman with longstanding neck pain who has been promptly operated for spinal cord compression. Imaging studies disclosed ill-defined cervical paravertebral soft tissue mass at the level of vertebra C5/6 abutting left-sided intervertebral joint and destroying neighboring both vertebral arch and processus spinosus. Submitted specimen was interpreted as a possible metastatic skeletal process by clinicians and referring pathologist favored diagnosis of giant cell tumor/osteoclastoma of the bone. Microscopic features were consistent with giant cell lesion where uniform mononuclear mosaic stromal component dominated the unevenly distributed loose clusters of osteoclast-like giant cells frequently imparting appearance of peculiar pseudoalveolar spaces. Additionally, alternating geographic xanthomatous and densely hyalinized/ osteoid-like zones with speckled, coarsely granular haemosiderin pigment completed the variegated structural composition. The tumor infiltrated adjacent striated muscles; either original bone structures and/or extracellular matrix deposits were not identified. Immunohistochemical stains with p63, SATB2, desmin, EMA, clusterin and S100protein turned out to be completely negative. FISH analysis revealed no rearrangement of CSF1 gene. The diagnosis of the diffuse tenosynovial giant cell tumor was rendered.

[Small cell type (Ewing-like) clear cell sarcoma of soft parts: a case report]

The authors present a unique case of small cell variant of clear cell sarcoma of soft parts in a 42-year old woman. The tumor originally arose in the right flank of the soft tissues and ultimately developed both a local recurrence and multiple distant skin metastases two years and ten months thereafter. Nonspecific morphology of small blue round cell tumor was preserved at all microscopically verified sites and initially led to the spectrum of erroneous diagnoses such as an extraskeletal myxoid chondrosarcoma, Ewing sarcoma as well as malignant melanoma. The distinctive features of clear cell sarcoma such as fascicular nested growth pattern, spindling, clear cell change and/or eosinophilic cytoplasm were not disclosed even by extensive sampling. Immunohistochemically, the tumor expressed only S100protein and HMB45; all other markers (CD99, FLI1, cytokeratins, EMA) were completely negative. The molecular analysis carried out in one of the cutaneous metastases revealed translocation t(12;22) (EWSR1-ATF1) and ultimately led to the correct diagnosis of unusual Ewing-like clear cell sarcoma. Discussed is the implementation of molecular tests in routine diagnostics considering the existence of both histologically and biologically different tumors with an identical pathogenic molecular background.

[Periosteal osteosarcoma - personal experience with five cases]

The authors present five cases of periosteal osteosarcoma located in the femur (4) and tibia (1) in children and young adults (1 female and 4 males) with an age range of 9 - 23 years (mean age 15 years). Radiographs in all cases showed a broad-based soft tissue mass attached to the cortex with periosteal reaction and in two of them cortical disruption with extensive medullary involvement. Follow-ups were available in four cases (range 11 - 73 months) and revealed pelvic metastasis after 15 months with ultimately rapid dissemination and death in a 9-year-old girl and metastasis to the humerus after 13 months in a 15-year-old boy. The former tumor widely extended into the medullary cavity and an amputation was carried out, the latter had a pure juxtacortical position and an en block resection was performed; both of them were treated with chemotherapy. All the lesions displayed distinctive structural patterns combining a large island of tumorous cartilage and hypocellular, bland-looking myxoid mesenchymal stroma with abrupt transition between both components. Contrary to conventional osteosarcoma, the delicate flocculent osteoid deposits were produced by innocuous stromal cells lacking apparent atypia. They were strictly situated outside the prevailing chondroid areas and disclosed sometimes only after a meticulous search. Immunohistochemical detection of SATB2, S100protein and D2-40 assisted effectively not only in recognition of the real stromal histogenetic derivation, but also in distinction of true differentiation of a heavily mineralized extracellular matrix. Molecular analysis revealed no IDH1/2 mutation in four examined cases. Regardless of unique low-grade morphology in rare periosteal osteosarcoma, an aggressive therapeutical approach similar to conventional osteosarcoma is justified, particularly in the case of a medullary extension.

[Where does Ewing sarcoma end and begin - two cases of unusual bone tumors with t(20;22)(EWSR1-NFATc2) alteration]

The authors present two cases of Ewing-like sarcoma of the humerus and femur of a 12-year-old boy and a 28-year-old male, respectively. Identical morphology in both tumors consisted of multiple solid nests with a mosaic collection of small, round, uniform cells with clear cytoplasm and no apparent nuclear atypia. A monotonous structural arrangement, including both rich vascularity of bordering septae and significant admixtures of eosinophil leucocytes, resulted in a final organoid "neuroendocrine-like" pattern. Immunohistochemistry revealed diffuse strong CD10, CD99 and CD138 positivity. Detailed molecular analysis in both tumors confirmed translocation t(20;22) resulting in an EWSR1-NFATc2 fusion gene. Additionally, this translocation was accompanied by amplification of the proximal part of the genes and surrounding areas. Clinically, both neoplasms behaved aggressively and they were primarily chemoresistant. Four years later, the patient with the lesion in the humerus developed a massive local recurrence with a disruption of osteosynthesis. The last follow-up disclosed suspicious metastatic deposits in the lung. The boy with the femoral tumor underwent a total femoral prosthesis and there are no signs of local or systemic recurrence after 11 months of follow-up. The authors discuss the taxonomic placement of these rare examples of Ewing-like sarcoma family in the light of new molecular discoveries.

Unusual Multiorgan Immunoglobulin G4 (IgG4) Inflammation: Autoimmune Pancreatitis, Mikulicz Syndrome, and IgG4 Mastitis

Autoimmune pancreatitis (AIP) type 1 is commonly associated with simultaneous involvement of extrapancreatic organs. Sclerosing cholangitis, sialadenitis, retroperitoneal fibrosis, Sjögren syndrome, and other extrapancreatic lesions are often observed concurrently with AIP. High levels of immunoglobulin G4 (IgG4) in the blood serum and affected tissues are typical of this diagnostic entity. We describe a case report of a 58-year-old female with findings of AIP (according to Asian criteria), IgG4-positive mastitis, and histologically verified Mikulicz syndrome. The effect of corticoid therapy supported the diagnosis of AIP and simultaneously led to the eradication of recurrent mastitis. To the best of our knowledge, this is the first reported case of concurrent findings of AIP and IgG4 mastitis. Our case report supports the concept of systemic IgG4 syndrome with multisystem involvement. Timely diagnosis and appropriate therapy can be effective in a high percentage of patients.

[Sarcomatoid (metaplastic) spindle cell carcinoma arising in a phylloid tumor with massive squamous metaplasia - a case report and review of the literature]

A 76-years-old woman underwent a partial mastectomy and a low-grade malignant homologous phyllodes tumor measuring 45 mm in maximum diameter was diagnosed. Beyond its typical dual composition the tumor displayed extensive intraductal squamous metaplasia. Approximately in one third of the lesion the original mesenchymal component cytologically and structurally changed which ultimately led to seeming stromal overgrowth. The loose storiform background contained isolated larger atypical elements with ample eosinophilic cytoplasm and obvious mitotic activity. This final fibromatosis-like arrangement was completed either by multiple dispersed abrupt squamous morules or just by pearl-like abortive form of squamous differentiation. Conventional in situ or invasive ductal carcinoma was not present. A combined expression of both low and high molecular weight cytoketatins, S100 protein, p63, CD10 and GFAP confirmed the incomplete basal/myoepithelial phenotype and ultimately led to the diagnosis of a spindle cell metaplastic carcinoma arising in a phyllodes tumor - a neoplasm unpublished so far. A review of the literature concerning epithelial malignancies originating from a milieu of phyllodes tumor guides discussion/speculation over the possible histopathogenesis of this vanishingly rare lesion.

KEYWORDS

breast - phylloid tumor - phyllodes tumor - spindle cell sarcomatoid/metaplastic carcinoma - squamous metaplasia.

[Secondary angiosarcomas after conservation treatment for breast cancers]

BACKGROUNDS

The cancerogenic effect of ionizing radiation was documented just several years after it started to be used as a treatment option. Ionizing radiation produces a small but detectable risk of carcinoma as well as bone and soft tissue sarcomas. Over the past 20 years angiosarcomas arising from the area of the irradiated breast have been reported with increasing frequency as the number of women undergoing the breast conserving surgery with consecutive radiotherapy has increased also. Angiosarcomas can originate from either lymphatic or capillary endothelium, namely lymphangiosarcomas and haemangiosarcomas. The most of haemangiosarcomas arising from the breast skin developed in the irradiated area after breast conserving procedure--secondary angiosarcomas. Lymphangiosarcoma is typically associated with longstanding extremity lymphedema--Stewart-Treves syndrome.

CASES

We report three cases of angiosarcomas which occured in this region after breast conserving treatment and we also review the literature.

CONCLUSION

Paradoxically, the decrease in the use of radiotherapy to the post-mastectomy chest wall and the axillary area is expected to reduce the incidence of angiosarcomas, while the increase in the use of breast conserving procedure plus radiotherapy could lead to increased incidence of angiosarcomas in the residual breast tissue. Special attention should be paid to skin leasions and changes occuring after breast conserving treatment and especially to the ones with the skinthickening. The early detection and diagnosis has the crucial prognostic value.

[Metastases to the breast from primary extramammary tumors--real diagnostic dilemma]

OBJECTIVE

To address the difficulty and possible pitfalls in diagnostics of breast mtttstases from extramanmnary primaries--a pathobiological phenomenon that is not always thought of. To underline the open-minded differential diagnostic algorithm that is naturally weakened by dominant straightaway logistics in a routine contemplation. To emphasize the importance of complete and relevant clinical data including the anamnesis. To evaluate the effectiveness velocity and cheapness of imunuohistochemistry at reaching the correct diagnosis.

DESIGN

Comprehensive study of the unusual pathogenetic setting based on personal experience with eight observations and literature review.

SETTING

Biopsy Lab s.r.o. and Sikl's Department of Pathology, Charles University and Faculty Hospital, Pilsen.

METHODS

Detailed clinicopathologic characteristics and review of morphologic spectrum in nine cases of extramammary tumors metastatic to the breast (three melanomas, two small cell carcinomas, one carcinoma from salivary gland, ovary, kidney and prostate). Standard immunohistochemistry was used as a reliable tool for phenotypic evaluation.

RESULTS

In total nine cases, eight women and one man, were identified among 3238 of malignant breast tumors in the years 2005-2010. There were three melanomas, two small cell carcinomas and by one carcinoma from salivary gland, ovary, kidney and prostate. The age ranged from 43 to 81 years and maximum size of lesion spanned 7-31 millimeters. All specimens were core needle biopsy and only in one patient the past medical history concerning the nonbreast malignancy was known (ovarian serous carcinoma). Two neoplasms (one of the melanomas and small cell carcinomas) were the first sign of underlying malignant process ever; in this melanoma the clinical workout to disclose primary skin lesion failed. These two tumors were also the only ones, where the multiple or bilateral involvement of breast was clinically documented. There was evident other organs spread in three cases at the time of diagnosis (generalization in melanoma and prostate carcinoma; skin metastasis in salivary gland carcinoma) and axillary lymph nodes involvement in two melanomas. In five patients where follow-up was available, three died of tumor in interval from five to eighteen months (in turn melanoma, small cell and prostate carcinoma). Four original pathologic verdicts turned out to be wrong (two melanomas, salivary gland and prostate carcinoma); in three of them final correct diagnosis was established even after additional clinical information about morphologically verified malignancy in the past.

[Primary sebaceous carcinoma of the breast; three casuistic reports]

OBJECTIVE

Presentation of three cases of primary sebaceous carcinoma of the breast particularly focusing on the clinical, biological and molecular genetic aspects regarding their possible pathogenetic relationship to the Muir-Torre and Lynch syndrome. Reviewed are basic principles of miscosatellite instability and dysregulations of mismatch repair genes by these inherited tumorous syndromes especially looking for morphologic and fenotypic parallels between sebaceous carcinomas of the breast and their cutaneous counterparts.

DESIGN

Three casuistic reports.

SETTING

Biopsy Lab s.r.o. and Sikl's Department of Pathology, Charles University and Faculty Hospital, Pilsen.

METHODS

Three casuistic reports are covered in detail including broad immunohistochemistry (LSAB+, Dako).

RESULTS

In three women aged 51 to 69 was diagnosed primary sebaceous carcinoma of the breast with maximum dimension ranged from 13 to 41 mm. Lumpectomy was performed at the smallest one and included sentinel lymph node examination turned out to be negative. The other two patients underwent modified mastectomy with axillary lymph node dissection. In tumor sized 25 mm, macrometastasis 4 mm in maximum dimension was identified in one axillary lymph node. Follow-up available in two women, both without regional metastasis, revealed no local or distant progression of the disease. The histology consisted of conventional G1-2 invasive duct carcinoma in all cases and sebaceous differentiation represented 10-40% of all neoplastic population. The patognomic features included cells with ample eosinophilic/clear foamy cytoplasm, partly with multiple crowded small vacuoles characteristically impressing the nuclei. All tumors were ER positive and Her2/neu 2+ lesion was not amplified. Strong diffuse nuclear expression of MLH1, PMS2, MSH2, MSH6 proteins in all cases confirmed unaltered mismatch repair genes pathway. Familial tumorous stigmas were not evident and subsequent close clinical monitoring in two of the patients tracked down no intern malignancy, including cutaneous sebaceous lesion.

[Ovarian tumor as a complication in diagnosis of the extraintestinal gastrointestinal stromal tumor--two case reports]

OBJECTIVE

The aim of this study is to address difficulties in diagnosis of the extraintestinal gastrointestinal stromal tumor (GIST) when even in ovary is the tumor. One should ever think of the GIST in the case of peritoneal dissemination of the spindle/epithelioid cell tumor. In contrary, the late intraabdominal recurrence of primary both epithelial and non-epithelial tumor of genital tract can be undistinguishable by pure morphology. Complete clinical records and accurate operation field topography are both of great value. Documenting this phenomenon, presented is both late intraabdominal dissemination of primary uterine endometrial stromal sarcoma and massive ovarian involvement by extraintestinal GIST.

DESIGN

Two case reports.

SETTING

Biopsy Lab s.r.o. and Sikl's Department of Pathology, Charles University and Faculty Hospital, Pilsen.

METHODS

The two casuistic reports are covered in detail including broad immunohistochemistry (LSAB+, Dako) and genetics (ABI Prism 310, PE/Applied Biosystems).

RESULTS

In 75-year-old woman, 5 cm tumor in maximum diameter of the mesentery was diagnosed as an extraintestinal GIST. Multiple peritoneal recurrence occurred ten years later and the tumor has been reclassified as a disseminated endometroid stromal sarcoma. Ultimately, comprehensive search of clinical files confirmed hysterectomy and adnexotomy in 1973. The second case describes 49-year-old woman operated for tumorous obliteration of the small pelvis where a tumor 9 cm in maximum diameter was found. Initially, predominant epitheloid morphology of the tumor led to the diagnosis of primary epithelial malignancy, sex-cord stromal tumor or metastatic melanoma of the ovary. Finally, the help of immunohistochemistry and molecular biology rendered the tumor as an extraintestinal GIST, ovarian primary not excluded.

[Basal-like carcinoma of the breast--the actual review and clinico-pathological corelations]

OBJECTIVE

Comprehensive review of current topic called basal-like carcinoma of the breast, focused on morphology, molecular biology and clinico-pathological aspects concerning biology, prognosis and rational therapy.

DESIGN

Review article.

SETTING

Biopsy Lab s.r.o. and Sikl's Department of Pathology, Charles University and Faculty Hospital, Pilsen.

METHODS

Summarized are recent data, diagnostic principals and clinico-pathological recommendations of basal-like carcinoma and outlined is comprehensive guide for daily diagnostic and therapeutic practice.

RESULTS

Basal-like carcinoma of the breast is a subset of tripple negative lesions (ER-/PR-/Her2-) and accounts for approximately 5-7% all ductal carcinomas. This is a highly aggressive tumor characterized by rapid systemic dissemination, especially to the lung and brain. By definition, there is expression of high molecular weight cytokeratins and in up to 50% of cases alteration of EGFR gene is found, which creates potential for targeted therapy with tyrosin kinase inhibitors. Basic morphology derives from medullary carcinoma with sharp margin from adjacent parenchyma and presents archetype of BRCA1 mutated familial cancer. Existence of the rare noninvasive in situ phase of the basal-like carcinoma having similar phenotype enables both early and reliable diagnosis even from small core biopsy specimens. Correct diagnosis of this relentless tumor not only brings the chance for effective monitoring specific organs apt to potential metastasis but also challenges for implementation of alternative therapeutic approach, because standard protocols usually fail.

[Pleomorphic epithelioid/clear cell malignant tumor of the uterus exhibiting both myoid and melanocytic differentiation--leiomyosarcoma or PEComa? A case report and a review of the literature]

30-year-old woman admitted for acute abdominal pain with peritoneal signs was immediately operated with findings of hemorrhage in small pelvis. Laparotomy revealed hemorrhagic, friable mass 3 cm in maximum diammeter arising from the uterine horn. The neoplasm broadly invaded myometrium with no evidence of endometrial cavity involvement. Microscopically, the tumor displayed solid mosaic pattern and consisted of large epithelioid cells with ample eosinophilic, finely granular cytoplasm ongoing apparent clear cell change elsewhere. There was marked nuclear irregularity with numerous atypical mitotic figures and multiple bizarre giant elements dispersed throughout the lesion. Unusual complex phenotype included co-expression of vimentin, smooth muscle actin, desmin, HMB45, Melan A, CD10 and EMA. No obvious stigmata of tuberous sclerosis were found and a five months follow-up after chemotherapy indicated no progression of disease. With some uncertainty the tumor was finally rendered as pleomorphic leiomyosarcoma with peculiar melanocytic differentiation. PEComa as an alternative term was coined. Expressed are both difficulty in explaining the histogenesis and ambiguity of the existing terminology of the uterine tumors with mixed myoid and melanocytic phenotype. Reviewed is the literature and discussed is the differential diagnosis.

[Warfarin-induced hemorrhagic pseudocyst in the pelvis of a woman with an inherited disorder of blood coagulation, complicated by pelvic bone pseudoxanthoma mimicking Erdheim-Chester disease]

A fifty-year-old woman with developmental dysplasia of the hip underwent total hip arhtroplasty, and subsequently developed recurrent venous thrombophilia of the lower extremities. Hematological examination revealed an inherited disorder of blood coagulation (homozygous mutation of the 5,10-methylenetetrahydrofolate reductase gene) and therefore longterm Warfarin anticoagulation therapy was started. A year later she was diagnosed with a large pelvic posthemorrhagic pseudocyst (hematoma) located below the musculus iliacus and adhering to bone in the region of posterior acetabulum. The condition was complicated by usuration and focal osteolysis of the adjacent pelvic bone. Histological examination of the hematoma showed characteristics of an unusual pseudoxanthoma mimicking Erdheim-Chester disease. The differential diagnosis of histological findings is discussed and recent relevant literature is reviewed.

[Benign mesenchymal stromal tumor of the breast simulating benign schwannoma in an 81-year-old male--a case report]

Presented is an unusual case of a benign mesenchymal stromal tumor of the breast in an 81-year-old male. The basic appearance of the lesion simulated benign schwannoma and was misinterpreted as a low-grade myxoid liposarcoma initially. Well-circumscribed, gray-white mass measuring 35 mm in maximum diameter was discovered deep in the parenchyma of the completely removed breast. Microscopically, the lesion consisted of myxoid, richly vascular background where dominated oval or spindle cells with impressive palisading replicating that of benign schwannoma. Rarely, the large multinucleated (floret-like type) cells were visible; no nuclear atypia or mitotic figures were found. Immunohistochemical examination confirmed expression of estrogen and progesterone receptors, antigen Bcl2 and also focal desmin positivity. Clinical examinations disclosed no objective reason for possible hyperestrinism; no other therapy followed and the patient is free of disease 19 months after operation. On the background of both detailed review and differential diagnosis of benign, so-called stromal tumor of the female breast, the rarity of this microscopic finding in male is documented.

[Harmatoma of the breast--case report]

OBJECTIVE

To describe rare hamartoma of the breast in a 31-year-old female.

DESIGN

Case report.

SETTINGS

Department of Special Diagnostics SPAU, Charles University Hospital Pilsen.

SUBJECT AND METHOD

A 31-year-old female was examined for breast asymmetry. A huge tumor was revealed in right mammary gland using ultrasonography. Encapsulated tumor 10x10x10 cm was removed. Subsequent histological examination revealed breast hamartoma. The patient is alive and well without signs of disease one year after excision.

CONCLUSION

Hamartoma of the breast is a rare benign tumor. Diagnostics is very complicated and it is almost impossible to establish correct diagnosis preoperatively. A simple excision is a sufficient treatment with good curative effect.

[Massive breast angiomatosis with dramatic course leading to acute total mastectomy--a case report]

OBJECTIVE

On the background of clinical, radiological and morphologic settings presented is unusual case of the rare angiomatosis of the female breast. Discussed are both clinicopathological aspects and differential diagnosis from the morphological point of view.

DESIGN

Case report.

SETTING

Biopsy Lab s.r.o. and Sikl's Department of Pathology, Charles University and Faculty Hospital, Pilsen.

METHODS

As a case report described is a rare case of the angiomatosis of the female breast. Implemented illustrations consist of local findings, CT scan, specimen gross appearance and histological pictures including immunohistochemistry. Applied antibodies and detection system LSAB+ were provided by Dako, visualization was performed by chromogen DAB (diaminobenzidin tetrahydrochlorid).

RESULTS

30-year-old woman suffering of painful, enormous breast asymmetry underwent core needle biopsy of the right breast. The mastogram showed diffuse process of ambiguous significance. During the next few days her condition dramatically changed and under the circumstances of florid apoplexy and suspicion of tumor of her right breast, total mastectomy was carried out. Histological picture revealed widespread, unlimited vascular lesion dissecting throughout the stroma of the entire gland. Bland morphology and the nature of tissue involvement eventually led to diagnosis of benign angiomatosis. The woman underwent several local plastic operations but is out of final reconstruction of her breast so far. Thirteen months after mastectomy there are no signs of recurrence.

[Isolated lymphadenopathy as the first presentation of systemic mastocytosis--description of two cases]

Presented are two cases of systemic mastocytosis in 46- and 63-year-old women, where the correct diagnosis was established in randomly disclosed cervical respectively intraabdominal lymphadenopathy. Both cases lacked characteristic skin and systemic mast-cell mediator symptoms at the time of histologic diagnosis. The first case was classified as a indolent systemic mastocytosis without any proven genetic alteration, the second one met the criteria of aggressive systemic mastocytosis with eosinophilia, where the point mutation asp816val in c-kit gene was confirmed and the patient responded unexpectedly well to Gleevec. Discussed are both conventional morphological differential diagnosis of mastocytosis in lymph nodes and recent advances in genetics of these systemic clonal mast cell proliferations. The latter not only outlines the oncopathogenesis but, in particular, also provides important prognostic and biological implications of this peculiar disease.

[Intraductal papillary proliferation of brest. Actual review and clinicopathological corelation]

OBJECTIVE

Complex summary addressing current view of the intraductal papillary lesions of breast, especially focused on morphology, exact terminology and clinicopathological aspects of effective therapy.

DESIGN

Review article.

SETTING

Biopsy Lab s.r.o. and Sikl's Department of Pathology, Charles University and Faculty Hospital, Pilsen.

METHODS

Summarized recent data, diagnostic principals and clinicopathological recommendations of papillary breast lesions created comprehensive guide for daily diagnostic and therapeutic practice.

RESULTS

The group of papillary tumors of the breast includes various lesions with different biologic potential. They are all presenting as pure intraductal lesions, but in case of multiple peripheral distribution imply possible risk for aggressive behavior. The reason is frequent occurrence of atypical ductal hyperplasia/intraductal (in situ) carcinoma in the adjacent tissue. Spectrum of secondary changes further complicates the diagnosis of papillary tumors, especially in core needle biopsy. Atypical papilloma is still very controversial issue and it essentially means situation when atypical ductal hyperplasia/conventional ductal in situ carcinoma arises in preexisting papillomas or extends to it from neighborhood. Generally, papillary lesions are suitable for effective conservative treatment in the case of proper clear resection margin. Finding of benign papilloma in core biopsy remains unsolved question yet.

[Metastasing and relapsing "low grade" adenosquamous metaplastic breast cancer--is there a really indolent lesion? A description of three cases and review of literature]

OBJECTIVE

To describe personnel experience with three unusual cases of low-grade adenosquamous carcinoma of the breast. Due to the aggressive course in two cases, the review of the literature does not concentrate on morphology and differential diagnosis only, but discuss overall biology of this lesion too.

DESIGN

Three case reports.

SETTING

Biopsy Lab s.r.o. and Sikl's Department of Pathology, Charles University and Faculty Hospital, Pilsen.

METHODS

Included are cases from mammary register of Biopsy Lab s.r.o. and from personnel consulting registry of Prof. Michal. In details are documented both clinical presentations, including follow up, and spectrum of histologic patterns of the lesion. Immunohistochemistry performed by streptavidin-biotin system (LSAB+, Dako) as detection system and diaminobenzidin tetrahydrochlorid as chromogen, employed standard myoepitelial markers (actin, CD10, calponin and p63), hormonal receptors, oncogen Her-2/neu, CK7, CAM5.2, CD34 and CD117.

RESULTS

Partial mastectomy and segmentectomy were performed in three women 46, 72 and 74 years-old resp. for tumor, which size ranged from 20-35 mm in maximum diameter (mean 28 mm). Histology revealed low-grade adenosquamous metaplastic carcinoma displaying typical biphasic appearance combining regular tubular structures with surrounding storiform, sclerosing fibrous stroma. Variably present was characteristic squamous metaplasia of the gland forming either luminal morules or evident squamous pearls. Using immunohistochemistry, a total absence of myoepithelial layer in epithelial structures was confirmed. The stromal component expressed smooth muscle actin in two cases, one of which contained areas of heterologous chondrosseal differentiation. There were recognized metastases by one woman in two ipsilateral axillary lymph nodes mimicking benign breast heterotopia in one of them. One patient experienced recurrence in the scar 37 months after mastectomy where only mesenchymal heterologous component element was found. In two women with aggressive course the original biopsy was falsely interpreted, once as phyllodes tumor and secondly as benign sclerosing pseudotumor.

CONCLUSION

low-grade adenosquamous carcinoma, despite its bland histology, should be understood as regular malignancy prone to frequent recurrences and recognized metastatic potential. It arises in the deep breast tissue and structurally resembles the microcystic adnexal carcinoma of the skin. Low-grade adenosquamous carcinoma, however, has nothing to do with syringomatous adenoma of the nipple, which is a benign tumor of the skin adnexa. Differential diagnosis includes spectrum of non-neoplastic slerosing lesions and above-mentioned phylloid tumor. The rarity of this neoplasm does not exclude deep knowledge.

[Syndrome of pseudomyxoma peritonei--description of three cases and survey of the problem]

OBJECTIVE

To describe personal experience with three heterogeneous cases of pseudomyxoma peritonei. Review of the literature concentrates on the pathogenesis and biologic spectrum of the rare syndrome.

DESIGN

Three case reports.

SETTING

Private Biopsy Lab s.r.o. and Sikl's Department of Pathology, Charles University and Faculty Hospital, Pilsen.

METHODS AND RESULTS

Included are cases from Biopsy Lab s.r.o. and from personal consulting registry of Prof. Michal, Sikl's Department of Pathology, Pilsen. Clinical presentation of three cases of pseudomyxoma peritonei documented is in details including long follow up. Broad variability of histologic appearance associated with different Clinical outcome is demonstrated. Immunohistochemistry performed by streptavidin-biotin system (LSAB+, Dako) as detection system, and diaminobenzidine tetrahydrochloride as chromogen, employed three monoclonal antibodies--MUC2 (Novocastra, 1:400), cytokeratin 7 (Dako, 1:200) and cytokeratin 20 (Dako, 1:100).

CONCLUSION

Pseudomyxoma peritonei is a clinical syndrome defined as presence of massive mucinous, viscous material in the peritoneal cavity, both floating and adhering to serosal surface (jelly-belly). The histologic examination should always follow with detailed and precise description of the epithelial component. The cytological and structural quality of the epithelium constitutes two basic forms with entirely different nature biology and prognosis. First and more frequent, so-called disseminated peritoneal adenomucinosis, where primary low grade (benign) mucinous appendiceal tumor is almost constant finding, often recurs but displays favorable prognosis. Second, so-called peritoneal mucinous carcinomatosis is an extraordinary manifestation of peritoneal carcinosis following generalization of the gastrointestinal mucinous adenocarcinoma. Histopathogenesis in both types is thought to arise from MUC2 positive goblet cells in GI and ovarian involvement is secondary. A normal macroscopic finding on appendix or "uneventful" appendectomy in anamnesis is not unusual.

[Acinic cell-like differentiation in invasive ductal carcinoma and in ductal hyperplasia of the breast--report of two cases]

Described are two epithelial lesions of the breast displaying extremely rare, widespread acinic cell-like differentiation (metaplasia). Two women, 70 and 40-year-old, one with invasive ductal papillocarcinoma, the other one with conventional intraductal hyperplasia without atypia, both demonstrated massive diffuse, PAS positive, granular eosinophilic transformation of the cell cytoplasm. This unusual cell appearance closely simulated acinar cells in normal serous salivary gland/acinic cell carcinoma or Paneth cells. Both extensive expression of lysozyme and finding of numerous zymogen granules ultrastructurally confirmed the acinic cell-like fenotype. Discussed is differential diagnosis of the breast neoplasm containing overt eosinophilic and granular cytoplasm. Reviewing literature and comparing our unique finding of unusual salivary-type differentiation in conventional ductal hyperplasia of the breast, biologic implications are considered.

Cystic hypersecretory carcinoma: rare and poorly recognized variant of intraductal carcinoma of the breast. Report of five cases

AIMS

To report five cases of a rare variant of intraductal carcinoma of the breast, so-called cystic hypersecretory carcinoma. The clinical and pathological characteristics of the lesion are described, along with a review of the literature.

METHODS AND RESULTS

The patients were females aged between 53 and 78 years (average 66.8 years). The size of the lesions ranged between 70 and 80 mm in largest dimension. In two cases, the development of high-grade invasive ductal carcinoma was observed; in one additional case there was recurrence of high-grade in-situ carcinoma after 3 years. This emphasizes the importance of correct diagnosis of this potentially aggressive lesion. Strong over-expression of HER-2/neu protein was observed in three cases, including the two with an invasive component. Protein p53 was variably positive in all cases. Steroid receptor immunohistochemistry yielded variable results with only one case being positive for both oestrogen and progesterone receptors. Interestingly, in most cases (4/5) staining for androgen receptors was observed.

CONCLUSIONS

Cystic hypersecretory ductal carcinoma of the breast is a rare distinctive variant of ductal carcinoma in situ. It has the potential for invasive growth and the development of metastases.

[Cystic hypersecretory carcinoma: rare and potentially aggressive variant of intraductal carcinoma of the breast. Report of five cases]

OBJECTIVE

To describe a poorly recognized histological and immunohistochemical features of cystic hypersecretory carcinoma of breast, including the overexpression of HER-2/neu protein and androgen receptors.

SUBJECT

Review of clinical and pathological features of 5 cases of cystic hypersecretory carcinoma.

SETTING

Private Bioptic Lab, Plzen and Department of Pathology, Charles University, Plzen.

SUBJECT AND METHODS

Five cases of rare variant of intraductal carcinoma of the breast, so-called cystic hypersecretory carcinoma, are reported. The patients were females aged between 53 and 78 years (average 66.8 years). The size of the lesions ranged between 7 and 8 cm in largest dimension.

RESULTS

In two cases, the development of high grade invasive ductal carcinoma was observed; in one additional case there was recurrence of high grade in situ carcinoma after three years. Strong overexpression of HER-2/neu protein was observed in three cases including those two with invasive component. Protein p53 was variably positive in all cases. Steroid receptor immunohistochemical study yielded variable results with only one case being positive for both estrogen and progesterone receptors. Interestingly, in most case (4/5) staining for androgen receptors was observed.

CONCLUSION

The importance of correct diagnosis of this potentially aggressive lesion is emphasized. The differential diagnosis of breast lesions with predominantly cystic growth pattern is discussed in detail.

Low mutational rate of K-ras codon 12 in singular bronchoscopy specimens in suspected lung cancer

Mutations of the K-ras gene are found in a subset of non-small- cell lung carcinomas (NSCLC). The aim of our study was to determine the K-ras codon 12 mutation in the first, singular bronchoscopy specimen in parallel with the cytological examination for the diagnosis of lung cancer. Samples were obtained by diagnostic bronchoscopy in 140 patients with suspected lung tumors. The analysis of K-ras mutations was carried out by a sensitive two-step mutation- enriched polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay. This method has been confirmed earlier to be positive for mutated tumor cells and negative for normal lung parenchyma and bronchus. Of the 140 patients with suspected cancer, 93 were diagnosed as NSCLC by cytology or histology in either the same specimen used for the detection of K-ras mutation or in later biopsies. However, only four K-ras codon 12 mutations were detected in the first bronchoscopic material: one in adenocarcinoma, two in squamous cell tumors, and one mutation was found in a patient with dysplasia which was diagnosed later as a squamous cell carcinoma. Our findings indicate that although the K-ras (codon 12) mutation is a gene lesion infrequently detectable in a singular specimen taken at the first bronchoscopy examination in cases of clinically suspected lung cancer, the detection of this mutation can help to confirm the cytological diagnosis of NSCLC or may be even diagnostic in cytologically negative cases.

[Anogenital mammary type sclerosing adenosis--two case reports and the review of literature]

OBJECTIVE

To describe a rare case of mammary type sclerosing adenosis arising in anogenital, mammary-like adnexal glands. Differential diagnosis is discussed and detailed review of literature is presented.

DESIGN

Two case reports.

SETTING

Private Biopsy Lab s.r.o. and Sikl's Department of Pathology, Charles University and Faculty Hospital, Pilsen.

METHODS

Included are two cases from Breast Registry, Biopsy Lab s.r.o. and from personal consulting registry of Prof. Michal, Sikl's Department of Pathology, Pilsen. Detailed morphology of the lesion is described and documented by pictures. The presence of myoepithelial cell is demonstrated by immunohistochemistry using streptavidin-bioptin detection system (LSAB+, Dako) and three conventional myoepithelial markers (actin S, calponin and CD10). Expression of estrogen and progesteron receptors and apocrine antigen GCDFP-15 were studied too.

RESULTS

There were two women at the age of 54 and 60-years with lesion located on vulva and anus; the maximum tumor diameter was 7 and 10 mm, respectively. The histological picture was virtually the same in both cases displaying under hyperplastic epidermis small glands proliferation set in sclerotic fibrous stroma. In spite of relatively sharp circumscription, the chaotic and irregular distribution of the glands imparted the invasive image of the lesion. The luminal cells showed no cytological and nuclear atypia and visible was only minimal regular mitotic activity. The signs of luminal, decapitation-type, apocrine secretion were dispersal seen throughout the lesion. By immunohistochemistry the myoepithelial cells regularly and systematically decorated periphery of the glands and all the composition was similar to sclerosing adenosis in the breast including massive hormonal receptors expression. In the periphery of one lesion an insolated, single, typical anogenital gland was found. Features of conventional papillary hidradenoma were not seen.

CONCLUSION

Mammary-type anogenital adnexal glands are regularly present in vulvar and perianal skin; these are considered there as a substrate for analogous lesion occurring in the breast (lactation change, papilloma and fibroadenoma, but also some types of carcinomas including primary extrammary Paget's disease). In these physiological structures there are combined features of both eccrine and apocrine adnexal glands creating a primitive caricature of basic tubulolobular unit in the breast. Their existence dispel historical dogma about running of the embryonal milk lines or mammary ridges and explains the findings of varied scale of neoplasms differing from well known lesion derived from conventional adnexal glands.

[Matrix-producing breast carcinoma with myoepithelial differentiation--description of 11 cases and review of literature aimed at histogenesis and differential diagnosis]

OBJECTIVE

Presentation of variable morphology of the so-called matrix-producing carcinoma, the rare variant of metaplastic breast carcinoma. Establish the extent of myoepithelial phenotype by immunohistochemistry and assess behaviour of the lesion.

DESIGN

Review of clinicopathologic data of 11 cases.

SETTING

Private Biopsy Lab s.r.o., Pilsen and Sikl's Department of Pathology, Charles University and Faculty Hospital, Pilsen.

METHODS

Included are eleven cases from Breast Registry, Biopsy Lab s.r.o., Pilsen and Pathology Department, Faculty Hospital in Hradec Králové and Martin and from Biopsy Lab in Horovice. Analyzed were morphology, stage, grade and follow up. Myoepithelial phenotype was demonstrated immunohistochemically by LSAB+ system (DAKO) and seven conventional myoepithelial markers (GFAP, aktin S, calponin, cytokeratin 14, p63, CD10 and P-cadherin) were used. Oncogene p53 and Her2/neu were also detected.

RESULTS

Matrix-producing carcinoma is an extremely rare type of metaplastic carcinoma of the breast, where high-grade epithelial component continually merges with heterologous mesenchymal chondroid component without overt spindle cell sarcomatoid pattern in between. There were all women at the age of 32 to 86-years (average 54 years, median 52 years) and the maximum tumor diameter ranged from 18 to 60 mm (average 32 mm). The axillary LN was positive in six cases in the time of diagnosis. The follow up available in 9 women ranged from three months to ten years (average 24 months); dissemination of the disease was observed in three cases; 2 of these patients died of disease after three and ten years, respectively. The heterologous mesenchymal chondroid component was produced in two different ways; one displayed typical structure of low-grade hyaline cartilage, in the second one the epithelial tumorous cells were embedded in the homogenous eosinophilic extracellular matrix giving appearance of chondroid aura. Metaplastic component constituted 5-75% of the tumor volume. Immunohistochemical evidence of myoepithelial differentiation in all neoplasms was demonstrated, with at least two conventional myoepithelial markers (actin S, calponin, GFAP, CK14, CD10, p63 and P-cadherin) being positive in every case. Expression of p53 was identified in six cases, all tumors were Her2/neu negative. Histologically the metastases were formed either by carcinoma cells only, or more frequently, they replicated the structure of primary lesion.

CONCLUSION

As a rare entity, matrix-producing carcinoma of breast displaying myoepithelial phenotype, deserves separate position in tumor classification. It differs from conventional myoepithelial carcinoma and from heterologous metaplastic carcinoma, where the matrix emanate from undifferentiated sarcomatous tissue, but precise histogenesis in not clear yet. This is a very aggressive lesion and our findings show that previous reports of indolent behaviour were preliminary. Spectrum of differential diagnosis, namely benign mixed tumor, phylloid tumor, primary breast sarcoma and colloid carcinoma warrant clear knowledge about this unique entity.

Bronchial carcinoid tumors: long-term outcome after surgery

The objective of the present study was to evaluate clinical condition and results of surgical treatment of patients with typical and atypical bronchial carcinoids. The study was based on retrospective analysis of a total of 96 patients (mean age 47.3 year, age range 21-76, 44 men and women 52), who were surgically treated for bronchial carcinoid between 1985-2001. We assessed symptomatology of the disease, type of surgical intervention, tumor histology and staging, and postoperative 5-year and 10 year survival rates. The main sign of disease was respiratory inflammation. The carcinoid syndrome was not found in any patient. Most patients (n=68) were operated for central form of the tumor. The micromorphological tumor diagnosis was established prior to surgery in 76.5% patients with the central form of carcinoid. Surgical treatment included lobectomy (n=49), bronchoplastic procedure (n=14), sleeve lobectomy (n=9), atypical resection and segmentectomy (n=11), pneumonectomy (n=7) and tumor enucleation (n=5). Histological analysis revealed typical carcinoid in 77 cases (80.2%) and atypical carcinoid in 19 (19.8%). Lymph nodes (N1 and/or N2) were examined by histology in 84 patients and lymph node metastases were found in 13 (19.4%) of 67 patients with typical carcinoid and in 5 cases (29.4%) of 17 with atypical carcinoid. In the postoperative period on patient died from embolism to the arteria pulmonalis. Postoperative complications (atelectasis, prolonged air leak, bronchopleural fistula) were observed in 11.4% of patients. Tumor relapse occurred only in two patients with typical carcinoid. Postoperative 5-year and 10-year rates amounted to 98.6% and 87.3%, respectively, in typical carcinoid 94.5% and 73.5% in atypical carcinoid. The survival rates of patients with typical and atypical bronchial carcinoids were not significantly different (p>0.05). The surgical management is the treatment of choice in bronchial carcinoids. Results of this study indicate that the 5-year survival in patients with either histological type of bronchial carcinoid is excellent and the prognosis of operated patients is very good even in the case of regional lymph nodes infiltration by the tumors.

[Female adnexal tumor of probable Wolffian origin (Wolffian adenoma)--2 case reports and literature review]

Presented are two cases of unusual adnexal tumor described under the term "female adnexal tumor of probable wolffian origin (FATWO)" in the bibliography. One lesion was 18 cm large tumor located in the ovary in 85-year-old woman, the second one was a 5 cm large pedunculated mass arising from broad ligament in 40-year-old female. Three main structural patterns often coexisted and comprised solid or diffuse, sieve-like and tubular arrangement of spindle or epithelial cells. Cellular atypia and mitotic figures were practically absent. Clinical follow up confirmed benign behavior in both cases. Discussed is differential diagnosis and review of the literature.

[Dedifferentiated chondrosarcoma of bone--report of 5 cases and literature review with emphasis on histogenesis]

Five cases of dedifferentiated chondrosarcoma of bone are presented. Three women and two men of age ranging from 57-72 years (median 63 years) suffered from tumors located in femur (2), scapula (1), humerus (1) and pelvis (1). They were all bulky tumors destroying the bones and infiltrating into the adjacent soft tissues in maximum diameter from 5-20 cm (median 12 cm). Both the short clinical histories lasting from 2-24 months (median 5 months) and persistent pains unrelieved by acylpirin were constant findings in all the cases. Four patients died of metastatic disease (mainly to lungs) with median survival of 8 months. All cases were the so-called "de novo" dedifferentiated chondrosarcomas without clinical or morphological evidence of the primarily benign or malignant chondroid lesions. The tumors displayed a typical dual composition with an abrupt interface between chondroid and nonchondroid components. The chondroid tissue resembled G1 chondrosarcoma in three cases, G2-3 chondrosarcoma in two cases. The second nonchondroid mesenchymal portion had the appearance of undifferentiated pleomorphic sarcoma in three cases, rhabdoid and giant cell tumor-like in one case. The new data and evidence provided by molecular biology dramatically changed the opinions of histogenesis of this unique neoplasm. At present, there is a generally accepted idea of common origin of both portions from a primitive stem cell. Therefore, this peculiar tumors should not be viewed merely as dedifferentiated conventional chondrosarcomas.

[Angiotropic lymphoma (intravascular lymphomatosis)--2 case reports]

Described are two cases of angiotropic lymphoma where eventually autopsy elucidated nonspecific neurologic symptoms. One patient suffering ambiguous encephalitic syndrome died three months later, the second one passed away after an unusually long three-year period of progressive dementia and cumulative motoric dysfunction. The autopsy disclosed pure intravascular malignant lymphoid aggregates (LCA, CD 20, Bcl 2-positive) in the brain and kidney of both patients. In the patients with the longer disease period, a dissemination to lung was also found. Definitive diagnosis was issued as a B cell type of angiotropic lymphoma. Skin, lymph nodes, spleen, and bone marrow were not affected in any case. The clinical differential diagnosis algorithm did not involve this rare etiology in these particular uncommon neurologic cases and even brain biopsy performed in both women did not recognize the substantiality of the disease.

[Primary hyperparathyroidism (osteitis fibrosa cystica generalisata Recklinghausen)]

The case of a 67-year-old man presenting with parathyroid gland adenoma associated with multiple organ manifestations of a rare normocalcemic form of primary hyperparathyroidism is described. The authors draw attention to the importance of correlating clinical and laboratory examinations with histological, radiological and scintigraphic findings for the establishment of diagnosis. They emphasize the role of two-phase 99mTC-MIBI (methoxyisobutyl-isonitril) scintigraphy not only for diagnostic purposes but also for exact localization of the adenoma by means of a gamma probe during surgery. They also point out the possibility of accompanying pathological conditions, in this case, the development of a tumor described as "brown tumor". This was shown by angiography as a hypervascularized and strongly stained expanding lesion. The authors conclude that the early surgical removal of this parathyroid gland adenoma was important for the patient's successful recovery.

[Metaplastic spindle-cell (fibromatosis-like) carcinoma of the breast--report of 4 cases]

The authors report about clinico-morphological features in four cases of spindle-cell metaplastic carcinoma of the breast, closely mimicking benign soft tissue fibromatosis or nodular fasciitis. All patients were females aged 54-72 years with a palpable nodule within the breast, 20-35 mm in size. Histologically, the tumor infiltrated surrounding tissue; it consisted of spindle cells with relatively bland morphology, arranged in a fascicular, storiform or random fashion. Mitotic activity was low, focally the tumors revealed regressive changes (hyalinization, myxoid degeneration). Cytokeratin expression was proven in all four cases. In two patients the tumor metastasized and the patients died of it; this fact confirms recently published data that despite its deceptively benign appearance, fibromatosis--like carcinoma of the breast is undoubtedly a malignant process with potentially aggressive behaviour. Differential diagnosis of this unusual variant of metaplastic breast carcinoma is discussed together with related therapeutic issues.

[Myoepithelial carcinoma in adenomyoepithelioma of the breast (malignant adenomyoepithelioma)--case report]

There is described fifty-year-old woman with so called malignant adenomyoepithelioma of the breast. The conventional benign looking adenomyoepithelioma with biphasic tubular pattern continually fused to unequivocal invasive lesion which by immunophenotype turned out to be myoepithelial carcinoma. The 15 months follow up was uneventful. Extensive literature overview and terminology consideration is presented. The paper discusses biologic consequences of this rare breast lesion and its close resemblance to almost identical lesions in the salivary glands and skin adnexa.

[Sclerosing epithelioid fibrosarcoma]

Sclerosing epithelioid fibrosarcoma (SEF) was first described in 1995 and since then 39 cases have been reported. Here we describe 6 cases of SEF (3 in women and 3 in men). The patients aged from 22 to 79 years. The tumours were located in soft tissues of the extremities (in 3 cases in the lower, in 2 instances in the upper extremity) and of the trunk (in 1 case). The lesions were partially nodular, of gray-white colour, and hard in consistency. Histologically, they were composed of epithelioid round to ovoid small cells with a sparse cytoplasm and a very low mitotic activity. The tumour cells formed cords and alveoli or were scattered individually within a dense hyalinized collagenous stroma. The neoplasms also contained foci of conventional fibrosarcoma, necrosis, calcification, and metaplastic bone. On immunohistochemistry, the neoplastic cells were positive for vimentin. Two cases were immunoreactive for epithelial membrane antigen and one tumour also for cytokeratins. The proliferative activity, assessed by MIB 1 antibody (Ki-67), was detected in 1-6% of neoplastic cells in primary tumours. Follow-up information was available in 5 patients. In two cases, there were local recurrences and distant metastases (in the lungs, upper extremity, and mediastinum). One of these patients died of SEF. The differential diagnosis of this relatively low-grade fibrosarcoma is broad and includes, along with a variety of benign and malignant soft tissue lesions, infiltrating carcinoma, and, to a lesser extent, sclerosing lymphoma.

[Metastases in peripheral lymph nodes as the first sign of anaplastic skeletal plasmacytoma--2 case reports]

The paper discusses two unusual cases of solitary skeletal plasmacytoma and multiple myeloma presenting clinically as a metastatic disease in cervical lymph nodes. The pathology report of lymph node plasmacytoma initiated an extensive clinical search for eventual discovery of skeletal disease in both patients. We are not aware of any report in the literature dealing with this issue (Medline 1970-2000). The early involvement of lymph nodes by plasmacytoma with the appearance of undifferentiated neoplasm is challenging and poses great difficulties in correct diagnosis; this is almost impossible from hematoxylin eosin slides. The problem is that one has to think about the rare possibility of metastasing plasmacytoma in differential diagnosis of anaplastic tumors in lymph nodes. Immunohistochemistry and clinical records are very helpful in making a final diagnosis.

Small cell variant of renal oncocytoma--a rare and misleading type of benign renal tumor

Here we report 3 cases of renal oncocytoma with a dominating small cell component arising in adult women. These 3 cases of small cell variant of renal oncocytoma were found among 134 cases of oncocytomas of the kidney in the routine and consultation files of the authors. Two of 3 cases were initially thought to be a malignant tumor by the referring pathologists. In all 3 cases minor areas of the tumors, which were identical to the classical renal oncocytomas were found. The small cell areas were arranged in a characteristic organoid pattern different from all the known types of the renal benign and malignant tumors. We summarize all morphologic, immunohistochemical, and ultrastructural features of this unusual oncocytoma variant with regard to its differential diagnosis. Int J Surg Pathol 9(3):215-222, 2001

[Severe pulmonary involvement in Erdheim-Chester disease (case report)]

Presented is a typical case of Erdheim-Chester disease (ECD) wherein the severe pulmonary manifestation led to an open lung biopsy and eventual morphologic recognition of the nonspecific clinical symptoms. The pulmonary involvement is described in almost 20% of cases and is prognostically unfavourable. About 20 cases of Erdheim-Chester disease were published and more than half of them had lethal outcome. The ECD affecting seriously lungs appears as non-specific interstitial lung disease and usually does not enter the broad clinical differential diagnosis. A detailed bibliography with special attention to the pulmonary involvement by this enigmatic disease is presented.