Clear cell adenocarcinoma associated with clear cell adenofibromatous components: a subgroup of ovarian clear cell adenocarcinoma with distinct clinicopathologic characteristics

We occasionally encountered clear cell adenofibromatous (CCAF) components coexisting in the ovarian clear cell adenocarcinoma (CCA). To reveal the clinicopathologic significance of CCAF components in CCA, we classified 67 cases of surgically resected CCA into CCA with and without CCAF components [CCAF(+) and (-) groups], and compared clinicopathologic parameters, that is, patient age, clinical stage, the degree of optimal cytoreduction, patient outcome, histologic grade and Ki-67 labeling index of the CCA, and the presence of endometriosis, between these 2 groups. Fourteen cases (21%) and 53 cases were classified as CCAF(+) and CCAF(-) groups, respectively. Of these 14 CCAF(+) cases, the CCAF components with atypia were observed adjacent to the CCAF components without atypia in 10, and adjacent to the obvious CCAs in 13 cases. In comparison with the CCAF(-) group, the CCAF(+) group showed a higher frequency of histologically low-grade tumors [93% (13 of 14) vs. 43% (23 of 53), P=0.0027], a lower Ki-67 labeling index (mean 35.9% vs. 44.0%, P=0.0492), and better patient prognosis (5-year survival 78.8% vs. 49.3%, P=0.0277). Endometriosis was much less frequent in the CCAF(+) group than in the CCAF(-) group [14.7% (2 of 14) vs. 67.9% (36 of 53), P=0.00096]. Multivariate analysis identified only optimal cytoreduction as independent favorable prognostic factor. These results suggest that CCAF besides endometriosis is associated with the development of CCA, and that the CCAF(+) group may be a distinct subgroup of CCA with less aggressive biologic behavior.

Impact of induction chemotherapy and preoperative chemoradiotherapy on operative morbidity and mortality in patients with locoregional adenocarcinoma of the stomach or gastroesophageal junction

BACKGROUND

Significant tumor downstaging has been achieved in patients with localized gastric or gastroesophageal adenocarcinoma by induction chemotherapy and preoperative chemoradiotherapy (CTX-CTXRT). However, the influence of CTX-CTXRT on operative morbidity and mortality has not yet been clarified. The aim of the present study was to document the frequency and nature of morbidity and mortality after surgery combined with CTX-CTXRT, and identify factors predictive of postoperative complications in patients with localized gastric or gastroesophageal adenocarcinoma.

METHODS

A prospectively collected database on 71 consecutive patients who underwent CTX-CTXRT at M.D. Anderson Cancer Center between January 1997 and August 2004 was reviewed. Postoperative morbidity and mortality were investigated, and risk factors for overall complications were identified by multivariate logistic regression analysis.

RESULTS

Overall morbidity and mortality rates were 38.0% (27 patients) and 2.8% (2 patients), respectively. Age greater than 60 years [relative risk 11.3 (95% confidence interval 2.50-50.6)] and body mass index (BMI) of 26 kg/m(2) or above [relative risk 4.08 (95% confidence interval 1.08 to 15.4)] were significant risk factors for overall complications.

CONCLUSIONS

CTX-CTXRT can be performed safely with an acceptable operative morbidity and a low operative mortality rate in patients with gastric or gastroesophageal cancer, with careful consideration of added risk associated with age and obesity.

Positive emission tomography for evaluating a complete clinical response in patients with ovarian or peritoneal carcinoma: correlation with second-look laparotomy

OBJECTIVE

Positive emission tomography (PET) provides a novel means of imaging malignancies. The following study was undertaken to evaluate the predictive value of PET in determining a pathologic complete response in patients with advanced ovarian or peritoneal carcinoma who had a complete clinical response following primary chemotherapy.

METHODS

Twenty-two patients with advanced-stage ovarian (N = 17) or peritoneal (N = 5) carcinoma who had achieved complete clinical and radiologic remission and normal CA-125 level after six cycles of chemotherapy and who had consented to a second look laparotomy procedure were studied. All patients received platinum based therapy and all but one patient, treated elsewhere, received paclitaxel in combination with platinum. Following IV administration of 20 mCi [(18)F]fluorodeoxyglucose (FDG), the entire abdomen and pelvis were scanned. Various technical modifications including bladder activity dilution, intravenous hydration with diuretic therapy, and mechanical bowel preparations, were used to reduce background activity. Second-look laparotomy findings were classified as negative, macroscopically positive if a biopsy of a suspicious area was histologically positive, or microscopically positive if only a nonsuspicious area was histologically positive. The effect of patient preparation prior to PET imaging was evaluated.

RESULTS

Persistent disease was found in 13 of the 22 patients (59%). Only one of nine sites with macroscopic and none of four with microscopic disease were accurately predicted. The sensitivity was only 10% and the specificity 42%. Intravenous hydration, diuretic therapy, and bowel preparation did not improve the results.

CONCLUSIONS

These results suggest that despite technical modifications the sensitivity of PET before second-look laparotomy for small-volume persistent disease is low.

[Value of fine needle aspiration cytology in the diagnosis and management of fibroadenoma of the breast]

Cytological and histopathological biopsies were obtained from 121 breast lumps clinically diagnosed as fibroadenomas. Of these 98.3 percent of the lesions were benign. The cytological diagnosis was benign in 95.1 percent of 101 (83.4% of total) cases confirmed as fibroadenomas, histopathologically, but inadequate for diagnosis in 4.9 percent. The remaining 20 lesions included one breast cancer and one primary malignant lymphoma. In this group aspiration cytology was inadequate for diagnosis in 20 percent of the cases (P < 0.05). The cytological reports cast suspicion in the two malignant cases. No lesion with benign cytology was subsequently shown to be malignant. Ninety-five (78.5%) cases of the lesions, representing 72 women under 35 years of age, which has been clinically diagnosed as fibroadenomas, showed fibroadenoma, histopathologically, in 89.5% of these cases. The other 26 (21.5%) lesions in 21 patients, who were over 35 years in age, had 61.5 percent fibroadenomas, cytological results cast suspicion of fibroadenoma in 87.1 percent of these cases. The other 16 histopathologically diagnosed fibroadenomas in patients over 35 years of age showed 62.5% were cytologically suspected of being fibroadenomas (P < 0.025). As a result of this study it is reasonable to suggest that a typical clinical fibroadenoma can be treated conservatively in women under 35 years, but only if an adequate cytological smear obtained by fine needle aspiration does not show malignant of suspicious cells.

Conservative management of breast fibroadenomas

Is it conservative or radical management to excise all fibroadenomas of the breast, especially in women less than 30 years old? Once a definite diagnosis is established by physical examination, fine-needle aspiration cytologic testing, and mammography, is it prudent to monitor women with small fibroadenomas (less than 4 cm in diameter)? We reviewed 498 cases of biopsy-proved fibroadenomas and 17 cases of phyllodes tumors (by biopsy) seen at Los Angeles County/University of Southern California Medical Center from 1986 to 1989. Analysis of patient age and measured tumor size in 203 fibroadenomas and 10 phyllodes tumor specimens revealed similar ranges for both tumors. The mean values were 28.5 years and 2.3 cm for fibroadenomas and 44 years and 3.8 cm for phyllodes tumors. No cases of coincident carcinoma within a fibroadenoma or of metastatic malignant phyllodes tumors were present in this review. As an alternative to excising all breast tumors, cytologically diagnosed fibroadenomas can be monitored, because they have no intrinsic premalignant potential and tend to regress with time. All breast tumors that rapidly increase in size should probably be excised at any age.

Benign breast tumours in an African population

A detailed prospective clinical study of 238 women presenting with benign breast swellings in the South Eastern equatorial rainforest of Nigeria clearly shows that 94% of lesions were due to two disorders, fibroadenomas and bacterial infections, and that they affected mostly young women in the peak of their reproductive life. Fibroadenoma which accounted for disease in no less than 69% of the women was multiple in 8%, bilateral in 11%, and was considered giant in size in 5% of the cases; by contrast, fibroadenosis was rare, accounting for swellings in only eight patients. Bacterial infections, chronic pyogenic mastitis and tuberculosis together caused breast swellings in 25% of the women studied. In tropical Africa, multiple chronic discharging sinuses suggest tuberculosis of the breast.

Fibroadenoma of the breast: a follow-up of conservative management

This report details the outcome after clinical diagnosis of mammary fibroadenoma in 110 women aged under 35 years. After fine needle aspiration cytology, and subsequent exclusions and failures of follow-up, 92 lesions were observed for a mean of 47 weeks (range 13-90 weeks), with regular measurements until removal of persisting lesions at 12 months. Fifteen lesions disappeared and 56 had the classical histology of fibroadenoma, mean size 2.5 cm; 30 of the latter continued to grow throughout the study. Cytology is essential to exclude malignancy if conservative treatment is considered, and is helpful in identifying a benign lesion. A period longer than 12 months may be required for resolution of a fibroadenoma and removal under local anaesthesia as a day case offers a simple alternative.

Endometrioid proliferative and low malignant potential tumors of the ovary. A clinicopathologic study of 46 cases

We evaluated 41 endometroid neoplasms with features intermediate between a benign endometrioid tumor and endometrioid carcinoma. Although these tumors showed various degrees of epithelial proliferation, they lacked the destructive stromal invasion of carcinoma. Intermediate endometrioid tumors were subdivided into proliferative endometrioid tumors (PET), endometrioid tumors of low malignant potential (ETLMP), and ETLMP with microscopic areas of invasion. PET were adenofibromas with solid aggregates of epithelial proliferation not exceeding 5 mm in any dimension, whereas ETLMP either had noninvasive cytologically malignant epithelium or aggregates of atypical epithelium measuring at least 5 mm in any dimension uninterrupted by fibromatous stroma. Of the seven PET, five were purely adenofibromatous, while two were mixtures of adenofibromatous and papillary components. Of the 31 ETLMP, 12 were adenofibromatous and 19 were either purely papillary or had mixtures of papillary and adenofibromatous components. An additional three ETLMP had one or more areas of microscopic invasion of the stroma in the form of an irregular or cribriform infiltration by atypical glands, often with squamous differentiation. These three neoplasms were designated "ETLMP with microinvasive carcinoma." The only neoplasm with extraovarian implantation at presentation, however, was an ETLMP with mixed adenofibromatous and papillary features, without microinvasion. None of the other patients with ETLMP had a metastasis or developed one within a follow-up period of between 0.8 and 11.2 years. Because they are very low-grade neoplasms, ETLMP should be separated from endometrioid carcinoma and not confused with PET, because PET have no malignant potential.

Case for conservative management of selected fibro-adenomas of the breast

To assess the safety of a conservative approach to fibro-adenoma of the breast we prospectively studied 321 women with this clinical diagnosis, and performed aspiration cytology and excision biopsy. There was histological confirmation of fibro-adenoma in 217 (68 per cent), the remainder having various benign conditions and 4 (1.3 per cent) had carcinoma. Aspiration cytology had a sensitivity of 87 per cent and a specificity of 76 per cent for fibro-adenoma. Three cases of carcinoma were identified cytologically and the fourth was regarded as suspicious. To estimate the risk of missing carcinoma we compared the annual frequency of carcinoma with fibro-adenoma in young women and found a ratio of 1:470 between 15 and 19 years, 1:133 between 20 and 24 years and 1:9 in the 25-29 age group. To assess patients' views on non-operative treatment of benign breast masses we asked 124 women, 10 days postoperatively, whether they preferred a conservative approach for a cytologically benign lump: 26 (21 per cent) opted for conservative management in the future and 8 (7 per cent) would have preferred conservatism rather than their recent excision. A conservative approach is safe for clinically and cytologically benign breast lumps in women under 25 years, but very few will accept it.

The establishment and operation of a computerized data bank in benign breast disease. (Preliminary results on 297 cases)

The principles of setting up and utilization of a data bank for breast benign pathology and medical gynecology are described. In presenting these principles the authors make an analysis of the loading phases with the two afferent programs for adding, changing and wiping out information. With respect to utilization, two applicative programs for computing the efficiency of the selective hormonal treatment (regarding each and all patients) are analyzed. The paper provides the necessary instructions which enable the specialist physician to work directly with the computer. The principles are exemplified by the results obtained with a first series of 297 menstruated patients with several clinical forms of benign breast disease (unique or multiple cysts, lesions corresponding to an adenoma or fibroadenoma, mammary lumps) hormonally treated in an average series of 3 therapeutic cycles.

Breast masses in adolescent females

Conservative management of breast masses in adolescents is generally advocated in consideration of the low incidence of breast cancer. A retrospective chart review of 130 female patients seen in a general adolescent clinic over a two-year period was performed. The mean age was 17.5 years (range 12-21). One hundred and seven (88% of available data) had self-discovered lesions. Fibrocystic disease was clinically diagnosed in 66 (51%) patients, while 19 (15%) had fibroadenomas and 17 (13%) had a normal breast examination. Of the remaining patients, six (5%) had mastalgia, five (4%) had mastitis/abscess, three (2%) has asymmetry, three (2%) had hypertrophy, two (1%) had breast changes of early pregnancy, two (1%) had hematoma, one (1%) had axillary lymphadenopathy, and six (5%) had unknown. Excisional biopsy was performed on eleven patients; it revealed fibroadenoma in eight, and one each had a hematoma, granular cell myoblastoma, and breast abscess. Improvement or complete resolution of breast masses was documented in 31 (47%) of the patients with fibrocystic disease.

Occurrence of breast carcinoma within a fibroadenoma. A review

Sixty-two cases of carcinoma within a breast fibroadenoma are adequately documented in the literature, including the present case. All are found in women. The mean age of occurrence is 42.4 years. This corresponds to the peak age of lobular in situ breast cancer but is much higher than the peak age for breast fibroadenomas. Sixty-five percent of patients harboring cancer within a fibroadenoma have lobular in situ malignant neoplasms. In 42% of the cases the surrounding breast tissue is also involved by cancer, a fact that dictates generous surgical margination of all fibroadenomas excised, especially in older women. The data indicate that the presence of the fibroadenoma is a parameter independent of the development of cancer in either the ipsilateral or contralateral breast and does not influence the clinical course of the malignant neoplasm, other than that it contributes to its earlier detection. Treatment should follow the general principles of therapy for the in situ or infiltrative breast cancers.

The role of the obstetrician-gynecologist in the management of breast lesions

This paper is based on the author's frequent experience in the diagnosis of breast masses in his everyday practice as an obstetriciangynecologist. It appears that gynecologists, by the very nature of their practices, are in an excellent position to head the case-finding expedition for breast lesions. Furthermore, the obstetrician-gynecologist can use acquired surgical skills to great advantage in the management of benign lesions and assist surgical associates in the management of the malignant lesions.

Ovarian surface papillomatosis of borderline malignancy

Bilateral ovarian surface papillomatosis of borderline malignancy is a rare condition. In our case it was associated with benign serous cystadenofibroma. The histologic diagnosis and the clinical aspects are discussed.

Benign and low grade variants of mixed mesodermal tumor (adenosarcoma) of the ovary and adnexal region

Eleven examples of a rare group of neoplasms composed of both epithelial and mesenchymal components are reported. Ten arose from the ovary and one arose separately in the para-ovarian region. The neoplasms are distinctive in that the stoma is more cellular than that of adenofibromas, but epithelial component is not malignant, as in carcinosarcoma and mixed mesodermal tumors, and the stoma is not sarcomatous in the low grade varieties. The 11 cases were highly variable in the cellularity and atypism of the stromal cells. The term, adenosarcoma, for these tumors is not acceptable because some were too low a grade to be regarded as sarcomas, and reports of the uterine counterpart disclose that some contain heterologous elements. For that reason, a term that will embrace the full spectrum of changes in the stroma--benign through sarcomatous--is needed. We propose that they be regarded as variants of mixed mesodermal tumor so that both the benign neoplasms and low grade sarcomas can be accommodated under one designation. Of the 11 cases, five lowest grade examples were all confined to the ovary and did not recur after surgical excision, but some of these were borderline in malignancy and probably would have progressed if untreated. Two of the 3 intermediate grade neoplasms extended beyond the ovary but were arrested by surgical excision. The 3 highest grade neoplasms were overly sarcomatous. One of these extended beyond the ovary but was arrested by combination chemotherapy. The para-ovarian adenosarcoma (also high grade) metastasized and proved fatal.

Management of breast lesions in children and adolescents

The records of 207 patients evaluated and treated for breast abnormalities during a 10-yr period were reviewed. Patients ranged in age from 1 wk through 16 yr. Seventy-eight per cent were female. Operative procedures were performed in 134 patients (64%). Most common diagnoses were fibroadenoma, premature thelarche, and precocious puberty in the females, and pubertal gynecomastia in the males. Age and sex separate patients into natural subgroups. In females beyond the neonatal period, premature thelarche and precocious puberty are the most likely cause of breast enlargement. Breast biopsy is only rarely indicated for a distinct mass lesion in the prepubertal breast. Mass lesions in the breast of adolescent females require excisional biopsy. In the male, pubertal gynecomastia is the most common form of breast enlargement and only occasionally requires subcutaneous mastectomy for cosmetic and psychologic reasons. Careful evaluation of all children with breast enlargement is indicated to uncover underlying causes and to avoid unnecessary operative procedures.