Case of Recurrent Superficial CD34‐Positive Fibroblastic Tumor ( SCPFT )

Superficial CD34-positive fibroblastic tumor (SCPFT) is a recently described rare superficial mesenchymal tumor. SCPFT has a distinctive morphologic appearance, marked by significant nuclear pleomorphism, low mitotic rate, and diffuse CD34 positivity. SCPFT is underdiagnosed because of its rarity and misdiagnosis as sarcoma, with very few reported cases of local recurrence or metastasis. Recognition and awareness of SCPFT are essential for accurate diagnosis and appropriate clinical management. We describe here the case of a 37-year-old male who presented with a right calf mass diagnosed as SCPFT with subsequent local recurrence of the tumor.

Superficial CD34-positive fibroblastic tumor (SCPFT): A review of pathological and clinical features

Superficial CD34-positive fibroblastic tumor (SCPFT) is a recently described rare mesenchymal tumor of borderline malignancy. It generally involves superficial soft tissue, with a predilection to the lower extremities. Microscopically this tumor is characterized by a fascicular and storiform growth pattern, spindled to epithelioid cells, nuclear atypia with pleomorphism, and eosinophilic granular, and fibrillar to glassy cytoplasm. Strong diffuse immunoreactivity for CD34 is very characteristic of this entity. Due to under-recognition, this tumor is generally underreported. Additionally, cases of recurrence are rarely reported in the literature. We will comprehensively review the English language literature on all reported cases of SCPFT, with emphasis on recurrence.

Pleomorphic giant cell carcinoma of prostate: Rare tumor with unique clinicopathological, immunohistochemical, and molecular features

Pleomorphic giant cell carcinoma (PGCC) of the prostate is a rare entity categorized as a variant of prostatic acinar adenocarcinoma in the 2016 World Health Organization (WHO) classification system. PGCC differs from conventional prostatic adenocarcinoma by having bizarre, markedly enlarged, and pleomorphic cells. It differs from high grade urothelial carcinoma by negativity for urothelial differentiation markers, and can be distinguished from sarcomatoid carcinoma by lack of spindle cells. Including two new cases described herein, there have been 51 cases of prostate PGCC reported in the English literature. Clinical features shared by cases of prostate PGCC include poor prognosis, occurrence in older patients, and frequent association with prior therapy. Pathologic features common to cases of prostate PGCC include admixture with a high-grade conventional prostate carcinoma component and absent or reduced expression of prostate differentiation markers. More recent studies have begun to elucidate the molecular characteristics of PGCC, detecting specific mutations and chromosomal translocations, and showing evidence of a high degree of molecular instability in these tumors. We report novel findings in two cases of PGCC including a PIK3CA p.His1047Arg mutation not previously described. One of our cases is the first to clearly demonstrate chronological loss of prostate markers during dedifferentiation from prior conventional prostate carcinoma to PGCC. Herein, we present our two new cases and comprehensively review the literature on all reported cases of PGCC with critical commentary on findings in cases of this rare tumor.

Leiomyoma of digit of hand: Report of three cases with literature review

Leiomyoma is a benign tumor of smooth muscle origin most common in areas of the body with abundant smooth muscle including the gynecologic, genitourinary, and gastrointestinal system. Leiomyoma outside of these locations is believed to arise from vascular smooth muscle and arrector pili muscles. Leiomyoma of an extremity is a rare diagnosis, especially when present in a digit of the hand due to the paucity of smooth muscle in this location. We report three cases of leiomyoma of a digit of the hand.

Seminal vesicle invasion combined with extraprostatic extension is associated with higher frequency of biochemical recurrence and lymph node metastasis than seminal vesicle invasion alone: Proposal for further pT3 prostate cancer subclassification

The 8th edition of the American Joint Committee on Cancer (AJCC) TNM staging system subdivides prostatic pT3 tumors into pT3a, which includes cases with extraprostatic extension (EPE) and pT3b, which is defined by the presence of seminal vesicle invasion (SVI) with or without EPE. Yet, it is not established whether combined SVI and EPE impart a worse prognosis compared to SVI alone. We studied a cohort of 69 prostatectomy patients with SVI with or without EPE. Patient age at the time of radical prostatectomy was documented and Gleason score and presence or absence of EPE and/or SVI were determined. Biochemical recurrence (BCR) was defined as a PSA rise >0.2 ng/mL. The frequency of BCR was 33.9% in cases with combined EPE and SVI versus 12.5% in cases with SVI alone (relative risk = 2.71). An additional cohort of 88 patients also showed a higher frequency of lymph node metastasis of 29% in patients with combined SVI and EPE at the time of radical prostatectomy versus a 10% frequency of lymph node metastasis in patients with SVI alone (relative risk = 2.9). Based on our data, we propose further subdividing pT3 prostate cancers into three groups: EPE alone (pT3a), SVI alone (pT3b), and combined EPE and SVI (pT3c). This classification system would more accurately identify patients with pT3 prostate cancer who are more likely to experience worse outcomes and provide clinicians with additional information to aid in follow-up and postoperative treatment decisions.

Anastomosing Hemangioma of the Breast: An Unusual Case at an Unusual Site

Anastomosing hemangioma (AH) is an unusual benign vascular lesion that commonly occurs in the kidney and genitourinary tract. We report a case of AH in a 49-year-old woman presenting as a mass in the breast, a site which, to the best of our knowledge, has not been previously documented in the English literature. Microscopic examination of the mass revealed a well-demarcated proliferation of anastomosing vascular spaces lined by bland endothelial cells, with focal hobnailing and scattered intravascular fibrin thrombi. No mitotic activity was observed and the Ki-67 proliferative index was low. These features were interpreted as AH, a lesion that may be difficult to distinguish from low-grade angiosarcoma or other benign vascular lesions of the breast which may demonstrate anastomosing channels. Due to the presence of atypical histologic features which can raise suspicion for angiosarcoma on biopsy, complete excision of these lesions is recommended for optimal treatment.

Solitary Fibrous Tumor of Breast with Anaplastic Areas (Malignant Solitary Fibrous Tumor): A Case Report with Review of Literature

Solitary fibrous tumor (SFT) is a rare, soft tissue neoplasm that rarely presents in breast tissue, with only 27 previously reported cases. To our knowledge, only one case of malignant SFT has been reported in the English literature. A 75-year-old Caucasian woman presented to our institution with a 3-month history of a palpable left breast mass. No other symptoms, including nipple discharge or skin changes, were noted. She underwent 3 previous biopsies for right breast masses, all of which were benign, with no evidence of spindle cell neoplasm, atypical hyperplasia, or malignancy. Microscopic examination of the mass demonstrated a classic area of SFT with areas of high-grade anaplastic component. In these areas, the tumor showed atypical epithelioid cells arranged in hypercellular sheets with diminished branching vasculature, nuclear pleomorphism, and increased mitotic count (up to 9/10 high-power fields). This case represents the second case of malignant SFT in the breast.

Clear cell carcinoma of testis: A review

Clear cell Mullerian-type adenocarcinoma of the testis is an exceedingly rare entity, and its histogenesis and clinical behavior are still poorly understood. We discuss three cases of clear cell carcinoma of the testis, compiled from a review of the literature and our personal experience. Microscopically, the tumors closely resembled clear cell carcinoma of the ovary, displaying papillae lined by clear cells with areas of hobnailing. The reported immunophenotypic features were also similar to that of ovarian tumors, as positivity for epithelial markers (CK7, CAM5.2, AE1/AE3, EMA) and Mullerian markers (PAX8, CA125) with negativity for estrogen and progesterone receptors have been observed. The pathogenesis of testicular clear cell carcinoma is still poorly understood, with reported cases displaying evidence of both mesothelial and Mullerian origin. In addition, molecular characterization of testicular clear cell carcinomas has yet to be accomplished; however, studies performed on ovarian clear cell carcinomas may provide insight to the origin, biologic behavior, and potential therapeutic modalities for this obscure, aggressive malignancy.

Pseudoangiomatous stromal hyperplasia of the prostate: report of an unprecedented entity in prostate pathology

Pseudoangiomatous stromal hyperplasia is a benign entity of the breast. It is histologically characterized by open, slit-like spaces lined by spindle cells of myofibroblast/fibroblast differentiation in a dense collagenous stroma. Although pseudoangiomatous stromal hyperplasia has been reported in ectopic breast tissue in anogenital mammary-like glands, it has not been previously reported in non-breast tissues. This includes prostatic tissue, which shares similar histology and pathology with the breast. Herein, we report the first case of prostatic pseudoangiomatous stromal hyperplasia based on histological, immunohistochemical, and electron microscopic findings. The patient was a 74-year-old man with a history of benign prostatic hyperplasia who presented with severe urinary retention and underwent transurethral resection of the prostate. In addition to benign prostatic hyperplasia, the prostate showed areas of irregular spaces lined occasionally by flattened spindle cells in a background of fibrocollagenous stroma. Immunohistochemically, these cells were diffusely positive for vimentin and negative for CD31, CD34, ERG, pancytokeratin, SMA, and D2-40. Electron microscopic findings also showed some cells with fibroblastic features lining these spaces. Given these findings, we postulated that pseudoangiomatous stromal hyperplasia of the prostate has some cells of fibroblastic lineage. Contrary to its breast counterpart where lining cells demonstrate diffusely and strongly positive staining for CD34 and PR, this prostate case showed negative staining for CD34 and PR. These findings indicate potential differences in the histogenesis of prostatic and breast pseudoangiomatous stromal hyperplasia.

Prostatic adenocarcinoma in the setting of persistent müllerian duct syndrome: a case report

Persistent müllerian duct syndrome (PMDS) is a form of disordered sex development in which rudimentary müllerian structures are identified in phenotypically and genotypically normal males. It is caused by defects in the anti-müllerian hormone (AMH) system. Since patients with PMDS present with undescended testes, testosterone production by Leydig cells later in life is often decreased. The role of androgens in prostate cancerogenesis is well known. Cryptorchid testes and diminished testosterone levels in post-pubertal life in patients with PMDS play a protective role against prostate cancer, and hence, prostate cancer is a rare event in patients with PMDS. Herein, we present a patient who underwent prostatectomy for high-grade prostatic adenocarcinoma with persistent müllerian structures (such as rudimentary uterus, fallopian tubes, and cervix) identified during surgery. To our knowledge, this is the second case reported in the English language literature where PMDS was associated with prostate cancer.

Sarcoid-like granulomas in renal cell carcinoma: The Houston Methodist Hospital experience

Sarcoid-like (SL) granulomas have been previously described in association with malignant tumors. These granulomas appear to be tumor-related but are not indicative of systemic sarcoidosis, and hence are referred to as SL reactions. These SL reactions can be seen within the primary tumor, its vicinity, or in uninvolved sites such as the spleen, bone marrow, skin, and/or regional lymph nodes draining the tumor. It is a widely held view that SL granulomas are caused by soluble antigenic factors, shed by tumor cells or released due to tumor necrosis. SL reactions reported in Hodgkin lymphoma have been associated with a better prognosis. SL granulomas are thought to play an important role in the host's defenses against metastatic extension. SL granulomas have been reported in approximately 4.4% of carcinomas. Isolated cases of renal cell carcinoma (RCC) with SL granulomas have been reported with questionable prognostic significance. We identified 11 cases of RCCs with SL granulomas. Interestingly, all cases had abundant clear cell cytoplasm (10 clear cell RCC cases and 1 clear cell papillary RCC). We propose that this clear, abundant cytoplasm of the tumor cells with high content of glycogen and lipids may trigger granuloma formation akin to that seen in seminomas with SL granulomas. To date, this is the largest case series of RCCs with SL granulomas.

Primary collision tumors of the kidney composed of oncocytoma and papillary renal cell carcinoma: A review

BACKGROUND

There are well known cases of hybrid tumors of chromophobe renal cell carcinoma (RCC) and oncocytoma in kidney, where both tumors have the same cell of origin - intercalated cell of the collecting duct. However, collision tumors composed of neoplasms originating from different cell lineages such as oncocytoma and papillary RCC are extremely rare. Herein, we made a collective literature review of reported cases of collision tumors composed of oncocytoma and papillary RCC, adding a case that we recently experienced.

MATERIAL AND METHODS

A PubMed database was search for collision tumors of the kidney composed of oncocytoma and papillary RCC and a collective literature review was made. To this cohort, we also added a recently encountered case with similar, confirmed by immunohistochemistry, morphological features.

RESULTS

To date 8 cases of a collision tumor composed of papillary RCC and oncocytoma have been described in the literature. All of them had a smaller papillary RCC component present within a larger oncocytoma.

CONCLUSION

Because of a few cases of such a collision tumors reported, it is difficult to make classification and right clinical management of these patients. None of the reported cases had tumor recurrence or progression on a follow-up. The presence of only small portion of papillary RCC in a large oncocytoma raises a possibility of under-sampling of malignant component in large oncocytomas in core biopsy or surgically resected specimens. We recommend better sampling, particularly at the periphery of otherwise classic oncocytomas to unveil this possible association.

Human Colors-The Rainbow Garden of Pathology: What Gives Normal and Pathologic Tissues Their Color?

CONTEXT

- Colors are important to all living organisms because they are crucial for camouflage and protection, metabolism, sexual behavior, and communication. Human organs obviously have color, but the underlying biologic processes that dictate the specific colors of organs and tissues are not completely understood. A literature search on the determinants of color in human organs yielded scant information.

OBJECTIVES

- To address 2 specific questions: (1) why do human organs have color, and (2) what gives normal and pathologic tissues their distinctive colors?

DATA SOURCES

- Endogenous colors are the result of complex biochemical reactions that produce biologic pigments: red-brown cytochromes and porphyrins (blood, liver, spleen, kidneys, striated muscle), brown-black melanins (skin, appendages, brain nuclei), dark-brown lipochromes (aging organs), and colors that result from tissue structure (tendons, aponeurosis, muscles). Yellow-orange carotenes that deposit in lipid-rich tissues are only produced by plants and are acquired from the diet. However, there is lack of information about the cause of color in other organs, such as the gray and white matter, neuroendocrine organs, and white tissues (epithelia, soft tissues). Neoplastic tissues usually retain the color of their nonneoplastic counterpart.

CONCLUSIONS

- Most available information on the function of pigments comes from studies in plants, microorganisms, cephalopods, and vertebrates, not humans. Biologic pigments have antioxidant and cytoprotective properties and should be considered as potential future therapies for disease and cancer. We discuss the bioproducts that may be responsible for organ coloration and invite pathologists and pathology residents to look at a "routine grossing day" with a different perspective.

An isolated inflammatory myofibroblastic tumor of adrenal gland

Inflammatory myofibroblastic tumor (IMT) is an uncommon lesion that shows a wide range of anatomic distribution. The adrenal gland, however, is a distinctly rare site of occurrence. To date, only a few cases of IMT arising in the adrenal gland have been reported in the English literature. Here, we report another case of isolated adrenal IMT. A 34-year-old man presented to the emergency department with a complaint of a sudden severe right-sided back pain. Subsequent computed tomographic scan imaging studies demonstrated a large right adrenal mass associated with a hematoma. The right adrenal gland was resected. Microscopic examination revealed an encapsulated cellular spindle cell proliferation with a prominent inflammatory infiltrate. Immunohistochemically, those spindle cells were diffusely and strongly positive for anaplastic lymphoma kinase-1, and focally and weakly positive for smooth muscle actin. S-100 protein and cytokeratin were negative. The findings were consistent with IMT arising from the adrenal gland. Although IMTs in the adrenal gland are rare, they should be considered in the differential diagnosis of adrenal masses. The clinical behavior of IMTs in general is currently indeterminate and a close clinical follow-up is recommended. The behavior of adrenal IMTs remains uncertain because of rare reported cases and lack of long-term follow-up. Further follow-up of reported cases and recognition of additional new cases is warranted to unmask the true biological behavior of adrenal IMTs.

Endometrial Stromal Sarcoma Presenting as Extrauterine Metastases

A case of endometrial stromal sarcoma that initially presented as an umbilical mass 5 years before and as a lung lesion 8 months before the primary tumor was detected in the uterus is reported. The morphologic features and immunohistochemical profile of the two initial extrauterine lesions suggested metastases from a primary endomerial stromal sarcoma of the uterus, which was confirmed by subsequent endometrial curettage. The tumors in all three locations were characterized histologically by small to medium-sized uniform cells with fewer than 10 mitoses per 10 high-power fields and distinct arterial vasculature that resembled the spiral arteries of the normal enometrium. Both the endometrial and umbilical tumors were immunoreactive for estrogen and progesterone receptors but showed no immunoreactivity for cytokertin. Additionally, the tumor cells of the umbilical mass showed no immunoreactivty for S-100 protein, HMB-45, smooth-muscle actin, or desmin. Endometrial stromal sarcomas are usually confined to the uterus at the time of diagnosis. When they preent initially as an extrauterine metastasis, diagnostic difficulties may arise. A recogition of the morphologic features, together with the immunoreactivity pattern, is needed in evaluating endometrial stromal sarcomas that present as extrauterine metastases.

Angiomyofibroblastoma

We report the clinicopathologic features of eight new cases of angiomyofibroblastoma and review the literature on this recently described entity. Most of our female patients had a vulvar mass that clinically was thought to be a Bartholin's gland cyst. The tumors were well circumscribed and measured 2.9 to 11 cm (mean, 5.2 cm). No recurrences or metastases were observed during follow-up, which ranged from 2 months to 4 years. The tumors were characterized by a myxomatous background with prominent vessels surrounded by plump stromal cells. Immunohistochemically, the stromal cells were reactive for vimentin, but staining for desmin was not always present. Angiomyofibroblastoma should be distinguished from aggressive angiomyxoma because the two entities behave differently. Morphologic and immunohistochemical features should also be considered.

Lymphoepitheliomalike Carcinoma of the Gallbladder

We report a case of a lymphoepitheliomalike carcinoma arising in the gallbladder of a 60-year-old woman. The gallbladder wall was completely replaced with a tumor that extended into the adjacent liver parenchyma.The tumor was histologically and immunophenotypically indistinguishable from lymphoepithelioma of the nasopharynx, which is an undifferentiated malignant epithelial neoplasm that is histologically distinctive owing to a prominent reactive lymphoid infiltrate. It is believed that the Epstein-Barr virus may play a role in the pathogenesis of nasopharyngeal lymphoepitheliomas; however, our case in the gallbladder was not associated with of Epstein-Barr virus DNA. To the best of our knowledge, this is the first published case of a lymphoepitheliomalike carcinoma of the gallbladder. Int J Surg Pathol 4(3):00-00, 1997

Well-Differentiated Intramedullary Osteosarcoma

Well-differentiated intraosseous osteosarcoma (WDIOS) is a rare tumor and histologically similar to parosteal osteosarcoma. This study reports the clinicopathological features of five patients with WDIOS tumor seen at the Instituto Nacional de Cancerologia in Mexico City. The patients' ages ranged from 29 to 42 years with a median age of 32 years. Four of the five patients presented with pain and a mass that had been present for more than 3 years prior to the diagnosis. Radiologically, four of the lesions were present in the long bones and showed a predominantly trabeculated appearance with some small ill-defined lytic areas. The bony sclerosis was more prominent within the medullary cavity than in the soft tissue extension. The majority of the tumors were large, averaging 21 cm in size. Histologically, the tumors were characterized by spindle cells with areas of cytologic atypia and presence of mature bone formation. In two patients a high-grade sarcoma component was found in addition to WDIOS component: in both patients the high-grade sarcoma component was identified in the amputation specimens, and in one of these it was also recognized in the pulmonary metastasis. This study demonstrated that WDIOS is a slowgrowing malignant neoplasm that may show a histologic progression to dedifferentiation (dedifferentiated osteosarcoma) and an aggressive behavior with distant metastasis.

Malignant Melanoma Metastatic to Gastrointestinal Tract

Malignant melanomas metastatic to the gastrointestinal (GI) tract show a wide range of histologic features, many of which can mimic primary GI malignancies. In this study, we evaluated the clinicopathologic features of 41 cases of malignant melanoma involving the GI tract. Thirty-two patients were men and nine were women; the average patient age was 51.7 years (range, 26-74 years). Twenty-eight patients had a history of malignant melanoma. Thirteen patients, however, did not have a prior history of malignant melanoma; on the basis of the clinical presentation and the behav ior of the GI lesions of these cases, they were presumed to be metastases from regressed or clinically undetected melanomas. The small intestine was the most common site. 12 patients had involvement of multiple GI sites. Clinical diagnoses at presentation included GI bleeding of unknown etiology, small bowel obstruction, rectal carcinoma, gastric ulcer, lymphoma, and cholelithiasis. The three major histologic patterns that mimicked primary GI neoplasms were carcinoma-like, carcinoid-like, and stromal sarcoma-like. The average survival times were 61.9 months after the diagnosis of primary melanoma and 14.4 months from the time of GI tract involvement. Site of malignant melanoma in the GI tract, histologic pattern, and history of a primary lesion outside GI tract did not show any prognostic significance. Although metastatic malig nant melanomas of the GI tract are rare, they should be considered in the differential diagnosis of primary GI tumors. Int J Surg Pathol 2(1):3-10, 1994

Periosteal Osteosarcoma of the Digits

A periosteal osteosarcoma arose in the first phalanx of the fourth finger of a 32-year-old woman's right hand. She had no predisposing factors for this cancer. The tumor was initially locally resected, but as recurrences developed, the finger and later the hand were amputated. Despite therapy with doxorubicin and cisplatin, distant metastases occurred and ultimately caused the patient's death. Primary conventional osteosarcomas of the short tubular bones of the hands and feet are rare, but surface lesions are rarer. This case constitutes the first reported periosteal osteosarcoma to arise in a phalanx.

Juxtaglomerular Cell Tumor of the Kidney

We present a case of juxtaglomerular cell tumor (JGCT) that developed in a 44-year-old woman with hypertension, which subsided after the tumor was removed. The tumor was 8.5 cm in greatest dimension and is thought to be the largest such tumor reported to date. Ultrastructural study confirmed the diagnosis of JGCT by the demonstration of the typical cytoplasmic rhomboidal secretory granules on electron microscopy. The tumor cells were also strongly reactive for CD34, a finding that has not been previously reported and that may be an adjunct to the diagnosis of JGCT in a patient with hypertension, hyperreninemia, and/or hypokalemia. At present, however, further studies on additional cases for CD34 expression will be necessary to fully evaluate the diagnostic utility of this marker in the diagnosing of JGCT.

Primary Pulmonary Alveolar Soft-part Sarcoma

Alveolar soft-part sarcoma rarely arises in the lung. Only two patients with tumors that were apparently primary in the lung have been documented in the literature. We report an additional case in a 25-year-old woman. The tumor formed a solitary 5 cm, solid mass in the left perihilar region. Clinical examination, radiologic studies, and follow-up examination of more than 1 year have failed to reveal tumor in an extrapul monary location. The light microscopic appearance was typical for alveolar soft-part sarcoma, and crystalloids were identified in the tumor cells by the periodic acid-Schiff stain and by electron microscopy, confirming the diagnosis. Immunocytochemical studies did not show evidence of myogenic, epithelial, or neuroendocrine differentia tion. Int J Surg Pathol 2(1):57-62, 1994

Metastasizing leiomyoma to heart

Cardiac smooth muscle tumors are rare. Three different clinical settings for these tumors have been reported, including benign metastasizing leiomyoma from the uterus, primary cardiac leiomyoma and leiomyosarcoma, and intravenous cardiac extension of pelvic leiomyoma, which is the most common. We present a case of a 55-year-old woman with a benign metastasizing leiomyoma to the heart 17 years after hysterectomy and 16 years after metastasis to the lung. Immunohistochemical stains for smooth muscle actin, desmin, and estrogen and progesterone receptors were positive, indicating a smooth muscle tumor of uterine origin. To our knowledge, this is only the fourth reported case of benign metastasizing leiomyoma to the heart and the first case of long-delayed cardiac metastasis after successful treatment of pulmonary metastasis. It illustrates that benign metastasizing leiomyoma should be included in the differential diagnosis of cardiac tumors in patients with a history of uterine leiomyoma, especially when associated with pulmonary metastasis.

Collagenous micronodules in prostate cancer revisited: are they solely associated with Gleason pattern 3 adenocarcinomas?

Collagenous micronodules (CMs) are microscopic stromal nodular eosinophilic fibrillar collagen deposition of uncertain histogenesis seen in prostatic adenocarcinoma. Per the 2005 International Society of Urologic Pathology (ISUP) consensus conference, they are categorized as Gleason pattern 3. This study analyzes morphological and clinical features of CMs from a large series of radical prostatectomies. Hematoxylin and eosin stained slides for 129 radical prostatectomies for adenocarcinoma of prostate with CMs and for 93 prostatic adenocarcinoma cases without CMs as comparison were examined out of a total of 667 cases performed from January 2010 to December 2011 at Houston Methodist Hospital. CMs were identified in 19% of all radical prostatectomies (129/667 cases). Almost all tumors with CMs were located in the peripheral zone (98%) as single or multiple foci of prostatic cancer glands. The vast majority of cases (96%) were identified in association with mucinous secretion. A cribriform Gleason pattern 4 was associated in 86 cases (67%). The CMs were associated with glomerulation (42%) and amphophilic luminal secretion (59%). 88 cases (68%) showed tumor foci with Gleason pattern ≥ 4 in close association with CMs. Multivariate analysis revealed CMs of the prostatic adenocarcinoma are closely related to mucinous secretion, cribriform growth pattern, and Gleason pattern 4. This study suggests that CMs are more frequently associated with Gleason pattern 4 cancer warranting morphologic reappraisal of CMs, rather than the consensus assignment of Gleason pattern 3.

Calcified amorphous tumor of the heart: case report and review of the literature

Calcified amorphous tumor of the heart (cardiac CAT) is a rare non-neoplastic cardiac mass that mimics malignancy on imaging and can cause symptoms due to flow obstruction or embolization of calcific fragments. We report a 57-year-old female with multiple medical problems affected by cardiac CAT. The echocardiogram showed a 2 x 1.7 cm right atrial mass. Under the clinical diagnosis of cardiac myxoma, a mass resection was performed. Microscopic examination of the resected mass showed nodular calcified amorphous debris with admixed degenerated fibrin and focal chronic inflammation. At the 1-year follow-up, the patient was free of disease. We performed a literature review of 16 previously reported cases. Histologically, a cardiac CAT consists of calcification and eosinophilic amorphous material in the background of dense collagenous fibrous tissue. A review of these cases shows a wide range of age at diagnosis and slight female predominance. The patients are either asymptomatic at presentation or complain of shortness of breath. The tumors have been found in all chambers of the heart, most commonly in the left ventricle. The sizes of the tumors range from 0.17 to 4 cm, with 62.5% of the tumors being mobile. Among the nine cases with documented follow-up study, all but one was free of disease and only one case of relapse was recorded. In conclusion, cardiac CATs are frequently asymptomatic at presentation, size is equal to or less than 4 cm, they can be located in all four chambers and are usually mobile, and they may relapse when not completely excised.

Adenoid cystic carcinoma of breast: Recent advances

Adenoid cystic carcinoma (ACC) of the breast is a rare special subtype of breast cancer characterized by the presence of a dual cell population of luminal and basaloid cells arranged in specific growth patterns. Most breast cancers with triple-negative, basal-like breast features (i.e., tumors that are devoid of estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 expression, and express basal cell markers) are generally high-grade tumors with an aggressive clinical course. Conversely, while ACCs also display a triple-negative, basal-like phenotype, they are usually low-grade and exhibit an indolent clinical behavior. Many discoveries regarding the molecular and genetic features of the ACC, including a specific chromosomal translocation t(6;9) that results in a MYB-NFIB fusion gene, have been made in recent years. This comprehensive review provides our experience with the ACC of the breast, as well as an overview of clinical, histopathological, and molecular genetic features.

De novo large cell neuroendocrine carcinoma of the prostate gland with pelvic lymph node metastasis: a case report with review of literature

Neuroendocrine (NE) differentiation in prostate carcinomas can be seen in two settings: as a focal finding in conventional acinar adenocarcinoma, identifiable by immunohistochemical staining, or as a primary NE tumor of the prostate gland, such as carcinoid, small cell carcinoma, or large cell NE carcinoma. Of particular interest is the large cell NE carcinoma, which had been previously reported in isolated cases or in limited case series. In this report, we describe a case of a large cell NE carcinoma diagnosed in a 48-year-old man who presented with difficulty in voiding and urine retention. A cystoscopy revealed an enlarged, elongated prostate with an intra-urethral obstructing mass in the prostatic urethra. Subsequently, a transurethral resection of prostate (TURP) was performed at an outside hospital under the clinical diagnosis of benign prostatic hyperplasia (BPH). Microscopic examination of the TURP specimen revealed several foci of low-grade transitional-zone-type adenocarcinoma corresponding to Gleason score 5 (3 + 2), and a focus of high-grade large cell NE carcinoma. Concurrent x-ray computed tomography scans of the chest, abdomen, and pelvis demonstrated an enlarged left pelvic lymph node, which was biopsied and the patient was diagnosed with metastatic large cell NE carcinoma. He subsequently underwent 8 cycles of neoadjuvant chemotherapy with Lupron, a laparoscopic robotic-assisted radical retropubic prostatectomy, and pelvic lymphadenectomy. He died of widely metastatic prostatic carcinoma with leptomeningeal metastases 13 months after radical prostatectomy. Here, we present a rare case of large cell NE carcinoma with a review of the published literature.

Intraoperative frozen section evaluation of ureteral and urethral margins: studies of 203 consecutive radical cystoprostatectomy for men with bladder urothelial carcinoma

Intraoperative frozen section (FS) evaluation of ureteral and urethral margins is frequently requested during radical cystoprostatectomy in patients with bladder urothelial carcinoma. However, it is still controversial whether intraoperative FSs of ureteral and urethral margins are necessary in all patients with cystoprostatectomy or a risk-based assessment with limited to the high risk patients is the best approach. A total of 203 radical cystoprostatectomy specimens with FS evaluation on margin status from men treated for bladder urothelial carcinoma from 2003 to 2010 in our institution were reviewed. Clinicopathologic features studied include: patients' age, pathologic tumor stage, presence of carcinoma in- situ (CIS), and intraoperative FS diagnosis. All 203 patients had intraoperative FS evaluation of ureter, and of these, 37 patients had additional urethra FS evaluation. Of the 203 ureteral FS cases, 17 (8.4%) had positive margin for CIS (16 cases) or CIS with invasive urothelial carcinoma (1 case). All 17 patients with positive ureteral margin on FS had concomitant CIS in the bladder (15.5%; 17 of 110 patients). In contrast, none of the patients without concomitant CIS (n=93) had positive ureteral margins on FS. Among 37 patients who also had FS evaluation on urethral resection margin, 3 patients (8.1%) had positive margins for CIS and all three of them had concomitant CIS in the bladder. Positive ureteral/urethral margin was not associated with patients' age or tumor stage, but was significantly associated with the presence of CIS in the bladder (p<0.001). Our study demonstrates that presence of concomitant CIS in bladder cancer was often associated with positive ureteral or urethral margin for CIS or invasive carcinoma; therefore, intraoperative FS evaluation may be indicated to these patients with concomitant bladder CIS. In contrast, in patients with no associated concomitant CIS in the bladder, FS of ureteral/urethral margins may not be necessary unless other clinical justification is present.

Heterogeneous clinicopathological features of intraductal carcinoma of the prostate: a comparison between "precursor-like" and "regular type" lesions

Intraductal carcinoma of the prostate (IDC-P) has been described as a lesion associated with intraductal spread of invasive carcinoma and consequently aggressive disease. However, there are a few reported cases of pure IDC-P without an associated invasive component, strongly suggesting that this subset of IDC-P may represent a precursor lesion. We compared the clinicopathological features between the morphologically "regular type" IDC-P and "precursor-like" IDC-P. IDC-P was defined as follows; 1) solid/dense cribriform lesions or 2) loose cribriform/micropapillary lesions with prominent nuclear pleomorphism and/or non-focal comedonecrosis. We defined precursor-like IDC-P as follows; 1) IDC-P without adjoining invasive adenocarcinoma but carcinoma present distant from the IDC-P or 2) IDC-P having adjoining invasive microcarcinoma (less than 0.05 ml) and showing a morphologic transition from high-grade prostatic intraepithelial neoplasia (HGPIN) to the IDC-P. IDC-P lacking the features of precursor-like IDC-P was categorized as regular type IDC-P. Of 901 radical prostatectomies performed at our hospital, 141 and 14 showed regular type IDC-P and precursor-like IDC-P in whole-mounted specimens, respectively. Regular type IDC-P cases had significantly higher Gleason score, more frequent extraprostatic extension and seminal vesicle invasion, more advanced pathological T stage, and lower 5-year biochemical recurrence-free rate than precursor-like IDC-P cases. Multivariate analysis revealed nodal metastasis and the presence of regular type IDC-P as independent predictors for biochemical recurrence. Our data suggest that IDC-P may be heterogeneous with variable clinicopathological features. We also suggest that not all IDC-P cases represent intraductal spread of pre-existing invasive cancer, and a subset of IDC-P may be a precursor lesion.

Diagnostic utility of E-cadherin and P120 catenin cocktail immunostain in distinguishing DCIS from LCIS

BACKGROUND

Breast carcinoma in situ (CIS) is classified into ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS). DCIS is treated with surgical excision while LCIS can be clinically followed with or without hormonal treatment. Thus, it is critical to distinguish DCIS from LCIS. Immunohistochemical (IHC) staining for E-cadherin is routinely used to differentiate DCIS from LCIS in diagnostically challenging cases. Circumferential diffuse membranous staining of E-cadherin is the typical pattern in DCIS, whereas LCIS lacks or shows decreased E-cadherin expression. Recent studies have shown that DCIS has membranous staining of P120 catenin and LCIS has diffuse cytoplasmic staining of P120 catenin. We developed a cocktail composed of E-cadherin and P120 catenin primary antibodies so that only one slide is needed for the double immunostains.

DESIGNS

Twenty-seven blocks of formalin-fixed paraffin-embedded tissue from 26 cases of DCIS or LCIS were retrieved from the archives of Houston Methodist Hospital. Four consecutive sections from the same blocks were used for H&E and immunohistochemical (IHC) stains. The E-cadherin antibody was a rabbit polyclonal antibody and the P120 catenin antibody was a mouse monoclonal antibody. The E-cadherin primary antibody was detected using a secondary antibody raised against rabbit antibody and was visualized with a brown color. The P120 catenin primary antibody was detected using a secondary antibody raised against mouse antibody and was visualized with a red color.

RESULTS

Using individual antibodies, 15 of 15 DCIS lesions had diffuse circumferential membranous E-cadherin staining (brown stain) or P120 catenin staining (red stain). All 12 LCIS cases showed cytoplasmic P120 red staining or loss of E-cadherin staining when the single P120 catenin or E-cadherin antibody was used. When stained with the antibody cocktail, all 15 DCIS samples showed diffuse red and brown membranous staining without cytoplasmic stain; all 12 LCIS samples showed diffuse cytoplasmic red staining for P120 catenin but no membranous staining for E-cadherin.

CONCLUSIONS

1. This antibody cocktail can be applied in daily practice on paraffin-embedded tissue and is especially useful in small biopsies with small foci of CIS lesions. 2. Immunohistochemical staining with the antibody cocktail showed 100% concordance with the traditional single antibody immunostaining using either E-cadherin or P120 catenin antibody. 3. Our antibody cocktail includes E-cadherin as a positive membranous stain for DCIS and P120 catenin as a positive cytoplasmic stain for LCIS, which may enhance accuracy and confidence in the differential diagnoses.

Diagnostic utility of WT-1 cytoplasmic stain in variety of vascular lesions

Vascular lesions are commonly encountered in routine pathologic practice and often pose diagnostic challenges owing to their morphologic diversity. Although WT-1 expression was reported in some vascular tumors, little is known about its staining patterns in a spectrum of vascular lesions from various locations. We examined WT-1 immunostain in 95 cases of vascular lesions including angiosarcomas (AS, 19 cases), hemangioendotheliomas (HE, 5), Kaposi's sarcomas (KS, 4), cavernous hemangiomas (CVH, 12), capillary hemangiomas (CPH, 7), pyogenic granulomas (PG, 4), lymphangiomas (LA, 4), hemangiopericytomas (HP, 5), glomus tumors (GT, 8), vascular malformation (VM, 13) and granulation tissue (GRT, 14). Strong WT-1 cytoplasmic stain was invariably observed in all cases of malignant and borderline vascular tumors including AS (19/19), KS (4/4) and HE (5/5). WT-1 was also consistently expressed in CPH (7/7), PG (4/4), and GRT (14/14), while it became weaker in VM (10/13) and often negative in CVH (2/12) and LA (0/4). WT1 stain was not demonstrated in HP (0/5) and rarely in GT (2/8). We conclude that consistent and diffuse WT-1 cytoplasmic stain in AS, HE and KS can be useful in distinguishing these tumors from poorly differentiated tumors with mimicking features. On the other hand, reliable WT-1 stain in CPH, PG and GRT may help in differential diagnosis with non-endothelial vascular tumors such as GT and HP. Recognizing the WT-1 cytoplasmic stain in a broad spectrum of benign and neoplastic tissues is critical in formulating appropriate immunohistochemical panels and avoiding misinterpretation of results.

Clinicopathological analysis of intraductal proliferative lesions of prostate: intraductal carcinoma of prostate, high-grade prostatic intraepithelial neoplasia, and atypical cribriform lesion

Intraductal carcinoma of the prostate (IDC-P) and high-grade prostatic intraepithelial neoplasia (HGPIN) are two distinct intraductal lesions; the former is usually associated with invasive carcinoma and has an aggressive course while the latter is considered a precancerous lesion. In addition, there are morphologically lesions not well characterized that fall between IDC-P and HGPIN, consequently termed "atypical cribriform lesions (ACLs)." Using whole mount radical prostatectomy specimens, we evaluated the relationship between these intraductal proliferative lesions and clinicopathological parameters. In this study, ACLs were characterized as a loose cribriform intraductal proliferation with greater architectural complexity when compared to HGPIN, but lacking significant nuclear pleomorphism and/or comedonecrosis. Of 901 radical prostatectomies (2006-2012), IDC-P, ACL, and HGPIN were recorded in 155, 22, 436 cases, respectively. Patients with IDC-P showed more aggressive pathologic features when compared to HGPIN. Invasive cancers in patients with ACL had higher Gleason score (P=.00016), larger tumor volume (P=.025), and more advanced pT stage (P=.023) than those with HGPIN. Cases with ACL showed a higher risk of biochemical recurrence than those with HGPIN and a lower risk than those with IDC-P based on log-rank tests (P=.0045 and P=.0069, respectively). In multivariate analysis, the presence of HGPIN was identified as an independent predictor for infrequent biochemical recurrence (P=.0058). We confirmed IDC-P as a marker of adverse pathologic features and clinical aggressiveness. Our results suggest that ACL should be distinguished from HGPIN and these lesions mandate active clinical surveillance.

Renal cell carcinoma: Evolving and emerging subtypes

Our knowledge of renal cell carcinoma (RCC) is rapidly expanding. For those who diagnose and treat RCC, it is important to understand the new developments. In recent years, many new renal tumors have been described and defined, and our understanding of the biology and clinical correlates of these tumors is changing. Evolving concepts in Xp11 translocation carcinoma, mucinous tubular and spindle cell carcinoma, multilocular cystic clear cell RCC, and carcinoma associated with neuroblastoma are addressed within this review. Tubulocystic carcinoma, thyroid-like follicular carcinoma of kidney, acquired cystic disease-associated RCC, and clear cell papillary RCC are also described. Finally, candidate entities, including RCC with t(6;11) translocation, hybrid oncocytoma/chromophobe RCC, hereditary leiomyomatosis and RCC syndrome, and renal angiomyoadenomatous tumor are reviewed. Knowledge of these new entities is important for diagnosis, treatment and subsequent prognosis. This review provides a targeted summary of new developments in RCC.

Tumor-to-Tumor Metastasis With Endometrial Carcinoma Metastatic to Squamous Cell Carcinoma of Vulva: The First Reported Case

Endometrial carcinoma metastasizing to the vulva is a rare occurrence, with only 15 reported cases in the literature. To our knowledge, no cases of tumor-to-tumor metastasis involving endometrial carcinoma as a donor tumor have ever been published. We report the first case of an endometrial carcinoma as a donor tumor metastasizing to a squamous cell carcinoma of the vulva, a recipient tumor. A 79-year-old woman with a history of endometrioid adenocarcinoma of the uterus presented with a vulvar lesion. Pathologic examination of the excised lesion confirmed the presence of metastatic endometrioid adenocarcinoma; however, it was found within a well-differentiated squamous cell carcinoma of the vulva. Surrounding the squamous cell carcinoma was a background of a high-grade vulvar intraepithelial lesion (vulvar intraepithelial neoplasia 3), and immunohistochemistry confirmed the presence of 2 separate tumors involved in a tumor-to-tumor metastasis. This unique case highlights the importance of awareness of the phenomenon, and expands the current spectrum of tumor-to-tumor metastases.

Flat pattern of nephrogenic adenoma: previously unrecognized pattern unveiled using PAX2 and PAX8 immunohistochemistry

Nephrogenic adenoma is a benign lesion of the urinary tract, particularly the urinary bladder. It is a gross and microscopic mimicker of urothelial neoplasm or metastatic carcinoma. Several histological patterns (tubular, tubulocystic, polypoid, papillary, fibromyxoid) have been recognized, but a flat pattern has not been described. Histologically, nephrogenic adenoma consists of tubules, cysts or papillae lined by flat to polygonal cells with frequent hobnail appearance. The stroma is often edematous or has a granulation tissue-like appearance with acute or chronic inflammation. By immunohistochemistry, nephrogenic adenomas are positive for renal epithelial markers CK7, CD10 and alpha-methylacyl-coenzyme A racemase, and negative for bladder urothelium or prostate markers. Recent studies have shown that nephrogenic adenomas are positive for PAX2 and PAX8. We encountered an interesting case of tubular nephrogenic adenoma with adjacent areas suspicious of flat urothelial atypia. Immunohistochemistry for PAX2 and PAX8 were positive in these areas, unveiling a flat pattern of nephrogenic adenoma. This case prompted us to study 15 cases of nephrogenic adenoma to determine additional instances of flat pattern and to assess the value of PAX2 and PAX8 immunoreactivity to diagnose nephrogenic adenoma. PAX2 and PAX8 immunostaining was positive in 14/15 and 15/15 cases, respectively. The flat pattern was present at least focally adjacent to tubular, polypoid and papillary areas, in 8/15 cases of nephrogenic adenoma. In conclusion, the flat pattern is a common finding in nephrogenic adenomas, but easily under recognized by morphologic examination and may be confused with flat urothelial lesions with atypia. Immunostains for PAX2 and PAX8 are useful in the detection of nephrogenic adenomas and particularly unveil those nephrogenic adenomas with flat pattern.

Inflammatory aortic aneurysm: possible manifestation of IgG4-related sclerosing disease

In this study, we investigate the hypothesis that IgG4-related autoimmune reaction is involved in the formation of inflammatory aortic aneurysms (IAA). We obtained 23 cases of IAA and 11 cases of atherosclerotic aortic aneurysms (AAA) as control group. We evaluated the expression of IgG4 in both IAA study cases and AAA control cases. In addition, immunohistochemical expression of C-Kit, CD21, CD34, S-100 protein, SMA, vimentin, p53, beta-catenin, and ALK-1, and EBV-LMP1 expression by in situ hybridization were performed only in IAA cases. Of the 23 patients, 20 were males and 3 were females (M: F ratio 6.7:1); age ranged from 43 to 81 years (average 64.3 years). Histologically, all 23 cases of IAA formed a mass that displayed inflammatory myofibroblastic tumor-like features. All lesions stained strongly and diffusely for vimentin and SMA (100%); 17 stained strongly and focally for CD34 (74%); and all were negative for C-Kit, CD21, S-100 protein, p53, beta-catenin, EBV-LMP1, and ALK-1. The numbers of infiltrating IgG4-positive plasma cells in IAA cases exceed that of AAA cases. Score 3 (>50 plasma cells/one 40X field) of IgG4-positive plasma cells was only seen in IAA cases (13/23, 57%), whereas none of the 11 cases of AAA showed score 3 IgG4-positive plasma cells (P=0.0018, Fischer's exact test). Our findings suggest that IAA may be an aortic manifestation of the IgG4-related sclerosing disease. The high number of positive plasma cells, >50 plasma cells/one 40X field is more specific for the IAA than for AAA; however, lesser number can be seen in both IAA and AAA patients.

Lymphovascular Invasion in Micropapillary Urothelial Carcinoma: A Study of 22 Cases

Context.—Micropapillary urothelial carcinoma (MPUC) is a known aggressive variant of urothelial carcinoma. However, the reasons for its aggressiveness remain unclear.

Objective.—To investigate the frequency of lymphovascular invasion in 22 cases of MPUC.

Design.—Consecutive tissue sections were stained with D2-40 and CD34 to highlight lymphovascular channels associated with MPUC. Spaces containing tumor cells were scored as positive for lymphovascular invasion if the staining pattern on immunohistochemistry was distinct and circumferential.

Results.—Of 22 cases, 21 (95%) had lymphovascular invasion on immunohistochemical staining, with 91% lymphatic invasion and 4% vascular invasion. Interestingly, 8 cases were originally signed out as negative for lymphovascular invasion on the basis of hematoxylin-eosin–stained sections; of these, 7 (88%) had focal lymphovascular invasion evident on immunohistochemical staining.

Conclusions.—Our results confirm that micropapillary lacunae are not lymphovascular channels. However, nearly all MPUC tumors (95% in this series) have evidence of lymphovascular invasion by immunohistochemical analysis. Our data support the use of micropapillary features as a morphologic marker for lymphovascular invasion and MPUC as an adverse histologic type of urothelial carcinoma.

Synchronous clear cell renal cell carcinoma and tubulocystic carcinoma: genetic evidence of independent ontogenesis and implications of chromosomal imbalances in tumor progression

Seven percent of renal cell carcinoma (RCC) cases are diagnosed as "unclassified" RCC by morphology. Genetic profiling of RCCs helps define renal tumor subtypes, especially in cases where morphologic diagnosis is inconclusive. This report describes a patient with synchronous clear cell RCC (ccRCC) and a tubulocystic renal carcinoma (TCRC) in the same kidney, and discusses the pathologic features and genetic profile of both tumors. A 67 year-old male underwent CT scans for an unrelated medical event. Two incidental renal lesions were found and ultimately removed by radical nephrectomy. The smaller lesion had multiple small cystic spaces lined by hobnail cells with high nuclear grade separated by fibrous stroma. This morphology and the expression of proximal (CD10, AMACR) and distal tubule cell (CK19) markers by immunohistochemistry supported the diagnosis of TCRC. The larger lesion was a typical ccRCC, with Fuhrman's nuclear grade 3 and confined to the kidney. Molecular characterization of both neoplasms using virtual karyotyping was performed to assess relatedness of these tumors. Low grade areas (Fuhrman grade 2) of the ccRCC showed loss of 3p and gains in chromosomes 5 and 7, whereas oncocytic areas displayed additional gain of 2p and loss of 10q; the high grade areas (Fuhrman grade 3) showed several additional imbalances. In contrast, the TCRC demonstrated a distinct profile with gains of chromosomes 8 and 17 and loss of 9. In conclusion, ccRCC and TCRC show distinct genomic copy number profiles and chromosomal imbalances in TCRC might be implicated in the pathogenesis of this tumor. Second, the presence of a ccRCC with varying degrees of differentiation exemplifies the sequence of chromosomal imbalances acquired during tumor progression.

Minimal or No Residual Prostatic Adenocarcinoma on Radical Prostatectomy: A 5-Year Experience With “Vanishing Carcinoma Phenomenon”

Context.—“Vanishing carcinoma phenomenon” (VC) has been defined as the finding of minute or no cancer on radical prostatectomy specimens after a positive biopsy.

Objective.—To discuss our experience with VC and to recommend guidelines for its detection.

Design.—One thousand seven hundred forty-one radical prostatectomy specimens (2004–2009) processed by whole-mount section procedure yielded 21 (1.2%) cases with VC and 6 (0.34%) cases with minimal carcinoma (≤2 mm) in the radical prostatectomy specimen. To find the eluding carcinoma in VC cases or more carcinoma in minimal carcinoma cases, the following was done: 3 levels of all the paraffin blocks were obtained; if negative, the paraffin blocks were melted, the tissue was flipped, and 3 levels were prepared. The tumor bank frozen tissue was also processed for routine examination.

Results.—Three deeper levels in the radical prostatectomy specimen of 21 VC cases failed to show malignancy; however, the flipping and recutting of the tissue yielded a focus of carcinoma (1–5 mm) in 16 of 21 cases and in 3 of 16 cases in the saved frozen tissue. In 1 of the 6 cases with minimal carcinoma, subsequent recuts of the flipped tissue displayed carcinoma (2 foci of tumor, &lt;1 mm each).

Conclusions.—In VC we recommend: embed and process any remaining prostatic tissue including any saved fresh-frozen tissue; obtain 3 levels of each paraffin block; if results are negative, melt and flip the tissue and obtain 3 more levels. Following the above guidelines, a hidden carcinoma may be detected in the majority of the cases of VC.

Solid-pseudopapillary neoplasm of pancreas with long delayed liver metastasis

Solid-pseudopapillary neoplasm (SPN) of the pancreas is a rare neoplasm that most commonly affects adolescent girls and young women. Solid-pseudopapillary neoplasm of the pancreas is considered to have malignant potential; 10% to 15% of cases are associated with metastasis, and these usually present at the time of initial diagnoses. Cases with metastases after resection are rare, and all reported cases have occurred less than 5 years after resection. We report a case of SPN in a 36-year-old woman who presented with liver metastasis 15.8 years after complete resection of the primary tumor in the pancreas. To the best of our knowledge, this is the longest time interval reported between resection of primary tumor and subsequent detection of metastatic disease. Solid-pseudopapillary neoplasm of the pancreas can present with metastases many years after resection of the primary tumor. Long-term follow-up is warranted, given the possibility of late metastasis.

Clinicopathologic and immunohistochemical characteristics of adult primary cardiac angiosarcomas: analysis of 10 cases

Primary cardiac angiosarcoma is a rare but the most common malignant neoplasm of the heart in adults. The objective of this study is to analyze the clinicopathologic characteristics of primary cardiac angiosarcoma. Ten cases of primary cardiac angiosarcoma treated in a single institution were analyzed for their clinical, pathologic, and immunohistochemical features. There were 6 men and 4 women, with a mean age of 40 years (range, 20-61 years). The patients commonly presented with dyspnea and distant metastasis. All tumors were located in the right atrium, with a mean tumor size of 6.8 cm. Tumors were hemorrhagic, with variegated tan-brown solid areas. Histologically, they exhibited high-grade morphology with mixed solid growth and anatomizing channels. Frequent mitoses and tumor necrosis were common. The tumors were strongly positive for CD31, CD34, FLI-1, and WT-1 but negative for AE1/3, D2-40, human herpesvirus 8, and epidermal growth factor receptor. The tumor cells were focally reactive to p53, with a high rate of Ki-67 expression. A complete tumor resection was not possible in any of the patients because of the size or extensive local invasion of the tumor. Overall survival ranged from 1 to 81 months (mean, 26.6 months) after initial histologic diagnosis. Primary cardiac angiosarcomas are rare tumors that commonly arise in the right atrium. The mean age is much younger than that of soft tissue angiosarcoma. Regional tumor extension and distant metastasis are extremely common at the time of diagnosis. Surgical resection with adjuvant chemotherapy is currently the preferred treatment, and survival time appears to be inversely correlated with the tumor size and degree of regional tumor extension at the time of surgery.

Expression of master regulatory genes controlling skeletal development in benign cartilage and bone forming tumors

Recent progress in skeletal molecular biology has led to the clarification of the transcriptional mechanisms of chondroblastic and osteoblastic lineage differentiation. Three master transcription factors-Sox9, Runx2, and Osterix-were shown to play an essential role in determining the skeletal progenitor cells' fate. The present study evaluates the expression of these factors in 4 types of benign bone tumors-chondromyxoid fibroma, chondroblastoma, osteoid osteoma, and osteoblastoma-using immunohistochemistry and tissue microarrays. Osteoid osteoma and osteoblastoma showed strong nuclear expression of Osterix and Runx2. In contrast, only a few chondroblastomas showed positive nuclear expression of Osterix. Strong nuclear expression of Sox9 was detected in all chondroblastomas, whereas nearly half of the osteoblastomas showed focal weak cytoplasmic expression of Sox9.