Intraductal Adenocarcinoma of the Prostate With Cribriform or Papillary Ductal Morphology: Rare Biopsy Cases Lacking Associated Invasive High-grade Carcinoma

Prostatic duct adenocarcinoma, characterized by pseudostratified columnar epithelium, has historically been considered invasive carcinoma, although it may commonly have an intraductal component. Usual (acinar) intraductal carcinoma of the prostate (IDC-P) is a noninvasive high-risk lesion typically associated with high-grade, high-stage prostate cancer. Whereas there have been rare biopsy studies of pure acinar IDC-P or IDC-P associated with only low-grade carcinoma, there have been no analogous series of IDC-P with cribriform or papillary ductal morphology on biopsy unassociated with invasive high-grade carcinoma. We identified 14 patients with biopsies showing IDC-P with ductal morphology, defined as prostatic duct adenocarcinoma confined to glands/ducts with immunohistochemically proven retention of basal cells. Our series includes 12 patients with pure IDC-P and 2 patients with concurrent low-volume Grade Group 1 invasive cancer in unassociated cores. Three patients underwent radical prostatectomy: 2/3 had high-grade cancer in their resection specimen (Grade Group 3, Grade Group 5), including 1 with advanced stage and nodal metastases; 1/3 had Grade Group 1 organ-confined carcinoma and spatially distinct IDC-P with ductal morphology. Five men had only follow-up biopsies: 2/5 had cancer (Grade Group 2, Grade Group 4); 1/5 had IDC-P (on 2 repeat biopsies); and 2/5 had benign transurethral resection of the prostate. In all 5 cases with invasive cancer, the invasive portion was comprised purely of acinar morphology; no invasive ductal component was identified. Five patients did not have follow-up biopsies and were treated with radiation therapy±androgen deprivation. One patient had no follow-up information. In an analogous situation to acinar IDC-P, we propose that rarely there is a precursor form of ductal adenocarcinoma that can exist without concurrent invasive high-grade carcinoma and propose the term "IDC-P with ductal morphology," consistent with the terminology for acinar prostate adenocarcinoma. Until more evidence is accumulated, we recommend reporting and treating patients with IDC-P with ductal morphology in a manner analogous to those with acinar IDC-P. As with pure IDC-P with acinar morphology, we would also recommend not grading pure IDC-P with ductal morphology. Finally, we propose a new addition to the diagnostic criteria of IDC-P to include intraductal lesions with ductal morphology consisting of papillary fronds or cribriform lesions lined by cytologically atypical pseudostratified epithelium.

Invasive micropapillary breast carcinoma: a retrospective study of classification by pathological parameters

Micropapillary breast carcinoma has been recognized as a morphologically and biologically distinct form of breast carcinoma. Although data suggest that patient outcomes in cases of micropapillary breast carcinoma do not differ significantly from other breast carcinomas, the impact that a micropapillary component might have on the pathological work-up of a case of breast carcinoma remains an important point of discussion (especially as pertaining to the risk of lymphovascular disease). In this study, we perform an extensive retrospective study of the pathological parameters of seven years of breast surgical pathology cases to explore the relationship that micropapillary morphology might have with other important pathological parameters of a breast cancer case work-up (e.g. tumour size, lymphovascular invasion, lymph node status). We also analyze our data set to see if a micropapillary component would influence hierarchical classification by pathological parameters. Micropapillary features correlated with a higher frequency of ER positivity and lymphovascular invasion; there was no statistical difference between those cases with and without a micropapillary component from the perspective of other clinicopathological parameters, however. The presence of micropapillary features did influence classification, however, and produced a distinct cluster amidst comparison of other pathological variables.

[Bethesda classification of fine needle punctures of the thyroid. Much ado about nothing really new?]

The Bethesda system for reporting thyroid cytopathology was published in 2008 (Baloch et al. 2008, Cytojournal 5:6; Baloch et al. 2008, Diagn Cytopathol 36:425-437) offering a classification system which is closely related to clinical data. The aim was to ensure adequate terminology without risk of errors in understanding, to advise clinicians concerning therapeutic options in relationship to cytological diagnoses as well as to facilitate the comparison of cytology data at national and international levels. However, mainly due to specific US American (both medical and legal) demands, this classification system is not yet fully appreciated in most European countries. The reasons are various: (a) Criteria for representative material are much more restrictive than those commonly used and in Germany a higher number of (unnecessary) repunctures would be the consequence. (b) It remains doubtful whether the introduction of a new and rather heterogeneous category of "atypia of undetermined significance or follicular lesion of undetermined significance" would contribute to a substantial decrease of findings classified as "follicular neoplasia". Furthermore it is unlikely that clinicians would be willing to accept the recommended conservative approach with repuncture if a new diagnostic category is associated with a calculated risk of malignancy in 5-15% cases. (c) Until now an integration of new developments in molecular markers into the Bethesda system is missing. Thus, for experienced cytologists the Bethesda system for reporting thyroid cytopathology offers very limited benefits in comparison to the currently used, established and highly accepted classification systems. However, a positive argument remains the fact that an internationally accepted classification system may improve the comparability of the results of national and international studies on thyroid findings.

Intraductal papillary mucininous neoplasm of the bile ducts: multimodality assessment with pathologic correlation

Mucin-producing intraductal papillary neoplasm (adenocarcinoma/adenoma) in the bile duct is becoming recognized as a specific type of neoplasm. Since, it bears a striking similarity to intraductal papillary mucinous neoplasms of the pancreas with regard to its histopathologic features, the term "intraductal papillary mucinous neoplasms of the bile duct" (IPMN-B) is frequently used, although no definite terminology or definition has been decided by World Health Organization. This neoplasm lacks ovarian-like stroma and communicates with the bile ducts, unlike biliary mucinous cystic neoplasm (MCN). On the other hand, malignant IPMN-B is categorized as an intraductal-growth type of intrahepatic cholangiocarcinoma (ICC). In comparison to other types of ICC, such as the mass-forming type and periductal-infiltrating type that have poor resectability and an unfavorable prognosis, malignant IPMN-B can be resected and demonstrates a more favorable prognosis. Meanwhile, unlike biliary MCN that is usually confined in a closed cyst, IPMN-B can spread along the mucosal surface of the bile ducts, and it should be widely resected. Therefore, multimodality assessment is needed to ensure the correct diagnosis of IPMN-B. We herein review the imaging findings of IPMN-B with pathologic correlation.

Solid?papillary carcinoma of the breast: Clinicopathological study of 20 cases

The purpose of the present paper was to evaluate the clinicopathological and biological features of 20 Japanese patients with solid-papillary carcinoma of the breast (SPC) or SPC associated with invasive breast cancer. All the patients were Japanese women, including two sisters. The mean age was 66.0 years. The incidence of SPC among all the breast cancers treated at two institutions was 1.1% and 1.7%, respectively. The mean disease-free interval was 4 years 11 months. Axillary lymph node metastasis or tumor recurrence did not occur in any of the cases. Fifteen cases of SPC contained invasive cancers that ranged from <5% to 60% of the entire tumor area. Histological types of invasive cancers were mucinous carcinoma in five cases and neuroendocrine cell carcinoma in 10 cases. These results indicate that SPC is a potential precursor lesion for neuroendocrine carcinoma as well as mucinous carcinoma. When all the cases were classified and analyzed according to both the 2002 tumor node metastasis (TNM) classification system and the Nottingham histological grade, SPC patients, even those with invasive cancers, seemed to have longer disease-free survival compared to patients with the other invasive breast cancers of matching grade and stage. Clinicopathologically, SPC could be regarded as a separate type of ductal carcinoma in situ.

Molecular classification and biomarker discovery in papillary thyroid carcinoma

Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy, with an incidence of approximately 22,000 cases in 2004 in the USA. Incidence is increasing, with a global estimate of half a million new cases this year. PTC is found in a variety of morphologic variants, usually grows slowly and is clinically indolent, although rare, aggressive forms with local invasion or distant metastases can occur. In recent years, thyroid cancer has been at the forefront of molecular pathology as a result of the consequences of the Chernobyl disaster and the recognition of the role of Ret/PTC rearrangements in PTC. Nonetheless, the molecular pathogenesis of this disease remains poorly characterized. In the clinical setting, benign thyroid nodules are far more frequent, and distinguishing between them and malignant nodules is a common diagnostic problem. It is estimated that 5-10% of people will develop a clinically significant thyroid nodule during their lifetime. Although the introduction of fine-needle aspiration has made PTC identification more reliable, clinicians often have to make decisions regarding patient care on the basis of equivocal information. Thus, the existing diagnostic tools available to distinguish benign from malignant neoplasms are not always reliable. This article will critically evaluate recently described putative biomarkers and their potential future role for diagnostic purposes in fine-needle aspiration cytology samples. It will highlight the evolution of our understanding of the molecular biology of PTC, from a narrow focus on specific molecular lesions such as Ret/PTC rearrangements to a pan-genomic approach.

Fine-needle aspiration of papillary thyroid carcinoma: distinguishing between cases that performed well and those that performed poorly in the College of American Pathologists Nongynecologic Cytology Program

CONTEXT

Although the cytologic features of papillary thyroid carcinoma in fine-needle aspiration specimens are well known, the correlation of these features with the ability of cytologists to identify this tumor has not been well studied.

OBJECTIVE

To compare the cytologic features of cases of papillary thyroid carcinoma that performed poorly with those of cases that performed well.

DESIGN

The cytologic features of 13 cases of papillary thyroid carcinoma from the College of American Pathologists Nongynecologic Cytology Program that performed poorly were compared with those of 15 cases that performed well.

RESULTS

Compared with cases that performed well, cases that performed poorly were significantly more likely to lack marked nuclear enlargement (38% vs 100%, P < .001), lack pale chromatin (8% vs 47%, P = .04), and lack intranuclear inclusions (8% vs 53%, P = .02). The differences between the 2 groups in staining, type of preparation, nuclear grooves, nuclear crowding, colloid, cellularity, nuclear pleomorphism, and Hurthle cell change were not significant.

CONCLUSIONS

Cases of papillary thyroid carcinoma that lack marked nuclear enlargement, pale chromatin, and intranuclear inclusions are significantly more difficult to recognize than cases that have these features. Increased awareness of these types of cases might improve the performance of thyroid fine-needle aspiration in clinical practice.

Diagnostic criteria in well-differentiated thyroid carcinomas

The criteria used for the differential diagnosis of well-differentiated thyroid tumors derived from follicular cells are reviewed taking into account the architectural characteristics together with the immunohistochemical and molecular features. The review is focused on follicular carcinoma, papillary carcinoma, follicular variant of papillary carcinoma, and oncocytic (Hürthle cell) tumors, as well as on the recently described borderline lesions: follicular and well-differentiated tumors of uncertain malignant potential, and well-differentiated carcinoma, not otherwise specified.

The many faces and mimics of papillary thyroid carcinoma

This article provides an overview of the 15 histologic variants of papillary thyroid carcinoma listed by the 2004 World Health Organization (WHO) monograph on endocrine tumors. The histologic features, differential diagnosis, and clinical course of each variant are discussed in some detail. The follicular variants (conventional and macrofollicular) constitute a morphologic challenge because the majority of these tumors are encapsulated and, also, because, in many tumors, not all neoplastic cells show the nuclear features considered to be diagnostic of papillary carcinoma. As a result, most of these tumors are missed even by experienced pathologists. Moreover, hyperplastic thyroid lesions, follicular adenomas, and Hashimoto's thyroiditis may contain cells with clear nuclei resembling those of papillary carcinoma. Papillary carcinomas composed entirely of hyperchromatic cells have been overlooked. The WHO monograph defines papillary carcinoma with focal spindle and giant cell carcinoma components but its clinical behavior is unknown. Papillary carcinoma with an insular pattern that does not show the artifactual separation of the cell nests has been misinterpreted as the solid variant of papillary carcinoma. Papillary microcarcinomas include not only the conventional type and the follicular variants but also the tall cell and columnar cell variants.

Papillary adenocarcinoma of the lung is a more advanced adenocarcinoma than bronchioloalveolar carcinoma that is composed of two distinct histological subtypes

To clarify the clinicopathological nature of papillary adenocarcinoma (PA) of the lung, 20 cases of PA were collected consecutively from resected adenocarcinoma of the lung, studied immunohistochemically and, using molecular techniques, compared with bronchioloalveolar carcinoma (BAC). Clinicopathologically, PA occurred in 7.4% and dominantly in female patients. Morphologically, PA was divided into two subtypes according to the presence of residual alveolar structures, detected by elastica van Gieson stain. One of these subtypes was closely related to the morphology of BAC and might be diagnosed as adenocarcinoma with mixed subtypes. The other PA subtype was composed of tall columnar cells and grew compressively, which was similar to type F adenocarcinoma previously reported by Noguchi et al. Immunohistochemical studies using lung tissue-specific antigens, progression markers and tumor suppressor products found that PA seemed a more advanced adenocarcinoma than BAC, but no differences were observed among PA subtypes. Molecular biological analysis using three microsatellite markers at chromosome 3p revealed more frequent loss of heterozygosity in PA than BAC, with no differences among PA subtypes. These findings suggest that PA is a more advanced adenocarcinoma subtype than BAC. Further investigations are needed to clarify true PA as clinicopathologically and biologically independent from other histological subtypes of adenocarcinoma of the lung.

Well-differentiated papillary villoglandular adenocarcinoma of the uterine cervix with a focal high-grade component: is there a need for reassessment?

Well-differentiated villoglandular adenocarcinoma of the uterine cervix is characterized by an exophytic growth pattern with variably sized papillae that are lined by stratified columnar cells with no more than moderate cytologic atypia. Based on the favorable outcomes in most of the previously reported cases, it has been suggested that some patients with this subtype may be managed conservatively. The case described herein is an otherwise prototypical well-differentiated villoglandular adenocarcinoma but which was associated with a 4.9-mm focus of poorly differentiated carcinoma at its invasive edge. A review of the literature revealed a variety of findings that suggests a need to reassess the potential morphologic and biologic spectrum of this group of tumors. Five of the approximately 89 reported cases were associated with a higher-grade component of the same or a different histologic subtype. At least one patient with apparently stage 1A1 disease was found to have a positive lymph node. Another patient with stage 1B1 disease but no stromal invasion died of her disease following multiple recurrences. Finally, the frequency of lymphovascular invasion and/or lymph node involvement in recent series far exceeds what was found in the two original series. Our case suggests that well-differentiated villoglandular adenocarcinoma is not a diagnosis that should be unequivocally rendered on a small biopsy since other components may be present and the patients may be undertreated. We urge caution when conservative management (cone biopsy alone when margins are negative and there is no lymphovascular invasion) is offered to patients with this tumor since knowledge about its true biologic spectrum appears to still be in evolution.

Prognostic analysis of pulmonary adenocarcinoma subclassification with special consideration of papillary and bronchioloalveolar types

AIMS

The third edition of the World Health Organization (WHO) classification of lung tumours has been published and is expected to become the standard nomenclature. The aim of this study was to assess the usability and prognostic significance of the WHO classification in comparison with other recent classifications.

METHODS AND RESULTS

One hundred and forty-seven resected pulmonary adenocarcinoma cases were reviewed and histologically classified according to the WHO classification (1999) and the classification by Noguchi (1995). Papillary carcinomas as described by Silver and Askin (1997) were also identified. Since the papillary type in the WHO classification is not strictly defined, we compared the following two kinds of WHO classification: (i) WHO-N; WHO classification adopting Noguchi Type F as the definition of the papillary type, namely, pure papillary adenocarcinoma without a bronchioloalveolar component; (ii) WHO-SA; WHO classification adopting papillary carcinoma by Silver and Askin as the definition of the papillary type, namely, tumour with papillary structure constituting at least 75% of the lesion. The bronchioloalveolar carcinoma of the WHO classification showed a better prognosis than other subtypes in both overall and Stage I disease limited survival analysis. In analysis limited to Stage III disease, only the papillary type of WHO-SA showed a significantly worse prognosis.

CONCLUSIONS

WHO-SA is recommended for prognostic correlation.

Follicular neoplasms of the thyroid: view, biases, and experiences

The authors review the group of thyroid tumors characterized by a follicular growth pattern; these include follicular adenoma, follicular carcinoma, and the follicular variant of papillary carcinoma. Most of these lesions can be diagnosed with ease, but a subgroup has generated recent controversy in the literature. The authors present their views based on their experience with the cytologic and histologic diagnosis of these tumors and propose a scheme to assist in their classification and appropriate clinical management.

Laparoscopic gastrectomy with regional lymph node dissection for upper gastric cancer

Recently, a minimally invasive operation for gastric malignancies has been developed, and this laparoscopic operation is seen as a technique that will raise quality of life for patients. Previously, we reported this technique, as well as the results of a distal gastrectomy with regional lymph node dissection using hand-assisted laparoscopic surgery (HALS) for gastric cancer located in the middle or lower third of the stomach. This paper describes total or proximal gastrectomy with regional lymph node dissection by HALS on 28 cases of gastric cancer located in the upper portion of the stomach. After the mobilization of stomach and lymph node dissection via HALS, an anastomosis of the esophagus was performed intracorporeally with a conventional circular stapling device (PCEEA), whereas jejunojejunostomy and jejunogastrostomy were carried out extracorporeally with a conventional hand-sewn procedure through a HALS wound. The operation time and the amount of blood loss in all the patients were considered to be satisfactory, and the average number of dissected lymph nodes per patient was similar to that in open surgery. The patients had minimal morbidity and quick recovery after their operation. This technique was thought to be not only less invasive, but also similarly curative compared with open gastrectomy.

Aspiration cytology of the oncocytic variant of papillary adenocarcinoma of the thyroid gland

OBJECTIVE

To study the cytologic features of the oncocytic variant of papillary adenocarcinoma of the thyroid gland to distinguish this subtype from other oncocytic lesions of the thyroid.

STUDY DESIGN

We reviewed the smears from aspiration biopsies of 6 proven cases of oncocytic variant of papillary adenocarcinoma and compared their cytologic features with smears from 19 oncocytic follicular neoplasms (11 adenocarcinomas and 8 adenomas). Smears were stained with a modified Giemsa stain (Diff-Quik).

RESULTS

All smears were cellular. Colloid was variable but more abundant in cases of the oncocytic variant of papillary adenocarcinoma. The cells in papillary adenocarcinoma had round to ovoid, overlapped nuclei; prominent intranuclear inclusions; and "grooves." Nucleoli were generally absent. In oncocytic follicular neoplasms, the cells had round nuclei and prominent nucleoli. Nuclear inclusions and grooves were seen but were not as prevalent as in papillary adenocarcinomas.

CONCLUSION

The oncocytic variant of papillary adenocarcinoma of the thyroid gland can be distinguished from other oncocytic lesions by fine needle aspiration biopsy, whereas the absence of prominent nucleoli in oncocytes favors the diagnosis of an oncocytic papillary adenocarcinoma.

Prognostic factors of clinical interest in poorly differentiated carcinomas of the thyroid

Poorly differentiated (PD) carcinomas of the thyroid represent an heterogeneous but distinct group of tumors, clinically and histopathogenetically intermediate between follicular-derived well-differentiated and anaplastic carcinomas. Although the diagnostic criteria for inclusion in the PD tumor group are far from well established, and despite controversies on nomenclature, the identification of PD carcinomas as tumors with trabecular/insular/solid (TIS) growth patterns and high-grade histopathological parameters is generally accepted. Recent data on large tumor series were focused on the recognition of clinicopathological features able to predict aggressive behavior. Patient age >45 yr, the presence of necrosis (either focal or extensive), and mitotic count >3 per 10 HPF have been found to be the most influent prognostic parameters. Therefore, as also proposed for other thyroid carcinomas (e.g., papillary carcinoma) grading of PD carcinomas on the basis of these latter parameters is encouraged to select those cases with a high risk of poor outcome.

Definition of poorly differentiated carcinoma of the thyroid: the Japanese experience

The terminology and definitions pertaining to thyroid malignancies of follicular cell origin that are neither well-differentiated papillary or follicular carcinomas nor undifferentiated anaplastic carcinomas remain controversial. Against this background, we previously proposed that "poorly differentiated carcinoma" should be added to the classification of thyroid carcinoma arising from follicular epithelium. The histological criteria and biological characteristics of poorly differentiated carcinoma of the thyroid were described. In this discussion, we make a new proposal concerning the histological classification of thyroid cancers derived from follicular epithelium. According to this proposal, thyroid cancers can be divided into common types and special types. In the common types, the usual histology should be included. The common types are well-differentiated carcinoma, poorly differentiated carcinoma, and undifferentiated carcinoma. The specific types include columnar-cell carcinoma, tall cell carcinoma, cribriform carcinoma, and other rare carcinomas.

Prognostic significance of scoring system based on histological heterogeneity of invasive ductal carcinoma for node-negative breast cancer patients

This study aimed to determine the prognostic significance of histological scoring system based on heterogeneity of invasive ductal carcinoma, for node-negative breast cancer patients. We studied 108 patients of node-negative invasive ductal carcinoma with invasive tumor >5 mm. Histological score of each patient was evaluated based on histological subtype of invasive ductal carcinoma and pattern of its heterogeneity. Score of each subtype was defined as follows; papillotubular carcinoma: score 1, solid-tubular carcinoma: score 2 and scirrhous carcinoma: score 3. The existence of histological heterogeneity was examined, and corresponding score was doubled in a pure case and scores of two dominant subtypes were summed in a composite case. Overall survival curves defined by sores were drawn by Kaplan-Meier method and the difference in survival rate was evaluated by log-rank test. The most significant difference of overall survival was recognized between low score group (scores 2, 3 and 4) and high score group (scores 5 and 6) (p<0.001). In addition, multivariate analysis confirmed that only histological score was an independent prognostic factor. These results suggested that assessment of histological heterogeneity of invasive ductal carcinoma could serve as independent potent prognostic factor for node-negative invasive ductal carcinoma of the breast, and this method might be useful to decide indication of postoperative adjuvant chemotherapy.

Cystic neoplasms of the pancreas

Although a minority of pancreatic cystic tumors are neoplastic, proper diagnosis of these neoplasms is important owing to their varied clinical course and behavior. The clinicopathologic features of pancreatic cystic neoplasms, including mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, solid pseudopapillary tumors, and serous microcystic adenomas, are discussed in this review.

Cachexia in patients with advanced cancer

Cancer cachexia generally is considered to be the end stage in the progression of nutritional deterioration and wasting of malignancy (Ottery, 1995). In patients with advanced cancer, this condition is very common and decreases quality of life, as well as survival (Fearon et al., 2001; Ottery; Smith & Souba, 2001; Whitman, 2000). However, if early diagnosis and intervention can control cachexia, the potential exists to greatly improve a patient's quality of life and prolong survival. Because metabolic alterations inhibit the effective use of conventional nutritional support, anti-inflammatory agents or fish oil are possible options. Orexigenic agents may be prescribed if patients wish to improve oral intake. Steroids and progestational agents may be used to attempt to improve mood and appetite. Nutrition affects symptoms that need to be managed effectively. Nurses should work aggressively to correct factors that contribute to decreased food intake (e.g., nausea, pain) and correct factors that worsen debility (e.g., anemia). Information must be presented so that informed choices can be made and realistic eating goals set. An interdisciplinary approach that involves the nurse, physician, dietician, and possibly social worker or case manager, as well as the patient and family, is necessary to identify nutritional alterations, assess specific needs, and plan individual interventions. Whitman (2000) stated that counseling is the most effective and least expensive intervention. It may be conducted by any member of the healthcare team and should be combined with other interventions. Palliation of cachexia in patients with advanced cancer is a challenge for nurses. Hopefully, early and judicious use of these interventions may decrease the significant morbidity and mortality that result from cancer cachexia.

Radiologic, pathologic and molecular attributes of two types of papillary renal adenocarcinomas

OBJECTIVE

Most papillary renal tumors are not as aggressive as clear cell carcinomas and thus carry a better prognosis. However, several reports in the literature have demonstrated a subset of patients with papillary tumors that have a more aggressive biology and advanced stage at presentation. We compared several parameters of these subsets of renal tumors in an effort to characterize these lesions.

PATIENTS AND METHODS

We reviewed 391 cases of nephrectomies that were performed for cancer over a 20-year period from four institutions. Of these, 41 were documented as papillary adenocarcinomas. We reviewed these cases with respect to stage at presentation, size, vascularity on (computerized tomography) CT scan, histology, and cytokeratin immunohistology.

RESULTS

Thirty-two of the lesions presented in the fifth, sixth, seventh and eighth decades of life (Type I), while most of the remaining 9 tumors (Type II) presented in the fourth decade of life, and in more advanced stages. Tumor volumes ranged from 84 cm3 to 1660 cm3. Type I tumors had an average size of 515 cm3 and an enhancement on CT of 36 +/- 4 Hounsfield units, compared with Type II tumors which had an average size of 164 cm3 and an enhancement on CT of 92 +/- 8 Hounsfield units. Type II tumors also had a higher mean Fuhrman score of nuclear pleomorphism than Type I, and a greater expression of cytokeratin.

CONCLUSIONS

We found that the more common Type I variant of papillary renal adenocarcinoma was less vascular on CT scan, larger in size, and had a lower amount of nuclear pleomorphism as well as decreased expression of cytokeratin 7. The more aggressive biological variant, Type II, presented in the earlier decades of life, with a smaller, but more vascular, cancer and had a greater nuclear pleomorphism. Nuclear pleomorphism still appears to have the best prognostic assessment. However, other molecular and genetic parameters of these tumors, as well as long-term survival data will be necessary to determine the significance of these findings.

Intraductal papillary-mucinous tumor of the pancreas: a historical review of the nomenclature and recent controversy

A number of studies on mucin-producing cystic neoplasm of the pancreas have been reported since the first report of the tumor in 1982. There has been some controversy about nomenclatures and clinicopathologic entities of mucin-producing cystic tumor, mucinous cystic tumor, and intraductal papillary tumor of the pancreas. In 1996 and 1997, new classifications of pancreatic neoplasms were published by the World Health Organization (WHO) and Armed Forces Institute of Pathology (AFIP). According to the new WHO and AFIP classifications, mucin-producing cystic neoplasm of the pancreas corresponds mainly to intraductal papillary-mucinous tumor and mucinous cystic tumor of the pancreas. and these two diseases are independent conditions. Intraductal papillary-mucinous tumor is regarded as a unique clinical entity, but controversy remains about the term and clinicopathologic entity. Some confusion and problems remain betweeen the two lesions. In this review, we review their historical background, terminology, WHO and AFIP classification, and problems with classification.

Altered expression of beta-catenin and c-erbB-2 in early gastric cancer

To investigate the possible relationship between altered expression (loss of membranous staining or nuclear accumulation) of beta-catenin and invasion/metastasis in early gastric cancer (EGC), beta-catenin was detected immunohistochemically in 116 cases of EGC, including 86 differentiated and 30 undifferentiated carcinomas. In parallel, immunohistochemical expression of c-erbB-2 was analyzed in all EGC cases. Regardless of histological type, altered expression of beta-catenin was found in 47% of mucosal carcinomas and 89% of carcinomas with submucosal invasion (p<0.001). Of particular interest is that beta-catenin alteration was found in almost all EGCs with lymph node metastasis, even though no significant statistical comparison could be made. These results suggest that molecular changes resulting in abnormal beta-catenin expression participate in the process of submucosal invasion and metastasis. While loss of expression was preferentially observed in undifferentiated EGCs, nuclear accumulation was found exclusively in 24% of differentiated EGCs. c-erbB-2 was overexpressed in only 16% of differentiated EGCs but there was no correlation between this overexpression and invasion or metastasis. However, it is intriguing that 12 out of 14 cases with c-erbB-2 overexpression also showed altered beta-catenin expression, suggesting that both molecules are involved in the development of a certain set of differentiated EGCs.

Aggressive digital papillary adenocarcinoma (aggressive digital papillary adenoma and adenocarcinoma revisited)

In 1987 a clinicopathologic study by the Armed Forces Institute of Pathology (AFIP) of rare sweat gland tumors, termed aggressive digital papillary adenoma and adenocarcinoma, was published. Since that time, the AFIP has continued to collect these tumors for study. Based on additional follow-up data, we think the original classification of these tumors requires revision. Sixty-seven cases of aggressive digital papillary adenoma and adenocarcinoma were studied according to their clinical characteristics and histologic features. Fifty of these were originally diagnosed as adenoma and 17 as adenocarcinoma. Follow up on 45 (67%) of the patients was obtained. None of the clinical or histologic parameters studied were found to be predictive of recurrence or metastasis, indicating that the originally proposed criteria for distinguishing between benign (adenoma) and malignant (adenocarcinoma) do not predict biologic behavior. When primary tumors were treated by subsequent reexcision or amputation, only one recurred (5%), when not so treated, 11 recurred (50%) regardless of the original diagnosis (p <0.05). Metastasis occurred in six (14%) cases and in three cases led to the death of the patient. Three of these metastatic cases had met the earlier criteria for adenoma. Pulmonary metastases were observed in five cases. No effective treatment for widespread metastatic disease has yet been developed. Because histologic features with prognostic significance could not be demonstrated in this retrospective review, we propose that all aggressive digital papillary tumors be designated aggressive digital papillary adenocarcinoma.

Influence of serum from healthy or breast tumor-bearing women on the growth of MCF-7 human breast cancer cells

Sera from women healthy (HW) or with breast (BCW), ovarian or endometrial cancer, were added (10%) to the culture media of MCF-7 cells and cell proliferation assessed 4 days later to verify: a) whether sera from BCW, obtained before or 8 days after tumor ablaction, influence the proliferation of these cells, b) whether the effects of serum from BCW are specific for mammary tumor cells. Sera from BCW, but not sera from women with ovarian or endometrial cancer, increased MCF-7 cell proliferation in comparison with sera from HW. After surgical ablation of the breast tumors, serum's ability to increase MCF-7 cell proliferation decreased significantly. These effects cannot be explained by differences on serum levels of estradiol or melatonin. These results suggest the presence of growth-promoting substances of possible tumoral origin in serum of BCW, a fact that should be considered as support for the surgical treatment of tumor masses.

Villoglandular adenocarcinoma of the endometrium: a clinicopathologic study of 61 cases: a gynecologic oncology group study

Papillary endometrioid or villoglandular adenocarcinoma (VGA) is a relatively common type of endometrial adenocarcinoma, but studies describing its behavior have yielded conflicting results. Patients with a component of VGA were identified in a review of 819 women entered in a Gynecology Oncology Group Study (Protocol 33) of clinical stages I and II endometrial adenocarcinoma. Cases with coexisting foci of serous or clear cell carcinoma were excluded from further consideration. Of the 61 cases that formed the study sample, there were 24 with pure villoglandular differentiation and 37 who were admixed with typical endometrioid adenocarcinoma (EA). The general clinicopathologic features of patients with pure and mixed VGA are compared with 469 patients with pure EA. The VGAs were better differentiated (grade 1 or 2--97% of VGA versus 74% EA, p = 0.001). but they were not significantly different with respect to median age, depth of invasion, or frequency of nodal spread. Six of the 61 patients with VGA died of their tumor. The disease-specific survival rate at 3 years for VGA is 94% (95% confidence interval: 0.88-0.99) compared with 88% (95% CI: 0.86-0.91) for EA. Two of the patients who died had pure villoglandular tumors and four had mixed villoglandular and endometrioid carcinoma. In view of the frequent admixture of VGA and EA and their generally similar biological characteristics, with a prognosis similar to that of typical EA, we conclude that VGA should be considered a variant of EA.

[Is the new WHO's histological typing clinically useful for the diagnosis of follicular cancer of the thyroid?]

We tried to re-diagnose our 57 cases of thyroid follicular cancer between 1965 and 1988 in accordance with Histological Typing of Thyroid Tumours published by WHO in 1988. 1) The incidence of follicular cancer in differentiated cancers was decreased from 17.9% to 8.3% (26 cases). The number of widely invasive type and minimally invasive type was 13 cases equally. 2) Twenty four cases were diagnosed as papillary cancer. The reason was that 20 cases had a small focus of papillary structure, and other 4 cases had features of follicular variant type of papillary cancer. These 24 cases had good prognosis as our 262 cases of papillary cancer, in contrast to 26 cases of follicular cancer having worse prognosis. 3) The incidence of distant metastasis in follicular carcinoma was increased from 28.1% to 42.3%; 23.9% in minimally invasive type and 61.5% in widely invasive type, respectively. New WHO classification is acceptable according to this clinical study of our cases. We would have to treat more aggressively the patient diagnosed follicular cancer by WHO classification because of high incidence of distant metastasis.

Endometrial adenocarcinoma histologic subtypes: clinical and pathologic profile

All cases of endometrial adenocarcinoma treated at the Geisinger Medical Center from January 1970 to June 1980 were retrospectively reviewed in an attempt to elucidate the clinical and pathologic profiles of the various histologic subtypes. Complete clinical and pathologic data was available in 418 cases of stage I endometrial adenocarcinoma. The frequency of the histologic subtypes were adenocarcinoma 66%, adenoacanthoma 16%, adenosquamous 5%, papillary 8%, clear cell 3%, and secretory 2%. Absolute 5-year survival was adenocarcinoma 88%, adenoacanthoma 91%, adenosquamous 62%, papillary 63% (P less than 0.01), clear cell 43% (P less than 0.001), and secretory 89%. When comparing the clinical and pathologic profile of the various histologic subtypes, adenosquamous (52%, P less than 0.001) and clear cell (43%, P less than 0.05) were associated with the highest percentage of grade 3 differentiation. Adenosquamous (38%, P less than 0.05) and clear cell (36%) also had the highest percentage of deep myometrial invasion. Papillary subtype (46%, P less than 0.05) was associated with the highest percentage of nulliparity. There was no difference among the subtypes when comparing menopausal status, exogenous estrogen, obesity, hypertension, diabetes, or uterine size. In summary, (1) adenocarcinoma and adenoacanthoma are the most frequent subtypes; (2) adenosquamous, papillary, and clear cell have decreased 5-year survival; (3) the decreased 5-year survival in adenosquamous and clear cell subtypes appears to be associated with increased grade 3 differentiation and deep myometrial invasion while the poor prognosis associated with papillary subtype was not related to grade or myometrial invasion.

[Histo-epidemiological observations on advanced gastric carcinoma]

480 cases of advanced gastric carcinoma are classified according to Laurén or WHO and correlated to age and sex of the patients. The modal value of the incidence for age of the mucinous histologic type is 61-65 years for the men and 71-75 years for the women, while in the signet ring cell histologic type is 50 years in both sexes. These relationship, obtained only by the WHO classification, suggest that mucinous and signet ring cell type constitute distinct histoepidemiological entities.

[Adenocarcinoma of the salivary glands. The pathohistology and subclassification of 77 cases]

Seventy-seven adenocarcinomas of the salivary glands recorded in the Salivary Gland Register between 1965 and 1984 were analysed and classified histopathologically. The following results were obtained: 1. 2% of all salivary gland tumours and 10% of all malignant epithelial salivary gland tumours were allotted to the group of adenocarcinomas. The age peak lies in the 7th to 8th decade. 60% occurred in women, 58.5% were localized to the parotid gland, 28.5% to the minor salivary glands (palate, lips, and cheek), 11.5% to the submandibular gland and only 1.5% to the sublingual gland. 2. Solid, tubular and papillary adenocarcinomas can be distinguished. Additional criteria are microcysts, mucus production and grade of differentiation. 3. The solid adenocarcinoma (13%) is predominantly localized in the parotid gland and characterized by a low differentiation, invasive growth and metastases. 4. 62.5% of tubular adenocarcinomas (52%) are localized in the parotid gland, 27.5% to the minor salivary glands and 10% to the submandibular gland. Most of the tumours are highly differentiated. A distinct mucus production is present in 40% of the cases. Microcysts are very frequent. 5. Papillary adenocarcinomas (28.5%) are localized in almost 50% of cases to the minor salivary glands, 45% to the parotid and only 5% to the submandibular gland. Microcysts and mucus production can be observed in 50% of the cases. 6.5% of the cases have a mixed tubular papillary structure. 6. In differential diagnosis, thyroid gland carcinomas and metastases of other adenocarcinomas must be distinguished, the former by negative result of the thyroglobulin reaction, and absent mucus production. 7. Adenocarcinomas arise from the salivary duct system. Solid or tubular adenocarcinomas imitate stages of the embryonal development of the salivary ducts.