Rare non-epithelial primary breast neoplasms: a ten-year experience at a Greek University Hospital

PURPOSE

Non-epithelial breast neoplasms cover a large spectrum of histopathological entities. The demographics and clinical features are similar to epithelial breast lesions but the diagnosis, prognosis and management options are often very different.

METHODS

During 2001-2010, 1362 patients were examined at the Pathology Department of the Aretaieion General Hospital for various breast lesions. All specimens were processed routinely and slides stained with hematoxylin-eosin were re-examined. The patient clinical records were examined for demographics, clinical presentation and therapeutic approach.

RESULTS

In 23/1362 cases (1.68%) pathological examination showed non-epithelial lesions: in 12/1362 cases (0.8%) haemangiomas (11 women, one man), in 4 /1362 cases (0.3%) myofibroblastomas (MFB), in 2/1362 cases (0.1%) primary breast non-Hodgkin's lymphoma (NHL), in 3 /1362 cases (0.2%) granular cell tumor (GCT), and in 2/1362 cases (0.1%) angiosarcomas (one developed after radiotherapy for breast cancer).

CONCLUSIONS

Non-epithelial primary breast tumors are rare (1.68%) and present significant difficulty in accurate preoperative diagnosis and in certain cases in pathological diagnosis as well, which is necessary for the selection of the appropriate treatment. Avoidance of inappropriate therapies requires a multidisciplinary management approach.

The immunohistochemical profile of oral inflammatory myofibroblastic tumors

OBJECTIVE

The aim of this study was to demonstrate the immunohistochemical profile of oral inflammatory myofibroblastic tumors (IMTs) along with morphologic analysis.

STUDY DESIGN

Three cases diagnosed as oral IMTs were selected to compile an immunohistochemical panel constituted by calponin, caldesmon, Bcl-2, desmin, fibronectin, CD68, Ki-67, S100, anaplastic lymphoma kinase (ALK), α-smooth muscle actin, cytokeratins AE1/AE3, muscle-specific actin, CD34, and vimentin. An oral squamous cell carcinoma with a focal area of desmoplastic stroma was used as control for the stained myofibroblastic cells.

RESULTS

All oral IMTs were positive for calponin, revealing a strong and diffuse expression in the spindle-shaped cells. The lesions were also positive for vimentin (3/3), fibronectin (3/3), α-smooth muscle actin (3/3), and muscle-specific actin (1/3) and negative for h-caldesmon, Bcl-2, desmin, CD68, Ki-67, S100, ALK, cytokeratins AE1/AE3, and CD34.

CONCLUSIONS

Within the results encountered, the present panel should be of great assistance in the diagnosis of oral IMTs.

The Spectrum of Pediatric Fibroblastic and Myofibroblastic Tumors

Fibroblastic and myofibroblastic tumors in neonates, infants, and children provide a diagnostic dilemma in surgical pathology due to their relative rarity and similarity in appearances. These tumors may be congenital or occur early during the first years of life or later during the first and second decades of life. The morphologic, immunocytochemical, ultrastructural, cytogenetic, and molecular features of the more "common" pediatric fibroblastic and myofibroblastic tumors are reviewed. In addition, the importance of a multimodal approach to tumor diagnosis is emphasized, with correlation with treatment and outcome differences among these unique fibroblastic and myofibroblastic tumors. The importance of providing an accurate diagnosis with pediatric fibroblastic and myofibroblastic tumors cannot be overstated, because treatment, prognosis, follow-up, and outcome are based on the initial assessment of these fascinating, but oftentimes, perplexing tumors.

[Indication of chemotherapy according to histological type of musculoskeletal sarcomas]

In high-grade musculoskeletal sarcomas, adjuvant chemotherapy is often performed to prevent distant metastases. As the efficacy of chemotherapy varies according to the histological type of sarcoma, its indication is determined according to the histological type and the stage. Prognoses are poor in patients with osteosarcoma, Ewing's sarcoma, or rhabdomyosarcoma, when surgery alone is performed. However, because these sarcomas are chemosensitive, their prognoses are improved with adjuvant chemotherapy, so it is absolutely necessary. Drugs commonly used for osteosarcoma include adriamycin, cisplatin, methotrexate, vincristine, and ifosfamide. For Ewing's sarcoma and rhabdomyosarcoma, vincristine, actinomycin-D, cyclophosphamide, etoposide, and ifosfamide are commonly used. On the other hand, the efficacy of chemotherapy is unclear in most of the non-round cell sarcomas, e. g., malignant fibrous histiocytoma, pleomorphic liposarcoma, and leiomyosarcoma, so adjuvant chemotherapy is relatively indicated and often performed preoperatively. The efficacy is evaluated by reduction of the tumor volume as a surrogate marker. Postoperative chemotherapy is performed when the preoperative chemotherapy is effective. Nowadays, several kinds of antitumor agents are usually used for non-round cell sarcomas, and many authors have reported various kinds of regimens and their clinical results. Among them, the key drugs are adriamycin and ifosfamide. Recently, taxanes and gemcitabine are sometimes used. For chemoresistant sarcomas, e. g., chondrosarcoma, chordoma, alveolar soft part sarcoma, chemotherapy is rarely indicated, even if the tumor is histologically high grade and large. Low-grade musculoskeletal sarcomas, e. g., low-grade chondrosarcoma, central low-grade osteosarcoma, parosteal osteosarcoma, well-differentiated liposarcoma, and dermatofibrosarcoma protuberans, are well cured only by surgical excision, and adjuvant chemotherapy is therefore not indicated. Superficially-located, small-size non-round cell sarcomas, even though histologically high grade, are well healed only by surgical excision, and adjuvant chemotherapy is rarely indicated.

Evaluation of biological potential of smooth muscle tumours

Smooth muscle tumours (SMTs) have been traditionally divided into benign leiomyomas (LM) and malignant leiomyosarcomas (LMS) based on cytological atypia, mitotic activity and other criteria. In most instances, this dichotomous approach works, but in some instances the biological potential cannot be determined with certainty. This is often because some, but not all criteria for malignancy have been met or because the tumours are occurring in unusual settings for which there are sparse substantive data. Tumours falling into the latter categories are often designated as 'smooth muscle tumours of uncertain malignant potential'. For most non-hormonally influenced SMTs, the presence of significant atypia plus mitotic activity equates with a diagnosis of LMS. However, not all tumours classified as LMSs have a similar prognosis, as a number of other factors, including tumour size, depth, grade and resectability, affect outcome. For example, cutaneous SMTs, regardless of mitotic activity and atypia, have potential largely limited to local recurrence, whereas subcutaneous and deep LMSs have a definite metastatic potential. Angioleiomyoma is the most common SMT of peripheral soft tissues, but deep peripheral LMs are distinctly rare and should be approached with caution. Hormonally influenced oestrogen- and progesterone receptor-positive uterine and extrauterine SMTs in women have unique criteria, including the allowance of higher mitotic activity for the benign LM designation. SMTs of female genital tract can be assessed with criteria similar to uterine tumours. Because of the rarity of these tumours, experience is more limited, and more caution is needed to assess the potential of tumours with mitotic activity and atypia. This review summarizes the current knowledge, guidelines, prognostic data and controversies for the classification of SMTs of soft tissue and most visceral sites.

An approach to the classification of spindle cell proliferations in the urinary bladder

Spindle cell proliferations of the urinary bladder are uncommon but may cause significant diagnostic difficulty resulting from the degree of morphologic overlap between clinically benign and malignant lesions. These difficulties may be amplified in small biopsies because some of the more specific diagnostic features may not be present for evaluation. In addition, the number of different diagnostic terms applied to the same entity has added confusion to this diagnostic area. This review discusses the nomenclature, morphologic criteria, and immunohistochemical features used to classify spindle cell proliferations occurring in the urinary bladder, including those with myofibroblastic, smooth muscle, skeletal muscle, epithelial (sarcomatoid urothelial carcinoma), fibroblastic, and neural differentiation. A separate discussion of 5 challenging differential diagnostic scenarios is also presented.

Angiomyxoid tumor with an intermediate feature between cellular angiofibroma and angiomyofibroblastoma in the male inguinal region

Angiomyofibroblastoma (AMFB) and cellular angiofibroma (CA) are angiomyxoid tumors which infrequently arise in the female vulvovagina and each has been proposed to be a distinct clinicopathological entity. The former in male genitalia is exceedingly rare and has been described as its male analog or under the name of male AMFB-like tumor, while the latter in men has not been reported. We describe an angiomyxoid tumor which appeared in the inguinal region of 72-year-old man. The present case had a histopathological characteristic and immunophenotype intermediate between AMFB and CA. Male genital angiomyxoid tumors share many immunopathological features with their female counterparts, suggesting that they are male homologs rather than analogs. Immature mesenchymal cells with a potential of the multilineage differentiation might be promoted toward neoplastic myoblasts, fibroblasts and adipocytes, resulting in genital angiomyxoid tumors showing a broad spectrum in the immunopathological phenotype.

Oral spindle cell neoplasms: a review of 307 cases

The infrequent exposure of pathologists to soft tissue spindle cell neoplasms coupled with overlapping histologic patterns can often make diagnosis challenging. We reviewed all nonodontogenic spindle cell neoplasms seen between 1982 and 2002 (86,162 total accessions). Diagnoses were reclassified according to current standards supplemented with immunohistochemistry. Of the 307 neoplasms reviewed (0.36% of total accessions), neural tumors were the most common benign entities, accounting for 21% of total cases. Kaposi's sarcoma was the most common malignancy, accounting for 67% of all cases. Diagnoses were revised for 57 cases. Schwannoma and neurofibroma were most commonly revised to palisaded encapsulated neuroma. There were 8 myofibromas and 1 inflammatory myofibroblastic tumor. There were no oral leiomyomas; that is, all 4 originally reported cases were reclassified as myofibroma, palisaded encapsulated neuroma, and solitary fibrous tumor. With the exception of Kaposi's sarcoma, oral soft tissue sarcomas were rare; most benign lesions were neural in origin. The relatively high prevalence of some tumors, such as myofibroma, likely reflects the use of immunohistochemistry in the diagnosis of spindle cell tumors.

Risk assignment in pediatric soft-tissue sarcomas: an evolving molecular classification

Pediatric soft-tissue sarcomas are increasingly being defined by both histologic appearance and underlying chromosomal abnormalities to determine their biologic behavior. Most sarcomas of this type have specific chromosomal translocations that create unique fusion genes. Expression of such fusion genes may have diagnostic, prognostic, and surveillance implications for the patient. This review analyzes the fusion gene expressions seen with seven of the major types of pediatric soft-tissue tumors and their impact on biologic behavior. In nearly 50% of the malignancies discussed, the diagnostic, prognostic, and surveillance implications of their specific fusion gene expressions are already defined or becoming established (alveolar rhabdomyosarcoma, Ewing sarcoma/primitive neuroectodermal tumor, and synovial sarcoma). In the remainder of the tumors, these questions are rapidly being addressed. To facilitate future fusion gene studies, pediatric surgeons, pathologists, and oncologists need to work as a coordinated team to ensure proper tumor procurement. Large clinical cooperative trials involving biologic studies of pediatric soft-tissue sarcomas could facilitate advancement of knowledge in this area of pediatric oncology.

Recent progress in the classification of soft tissue tumors: role of genetics and clinical implications

Soft tissue tumors comprise a vast and heterogeneous group of neoplasms. Because different tumors often have different biological behaviors and respond differently to various therapeutic modalities, precise classification is paramount. The majority of soft tissue tumors were first delineated on the basis of morphologic and clinical findings, which in many cases were adequate to accurately separate different tumors into homogeneous groups; however, it has increasingly been appreciated that many entities are actually heterogeneous groups of tumors that have similar histologic and pathologic characteristics but differ in their clinical behavior and underlying pathogenesis. Within the past several years, great strides have been made in the purification of different entities. This accomplishment has largely been because of advances in our understanding of the molecular genetics that underlie the pathogenesis of many sarcomas and the development of new and specific tumor markers. This review highlights some important recent work in two selected soft tissue tumors-gastrointestinal stromal tumor and inflammatory myofibroblastic tumor. These examples illustrate the type of progress that is being made in the classification of soft tissue tumors.

Myofibroblastic tumours: an update

The concept of the myofibroblast is relatively new, since this cell type was defined less than 30 years ago, and there is as yet no firm consensus as to how a myofibroblast should be defined either morphologically or phenotypically. Because its attributes place it midway between a fibroblast and a smooth muscle cell and because it appears capable of functional and phenotypic modulation, some authorities argue that there is no such thing as a truly myofibroblastic tumour. However, since most diagnostic tumour pathology is based on phenotypic features of the excised lesion, it is an unavoidable fact that a wide range of soft tissue tumours show convincing myofibroblastic features. Lesions in this category fall into four main groups--the family of reactive fasciitis-like lesions, a group of benign lesions most of which have been fairly recently recognized (e.g., mammary myofibrolastoma, intranodal myofibroblastoma, angiomyo-fibroblastoma and dermatomyofibroma), the locally aggressive fibromatoses (either superficial or deep) which share features of fibroblasts and myofibroblasts in varying degree and, finally, sarcomas showing myofibroblastic differentiation. These latter include low grade lesions such as so-called infantile fibrosarcoma, inflammatory myofibroblastic tumour and a distinctive form of low grade myofibroblastic sarcoma, as well as some of the high grade lesions formerly known as MFH. Based on the advances made in the past 20 years, it makes no sense to deny the existence of myofibroblastic tumours (especially in an era when histogenetic concepts have crumbled)--instead we need to work towards a reproducible and agreed definition of the myofibroblast.

Subclassification of gastrointestinal stromal tumors based on evaluation by electron microscopy and immunohistochemistry

Fifty-six gastrointestinal stromal tumors (GIST) were subclassified by ultrastructural examination and by immunophenotypic analysis using a panel of 13 antibodies. Eighty percent of the tumors originated in the stomach and small intestines. The neoplasms were classified as follows: 42.9% smooth muscle tumors (4 leiomyomas, 9 spindle cell and 8 epithelioid leiomyosarcomas, and 3 mixed spindle cell and epithelioid leiomyosarcomas); 37.5% gastrointestinal autonomic nerve tumors (GANT), 47.6% of which arose in the small intestines; 8.9% mixed leiomyosarcoma/neurogenic tumors; and 10.7% undifferentiated GIST, not otherwise specified. The muscle common actin antibody HHF-35, variably reactive with tumor cells composing 23 of 24 smooth muscle tumors, was found to be the most sensitive marker of leiomyocyte differentiation. One immunophenotypically questionable spindle cell leiomyosarcoma was diagnosed by electron microscopy. Since neuron specific enolase positive cells were found in 1/3 of the leiomyosarcoma cases, the ultrastructural demonstration of synapse-like structures and neurosecretory granules was required for diagnosing GANTs. The immunophenotype of the ultrastructurally undifferentiated GIST was vimentin and CD34+. Variable numbers of ultrastructurally undifferentiated cells also we found in all of the tumors except 2 leiomyomas. CD34 was also expressed in smooth muscle (54%) and GAN (62%) tumors. Despite their similar light microscopic appearance, GIST are phenotypically heterogeneous, requiring both ultrastructural and immunohistochemical studies for accurate characterization.

Inflammatory leiomyosarcoma: a morphological subgroup within the heterogeneous family of so-called inflammatory malignant fibrous histiocytoma

Twelve cases of inflammatory leiomyosarcoma are presented. These tumours arose in the deep soft tissues of the trunk and proximal limbs. The age of the patients ranged from 13-53 years (median 36 years); there was an approximately equal sex ratio. Follow-up data was available for nine patients (mean duration 3.3 years); local recurrence occurred in three and lung metastases in one. Lesions were spindle cell neoplasms with fascicular areas which occupied between 5% and 80% of the tumour. Areas with a distinct storiform pattern were also seen in 10 cases. A prominent inflammatory cell component was evident in all tumours, often masking the neoplastic spindle cells. Histiocytes were identified in all cases, with aggregates of xanthoma cells seen in eight tumours. In 10 cases there was also a dense lymphoid infiltrate and in two a marked polymorphonuclear leukocyte infiltrate was evident. Immunohistochemistry showed in all tumours that the spindle cells stained positively for myogenic markers (8 of 12 positive for desmin, 10 of 12 for alpha smooth muscle actin and 11 of 12 for HHF-35). CD68 was expressed by the histiocytic infiltrates. Many of these tumours were diagnosed initially as inflammatory malignant fibrous histiocytoma. We provide evidence that at least one subset of neoplasms, which would have been formerly classified under this rubric, in fact show smooth muscle differentiation. Further studies are required to investigate the possibility that other tumour types or lines of differentiation may be present within the category of so-called inflammatory malignant fibrous histiocytoma.

Diagnostic imaging of muscular tumors

Eight patients with muscular tumors--all malignant--were reviewed. Seven patients were examined by magnetic resonance imaging. Some of them also underwent conventional radiology and computed tomography. One patient was examined by computed tomography only. An overview and short description of the muscular tumors are given. The findings with the different imaging techniques are presented, followed by a discussion of the role of the imaging techniques. The final conclusion is that MRI is the modality of choice for detection, staging, and follow-up of muscular tumors, although the signal intensity features are not always specific.

Intramuscular angioma: a clinicopathological analysis of 74 cases

We have studied 74 benign intramuscular angiomas in order to try and correlate clinical behaviour with histological appearances. The purpose was to find means of predicting those which would recur. Mean age at presentation was 17.6 years and 85% of the cases presented before age 30. The male: female ratio was 1.4:1. Anatomical distribution was 32% lower limb, 27% head/neck, 24% upper limb and 17% trunk. Reliable histological subclassification proved impossible since almost all lesions were of mixed type, albeit often with a single predominant vessel type--of which venous (42%) was the most common. Over 90% of the lesions contained a variably prominent adipocytic component. More than 50% of patients suffered local recurrence. Neither predominant vessel type nor anatomical localization correlated with recurrence, which was always due to incomplete excision.

Mesenchymal, non-meningothelial tumors of the central nervous system

The spectrum of non-meningothelial mesenchymal tumors that may arise within the central nervous system is presented, based on the current classification of soft tissue tumors. Among malignant types, hemangiopericytoma, rhabdomyosarcoma, mesenchymal chondrosarcoma, and malignant fibrous histiocytoma are the most frequent ones. Rare tumor entities are mentioned. As in soft tissue sarcomas, diagnosis is mainly based on light and electron microscopy, while immunohistochemistry can improve accuracy of diagnosis.

Identification of desmosomes in the granular cell tumor. Implications in histologic diagnosis and histogenesis

Electron-microscopic examination of a malignant granular cell tumor revealed cells with abundant granular and glycogen-containing cytoplasm and eccentric nuclei. Numerous junctional structures including desmosomes were identified between tumor cells which, moreover, displayed a pattern of gland formation with the presence of short microvilli in one pole of the cell. The presence of junctional structures may provide a feature for positive identification of this tumor by electron microscopy. The findings may also have implications to further our understanding of the histogenesis of this tumor. This case further raises the question of familiar occurrence of this tumor.

Granular cell tumors of the larynx

Granular cell tumors of the larynx are uncommon lesions. Only 15 were identified at the Columbia-Presbyterian Medical Center, New York, during the past 45 years. These tumors produce hoarseness usually and are identified as small keratotic, polypoid, or sessile nodules involving the glottic region (most often posterior glottis, arytenoid, or vocal process). These lesions can usually satisfactorily be treated by endoscopic excision. On histologic examination, pseudoepitheliomatous hyperplasia is frequently seen and may be misinterpreted as squamous cell carcinoma.

Transnasal excision of a neurohypophyseal tumor

Neurohypophyseal tumors are rare. A case of a glioma of the neurohypophysis is presented. The tumor closely resembled pituicytomas or infundibulomas. Management of these lesions poses special problems as their natural history is unclear. This tumor was excised via the transnasal, transphenoidal route and there has been no recurrence during the subsequent thirty months. The transnasal approach for posterior lobe tumors appears to be acceptable for those confined to the sella turcica or displaying minimal suprasellar extension. The literature is reviewed.