Faculty Bibliography

BACKGROUND: Cytology has been proposed as a potential screening tool in the evaluation of squamous anorectal disease in view of the morphologic similarities between anal and cervical squamous lesions. Previous studies have demonstrated that p16 overexpression correlates with the degree of dysplasia in the uterine cervix with promising results. Due to potential diagnostic pitfalls in anal cytology, p16 overexpression in these specimens was studied. METHODS: Patients with anorectal cytology who underwent follow-up biopsy within 1 year were selected. Forty-three anorectal cytologic specimens from 29 patients were selected. One slide of each case was destained. Avidin-biotin immunocytochemical studies with the monoclonal antibody CINtec p16(INK4a) were performed. The results of the p16 immunostaining were correlated with the histologic findings. RESULTS: Twenty-eight of the 43 cases demonstrated the presence of squamous cells immunoreactive for p16 in cytology specimens. The p16-positive cells were identified in cases of low-grade squamous intraepithelial lesion (LSIL) (n = 3 cases), high-grade squamous intraepithelial lesion (HSIL) (n = 22 cases), and invasive squamous carcinoma (n = 1 case), and in 2 cases with negative follow-up biopsies. No cell immunoreactive for p16 was found in 15 cases (5 benign cases and 10 cases with either LSIL or HSIL). The sensitivity and specificity of p16 immunoreactivity in the detection of anal intraepithelial neoplasia or carcinoma were 72% and 71%, respectively. The positive and negative predictive values were 93% and 33%, respectively. CONCLUSIONS: The presence of p16 immunoreactivity is a good predictor of dysplasia in anal specimens. However, the sensitivity and specificity of this marker are not high

We report incidental extramedullary hematopoiesis (EMH) in breasts of 2 patients following neoadjuvant chemotherapy for locally advanced breast cancer. Neither of the patients had a history of hematologic disorders. After chemotherapy, one of the patients had a complete pathologic response and the other had residual carcinoma. In both cases, EMH was mostly seen as myelopoiesis in a background of chemotherapy-induced changes. In the patient with residual carcinoma, EMH was observed in the contralateral prophylactic mastectomy specimen. EMH should be considered a diagnostic pitfall in the differential diagnosis of unusual cellular infiltrates in breast after neoadjuvant chemotherapy. To our knowledge, the association of EMH and neoadjuvant chemotherapy has not been previously reported

BACKGROUND: Nontraumatic inflammatory hilar strictures are uncommon, but are known to mimic malignancy. This study examines the clinical and pathologic features of benign idiopathic strictures. STUDY DESIGN: Patients without a history of trauma or earlier biliary operation treated for benign strictures were identified. Clinical information was obtained from the medical record and all resected specimens were reexamined. RESULTS: From January 1992 to July 2003, 275 patients with proximal biliary strictures were referred. Among these, 22 patients had a final histologic diagnosis of benign stricture, despite a suspected preoperative diagnosis of malignancy. All 22 patients underwent resection of the extrahepatic biliary tree, which in 10 patients was combined with en bloc partial hepatectomy. Histologic reexamination identified five different benign processes: lymphoplasmacytic sclerosing pancreatitis and cholangitis, primary sclerosing cholangitis, granulomatous disease, nonspecific fibrosis/inflammation, and stone disease. Major postoperative morbidity occurred in 6 (26%) patients but none died. No preoperative clinical or radiographic features were identified that could reliably distinguish patients with benign strictures from those with cancer. CONCLUSIONS: 'Malignant masquerade' of the proximal bile duct results from several different underlying conditions, and differentiating benign strictures from cancer remains problematic. The treatment approach should continue to be resection for presumed malignancy

BACKGROUND: Lesions that contain abundant myoepithelial cells may present as a diagnostic challenge in fine-needle aspiration (FNA) specimens. Potential diagnostic problems may arise due to morphologic heterogeneity of myoepithelial cell-rich lesions and difficulty in predicting malignancy in FNA specimens. An accurate diagnosis is important, because malignant myoepithelial cell-rich lesions require a wider local excision and lymph node dissection. The authors characterized the cytologic features of myoepithelial cell-rich lesions in an attempt to define the criteria that facilitate distinction between benign and malignant tumors. METHODS: FNA biopsies of myoepithelial cell-rich lesions with corresponding histologic specimens were selected. The cytology specimens were evaluated for the following criteria: cellularity, cell morphology, pleomorphism, chromatin pattern, presence of nucleoli, background material, necrotic debris, and presence of mitotic figures. A review of the histologic sections was performed for diagnostic confirmation. RESULTS: Seventeen specimens from 17 different patients were selected. The histologic diagnoses were myoepithelial carcinoma (n = 6 patients), malignant mixed tumor with predominant myoepithelial carcinoma (n = 2 patients), epithelial-myoepithelial carcinoma (n = 1 patient), and benign mixed tumor (n = 8 patients). The primary sites included the parotid gland (n = 10 patients), submandibular gland (n = 3 patients), minor salivary gland (n = 3 patients), and breast (n = 1 patient). Most specimens, whether they were benign or malignant, were very cellular. Pleomorphism, coarse chromatin, prominent nucleoli, mitotic figures, and necrosis were observed only in malignant specimens. Background material and ductal cells were seen in both benign and malignant specimens. CONCLUSIONS: The presence of pleomorphism, coarse chromatin, prominent nucleoli, mitotic figures, and/or necrosis should raise the possibility of myoepithelial carcinoma in FNA specimens from myoepithelial cell-rich lesions

BACKGROUND: Uterine serous carcinomas (USCs) can exhibit an architecturally well-differentiated tubuloglandular morphology with or without an accompanying papillary growth pattern. These features make it difficult to distinguish USCs from endometrial endometrioid carcinomas (EECs). Given the aggressive behavior of USC, compared with EEC, and differences in management, it is important to correctly classify endometrial carcinomas that exhibit a tubuloglandular architecture with high nuclear grade. We sought an immunohistochemical panel to minimize subjectivity in the distinction of USC from EEC. MATERIALS AND METHODS: We identified 8 problematic endometrial cancers, exhibiting a tubuloglandular growth pattern and high nuclear grade, whose classification as EEC or USC was debated or resulted in disagreement. We selected 13 cases of International Federation of Gynecology and Obstetrics (FIGO) grade 2 EEC and 16 cases of USC as controls. An immunohistochemical panel, including p53, beta-catenin, cyclin D1, estrogen receptor (ER), progesterone receptor (PR), and PTEN, was evaluated. RESULTS: As a group, the clinical features and immunoprofile of the study cases resembled those of the serous controls. The study cases expressed p53, beta-catenin, cyclin D1, and ER and PR, and showed loss of PTEN in 75%, 12.5%, 0%, 37.5%, 37.5%, and 12.5% of cases, respectively. p53, beta-catenin, cyclin D1, ER and PR expression, and PTEN loss were seen in 87.5%, 0%, 19%, 31%, 12%, and 0% of the serous controls and in 7%, 70%, 54%, 92%, 92%, and 61.5% of the endometrioid controls, respectively. The combination of lack of p53 expression, positive PR expression, and loss of PTEN best distinguished between EEC and USC using discriminant analysis (multivariate P = 0.008, <0.001, and 0.05, respectively). CONCLUSION: In endometrial carcinomas exhibiting high nuclear grade and low architectural grade, using a panel of immunohistochemical stains may facilitate the distinction of USC from EEC. Our clinical and immunohistochemical data also support the concept that there is a group of endometrial adenocarcinomas composed of tubular glands that are indeed serous carcinomas

BACKGROUND: Our objective was to correlate the extent of margin positivity and the findings on re-excision specimens of infiltrating mammary carcinoma. METHODS: We selected 50 consecutive cases of infiltrating mammary carcinoma, including both infiltrating ductal carcinoma and infiltrating lobular carcinoma, with positive margins followed by re-excision. Margin positivity was defined as the presence of cancer at the inked margin. The extent of margin positivity was assessed by measuring the linear involvement of the inked margin by the carcinoma. RESULTS: Twenty-one of 50 cases (42%) showed positive findings on re-excision, including either infiltrating carcinoma or carcinoma in situ or both. Nine of 14 cases (64%) with ductal carcinoma in situ or infiltrating ductal carcinoma on re-excision and 4 of 7 cases (57%) with lobular carcinoma in situ or infiltrating lobular carcinoma on re-excision had initial linear margins >1.0 cm, whereas 28 of 29 cases (96%) with negative findings on re-excision had initial linear margins <1.0 cm. CONCLUSIONS: Linear measurement of the inked margin involved by infiltrating mammary carcinoma can be used as a predictor of findings on re-excisions

We report the case of a 74-year-old white man with a mass in the head of the pancreas, which was found incidentally on computerized tomographic scan during a workup for deep vein thrombosis. Endoscopy with pancreatic duct brushings yielded a diagnosis of adenocarcinoma. A pancreaticoduodenectomy followed, with complete resection of the tumor. Pathologic examination showed 2 distinct components. One component was a conventional infiltrating pancreatic ductal adenocarcinoma, and the other component was high-grade sarcoma with features of malignant fibrous histiocytoma. To our knowledge, this carcinosarcoma is the seventh reported case of a primary pancreatic neoplasm with mixed carcinomatous and sarcomatous elements

The purpose of this study was to compare the ultrastructural features of bronchioloalveolar carcinomas, contrasting the well-differentiated alveolar component and the poorly-differentiated solid component in the same tumor. We studied 7 cases of non-mucinous bronchioloalveolar carcinomas by electron microscopy. Two of these cases showed lamellar bodies in both the alveolar and solid components and the remaining 5 cases revealed Clara cell granules in both components. We conclude that the neoplastic cells in bronchioloalveolar carcinoma retain their ultrastructural phenotypes after becoming invasive carcinoma with loss of alveolar differentiation