Axillary lymph node metastasis in stage T1a breast cancer: a pathologic review of 82 patients.

The recent shift toward the diagnosis of smaller breast cancers has led to the reevaluation of their treatment. Because of the low incidence of nodal involvement, recent studies have recommended selective axillary lymph node dissection (AxLND) for early breast cancer. The incidence of nodal involvement is a critical factor in defining the role of AxLND. Large series based on cancer registry data report the incidence of nodal positivity in stage T1a cancer to be 16 to 23 per cent. In contrast, data that include only pathologically reviewed cases report the incidence to be 0 to 6 per cent. We reviewed the medical records of 148 stage T1a breast cancer patients from 1987 through 1994 in two community hospitals as identified by the local tumor registry. After chart review, 115 cases with AxLND underwent pathologic review; 82 were confirmed as stage T1a. Only 3 of 82 (4%) patients were node positive. All three node-positive tumors were of infiltrating ductal histology. No tumor characteristic was predictive of nodal metastasis. Data from the tumor registry and from pathology reports overstated the incidence of nodal involvement (5 and 9%, respectively). In light of the limited clinical benefit and associated cost and morbidity of AxLND, selected informed patients may be spared AxLND.

Glandular peripheral nerve sheath tumors.

BACKGROUND: Peripheral nerve tumors (PNT) containing glands are uncommon. Which types of PNT contain glands is a matter of controversy, a factor bearing on the prognosis of these tumors. METHODS: The authors reviewed the files of 11 patients with glandular PNT seen in their laboratory and 27 patients reported in the literature. RESULTS: The 11 instances of glandular PNT seen in their laboratory affected male and female patients equally; patients ages ranged from 8 to 68 years (mean, 28 years). Six patients had neurofibromatosis-1 (NF-1). Eleven of the tumors were histologically malignant PNT, and one was a benign neurofibroma. There were no schwannomas (neurilemomas). The glands were discrete, usually localized to a few areas and in every patient were lined by a keratin-positive epithelium, which in two patients was malignant. One tumor also contained areas of rhabdomyosarcoma, chondrosarcoma, and osteosarcoma (a pluridirectional malignant PNT). Treatment in all patients was some form of surgical resection, followed by radiation in three and chemotherapy in two. Follow-up data were available for nine patients; six of eight patients died with disease. Review of the literature revealed two purported glandular schwannomas (neurilemomas). The authors think these patients had schwannomas containing trapped skin adnexa. Overall, 74% of the patients had NF-1. Ninety-two percent of the tumors were histologically malignant, and 23% of the malignant tumors were pluridirectional malignant PNT. Of the 21 patients for whom follow-up was available, 71% died with tumor. CONCLUSION: Most glandular PNT are histologically malignant and often are fatal.

Prostatic duct adenocarcinoma. Findings at radical prostatectomy.

Previous studies of prostatic duct adenocarcinoma have reported a poor prognosis, but they included few patients treated by radical prostatectomy. The authors studied 15 cases treated with radical prostatectomy to define more completely their pathologic features and determine the clinical outcome in these surgically treated patients. The study included morphometry and DNA image analysis using the CAS-200 system. The most common presentation was urinary outlet obstruction (n = 9), and most patients were clinical Stage B with palpable prostatic lesions (n = 12). Compared with acinar cancers of similar clinical stage, duct cancers were large (tumor volume, 8.4 +/- 10.0 cc) and occupied a large portion of the gland (23 +/- 21%). Duct cancers were in an advanced final pathologic stage with 93% having capsular penetration, 47% positive margins, 40% seminal vesicle invasion, and 27% positive pelvic lymph nodes. The DNA analysis on cells disaggregated from paraffin revealed that 54% of cases were diploid, 15% tetraploid, 8% aneuploid, and 23% tetraploid/aneuploid. On clinical follow-up, eight patients had no evidence of tumor at intervals ranging from 1 to 28 months, and seven patients (47%) had persistent tumor at intervals of 3 to 18 months. This study demonstrates that duct cancers are in an advanced pathologic stage by the time of presentation and have a much higher short-term failure rate after radical prostatectomy compared with acinar cancers.

Multiple spinal metastases from paraganglioma.

Isolated vertebral body metastases from paraganglioma are exceedingly rare. They have been reported to occur in the presence of active primary tumor in the neck, local recurrence, or widespread metastases. A unique case of carotid body tumor (paraganglioma) is reported with the following features: (1) multiple vertebral body metastases (C6, T9, and L3) presenting with spinal cord compression, and no evidence of local recurrence or other metastatic disease; (2) absence of mitoses on the original specimen or the metastatic deposit; and (3) a prolonged interval (9 years) to the development of symptomatic metastases.

Comparison of DNA ploidy and nuclear size, shape and chromatin irregularity in tissue sections and smears of prostatic carcinoma.

Image analysis measurements of nuclear size, shape, texture and DNA ploidy were compared in smears versus the corresponding 4-microns tissue sections, both prepared from radical prostatectomy specimens obtained from resections for prostatic cancer. Thirty-nine cases (78%) showed concordant DNA histograms between the smear and the tissue section. In six cases (12%), both preparations were nondiploid, but a tetraploid population was also present in one, but not both, of the preparations. In five cases (10%), there was a major discordance between the smear and the tissue section, with one preparation diploid and the other nondiploid. One source of discrepancy between the smear and tissue histograms was the overlapping of larger nuclei in tissue sections, which often precluded the analysis of the most atypical cells. Some tissue histograms were difficult to interpret due to wide coefficients of variation, irregular peaks and some shift from 2n in the diploid peaks. The best morphometric correlation (0.78) between the smears and the tissue sections was for the modal nuclear shape. Nuclear size and texture measurements showed poorer correlations. These findings suggest that cytologic preparations of prostatic carcinoma should be preferred for image analysis.

Pathologic findings in clinical stage A2 prostate cancer. Relation of tumor volume, grade, and location to pathologic stage.

Transurethral resections (TUR) and totally embedded radical prostatectomies from 39 clinical Stage A2 prostate cancers were morphometrically analyzed and compared with 56 prior similarly studied clinical Stage B cancers. All the clinical A2 radical prostatectomies contained residual tumor with 26% having capsular penetration. Clinical Stage A2 tumors were much more heterogeneous than clinical Stage B tumors with respect to tumor location, grade, and amount. In particular, many clinical A2 cases were predominantly central or central and anterior in location (59%) and low-grade compared with clinical Stage B cases where most lesions were posterior, peripheral, and intermediate grade. Percent of tumor in TUR best predicted final pathologic stage versus TUR grade or volume. Despite statistically significant correlations between tumor percent and/or grade on TUR and final stage, predictability of final stage for individual patients from TUR data was poor. The complex interrelation of tumor location, grade, and amount resulted in wide and overlapping ranges for these parameters for organ-confined and nonconfined cases.

Immunoperoxidase staining as a diagnostic aid for hepatocellular carcinoma.

Hepatocellular carcinoma may share histologic features with a wide variety of epithelial tumors. To facilitate its pathologic diagnosis, clinical and pathologic material was reviewed from 62 patients with hepatocellular carcinoma and immunostaining was performed with polyclonal anti-carcinoembryonic antigen (pCEA), monoclonal anti-carcinoembryonic antigen (mCEA), anti-epithelial membrane antigen (EMA), and an antikeratin (KER AE1/AE3). Clinical information and follow-up were available for all patients from several sources. Cases with ambiguous clinical data or findings suggestive of metastatic carcinoma to the liver were excluded. In addition, the following tumors were immunostained and compared to hepatocellular carcinoma: 10 cholangiocarcinomas; 14 pancreatic adenocarcinomas; 4 gastric adenocarcinomas; 3 breast carcinomas; 5 renal carcinomas; 3 combined germ cell tumors of the testis; 3 adrenal cortical carcinomas; and 4 melanomas. The pCEA stained bile canaliculi in normal liver and in 39 of 62 (63%) hepatocellular carcinomas. This canalicular staining pattern of pCEA was unique to hepatocellular carcinoma. The mCEA (1 of 62, 1.6%) was almost always negative, and KER AE1/AE3 (9 of 59, 15.3%) was occasionally positive. The EMA stained 25 of 62 (40.3%). The adrenal cortical carcinomas and melanomas were negative for all antigens except rare pCEA and focal EMA staining in an adrenal tumor. Other carcinomas showed cytoplasmic pCEA (36 of 44, 81.8%), mCEA (40 of 46, 87.7%), EMA (41 of 43, 95.4%), and KER AE1/AE3 (42 of 44, 95.5%). Canalicular staining with pCEA is specific for hepatocellular carcinoma, while negativity with mCEA and KER AE1/AE3 is suggestive of hepatocellular differentiation.

Neuroendocrine differentiation in the glandular peripheral nerve sheath tumor. Pathologic distinction from the biphasic synovial sarcoma with glands.

We studied eight glandular peripheral nerve sheath tumors and seven biphasic synovial sarcomas with glands with the objectives of (a) characterizing the nerve sheath tumors, especially with respect to a possible neuroendocrine differentiation, and (b) identifying features that could be used to distinguish between the two lesions. In a mainly immunohistochemical study, neuroendocrine differentiation of glandular cells was observed in five of eight (62.5%) nerve sheath tumors. The neuroendocrine cell markers found included chromogranin (five of eight cases), serotonin (four of seven cases), pancreatic polypeptide (two of five cases), and gastrin (two of six cases). These findings--together with histological, histochemical, and ultrastructural observations made in this and in other studies--point to a foregut type of intestinal differentiation for the glands in a majority of glandular peripheral nerve sheath tumors. Specific histological and immunohistochemical differences between the nerve sheath tumors and the synovial sarcomas were identified. The main histological differences were a sharp distinction between the spindle and glandular cells of the former but not the latter lesion, and the presence of goblet-type cells only in the glandular peripheral nerve sheath tumors. Major immunohistochemical differences included neuroendocrine differentiation and reactivity for S-100 protein and CEA (seen only or mainly in the nerve sheath tumors), and the reactivity of spindle cells of only the biphasic synovial sarcomas for epithelial membrane antigen.

Adenocarcinoma of the upper esophagus arising in ectopic gastric mucosa. Two case reports and review of the literature.

Although ectopic gastric mucosa is often mentioned as a source of upper esophageal adenocarcinoma, few such cases have actually been documented. We report two cases and offer a review of the literature. Ectopic gastric mucosa in the upper esophagus is a relatively common congenital condition, but the risk of malignant transformation is extremely low. Ectopic gastric mucosa should be distinguished from Barrett's esophagus, an acquired condition with a well-documented predilection for developing adenocarcinoma.

Histologic characteristics of vulvar nevocellular nevi.

Reports in the literature stress the premalignant potential of vulvar melanocytic lesions and the unusual histologic features associated with some vulvar nevi in premenopausal women. We examined biopsies of 85 pigmented vulvar lesions taken from women 13 to 73 years of age. There were 59 nevocellular nevi, 16 lentigines, 4 melanomas, and 6 miscellaneous lesions. The nevocellular nevi were compared to a control series of 200 nevi from the torsos of women 20 to 60 years old. Three vulvar nevi were considered to be unusual, but not dysplastic. These histologically unusual nevi occurred in women 20 to 30 years old. The lesions exhibited notable enlargement of junctional melanocytic nests with variability in the size, shape and position of the nests. Similar changes were not observed in the control group. There was a significant association (p less than 0.05) between the occurrence of these unusual lesions and their presentation on the vulva; however, these lesions showed no predilection for any particular site on the vulva. There was no evidence of an increased incidence of vulvar dysplastic nevi when compared with the control series.

Cerebellopontine angle lipoma.

Cerebellopontine angle lipomas are rare lesions that differ from other intracranial lipomas in that they typically present with slowly progressive focal signs and symptoms identical to those of other tumors of this location, and by their propensity for intimate involvement of the adjacent cranial nerves. The lipomas in this study demonstrated this tendency to splay apart and infiltrate the cranial nerves, with the fatty tissue adjacent to the nerves invariably containing portions of the cranial nerves. Hence, the dissection of the adipose tissue from the nerves led to greater than anticipated postoperative neurologic deficits. Therefore, minimal excision of tumor is recommended to achieve decompression. Since preoperative evaluation does not distinguish with certainty this lesion from others more common to this location, intraoperative examination of frozen sections is required to confirm the diagnosis.

Schneiderian papillomas: a clinicopathologic study of 67 cases.

The clinical and pathologic features of schneiderian papillomas were studied in 67 patients. There were 40 male and 27 female patients, and the mean age at diagnosis was 49 +/- 17.9 (SD) years. Nasal obstruction or perception of a nasal mass was the most common presenting symptom; mean duration of symptoms was 10.8 +/- 15.8 (SD) months. Almost equal numbers of papillomas had predominantly endophytic (inverted) (n = 32) and predominantly exophytic (fungiform) (n = 30) patterns, and five had mixed patterns. Multiple morphologic variables were evaluated in the initial specimens, including cytologic atypia and number of mitotic figures; there were no statistically significant correlations between these variables and biologic behavior. Of the 39 patients for whom follow-up information was available (mean follow-up period, 38.6 months), six patients (all with predominantly endophytic patterns) had copresented with schneiderian papillomas and carcinomas. The remaining 33 patients initially had only benign schneiderian papillomas. In these 33 patients, recurrences developed in 11 (33 per cent), local invasion in two (6 per cent) (both with inverted papillomas), and epidermoid carcinoma in one (3 per cent) (with an inverted papilloma). Three patients had evidence of disease when last examined, and two patients had died of disease (both after copresentation with schneiderian papillomas and carcinomas). The continued use of the term inverted papilloma (endophytic pattern) as a specific subset of schneiderian papillomas is recommended, as all serious complications, including progression to local invasion, copresentation with carcinoma, and development of carcinoma, were associated with these lesions.