Sclerosing mucoepidermoid carcinoma with eosinophilia of the thyroid: more aggressive than previously reported.

Sclerosing mucoepidermoid carcinoma with eosinophilia (SMECE) of the thyroid is a rare traditionally "low-grade" tumor that predominantly occurs in women. Approximately 50 cases have been reported in the literature. It arises in a background of Hashimoto thyroiditis and is characterized by nests of epidermoid and mucin-secreting cells located within an eosinophil-rich sclerotic stroma. Herein, we outline the clinicopathological and immunohistochemical characteristics of 6 cases of thyroid SMECE. All tumors were detected in women (age, 36-89 years; average, 59 years), and all patients underwent total thyroidectomies. Clinicopathological findings included extensive tumor invasion into the adjacent soft tissues, trachea, pharynx, and esophagus. Of 6 specimens, 5 had positive surgical margins. Cervical lymph node metastases were seen in 4, and distant metastases were in 3 patients. Immunohistochemically, all tumors were positive for CK19, galectin 3, and p63 and negative for calcitonin, calponin, S-100, and smooth muscle actin. Interestingly, 2 tumors also showed faint focal staining for thyroglobulin, and 2 others had focal positivity for thyroid transcription factor 1. Together, galectin 3 and CK19 expression supported the malignancy of these lesions, and p63 expression raised the possibility that these tumors originated from the ultimobranchial body. In summary, SMECE tumors in our series exhibit a clear female predominance with aggressive behavior and appear to arise from pluripotent solid cell nests. A correct diagnosis is crucial to providing SMECE patients with the appropriate treatment options, and we recommend a closer follow-up schedule than previously considered.

The feasibility of multiparametric magnetic resonance imaging for targeted biopsy using novel navigation systems to detect early stage prostate cancer: the preliminary experience.

BACKGROUND AND PURPOSE: The feasibility and diagnostic performance of multiparametric magnetic resonance imaging (mp-MRI) has to be proven further. In this study, we evaluate the role of mp-MRI for targeted biopsy of early stage prostate cancer (PCa). PATIENTS AND METHODS: A total 32 consecutive patients with transrectal ultrasonography (TRUS)-guided biopsy-proven PCa meeting low-risk criteria and pursuing active surveillance were selected to undergo mp-MRI 3 Tesla (3T) with endorectal coil. Patients were divided then into three groups based on the method used to target the mp-MRI designated region of interest (ROI): Group 1 underwent TRUS-guided prostate biopsy using an MRI-based coordinate plan (cognitive targeting). Group 2 underwent MRI-targeted TRUS-guided prostate biopsy using MyLabTMTwice, which superimposed the archived MRI images onto the real-time ultrasonography image allowing targeted biopsy of the ROI (fusion targeting). Group 3 included selected patients who had an elevation in prostate-specific antigen levels, or patients followed after radiation therapy (two patients) for suspicious unifocal MRI lesion recurrence. These patients underwent MRI-guided biopsy of the suspicious ROI using the navigation system DynaTRIM. RESULTS: The cancer detection rate in group 1 was 33.3% (3 of 10 patients), while in group 2, it was significantly higher at 46.2%. The sensitivity and specificity for group 1 was 45.5% and 33.3%, vs 61.9% and 20.8% in group 2, respectively. The positive predictive value in group 1 was 50.0% vs 53.8% in group 2 (P=0.04). In group 3, the cancer detection rate was much higher (80%) than in group 2, (P=0.005) although the majority of these patients (7 of 10) had a previously diagnosed prostate cancer on TRUS-guided 12-core biopsy. CONCLUSION: Our preliminary experience of mp-MRI suggests the detection of early stage prostate cancer with low-risk features yields potential candidates for active surveillance or focal targeted therapy. The MRI-TRUS fusion system increases diagnostic yield compared with cognitive MRI-directed TRUS-guided biopsy.

Muscularis mucosae versus muscularis propria in gallbladder, cystic duct, and common bile duct: smoothelin and desmin immunohistochemical study.

The muscle layer in the cystic duct and common bile duct is not well defined, and it is unresolved whether it represents muscularis mucosae or muscularis propria. Smoothelin is a novel smooth muscle-specific contractile protein expressed only in fully differentiated smooth muscle cells of the muscularis propria and not in proliferative or noncontractile smooth muscle cells of the muscularis mucosae. In this study, we characterize the histologic aspects of the muscle layer in gallbladder, cystic duct, and common bile duct by evaluation of routine histologic sections and the utilization of immunohistochemistry using desmin and smoothelin. Formalin-fixed, paraffin-embedded sections of the gallbladder (15 cases), cystic duct (11 cases), and common bile duct (10 cases) were stained for smoothelin and desmin. Staining intensity was evaluated as weak or strong. The staining pattern score was evaluated as follows: 0 or negative = less than or equal to 5% positivity, +1 or focal = 6% to 10% positivity, +2 or moderate = 11% to 50% positivity, and +3 = greater than 50% muscle cells positivity. With desmin, strong and diffuse (+3) staining was observed in all gallbladder cases (15/15, 100%), highlighting one continuous muscle layer. The muscle layer was discontinuous and interrupted in all cystic duct cases and in most common bile ducts, highlighted by the desmin stain. Smoothelin intensely stained (at least +2) muscle fibers in the gallbladder in 11 (73%) of 15 cases similar to that observed with desmin staining. In contrast, common bile ducts predominantly had absent or weak and focal immunostaining (0 or +1 staining) with smoothelin (7/10, 70%), with only a few cases (3/10, 30%) having +2 staining (no cases with +3). Cystic ducts also showed absent or weak and focal immunostaining with smoothelin, with 5 (44%) of 11 cases showing 2+ immunostaining with smoothelin (no cases with 3+). Based on our findings, we conclude that, in the gallbladder wall, the muscle layer is muscularis propria and there is no muscularis mucosae present. In the cystic duct and common bile duct, only an attenuated and incomplete muscle layer of muscularis mucosae is present; because there is no muscularis propria, there probably is limited contractile function. Differentiating these anatomical muscle structures may be important for the pathologic staging of carcinoma in these organs.

Immunohistochemical comparison of chordoma with chondrosarcoma, myxopapillary ependymoma, and chordoid meningioma.

Chordoma originates from embryonic notochordal remnants in the midline along the spinal axis and is characterized by cords and lobules of neoplastic cells arranged within myxoid matrix. Because of histologic similarities with myxoid matrix and overlapping immunohistochemical profile, chondrosarcoma, myxopapillary ependymoma, and chordoid meningioma enter in the histologic differential diagnosis at this site. Therefore, the judicious use of a panel of selected immunostains is unquestionably helpful in diagnostically challenging cases. To find useful immunohistochemical markers for assisting in differential diagnosis between chordoma and other tumors with chordoid morphology, an immunohistochemical study using D2-40, epithelial membrane antigen (EMA), pan-cytokeratin (panCK), glial fibrillary acidic protein (GFAP), S-100 protein, galectin-3, neural cell adhesion molecule (NCAM), beta-catenin, E-cadherin, and carcinoembryonic antigen was performed on 14 chordomas, 7 chondrosarcomas, 9 myxopapillary ependymomas, and 4 chordoid meningiomas. Chordoma typically showed positive for EMA and panCK and negative for D2-40 and GFAP; whereas chondrosarcoma revealed positive for D2-40, and negative for EMA, panCK, and GFAP; myxopapillary ependymoma positive for GFAP and negative for EMA; and chordoid meningioma positive for EMA, and negative for panCK and GFAP. On the basis of our immunohistochemical study, a panel of D2-40, EMA, panCK, and GFAP allowed the correct recognition of all tumors examined. Other immunohistochemical markers including S-100 protein, galectin-3, NCAM, beta-catenin, E-cadherin, and carcinoembryonic antigen were of little value in differential diagnosis. In summary, the best immunohistochemical markers useful for the evaluation of tumors with chordoid morphology were D2-40, EMA, cytokeratin, and GFAP. D2-40 was a true chondroid marker to be useful for the differential diagnosis with chordoma.

Myxoid adrenal cortical neoplasms.

Myxoid adrenal cortical neoplasms are rare, and to our knowledge, only about 23 cases have been reported in the literature, including 13 carcinomas and 10 adenomas. We recently experienced 4 cases of myxoid adrenal cortical neoplasms (3 benign and 1 borderline malignancy) and studied the clinical, histopathological, and immunohistochemical features of these neoplasms. There were 2 male and 2 female patients (age range, 37-61 years, mean, 48 years). All but 1 patient had hormone-related symptoms. The tumors weighed from 24.1 to 94 g (size, 4.1-9.8 cm). They were variably encapsulated with areas of hemorrhage. Histologically, the tumor cells were arranged in delicate arborizing cords or trabecula with myxoid areas varying from 30% to 70%. Three tumors were benign and 1 was of borderline morphology with mitoses of 3/10 high-power fields and mild to moderate nuclear pleomorphism. Two cases contained areas of myelolipomatous component. The tumor cells were positive for vimentin, synaptophysin, and inhibin but negative for cytokeratin. All patients are alive with no recurrence of their tumors or evidence of metastasis (follow-up of 14-20 months). Myxoid changes in adrenal cortical neoplasms are rare but can be seen in both an adenoma and a tumor of uncertain malignant potential. Because of prominent myxoid changes, other myxoid tumors occurring in the retroperitoneum should be excluded. The usual clinical and histological features can be applied to classify the lesions as benign, borderline tumor, or malignant. In our series, there was no case with frank malignant tumor.

Clinicopathologic study of 24 patients with primary cardiac sarcomas: a 10-year single institution experience.

Primary cardiac sarcomas are exceptionally rare. We present a 10-year, single-institution experience with 24 primary adult cardiac sarcomas. These cases were retrieved from the Department of Pathology data file of the Methodist Hospital at Houston, TX. Clinical presentation and pathologic features were analyzed. Histologic classification was followed according to the criteria set by the World Health Organization, and grading according to the system proposed by the Federation Nationale des Centres de Lutte Contrele Cancer. There were 14 men and 10 women (male/female, 1.4:1) with a mean age of 42.2 years (range 20-68 years). The tumors involved the right atrium in 14 cases, left atrium in 6 cases, right ventricle in 2 cases, and left ventricle in 2 cases. The tumor size ranged from 2.0 to 17.0 cm (mean 7.2 cm), and, histologically, there were 10 angiosarcomas, 9 unclassified sarcomas, 3 synovial sarcomas, and 2 leiomyosarcomas. All 10 angiosarcomas originated from the right atrium, whereas 5 of the unclassified sarcomas were from the left atrium. Although cases were limited, no predilection site was found for the other histologic types. All tumors were graded as 2 (5 cases) or 3 (19 cases) in differentiation. The prognosis was poor with a median survival time of 25 months after diagnosis. The grade was not statistically significant on survival (P = .14). In conclusion, angiosarcoma and unclassified sarcomas are the most common sarcomas of the heart accounting for 76%, but rare tumors such as synovial sarcoma and leiomyosarcoma may also occur in this organ. The survival of cardiac sarcomas is poor.

Histologic variants of infiltrating urothelial carcinoma.

CONTEXT: The spectrum of urothelial carcinoma is broad, and variant morphologies are being reported continually. Many of these variants have been extensively documented and even established as subclasses of urothelial carcinoma. OBJECTIVE: To review the established and more recently described variants of urothelial carcinoma. The significance of recognizing these variants is discussed. DATA SOURCES: The literature is reviewed in conjunction with our experience pertaining to urothelial carcinomas of the bladder and ureters. CONCLUSIONS: Urothelial carcinoma displays many forms, and some of these variant morphologies may introduce diagnostic difficulties because of their similarity to other malignancies and/or benign lesions. Additionally, it is important to recognize variants that are associated with different outcomes from conventional urothelial carcinoma. For these reasons, familiarity with the diverse morphology of urothelial carcinoma is not simply an academic exercise but is important in providing quality care for patients affected by this disease.