New challenges in detecting, grading, and staging endometrial cancer after uterine morcellation.

STUDY OBJECTIVE: To evaluate the accuracy in diagnosing endometrial disease after uterine morcellation. DESIGN: Prospective case series. SETTING: University medical center. PATIENTS: Five women undergoing hysterectomy without morcellation because of benign indications and 5 women with endometrial cancer. INTERVENTIONS: Uterine specimens were obtained from all 10 study patients. The uteri were sent for pathologic analysis, processed, and fixed according to standard protocols. A single investigator then morcellated all 10 uteri. A single pathologist blinded to specimen group reviewed each specimen. MAIN RESULTS: The pathologist identified endometrial cancer in 4 of 5 specimens of known cancer. The fifth specimen was interpreted as benign despite the presence of grade 1, stage IA endometrial adenocarcinoma. None of the morcellated specimens could be staged. CONCLUSION: The increasing use of uterine morcellation will result in new challenges for gynecologic oncologists secondary to difficulty in detection, and accurate grading and staging of endometrial cancer.

The significance of the diagnosis of atypia in breast fine-needle aspiration.

The diagnosis of atypia in breast fine-needle aspiration (FNA) continues to be an area of debate in cytology practice. The aim of this study was to assess the clinical significance of this term and to evaluate potential morphological criteria, which would determine the patient's outcome. A computer-based search was carried out to retrieve breast FNAs performed between 1990 and 2000 that were diagnosed as atypical. Cases followed by surgical resection were reexamined for the presence of morphological features potentially differentiating benign and malignant lesions. Out of 1,568 breast FNAs, there were 64 cases (4%) with a diagnosis of atypia. Thirty-eight cases had surgical follow-up material that revealed malignancy in 14 cases (37%) and benign lesions in 24 cases (63%). The benign diagnostic categories included fibrocystic change (12/24), fibroadenoma (3/24), tubular adenoma (2/24), and nonspecific findings (7/24). The malignant diagnoses included ductal carcinoma (9/14), lobular carcinoma (3/14), ductal carcinoma in situ (DCIS; 1/14), and tubular carcinoma (1/14). The evaluation of cytological criteria used to differentiate benign from malignant lesions (i.e., cellularity, loss of cohesion, myoepithelial cells, nuclear enlargement, nuclear overlap, prominent nucleoli) revealed significant overlap between benign and malignant cases, particularly in cases of fibroadenoma, tubular adenoma, and proliferative breast disease. The surgical follow-up of four hypocellular cases revealed lobular carcinoma in two cases and ductal carcinoma in the remaining two cases. Our study confirmed that the diagnosis of atypia is clinically significant because it is associated with a high probability of malignancy. No morphological criterion is able to reliably differentiate benign and malignant lesions in cases diagnosed with atypia. Diagnosis of atypia is particularly significant in hypocellular cases. We recommended that breast FNAs with a diagnosis of atypia be evaluated further histologically.

How stereotactic core-needle biopsy affected breast fine-needle aspiration utilization: an 11-year institutional review.

To determine the effect of stereotactic core-needle biopsy (SCNB) on the utilization of breast fine-needle aspirate (FNA) biopsy, we retrospectively reviewed 1,568 cases of breast FNAs that were obtained from 1,188 patients between the years 1990 and 2000. There were 378 positive and atypical cases and 497 negative and unsatisfactory cases in the pre-SCNB group (between 1990 and 1996; 7 years); and 225 positive and atypical cases and 468 negative and unsatisfactory cases in the post-SCNB group (between 1997 and 2000; 4 years). The average number of cases per year in the pre- and post-SCNB groups was 125 and 173, respectively. While the average positive/atypical cases per year in both groups remained relatively constant, the average negative/unsatisfactory cases per year were significantly increased in the post-SCNB group (117 in the post-SCNB vs. 71 in the pre-SCNB). The increase in this group was due to a true increase in the negative diagnoses, since unsatisfactory rate decreased in the post-SCNB group (12.6% in the post-SCNB vs. 9.3% in the pre-SCNB). The sensitivity, specificity, positive predictive value, and negative predictive value were 90%, 79%, 92%, and 82% in the pre-SCNB group and 93%, 86%, 91%, and 90% for the post-SCNB group, respectively. In conclusion, the implementation of SCNB did not result in a decrease in the total number of breast FNAs; however, the distribution of cases changed. FNA is increasingly used to complete the triple test in clinically and radiographically negative cases.

Notch-1 and Notch-4 biomarker expression in triple-negative breast cancer.

Triple-negative breast cancer (TNBC) demonstrates lack of expression of hormone receptors and human epidermal growth factor receptor. However, there is no targeted therapy for TNBC. The authors analyzed 29 TNBC cases for Notch-1 and Notch-4 biomarker expression and subcellular location, Ki67 proliferation rate, and relevant clinical/survival data. Results demonstrated an unfavorable Ki67 rate in 90% of cases, Notch-1 expression in tumor and endothelial cells in 100% of cases, and Notch-4 expression in tumor cells in 73% of cases and endothelial cells in 100% of cases. Additionally, subcellular localization of Notch-1 and Notch-4 was predominantly nuclear and cytoplasmic. In conclusion, (a) the majority of TNBCs are high-grade infiltrating ductal carcinomas with high Ki67 proliferation rate and (b) both Notch-1 and Notch-4 receptors are overexpressed in tumor and vascular endothelial cells with subcellular localization different from that of hormone-positive breast cancer. Targeting Notch signaling with gamma secretase inhibitors should to be explored to further improve the survival rate of TNBC patients.

Pseudoangiomatous stromal hyperplasia (PASH) of the breast: a clinicopathological study of 79 cases.

BACKGROUND: Pseudoangiomatous stromal hyperplasia (PASH) of the breast is a benign lesion that can present as a palpable nodule or as an incidental finding in breast biopsies. DESIGN: The study comprised 79 cases diagnosed at Loyola University Medical Center from 2002 to 2009. The pathology slides were reviewed to document the distribution, type, and association with preneoplastic or neoplastic epithelial lesions. Z-test for independent proportions is used for analysis. RESULTS: A total of 76 patients were female and 3 were male. In all, 59.8% of patients presented with a breast mass and in 40.2% the lesion was an incidental finding. Classical PASH morphology was seen in 97.6% and proliferative PASH in 2.4%. Associated epithelial lesions were benign proliferative changes in 60.4%, atypical ductal and atypical lobular hyperplasia in 25.6% and infiltrating carcinoma in 11% of cases. CONCLUSIONS: Based on these results, extensive sampling of biopsy specimen with PASH and appropriate clinical and radiologic follow-up is recommended.

Sonographic appearance of ruptured ovarian cyst in the neonatal period.

Rupture is a rare complication of ovarian cysts diagnosed during the prenatal period. We present a case that focuses on the postnatal sonographic appearance of rupture of an ovarian cyst after vaginal delivery. Histopathologic correlation is provided. The main sonographic features include complicated ascites and a collapsed cystic structure in the abdomen. Ruptured ovarian cyst should be included in the differential diagnosis of unexplained ascites in a newborn girl.

Myeloid sarcoma of the vulva as the presenting symptom in a patient with acute myeloid leukemia.

BACKGROUND: Myeloid sarcoma is a tumor of myeloblasts or immature myeloid cells occurring in an extramedullary site. Myeloid sarcoma of female genital tract is very rare with no cases of vulvar location reported in English-language literature. CASE: A 73-year-old female presented with an indurated mass encompassing her left labia majora and vulva. The mass was diagnosed as vulvar myeloid sarcoma. The patient's peripheral blood smear revealed Auer rods and other findings consistent with a diagnosis of acute myeloid leukemia (M-2 type, FAB classification). CONCLUSION: To the best of our knowledge this case is the first report in the English-language literature of the myeloid sarcoma of the vulva. Correct diagnosis of myeloid sarcoma in an otherwise asymptomatic patient is crucial for early administration of antileukemic chemotherapy.

Mesonephric adenocarcinoma of the vagina with a 3-year follow-up.

BACKGROUND: Mesonephric adenocarcinoma of the vagina is exceedingly rare, with only one well-documented case in the literature. Little is known regarding clinical presentation, pathological characteristics, therapy, or prognosis of the vaginal mesonephric adenocarcinoma. CASE: A 55-year-old woman presented with a polypoid mass at the right vaginal apex, extending to the right paravaginal tissue. The tumor was an adenocarcinoma with ductal and tubular pattern arising in a background of mesonephric remnants. Tumor cells showed immunoreactivity for pankeratin, epithelial membrane antigen (EMA), and calretinin. The right fallopian tube and one paravaginal lymph node were positive for metastases. The patient is disease-free 3 years after surgery, radiation therapy, and chemotherapy. CONCLUSION: We report the second case of mesonephric adenocarcinoma of the vagina with metastasis to the right fallopian tube and to one paravaginal lymph node.