Initial report of a case of carcinosarcoma of the supraglottis.

Minor salivary gland carcinosarcoma is a rare malignancy with an ominous prognosis. This report recounts a single case of supraglottic minor salivary gland carcinosarcoma that was treated aggressively. We discuss the peculiarities of the histology, with special mention of the distinction that must be made between mucosal-origin and salivary-gland-origin carcinosarcoma. Carcinosarcomas are aggressive regardless of their origin, but differentiating their origin is important because the prognosis is worse for those that arise in salivary glands than for those that originate in the surface epithelium. This report adds to the literature a new case of minor salivary-gland-origin carcinosarcoma involving the upper airway. It is the first case we could identify in which the supraglottis was involved.

Mutations of c-kit JM domain are found in a minority of human gastrointestinal stromal tumors.

The c-kit gene encodes a transmembrane receptor kinase (KIT) which is expressed in the majority of human gastrointestinal stromal tumors (GISTs), a subtype of gastrointestinal mesenchymal neoplasms. A previous study identified mutations in the juxtamembrane (JM) domain of c-kit in five of six GISTs (Science 279: 577, 1998). To better define the frequency and spectrum of c-kit gene mutations in mesenchymal neoplasms of the GI tract that had been characterized for KIT protein expression, we examined archived tissue samples for mutations in the JM domain by PCR amplification and DNA sequencing. c-kit JM domain mutations were found in nine of 56 mesenchymal tumors (46 GISTs, eight leiomyomas, two leiomyosarcomas) and occurred exclusively in GISTs (21%). Seven of the nine mutations consisted of intragenic deletions of one to 19 codons. There was one insertion mutation that added 12 codons and one missense mutation (Val560Asp). None of the mutations disrupted the downstream reading frame of the gene. The single missense mutation (Val560Asp) is very similar to the only other missense mutation reported in GISTs (Val599Asp). Of the 46 GISTs, 43 were strongly positive for KIT protein expression and negative for diffuse expression of desmin. Neither KIT expression nor gene mutations were found in gastrointestinal leiomyomas or leiomyosarcomas. We conclude that mutation of the c-kit JM domain does not occur in gastrointestinal mesenchymal neoplasms with well developed-smooth muscle differentiation, and is restricted to GISTs. However, since these mutations are only found in a minority of GISTs, further investigation into the mechanisms of c-kit gene activation in this group of neoplasms is warranted.

Quantitative image cytometry of infiltrating ductal carcinoma: comparison with prognostic parameters and reproducibility of histological grade.

Quantitative image cytometry was used to compare 18 parameters relating to ploidy, nuclear area, and chromatin texture to axillary lymph node status, tumor size, and histological grade for 34 infiltrating ductal carcinomas, each of which had been graded independently by each of six surgical pathologists. Zinc formalin-fixed, paraffinembedded tumors were assessed using the Elston and Ellis modification of the Bloom and Richardson histological grading scheme. When axillary lymph node-negative tumors were compared with those involving four or more nodes, % 2 c (diploid) cells, nuclear area, and eight of 12 chromatin texture parameters showed statistically significant differences. Carcinomas < 2 cm had more % 2 c (diploid) cells and fewer % > 4 c (hypertetraploid) cells than larger neoplasms. For tumors having nuclear pleomorphism score two versus those with score three, nuclear area, four of five parameters related to ploidy level, each of five parameters related to run-length matrix features and one of four co-occurrence matrix features showed significant differences. Nearly all of these cytometric parameters also showed significant differences for histological grade and mitotic count, which was strongly correlated with nuclear pleomorphism. In examining the cytometric parameters in relation to the interobserver reproducibility of histological grade and its components, the largest number of statistically significant parameters related to the nonreproducibility of nuclear pleomorphism. The findings indicate that as the grade of infiltrating ductal carcinomas increases, there are fewer % 2 c (diploid) cells and more % > 4 c (hypertetraploid) and % > or = 5 c (polyploid) cells. In addition, the cells of high grade tumors have larger nuclear areas and more small and large dense chromatin clumps, which increase in such number that they tend to join together. When compared with the cytometric parameters, nuclear pleomorphism is the most sensitive component of grade to nonreproducibility.

Proliferating cell nuclear antigen immunoreactivity and prognosis of gastrointestinal stromal tumors.

To determine the prognostic value of proliferating cell nuclear antigen (PCNA) immunoreactivity in gastrointestinal stromal tumors (GISTs), we analyzed 42 GISTs using the PC10 antibody. Thirty-nine GISTs with adequate follow-up were classified as non-aggressive or aggressive based exclusively on clinical behavior; a 2-year minimum follow-up was required for nonaggressive lesions. The percentage of PCNA-positive nuclei (%PCNA(+)) was significantly greater in colorectal GISTs compared with gastric tumors. No significant differences in %PCNA(+) were observed between gastric and small intestinal or small intestinal and colorectal tumors. The %PCNA(+) strongly correlated with mitotic rate, nuclear pleomorphism, and clinical behavior, whereas size and cellularity weakly correlated with %PCNA(+). Thirty-six GISTs could be classified as having low or high risk for aggressive clinical behavior based on a combination of tumor size, mitotic rate, and %PCNA(+). Twelve of 13 low-risk tumors were clinically nonaggressive, whereas 19 of 23 high-risk tumors were clinically aggressive. This correlation with clinical outcome was highly significant (P = 0.00002). Risk analysis by individual anatomical site also strongly correlated with clinical behavior for gastric (P = 0.0023) and small intestinal (P = 0.0056) tumors. There were too few colorectal GISTs with adequate follow-up and PCNA data for site-specific risk analysis. We conclude that tumor size, mitotic rate, and %PCNA(+) can be used as parameters to predict the clinical behavior of GISTs.

Sinonasal intestinal-type adenocarcinoma: immunohistochemical profile and comparison with colonic adenocarcinoma.

Sinonasal intestinal-type adenocarcinomas (ITAC), as their name implies, bear a striking resemblance to primary intestinal neoplasia. The value and limitations of immunohistochemistry in making this distinction have not been previously defined. We determined the immunohistochemical staining profile of 12 sinonasal ITAC and compared their staining with that of 12 histologically similar colonic adenocarcinomas. All ITAC stained for cytokeratin and epithelial membrane antigen. Additional positive reactions were as follows: B72.3, 11 of 12; Ber EP4, 11 of 12; Leu M1, 8 of 12; HMFG-2, 12 of 12; and BRST-1, weak staining in seven of 12 cases. All 12 ITAC were negative for vimentin, synaptophysin, and actin. Colonic carcinomas stained similarly for these markers. Three additional antigens differed in their expression in ITAC versus colonic tumors. Carcinoembryonic antigen was strongly present in only two of 12 ITAC, with focal positivity in six of 12 and no staining in four of 12 cases. In contrast, all 12 colonic adenocarcinomas were strongly positive for carcinoembryonic antigen. Chromogranin-positive cells were present and often numerous in nine of 12 ITAC, in contrast to only rare positive cells in three of 12 colonic tumors. Neuron-specific enolase was present in five of 12 ITAC but was absent from all colonic tumors studied. ITAC are less often and less strongly carcinoembryonic-antigen positive and more prone to exhibit divergent neuroendocrine differentiation. These features may be of some value in distinguishing ITAC and colonic metastases. Neuroendocrine differentiation in ITAC was associated with higher mortality. Of the five patients with ITAC having 1+ to 2+ chromogranin positivity, only one was free of disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Interobserver reproducibility of the Nottingham modification of the Bloom and Richardson histologic grading scheme for infiltrating ductal carcinoma.

The interobserver reproducibility of the Nottingham modification of the Bloom and Richardson histologic grading scheme for invasive breast carcinoma was tested. Six surgical pathologists from four institutions independently evaluated histologic grade and each of its three components for 75 infiltrating ductal carcinomas. The number of slides per case ranged from one to nine (median 3). Pairwise kappa values for agreement ranged from moderate to substantial (0.43-0.74) for histologic grade. Generalized kappa values indicated substantial agreement for tubule formation (0.64), moderate agreement for mitotic count (0.52), and near moderate agreement for nuclear pleomorphism (0.40). Normalizing the mitotic counts per mm2 showed only slight improvement in agreement over the published range of mitotic counts for three different field areas. The results suggest that steps to discriminate between categories for nuclear pleomorphism would likely be of benefit for improving the interobserver reproducibility of histologic grade. Nevertheless, the Nottingham modification of the Bloom and Richardson grading system is recommended as a suitable scheme for evaluating invasive breast carcinomas in the routine clinical setting.

Differentiation and risk assessment of gastrointestinal stromal tumors.

Predicting prognosis and identifying the line of differentiation in gastrointestinal stromal tumors (GIST) have been problematic. The first part of this review briefly summarizes ultrastructural studies and then focuses on the many immunohistochemical studies of cellular differentiation in GIST. The second part reviews pathologic evaluation of GIST from the perspective of risk assessment. A scheme is proposed for segregating GIST into groups with low and high risk for aggressive clinical behavior.

Immunohistochemical detection of neuroblastomatous foci in composite adrenal pheochromocytoma-neuroblastoma.

To determine if immunohistochemistry might aid in the identification of neuroblastomatous foci in composite adrenal tumors, the authors analyzed two examples of composite adrenal pheochromocytoma-neuroblastoma, 18 pure pheochromocytomas, and six pure neuroblastomas using peanut agglutinin and a panel of antibodies directed against neuroendocrine and neural-associated antigens. Pure pheochromocytoma had the following immunopositivity: vimentin 14/18, chromogranin 18/18, synaptophysin 18/18, S100 protein 0/18 (tumor cells), neurofilament 14/18, J1 beta-tubulin (J1) 18/18, microtubule-associated protein-2 13/18, glial fibrillary acidic protein 13/18, and peanut agglutinin 17/18. Pure neuroblastoma reacted positively as follows: vimentin 0/6, chromogranin 5/6, synaptophysin 4/6, S100 protein 0/6 (tumor cells), neurofilament 5/6, J1 6/6, microtubule-associated protein-2 6/6, glial fibrillary acidic protein 1/6, and peanut agglutinin 6/6. Each component of both composite tumors reacted similarly to the pure neoplasms. Although the frequency of positive staining was similar for pheochromocytoma and neuroblastoma, the intensity and pattern differed for several antigens. Pheochromocytoma was diffusely positive for synaptophysin and chromogranin, whereas staining was focal and punctate in neuroblastoma. Microtubule-associated protein-2, J1, and neurofilament antibodies highlighted the fibrillar background of neuroblastoma, which pheochromocytoma lacked. Pheochromocytoma contained focal, ball-like immunoreactivity for glial fibrillary acidic protein and vimentin, which was absent in neuroblastoma. These immunohistochemical distinctions can assist the clinically important recognition of neuroblastomatous foci in composite adrenal pheochromocytoma-neuroblastoma.

Plasmacytoid monomorphic adenoma of salivary glands. Absence of myogenous differentiation and comparison to spindle cell myoepithelioma.

The immunohistochemical and ultrastructural features of two salivary gland monomorphic adenomas composed of plasmacytoid cells (so-called plasmacytoid myoepitheliomas) were studied to determine if the plasmacytoid cells contained detectable evidence of myogenous differentiation. The results were compared with the immunohistochemical profile of three salivary gland myoepitheliomas of spindle-cell type. The plasmacytoid tumors were each immunoreactive for vimentin, cytokeratin, S100 protein, and glial fibrillary acidic protein (GFAP). They were negative for muscle-specific actin (MSA), smooth-muscle actin (SMA), and desmin. Conversely, two of three spindle-cell myoepitheliomas were immunoreactive for MSA and SMA, in addition to vimentin, cytokeratin, and S100 protein. One tumor also contained focal positivity for desmin and GFAP, and a single spindle-cell tumor was vimentin-positive only. Ultrastructurally, plasmacytoid cells were characterized by focal desmosomes, basal lamina, and abundant intermediate cytoplasmic filaments. Dense bodies typical of smooth-muscle cells and actin-sized filaments were absent. Immunohistochemically and ultra-structurally, the plasmacytoid cells lack any evidence of myogenous differentiation and should not be considered a subtype of myoepithelioma.

Muscle differentiation and clinicopathologic features of gastrointestinal stromal tumors.

We analyzed 46 gastrointestinal stromal tumors (GISTs) using a panel of antibodies to determine the frequency of smooth muscle differentiation and the relationship of immunophenotype to histopathologic features and clinical behavior. Thirty-six GISTs were classified as benign or malignant based exclusively on clinical behavior; a 2-year minimum follow-up was required for benign lesions. GISTs were immunopositive in the following categories: vimentin 45 of 46, desmin nine of 45, muscle-specific actin (MSA) 36 of 46, alpha-smooth muscle actin (SMA) 34 of 46, chicken gizzard actin-7 zero of 38, cytokeratin two of 46, S100 protein six of 46, glial fibrillary acidic protein (GFAP) zero of 46, synaptophysin zero of 46, and chromogranin one of 46. At least one muscle marker was positive in 39 of 46 tumors. Five GISTs were MSA positive/SMA negative, and three were MSA negative/SMA positive. All desmin-positive cases reacted with MSA or SMA. Eight GISTs were positive for vimentin, MSA, SMA, and desmin, whereas seven were vimentin positive only. Compared with the latter, the former tended to be smaller, less often necrotic, and clinically benign (p less than 0.05 for each). All vimentin-positive only GISTs were malignant. Immunohistochemical features did not correlate with tumor site, cellularity, nuclear pleomorphism, or mitotic rate. Benign GISTs were less cellular than were malignant GISTs (p less than 0.05), but they did not differ statistically in degree of nuclear pleomorphism, necrosis, mitotic rate, or size. We conclude that (a) 85% of GISTs react with at least one muscle antibody; (b) immunohistochemical features are unrelated to anatomic site; (c) SMA is, in effect, as sensitive as MSA, whereas desmin is less sensitive; and (d) simultaneous vimentin, MSA, SMA, and desmin positivity correlates with a benign outcome.

Sinonasal malignant melanoma. A clinicopathologic and immunohistochemical study of 14 cases.

The clinical, light microscopic, and immunohistochemical features of 14 sinonasal malignant melanomas were studied to show their diverse morphologic appearance and distinction from therapeutically more amenable neoplasms that occur in this region. The tumors arose in 6 men and 8 women (median age, 70 years). Eleven patients died of disease 7 to 44 months (median, 18 months) after diagnosis. The absolute median survival time was 18.5 months (range, 7 to 44 months). The predominant microscopic appearance was categorized as small blue cell in eight cases, spindle cell in three cases, epithelioid in two cases, and pleomorphic in one case. Eight tumors had multiple patterns. Five sinonasal malignant melanomas had theque-like growth, five had junctional change, and 10 contained at least rare melanin pigment. Fourteen, 13, and 12 sinonasal malignant melanomas were immunoreactive with anti-vimentin, HMB45, and anti-S100 protein antibodies, respectively. One epithelioid tumor positive for vimentin, S100, and HMB45 also contained scattered epithelial membrane antigen-positive and cytokeratin-positive cells, which emphasizes the need for a battery of stains to distinguish sinonasal malignant melanoma from carcinoma. All tumors were negative for leukocyte common antigen, muscle-specific actin, and synaptophysin. Diffuse immunopositivity for vimentin, S100 protein, and HMB45 allows distinction of sinonasal malignant melanomas from histologically similar neoplasms.

An immunohistochemical study of normal endometrial stroma and endometrial stromal neoplasms. Evidence for smooth muscle differentiation.

To determine the immunohistochemical staining profile of endometrial stromal cells, we analyzed a series of formalin-fixed, paraffin-embedded normal endometrial tissues, stromal nodules, and stromal sarcomas for immunoreactivity with a panel of eight antibodies. Normal proliferative-phase (five cases) and secretory-phase (five cases) endometrial stromal cells showed the following immunopositivity: vimentin 10 of 10, muscle-specific actin (MSA) 10 of 10, alpha-smooth muscle actin (alpha sm) 10 of 10, desmin nine of 10, cytokeratin (AE1/AE3 and CAM 5.2) zero of 10, epithelial membrane antigen (EMA) zero of 10, and S-100 protein zero of 10. Antibodies to vimentin, MSA, and alpha sm stained a greater number of proliferative-phase stromal cells as compared with secretory-phase cells. Only rare stromal cells were immunoreactive for desmin, except for one case in which predecidual cells were diffusely positive. Both endometrial stromal nodules reacted with antibodies to MSA, alpha sm, and desmin, and one was vimentin positive. Each was unreactive for epithelial markers and S-100 protein. The 12 endometrial stromal sarcomas had the following immunopositivity: vimentin 11 of 12, MSA 10 of 12, alpha sm 10 of 12, desmin seven of 12, AE1/AE3 one of 12, CAM 5.2 two of 12, EMA zero of 12, and S-100 protein zero of 12. The antibodies to MSA and alpha sm usually stained a greater number of cells than did the desmin antibody. Three stromal sarcomas had sex cord-like areas, one of which exhibited focal CAM 5.2 positivity. These immunohistochemical findings for normal and neoplastic endometrial stromal cells indicate smooth muscle differentiation and are similar to those of smooth muscle neoplasms and myofibroblastic cells.

Vulvar squamous cell carcinoma and papillomaviruses: two separate entities?

Vulvar squamous precancers (vulvar intraepithelial neoplasia) are associated with sexual factors, cigarette smoking, and human papillomaviruses. However, epidemiologic studies of invasive carcinoma of the vulva have produced conflicting evidence for these associations, in part because of a strong association with vulvar inflammatory disease (dystrophies) in older women. We analyzed a series of 42 vulvar invasive carcinomas for papillomavirus nucleic acids by deoxyribonucleic acid-deoxyribonucleic acid in situ hybridization and correlated their presence with age, smoking history, and morphologic type. The carcinomas were divided into well-differentiated, moderately and poorly differentiated, and intraepithelial-like growth patterns, the latter composed of nests of invasive neoplastic epithelium with preserved cell polarity, similar to intraepithelial disease. Of the lesions studied, 28% were human papillomavirus deoxyribonucleic acid-positive. Intraepithelial-like neoplasms segregated in women with a younger mean age (64 versus 73 years) than that of women with conventional squamous cell carcinoma and they more frequently had a history of cigarette smoking (88% versus 28%). Moreover, intraepithelial-like lesions contained human papillomavirus nucleic acids more frequently (67% versus 13%) when analyzed by in situ hybridization. These observations confirm the diverse nature of vulvar squamous cell carcinoma and may explain in part why conflicting results are obtained from studies investigating the role of sexual and viral factors in the genesis of vulvar cancer. They suggest that many invasive vulvar cancers may not be linked to papillomaviruses.

Histologic classification of sinonasal intestinal-type adenocarcinoma.

Kleinsasser and Schroeder recently described a histologic classification system for woodworker-associated, intestinal-type adenocarcinomas of the sinonasal region. To determine if their approach is easily applied and prognostically meaningful for both woodworker-associated and sporadic intestinal-type adenocarcinomas in the sinonasal region, we analyzed 15 such cases. The 12 men and three women ranged in age from 37 to 75 years. Only four were woodworkers. All tumors arose in the nasal cavity or paranasal sinuses. The three authors independently classified the tumors with unanimous agreement in 11 (73%) of 15 cases. Disagreements were resolved by group review and consensus. Ten tumors were papillary tubular cylinder cell type; these were subdivided into grades I (four cases) and II (six cases) on the basis of cytologic atypia. Three tumors were alveolar goblet cell type; one tumor was signet-ring type; and one had a mixed pattern. Median survivals were papillary tubular I, 9 years; papillary tubular II, 3 years; and alveolar goblet cell, 7 years. It is concluded that this classification system is easy to apply, reproducible, and appears to identify a group of sinonasal intestinal-type adenocarcinomas (papillary tubular I) with a prolonged survival.

Benign fibrous histiocytoma of the skin with potential for local recurrence: a tumor to be distinguished from dermatofibroma.

We studied eight patients with benign fibrous histiocytoma (BFH) of the skin that differed, morphologically and biologically, from ordinary dermatofibroma (DF) and compared their tumors with a consecutive series of 141 DF. The patients ranged in age from 13 to 49 yr. Their lesions consisted of cutaneous nodules, 2 cm or less in size, that had been present for less than 1 yr. Seven were located on an extremity. Three of six patients (50%) who could be followed had recurrences 2, 5, and 8 mo following excision of their tumors. Microscopically, seven of the eight cutaneous BFH (CBFH) involved both dermis and subcutis. Five were distinctly multinodular. Subcutaneous involvement and/or multinodularity were present in each case. Fibroblastic and histiocytic cells were arranged in a monotonous storiform pattern throughout most or all of each lesion. There was moderate nuclear variability, but pleomorphism was absent. Several of the tumors contained sparse inflammatory, multinucleate, and foam cells and hemosiderin deposits. Vascularity was prominent. We believe that the multinodular architecture of CBFH and its involvement of both dermis and subcutis usually allow distinction from DF. The latter is uninodular, centered in the dermis, and exhibits only minor subcutaneous extension. Most DF lack the diffuse, well developed storiform appearance of CBFH. Local recurrence further distinguishes CBFH from DF, which rarely recurs. Rather than representing an aberrant form of DF, the clinical and microscopic features of CBFH suggest that it is closely related to, if not identical with, BFH of other tissues and organs.

Prediction of 'high-risk' cervical papillomavirus infection by biopsy morphology.

Certain human papillomavirus (HPV) types (such as type 16) have been linked to high-grade precancers and invasive carcinomas of the cervix. However, the accuracy with which morphologic characteristics will predict the presence and type of HPV infection is controversial. Three pathologists independently classified 102 consecutive cervical biopsies with the use of specific criteria and correlated their findings with the presence of HPV 11, 16, and 18 RNA sequences by in situ hybridization. Based on the presence and distribution of nuclear atypia, abnormal mitotic figures, and koilocytosis, biopsies were classified into borderline condyloma, condyloma, borderline cervical intraepithelial neoplasia (CIN) with koilocytotic atypia (CINK), and CIN. Two or more observers agreed on the diagnosis in 96% of cases. HPV 16-related sequences alone were detected in 0% of borderline condylomata, 17% of flat condylomata, 43% of borderline CINK, 67% of CINK, and 77% of CIN lesions. Other HPVs, including those producing signals with more than one probe, were present in 0, 50, 14, 9, and 0% of these lesions, respectively. The authors data suggest that consistent identification of HPV-related cervical disease requires the presence of specific cytologic changes. In the authors' series, when HPV-related disease is present, CIN is the most common lesion and most (71%) contain HPV 16-related nucleic acids. Thus, a high proportion (88%) of histologic abnormalities associated with HPV-16 could be distinguished as CIN by morphologic characteristics alone, and this distinction could be made by most observers.

Fatal acute pontocerebellar hemorrhage due to an unsuspected spheno-occipital chordoma.

Patients with cranial chordomas typically present with a several-month history of progressive cranial nerve palsies. We report the first case (to our knowledge) of a clinically unsuspected sphenooccipital chordoma evolving into an acute pontocerebellar hemorrhage.

Characterization of sulfasalazine's interference in the measurement of conjugated bilirubin by the Ektachem slide method.

We describe the cases of four patients who were taking sulfasalazine for inflammatory bowel disease, whose conjugated bilirubin concentrations in serum exceeded their corresponding total bilirubin concentrations as measured with a multilayer film analyzer, the Ektachem 400. Sulfasalazine added to pooled human serum at therapeutic concentrations increased the apparent conjugated bilirubin, as measured with the Ektachem, in a linear and dose-related fashion. Measured unconjugated bilirubin was simultaneously decreased to values less than -3 mg/L. The same interference occurred on the Ektachem 700, but an algorithm prevented the instrument from reporting the results. The major metabolites of sulfasalazine in blood did not interfere with analysis for those fractions of bilirubin. Sulfasalazine's strong absorbance at 400 nm explains its interference with determination of conjugated bilirubin in this instrument.