Second opinions in surgical pathology.

When to obtain opinions in anatomic pathology is a complex issue. The authors discuss the cognitive process of morphologic interpretation, the influence of expertise on the need for a second opinion, the role of ego, and the impact of economic factors on the patterns of consultation.

Problematic uterine smooth muscle neoplasms. A clinicopathologic study of 213 cases.

A recent trend in the classification of uterine smooth muscle neoplasms (USMNs) into clinically benign and clinically malignant groups has been to move from exclusive reliance upon mitotic index (MI) to an approach that incorporates additional histopathologic characteristics. In furtherance of this goal, we assessed a variety of histopathologic features of 213 problematic smooth muscle neoplasms for which we had > or = 2 years of clinical follow-up data or for which there was an unfavorable outcome. One hundred and thirteen of these patients have had a minimum follow-up of 5 years, and 48 have been followed for > or = 10 years. Cases eliminated from the study group included USMNs with a significant myxoid or epithelioid component and cases of intravenous leiomyomatosis. USMNs, whether cellular or not, with no cytologic atypia and with a mitotic index (MI = number of mitotic figures [mf]/10 high-power fields [hpf]) of < 5 mf/10 hpf (usual leiomyomas) were also excluded unless they had unusual features or were associated with an adverse clinical outcome. Fifty-six patients were initially treated by myomectomy or another form of local tumor removal; the remainder had a hysterectomy. From a wide variety of light microscopic features assessed, the important predictors that emerged, using a variety of data exploratory techniques, were MI, the degree of cytologic atypia, and the presence or absence of coagulative tumor cell necrosis (CTCN). Stratification of the USMNs with respect to these three features resulted in a five-group classification of USMNs with the following major characteristics. Group 1: Of the 89 USMNs with an MI in the range 5 < or = MI < 20 without CTCN and with no more than mild atypia, 88 were clinically benign. One patient with a tumor in this group died of metastatic disease 96 months after her uterine cervical primary neoplasm was removed. Combining our data with that in the literature, the failure rate in this group is approximately 1/200 (0.5%). This low failure rate warrants the use of the label "leiomyoma with increased mitotic index" for USMNs with these histologic features. Two patients whose USMNs were characterized by mild atypia, no necrosis, and MI < 5 developed identical-appearing pulmonary metastases and were judged in retrospect to have the syndrome "benign metastasizing leiomyoma." Group 2: USMNs with no CTCN and diffuse moderate to severe atypia fell into two groups based on the MI. For those patients whose neoplasms had an MI > or = 10 mf/10 hpf, four of 10 failed.(ABSTRACT TRUNCATED AT 400 WORDS)

Primary extrauterine endometrial stromal neoplasms: a clinicopathologic study of 20 cases and a review of the literature.

We present the results of a clinicopathologic study of 20 patients with primary extrauterine endometrial stromal sarcoma (ESS). The sites of the primary neoplasm and the number of patients with sufficient follow-up for survival analysis are as follows: ovary (three of four), fallopian tube (one of one), pelvic cavity (six of eight), abdominal cavity (five of six), and retroperitoneum (one of one). Evaluation of all patients included the mitotic index (MI) and cytologic atypia. Thirteen of the sixteen patients eligible for survival analysis had tumors with an MI < 10 and would be classified as low-grade stromal sarcomas in the Norris and Taylor scheme. Eight (62%) of the 13 had one or more relapses; of these, three died of disease at 35, 108, and 120 months, respectively, and another patient was alive with disease at 96 months. The other four patients who were treated after a relapse showed no evidence of disease after relapse at 36, 57, 63, and 146 months, respectively. Two of the 13 patients had tumor considered unresectable at the time of diagnosis; both died of disease at 5 and 10 months, respectively. Neither MI nor cytologic atypia were predictive of tumor recurrence or death from tumor. We also extracted clinical and morphologic data from all previous reports of primary extrauterine ESS, combined them with our 20 patients, and then compared the combined group with 17 cases of primary high-stage uterine ESS we presented in an earlier report. Not surprisingly, the behavior of the primary extrauterine ESS was more reminiscent of high-stage primary uterine ESS than low-stage primary uterine ESS.

Well-differentiated serous neoplasms of the ovary.

Serous neoplasms of the ovary, which constitute the largest subgroup of the surface epithelial tumors, cluster into three distinctly clinicopathologic groups: benign neoplasms, which are architecturally noncomplex, confined to the ovary, and composed of cytologically bland cells; carcinomatous neoplasms, which have spread beyond the ovary and are cytologically malignant; and an intermediate group, which raises serious problems in taxonomy, differential diagnosis, and prognosis. This chapter focuses on differential diagnosis, emphasizing the authors' experience as well as reports from other investigators.

Well-differentiated mucinous neoplasms of the ovary.

Well-differentiated mucinous ovarian neoplasms fall into several more or less distinct morphologic groups. One of the major problems, however, is correlation of morphologic groups with clinical outcome. The authors analyze this problem in regard to the major morphologic distinctions, morphologic syndromes, and taxonomic quandaries, concluding with an overview of miscellaneous significantly related topics.

Miscellaneous types of surface epithelial neoplasms. The well-differentiated end of the morphologic spectrum of endometrioid, clear-cell, and Brenner tumors and mixed epithelioid tumors of low malignant potential of müllerian type.

Benign ovarian neoplasms with endometrioid or clear-cell differentiation are rare, but benign Brenner tumors are not unusual. A subgroup of endometrioid, clear-cell, and Brenner neoplasms, characterized by morphologic features intermediate between benign and malignant, has been labelled by various investigators as borderline, of low malignant potential (LMP), or proliferating. This chapter reviews the definition of each of these cell types, evaluates the significance of the LMP category, and concludes with a discussion of well-differentiated ovarian neoplasms with mixed differentiation of the müllerian type.

Clinicopathology of malignant surface epithelial neoplasms of the ovary.

Because clinical outcome in patients with malignant surface epithelial neoplasms (M-SENs) of the ovary is highly varied, stratification of patients into favorable and unfavorable prognostic groups is an important clinicopathologic function. This chapter analyzes the various prognostic factors, with an emphasis on M-SENs of grades II and III.

Interobserver reproducibility in the diagnosis of ductal proliferative breast lesions using standardized criteria.

Although the categorization of proliferative breast lesions provides valuable information regarding subsequent risk of breast cancer, the ability of pathologists to classify such lesions in a reproducible fashion has not been adequately evaluated. To assess further interobserver reproducibility in the categorization of proliferative breast lesions, six pathologists each reviewed 24 proliferative ductal lesions and classified them as either usual hyperplasia (H), atypical hyperplasia (AH), or carcinoma in situ (CIS). Before evaluation of the study slides, all the participants were instructed to use the diagnostic criteria of Page and co-workers and were provided with both a written summary of these criteria and a set of teaching slides with representative examples of each type of lesion. Complete agreement among all six pathologists was seen in 14 cases (58%); five or more agreed in 17 cases (71%); and four or more arrived at the same diagnosis in 22 cases (92%). No pathologist consistently rendered more "benign" or "malignant" diagnoses than any other. After assigning numerical values for each diagnostic category (H = 1, AH = 2, CIS = 3), the scores for the group of 24 cases did not differ significantly by pathologist (p = 0.68; average score range, 1.7-2.0). Our results indicate that with the use of standardized criteria, interobserver concordance in the diagnosis of proliferative ductal breast lesions can be obtained in the majority of cases.