An Atypical Rash on the Chest.

A 71-year-old man presented with a rapidly progressing rash and swelling of the left side of the chest wall. What is your diagnosis?

Clinicopathological Follow-up of Breast DCIS Diagnosed on Biopsies: A Single Institutional Study of 575 Patients.

Stratifying ductal carcinoma in situ (DCIS) patients into different upgrading risk groups is important in exploiting more precise therapeutic options. Evaluation of estrogen receptor/progesterone receptor/human epidermal growth factor receptor 2 (ER/PR/HER2) status and axillary lymph node metastatic status for DCIS and their upgraded invasive counterparts can also provide diagnostic and therapeutic implications. We retrospectively studied 575 patients with first-time diagnosis of DCIS on biopsies, and followed up their final diagnosis, ER/PR/HER2 status, and axillary lymph node involvement on excisions. As a result, biopsy-diagnosed DCIS had an overall 19.1% risk to be upgraded on subsequent excisions, with 4.7% being upgraded to microinvasive carcinoma (pT1mi) and 14.4% to overt invasive carcinoma (⩾pT1a). Factors significantly associated with higher upgrading risk on multivariate analysis include biopsy guidance by ultrasound (P <.001), DCIS with suspicious microinvasion (P < .001), and DCIS diagnosed in left breast (P = .026). DCIS diagnosed in younger patients (⩽40 years old) or DCIS with high nuclear grade showed higher upgrading risk only on univariate analysis. About 80% ER + /PR + and ER-/PR- DCIS remained the same ER/PR status after being upgraded, and ER + /PR - DCIS had the highest risk (63.6%) of having HER2 amplification in upgraded invasive carcinoma. For upgraded DCIS, microinvasive carcinoma was more likely to have HER2 amplification (50%) than overt invasive carcinoma (29.5%). Besides, pure DCIS had a low risk of axillary lymph node macrometastasis (0.74%), while the risk increased in DCIS with microinvasion (4.4%) and was highest in overt invasive carcinoma (14.7%). The findings of this study are clinically relevant with respect to criteria that might be used in selecting patients for de-escalation trials.

Correlation between modified Magee equation-2 and Oncotype-Dx recurrence scores using both traditional and TAILORx cutoffs and the clinical application of the Magee Decision Algorithm: a single institutional review.

BACKGROUND: Oncotype Dx (ODX) is used to predict recurrence risk for estrogen-positive (ER +), HER2-negative and lymph node negative breast cancer, however, due to the cost its use may be limited in low-resource areas. The aim of this study is to assess the concordance between the modified Magee Equation-2 (MME-2) and ODX recurrence scores (RS). The secondary aim is to apply the Magee Decision Algorithm (MDA) using the MME-2 to determine which patients are unlikely to benefit from ODX testing. METHODS: All newly diagnosed ER + , HER2 negative, lymph node negative breast cancer patients with available ODX-RS from 2008-2018 were included. The original pathology reports were reviewed and chart review was performed. The MME-2 scores were calculated and correlated with the ODX-RS. The MDA was applied to our cohort to assess which patients would not benefit from ODX testing. RESULTS: A total of 579 patients were included. There was an overall moderate correlation between ODX-RS and MME-2 score (Pearson correlation coefficient = 0.635). The overall concordance between ODX and MME-2 scores was similar when using both the traditional and TAILORx cutoffs (63.3% vs. 63.7%, respectively). Applying the MDA, for patients with MME-2 scores < 18, 96.8% of patients had the expected ODX-RS of < 25. For patients with MME-2 RS > 30, 90% had the expected ODX-RS of > 25. Concordance was highest in the high-risk category using both cutoffs. For patients with MME-2 18-25 and a mitotic score of 1, 88.8% had the expected ODX-RS of > 25. CONCLUSION: There is a moderate correlation between MME-2 score and ODX-RS. The overall concordance was similar for both traditional and TAILORx cutoffs. The strongest concordance was found in the high-risk category for both cutoffs. The MME-2 can be used to identify patients unlikely to benefit from ODX testing using the MDA.

Clinicopathological and radiological characterization of myofibroblastoma of breast: A single institutional case review.

Myofibroblastoma is a rare type of benign myofibroblastic neoplasm in the breast. It is clinically presented as a well-circumscribed mass, usually small in size (usually less than 4.0 cm), and can mostly be cured by local excision. Rare cases of giant myofibroblastoma greater than 10 cm have been reported, but also follow a benign clinical course. Histologically, breast myofibroblastoma is featured by bland fascicles of spindle cells intermixed with thick hyalinized collagen bundles. Mast cells are frequently found within the stroma. However, a wide spectrum of morphological variants can occur in myofibroblatoma, making its diagnosis challenging sometimes. Differential diagnosis of myofibroblastoma with other spindle cell lesions in the breast, either benign or malignant, is also important in practice. In this study, we collected 15 cases of breast myofibroblastoma diagnosed in our institution during a 20 year period. The sizes of these cases range from 0.4 cm to 35.2 cm (mean is 3.7 cm). To our knowledge, the case of giant breast myofibroblastoma we presented here is the largest one reported to date. The histological examination of the cases show great morphological variations. Besides the classical type, features of cellular, collagenized, palisading, epithelioid, myxoid, myoid, solitary fibrous tumor-like are also identified in the case series. Immunohistochemical staining patterns as well as clinical features of the cases are also summarized and compared. All cases in this study show no recurrence on follow-up. In addition, cases that are important differential diagnosis for breast myofibroblastoma are also studied. Their key histological characteristics are compared with myofibroblastoma, and their immunohistochemical and molecular features are discussed.

Comparison of cytocentrifugation supernatant fluid and formalin-fixed paraffin-embedded tissue for targeted next-generation sequencing.

BACKGROUND: The emergence of less invasive procedures coupled with the growth of molecular testing have created a need for clinical laboratories to optimize workflows to enable tissue preservation and ancillary testing. In the preparation of formalin-fixed paraffin-embedded cell blocks (FFPE CBs), there is a cytocentrifugation step for cell pellet extraction that results in postcentrifugation supernatant fluid (SN). This SN, which in most routine workflows is discarded, has been suggested to contain adequate cellular material for molecular testing. In the current study, the authors describe the use of DNA and RNA extracted from SN for the detection of clinically relevant biomarkers by next-generation sequencing (NGS). METHODS: After cell pellet removal, cytocentrifugation SN from 30 endobronchial fine-needle aspiration rinses that were positive for malignancy on FFPE CB were collected. DNA and RNA were extracted from the SN and tested using an in-house NGS Solid Tumor Focus Assay. The NGS results were compared with findings from corresponding FFPE samples. RESULTS: Testing was successful in all 30 samples. There was 100% concordance between variants observed in the SN and corresponding FFPE specimens, which included 50 single-nucleotide variants, 9 copy number amplifications, 3 structural variants, and 2 indels. Furthermore, there was excellent correlation (correlation coefficient, 0.93) between the variant allele frequency of mutations observed in SN compared with that noted in corresponding FFPE CBs. CONCLUSIONS: Cytocentrifugation SN is a valuable source for NGS, is comparable to FFPE that preserves tissue for other ancillary testing, and can reduce the failure rate of testing that may result from insufficient material being available in the CB.

Extravesical Pagetoid Spread of Urothelial Carcinoma in Situ. A Report of Five Cases.

BACKGROUND: Urothelial carcinoma in situ (CIS) of the bladder is classified as a flat lesion of the urothelium; it has a tendency to be multifocal and carries a high risk of recurrence and persistence. Approximately one-third of patients with urothelial CIS of the bladder develop invasive carcinoma if left untreated. There are a few reported cases of extravesical intramucosal extension (pagetoid spread) of urothelial CIS without prior documentation of primary muscle-invasive carcinoma. CASES: We present 5 cases of urothelial CIS that exhibited pagetoid spread to prostatic ducts, seminal vesicles, and the vagina. CONCLUSION: Pagetoid spread of urothelial CIS of the bladder may introduce uncertainty with regard to assignment of proper disease staging, and therefore uncertainty about appropriate cancer management.