Comparative analysis of margin status in breast conservation surgery and its correlation with subsequent re-excision findings.

PURPOSE: Breast-conservation surgery (BCS) has become a standard treatment option for invasive breast carcinoma (IBC) and ductal carcinoma in situ (DCIS). The strongest predictor of local recurrence remains the surgical margin status. We evaluated the margin positivity by quantifying the tumor on positive margins and analyzing the histologic factors including type and extent in determining the likelihood of residual disease upon re-excision. METHOD: Retrospective analysis of 210 BCS performed at Mount Sinai Medical Center from the period of January 2011 - December 2017 revealed that 58 had IBC, DCIS, or both, with positive margins that were followed by re-excision. RESULT: The margins had IBC in 18 (31%), DCIS in 32 (55.2%) and both in 8 (13%) cases. Thirty-eight cases (65.5%) were free of carcinoma on re-excision. Of 40 cases with margins positive for DCIS, 16 (40%) had residual DCIS. Of 26 cases with IBC at the margins, and 5 had residual disease (19%). This difference was statistically significant (p = 0.002). Of 21 cases with extensive DCIS, 12 had residual disease (p = 0.02) as compared to only 4 out of 19 without extensive DCIS. None of the cases with clinging/micro-papillary DCIS had residual disease, while 51% of the other types (solid, cribriform, come-do) had residual disease (p = 0.02). The area of DCIS as measured on the involved margin correlated with the amount of residual disease on re-excision (p = 0.03). CONCLUSION: Margins positive for DCIS are more likely to have residual disease on re-excision in comparison to margins positive for only IBC. The type and extent of DCIS appears to influence the likelihood of residual disease.

Granulomatous inflammation of the breast in a pregnant woman: report of a case with fine needle aspiration diagnosis.

BACKGROUND: Granulomatous inflammation of the breast is an inflammatory process with multiple etiologies. It can accompany breast carcinoma or be idiopathic. It often presents clinically in a fashion mimicking carcinoma. Idiopathic granulomatous mastitis is strongly associated with lactation and is reported to occur in postpartum patients. This is the second fine needle aspiration (FNA) report of idiopathic granulomatous inflammation in the breast of a pregnant woman. CASE: A 27-year-old, 7-month-pregnant woman presented with a hard nodule in her right breast; on ultrasound examination it showed mixed echogenicity, suspicious for carcinoma. FNA showed granulomatous inflammation. The smears were highly cellular, with many clusters of and single epithelioid cells displaying moderate pleomorphism and prominent nucleoli in a background composed of neutrophils, plasma cells, lymphocytes and multinucleated cells. Core needle biopsy revealed a nonnecrotizing, granulomatous lesion. CONCLUSION: The diagnosis of granulomatous inflammation can be challenging, and the cytologic features can be difficult to separate from those of carcinoma. The relatively rare occurrence of this lesion and its cytologic features make it a potentially difficult diagnosis and diagnostic pitfall.

Evaluation of the Triage Micro Parasite Panel for detection of Giardia lamblia, Entamoeba histolytica/Entamoeba dispar, and Cryptosporidium parvum in patient stool specimens.

A study comparing the Triage Micro Parasite Panel (Biosite Diagnostics, Inc., San Diego, Calif.) to conventional O&P examination (O&P) was performed using patient fecal specimens. Five hundred twenty-three stool samples were compared. Nineteen specimens were found to be positive by Triage, and 29 were found to be positive by O&P. Seven specimens were positive for Giardia lamblia, four were positive for Entamoeba histolytica/E. dispar, and three were positive for Cryptosporidium parvum as determined by both methods. There was one false positive by Triage (C. parvum) and four false negatives by O&P (two G. lamblia, one E. histolytica/E. dispar, and one C. parvum). The Triage test accurately detected all 18 specimens that contained one of the three organisms that it was designed to detect. The Triage test is a rapid, easy-to-use enzyme immunoassay for the detection of G. lamblia, E. histolytica/E. dispar, and C. parvum in fresh or fresh-frozen fecal specimens. These data suggest that the Triage test can be used as a screen for the immediate testing of stool specimens for these three pathogenic parasites. If Triage test results are negative, O&P can be performed if parasitic infections other than G. lamblia, E. histolytica/E. dispar, or C. parvum are suspected.

Löwenstein-Jensen media. No longer necessary for mycobacterial isolation.

Isolation of mycobacteria on Löwenstein-Jensen media (LJ) and in the BACTEC MB9000 (MB) system was compared. Of 2,271 specimens, 317 were positive for 331 mycobacteria isolated in 1 or both media. The MB was positive in 238 isolates, and LJ was positive for 239 isolates; 92 isolates were detected by MB only and 93 by LJ only. Of the 331 isolates, 146 were recovered by both media. MB recovered 38 of 38 Mycobacterium tuberculosis complex isolates, while LJ recovered 23. MB recovered 94.1% (96/102) of Mycobacterium avium complex isolates and LJ 69.6% (71/102). The MB recovered 81% (65/80) Mycobacterium fortuitum-chelonae isolates and LJ 68% (54/80). Of the remaining species, MB isolated 39, while LJ isolated 91. Only 1 organism that was isolated on LJ alone was medically significant based on medical record review. The addition of LJ media to the MB9000 system is not warranted, as it causes clinically irrelevant workload, increased expenditures for the laboratory, and could cause the inappropriate treatment of patients.

Infiltrating breast carcinoma smaller than 0.5 centimeters: is lymph node dissection necessary?

BACKGROUND: The incidence of axillary lymph node metastases from infiltrating breast carcinomas measuring 1.0 cm or smaller reported in the literature varies from 0% (for tumors measuring < or =0.5 cm) to 27.1% (for all tumors < or =1 cm). METHODS: The authors examined all infiltrating breast carcinomas measuring 1.0 cm or smaller with axillary lymph node dissections in patients seen at their institution between January 1990 and March 1997 (117 cases) to determine the incidence of axillary lymph node metastases. All tumors were evaluated for patient age, histologic type of tumor, modified Bloom-Richardson grade, estrogen and progesterone receptor status, ploidy, S-phase fraction, and angiolymphatic vessel invasion, to determine whether there was a relation between the indicators and axillary lymph node metastases. The authors also performed immunohistochemical stains for the basement membrane components laminin and Type IV collagen on the tumors demonstrating metastases and on an equal number of size- and date-matched tumors not demonstrating metastases. RESULTS: Twelve cases of infiltrating carcinoma with axillary lymph node metastases were identified (a 10.3% overall incidence of metastases). Lymph node metastases were not identified in any of the cases with tumors measuring < or =0.5 cm (24 cases). The incidence of axillary lymph node metastases for carcinomas 0.6-1.0 cm was 12.9% (12 of 93 cases). High nuclear grade was found to correlate with the presence of lymph node metastases (P = 0.007). No statistically significant correlation was found between the other indicators examined and axillary lymph node metastases or between basement membrane staining and axillary lymph node metastases. CONCLUSIONS: The authors concluded that infiltrating breast carcinomas measuring < or =0.5 cm are unlikely to have demonstrable axillary lymph node metastases. Lymph node dissections in these women may be unnecessary. Nuclear grade may be the best predictor of lymph node metastases in T1b tumors.

A comparison of the Bactec 9000MB system and the Septi-Chek AFB system for the detection of mycobacteria.

The Bactec MB9000 (MB) continuous monitoring system was compared to the Septic-Chek AFB (SC) for the detection of Mycobacterium species from all patient sources. A total of 1485 specimens were evaluated. Two hundred forty-eight specimens grew mycobacteria in one or both systems. The isolates recovered were 18 Mycobacterium tuberculosis (MTB), 109 M. avium complex (MAC), 59 M. fortuitum-chelonae complex (MFC), 51 pigmented mycobacteria (PGM), and 11 nonpigmented mycobacteria, not MTB/MAC (NP). Of the 248 positive specimens, 157 were positive in both systems; 73 in the SC only; and 18 in the MB only. The mean times to detection for specimens were 11.5 days for MB versus 16.4 days for SC. The false positivity rate in the MB was 5.8%. Contamination rates for the MB and the SC were 12.7% and 19.8%, respectively. These data suggest that the automated MB system has clear advantages over the manual SC system in terms of earlier time to detection of significant mycobacteria, less technical hands-on time, and a lower contamination rate.

DNA flow cytometric measurements in breast cancer: a review of the instrumentation principles and clinical significance.

Breast cancer treatment remains a controversial and challenging issue. Treatment of this disease is often guided by the clinical stage and type of tumor present, as well as information provided by a variety of prognostic indicators which can be employed. DNA analysis by flow cytometry is a relatively new technique that is emerging as a powerful tool to predict the biologic behavior of breast tumors. A majority of studies have demonstrated that the S-phase fraction measured by DNA flow cytometric is an independent predictor of patient outcome. There is less conclusive information regarding the association of DNA ploidy with the clinical behavior of breast malignancies, although, tumor grading often closely parallels this DNA parameter. New flow cytometry methodology involves multiparameter analysis that allows a simultaneous examination of DNA ploidy and cell cycle analysis with surface or internal molecules. This newer approach permits a precise delineation of DNA characteristics in distinct cell populations within a tumor and will likely enhance the utility of this procedure in determining the biologic behavior of the breast tumor.

Histologic findings in postcryosurgical prostatic biopsies.

The increasing use of cryosurgical ablation of the prostate for prostatic carcinoma necessitates that surgical pathologists be aware of the cryosurgically induced histologic changes in the prostate. Twenty-one patients at our institution underwent prostatic cryosurgery, and 17 subsequently had follow-up biopsies. The Gleason combined scores ascribed to the original tumors were 4 (two patients), 5 (six patients), 6 (seven patients), 7 (one patient), and 8 (one patient). Histologic examination revealed residual carcinoma (four patients, with Gleason combined scores of 4, 5, 6, and 8), necrosis (all 17 patients), hyalinization (nine patients), fibrosis (nine patients), granulomatous inflammation (three patients), foci of calcification (eight patients), squamous metaplasia (four patients), transitional metaplasia (two patients), hemosiderin deposition (six patients), edema (two patients), bacterial colonization (one patient), and hemorrhage (one patient). The grade of residual carcinoma in all four patients was identical with the grade assigned before the cryosurgical ablation. The stroma surrounding the residual tumor did not display any postcryosurgical histologic changes, and we postulate that these areas were not adequately frozen. In conclusion, prostatic cryotherapy induces a variety of histologic changes in normal and diseased tissue.

Evaluation of the mycobacteria growth indicator tube compared to Septi-Chek AFB for the detection of mycobacteria.

The Mycobacteria Growth Indicator Tube (MGIT) and the AFB Septi-Check (SC) systems were compared for the ability to detect myobacterial isolates, time to detection, and rate of bacterial contamination. Fifty-eight mycobacterial culture positive specimens were studied. MGIT and SC were both positive in 30 of the 58 specimens (52%); SC alone was positive in 22 (38%), and MGIT alone was positive in 6 (10%) of the 58 specimens. Among the 30 isolates identified in both systems, there were 7 Mycobacterium tuberculosis, 14 M. avium, 6 M. fortuitum-chelonae complex, and 3 other mycobacterial species. MGIT detected Mycobacterium tuberculosis faster; SC detected M. avium complex faster and more often; and M. fortuitum-chelonae isolates were detected at the same rate. MGIT showed more contamination (12.6%) than did the SC (7.8%). MGIT is comparable to SC for the detection of MTB, but MAC isolates were detected more often and faster in the SC system.

Malignant glomus tumor. A case report of widespread metastases in a patient with multiple glomus body hamartomas.

Glomus tumors are characteristically benign solitary tumors. A few cases of malignant glomus tumors have been reported; however, they are usually only locally invasive, and metastases are exceedingly rare. We report a case of widespread metastases of a malignant glomus tumor involving the skin, lungs, jejunum, liver, spleen, and lymph nodes in a 63-year-old man with end-stage chronic renal failure. At autopsy, multiple glomus body hamartomas were also noted throughout the dermis proximal to the skin tumors. Histologically, the tumor was composed of monotonous round cells in solid sheets and investing numerous capillary-sized vessels. Approximately four to six mitoses were present per high-power field. The tumor cells were strongly immunoreactive for actin and vimentin, and ultrastructurally there were whorls of microfilaments with focal condensations. This case is exceptional because of its aggressive course.

Gastric syphilis. Primary diagnosis by gastric biopsy: report of four cases.

Gastric involvement in secondary or tertiary syphilis is rarely recognized clinically, and its diagnosis by examination of endoscopic biopsy specimens has been reported infrequently. We report four cases of gastric syphilis with the primary diagnosis made by gastric biopsy. The patients, all male, ranged in age from 38 to 78 years and presented with gastric complaints, the most common being upper gastrointestinal tract bleeding (three of four). Gastroscopy showed either erosive gastritis or gastric ulcers with heaped, nodular edges. The clinical diagnoses ranged from benign ulcer disease to infiltrating carcinoma and lymphoma. Gastric biopsy specimens in all cases showed a severe gastritis with dense plasmacytic infiltration, associated with varying numbers of polymorphonuclear leukocytes and lymphocytes, variable degrees of glandular destruction and reactive atypia, and a vasculitis without proliferative changes. Modified Steiner silver impregnation stain revealed numerous spirochetes in all four cases and associated Helicobacter pylori infection in one case. Serologic studies for syphilis were positive in all four cases (rapid plasma reagin test, fluorescent treponemal antibody absorption test). None of the patients were seroreactive for antibodies to human immunodeficiency virus. These recent cases of gastric syphilis emphasize the importance of remaining alert to the protean clinical manifestations of syphilis and aware of the histopathologic patterns of this disease.

Clinical assessment of anaerobic isolates from blood cultures.

Patients at two tertiary-care medical centers were evaluated to determine the clinical significance of anaerobic isolates from their blood specimens and to identify whether aerobic and/or anaerobic conditions were necessary for the detection of Streptococcus pneumoniae isolates. Significant anaerobes were isolated from only 0.1% and 0.4% of all blood cultures collected. The majority of patients with significant anaerobes had clinical conditions in which anaerobes are known to cause infections. Of the S. pneumoniae organisms, 83% were isolated only from the aerobic bottles of a blood culture set. These data lend support to the recommendations for the selective ordering of anaerobic blood cultures without compromising the isolation of S. pneumoniae.

Congenital self-healing reticulohistiocytosis. Report of a case with 7-year follow-up and a review of the literature.

A case of congenital self-healing reticulohistiocytosis in an otherwise healthy newborn boy is presented. Histological, immunohistochemical, and ultrastructural findings are described and the nosologic position of this entity is discussed.

Comparison of blood-culture results after five and seven days of incubation using the BACTEC NR660.

We compared 16,606 blood cultures for microbial growth on days 5, 6, and 7 of incubation using the BACTEC NR660. Only 20 potentially significant organisms (0.8% of positive cultures) were detected after day 5 and only one resulted in a change of patient management. We recommend users of the BACTEC NR660 consider a 5-day protocol for routine blood cultures.

Thymic hyperplasia. A clue to the diagnosis of hyperthyroidism.

The association of simultaneous abnormalities of the thyroid and thymus is well documented, particularly in the case of Graves' disease. We present a case of a natural death following thyroid storm in which marked thymic hyperplasia was present. This finding can be helpful in determining the cause of death.