Association of infiltrating lobular carcinoma with positive surgical margins after breast-conservation therapy.

OBJECTIVE: To determine whether infiltrating lobular carcinoma (ILC) is associated with high positive-margin rates for single-stage lumpectomy procedures, and to define clinical, mammographic, or histologic characteristics of ILC that might influence the positive-margin rate, thereby affecting treatment decisions. SUMMARY BACKGROUND DATA: Infiltrating lobular cancer represents approximately 10% of all invasive breast carcinomas and is often poorly defined on gross examination. METHODS: A group of 47 patients with biopsy-proven ILC undergoing breast-conservation therapy (BCT) at the University of Virginia Health Sciences Center between 1975 and 1999 was compared with a group of 150 patients with infiltrating ductal cancer undergoing BCT during the same time period. The pathology of the lumpectomy specimen was reviewed for each patient to confirm surgical margin status. Office and surgical notes as well as mammography reports were examined to determine whether the lesions were deemed palpable before and during surgery. Patients were stratified according to age, family history, tumor size, tumor location, and histologic features of the tumor. RESULTS: The incidence of positive margins was greater in the ILC group compared with the infiltrating ductal cancer group. Patient age, family history, and preoperative palpability of the tumor did not correlate with surgical margin status. Of the mammographic features identified, including spiculated mass, calcifications, architectural distortion, and other densities, only architectural distortion predicted positive surgical margin status. Tumor grade, tumor size, lymph node status, and receptor status were not predictive of surgical margin status. CONCLUSIONS: For patients with ILC, BCT is feasible, but these patients are at high risk of tumor-positive resection margins (51% incidence) after the initial resection. Only the mammographic finding of architectural distortion was identified as a preoperative marker reliably identifying a subgroup of ILC patients at especially high risk for a positive surgical margin. For all patients with ILC considering BCT, careful counseling about the potential need for a second procedure to treat the positive margin should be included in the treatment discussion.

Apparent ipsilateral decrease in breast size at mammography: a sign of infiltrating lobular carcinoma.

PURPOSE: To assess if infiltrating lobular carcinoma (ILC) is associated with an ipsilateral mammographic decrease in breast size. MATERIALS AND METHODS: Mammographic change in size was evaluated by measuring the distance from the nipple to the pectoralis major muscle on the mediolateral oblique view of the diagnostic mammogram and on a preceding mammogram in 30 patients with ILC. Clinical, mammographic, and histopathologic findings were retrospectively reviewed. RESULTS: Five patients (17%) had an ipsilateral decrease in mammographic size. No patients noticed a physical decrease in breast size. Patients with an ipsilateral decrease in mammographic size most commonly had breast thickening at examination (four of five patients [80%], P < .001) and either a focal asymmetry density (three of five patients [60%]) or architectural distortion (one of five patients [20%]) at mammography; those patients with no change in size most commonly had a palpable mass (six of 25 patients [24%]) or normal findings (19 of 25 patients [76%]) and a mass (13 of 25 patients [52%]) at mammography. The mean tumor size was 66 mm for those with an ipsilateral size decrease and 16 mm for those with no size decrease (P < .001). At histologic analysis, tumors associated with an ipsilateral decrease in mammographic size had more diffuse involvement of the breast, and discrete masses were not seen. CONCLUSION: An apparent decrease in mammographic size may help identify cases of ILC, especially when associated with thickening at clinical examination and focal asymmetric density at mammography.

The Histologic Spectrum of Apocrine Lesions of the Breast

Apocrine proliferations most often are metaplasia as a component offibrocystic change. However, the appearance of apocrine metaplasia within various breast lesions, such as papillomas, ductal adenomas, and sclerosing adenosis, may complicate their diagnosis. Distinguishing benign from malignant apocrine proliferations can be problematic owing to the nuclear characteristics of apocrine cells. In this article, we characterize the spectrum of apocrine proliferations in the breast ranging from benign to malignant and attempt to clarify the difficult lesions that are intermediate between hyperplasia and ductal carcinoma in situ.

Angiosarcoma arising in a bone infarct.

A primary angiosarcoma of the femur arose in continuity with a bone infarct in a 74-year-old man. The tumor, resected by amputation, had pleomorphic polygonal and spindle cells in solid and cystic patterns with focal vasoformative features. The immunohistochemical stains CD31, CD34, factor VIII-related antigen, and Ulex europeus corroborated the endothelial differentiation of the tumor. The patient died after developing pulmonary metastases. This is the oldest reported patient with a well-documented angiosarcoma associated with a bone infarct.

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.

Recommendations for the reporting of resected prostate carcinomas.

The Association of Directors of Anatomic and Surgical Pathology has developed recommendations for the surgical pathology reporting of common malignant tumors. The recommendations for resected prostate carcinomas are reported herein.

Fine-needle aspiration cytology of spindle-cell argyrophilic mucin-producing carcinoma of the breast.

An unusual breast carcinoma with prominent spindle cells, intracytoplasmic mucin, and argyrophilia in an 82-yr-old woman was sampled preoperatively by fine-needle aspiration (FNA). The smears contained highly cellular sheets and fragments of uniform spindle cells with abundant vacuolated cytoplasm. The cells were mucicarmine positive and contained many cytoplasmic argyrophilic granules. The findings were confirmed by histologic examination of the excised tumor, which was also studied with a panel of immunohistochemical stains. A review of the literature indicated that spindle-cell argyrophilic mucin-producing carcinoma (SCAMPC) of the breast is a very rare neoplasm presenting primarily in elderly patients. The FNA cytologic features seem to be unique and should allow distinction from other primary breast lesions.

Aggressive angiomyxoma in males. A report of four cases.

Aggressive angiomyxoma (AAM) is a rare, locally infiltrative but nonmetastasizing tumor of the pelvic and perineal soft tissues that occurs almost exclusively in adult females. The authors describe four cases of AAM in adult males that arose in the scrotum. There was some histologic variation among the tumors. One case was focally hypercellular around the blood vessels, two were more densely cellular throughout, and one had cystic degeneration. Three of the tumors were widely infiltrative, and one of the four tumors recurred locally. The clinicopathologic features of these cases are similar to those of AAM occurring in females. In either sex, AAM should be distinguished from benign myxoid tumors with a low risk of local recurrence and fully malignant myxoid tumors with distant metastatic potential.

Reduction of femoral arterial bleeding post catheterization using percutaneous application of fibrin sealant.

The number of cardiac catheterizations performed yearly is growing with correspondingly increasing amounts of morbidity, complications, and hospital costs. This study suggests that fibrin sealant instillation via an arterial sheath at the completion of femoral catheterization may improve hemostasis. Results using fibrin sealant in 12 unheparinized dogs documented significant reductions (McNemar's exact test) versus control for groin ecchymoses (1 versus 8, P = .008) and radiolabeled hematoma formation (0 versus 7, P = .016). Also swelling was less in the fibrin sealant treated groins when compared to control groins (1 versus 6, P = .125), but failed to reach statistical significance. Results in eight heparinized dogs (activated clotting time 374 +/- 22, mean +/- SEM) revealed a statistically significant reduction in signs of gross bleeding in the fibrin sealant-treated groins (1 versus 8, P = .016). This method may contribute to reduced morbidity, complications, and length of hospitalization. It may also allow for earlier patient mobilization after cardiac catheterization.

The biopsy. The pathologist's point of view.

The science of medicine is constantly evolving. Surgical pathology must respond to these changes. For example, incisional biopsies once taken during an open surgical procedure are now being replaced by FNA biopsies performed on the outpatient. Pathologists are being asked to diagnose lesions on smaller pieces of tissue and fewer cells. Advances in molecular biology are allowing diseases to be examined at the molecular level. The pathologist is now asked to integrate this molecular data into his or her diagnostic process (e.g., lymphomas). The impact on the pathologist of the increased complexity imposed on examination of tissues cannot be overstated. Despite these difficulties, diagnosis always comes down to the integration of the morphologic features with the clinical findings. As such, the diagnosis will always depend on close teamwork between the surgeon and the pathologist.

Frozen section examination of breast biopsies. Practice parameter.

Traditionally, if the clinical diagnosis is cancer, fresh breast tissue is submitted for frozen section examination before immediate mastectomy. Although this is still true, many breast biopsies are currently performed as outpatient procedures in the setting of an abnormal mammogram or a vaguely palpable abnormality. Frequently the lesion is small (less than 1.0 cm.) or is not grossly visible. The appropriate pathologic examination of breast biopsy material is determined by whether it is a mass or only a cluster of calcifications seen on a mammogram. Each breast biopsy specimen must be handled in a manner that will maximize the opportunity to arrive at the correct histologic diagnosis. In many instances, this means that a frozen section examination is contraindicated.

Papillomas of the breast. A histologic spectrum including atypical hyperplasia and carcinoma in situ.

We have illustrated intraductal papillomas that have a variety of alterations not found in "ordinary" or typical papillomas. Many of these changes are indistinguishable from ductal carcinoma in situ. A priori, one might expect that patients with papillomas associated with changes identical to ductal carcinoma in situ would be at an increased risk for subsequent invasive carcinoma. We suspect that there is an increased risk based on the fact that seven of our 26 cases (27 percent) had fully diagnostic ductal carcinoma in situ or invasive carcinoma in the breast. However, the degree of increased risk has not been definitely established.

Removal of an infected right atrial mass in a patient with sickle cell disease.

The use of indwelling central catheters for hyperalimentation, chemotherapy, and long-term venous access is increasing. We report the successful removal of an infected right atrial mass associated with the use of a central catheter in an adult with sickle cell disease. The clinical options for the treatment of infected atrial thrombus as well as the challenge of performing cardiopulmonary bypass in patients with sickle cell disease are briefly discussed.