Potential role of increasing number of sections in frozen section diagnosis of ovarian tumors.

OBJECTIVE: To assess the accuracy of intraoperative frozen section of ovarian tumours at our institution and to identify the possible reasons for misdiagnosis. STUDY DESIGN: Between January 2002 and August 2013, a total of 684 patients were included in the study. Frozen section diagnosis was compared with the final paraffin section diagnosis as the gold standard. The sensitivity, specificity, and positive and negative predictive values of frozen-section diagnosis were calculated for benign, borderline and malignant tumours. Clinicopathological parameters influenced by misdiagnosis were evaluated performing multivariate logistic regression analysis. RESULTS: The overall accuracy was detected as 96.1%. Frozen-section diagnoses of 26 patients (3.8%) showed discordance. The specificity (99.7%) and PPV (99.4%) of frozen-section diagnosis was highest in the malignant category. In BOTs, diagnostic agreement was observed in 57 of 70 (81.4%) cases. The PPV (81.4%) was lowest for these patients. Tumour diameter of ≥10 cm (OR [95% CI]= 3.0 [1.1 to 8.2]; P=0.030) and mucinous histology (OR [95% CI]= 2.5 [1.0 to 6.2]; P=0.042) were significant predictors of misdiagnosis. With the increase in the number of sections, the accuracy rate of frozen section diagnosis was decreased. While not statistically significant (p=0.361). CONCLUSION: The number of sections is increased parallel to increase in tumor diameters. On the contrary, the diagnostic accuracy was no significantly increased with an increase in the number of sections. This discrepancy may be associated with falling tumor size per frozen section. A prospective study based on a certain tumour diameter per frozen section may better demonstrate the positive effect of the number of sections.

Primary yolk sac tumor of endometrium: report of two cases and review of literature.

Primary YST of the endometrium is very rare, therefore there is no guideline for treatment. We report two cases of endometrial YSTs presenting different symptoms and showing different prognoses and discuss the clinical management of these tumors. The present report shows first time that bone and lung metastasis in primary YSTs of endometrium. As the number of reported cases with endometrial YSTs, more information about the prognosis of the disease may be obtained.

Reproducibility of endometrial intraepithelial neoplasia diagnosis is good, but influenced by the diagnostic style of pathologists.

Endometrial intraepithelial neoplasia (EIN) applies specific diagnostic criteria to designate a monoclonal endometrial preinvasive glandular proliferation known from previous studies to confer a 45-fold increased risk for endometrial cancer. In this international study we estimate accuracy and precision of EIN diagnosis among 20 reviewing pathologists in different practice environments, and with differing levels of experience and training. Sixty-two endometrial biopsies diagnosed as benign, EIN, or adenocarcinoma by consensus of two expert subspecialty pathologists were used as a reference comparison to assess diagnostic accuracy of 20 reviewing pathologists. Interobserver reproducibility among the 20 reviewers provided a measure of diagnostic precision. Before evaluating cases, observers were self-trained by reviewing published textbook and/or online EIN diagnostic guidelines. Demographics of the reviewing pathologists, and their impressions regarding implementation of EIN terminology were recorded. Seventy-nine percent of the 20 reviewing pathologists' diagnoses were exactly concordant with the expert consensus (accuracy). The interobserver weighted κ values of 3-class EIN scheme (benign, EIN, carcinoma) diagnoses between expert consensus and each of reviewing pathologists averaged 0.72 (reproducibility, or precision). Reviewing pathologists demonstrated one of three diagnostic styles, which varied in the repertoire of diagnoses commonly used, and their nonrandom response to potentially confounding diagnostic features such as endometrial polyp, altered differentiation, background hormonal effects, and technically poor preparations. EIN diagnostic strategies can be learned and implemented from standard teaching materials with a high degree of reproducibility, but is impacted by the personal diagnostic style of each pathologist in responding to potential diagnostic confounders.

Unusual spindle cell tumor of thyroid (SETTLE).

Spindle epithelial tumor with thymus-like differentiation (SETTLE) is a rare tumor seen mostly in children and adolescents. It is presumed that it arises from ectopic thymus or remnants of branchial pouches that differentiate along the thymic line. Unusual spindle cell-predominant histology makes this entity difficult to recognize. The clinical course is not exactly known due to the small number of reported cases but metastasis has been documented during initial presentation. We report a case of SETTLE in the neck where preoperative clinical and radiological impression was that of a mass in the left submandibular gland area. However, during the operation it was felt by the surgeon that the mass was in continuity with the left thyroid lobe.

Cloacogenic Adenocarcinoma of the Vulva: A Case Report and Review of the Literature.

Primary adenocarcinoma of the vulva, unrelated to the native glands of perineum is an extremely rare neoplasm. Despite awareness of this lesion for over 40 years, the origin is not beyond speculation. The most reasonable hypothesis is based on the remnants of cloacal differentiation during early days of life. Here we report the case of a 60-year-old patient with a vulvar mass, who underwent partial vulvectomy and bilateral regional lymph node dissection. The tumor was composed of papillary and complex glandular structures and exhibited diffuse positivity for cytokeratin 20 and polyclonal CEA, CDX2, and focal positivity with cytokeratin 7. Unlike the indolent behavior of this malignant neoplasm according to the literature, we found two metastatic inguinal lymph nodes. She did not receive adjuvant therapy and is still alive, free of disease 38 months after surgery. We present different aspects of vulvar adenocarcinomas with a case report.

Papanicolaou smear findings in solid-organ transplant recipients compared with normal subjects according to the Bethesda 2001 system.

OBJECTIVES: Solid-organ transplant recipients are at increased risk of developing cancer including cervical cancer compared with woman in the general population, mostly due to long-term immunosuppressive therapy. The Papanicolaou smear remains the primary method of screening cervical pathology including preinvasive and invasive lesions. The objective of this study was to evaluate Pap smear findings in solid-organ transplant recipients, determine the prevalence of abnormal smears, and compare these patients with the general population. MATERIALS AND METHODS: We retrospectively examined 111 women patients who received liver or kidney transplant between January 1990 to December 2012 at Baskent University Ankara Hospital. Pap smear findings were compared with normal control patients matched for same age and technical procedure of cervical cytology. To selection of control patients, propensity score matching program was performed. All Pap smears were re-examined according to Bethesda 2001 criteria. RESULTS: In 111 transplant patients, 2 patients (1.8%) had atypical squamous cells of undetermined significance, 8 patients (7.2%) had low-grade squamous intraepithelial lesion, 15 patients (13.5%) had Candida infection, 2 patients (1.8%) had Trichomonas vaginalis, 1 patient (0.9%) had herpes simplex infection, 13 patients (11.7%) had bacterial vaginosis, 15 patients (13.5%) had reactive changes due to inflammation, and 18 patients (16.2%) had atrophy. When we compared our results with the control group, there were statistically significant differences (P ≤ .05) between the 2 groups in epithelial cell abnormalities (low-grade squamous intraepithelial lesion), Candida infection, bacterial vaginosis, and atrophy. CONCLUSIONS: Pap smear screening potentially may help recognize cervical preinvasive and invasive lesions. The risk of developing cervical intraepithelial neoplasia is greater in transplant recipients because of immunosuppressive therapy. The incidence of low-grade squamous intraepithelial lesion was significantly greater in transplant recipients than the general population. Intensive follow-up with Pap smear in transplant recipients is important in the early detection of these lesions.

Hepatic parenchymal changes and histologic eosinophilia as predictors of subsequent acute liver allograft rejection.

During the first episode of acute cellular rejection (ACR) after liver transplantation, centrilobular changes in liver biopsy specimens may be possible indicators of subsequent episodes of ACR, early chronic rejection, or acute graft loss. The purpose of this study was to identify differences between the histopathological findings in liver biopsy specimens obtained during the first rejection episode in patients who subsequently developed further episodes of ACR and those who did not. The histopathological findings in 22 patients who had a single episode of acute rejection (group 1) were compared with those in 23 patients who had multiple episodes of acute rejection (group 2). Only the first liver biopsy samples of the latter group were taken into consideration. We assessed the predictive value of centrilobular necrosis, central vein endothelialitis, pericentral inflammation, hepatocellular ballooning, cholestasis, hepatocellular apoptosis, lobular inflammation, the degree of portal eosinophilia, and characteristic portal tract features in poor responders to antirejection treatment. The time to the first episode of ACR and the rejection activity index were similar in patients in both groups. Hepatocellular apoptosis, hepatocellular ballooning, and central vein endothelialitis were common features of both groups. The incidences of pericentral inflammation, centrilobular necrosis, and portal eosinophilia were significantly higher in patients in group 2 than in those in group 1 (P < 0.05). Patients with pericentral inflammation, centrilobular necrosis, and marked portal eosinophilia during an initial episode of acute rejection may be more likely to develop subsequent episodes of ACR.

Prenatal diagnosis of a partial monosomy 7q11-->q31 in a fetus with split foot.

OBJECTIVE: A 27-year-old woman was referred to our laboratory for genetic counseling at 26 weeks of gestation due to abnormal ultrasound findings including intrauterine growth retardation, Dandy-Walker malformation and lower extremity anomalies. METHODS: Chromosome analysis was performed on fetal blood sample obtained by cardiocentesis. RESULT: We observed an abnormal karyotype with a structural abnormality of the long arm of chromosome 7. Both parents' chromosomes were normal; thus, the fetal karyotype designation was 46,XX, del(7)(pter-->q11::q31-->qter) de novo. Skin biopsy sample was taken to confirm the karyotype after therapeutic abortion was performed. The result was identical. Postmortem examination and autopsy showed facial dysmorphism, malformations of the lower extremities and central nervous system anomalies. CONCLUSION: 7q interstitial deletions cause a wide spectrum of congenital abnormalities and syndromes linked to the deleted segments. Our case had a rather wide chromosome region deleted and it is important, because prenatal diagnosis was performed. Thus, the family had the chance to evaluate the situation and decided to terminate the pregnancy after genetic counseling.

Relationship of HLA-DR expression to rejection and mononuclear cell infiltration in renal allograft biopsies.

Research on renal biopsies has shown that HLA class I antigens are distributed throughout the renal parenchyma, but that the distribution of HLA-DR varies greatly. We investigated HLA-DR expression in biopsies of 90 renal transplants, and also semiquantitatively assessed the proportions of CD68-, CD3-, and HLA-DR-positive infiltrating cells by immunohistochemistry. The relationships between tubular DR expression and interstitial lymphocyte and macrophage infiltration were examined. Forty of the biopsies showed acute rejection (AR), 33 showed chronic rejection (CR), 10 showed suspected rejection (SR), and 7 showed no evidence of rejection (NR). HLA-DR expression was noted in 35/40 (87.5%) of the AR cases, 22/33 (66.6%) of the CR cases, and 6/10 (60%) of the SR cases. Only 1 (14.3%) of the NR cases exhibited HLA-DR antigen expression in the renal tubules. The proportions of lymphocyte and macrophage infiltration observed in the interstitium were significantly correlated with tubular DR expression in all cases (p<0.01). At 6 months after biopsy was done, 24/35 (68.6%) of the AR patients with tubular DR expression had showed second episode of rejection or showed deteriorated renal function. The remaining 11 AR cases with tubular DR expression had stable renal function at this stage. The cases that had no significant tubular DR expression had no problems with rejection or functional deterioration. These findings are consistent with the theory that expression of HLA-DR antigens on renal tubular cells may be a marker of rejection and poor graft outcome.