Back to Basics: Traditional Nottingham Grade Mitotic Counts Alone are Significant in Predicting Survival in Invasive Breast Carcinoma.

BACKGROUND: Newer multigene molecular profiling assays for breast carcinoma rely heavily on the quantification of genes of proliferation, whereas traditional histological grading reports the mitotic count. The mitotic activity of invasive breast carcinomas may be undervalued; therefore, an evaluation of the prognostic significance of mitotic score in predicting prognosis was performed. METHODS: Retrospective analysis of a single institutional cohort of newly diagnosed estrogen receptor positive (ER+), HER2 negative (HER2-) unilateral invasive breast carcinomas was performed. Mitotic scores from the 3-part Nottingham combined histological grade were compared with clinical parameters. Mitoses were counted on Olympus BX50 microscopes and assigned scores of 1-3 based on observed mitoses. RESULTS: A total of 1292 ER+, HER2- invasive breast carcinoma patients were identified, with a median follow-up time of 2.6 years (range 0-14 years). Higher mitotic score was significantly associated with younger age, larger tumor size, angiolymphatic invasion, node-positive disease, higher stage, and the use of hormonal and cytotoxic chemotherapy. Mitotic score was significant in modeling time to local/regional recurrence (p = 0.02), recurrence-free survival/RFS (p < 0.001), and overall survival/OS (p = 0.01) with higher mitotic scores associated with worse outcomes. Higher mitotic score correlated significantly with intermediate/high risk Oncotype Dx recurrence scores (p = 0.009). CONCLUSIONS: First-generation molecular profiling assays for estrogen receptor positive invasive breast carcinomas derive much of their predictive power from quantifying genes of proliferation into a single score. Sometimes overlooked in the profusion of molecular data, the time-tested, mitotic count in the Nottingham combined histological grade is a good single-parameter predictor of survival.

Plexiform leiomyoma of the esophagus: a complex radiographic, pathologic and endoscopic diagnosis.

Radiographic identification of an abnormal lesion in the esophagus routinely occurs during workup of patients with symptomatic dysphagia. Leiomyoma is the most common benign finding; however, plexiform leiomyoma, a distinctive but rare variant, follows an unusual pattern of growth which can be a challenging surgical resection. A review of indexed literature identified a single previous report. We contribute a second case of plexiform leiomyoma with a discussion of the clinical, radiographic, and pathologic characteristics, as well as the differential diagnosis for plexiform lesions.

Metastatic Fibrolamellar Hepatocellular Carcinoma to the Pancreas.

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare variant of hepatocellular carcinoma, usually presenting in the younger population (<40 years) without underlying liver disease. Although it has a better prognosis than hepatocellular carcinoma, it has a high rate of recurrence months to years after primary resection. While sites of recurrence usually involve the liver, regional lymph nodes, peritoneum, and lung, metastasis to the pancreas is extremely rare, with only 2 other cases reported in the literature. We present the case of a 46-year-old patient with metastatic FL-HCC to the pancreas 30 years after diagnosis and 26 years since his last resected liver recurrence.

Tumoral Calcinosis Causing Bilateral Thigh Pain.

We report a case of a 75-year-old female with bilateral thigh pain for several years secondary to soft tissue calcification. Massive calcinosis of the soft tissues is a unique, but not uncommon, radiographic finding. On the contrary, tumoral calcinosis is a rare familial disease. The term tumoral calcinosis has been overly used to describe any massive collection of periarticular calcification. The original definition of tumoral calcinosis refers to a hereditary disease associated with massive periarticular calcification without an underlying cause. The lesions of tumoral calcinosis are typically lobulated, well-demarcated calcifications most often distributed along the extensor surfaces of large joints. Many conditions have similar radiographic appearances, including the calcinosis of chronic renal failure, calcific tendinitis, synovial osteochondromatosis, synovial sarcoma, myositis ossificans, tophaceous gout, and calcific myonecrosis. The radiologist plays a critical role in guiding the appropriate tests that can result in a conclusive diagnosis of tumoral calcinosis.

Posttraumatic Pseudolipoma (Fat Necrosis) Mimicking Atypical Lipoma or Liposarcoma on MRI.

We report a case of a 53 year old female who presented with a painless mass over her left greater trochanter. Evaluation with MRI and ultimately biopsy led to a diagnosis of fat necrosis. If this diagnosis had been considered with greater confidence, a conservative approach could have been taken and biopsy avoided. In patients with lesions demonstrating classic locations and imaging features of fat necrosis, observation without biopsy is appropriate.