Interobserver reliability in the histopathological diagnosis of cartilaginous tumors in patients with multiple osteochondromas.

The distinction between benign and malignant cartilaginous tumors located peripherally in the bone may be a challenging task in surgical pathology. The aim of this study was to investigate interobserver reliability in histological diagnosis of cartilaginous tumors in the setting of multiple osteochondromas and to evaluate possible histological parameters that could differentiate among osteochondroma, low- and high-grade secondary peripheral chondrosarcoma. Interobserver reliability was assessed by 12 specialized bone-tumor pathologists in a set of 38 cases. Substantial agreement on diagnosis among all the reviewers was observed (intraclass correlation coefficient=0.78). Our study confirmed that mitotic figures and nuclear pleomorphism are hallmarks of high-grade secondary peripheral chondrosarcoma. However, despite the substantial agreement, we demonstrated that histology alone cannot distinguish osteochondroma from low-grade secondary peripheral chondrosarcoma in the setting of multiple osteochondromas, as nodularity, the presence of binucleated cells, irregular calcification, cystic/mucoid changes and necrosis were not helpful to indicate malignant transformation of an osteochondroma. On the other hand, among the concordant cases, the cartilage cap in osteochondroma was significantly less thicker than in low- and high-grade secondary peripheral chondrosarcoma. Therefore, our study showed that a multidisciplinary approach integrating clinical and radiographical features and the size of the cartilaginous cap in combination with a histological assessment are crucial to the diagnosis of cartilaginous tumors.

Effect of combined locally delivered growth factors and systemic sildenafil citrate on microrecanalization in biodegradable conduit for vas deferens reconstruction.

OBJECTIVE: To investigate the effect of the combination of locally delivered growth factors and oral sildenafil citrate on cross-conduit microrecanalization. METHODS: A total of 42 rats were divided into 7 groups. Of the 42 rats, 6 underwent bilateral vasectomy and bilateral end-to-end vasovasostomy and 12 underwent bilateral vasectomy. Of the latter 12, 6 received sildenafil citrate orally (10 mg/kg/d) for 24 weeks and 6 received placebo. A total of 24 rats underwent bilateral vasectomy and bilateral reconstruction with implantation of a 5-mm biodegradable conduit that bridged the 2 vasal ends. Of the 24 rats with conduits, 12 also had 250 pg of transforming growth factor-ß and 12.5 pg of platelet-derived growth factor-ß sustained release nanoparticles placed in immediate proximity to the conduit. The remaining 12 rats with conduits (6 without growth factors and 6 with growth factors) also received sildenafil citrate orally (10 mg/kg/d) for 24 weeks; the others received placebo. The reconstructed segments were harvested for histologic examination at 24 weeks. RESULTS: Five of 6 primary vasovasostomy and no vasectomy-only rats sired litters. Significantly more microcanals per conduit were observed in rats receiving sildenafil citrate: without growth factors, 3.9 vs. 0 canals/conduit (P < 0.001); with growth factors, 5.5 vs. 0.25 canals/conduit (P < 0.001). The rats receiving sildenafil citrate with growth factors showed a trend toward more microcanals per conduit than the rats receiving sildenafil citrate without growth factors (5.5 vs 3.9; P = .10). Rats receiving growth factors but no sildenafil citrate did not produce more canals than the rats receiving neither growth factor nor sildenafil citrate (0.25 vs 0; P = NS). CONCLUSION: Orally administered sildenafil citrate enhances formation of microcanalization after postvasectomy reconstruction using a biodegradable conduit in a rat model. Locally delivered growth factors appear to increase the number of microcanals.

The use of touch preparation for the evaluation of sentinel lymph nodes in breast cancer.

BACKGROUND: This study was undertaken to evaluate the accuracy of touch preparation (touch prep) in the evaluation of sentinel lymph nodes (SLNs). METHODS: We performed a retrospective review of 402 breast cancer patients who underwent SLN biopsy. RESULTS: A SLN was identified in 381 patients. Of 61 patients with a true positive result, 59 underwent axillary node dissection, and in 22 the SLN was the only node with metastases. Thirty-six (9.44%) had at least 1 false negative result. Twenty-five with a false negative results were due to macrometastases, with 17 (2.4%) false negatives occurring in patients with invasive ductal and 6 (5.5%) in those with invasive lobular histology, P = .04. Touch prep had an overall sensitivity of 62.89% and specificity of 98.94%. CONCLUSIONS: Touch prep for the evaluation of SLNs in breast cancer compares favorably to reported results for frozen section. False negative findings are more likely with micrometastases and invasive lobular histology.

Competency assessment of residents in surgical pathology using virtual microscopy.

Our goal was to develop an efficient and reliable performance-based virtual slide competency examination in general surgical pathology that objectively measures pathology resident's morphologic diagnostic skill. A Perl scripted MySQL database was used to develop the test editor and test interface. Virtual slides were created with the Aperio ScanScope. The examination consisted of 20 questions using 20 virtual slides. Slides were chosen to represent general surgical pathology specimens from a variety of organ systems. The examination was administered in a secure environment and was completed in 1 to 1 1/2 hours. Examination reliability, as an indicator of the test's ability to discriminate between trainee ability levels, was excellent (r = 0.84). The linear correlation coefficient of virtual slide competency examination score versus months of surgical pathology training was 0.83 (P = .0001). The learning curve was much steeper early in training. Correlation of virtual slide competency examination performance with resident's performance on the 64 item Resident In-Service Examination surgical pathology subsection was 0.70. Correlation of virtual slide competency examination performance with global end of rotation ratings was 0.28. This pilot implementation demonstrates that it is possible to create a short, reliable performance-based assessment tool for measuring morphologic diagnostic skill using a virtual slide competency examination. Furthermore, the examination as implemented in our program will be a valid measure of an individual resident's progress in morphologic competency. Virtual slide technology and computer accessibility have advanced to the point that the virtual slide competency examination model implemented in our program could have applicability across multiple residency programs.

Recommendations for the reporting of surgically resected thymic epithelial tumors.

Thymic epithelial tumors include thymoma and thymic carcinoma. Histologic findings and extent of disease are key determinants of prognosis and help guide postoperative management in patients with thymic epithelial tumors. Given the relative rarity of these tumors, the use of tumor guidelines and checklists can facilitate accurate and comprehensive pathologic reporting in this setting. Diagnostic nomenclature (World Health Organization, Suster-Moran classifications) and staging criteria (modified Masaoka system) are emphasized.

Early microrecanalization of vas deferens following biodegradable graft implantation in bilaterally vasectomized rats.

We evaluated a biodegradable graft for reconstruction of rat vasa deferentia with long obstructed or missing segments. A total of 47 Sprague-Dawley rats underwent bilateral vasectomy and were divided into groups according to length of the vas deferens affected (0.5, 1, 1.5 cm). After 8 weeks, poly-(D,L-lactide) (PDLA) grafts were used to reconnect the vas deferens. Grafts and adjoining vasa deferentia were excised 8 and 12 weeks later and evaluated microscopically. At 8 weeks, microscopic changes included a robust inflammatory response around the grafts. All grafts were still intact but in the early stages of degradation. No microtubules, indicative of vas deferens recanalization, were identified. One specimen showed evidence of healing and neovascularization at the interface zone between the vas deferens and the graft. At 12 weeks, grafts were further degraded but still present. Microscopic evaluation showed decreased inflammation. Seven specimens showed neovascularization at the interface zone; two of these showed distinct epithelialized vas deferens microcanals at the graft edges. One specimen showed a microcanal spanning the entire 0.5-cm graft. A time period of 8 weeks is not ample enough for vas deferens regeneration in the setting of a biodegradable PDLA graft; however, early evidence of re-growth was seen at 12 weeks. A longer healing time should permit further biodegradation of the graft, as well as re-growth and possible eventual reconnection of the vas deferens, allowing passage of sperm. These findings suggest a potential role for biodegradable grafts in the reconstruction of vas deferens with long obstructed segments.

Involvement of growth factors in the process of post-vasectomy micro-recanalization.

PURPOSE: We investigated the role of growth factors in the process of post-vasectomy micro-recanalization using real-time polymerase chain reaction, enzyme-linked immunosorbent assay and histopathological analyses of the vasectomy sites and controls at different time points in a rat model. MATERIALS AND METHODS: Unilateral vasectomies were performed in 18 rats with sham surgery on the contralateral side. Vasectomy sites and vas segments of similar length from the sham operated sides were taken for analysis at 2, 8 and 12 weeks. Real-time polymerase chain reaction was used to test the expression of mRNA of 7 common growth factors and select growth factor receptors. Enzyme-linked immunosorbent assay was performed for growth factors with strong positive polymerase chain reaction findings. Histopathological examination was performed by a staff pathologist (BRD) to detect micro-recanalization, defined as tubules visible on hematoxylin and eosin staining with an epithelial lining of cuboidal or columnar cells. RESULTS: Micro-canals were found in 2 of 18 rat specimens. Real-time polymerase chain reaction of all specimens demonstrated a 12-fold increase in platelet-derived growth factor-beta, a 6-fold increase in platelet-derived growth factor-beta receptor, an 11-fold increase in platelet-derived growth factor-alpha, a 7-fold increase in platelet-derived growth factor-alpha receptor and a 9-fold increase in transforming growth factor-beta compared to the sham operated side. All increases were sustained and statistically significant (p <0.05). Enzyme-linked immunosorbent assay revealed statistically significantly increased expression of platelet-derived growth factor-beta protein. CONCLUSIONS: The demonstrated micro-recanalization and sustained growth factor up-regulation at vasectomy sites suggest a possible mechanism for post-vasectomy ejaculate sperm identification. There is a need for further research on the potential role of select growth factors in reconstruction of the male reproductive tract.

The relationship of molecular markers of p53 function and angiogenesis to prognosis of stage I epithelial ovarian cancer.

PURPOSE: Multiple angiogenic factors may influence tumor progression and metastasis. Several are modified by the p53 gene. We sought to identify molecular markers for high-risk stage I epithelial ovarian cancers. EXPERIMENTAL DESIGN: Seventy-seven consecutive stage I epithelial ovarian cancers were evaluated for p53, CD31 microvessel density, thrombospondin-1, vascular endothelial growth factor (VEGF), p21 immunohistochemical staining, and p53 gene mutations. Molecular marker impact upon disease-specific survival, disease recurrence, and distant recurrence was evaluated with Cox regression. RESULTS: There were 12 deaths from disease. Twelve of the 77 tumors contained p53 mutations-10 missense and 3 null (one tumor had two mutations). Fesddration Internationale des Gynaecologistes et Obstetristes substage (IA/IB versus IC; P < 0.001) and VEGF staining (P = 0.02) were significant in bivariate models with relationship to disease-specific survival. Stage (P = 0.0004), grade (P = 0.008), histology (P = 0.0025), p53 dysfunction (positive stain and/or mutation; P = 0.048), and microvessel density (P = 0.04) were significant in bivariate models with relationship to time to recurrence. In multivariate analyses among stage IC patients, failure to receive chemotherapy and microvessel density were associated with disease-specific survival, time to recurrence, and time to distant recurrence with hazard ratios of 4.8 to 44.1. CONCLUSIONS: The p53-dependent molecular markers of angiogenesis are of limited utility in developing a clinical strategy for postoperative management of stage I ovarian carcinoma. Microvessel density impacts survival and metastasis for high-risk stage IC disease. Adjuvant chemotherapy is necessary, but not sufficient, for cure of high-risk stage I epithelial ovarian cancers.

A preliminary diagnosis service provides prospective blinded dual-review of all general surgical pathology cases in an academic practice.

Quality assurance of diagnostic accuracy in surgical pathology is an important part of a pathologist's total quality management program. At our academic institution, the quality of diagnostic accuracy is monitored via dual-review of every general surgical pathology case, which accounts for nearly 20,000 cases per year. This comprehensive dual-review is achieved by operating a preliminary diagnosis service, staffed by a senior or board eligible resident. Analysis of a portion of our dual-review data (6300 cases) demonstrates an overall diagnostic concordance rate of 95.4% and a clinical major discrepancy rate of 0.29% between the preliminary diagnosis and staff pathologist diagnosis, comparable to other published rates. The incorporation of a preliminary diagnosis service into our academic surgical pathology practice has proven to be beneficial with regard to quality assurance and resident education. Other academic institutions may similarly benefit from the addition of such a service.

Cytokeratin 5/6 immunostaining in cutaneous adnexal neoplasms and metastatic adenocarcinoma.

The differentiation of primary cutaneous adnexal neoplasms (CANs) from dermal-based metastatic lesions can be difficult. Cytokeratin 5/6 (CK 5/6) has a relatively limited expression profile, being relatively specific for mesothelium and other "pavement" type epithelium such as squamous epithelium. To date, the degree and distribution of CK 5/6 expression in cutaneous neoplasms has not been extensively studied. We speculate that since most of CANs arise from similar epithelium, they should express CK 5/6 and, therefore, CK 5/6 could potentially be helpful in distinguishing these lesions from most of metastatic neoplasms, which usually do not express this marker. Formalin-fixed, paraffin-embedded tissue sections from 228 previously classified CANs and 27 metastatic adenocarcinomas (17 breast, 4 colon, 2 prostate, 2 ovary, 1 lung, and 1 esophagus) were immunostained with anti-CK 5/6. Anti-CK 5/6 labeled 2 of 2 proliferating trichilemmal tumors, 6 of 6 poromas, 4 of 5 hydrocystomas, 10 of 10 cylindromas, 10 of 10 eccrine acrospiromas, 8 of 10 pilomatricoma, 10 of 10 nevus sebaceus, 9 of 9 desmoplastic trichoepitheliomas, 7 of 7 nevus sebaceus with basal cell carcinomas, 10 of 10 pilar cysts, 14 of 14 trichilemmomas, 10 of 10 syringomas, 6 of 7 chondroid syringomas, 10 of 10 hidradenoma papilliferum, 9 of 9 sebaceus adenomas, 3 of 3 microcystic adnexal carcinomas, 10 of 10 eccrine spiradenomas, 4 of 4 syringocystadenoma papilliferum, 3 of 5 ocular sebaceous carcinomas, 28 of 28 basal cell carcinomas, 16 of 16 trichoepitheliomas, and 33 of 33 trichoepitheliomas with basal cell features. By contrast, 9 of 27 metastatic adenocarcinomas stained positively, although only two of these stained strongly. Cumulatively, CK 5/6 was expressed by most (97%) of CANs, while only 33% of metastatic adenocarcinomas showed positive expression. The sensitivity of this marker in the malignant lesions (other than basal cell carcinoma) is 78%, while the specificity is 67%. If all lesions are considered, the sensitivity increases to 97%. Therefore, CK 5/6 may prove to be a useful adjunct marker in distinguishing CANs from metastatic lesions.

Coauthorship in pathology, a comparison with physics and a survery-generated and member-preferred authorship guideline.

In a large and detailed survey of scientific coauthorship in pathology, 3500 members of the US and Canadian Academy of Pathology (USCAP) were surveyed via the Internet with a final response rate of 22.5%. The results were compared with a previous survey of members of the American Physical Society (APS). The fields are found to be very similar. For example, there is no well-defined way to determine coauthorship: the byline is arrived at without the use of public coauthorship standards according to 90% of respondents (92% in physics). A substantial amount of inappropriate authorship is present in both fields using a variety of authorship guidelines. For example, using the guideline of the International Committee of Medical Journal Editors (the "Uniform Requirements for Manuscripts Submitted to Biomedical Journals" [ICMJE]), the average number of coauthors judged to be inappropriate in pathology on papers with 4 coauthors is 1.0 (1.2 in physics), and using the guideline requiring "direct contributions to scientific discovery or invention," we find 1.6 (1.5 in physics). Finally, it is suggested that authorship guidelines should be constructed by public surveys rather than closed-door committees: an authorship guideline constructed from previous survey feedback (from APS members) was found to be preferable to USCAP members (it received 40% of the vote, the ICMJE received 24% of the vote).

Immunohistochemical analysis of biliary tract lesions.

The distinction among inflammatory, benign, and malignant lesions of the biliary tract can at times be difficult. Several methods have been used, including immunohistochemistry (IHC), with variable success. We evaluated a panel of IHC stains to determine their utility in discriminating between bile duct lesions. Formalin-fixed, paraffin-embedded 4-microm sections from 12 inflammatory lesions, 10 bile duct adenomas, and 13 bile duct carcinomas were immunostained using a modified avidin-biotin-complex technique after epitope enhancement using antibodies for p53, Ki-67, and bcl-2. For p53 and bcl-2, greater than 1% of cells staining positive was interpreted as positive. The proliferation index was calculated by determining the number of Ki-67-positive cells in a 1000 cell count. In the inflammatory group, 0 of 12 reacted with anti-p53, 2 of 12 were positive with anti-bcl-2, and the proliferation index with was 22.9% +/- 3.9%. Two of 10 bile duct adenomas showed reactivity with anti-bcl-2, and none were decorated with anti-p53 or Ki-67. In the carcinoma group, 6 of 13 were positive with anti-p53, 9 of 12 were positive with anti-bcl-2, and the proliferation index was 35.3% +/- 5.5%. The proliferation rates differed significantly between groups (P < 0.05). The presence of bcl-2 and p53 immunoreactivity coupled with a high proliferative rate in a biliary tract lesion suggests a malignant process. A panel using these antibodies may be useful in difficult cases.

C-erb B2 (Her2/neu) is neither overexpressed nor amplified in hepatic neoplasms.

The human c-erb B2 proto-oncogene (Her2/ ) encodes a 185-kD transmembrane putative growth factor receptor of the tyrosine kinase family. Overexpression or amplification of this oncoprotein/oncogene has been established in breast, ovarian, salivary gland, and gastric carcinomas and has been implicated in other neoplasms. Recently, overexpression of c-erb B2 has been demonstrated in hepatocellular carcinoma using enzyme-linked immunosorbent assay. Patients with hepatocellular carcinoma have a poor prognosis, and overexpression of c-erb B2 may have prognostic and treatment implications. The authors evaluated the expression and amplification of c-erb B2 in hepatic neoplasms utilizing routine immunohistochemistry and fluorescence in situ hybridization. Formalin-fixed paraffin-embedded tissue sections from 27 hepatocellular carcinomas and 7 hepatocellular adenomas were immunostained with anti-c-erb B2 utilizing a modified avidin-biotin technique following heat induced antigen retrieval. Ten sections from hepatocellular carcinomas were subjected to fluorescence in situ hybridization assay. Positive and negative controls stained appropriately. Slides were evaluated independently by two pathologists. None of the hepatocellular carcinomas or hepatocellular adenomas was immunoreactive with anti-c-erb B2. Adjacent cirrhotic liver parenchyma, present in 11 cases, was also uniformly negative. None of hepatocellular carcinomas showed any evidence of c-erb B2 amplification by fluorescence in situ hybridization. Immunoreactivity for c-erb B2 was not demonstrated in hepatocellular adenomas, cirrhotic livers, or hepatocellular carcinomas using routine immunohistochemical methods. C-erb B2 amplification was not demonstrated in hepatocellular carcinomas. Neither overexpression nor amplification of c-erb B2 (Her2/ ) can be regarded as a useful prognostic factor in hepatocellular carcinoma.

Failure of BRCA1 dysfunction to alter ovarian cancer survival.

PURPOSE: Many factors modify ovarian cancer survival. There are conflicting reports regarding survival of individuals with hereditary BRCA1-related ovarian cancer. None have controlled for other mechanisms of BRCA1 silencing in the control cohort. EXPERIMENTAL DESIGN: Fifty-nine cancers with presumed BRCA1 dysfunction because of mutation (24 germ-line and 16 somatic) or absent BRCA1 mRNA because of promoter hypermethylation (n = 19) were identified among 250 consecutively screened ovarian cancers. Controls were matched from the same population based on p53 mutation type, age at diagnosis, Fédération Internationale des Gynaecologistes et Obstetristes surgical stage and histological grade, residual disease, preoperative CA125, disease site, and the presence of BRCA1 mRNA translatable in an in vitro protein expression assay. BRCA1 promoter hypermethylation was determined by the methylation-specific PCR technique. The significance of promoter hypermethylation was confirmed by the absence of detectable BRCA1 mRNA. RESULTS: The median survival for individuals with ovarian cancer BRCA1 dysfunction was 4.1 years versus 3.5 years in the case matched controls (P = 0.98). Grouped on the basis of the mechanism of BRCA1 dysfunction, median survival was 4.5, 2.8, and 2.3 years for germ-line, somatic, and BRCA1 promoter-silenced ovarian cancers. However, for the corresponding matched controls with wild-type BRCA1 sequence, the median survival was virtually identical: 4.6, 2.8, and 3.3 years, respectively. In a Cox proportional hazards analysis, only residual disease (P = 0.0001), age (P = 0.01), and Fédération Internationale des Gynaecologistes et Obstetristes stage (P = 0.011) entered the survival model. CONCLUSIONS: In contrast with other published reports, we are unable to detect large survival differences between matched case-control cohorts of ovarian cancers with BRCA1 inactivation by any of three independent mechanisms.