Analysis of histological features in needle core biopsy of breast useful in preoperative distinction between fibroadenoma and phyllodes tumour.

AIMS: Fine Needle Aspiration Cytology (FNAC) has been replaced by Needle core biopsy (NCB) as the pathological investigation of choice in pre-operative diagnosis of breast lesions. Despite the greater yield of material with spatial information, the distinction between fibroepithelial lesions of the breast, fibroadenoma (FA) and benign phyllodes tumour (PT), remains problematic. The aim of this study was to confirm a set of histological features which may assist in the pre-operative distinction between FA and PT on NCB and to explore novel strategies to refine the analysis of the data. METHODS: Previously defined histological criteria were applied to 112 NCBs of fibroepithelial lesions of the breast. Contingency tables for frequency analysis, logistic regression, receiver operating characteristic (ROC) and linear discriminant analysis were used. RESULTS: Frequency analysis identifying significant differences agreed with published data. Correct categorisation was possible in 95% of cases using logistic regression analysis (age and mitotic index) and in 94% using discriminant analysis (age, mitoses and %stroma). ROC analysis identified cut off values (between FA and PT) for age (50-55 years), %stroma (85-90) and mitoses (>or=1/2.2 mm(2)). CONCLUSION: The results confirm previously published observations and provide novel putative predictive tools, to be tested prospectively.

Metastasis of Primary Colon Cancer to the Breast - Leave Well Alone.

BACKGROUND: Metastasis to the breast is rare. Its management differs from that of primary breast cancer, as illustrated by this case of a colonic metastasis to the breast. CASE REPORT: A 78-year-old woman presented with a breast lump 16 months after a palliative colonic resection for an obstructing colon cancer (T4 N0 M1). Core biopsy of the breast lump revealed morphological features identical to the original bowel cancer. In view of her progressive metastatic disease, the breast lump was simply observed. She passed away 4 months later from advanced intra-abdominal carcinomatosis. DISCUSSION: There are 19 cases of colonic metastasis to the breast in the literature. In the literature, colonic metastases to the breast are usually excised. CONCLUSION: Excision of a colonic metastasis to the breast can be avoided if the patient's life expectancy is short.

Molecular assessment of sentinel lymph node in breast cancer management.

Sentinel lymph node biopsy (SLNB) is becoming accepted as standard of care for axillary staging in breast cancer. World Health Organization (WHO) re-classification of axillary metastases into macrometastases, micrometastases and individual tumour cells has highlighted the issues of sampling and further histological examination of the initially negative SLNB. Molecular detection of metastatic breast cancer cells in lymph nodes is now available as a commercial kit for intraoperative use and can resolve the sampling issue. Semiquantitative assessment of axillary lymph node tumour burden can now be made using two separate technologies (histology and reverse transcriptase-polymerase chain reaction). The clinical implications of low metastatic axillary lymph node tumour burden are not clear, and future trials need to include molecular data. The consequences of the availability of molecular assessment are reviewed.

Radial scar lesions of the breast diagnosed by needle core biopsy: analysis of cases containing occult malignancy.

AIM: To identify and review cases of false negative needle core biopsy (NCB) in the preoperative investigation of radial scar/complex sclerosing lesion (RS/CSL) lesions - that is, benign NCB from RS/CSL which contained malignancy on excision. METHODS AND RESULTS: A total of 11 false negative NCB in RS/CSL lesions from 281 (3.9%) were identified (6 cases: B1, 2 cases: B2 and 3 cases: B3). In 6 of 11 cases a radial scar or stromal sclerosis was seen in NCB. Localisation biopsy showed duct carcinoma in situ in six cases, duct carcinoma in situ with invasive carcinoma in three and invasive carcinoma in two. In all 11 cases, needle tracks were identified as missing the malignant epithelium by a mean of 5 mm (median:4 mm; range:1-20 mm). In 9 of 11 cases, the malignancy was missed by <6 mm. CONCLUSIONS: Despite evidence of accurate targeting of lesions, the use of NCB instead of fine needle aspiration cytology has not eliminated the problem of false negative biopsy in RS/CSL, and excision is recommended.

Leiomyosarcoma of the inferior vena cava: clinical experience with four cases.

BACKGROUND: Leiomyosarcoma of the inferior vena cava is a rare tumor that presents in an insidious manner with non-specific symptoms. Given its rarity, there are no consensus guidelines to its management. The aim of this study was to report the clinical experience in the management of patients presenting to our institution during a 12 year period. PATIENTS AND METHODS: Four patients with leiomyosarcomas of the inferior vena cava were managed at our institution during the period reviewed. Patient details were identified through a search of the pathology department computerized database, and case notes were retrospectively reviewed to obtain details of presentation and management. RESULTS: There were 3 females and 1 male with a mean age of 59 years. All tumors were identified within 2 months of first symptoms. Three of the 4 had localized tumors whilst 1 patient had lung metastases at presentation. The three patients with resectable tumors underwent radical surgical excision of the tumor, and two patients had postoperative radiotherapy. One patient died of recurrence at 7 months, and another at 30 months. The third patient is currently well and disease free at 16 months. The fourth patient with metastatic disease was treated with chemotherapy alone and survived 36 months. CONCLUSION: Leiomyosarcoma of the inferior vena cava is an uncommon tumor that presents with non-specific symptoms. At the time of presentation, tumors are usually large and resection is challenging but probably offers the best opportunity for long-term survival.

Aberrant expression of 5-lipoxygenase-activating protein (5-LOXAP) has prognostic and survival significance in patients with breast cancer.

5-lipoxygenase (5-LOX)-activating protein, 5-LOXAP also known as LOX5AP or FLAP, is a protein that works closely with 5-LOX in regulating the metabolism of arachidonate. Some of the eicosanoid products of 5-LOX/5-LOXAP are known to play active roles in the function of cancer cells, including breast cancer cells. The current study investigated the expression of 5-LOXAP in clinical breast cancer and the prognostic impact of 5-LOXAP and 5-LOX in patients with breast cancer. A cohort of breast tumour tissues (n = 122) with normal background tissues (n = 32) were investigated. 5-LOXAP and 5-LOX transcripts were determined using RT-PCR and quantitative RT-PCR. Levels of the transcripts were analysed against clinical and pathological information. Breast tumour tissues had significantly higher levels of 5-LOX transcript compared with normal tissues (P = 0.015). The transcript was seen at significantly higher levels in node positive tumours than that in node negative tumours (P = 0.02). The prognostic significance was assessed using both a prognostic index and clinical outcome. Value of 5-LOXAP was first demonstrated when using the Nottingham Prognostic Index (NPI) as an indicator, in that patients with predicted poor prognosis had significantly higher levels of 5-LOXAP than patients with good prognosis (P = 0.0407). Furthermore, patients who died of breast cancer-related causes had significant higher levels of 5-LOXAP than those patients who remained disease free, following a median 10-year followup. A survival analysis has shown that high levels of 5-LOXAP were significantly correlated with overall survival (mean survival 109.6 month vs. 139.4 months, in tumour from patients with high and low levels of 5-LOXAP, P = 0.05). The same disadvantage of high levels of 5-LOXAP was also seen with disease-free survival (105.2 months vs. 135.6 months, P = 0.017). Analysis of 5-LOXAP together with 5-LOX transcript did not enhance the significance of the survival. However, when 5-LOXAP was considered together with 12-LOX, it improved the predictive power for both overall and disease-free survival (109.0 month vs. 143.1 months, P = 0.0156 for overall survival and 98.3 months vs. 141.3 months for disease-free survival, P = 0.0022). In conclusion, 5-LOXAP expression was aberrant in human breast cancer, particularly in aggressive tumours. Furthermore, 5-LOXAP had a significant prognostic value in patients with breast cancer. This identifies 5-LOXAP as a potential therapeutic target in breast cancer.

Effect of lymphatic tumor burden on sentinel lymph node biopsy in breast cancer.

Distal obstruction of the lymphatics by tumor and extensive tumor infiltration of the draining lymph nodes may prevent migration of the tracer to the sentinel lymph node (SLN), adversely affecting SLN identification. Rerouting of lymphatic drainage may divert flow to internal mammary nodes and cause an alternative nonsentinel node to become "sentinel," increasing the risk of a false-negative result. A total of 618 breast cancer patients underwent SLN biopsy using 99mTc albumin colloid and patent blue V injected peritumorally. This was followed by standard axillary node clearance in all patients at the same operation. The overall SLN identification and false-negative rates were 96% (593/618) and 7.6% (17/223), respectively. There was no difference in the SLN identification rate and the false-negative rate with increasing axillary tumor burden (as determined by the total number of positive nodes in the axilla). Further detailed analyses are based on the 64 patients from one center (Cardiff) who had at least one positive SLN and proceeded to axillary clearance. A total of 83 positive SLNs were removed from 64 patients. Tumor burden in the positive SLN was assessed by measuring the size of the metastasis and percentage replacement of the SLN by tumor, and by documenting extranodal invasion. Increasing tumor burden in the SLN (as determined by percentage replacement of SLN by tumor and presence of extranodal invasion) was associated with decreased radioisotope uptake (p = 0.005 and p < 0.0001, respectively). There was no correlation between radioisotope uptake and the size of the metastasis in the SLN. There was no correlation between blue dye uptake, internal mammary drainage on lymphoscintiscan, and tumor burden in the positive SLN. In conclusion, increased axillary lymphatic tumor burden is not associated with failure to identify a SLN or false-negative results when both blue dye and radioisotope are used for SLN biopsy. In an individual SLN, the percentage replacement by tumor, but not the absolute size of the metastatic deposit is associated with reduced radioisotope uptake. Extranodal invasion in the SLN is a marker of lymphatic obstruction and is significantly associated with reduced radioisotope uptake. The lymphatic tumor burden does not seem to affect blue dye uptake or internal mammary drainage.

Eosinophilic angiocentric fibrosis and granuloma faciale: analysis of cellular infiltrate and review of literature.

Eosinophilic angiocentric fibrosis (EAF) is a rare specific inflammatory condition that affects the nose and upper airways and is characterized by distinctive histopathologic features. We report the clinical, histopathologic, and radiologic features of EAF in an elderly woman who presented to us with complete stenosis of the left nostril, nasal swelling, and granuloma faciale (GF) of the overlying nasal skin. The histopathologic spectrum of the early, intermediate, and late stages of EAF in the deeper nasal tissues is illustrated along with the adjacent changes of GF in the overlying nasal skin. Quantification of immunohistochemically stained lymphocyte cell subsets in the perivascular inflammatory component was performed by using software to compare the proportions of lymphocyte subsets in the two conditions. The results showed similar proportions of perivascular CD4 T lymphocytes in EAF and GF. We believe that both EAF and GF may represent unusual tissue responses. Similar analysis in other cases will help confirm these findings. A review of the literature suggests that the condition, if localized, is amenable to surgical treatment. In progressive late stages, EAF causes fibrotic stenosis of the affected site with localized extension.