Stereotactic core biopsy of nonpalpable breast lesions.

We report our experience with stereotactic core breast biopsies (SCBB) for mammographically suspicious, nonpalpable breast lesions. Ninety-seven patients, ages 29 to 94 (mean 57.3 years) underwent SCBB with a 14-gauge Biopty gun. A mean of 5.0 cores was taken from each lesion. Lesions were mammographically categorized by suspicion (high, > 60% chance of malignancy; intermediate, 25-60%; low, < 25%) and according to lesion character (well-defined mass, indistinct mass, spiculated mass, asymmetric density, and clustered microcalcifications [CM]). Histologic and radiographic findings were correlated at the time of biopsy and again retrospectively, with 92 percent correlation and eight percent partial or non-correlation. Of the latter, five of eight lesions represented CM not seen in the histologic samples. Of the 97 sampled lesions, 72 (74%) had been radiographically categorized as low suspicion, 10 (10%) as intermediate, and 15 (16%) as high. The procedure saved 74 women (76%) from open biopsy and added a diagnostic procedure for eight women (8%). Fifteen women (15%) went directly to mastectomy; therefore, the SCBB neither added nor saved a procedure for patients with cancer. Of the 72 lesions categorized as low suspicion, 65 (90%) were potentially saved from open biopsy, while nine of 25 lesions (36%) in the intermediate and highly suspicious groups were potentially spared a procedure. There were no false positive or negative cases among those who had an additional procedure or follow-up. The diagnoses made on SCBB included 15 carcinomas, one case each of atypical ductal and atypical lobular hyperplasia, one reactive lymph node, one intraductal papilloma, one collagenous spherulosis, one membranous fat necrosis, and numerous cases of fibrocystic change and fibroadenoma. In conclusion, we believe that this SCBB method can be an accurate and cost-effective tool in the management of these lesions.

Fine-needle aspiration cytology of an endometrioid-like variant of yolk sac tumor.

A 36-year-old male with a history of immature teratoma and embryonal carcinoma of the testis was admitted to the hospital for abdominal pain and fever. A CT scan revealed a large right abdominal mass. The patient's serum alpha-fetoprotein (AFP) was 46.8 ng/ml (reference < 25 ng/ml). Fine-needle aspiration (FNA) of the mass revealed malignant glandular cells. Chemotherapy was instituted, followed by resection of the large abdominal mass. The tumor was grossly encapsulated, consisting of large areas of necrotic, hemorrhagic tissue surrounded by smaller, multiloculated cysts. Microscopically, the tumor had a villoglandular pattern and variably stratified tall columnar cells. A prominent feature of the columnar cells was supranuclear and subnuclear vacuolization. Intracytoplasmic PAS-positive, diastase-resistant hyaline globules were occasionally present. AFP by immunoperoxidase was prominent within the tumor. This recurrence of the previously diagnosed testicular teratoma with embryonal carcinoma represents a yolk sac tumor with components strongly resembling endometrioid carcinoma, a variant only recently described in eight cases of ovarian origin (Clement et al.: Am J Surg Pathol 1987; 11(10):767-778). We believe this is the first reported case of an endometrioid-like variant of testicular yolk sac tumor and also the first report of the FNA cytology findings in this variant.

Painless hematuria and urethral discharge secondary to ectopic prostate.

We report a case of ectopic prostatic tissue found in the penile urethra of a 16-year-old boy. A literature review and discussion of this rare entity are presented.

Aggressive bladder carcinoma in an adolescent. Report of a case with immunohistochemical, cytogenetic, and flow cytometric characterization.

Malignant bladder neoplasms of urothelial origin are rare among children; fewer than 125 cases have been reported. Typically, these tumors are single papillary lesions of low grade and stage that have an excellent prognosis following surgical excision. A grade III transitional cell carcinoma of the bladder occurred in a 14-year-old boy who had no urinary tract malformation, carcinogenic exposure, or family history of cancer. Immunohistochemical stains of the tumor were positive for cytokeratin and high-molecular-weight keratin. The tumor tissue failed to stain with an antibody to the patient's blood group [anti-ABO(H)] but was positive for the Thomsen-Frieden-reich antigen. Flow cytometry of the tumor cells demonstrated a diploid or near-diploid DNA content. A karyo-type of the tumor showed a modal chromosome number of 46 with one reciprocal translocation between chromosomes 17 and 22 and a nonreciprocal translocation between chromosomes 18 and 22. The tumor was unique because of its highly aggressive nature and its diploid chromosome number. This case represents the first indepth characterization of a transitional cell carcinoma in a pediatric patient by flow cytometry and cytogenetics, as well as a variety of immunohistochemical studies including ABO(H) blood group and Thomsen-Freidenreich antigens.

Peripheral in-continuity tissue examination.

When treating skin cancers, it is essential to remove the entire neoplasm if possible. Immediate reconstruction is most helpful in returning the patient to a useful and satisfactory life. The Mohs histologic technique can be time-consuming and cumbersome. Reconstruction can be delayed. A modification of Mohs technique, peripheral in-continuity tissue examination (PITE), is described in which the surgeon and the pathologist combine their talents to remove the tumor. All margins are evaluated, and the surgical defect is closed primarily. Larger and more complex tumors can be removed and defects immediately reconstructed using this efficient technique, obviating the inconvenience, pain, and expense of multiple, separate procedures.

Histologic assessment of lymph nodes in mycosis fungoides/Sézary syndrome (cutaneous T-cell lymphoma): clinical correlations and prognostic import of a new classification system.

Mycosis fungoides and the Sézary syndrome share common cutaneous histopathologic features, and this spectrum of malignant disease is referred to here as cutaneous T-cell lymphoma (CTCL). A method (LN classification) for describing the histopathologic features of lymph nodes in CTCL is presented. In this system, lymph node biopsy specimens are scored according to the number of atypical lymphoid cells in T-cell-dependent paracortical zones and the preservation or distortion of the lymph node architecture. Lymph node architecture is preserved in lymph nodes scored LN1 to LN3, and these nodes may have coexistent dermatopathic change. LN1 nodes have single infrequent atypical lymphocytes in paracortical T-cell regions. LN2 nodes have small clusters of paracortical atypical cells. LN3 nodes have large clusters of atypical cells. LN4 nodes are partially or totally effaced by atypical cells. This system was used to classify 96 lymph node biopsy specimens obtained within six months of the initial diagnosis of CTCL; no LN1 nodes, 37 LN2, 44 LN3, and 15 LN4 nodes were found. The LN class was significantly correlated with the extent of skin, blood, and visceral involvement, as well as with survival. Patients with LN2 lymph nodes have an estimated five-year survival of 70 per cent, while patients with LN3 and LN4 nodes have estimated five-year survivals of 30 and 15 per cent, respectively. The survival differences between the LN subgroups were all significant (P less than 0.05). The LN classification system was clearly shown to be reproducible among experienced pathologists. The LN system for the histopathologic classification of lymph nodes in CTCL is of prognostic value and should be used to assess lymph node biopsies in patients with CTCL.

Avidin-biotin technique is more sensitive than lectin assay for detecting the Thomsen-Friedenreich antigen (T-antigen) in transitional cell carcinoma of the bladder.

Avidin biotin technique and lectin assay has been compared in a double-blind study for detection of the T-antigen in transitional carcinoma of the bladder. Utilizing the tumor registry from the U.S. Naval Hospital in Bethesda, Maryland, patients with transitional cell carcinoma of the bladder were identified. Thirty-three patients were selected with a total of 43 specimens. Tissues from 26 patients with a total of 43 specimens that showed no lesions and had no known history of genitourinary diseases were used as controls. These tissues were studied for the presence of T-antigen utilizing avidin biotin or lectin techniques. T-antigen was detected in 60% of the specimens with lectin technique, while 95% was detected with avidin biotin methods. The T-antigen was not detected by either method even after the treatment with neuraminidase in six patients. These patients had high grade and high stage tumors. This study demonstrated that normal urothelium has concealed T-antigen that can be exposed by treating the tissue with neuraminidase. However, the T-antigen is unconcealed in low grade tumor but disappears in high grade invasive tumor. Avidin biotin technique appears to be a more sensitive method for detecting the presence or absence of the T-antigen.

Peroxidase antiperoxidase versus specific red cell adherence in detection of O (H) antigen in bladder cancer: a blind study.

We have previously demonstrated that the presence or absence of ABO(H) cell surface antigens correlated with stage, grade, and prognosis of patients with bladder cancer. However, because of the weak antigenecity of 0(H), certain investigators have reported a high rate of false-negative results utilizing specific red cell adherence (SRCA) test of Davidsohn. Since approximately 45% of the population is blood group O(H), this high rate of false-negative result renders the test unreliable in an ordinary laboratory. The present study is comparing the results of SRCA to that of peroxidase antiperoxidase (PAP) technique in a double-blind fashion in 29 patients with bladder cancer having O(H) blood group. In terms of grade, stage, frequency of recurrent tumor, and quality of slides, the results of PAP is superior over SRCA. Furthermore, the convenience, permanence, and ready availability of PAP will enhance the utility of this test in a conventional histopathologic laboratory with a high rate of accuracy and reproducibility.

Immunoperoxidase versus specific red cell adherence in detection of ABO(H) antigens on normal urothelium. Double-blind study.

In this study we compared the sensitivity of SRCA for detecting A, B, O(H) blood group antigens on the urothelial surface of normal renal pelvis, ureter, and bladder to that of immunoperoxidase staining via the avidin-biotin complex (ABC) method. In all, forty-three mucosal specimens from 23 patients were compared. There was little difference between SRCA and immunoperoxidase for the detection of A and of B antigens. H(O) antigen was detected in 94 per cent of the blood group O patients using immunoperoxidase while only 46 per cent were detected using the SRCA method. We therefore concluded that immunoperoxidase was superior to SRCA in detecting the H(O) antigen not only in normal ureter but also in normal renal pelvis and normal bladder.

Erdheim-Chester disease: a distinct lipoidosis or part of the spectrum of histiocytosis?

Erdheim-Chester disease has always been considered a distinct lipoidosis based on clinical and radiographic criteria. Pathologically, it has been indistinguishable from Hand-Schüller-Christian disease. Analysis of the 15 reported cases lends some doubt as to the diagnostic criteria. A new case is presented that strongly suggests that Erdheim-Chester disease is actually part of the spectrum of the histiocytoses.

Double blind comparison of T-antigen and ABO(H) cell surface antigens in bladder cancer.

Transitional cell carcinoma of the bladder is a major cause of cancer deaths. Recently, much attention has been focused on ABO(H) antigen deletion in terms of prediction of prognosis. Furthermore, several studies have shown a correlation between T-antigen (a precursor of blood MN glycoprotein) expression in carcinomas of the breast, colon, and stomach. We have studied 56 specimens from 41 patients with transitional cell carcinoma of the bladder for T-antigen expression and ABO(H) antigen deletion. Results were analyzed with respect to tumor grade, tumor stage, and clinical course. The data indicate that T-antigen expression was not completely useful prognostically; it did not correlate with grade, stage, or clinical course. ABO(H) antigen expression or deletion was found to be a better predictor of tumor behavior than tumor grade, despite a false negative rate of 20 to 30 per cent in blood group O patients. We suggest that use of immunoperoxidase techniques will increase the sensitivity in group O patients, thus making ABO(H) deletion a useful predictive parameter of tumor aggressiveness. This is currently being evaluated in our patients.

Histologic evaluation of chronic gastroesophageal reflux. An evaluation of biopsy methods and diagnostic criteria.

Controversy exists regarding the appropriate method for biopsy confirmation of esophageal reflux injury. We have compared endoscopic pinch biopsy (PB) with endoscopically directed Rubin tube suction biopsy (SB) in 40 patients with symptomatic gastroesophageal reflux disease (GERD). Utilizing a plastic tube attached alongside the endoscope, SB at specific sites in the esophagus can be easily obtained. Suction biopsy was rated superior to PB for adequacy of tissue, ability to make an interpretation, and certainty in diagnosis. These differences were most pronounced in patients with endoscopic grades 0 and 1 + esophagitis in which 59% of PBs were uninterpretable compared to 23% of SBs. The passage of the Rubin tube was easily done and could be performed repeatedly. Six of 40 patients (15%) developed substernal chest discomfort in the 24 hr following SB. We conclude that SB is the most appropriate way to evaluate histologic changes related to reflux injury and that this method is mandatory in symptomatic patients with minimal endoscopic evidence of esophagitis (0-1 +).

Apocrine adenocarcinoma of the vulva with associated Paget's disease. Diagnosis of lymph node metastases by fine needle aspiration biopsy.

The cytologic features of a fine needle aspiration biopsy of lymph node metastases from a vulvar adenocarcinoma with apocrine differentiation are documented. Cytologic findings that suggested apocrine differentiation included extreme nuclear eccentricity, punctate eosinophilic cytoplasmic granules and moundlike protrusion of apical cytoplasm. The cytologic findings correlated well with the histologic and histochemical features of the primary vulvar adenocarcinoma and its lymph node metastases.

Adenocarcinoma of the lung causing ectopic adrenocorticotropic hormone syndrome.

A patient with a left lower lung mass had muscle weakness, generalized hyperpigmentation, metabolic alkalosis, and profound hypokalemia. His elevated serum cortisol, corticosterone, and adrenocorticotropic hormone (ACTH) concentrations were not suppressed after midnight dexamethasone administration. Light and electron microscopic sections of the lung mass fitted the pathological criteria for adenocarcinoma. Immunocytochemical analysis of the tumor demonstrated specific staining with antibody to beta-endorphin, suggesting that the tumor cells made the common precursor molecule of ACTH, beta-lipotropin, and endorphin. This is, to the best of our knowledge, only the second case report of pulmonary adenocarcinoma associated with the syndrome of ectopic ACTH.

Gingival granula cell tumors of the newborn (congenital "epulis"): a clinical and pathologic study of 21 patients.

The clinical and pathologic features of 24 gingival granular cell tumors in newborns are reviewed. These tumors occurred exclusively in females and were localized on the anterior alveolar ridge (maxilla: 14; mandible: 9); the gingiva overlying future canine and lateral incisor teeth was most frequently involved. Follow-up data for 15 patients (average duration 15 years) indicated a lack of tumor recurrence despite incomplete resection in 11 instances. Tumors resected early in the newborn period were larger (maximum diameter 2.0 cm) and showed confluent to nodular submucosal growth with relatively less collagen. Some showed features suggesting involution. The histology in most cases supported a mesenchymal origin rather than one from odontogenic epithelium. Immunohistochemical staining for selected oncofetal and other antigens was negative. Electron microscopy did not entirely resolve the controversy regarding histogenesis.

Granular cell tumor: a clinicopathologic study of 110 patients.

The clinicopathologic features of 118 granular cell tumors (GCT) encountered at two affiliated hospitals were reviewed. A total of 110 patients were affected over this 32-year period of study (71 men, 39 women), and in 5% GCT were multiple. Patients ranged in age from 16 to 58 years (average 32 years) and were symptomatic for an average duration of 11 months prior to diagnosis. There was a greater than expected frequency of GCT among black patients (29%). Although tongue was the single most common anatomic site involved, relatively more GCT (44%) occurred in skin or subcutaneous tissue. Less common locations were breast parenchyma (10 cases), rectal mucosa and anus (6), vulva (4), esophagus and larynx (2 cases each). The correct preoperative diagnosis of this protean tumor was made in only three patients. GCT were surgically treated with the average diameter of resected tumor being 1.2 cm (range 0.2--3.5 cm). Pseudoepitheliomatous hyperplasia was noted in 11 tumors and in one vulvar GCT there was overlying in situ squamous cell carcinoma. Tumors were incompletely excised in 24 of 56 patients having adequate followup; only five of these 24 patients experienced a local recurrence of tumor. Malignant behavior was not observed. Results of histochemical and ultrastructural study are briefly discussed. The precise histogenesis of GCT is uncertain but Schwann cell origin is favored in most cases.