Frequency and clinical significance of simultaneous association of lobular neoplasia and columnar cell alterations in breast tissue specimens.

Lobular neoplasia (LN) and columnar cell alterations (CCAs) may share similar genetic abnormalities, but there is no appreciable literature that addresses the simultaneous occurrence of these lesions in breast core biopsy (CNB) specimens or resection specimens. Three groups of breast tissue were examined: group 1, 68 CNB specimens targeted for "suspicious" microcalcifications (Breast Imaging Reporting and Data System [BI-RADS] 4) and diagnosed with LN; group 2, 2,516 CNB reports for a 1-year period; and group 3, 400 consecutive breast carcinoma resection specimens analyzed for LN and CCAs within the vicinity of carcinoma. In group 1, LN was associated with CCAs in 54% of cases (37/68). In group 2, LN was found in association with CCA in 1.3% of cases (32/2,516). In group 3, 13.0% of cases of CCAs (52/400) were associated with LN. Our study suggests the association of these two lesions in breast tissue is nonrandom and that they may have a common progenitor pathway of neoplastic development.

Pulmonary valve papillary fibroelastoma. A case report and review of the literature.

Papillary fibroelastomas are rare and benign cardiac tumors that typically affect the cardiac valves. To the best of our knowledge, the English literature contains only 1 case report of pulmonary valve fibroelastoma diagnosed by echocardiogram and confirmed by surgical resection. There is a paucity of pathology literature on this subject. We describe an additional case of pulmonary valve fibroelastoma diagnosed by transesophageal echocardiography and magnetic resonance imaging confirmed by pathologic examination in a patient who also had a thymoma.

Small-cell variant of synovial sarcoma: fine-needle aspiration with ancillary features and potential diagnostic pitfalls.

We report a small-cell variant of synovial sarcoma examined by fine-needle aspiration (FNA) biopsy. The patient is a 23-yr-old female who had a synovial sarcoma involving the left infratemporal region, diagnosed at 7 yr of age, followed by a metastatic lesion involving the lung and chest wall 16 yr later. The chest wall metastases was sampled by FNA biopsy. The aspirate consisted of numerous, small, round cells with very high nuclear-to-cytoplasmic ratios. The cytomorphologic features could potentially be confused with other pediatric small round cell tumors. Ancillary studies demonstrated positive staining of the neoplastic cells for cytokeratin, epithelial membrane antigen (EMA), and CD99. The differential diagnosis of other small round cell tumors that may be mistaken for the small-cell variant of synovial sarcoma are presented. We believe that this is the first FNA report detailing the cytologic and ancillary features of the small-cell variant of synovial sarcoma.

Prognostic information from fine-needle aspiration biopsy of breast carcinoma.

Fine-needle aspiration of the breast is one of the most common procedures performed on patients with a palpable breast mass. The pathologist needs to be aware of the diagnostic and prognostic parameters that must be included in the cytopathology report of breast carcinomas. These fundamental parameters include tumor type, nuclear grade of the carcinoma, and hormone receptor status.

Distribution of calponin and smooth muscle myosin heavy chain in fine-needle aspiration biopsies of the breast.

The cell types that may be present in any fine-needle aspiration biopsy (FNAB) of breast include epithelial cells (EC), myoepithelial cells (MEC), bipolar stromal cells (BSC), vascular pericytes/endothelial cells (VPEC), and adipose cells (AC). The recognition of most of these benign cellular elements in aspirates of the breast is relatively straightforward, based on distinct cytomorphologic criteria. However, there is controversy regarding the recognition of MEC because BSC are often referred to as MEC by cytopathologists. It is important to identify MEC in breast aspirates, because their presence has been associated with benign epithelial proliferations. In this study we used immunocytochemical methods on archival cytology slides with antibodies specific for MEC, calponin, and smooth muscle myosin heavy chain (SMMHC), to determine the distribution of MEC in FNAB of the breast and to ascertain the distribution of MEC in in situ and invasive carcinomas. Fifteen benign FNABS of breast and corresponding tissue biopsies were obtained along with 10 malignant FNABS and corresponding excisional breast biopsies from 1989-1993. Calponin and SMMHC antibodies were used on archival alcohol-fixed Papanicolaou-stained direct smears as well as the corresponding tissue sections. The distribution and pattern of positive immunostaining with both antibodies were recorded on the benign elements and the carcinomas for both cytologic and histologic slides. Benign breast tissues demonstrated strong continuous immunostaining for calponin and SMMHC of MEC. The interlobular stromal cells as well as intralobular stromal cells showed no immunostaining with either antibody. In cytologic preparations, MEC staining with calponin and SMMHC appeared as spindle cells between epithelial cells or along the edges of the epithelial groups. The bipolar stromal cells did not stain with either antibody. The tissues with DCIS (ductal carcinoma in situ) often showed the presence of MEC with strong calponin immunostaining, but sometimes the immunostaining was discontinuous or entirely absent around markedly dilated ducts. The SMMHC antibody was invariably negative, with architectural DCIS in dilated ducts. Two cases of DCIS with prominent periductal fibrosis or inflammation were positive for calponin, but the periductal stromal cells were calponin- and SMMHC-negative. Invasive carcinoma was negative for both calponin and SMMHC, but areas of DCIS were often positive in a discontinuous pattern. In conclusion, 1) Benign cellular elements from breast tissue FNAB showed strong continuous decoration of MEC with both calponin and SMMHC. Vascular pericytes and vascular smooth muscle were positive for both antibodies, but these cells were not observed in the FNAB. Benign proliferative epithelium showed no local increase in MEC with either antibody. Bipolar stromal cells in tissue and smears did not stain for MEC antibodies. 2) BSC did not correspond morphologically to MEC, and were not decorated with calponin or SMMHC. 3) Calponin-positive MEC were commonly associated with in situ ductal lesions, although they may at times have been discontinuous or absent entirely. DCIS may be recognized in FNAB by the presence of calponin-positive MEC associated with tumor cell groups. 4) Invasive carcinomas were invariably negative for MEC with these antibodies.

Fine-needle aspiration cytology of a mediastinal seminoma associated with multilocular thymic cyst.

Multiloculated thymic cysts are uncommon lesions that can be either acquired or associated with malignancies. This report describes the fine-needle aspiration (FNA) cytology of a mediastinal seminoma with prominent cystic change, confirmed by surgical pathology examination and ancillary studies performed on both the cytology and tissue specimens. The FNA cytology revealed clusters of malignant oval-to-polygonal-shaped cells with large oval nuclei possessing prominent nucleoli set in a pale-to-eosinophilic cytoplasm. These cells were surrounded by a dense lymphoid infiltrate along with a few noncaseating granulomas. The large malignant seminoma cells stained positive for placental alkaline phosphatase (PLAP) and negative for both low molecular and broad-spectrum cytokeratin. The differential diagnosis of malignancies associated with thymic cysts is presented. To the best of our knowledge, this is the first report of aspiration cytology of a mediastinal seminoma associated with a multilocular cyst.

The surgical pathologist's approach to fine needle aspiration.

The diagnostic process begins with triage of the FNAB, depending on the patient's problem. Portions of the specimen can then be set aside for appropriate immunocytochemistry, hormone receptors analysis, electron microscopy, flow cytometry, or molecular studies. Microscopic evaluation, as in surgical pathology, begins with scanning objective examination of tissue architecture, followed by study of cellular characteristics, and finally the nuclear features. Cytopathology and surgical pathology are no longer distinct entities.

Immunocytochemistry on cytologic specimens of limited quantity.

Some cytologic specimens may be limited in quantity, and this may hamper or preclude the performance of immunocytochemistry (ICC) in cases where more than one antibody (ab) is required by ICC to arrive at a definitive diagnosis. There is very little information in the cytology literature regarding the use of ICC for specimens that are limited in quantity. In this study, we describe a method, derived from the principles of double immunolabelling, whereby more than one ab test can be repeatedly used on the same Papanicolaou stained slide. Multiple cytologic scrape preparations fixed in 95% ethanol were obtained from fresh surgical specimens including carcinomas of the breast, endometrium, stomach, ovary and colon. Nonneoplastic tissues included tonsil (2), lymph node (2) and myometrium. Papanicolaou stained slides or unstained slides were subjected to two sequential ICC procedures, the first in which the ab was known to be nonreactive with the cells (insulin, glucagon, or somatostatin) and the second in which the ab was known to be positive in the cells. Positive controls for the known positive abs included a single-step ICC procedure as well as the tissue section. The test abs included CAM 5.2, AE1/3, K903, LCA, L26, UCHL-1, s-100, mCEA, GCDFP-15, vimentin, muscle specific actin and desmin. Identical two-step ab procedures were carried out on the tissues from the same surgical specimens. For Papanicolaou stained cytologic specimens, abs were reactive and gave excellent results for the repeat second-step ICC method. There was no false positive or false negative staining. This "repeat ICC" method also gave excellent results on the tissue sections. Immunocytochemistry can be performed more than once on the very same cytologic specimen if the initial ICC antibody attempt is negative. This method may be especially useful in situations where more than one antibody is needed on a very limited cytologic sample size.

Immunocytochemistry on the Thinprep processor.

INTRODUCTION: For cytologic specimens, the vast majority of immunocytochemical studies (ICC) are performed on non-gynecologic specimens for diagnostic purposes, and they can be performed on unstained or previously stained direct smears. Although the ThinPrep processor (TPP) has been approved for the preparation of non-gynecologic specimens, there is scant literature describing the utility of ICC methodology on cytology specimens fixed and processed by this method. MATERIALS AND METHODS: Forty-one fresh specimens were obtained from the surgical gross room and aspirated or scraped to collect cells for thin layer (TL) and direct smears (DS). Specimens included a variety of neoplastic and nonneoplastic samples that were either Papanicolaou (P) stained or unstained (US). One group of US TL slides was subjected to antigen retrieval (AR). Staining was graded semiquantitatively. Each sample acted as its own control. Antibodies (abs) included: CAM5.2, AE1/3, K903, vimentin, MSA, desmin, s-100, HMB45, PSA, PAP, chromogranin, NSE, insulin, synaptophysin, pCEA, mCEA, mCEAD14, LCA, L26, UCHL-1, OPD-4, thyroglobulin, GCDFP, ER/PR, laminin, collagen IV, PLAP, HCG, CD68, HAM56, and MAC387. RESULTS: Semiquantitative staining overall results comparisons: TLP > DSP TLP < DSP TLP = DSP TLUS > DSUS 11/25 (44%) 6/25 (24%) 8/25 (32%) 9/24 (38%) TLUS < DSUS TLUS = DSUS 3/24 (12%) 12/24 (50%) TLP Vs. TLUS TLP > TLUS TLP < TLUS TLP = TLUS 8/41 (20%) 9/41 (22%) 24/41 (58%) There were five false-negative results, 2 with TL and 3 with DS, and 1 false-positive TL. DISCUSSION: Immunocytochemistry performed on the ThinPrep Processor showed equal or greater intensity and distribution of proper staining when compared to direct smears with the following advantages: (1) cleaner background, easier to interpret; (2) less abs required in a smaller area; (3) IPX can be done on Papanicolaou-stained thin layer slides; (4) thin layer slides can be modified for multiple abs tests; (5) additional thin layer slides can be prepared for ICC bases on needs. No significant differences of immunostaining were seen when comparing thin layer Papanicolaou-stained and unstained slides. Antigen retrieval offered no advantage in this study.

Inflammatory cell types and clinical features of interstitial cystitis.

PURPOSE: We tested whether the types of inflammatory cells seen on bladder biopsies were associated with other clinical features and urinary markers of interstitial cystitis. MATERIALS AND METHODS: Bladder biopsies from 30 interstitial cystitis patients were evaluated by immunohistochemical staining for T cells, B cells, macrophages and human leukocyte antigen-DR positive cells. These findings were tested for associations with clinical features and urinary markers of interstitial cystitis using alpha = 0.01 because multiple tests were performed. RESULTS: Overall severity of inflammation was significantly associated with age at symptom onset, symptom relief after bladder distention and urinary interleukin-6 levels. Patients with severe inflammation had trends toward smaller bladder capacity under anesthesia, increased bladder vascularity and mucosal cracks, lower urinary MUC-1 glycoprotein levels and absence of bloating as a symptom. B cell staining was significantly associated with severe inflammation, symptom relief after distention and absence of bloating as a symptom. T cell staining was significantly associated with severe inflammation and age at symptom onset. Human leukocyte antigen-DR staining had trends with symptoms, including presence of bloating, constant urge to void and absence of burning. Macrophage staining did not associate with any features tested at the alpha = 0.05 level. CONCLUSIONS: Interstitial cystitis patients with severe inflammation have different age, treatment response and urinary marker levels than those with mild inflammation. These findings suggest that the 2 patient groups have different underlying pathophysiologies. The significant associations for T and B cell staining were similar to those for overall inflammation.

Recurrent type I membranoproliferative glomerulonephritis after renal transplantation and protective role of cyclosporine in acute crescentic transformation.

Almost all diseases affecting the native kidney may recur in the transplanted kidney, with one of the most frequent being recurrent glomerulonephritis. Among the glomerulonephritides, membranoproliferative glomerulonephritis (MPGN), immunoglobulin A nephropathy (IgA), and focal-segmental glomerulosclerosis (FSGS) have the highest rates of recurrence. Here we report a patient who, after living-related kidney transplantation, suffered allograft loss shortly after surgery due to recurrence of glomerulonephritis. Two weeks prior to transplant nephrectomy light microscopic examination of the allograft biopsy failed to show glomerulonephritis. Subsequent histopathology of the transplant nephrectomy specimen demonstrated a crescentic form of type I MPGN following withdrawal of cyclosporin A (CsA) and intense course or oral steroid therapy. The entity of recurrent type I MPGN in kidney transplantation is reviewed, and a possible protective role of CsA against rapidly progressive crescentic type I MPGN is explored.

KRAS oncogene mutations suggest a common histogenetic origin for pleomorphic giant cell tumor of the pancreas, osteoclastoma of the pancreas, and pancreatic duct adenocarcinoma.

Giant cell neoplasms of the pancreas are rare tumors of uncertain histogenesis. Mutation of the KRAS oncogene is common in typical pancreatic duct adenocarcinoma. We have analyzed DNA from five pancreatic tumors with giant cells for mutations in the KRAS oncogene and found alterations of the second position of codon 12 in each case (four G > A transitions and one G > C transversion). The common mutation pattern in tumors with giant cells and duct adenocarcinoma suggests a common route to malignant transformation and may indicate a shared histogenesis. We also tested 11 cases of malignant fibrous histiocytoma, a histological mimic of pleomorphic giant cell tumor, for mutations in the KRAS oncogene. The absence of KAS mutations in each of the malignant fibrous histiocytomas (MFHs) and in other histologically similar tumors may provide assistance in the differential diagnosis of pleomorphic pancreatic tumors.

Expression of aromatase protein and messenger ribonucleic acid in tumor epithelial cells and evidence of functional significance of locally produced estrogen in human breast cancers.

The expression of aromatase by breast cancer cells and the role of locally produced estrogen in the stimulation of tumor growth has been controversial. The present study was performed to determine the site of aromatization in human breast cancers, using both immunocytochemistry and in situ hybridization. The functional significance of locally produced estrogens on growth of the tumor was addressed by measuring aromatase activity and a marker of proliferation (PCNA score). In addition, histocultures of some tumors were carried out to investigate whether testosterone aromatization could stimulate tumor proliferation. Of the 19 tumors investigated, 10 (52.6%) showed significant immunoreactivity to antiaromatase antibody in the cytoplasm of tumor epithelial cells and in surrounding stromal cells. The presence of aromatase mRNA detected by ISH was also located in tumor epithelial cells and stromal cell, and the pattern of expression was the same as with immunocytochemistry. In the ten tumors that showed immunoreaction to aromatase, the average aromatase activity measured in cryosections was 286.5 +/- 18.6 (SE) fmol estrogen/mg protein.h, whereas in nine tumors with weak aromatase immunoreaction, the enzyme activity was 154.7 +/- 19.3 (SE) fmol estrogen/mg protein-h (P < 0.05). The mean PCNA score was 33.8 +/- 5.1 (SE)% in strongly stained tumors and 20.8 +/- 2.0 (SE)% in weakly stained tumors (P < 0.05). Aromatase activity level and PCNA score were significantly correlated. In histoculture of four tumors, estradiol increased the incorporation of [3H]-thymidine into DNA. In two of these tumors, aromatase activity was high and [3H]-thymidine incorporation into DNA was also stimulated by testosterone. In the other two tumors that had low aromatase activity, no such stimulation occurred with testosterone. The results indicate that aromatase is expressed mainly in tumor epithelial cells and that sufficient amounts of estrogen are synthesized by the tumor to produce a proliferative response. It is concluded that estrogen synthesis by cancer cells could play a important role in promoting growth in a significant proportion of breast tumors.

Transitional cell bladder carcinoma with presentation mimicking ovarian carcinoma.

In the case described here, the patient's initial presentation suggested ovarian carcinoma. She had recurrent ascites, a pelvic mass, elevated CA-125, and extensive peritoneal carcinomatosis with transitional cell histology. The presence of hematuria prompted a cystoscopy, which revealed the true site of origin to be the urinary bladder rather than ovaries. This presentation is extremely rare for bladder cancer. Since transitional cell tumors from the bladder have a much worse prognosis than those of ovarian origin, it is important to identify the primary site correctly. Therefore, cystoscopy is essential for patients with hematuria, and should be considered in cases of apparent primary peritoneal carcinoma with transitional cell histology.

The immunohistochemical discrimination of endometrioid adenocarcinomas.

Carcinomas of endometrioid histology frequently arise in the endometrium, ovary, and endocervix and involve the pelvic tissues in women. Adenocarcinomas of psuedoendometrioid morphology developing in the colon also frequently involve the ovary. The authors retrospectively examined 97 adenocarcinomas from the uterus, cervix, ovary, and colon to ascertain whether the site of origin could be determined by using a battery of antibodies with the immunoperoxidase method on formalin-fixed tissue. This study was restricted to tumors with endometrioid morphology. There were 27 endometrial, 16 ovarian, 23 endocervical adenocarcinomas, and 31 psuedoendometrioid colonic adenocarcinomas. The battery of antibodies included vimentin (V), monoclonal carcinoembryonic antigen (mCEA), and monoclonal CEA D-14. V-positive cells were defined by the presence of a crisp paranuclear band of staining, and CEA-positive cells showed irregular or diffuse cytoplasmic staining. V diffusely decorated 22 of 27 (81.4%) of endometrial tumors, 3 of 23 (13%) of endocervical tumors, (rare, focal staining), diffusely stained 5 of 16 (31.3%) of ovarian tumors, and was rare and focal in 2 of 31 (6.4%) of colon tumors. Both CEA antibodies were negative for cytoplasmic staining in both endometrial and ovarian tumors, but decorated from 65.2% (CEA D-14) to 95.6% (monoclonal CEA) of endocervical tumors and from 83.8% (CEA D14) to 90.3% (mCEA) of colonic tumors. The authors conclude that endometrioid adenocarcinomas developing in endometrium and ovary are most often strongly V positive and CEA negative, which greatly aids in distinguishing them from endometrioid or pseudoendometrioid tumors arising in endocervix and colon, which are only rarely, and very focally V and CEA positive. The antibodies do not allow for discrimination between endocervical and colonic tumors. CEA D-14 offered no immunodiagnostic superiority over mCEA. These results support the use of immunohistochemistry is assisting in the distinction of endometrial from endocervical primary sites in curettage specimens and in metastatic sites.

Correlations of morphology, proliferation indices, and oncogene activation in ductal breast carcinoma: nuclear grade, S-phase, proliferating cell nuclear antigen, p53, epidermal growth factor receptor, and c-erb-B-2.

The proliferative capacity of breast carcinomas has prognostic significance as measured by S-phase fraction (SPF), yet the molecular parameters that influence the proliferative capacity of breast carcinomas have not been fully elucidated. Ninety-three cases of invasive ductal breast carcinomas, not otherwise specified, were studied by immunohistochemistry and flow cytometry to determine what correlations exist between nuclear grade (NG), SPF, proliferating cell nuclear antigen and the overexpression of p53, epidermal growth factor receptor (EGFR), and c-erb-B-2 in formalin-fixed tissues by the immunoperoxidase method. NG predicted elevated SPF in 78% of cases and was associated with high proliferating cell nuclear antigen score. The presence of p53 was detectable in 13% of cases, and, in each case, the NG was high (Grade 3), with nine aneuploid tumors and three diploid tumors. The SPFs for all p53-positive cases were markedly elevated, with 77.8% of the cases with SPF > 15%. EGFR was present in 20.4% of all tumors, including 77.8% of tumors positive for p53 and 14% of tumors negative for p53 (P < .001). The mean SPF for p53-positive EGFR-positive tumors was 17.5% versus 21.1% for p53-positive EGFR-negative tumors. The mean SPF for p53-negative tumors was significantly less, regardless of the presence of EGFR. The gene c-erb-B-2 was found in 28% of tumors, all of which were p53 negative. These data clearly show a close relationship between high NG and elevated SPF. As determined by flow cytometry, SPF is more consistent and more reliably related to NG than proliferating cell nuclear antigen.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunocytochemical staining of unstained versus previously stained cytologic preparations.

Immunoperoxidase (IP) staining of fine needle aspiration specimens may provide useful adjunct information in cytodiagnosis. IP may be used on unstained direct smears or cell block material if available. In the absence of such material, IP is sometimes used on previously stained (Papanicolaou) smears. Few studies have examined the adequacy of such preparations, however. We compared IP staining results on unstained, alcohol-fixed or air-dried smears versus alcohol-fixed, previously Papanicolaou stained smears and versus alcohol-fixed, decolorized, Papanicolaou-stained smears, using antibodies to keratin (CAM 5.2, AE1/AE3 and K903), epithelial membrane antigen, monoclonal carcinoembryonic antigen, desmin, muscle-specific actin (HHF-35), vimentin, leukocyte common antigen, B and T cell markers L26 and UCHL-1, and prostate-specific antigen. Seventy-five sets of smears were made from various neoplastic or nonneoplastic tissues received as surgical specimens, and antibodies were selected for anticipated positive staining. The results were graded in a semiquantitative fashion. All the methods gave comparable results regarding expected positive staining, background staining and preservation of cellularity. We conclude that these methods of smear preparation are of equal utility in adjunctive immunocytochemical studies.

Intraoperative immunocytochemistry of cytologic scrape specimens. A rapid immunoperoxidase method for triage and diagnosis.

We investigated a rapid immunoperoxidase (IPX) method utilizing a wide variety of antibodies for use on cytologic scrapings of fresh tissue that were submitted for intraoperative frozen section. The handling, fixation and IPX staining of these cytologic scrape specimens are more rapid and convenient than frozen tissue sections and spare tissues that may be of small quantity for appropriate special diagnostic studies (flow cytometry, cell markers, genetic studies, electron microscopy, and so forth). Fresh tissues from normal organs and tumors were scraped with a scalpel blade, smeared on an uncoated glass slide and immersed in 95% alcohol for one minute. Antibodies investigated by this method included: CAM 5.2, AE1/3, keratin 903, desmin, vimentin, HHF-35, CEA, PLAP, NSE, S-100, HMB45, LCA, L26 and UCHL-1. Twenty-three fresh epithelial and mesenchymal tissues from the uterus, colon, tonsil, lymph node, kidney and adrenal gland were examined, along with 29 tumors. There were 21 carcinomas, 3 melanomas, 3 sarcomas and 2 lymphomas. Using the streptavidin-biotin technique with aminoethylcarbazole localization, IPX results were available in 15-20 minutes, comparable to the time required for the reporting of a frozen section diagnosis. Keratins, vimentin, desmin and LCA gave the best results. HMB45 was weakly reactive in one case. This rapid cytologic IPX method may be used as an adjunct to frozen sections and cytologic imprints for intraoperative diagnosis or for efficient triage of poorly differentiated tumors for special studies at the time of frozen section.

Brucella melitensis: an unexpected isolate from cerebrospinal fluid.

A specimen of cerebrospinal fluid was initially handled with 'category 3' precautions because the patient came from Somalia, where tuberculosis and HIV infection are endemic. An isolate from the specimen, initially thought to be a Neisseria species, was subsequently handled on the open bench. It was later identified as Brucella melitensis. Laboratory procedures should allow for the possibility of brucella in such specimens until a positive identification has been made.