Anatomic Abstracts

March 2003

Breast core biopsy and therapeutic excision of invasive
breast carcinoma
Breast core biopsy is a major nonoperative method of diagnosis. Increasingly, there is also a need to provide prognostic data to facilitate timely patient management. The authors presented the results from 500 patients with invasive breast carcinoma who underwent core biopsy followed by a therapeutic surgical procedure. Grade and type of the invasive and in situ carcinoma, together with the presence or absence of vascular invasion, were compared between biopsy and definitive surgical excision. There was 67 percent agreement with overall grade (kappa value, 0.48), with scores for tubule formation, pleomorphism, and mitotic scoring achieving values of 82 percent, 73 percent, and 58 percent, respectively. Only 60 percent of grade one and two carcinomas showed concordance, but 84 percent of grade three tumors showed agreement between core and excision results. Tumor typing, vascular invasion, and grading of ductal carcinoma in situ had agreement values of 74 percent, 69 percent, and 65 percent, respectively. The major problem with assessing prognostic factors on needle biopsy specimens is undersampling of the most informative areas. However, a high level of agreement was achieved in this study in those patients in whom preoperative assessment of prognostic factors is most likely to be beneficial—that is, those with grade three carcinomas.

Harris GC, Denley HE, Pinder SE, et al. Correlation of histologic prognostic factors in core biopsies and therapeutic excisions of invasive breast carcinoma. Am J Surg Pathol. 2003;27(1):11-15.

Reprints: Dr. Gavin C. Harris, Dept. of Histopathology, Nottingham City Hospital, Hucknall Rd., Nottingham, United Kingdom; gharris@doctors.org.uk

Fourteen-gauge needle core biopsy of mammographically evident radial scars
Radial scars are benign lesions that may mimic breast carcinoma on mammography. They usually are managed by excision biopsy. The authors reported their experience with stereotactic needle core biopsy (SNCB) sampling compared to excision of the lesion in 75 patients. Sixty-three patients were sampled by core biopsy: SNCB was used in 55 patients (87 percent) and ultrasound-guided needle core biopsy (UNCB) was used in eight patients (13 percent). One patient who underwent SNCB did not undergo a followup excision biopsy. Radial scars were diagnosed preoperatively by core biopsy in 51 of 62 patients who underwent excision (82 percent; 95 percent confidence interval, 70 to 91 percent). The sensitivity for SNCB was 85 percent (95 percent CI, 73 to 94 percent), and the sensitivity for UNCB was 63 percent (95 percent CI, 24 to 91 percent). Of 54 patients who underwent SNCB and excision, four patients had coexistent ductal carcinoma in situ (DCIS) at the time they underwent surgical excision: SNCB identified DCIS in one patient and identified atypical ducal hyperplasia in three patients. In the group of 75 radial scars, five (seven percent) were associated with DCIS, and there were no invasive carcinomas. Atypical ductal hyperplasia was present in association with 42 of 74 radial scars (57 percent) that were excised surgically. Twenty-nine of the radial scars were sampled preoperatively by SNCB. Atypical ductal hyperplasia was found in 21 patients (72 percent; 95 percent CI, 53 to 87 percent). These findings suggest that patients with SNCB-proven radial scars among a screened population can be managed safely by mammographic followup if there is no associated DCIS, atypical ductal hyperplasia, or lobular carcinoma in situ. Spiculated abnormalities with discordant SNCB results require surgical biopsy.

Cawson JN, Malara F, Kavanagh A, et al. Fourteen-gauge needle core biopsy of mammographically evident radial scars. Is excision necessary? Cancer. 2003;97;345-351.

Reprints: Jennifer N. Cawson, Breast Screen Department, St. Vincent's Hospital, First Floor, Healy Wing, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia; cawsonjn@svhm.org.au

Isolated bone marrow manifestation of Hodgkin lymphoma associated with HIV
Human immunodeficiency virus-associated Hodgkin lymphoma frequently involves bone marrow and is usually recognized at staging after Hodgkin lymphoma diagnosis on a lymph node or other tissue biopsy. Occasionally, however, marrow involvement is the only apparent manifestation of disease, and diagnosis can be problematic. Of 42 patients with newly diagnosed human immunodeficiency virus-associated Hodgkin lymphoma, 22 subjects had positive marrow involvement at diagnosis, and 16 of them had additional substantial histological or clinical extramedullary Hodgkin lymphoma. In the remaining six patients, bone marrow was the only site of disease at diagnosis. In all six cases, bone marrow biopsy revealed obvious lymphomatous involvement. Reed-Sternberg cells were identified morphologically and immunophenotypically in all cases. Spared marrow tissue consistently showed fibrosis. All of the study subjects were males (median age, 35 years; range, 31 to 58 years), and all presented with fever, blood cytopenias, and severe CD4+ lymphocyte depletion (median, 70 cells/mm³). After diagnosis, all staging procedures were negative, and all patients were treated with chemotherapy. Median survival was four months (range, two to 118 months). Longer survival occurred in the patients who completed chemotherapy regimens; three subjects, however, died shortly before completing chemotherapy, two of them from Hodgkin lymphoma. The occurrence of isolated bone marrow HIV-associated Hodgkin lymphoma may be underestimated in HIV-infected patients. In those people with unexplained fever and blood cytopenias, bone marrow biopsy should be performed with the aim of assessing for Hodgkin lymphoma, even in the absence of nodal and visceral lymphomatous involvement. A rapid diagnosis of isolated bone marrow HIV-associated Hodgkin lymphoma could expedite therapy.

Ponzoni M, Fumagalli L, Rossi G, et al. Isolated bone marrow manifestation of HIV-associated Hodgkin lymphoma. Mod Pathol. 2002;15(12):1273-1278.

Reprints: Dr. Maurilio Ponzoni, Dept. of Pathology and Infectious Diseases, S. Raffaele H Scientific Institute, Via Olgettina 60, 20132 Milan, Italy; ponzoni.maurilio@hsr.it

Diagnostic sensitivity of bronchoalveolar lavage vs. lung fine-needle aspirate
Bronchoalveolar lavage and lung fine-needle aspirate are commonly performed as the first line of investigation for a myriad of pulmonary problems associated with abnormal imaging findings, including mass, cavitary lesion, and infiltrates. The relative sensitivities of these two procedures are not well established for cytologic diagnosis of lesions for any single disease event. Between January 1989 and June 2000, 52 episodes of closely timed (65 percent within three days) bronchoalveolar lavage (BAL) and lung fine-needle aspirate (LFNA) procedures were identified in 45 patients for a single disease event. The clinical scenarios as per the sample requisitions were: consolidation/infiltrate (60 percent), mass/nodule (23 percent), cavitary lesion (5.7 percent), pneumonia (5.7 percent), or not specified (5.7 percent). In 18 of the 52 pairs (35 percent), LFNA uniquely identified malignancy (12 percent) or infectious agents such as Aspergillus and acid-fast bacteria (23 percent) with a corresponding nondiagnostic BAL. In one episode with a clinical diagnosis of infiltrates, the BAL was positive for acid-fast bacteria and the LFNA was negative. Chi-square analysis of the data revealed statistical significance (P<.0001), indicating LFNA to be a better method than BAL for the cytologic diagnosis of pulmonary pathology.

Clark BD, Vezza PR, Copeland C, et al. Diagnostic sensitivity of bronchoalveolar lavage versus lung fine needle aspirate. Mod Pathol. 2002:15(12):1259-1265.

Reprints: Dr. Andrea Abati, Cytopathology Section, Laboratory of Pathology/NCI/ NIH, Bldg. 10, Room 2A19, Bethesda, MD 20892-1500; abatia@mail.nih.gov