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October 2001
Invasive micropapillary carcinoma of the breast: Does size matter?
The authors reported on 80 cases of infiltrating ductal carcinoma of the breast having a pure or partial micropapillary component. Study subjects ranged in age from 36 to 92 years (mean, 58.8 years) and tumor size ranged from 0.1 to 10 cm (mean, 2 cm). Twenty-five percent of cases were less than or equal to 1.0 cm and 7.5 percent were less than or equal to 0.5 cm. Overall, 62.5 percent of cases showed lymphatic invasion and 72.3 percent with axillary dissections showed positive axillary lymph nodes. Small tumor size was not predictive of favorable behavior. Forty-five percent of tumors of less than 1 cm in size and 33.3 percent of tumors of less than 0.5 cm showed lymphatic invasion, while 64.3 percent of tumors of less than 1 cm and 75 percent of tumors of less than 0.5 cm were associated with positive lymph nodes. The authors concluded that recognizing this entity, even as a small component of a more ordinary breast carcinoma, is important in predicting lymph node metastasis, regardless of overall tumor size.
Walsh MM, Bleiweiss IJ. Invasive micropapillary carcinoma of the breast: eighty cases of an underrecognized entity. Hum Pathol. 2001;32: 583-589.
Reprints: Ira J. Bleiweiss, MD, Dept. of Pathology, Box 1194, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029
Pap smear adequacy: Are endocervical cells necessary?
The clinical importance of identifying endocervical gland cells in Pap smears is controversial. Policies range from short interval rescreening to no change in screening interval based on this finding. The authors of this study used the Dutch Network and National Database for Pathology to evaluate more than 400,000 Pap smears obtained between 1990 and 1991 with regard to outcome over the subsequent seven years. They compared the incidence of cervical intraepithelial neoplasia 1, 2, and 3 as well as invasive carcinoma between the more than 395,000 Pap smears with endocervical cells present and the 53,000 Pap smears without endocervical gland cells. No difference was noted in the incidence of any grade of CIN or invasive cancer between the two groups. The authors concluded that the risk of severe cervical neoplasia during the next six to eight years for women who had a negative Pap smear does not depend on endocervical status. Therefore, an additional smear for women with negative smears without endocervical cells is not justified.
Bos AB, van Ballegooijen M, et al. Endocervical status is not predictive of the incidence of cervical cancer in the years after negative smears. Am J Clin Pathol. 2001;115:851-855.
Reprints: A. B. Bos, Dept. of Public Health, Faculty of Medicine, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, Netherlands
Usefulness of Fli-1 in differentiating vascular neoplasms from mimics
Vascular tumors with solid growth pattern, epithelioid change, or spindle cell morphology may be confused with a variety of nonvascular neoplasms. An endothelial marker of higher sensitivity and specificity than those currently used would be valuable in this setting. The authors described Fli-1, a nuclear transcription factor that appears to fulfill this need, although it is also expressed in Ewing's sarcoma/primitive neuroectodermal tumor and lymphomas. Of 53 vascular tumors immunohistochemically stained and scored for Fli-1 in a study, 50 were positive, with nuclear expression in more than 50 percent of cells. This includes 11 of 13 epithelioid angiosarcomas, two of two spindle cell hemangiomas, eight of nine epithelioid hemangioendotheliomas, and 12 of 12 Kaposi's sarcomas. In contrast, none of 68 nonvascular tumors (16 sarcomas, seven melanomas, and 45 carcinomas) revealed nuclear positivity. The authors caution that significant differences in concentration between different lots of the polyclonal antibody make it necessary to establish an optimal dilution for each lot prior to use.
Folpe A, Chand EM, Goldblum JR, et al. Expression of Fli-1, a nuclear transcription factor, distinguishes vascular neoplasms from potential mimics. Am J Surg Pathol. 2001;25:1061-1066.
Reprints: Andrew L. Folpe, MD, Dept. of Pathology, H-175, Emory University Hospital, 1364 Clifton Rd. NE, Atlanta, GA 30322; afolpe@bellsouth.net
Is a normal appendix really normal?
The authors conducted a study to address the question: Are appendices removed from patients with clinically suspected appendicitis really normal if they appear normal on histological examination? The study included 15 acutely inflamed appendices, 39 histologically normal appendices from patients with suspected appendicitis, and 11 negative control specimens. Using immunofluorohistochemistry and confocal laser microscopy, the authors looked for a variety of inflammatory mediators, including cyclooxygenase 1 and 2, prostaglandin E2, nitric oxide synthase, and major histocompatibility complex class II. They identified strong expression of all inflammatory mediators studied in the mucosa of all histologically inflamed appendices and in more than 50 percent of the histologically normal appendices from clinically suspicious patients but in none of the appendices used as controls. The authors concluded that there is a subgroup of normal appendices from appendicitis patients in which the evidence of an inflammatory pathologic condition is obvious only at a molecular level.
Nemeth L, Reen DJ, O'Briain S, et al. Evidence of an inflammatory pathologic condition in "normal" appendices following emergency appendectomy. Arch Pathol Lab Med. 2001;125:759-764.
Reprints: Prem Puri, MS, FRCS, Children's Research Centre, Our Lady's Hospital for Sick Children, Crumlin, Dublin 12, Ireland; ppuri@crumlin.ucd.ie
High-grade prostatic intraepithelial neoplasia on needle biopsy: features that predict risk for subsequent carcinoma
Histopathologic features that could predict which patients with high-grade prostatic intraepithelial neoplasia (HG-PIN) on initial biopsy were more likely to have carcinoma on followup biopsy would be useful in identifying men who need additional biopsies. The authors studied 245 men with HG-PIN on initial biopsy and at least one followup biopsy. Carcinoma was identified in 32.2 percent of men on subsequent biopsy. The cancer was identified on the first repeat biopsy in 24.5 percent of the men (median interval from diagnosis of HG-PIN to subsequent first biopsy, 5.3 months). Interestingly, the authors noted no correlation with serum prostate-specific antigen level or rate of change of serum PSA and risk of cancer on subsequent biopsy. The only independent histologic predictor was the number of positive cores on initial biopsy. Among those with more than one followup biopsy (81/245), the following features in the initial biopsy, in addition to the number of positive cores, predicted carcinoma: presence of mitoses, predominant micropapillary and cribriform HG-PIN, and very large prominent nucleoli. Cancer was identified in only two of 15 men with more than two repeat biopsies. These findings, if confirmed by additional studies, would be useful for developing a rational strategy for following men with HG-PIN on biopsy.
Kronz JD, Allan CH, Shaikh AA, et al. Predicting cancer following a diagnosis of high-grade prostatic intraepithelial neoplasia on needle biopsy: data on men with more than one follow-up biopsy. Am J Surg Pathol. 2001;25:1079-1085.
Reprints: Jonathan I. Epstein, MD, Johns Hopkins Hospital, Weinberg Bldg., Rm. 2242, 401 N. Broadway St., Baltimore, MD 21231; jepstein@jhmi.edu
Mucoepidermoid carcinoma: reassessing histological grading
A group of experienced ENT/oral pathologists examined the validity and reproducibility of histological grading and the MIB-1 index as prognosticators for mucoepidermoid carcinoma. The authors studied material collected over two decades from a group of 80 patients. They compared their grading systems with the standardized system recommended by the Armed Forces Institute of Pathology. By their own systems, all grade I tumors were localized and did not experience relapse. The local failure rates at 75 months for grades II and III tumors were 30 and 70 percent, respectively. The authors identified tumor grade, stage, and margin status as correlating with disease-free survival but did not find the MIB-1 index to be useful. In terms of reproducibility, the authors found that the grade assigned by the AFIP criteria was more reproducible than that assigned by their systems but that the AFIP system tended to systematically downgrade tumors. The authors indicated that adding criteria such as vascular invasion and pattern of tumor infiltration to the AFIP schema would help enhance predictability.
Brandwein MS, Ivanov K, Wallace DI, et al. Mucoepidermoid carcinoma. A clinicopathologic study of 80 patients with special reference to histological grading. Am J Surg Pathol. 2001;25:835-845.
Reprints: Margaret S. Brandwein, MD, Box 1189, Dept. of Pathology and Otolaryngology, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 11021; m_brandwein@mssm.edu
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