Cystic pancreatic endocrine tumors are rare neoplasms that pose a preoperative diagnostic challenge. The authors conducted a study to evaluate the preoperative diagnostic strategy for addressing these tumors and to assess their clinical and pathologic characteristics. They retrospectively enrolled in the study six subjects with cystic pancreatic endocrine tumors (PET). They performed endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) in four cases. The authors reported in detail all cytomorphologic data from conventional smears, ThinPrep preparations, and cell block preparations. Enrolled in the study were three male and three female patients who were a mean age of 52.3 years. Tumor size ranged from 10 mm to 60 mm (mean, 29.8 mm). The authors found that EUS-FNAB contributed to an accurate diagnosis in all cases. Cytologically, loosely cohesive aggregates and single cells were predominant. Cells were small and typically plasmacytoid, with occasional cytoplasmic vacuolization. Nuclei were round or oval and uniform, with finely and evenly distributed chromatin. Immunocytochemistry confirmed endocrine differentiation. Histologic findings were typical for endocrine proliferation. All tumors were well differentiated. The authors concluded that cystic PET is an unusual finding that presents diagnostic challenges for endoscopists and cytologists. EUS-FNAB with the ThinPrep preparation technique and cell block material helped improve diagnostic accuracy. Immunocytochemical staining with endocrine markers confirmed the diagnosis.
Charfi S, Marcy M, Bories E, et al. Cystic pancreatic endocrine tumors: an endoscopic ultrasound-guided fine-needle aspiration biopsy study with histologic correlation. Cancer Cytopathol. 2009;117(3):203–210.
Correspondence: Dr. Slim Charfi at firstname.lastname@example.org
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Melanomas that arise in association with blue nevi or that resemble blue nevi are extremely rare and have been termed malignant blue nevi. The authors reported on a single institutional clinicopathologic study of blue nevus-like melanomas (BNLMs). The study involved 26 patients with a malignant blue nevus who were identified over a period of 29 years at the Sydney Melanoma Unit at the University of Sydney, in Australia. Twenty-three of the patients were included in the study after pathologic review. Clinical out-comes for those patients were compared with the outcomes for a control group of patients with melanoma who were matched for age, gender, Breslow thickness, Clark level, ulceration, and anatomic site. Study subjects were a median age of 44 years and 65 percent were male. The tumors were distributed evenly among skin sites and had a median Breslow thickness of 5.5 mm. After a median followup of 36.5 months, the authors found no difference in survival rate (P=.702) between patients with BNLM and patients in the control group. The authors concluded that BNLMs tended to present at a more advanced stage and with thicker primary tumors but had a metastatic pattern comparable to other types of melanoma and were not more aggressive than other types of melanoma. Consequently, BNLMs should be treated in the same way as any other melanoma variants based on clinical staging and pathologic prognostic indices.
Martin RC, Murali R, Scolyer RA, et al. So-called “malignant blue nevus”: a clinicopathologic study of 23 patients. Cancer. 2009;115(13):2949–2955.
Correspondence: Dr. John F. Thompson at email@example.com
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Sentinel lymph node status in melanoma patients is of prognostic value. But it is unclear whether lymphatic invasion is associated with sentinel lymph node positivity. To assess this, the authors evaluated lymphatic invasion using D2-40/S-100 dual immunohistochemistry in primary cutaneous melanomas with known sentinel lymph node status. They retrospectively reviewed 27 biopsy specimens of primary cutaneous melanoma from 27 patients and examined lymphatic invasion with and without D2-40/S-100 dual immunohistochemistry. The authors also evaluated such clinicopathologic variables as age, gender, histologic type, Breslow thickness, Clark level, ulceration, and mitoses. The results showed unequivocal lymphatic invasion in 10 of 27 melanomas using D2-40/S-100 dual immunohistochemistry compared with one of 27 using routine histology. Eight of 10 melanomas with lymphatic invasion were sentinel lymph node negative. No statistical association was found between the presence or absence of lymphatic invasion and sentinel lymph node status. The authors concluded that D2-40/S-100 dual immunohistochemistry increases the sensitivity for detection of lymphatic invasion in melanoma but does not predict sentinel lymph node involvement.
Petitt M, Allison A, Shimoni T, et al. Lymphatic invasion detected by D2-40/S-100 dual immunohistochemistry does not predict sentinel lymph node status in melanoma. J Am Acad Dermatol. 2009;61(5):819–828.
Correspondence: Dr. Brent Kelly at firstname.lastname@example.org
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The significance of immunohistochemical detection of DNA mismatch repair proteins or microsatellite instability testing, or both, in identifying patients at risk for germline deficiency in DNA mismatch repair genes is well established in colorectal carcinomas. However, the proper use of such techniques in sebaceous neoplasms, another tumor type that has been implicated in patients with hereditary DNA mismatch repair deficiency, has not been clearly defined. The authors conducted a study in which they stratified a series of 27 patients with one or more sebaceous neoplasms based on the pattern of immunohistochemical expression of MLH1, MSH2, MSH6, and PMS2, and comparatively analyzed their clinical and pathologic characteristics, including tumor-infiltrating lymphocytes and peritumoral lymphocytic response as determined by immunohistochemical staining for CD3. The study tissue samples included 30 sebaceous carcinomas, 14 sebaceous adenomas, and seven sebaceous hyperplasias, as well as eight concurrent nonsebaceous lesions from six patients. Overall, 12 of the 27 (44 percent) patients showed abnormal immunohistochemical staining with mismatch repair proteins in their sebaceous tumors. The most common abnormality was concurrent loss of MSH2 and MSH6, which was seen in eight of 12 patients (67 percent). Sebaceous adenomas and carcinomas occurring in the same patients showed an identical staining pattern, as did hereditary nonpolyposis colorectal cancer-related nonsebaceous tumors in the same patients. When compared with patients who had normal expression of mismatch repair proteins, patients with abnormal expression tended to be younger (median age, 56.5 years versus 68 years), more likely to have malignancy sites outside the head and neck (9 of 12 versus 0 of 15), and more likely to have synchronous or metachronous visceral malignancies (8 of 12 versus 3 of 15) and a positive family history. Furthermore, sebaceous tumors with abnormal expression had significantly higher CD3-positive tumor-infiltrating lymphocytes and peritumoral lymphocytic response. Therefore, all of these factors—age less than 60 years, involvement of nonhead and nonneck sites, visceral malignancy, family history fulfilling at least Bethesda guidelines, and lymphocytic infiltration—were of value in predicting abnormal expression of DNA mismatch repair proteins. However, their sensitivity was only modest, being 58 percent, 75 percent, 67 percent, 78 percent, and 75 percent, respectively. Given that sebaceous neoplasms are only infrequently encountered and that immunohistochemistry is easily available and reasonably reliable, the authors recommend that, when identifying hereditary DNA mismatch repair deficiency, routine immunohistochemical detection of DNA mismatch repair proteins be performed in all sebaceous neoplasms, regardless of a patient’s age or other clinical characteristics.
Orta L, Klimstra DS, Qin J, et al. Towards identification of hereditary DNA mismatch repair deficiency: sebaceous neoplasm war-rants routine immunohistochemical screening regardless of patient’s age or other clinical characteristics. Am J Surg Pathol. 2009:33(6):934–944.
Correspondence: Dr. Jinru Shia at email@example.com
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American Joint Committee on Cancer anatomic stage group is considered relatively nondiscriminatory for predicting differences in survival after pancreatectomy for ductal adenocarcinoma. The authors conducted a study to investigate the potential for improving the predictive value of AJCC staging by incorporating individually predictive histologic features into AJCC tumor-node-metastasis classification of anatomic extent and by determining the simplest combination of tumor characteristics for predicting survival. The authors determined survival rates for 137 patients who underwent pancreatectomy for ductal adenocarcinoma with curative intent (stage groups IA to IIB) at the Moffitt Cancer Center, Tampa, Fla., during the last two decades. They used data obtained from medical record review, the Moffitt cancer registry, and the Social Security Death Index. His-tologic characteristics were confirmed by expert review. Median survival was 21.2 months after pancreatectomy, with a three-year disease-specific survival rate of 36 percent. Univariate Kaplan-Meier analysis and multivariate Cox proportional hazard modeling found worse survival rates with local extrapancreatic extension, poorly differentiated histology, and lymphatic invasion within tumor (P<.05). Survival was not worse with nodal metastases, microscopically positive resection margins, and perineural or venous invasion, nor was survival better with cancer arising from an intraductal papillary mucinous neoplasm. Kaplan-Meier estimates for different variable combinations showed prognosis was best for well- or moderately differentiated tumors without lymphatic invasion that were confined to the pancreas (9.9-year median survival). Prognosis was worst for poorly differentiated tumors with lymphatic invasion and local extension beyond the pancreas (8.5-month median survival). And prognosis was inter-mediate for well- or moderately differentiated tumors with lymphatic invasion or local extension beyond the pancreas (21.2-month median survival). The authors concluded that a simple combination of tumor differentiation, lymphatic invasion within the tumor, and local extrapancreatic extension predicts survival after pancreatectomy for ductal adeno-carcinoma.
Helm J, Centeno BA, Coppola D, et al. Histologic characteristics enhance predictive value of American Joint Committee on Cancer staging in resectable pancreas cancer. Cancer. 2009;115(18):4080–4089.
Correspondence: Dr. James Helm at firstname.lastname@example.org and Dr. Mokenge P. Malafa at email@example.com
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Atypical spitzoid melanocytic tumor is an ambiguous diagnosis that has overlapping features of spitz nevus and melanoma. Many children and teenagers with this diagnosis will get a sentinel lymph node (SLN) biopsy. Individuals with positive SLN typically will go through treatment for a melanoma. There is little long-term followup of these individuals from which to determine if this practice is appropriate. To better understand the biology of these tumors, the authors retrospectively reviewed the clinical and pathological findings of children and teenagers with atypical spitzoid melanocytic tumor (ASMT) and positive SLN. All children and teenagers were younger than 18 years at the time of diagnosis and were followed for at least three years. Eleven individuals—six girls and five boys—with primary ASMT and positive SLN were identified. The primary tumors ranged in thickness from 2.1 to 12 mm (median, 4.6 mm; mean, 5 mm). The tumor mitotic rate ranged from 1 to 10 mitoses/mm (median, 3/mm). The positive SLNs included six nodes with intranodal melanocytic aggregates measuring less than 1 mm in greatest dimension and five nodes in which the size of the melanocyte deposits was 1 mm or more. All patients with ASMT and positive SLN remained free of disease at a median followup of 47 months (mean, 61 months; range, 36–132 months). In contrast, two of five patients younger than 18 years who had a histologically unambiguous melanoma and a positive SLN died of metastatic melanoma. The overall disease-specific mortality rate for all patients younger than 18 years who were diagnosed with melanoma was 12 percent. The authors’ findings confirm that children and teenagers with ASMTs and positive SLNs have a less aggressive clinical course than those with histologically unambiguous melanoma.
Busam KJ, Murali R, Pulitzer M, et al. Atypical spitzoid melanocytic tumors with positive sentinel lymph nodes in children and teenagers, and comparison with histologically unambiguous and lethal melanomas. Am J Surg Pathol. 2009;33(9):1386–1395.
Correspondence: Dr. Klaus J. Busam at firstname.lastname@example.org
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Anatomic pathology abstracts editors: Michael Cibull, MD, professor and vice chair, Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington; Melissa Kesler, MD, and Rouzan Karabakhtsian, MD, assistant professors of pathology and laboratory medicine, University of Kentucky College of Medicine; and Megan Zhang, MD, visiting fellow, Division of Dermatopathology, University of California, San Francisco.