Atypical diagnosis rendered on breast needle core biopsy
The three recent papers referenced herein assess the problem of
what to do with the patient for whom a diagnosis of atypical ductal
hyperplasia or lobular intraepithelial neoplasia has been made on
an image-guided needle core biopsy. Middleton et al, who addressed
lobular lesions in their study, found little evidence to support
excision unless there was also an associated radiographic mass.
In their study, all six cases with invasive carcinoma on excision
had this finding. The two studies that addressed atypical hyperplasia
identified cytologic atypia as an important predictor of significant
residual disease. The study by Bonnett et al also noted that atypical
papillary pattern, number of atypical foci (>4), and larger span
of microcalcifications (>2.0 cm) were associated with an increased
risk of residual ductal carcinoma in situ. In addition to cytologic
atypia, Yeh et al. added apoptosis/individual cell necrosis as a
noteworthy feature in identifying a more serious lesion on excision.
These three papers do not provide definitive answers by themselves.
They do, however, provide ammunition in the struggle to develop
meaningful clinical recommendations based on the pathologic findings
observed in small specimens obtained from “minimally invasive”
Yeh IT, Dimitrov D, Otto P, et al. Pathologic review
of atypical hyperplasia identified by image-guided breast needle
core biopsy. Correlation with excision specimen. Arch Pathol
Lab Med. 2003;127:49-54.
Reprints: Dr. I-Tien Yeh, Dept. of Pathology, University of Texas
Health Science Center, San Antonio, 7703 Floyd Curl Drive, San Antonio,
TX 78229; yehi@uthscsa.Edu.
Middleton LP, Grant S, Stephens T, et al. Lobular carcinoma in situ
diagnosed by core needle biopsy: When should it be excised? Mod
Reprints: Dr. Lavinia P. Middleton, Dept. of Pathology, University
of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 85,
Houston, TX 77030; email@example.com.
Bonnett M, Wallis T, Rossmann M, et al. Histopathologic analysis of atypical lesions in image-guided core breast biopsies. Mod Pathol. 2003;16(2):154-160.
Reprints: Dr. Daniel Visscher, Dept. of Pathology, Mayo Clinic, 200 First St.
SW, Rochester, MN 55905; firstname.lastname@example.org.
Renal carcinomas associated with PRCC-TFE3 gene fusion
Molecular analysis of tumors may help identify neoplasms with unique
clinicopathologic features and may also provide insight into treatment
strategies. The authors described 11 renal carcinomas with a t(X;1)(p11.2;q21)
or the resulting PRCC-TFE3 gene fusion, or both. A characteristic
morphologic feature of these neoplasms is the immediate juxtaposition
of cells with clear and eosinophilic cytoplasm with nested and papillary
architecture. Such features may cause these neoplasms to be confused
with conventional clear cell, papillary, or recently described ASPL-TFE3
renal carcinomas. Unlike conventional clear cell or papillary renal
carcinomas, however, these neoplasms are negative or only focally
positive for cytokeratin and epithelial membrane antigen and are
positive for TFE3 protein (90 percent), RCC antigen (90 percent),
and CD10 (100 percent). They may mimic ASPL-TFE3 renal carcinomas
clinically and on histomorphology; however, unlike ASPL-TFE3 carcinomas,
they show more consistent epithelial features on ultrastructural
examination and appear to have a less invasive growth pattern. The
authors noted that PRCC-TFE3 tumors are likely slow-growing indolent
lesions, with some having a long interval to metastasis. The presence
of a fibrous pseudocapsule that may be calcified appears to be a
gross characteristic of these tumors.
Argani P, Antonescu CR, Couturier J, et al. PRCC-TFE3
renal carcinomas: morphologic, immunohistochemical, ultrastructural,
and molecular analysis of an entity associated with the t(x;1)(p11.2;q21).
Am J Surg Pathol. 2002;26:1553-1566.
Reprints: Dr. Pedram Argani, Johns Hopkins Hospital,
Surgical Pathology, Weinberg Building, Room 2242, 401 N. Broadway,
Baltimore, MD 21231-2410; email@example.com.
Clinical significance of gastrointestinal involvement in mantle cell lymphoma
The reported frequency of gastrointestinal tract involvement in
patients with mantle cell lymphoma (MCL) is 15 to 30 percent. This
figure, however, is most likely underestimated because most patients
with MCL involving the GI tract that was previously reported were
examined endoscopically only if they had GI tract symptoms. How
endoscopic assessment influences the management of MCL patients
is unknown. In this study, only 26 percent of patients presented
with GI symptoms at the time of diagnosis. MCL was present histologically
in the lower GI tract of 53 of 60 patients (88 percent) and in the
upper GI tract of 28 of 58 patients (43 percent). Microscopic evidence
of MCL was found in 84 percent of patients with normal visual (macroscopic)
findings by lower endoscopy and in 45 percent of patients with macroscopically
normal findings by upper endoscopy. Despite this high frequency
of GI tract involvement, the use of upper and lower endoscopy with
biopsies in this group of patients resulted in changes in clinical
management in only three (four percent) patients. Gastrointestinal
tract involvement was found in most patients with MCL, usually at
a microscopic level involving macroscopically normal mucosa. Aggressive
staging evaluation of the GI tract was found to have little impact
on patient-management decisions in this study.
Romaguera JE, Mederios LJ, Hagemeister FB, et al. Frequency of gastrointestinal
involvement and its clinical significance in mantle cell lymphoma. Cancer.
Reprints: Dr. Jorge E. Romaguera, University of Texas M.D. Anderson Cancer Center,
1515 Holcombe Blvd., P.O. Box 429, Houston, TX 77030; firstname.lastname@example.org.
Morphologic reappraisal of serrated colorectal polyps
The “hyperplastic polyp” is considered a benign lesion
with no malignant potential, whereas “serrated adenoma”
is a precursor of adenocarcinoma. The morphologic complexity of
serrated adenoma varies from being clearly adenomatous to being
difficult to distinguish from hyperplastic polyp. This creates a
need for more detailed morphologic analysis of all serrated polyps.
The authors evaluated 24 morphologic variables in 289 serrated polyps
from the colon and rectum. They performed cluster analysis and discriminant
analysis. A subset of polyps was immunostained for hMHL1 and hMSH2.
Major differences were found between right-sided and left-sided
polyps. A distinct group of serrated polyps with abnormal proliferation
was identified throughout the colon and rectum. These polyps demonstrated
decreased expression of hMHL1 and hMSH2 compared with polyps with
normal proliferation. Left-sided serrated polyps with normal proliferation
further clustered into three groups: vesicular cell-type, goblet
cell-type, and mucin-poor-type. The authors recommend evaluating
localization, size, and morphologic features when serrated polyps
are included in colorectal carcinogenesis research. Polyps with
abnormal proliferation are similar to the polyps in “hyperplastic
polyposis” and, because of their decreased expression of hMLH1
and hMSH2, may be the subset of polyps associated with the development
of colorectal carcinoma via the microsatellite instability pathway.
Torlakovic E, Skovlund E, Snover DC, et al. Morphologic
reappraisal of serrated colorectal polyps. Am J Surg Pathol.
Reprints: Dr. Dale C. Snover, Dept. of Pathology, Fairview Southdale Hospital, 6401 France Ave. S., Edina, MN 55435; email@example.com.
Anatomic pathology abstracts editors
Michael Cibull, MD, professor of pathology and laboratory medicine and director
of surgical pathology, University of Kentucky Medical Center, Lexington.
Subodh Lele, MD, assistant professor of pathology and laboratory medicine,
University of Kentucky Medical Center.