College of American Pathologists
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November 2003

Adrenal cortical neoplasms in the pediatric population: an analysis of 83 patients
Adrenal cortical neoplasms in pediatric patients younger than 20 years of age are rare. The clinical manifestations and biologic behavior of these lesions can be distinct from their histologically similar counterparts in the adult population, making pathologic criteria for distinguishing benign from malignant tumors equivocal. The authors studied 83 adrenal cortical neoplasms to determine if adult clinical and histologic features can be applied to pediatric patients in an outcome-based analysis. Most of the patients (50 girls and 33 boys) presented with hormone-related symptoms that were present for a mean of 6.8 months. The tumors ranged in size from 2 to 20 cm (mean, 8.8 cm). Among the histologic parameters examined were capsular or vascular invasion, or both, extraadrenal soft tissue extension, growth pattern, cellularity, necrosis, cytoplasmic eosinophilia, nuclear pleomorphism, nuclear-to-cytoplasmic ratio, prominent nucleoli, mitotic figures, atypical mitotic figures, bands of fibrosis, and calcifications. Immunophenotypically, there was reactivity with inhibin, vimentin, and CK5, and focally with p53 and Ki-67. All patients underwent adrenalectomy, and 20 patients received adjuvant therapy. All patients with tumors classified as adenomas (n=9) were alive without evidence of disease (mean, 14.7 years), whereas 21 patients with carcinomas died with disease (2.4 years). Only 31 percent of histologically malignant tumors behaved in a clinically malignant manner. Features associated with an increased probability of malignant clinical behavior included tumor weight greater than 400 g, tumor size greater than 10.5 cm, vena cava invasion, capsular or vascular invasion, or both, extension into periadrenal soft tissue, confluent necrosis, severe nuclear atypia, more than 15 mitotic figures/20 high power fields, and presence of atypical mitotic figures. Vena cava invasion, necrosis, and increased mitotic activity (more than 15 mitotic figures/20 high power fields) independently suggested malignant clinical behavior in multivariate analysis.

Wieneke JA, Thompson LDR, Heffess CS. Adrenal Cortical Neoplasms in the Pediatric Population: a Clinicopathologic and Immunophenotypic Analysis of 83 Patients.Am J Surg Pathol. 2003;27(7):876-881.

Reprints: Dr. Jacqueline A. Wieneke, Dept. of Endocrine and Otorhinolaryngic-Head & Neck Pathology, Bldg. 54, Room G-066-10, Armed Forces Institute of Pathology, 6825 16th St. NW, Washington, DC 20306-6000;

Colon cancer survival relative to the number of lymph nodes analyzed
The authors conducted a study to determine the relationship between survival and the number of lymph nodes analyzed from surgical specimens in patients with adenocarcinoma of the colon. Intergroup Trial INT-0089, a mature trial of adjuvant chemotherapy for high-risk patients with stages II and III colon cancer, was used. The investigators performed a secondary analysis of this group with overall survival as the main end point. Cause-specific survival and disease-free survival were secondary end points. Rates for these outcome measures were estimated using Kaplan-Meier methodology. A log-rank test was used to compare overall curves, and Cox proportional hazards regression was used for multivariate assessment of predictors of outcome. The median number of lymph nodes removed at colectomy was 11 (range, one to 87). Of 3,411 assessable patients, 648 had no evidence of lymph node metastasis. Multivariate analyses were performed on the node-positive and node-negative groups separately to ascertain the effect of lymph node removal. Survival decreased with increasing lymph node involvement (P=.0001 for all three survival end points). After controlling for the number of nodes involved, survival increased as more nodes were analyzed (P=.0001 for all three end points). Even when no nodes were involved, overall survival and cause-specific survival improved as more lymph nodes were analyzed (P=.0005 and P=.007, respectively). The authors concluded that the number of lymph nodes analyzed for staging colon cancers is, itself, a prognostic variable for outcome. The impact of this variable is such that it may be important enough to include in evaluating future trials.

Le Voyer TE, Sigurdson ER, Hanlon AL, et al. Colon Cancer Survival is Associated with Increasing Number of Lymph Nodes Analyzed: a Secondary Survey of Intergroup Trial INT-0089. J Clin Oncol. 2003;21(15): 2912-2919.

Reprints: Dr. Elin R. Sigurdson, Fox Chase Cancer Center, 7701 Burholme Ave., Philadelphia, PA 19111

Avoiding misinterpretation of E

ECICas a primary cervical lesion
Misinterpretation of endometrial endometrioid carcinoma involving the cervix (EECIC) as a primary cervical lesion may lead to understaging of the endometrial tumor and improper therapy. In this study, the authors described 15 such cases from consultation material in which the nature of the cervical process was not clear or misinterpreted by the referring pathologist. Among the lesions that may be confused with EECIC are mesonephric remnant hyperplasia, tubal/tuboendometrioid metaplasia, endosalpingiosis, minimal deviation cervical endometrioid carcinoma, and cervical adenocarcinoma with cystic dilatation of glands. These lesions can have features that may overlap with those found at least focally in EECIC. In 12 of 15 cases, direct extension from contiguous carcinoma was confirmed. Immunohistochemistry for vimentin, carcinoembryonic antigen, and estrogen receptor had similar results in the cervical and endometrial tumors in cases in which this was done. These findings, along with morphologic similarity between the two tumors, helped in interpreting the cervical process as EECIC. The authors suggested that awareness of this phenomenon and rigorous sampling of the corpus and cervix can help in resolving this issue in most cases on careful analysis of routinely stained slides.

Tambouret R, Clement PB, Young RH. Endometrial Endometrioid Adenocarcinoma with a Deceptive Pattern of Spread to the Uterine Cervix: a Manifestation of Stage IIb Endometrial Carcinoma Liable to be Misinterpreted as an Independent Carcinoma or a Benign Lesion. Am J Surg Pathol. 2003; 27: 1080-1088.

Reprints: Dr. Rosemary Tambouret, Massachusetts General Hospital, Dept. of Pathology, 55 Fruit St., Boston, MA 02114; rtambouret @partners.orgn