Ultrastructure of cystosarcoma phyllodes and fibroadenoma. A comparative study

Electron microscopic studies were conducted on 11 cases of cystosarcoma phyllodes (6 benign, 3 malignant, 2 recurrent), 1 stromal sarcoma, and 15 cases of fibroadenomas. Particular emphasis was placed on examination of the epithelial-stromal junction. The epithelial cells were basically similar in all cases. The basal lamina of fibroadenomas tended to be reduplicated, whereas in cystosarcoma phyllodes the basal lamina was less reduplicated and even focally absent. A continuous layer of delimiting fibroblasts was not present in either type of tumor. Stromal cells were generally fibroblasts, with 2 of 15 being fibroadenomas and 2 of 11 cystosarcoma phyllodes showing myofibroblastic differentiation. The stromal sarcoma also showed smooth muscle differentiation. The authors conclude that the epithelial-stromal junction is abnormal in both fibroadenomas and cystosarcomas, but the abnormality is different in these two tumors. Increasing prominence of stromal cell junctions and of lysosomes also correlated with the diagnosis of cystosarcoma, particularly the malignant variant.

Vincristine, dactinomycin, and cyclophosphamide in the treatment of malignant germ cell tumors of the ovary. A Gynecologic Oncology Group Study (a final report)

Seventy-six patients with malignant germ cell tumors of the ovary received vincristine, dactinomycin, and cyclophosphamide (VAC) postoperatively. Fifty-four were treated after removal of all gross disease. The majority of these remain disease-free. Indeed, only 15 (28%) have failed, including 11 of 24 with pure endodermal sinus tumor, 3 of 11 (27%) with mixed germ cell tumor containing endodermal sinus elements, and only 1 of 20 with immature teratoma grade 2 or 3, a patient seen initially with recurrent disease. Postoperative VAC therapy, however, did not appear to be effective in patients with unresectable or incompletely resected germ cell tumors of the ovary. Fifteen of 22 patients (68%) with incompletely resected germ cell tumors failed VAC therapy, including 4 of 7 with pure endodermal sinus tumor, 5 of 5 with mixed germ cell tumors containing endodermal sinus elements, 2 of 2 with embryonal carcinoma, and 4 of 8 with immature teratoma. In failing, patients' median time to progression was 8 months. Dose-limiting toxicity was seen in 30% of the entire group. Combined cisplatin, vinblastine and bleomycin therapy now is being tested in this group of tumors.

Intraoperative imprints for the identification of parathyroid tissue

Parathyroid exploration involves identification of all accessible parathyroid glands and the distinguishing of normal and pathologic parathyroid glands. Close collaboration of the surgeon and the surgical pathologist is characterized by courtesy and efficiency with special techniques by each that facilitate accuracy and speed, particularly at the conclusion of the surgical exploration when the biopsy specimens have been passed to the pathologist on a "parathyroid map" and the patient remains anesthetized. Parathyroid imprint by touch preparation technique allowed cytologic examination in less than 1 minute per specimen, with ready identification of the presence or absence of parathyroid tissue. Pathologic diagnoses were also possible on abnormal parathyroid glands when the parathyroid imprint was used as a screening procedure to select specimens for frozen section. Accuracy and speed were excellent as used in this series of parathyroid surgical pathology consultations. Intraoperative imprint confirmation of parathyroid tissue is suggested as an improvement in pathologic consultation during parathyroid exploration.

The autopsy and cancer

The autopsy plays an important role in neoplastic disease. Over one third of all adult autopsies disclose cancer, and clinical diagnostic errors are disclosed in approximately 40% of these. There is no evidence that diagnostic accuracy has improved in recent years. In addition to monitoring diagnostic accuracy--particularly with reference to new technologies--the autopsy is also important in detecting both new types of cancer and new causative agents and patterns of incidence and behavior in "old" types of cancer. It also plays a major role in characterizing the toxic effects of new therapeutic regimens and in establishing true causes of death (including accurate primary cancer sites) for setting local, national, and international research and health care priorities.

Surgical staging in endometrial cancer: clinical-pathologic findings of a prospective study

The pathologic features of a prospective study of FIGO stage I endometrial cancer is presented. The uterus, tubes, ovaries, and pelvic lymph nodes of 222 cases and aortic nodes of 157 cases have been analyzed. The surgical-pathologic specimen would suggest a negligible risk for lymph node metastasis if: cancer is confined to the endometrium irrespective of grade, invasion is superficial for grades 1 and 2 tumor, the intermediate third of the myometrium is invaded for grade 1 tumor only, and occult disease is not present in the cervix and/or adnexa. Conversely, a substantial risk for lymph node metastasis exists if the surgical-pathologic study identifies superficial myometrial invasion by grade 3 cancer, intermediate myometrial invasion by grade 2 or 3 cancer, deep myometrial invasion by cancer of any grade, vascular space involvement, and extension of tumor to the cervix and/or adnexa.

Ultrastructure of papillary serous carcinoma of the endometrium

Three cases of papillary serous carcinoma of the endometrium ( PSCE ) have been studied by transmission electron microscopy, and the ultrastructural findings compared with those in classical "endometrioid" carcinoma of the endometrium ( CECE ) and papillary serous carcinoma of the ovary ( PSCO ). PSCE possesses many ultrastructural features in common with both CECE and PSCO , as well as with clear cell carcinoma of the endometrium, emphasizing the close relationship existing among these different tumors of Müllerian origin. The only useful ultrastructural distinguishing features between serous and endometrioid carcinomas of similar histologic grade are more numerous secretory granules in the former and prominent paranuclear microfilaments and tonofilaments in the latter. Despite its lack of ultrastructural distinctiveness, the clinical behavior of PSCE justifies its consideration as a unique clinicopathologic entity.

New aspects of endometrial carcinoma

We have presented a review of aspects of endometrial carcinoma that have received prominent attention since the last review of this subject published in these pages in 1976. These include the relationship of exogenous oestrogens to the development of endometrial cancer; the differential diagnosis of carcinoma from endometrial metaplasias and hyperplasias; the prognostic and therapeutic significance of various histological patterns of carcinoma, including adenoacanthoma, mixed adenosquamous carcinoma, and papillary serous carcinoma; pathological and clinical distinctions between 'true' myometrial, cervical and ovarian invasion and histological findings which mimic these patterns but do not have the same unfavourable prognostic significance; and the prognostic significance of partially or completely host-related factors such as immunological response, hormone receptors, and both exogenous and endogenous hyperoestrinism. Many of the questions posed here remain at least partially unresolved, and it is hoped that further studies will be performed in these areas.

Hepatocellular carcinoma in young people

The clinical and pathologic features of 23 cases of hepatocellular carcinoma occurring in patients younger than age 35 years (mean age, 17.4 years) were analyzed. Ten of these (43%) were the fibrolamellar oncocytic variant (FLO), characterized by large polygonal neoplastic hepatocytes and lamellar bundles of collagen. The remainder (non-FLO) showed the usual wide range of gross and histologic patterns typical of hepatocellular carcinoma in older age groups. Overall, hepatocellular carcinoma was more common in females than in males. The FLO variant was characterized by a longer duration of symptoms prior to diagnosis, increased frequency of resectability of the tumor, and infrequency of mitoses. Of particular importance is the fact that 5 of 10 patients with the FLO variant are alive and clinically free of disease 1 1/2 to 8 years postoperatively, while none of the 13 patients with non-FLO hepatocellular carcinoma is alive and free of disease. There was no significant difference between the two groups in mean age at diagnosis, presence of single versus multiple hepatic tumors, vascular invasion, or tumor necrosis. Although cirrhosis was present in three non-FLO patients and none of the FLO patients, the difference was not statistically significant. The prognosis of hepatocellular carcinoma in young patients does not appear to differ from that in older patients, with the exception of the fibrolamellar oncocytic variant, a variant which is common in younger patients.

Immunohistochemical localization of carcinoembryonic antigen in microglandular hyperplasia and adenocarcinoma of the endocervix

Immunoperoxidase localization of carcinoembryonic antigen (CEA) was performed on tissue sections of microglandular hyperplasia and adenocarcinoma of endocervical origin to see if CEA would be a marker of malignancy in this context. Twenty (95%) of 21 of the benign lesions were negative and one was focally positive. Nine (64%) of 14 adenocarcinomas were widely positive, four were focally positive, and one was negative. These results suggest that extensive immunohistochemical positivity for CEA in endocervical glandular lesions is indicative of malignancy.

Cystic mesothelioma of the peritoneum: a report of five cases and review of the literature

Five cases of the recently characterized cystic mesothelioma of the peritoneum are presented. The patients, all women, ranged in age from 23-50, and were seen with large, solitary or multiple, multicystic masses involving the abdominal and pelvic peritoneum. Histologically, they consisted of interconnecting cystic cavities lined by a single layer of flattened to cuboidal cells with variable nuclear atypia. These cells in one case showed ultrastructural features consistent with mesothelial origin. In follow-up periods ranging from 1-13 years, two patients have had recurrence of disease, but all patients are still alive. When these cases are combined with the ten previously reported, the recurrence rate in patients followed for two years or more is 50% (four of eight). This lesion may represent a clinically "borderline" variant between the better known benign (adenomatoid tumor) and malignant mesotheliomas of the peritoneum.

Cystic mesothelioma of the peritoneum: a report of five cases and review of the literature

Five cases of the recently characterized cystic mesothelioma of the peritoneum are presented. The patients, all women, ranged in age from 23-50, and were seen with large, solitary or multiple, multicystic masses involving the abdominal and pelvic peritoneum. Histologically, they consisted of interconnecting cystic cavities lined by a single layer of flattened to cuboidal cells with variable nuclear atypia. These cells in one case showed ultrastructural features consistent with mesothelial origin. In follow-up periods ranging from 1-13 years, two patients have had recurrence of disease, but all patients are still alive. When these cases are combined with the ten previously reported, the recurrence rate in patients followed for two years or more is 50% (four of eight). This lesion may represent a clinically "borderline" variant between the better known benign (adenomatoid tumor) and malignant mesotheliomas of the peritoneum.

Ultrastructure of congenital cystic adenomatoid malformation of the lung

Four cases of congenital cystic adenomatoid malformation of the lung are presented with ultrastructural analysis. In some of the cases the ultrastructure is similar to that described in normal fetal airways during the early embryonic phase of lung development. Varying degrees of differentiation are noted, confirming what has previously been observed ultrastructurally in this lesion. One new finding is the presence of tonofilaments in one of our cases, which may represent a metaplastic change. Although the exact nature of the insult is unknown, there may be a developmental defect affecting epithelial differentiation as well as the interaction between the developing pulmonary mesenchyme and distal respiratory units.

Endometrial carcinoma in Miyagi Prefecture, Japan: histopathologic analysis of a cancer registry-based series and comparison with cases in American women

Cases of endometrial carcinoma (104) from the Cancer Registry of Miyagi Prefecture, Japan, during the period from 1966--1977 have been reviewed histologically. The most impressive differences between tumors in this low-risk population and those reported in American women are higher frequencies of the mixed adenosquamous histology, myometrial vascular invasion, and lymphoid infiltration within and around the tumors in the Japanese cases. The possible significance of these observations, both clinical and epidemiologic, is discussed in detail.

Epidemiologic pathology of ovarian tumors: a histopathologic review of primary ovarian neoplasms diagnosed in the Denver Standard Metropolitan Statistical Area, 1 July-31 December 1969 and 1 July-31 December 1979

We report a population-based histopathologic review of primary ovarian neoplasms. No significant changes in incidence were encountered between the 1969 and 1979 review periods. The most frequent single tumor was benign cystic teratoma (26.5%), while the coelomic-derived "epithelial" tumors constituted the most frequent group (57.6% of all tumors and 93.8% of all malignant tumors). The high frequency of borderline tumors reported by others in nonpopulation-based material is confirmed, and the usual disseminated state of invasive carcinomas at the time of diagnosis is noted. Other data concerning incidence and bilaterality rates, patient ages, multiple primary malignancies, and problems in differential diagnosis and tumor grading are discussed.

Limited subtotal thyroidectomy for Graves' disease

Limited subtotal thyroidectomy was performed in 42 of 43 patients with Graves' disease. Twenty of 23 patients (87%) who were followed up for an average of 54 months after operation remained euthyroid. Only one patient (4.3%) had recurrent thyrotoxicosis. There were no deaths and no permanent complications. A coexisting, invasive papillary cancer necessitated total thyroidectomy in one patient, and occult papillary cancers were discovered histologically in three others. This study supports the thesis that postoperative thyroid function depends on the volume of remaining thyroid tissue. While preserving thyroid function, limited subtotal thyroidectomy lowers postoperative complications and induces no increase in recurrent thyrotoxicosis.

The surgical pathologist as researcher

Most surgical pathologists have the opportunity to perform research. Research in surgical pathology can be classified as: (1) observational; (2) manipulative with human tissues; (3) experimental with nonhuman models; and (4) technical, instructional, and delivery. Examples of each of these forms of research are presented, as are comments on the academic stature and funding problems of research in surgical pathology.

Ultrastructural analysis of apocrine carcinoma of the human breast

A case report with ultrastructural analysis of an apocrine carcinoma of the breast is presented. The key finding with electron microscopy is numerous large mitochondria with abundant incomplete cristae. The ultrastructure of this tumor is compared to the ultrastructure of apocrine cells in the skin, oncocytes, and apocrine metaplastic cells of the breast. The apocrine carcinoma cells have some of the features of typical metaplastic breast epithelium and some features of oncocytes. Their exact origin remains open to speculation.

Endometrial carcinoma: clinical-pathologic comparison of cases in postmenopausal women receiving and not receiving exogenous estrogens

Clinical and pathologic findings were compared in 43 postmenopausal endometrial carcinoma patients who had received exogenous estrogens prior to diagnosis and 79 similar patients unexposed to estrogens. Estrogen non-users were more likely to manifest lower parity, later menopause, obesity, hypertension, and diabetes, all of which have been considered to be constitutional risk factors for the development of endometrial carcinoma. Although estrogen users and non-users had similar extent of disease as judged by clinical stage, there was a tendency to more myometrial invasion in hysterectomy specimens from non-users, as well as greater frequency of unfavorable histologic types and grades of tumor. At short-term follow-up, more recurrences occurred in non-users, and this tendency appeared to be independent of clinical stage, histologic type, histologic grade, or modality of treatment. The significance of these and other observation to the determination of the risk-benefit ratio for estrogen administration is discussed.

Adenocarcinoma of the cervix: histopathologic and clinical features

Primary adenocarcinoma of the cervix and endocervix is an unusual lesion. It is cytologically evasive, diagnostically challenging, histologically variable, and therapeutically perplexing. During the period 1954 through 1971, 53 cases were diagnosed at the Medical College of Virginia, representing 3% of all invasive cervical carcinomas. Clinical material, therapy, and five-year survival statistics have been complied for each histologic type of adenocarcinoma. The average age of the patients was 53.8 years, and the most frequent complaint was abnormal uterine bleeding. Histologically, the majority had adenocarcinomas of the endocervical type. Others, in order of descending frequency, had endometrioid, clear cell, colloid, and adenoid cystic carcinomas. Patients treated for endometrioid carcinomas had the best five-year survival rates. Standardization of the diagnostic process and the use of modern radiation therapy have significantly improved survival. All patients having radiation plus operation or operation alone lived five years or more.

Elastosis and other stromal reactions in benign and malignant breast tissue: an ultrastructural study

The stroma and stromal reaction in normal breast, benign, and malignant breast tissue was studied by electron microscopy. Elastosis is the main stromal response in infiltrating duct and lobular carcinomas. Medullary carcinoma elicits no significant elastosis but intraductal carcinoma has significant local elastosis. Benign conditions such as fibroadenoma and sclerosing adenosis produced no significant elastosis. The high number of elastic fibers and the high microfibril:elastin ratio indicate that most of the elastic fibers are recently secreted, probably by fibroblasts and myofibroblasts. The factors stimulating the increased production of elastic fibers and the prognostic significance of elastosis remain unclear.

Yolk sac carcinoma (endodermal sinus tumor): ultrastructure and histogenesis of gonadal and extragonadal tumors in comparison with normal human yolk sac

Human yolk sac carcinomas have been studied only twice with the electron microscope, and have never been compared at this level with normal human yolk sac. In the present study, the ultrastructural features of three primary ovarian yolk sac carcinomas, omental metastases from one of these, and a primary retroperitoneal yolk sac carcinoma in a male are reported, as are the ultrastructural findings in human yolk sac from normal 7- and 12-week gestations. The most prominent feature of the tumors is the presence of voluminous basement membrane material (the nature of which is confirmed by indirect enzyme-labeled antibody technique in one case) in both intra-and extracellular location, corresponding to the PAS-positive hyaline globules seen in these tumors by light microscopy. The tumor cells are also demonstrated to produce this material in tussue culture. Although basement membrane has not been described previously in normal human yolk sac at 8 and 10 weeks' gestation, it was present in the 7-week specimen which we studied, suggesting that its production may be a feature of only very young sac. Other ultrastructural findings are also similar in human yolk sac carcinoma, normal human yolk sac, and rodent yolk sac and yolk sac carcinomas. Thus, these studies confirm the suggested germ cell-derived yolk sac origin of the human tumor.

Endometrial carcinoma in women under 40 years of age: comparison of cases in oral contraceptive users and non-users

Women under 40 years of age rarely develop carcinoma of the endometrium, this age group comprising less than 3% of all cases in most large series. The Registry for Endometrial Carcinoma in Young Women Taking Oral Contraceptive Agents has recorded and studied 30 cases in women under 40 with a history of oral contraceptive administration, and these are compared with 25 cases in the same age group which were accessioned at the Armed Forces Institute of Pathology prior to the era during which these agents have been available, and with series reported in the literature totaling 137 cases with no contraceptive history. In the first group, special attention is paid to the 20 women who received sequential agents exclusively or predominantly, since the association with these agents (primarily Oracon) is much higher than would be expected from the fact that less that 10% of oral contraceptives used in this country are of the sequential type. An analysis of the three groups reveals a similar incidence of the various histologic types (primarily well differentiated tumors with a relatively favorable prognosis), the only difference being the presence of secretory features in 14 of 29 oral contraceptive users vs. only two of 25 women not taking these agents. Clinical and pathologic staging were also predominantly favorable, and comparable in all groups. There were, however, notably higher incidences of nulliparity, obesity, and sclerocystic ovaries--all features traditionally associated with endometrial carcinoma--in the patients not receiving oral contraceptives or receiving combined agents, suggesting that the group receiving sequentials may not represent the same constitutionally predisposed population. Only three of 55 women among our personally reviewed cases have thus far died of cancer (one in the contraceptive group and two in the non-user group) and all three of these had poorly differentiated tumors with myometrial invasion. The excellent prognosis for most patients in this age group is thus confirmed.

Squamous cell carcinoma originating in an hepatic cyst. Case report with a review of the hepatic cyst-carcinoma association

A case of squamous cell carcinoma originating in an hepatic cyst is presented. A review of the literature reveals five other cases of carcinoma arising within congenital intrahepatic cysts; three adenocarcinomas and two squamous cell carcinomas. Neoplastic transformation may also be seen in association with Meyenburg complexes, considered by some to be the structures from which congenital cysts arise.

Squamous cell carcinoma originating in an hepatic cyst. Case report with a review of the hepatic cyst-carcinoma association

A case of squamous cell carcinoma originating in an hepatic cyst is presented. A review of the literature reveals five other cases of carcinoma arising within congenital intrahepatic cysts; three adenocarcinomas and two squamous cell carcinomas. Neoplastic transformation may also be seen in association with Meyenburg complexes, considered by some to be the structures from which congenital cysts arise.

Solitary thyroid nodules

A study was made of 67 patients with solitary thyroid nodules in which strict criteria to eliminate the probability of cancer, including a history of radiation to the neck, were used. Twelve (17.9%) were found to have histologic malignancy. This figure is threefold that of a study made by one of the authors 11 years earlier, but comparable to others more recently reported from cancer centers elsewhere. It is not certain whether the apparent increase is actual or merely the result of more careful screening of patients for referral. Shrinking of the nodule by thyroid suppression therapy had been definite but incomplete in three nodules, one of which was found to be malignant. Excision is recommended for all persistent thyroid nodules.

Epithelioid sarcoma: case report with ultrastructural review, histogenetic discussion, and chemotherapeutic data

A case of abdominal wall epithelioid sarcoma, studied by light and electron microscopy over a 3-year period, is presented. Ultrastructurally, there appear to be two types of tumor cells, light and dark, which differ by virtue of a heavier concentration of microfibrils and dilated rough endoplasmic reticulum in the dark cells. Both tumor cell types contain prominent Golgi systems, abundant free ribosomes, and numerous pinocytotic vesicles. The ultrastructural characteristics of the tumor cells resembel those of epithelioid cells of experimental human granulomas, as well as those of normal human synovium. A multifaceted relationship between histiocytes and synovial cells is demonstrated and it is concluded that the tumor is probably derived from mesenchymal reserve cells capable of differentiating a long histiocytic or synovial lines. Preliminary chemotherapeutic data are reviewed.

Immature teratoma of the ovary with a neural component ("solid" teratoma). A clinicopathologic study of 20 cases

Twenty cases of immature teratoma of the ovary with a neural component are analyzed. A plea is made for use of the nomenclature adopted from the new World Health Organization classification of ovarian tumors, the past confusion over terminology and histogenesis of this rare tumor is discussed. All the primary tumors in the present series contained at least some immature tissues (predominantly of neural origin) and were thus graded from 1 to 3 according to the criteria of Thurlbeck and Scully. No grade 0 tumors ("benign solid teratomas") were identified. We believe that thorough sectioning almost always insures the identification of immature elements. The prognosis was closely related to the histologic grade, but correlated poorly withthe clinical stage, the latter being influenced by the common finding (25 per cent of the cases in this series) of peritoneal implants composed exclusively of mature glial tissue, which is associated with a benign clinical evolution. This phenomenon of maturation or differentiation appears to be the rule rather than the exception in this tumor, since implants are usually of better or equal differentiation when compared with their primary tumors and older patients tend to have lower grade tumors than younger patients. Since the majority of patients with this tumor are young, primary surgical therapy should be conservative, unilateral salpingooophorectomy often being sufficient. Spontaneous or operative rupture of the tumor capsule carries an increased risk of subsequent dissemination. We have noted impressive clinical responses in patients with disseminated tumors of a high histologic grade after treatment with triple chemotherapy (vincristine, actinomycin D, and cyclophosphamide) but do not recommend adjuvant therapy in patients with only grade 0 implants.

Squamous cell carcinoma originating in an hepatic cyst. Case report with a review of the hepatic cyst-carcinoma association

A case of squamous cell carcinoma originating in an hepatic cyst is presented. A review of the literature reveals five other cases of carcinoma arising within congenital intrahepatic cysts; three adenocarcinomas and two squamous cell carcinomas. Neoplastic transformation may also be seen in association with Meyenburg complexes, considered by some to be the structures from which congenital cysts arise.

Reproducibility of the mitosis count in the histologic diagnosis of smooth muscle tumors of the uterus

In order to ascertain the reproducibility of the mitosis count in histologic tumor diagnosis, a reference set of 10 microscopic slides from smooth muscle tumors of the uterus was shown to six different pathologists, who were asked to record the number of mitotic figures per 10 high power fields in the most active region of each slide. The results, when tubulated, revealed considerable observer variation in this supposedly objective and quantitative diagnostic criterion. The diagnosis of benignity or malignancy, based on this criterion alone, were unamimous in only four of the 10 cases, whereas the diagnoses based on a constellation of histologic criteria were unanimous in all cases and correlated well with the subsequent clinical evolution of those cases with follow-up data. Possible reasons for the lack of reproducibility of the mitosis count are discussed. We conclude that a qualitative estimation of mitotic activity is helpful as one of the diagnostic and prognostic criteria in the assessment of uterine and other smooth muscle tumors, but that it cannot be used as the sole criterion for distinguishing benign from malignant tumors.

Signet-ring cell carcinoma of the breast. The mucinous variant of infiltrating lobular carcinoma?

Five cases of the type of mammary carcinoma that has been designated "signet-ring cell carcinoma" are presented. This tumor is characterized by the presence of numerous cells containing intracellular mucin, without large amounts of extracellular mucin as is seen in colloid (gelatinous, mucinous) carcinoma of the breast. Although such cells may be seen in many mammary carcinomas, they are never as frequent as in the variant described. Ultrastructurally, the most characteristic finding is the presence of numerous intracellular lumina containing material which appears to represent the mucin identified with the light microscope. This finding differs from that in colloid carcinoma, in which the scantier intracellular mucin occurs in the form of intracytoplasmic membrane-bound vesicles. The five tumors in the present series were all associated with either in situ lobular carcinoma or a "sinus catarrh"-like pattern of nodal metastases, or both. On the basis of these light and electron microscopic data, the signet-ring cell carcinoma is suggested as a variant of infiltrating lobular carcinoma, clinically and pathologically distinct from colloid carcinoma.

Epidermoid cysts of the ovary: a report of five cases with histogenetic considerations and ultrastructural findings

Five cases of epidermoid cysts of the ovary are added to the two-reported in the literature. This rare lesion was uniformly an incidental finding in the study of hysterectomy specimens. Its main interest is in its histogenesis, which is suggested to involve metaplasia of the coelomic surface epithelium of the ovary. Ultrastructural evidence is one case strongly favors this possibility, thus adding another line of differentiation to those already established for the multipotent coelomic epithelium. However, some cases may be teratoid in origin, as has been suggested for the analogous lesion in the testis.

Signet-ring cell carcinoma of the breast. The mucinous variant of infiltrating lobular carcinoma?

Five cases of the type of mammary carcinoma that has been designated "signet-ring cell carcinoma" are presented. This tumor is characterized by the presence of numerous cells containing intracellular mucin, without large amounts of extracellular mucin as is seen in colloid (gelatinous, mucinous) carcinoma of the breast. Although such cells may be seen in many mammary carcinomas, they are never as frequent as in the variant described. Ultrastructurally, the most characteristic finding is the presence of numerous intracellular lumina containing material which appears to represent the mucin identified with the light microscope. This finding differs from that in colloid carcinoma, in which the scantier intracellular mucin occurs in the form of intracytoplasmic membrane-bound vesicles. The five tumors in the present series were all associated with either in situ lobular carcinoma or a "sinus catarrh"-like pattern of nodal metastases, or both. On the basis of these light and electron microscopic data, the signet-ring cell carcinoma is suggested as a variant of infiltrating lobular carcinoma, clinically and pathologically distinct from colloid carcinoma.

Squamous cell carcinoma of the skin and lip in renal homograft recipients

Forty-four squamous cell carcinomas (SCC) of the skin and lip were observed in 9 of 464 renal homograft recipients. Clinically and histologically the SCC's fell into two groups. Two patients with widespread warts, suggestive of epidermodysplasia verruciformis, showed multiple SCC's predominantly on the upper extremities which were associated with minimal solar elastosis of the adjacent dermis. The other seven patients did not have widespread warts; their SCC's occurred predominantly on the head and neck and were associated with prominent solar elastosis of the adjacent dermis. The degree of solar elastosis was particularly striking in view of the young age of this group (mean age: 37 years). Inflammatory cellular response to the transplant SCC's was significantly diminished in comparison with a group of control SCC's from non-immunosuppressed patients. In both transplant groups sunlight appears to be an important etiologic factor; in the first group viruses may also be important.

Staging in the therapy of cancer of the breast

Clinical and pathologic staging of breast cancer are discussed. A new pathologic staging system is presented: numerical scores are assigned, in cases of infiltrating ductal carcinoma of no specific subtype, for tumor size, histologic grade, amount of stromal infilttration, vascular invasion, axillary lymph nodal metastases, and sinus histiocytosis in axillary lymph nodes. Staging by this system correlates well with survival in cases treated by radical mastectomy. The essential features to be studied in pathologic specimens of breast cancer are also indicated.

Endometrial carcinoma in young women taking oral contraceptive agents

The first 21 cases recorded in the Registry for Endometrial Carcinoma in Young Women Taking Oral Contraceptive Agents are reported. We have found no other such cases in the literature, and indeed several authors have stated that these agents, because of their predominantly progestional action, would be expected to be protective against this disease. In 8 of the 21 patients, factors were present which militated against a close relation between oral contraceptives and carcinoma, and 5 of these 8 patients had taken only or predominantly combined agents. On the other hand, 11 of the remaining 13 patients took sequential agents, a ratio directly opposite that of the usage of combined and sequential agents in the American population. The possible reasons for the excess of sequential agents, chiefly Oracon, are discussed, and directions for future study are suggested.

Adenomyomatosis of endometrium and endocervix-a hamartoma

A 44-year-old woman was found to have a sessile lesion replacing most of her endometrium and endocervical mucosa, consisting of an intimate admixture of endometrial glands, endometrial stroma, and smooth muscle. On the basis of a previous curettage, it was concluded that the lesion had been present for at least seven years. The lesion is considered to be related to the pedunculated adenomyomatous polyp. The possibilities that it may represent adenomyosis, neoplasm, or hamartoma are discussed, and the latter is considered to be the most likely possibility. The presence of smooth muscle distinguishes the present case from the recently described and probably closely related entities of papillary adenofibroma, benign müllerian tumor, and müllerian adenosarcoma.

Minimal deviation adenocarcinoma ("adenoma malignum") of the cervix: a reappraisal

Five cases of so-called "adenoma malignum" of the cervix are presented. This term has been used to describe an extremely well-differentiated adenocarcinoma characterized histologically be distorted and architecturally irregular endocervical glands which penetrate deeply into the wall of the cervix, but without more than minimal and focal evidence of gland cell stratification, anaplasia, or mitotic activity. Despite this innocuour histologic appearance, these tumors have classically been thought to be clinically highly malignant, with an almost invariably rapid lethal outcome. This discrepancy between the histology and behavior has been presented as justification for the otherwise paradoxical name, "adenoma malignum". In the present series, all patients were treated with modern radiotherapeutic techniques, and four of the five are long-term survivors. Of the patients in the literature who died after rapid dissemination, none received treatment with acceptable radiotherapeutic techniques. Thus, we believe that with proper therapy this tumor is no more malignant than one would expect for a highly differentiated adenocarcinoma, and we suggest that the name, "adenoma malignum," be replaced by "minimal deviation adenocarcinoma of the cervix."

Pseudomyxoma peritonaei: a report of ten cases

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