Time Trends of Benign/Malignant Breast Biopsy Ratios a Multicenter Italian Study

Aims and background

Although they have been decreasing over time due to improved specificity of diagnostic assessment, benign biopsies of the breast are still common. Benign biopsies should be regarded as negative events, due to their economical and psychological cost and their possible negative impact on cosmesis and on further diagnostic evaluation.

Methods

Retrospective data on benign/malignant breast biopsies ratio (B/M) were collected in 9 Italian centers for a period of 10-15 years. The time trend of B/M and its association to age or to single centers was evaluated.

Results

Overall 31,001 cases were considered. A strong association of B/M to age was evident (average B/M values were 5.0, 1.3, 0.6, and 0.2 for women aged <40, 40-49, 50-59, and >59 years). A significant trend of decreasing B/M over time was observed only for one center. Age standardized B/M was significantly different (P<0.000001) between centers, ranging between 0.34 and 1.69. Multivariate analysis confirmed an independent significant association of age and center to B/M.

Conclusions

Marked differences in B/M are evident between centers, which cannot be explained by the confounding effect of age or by any apparent difference in the diagnostic protocol. The observed differences are likely ascribed to individual variations in diagnostic aggressivity. A progressive increase of the predictive value of calls for surgical biopsy may be achieved over time and centers with a high B/M should make every effort to optimize their performance. Acceptable (<40=5, 40-49=1.5, 50-59=0.75, >59=0.3) and desirable (2.5, 0.75, 0.35, 0.15) age specific reference standards for B/M are proposed.

The 2015 World Health Organization Classification of lung tumors: new entities since the 2004 Classification

In the last few years different new pulmonary neoplastic lesions have been recognised and some of them, namely NUT carcinoma, PEComatous tumors, pneumocytic adenomyoepithelioma, pulmonary myxoid sarcoma, myoepithelial tumors/carcinomas entered in the last 2015-WHO classification of lung tumors. In addition angiomatoid fibrous histiocytoma and ciliated muconodular papillary tumor have been morphologically and genetically characterized albeit not yet included in the 2015-WHO classification. In the present paper we summarised the clinical, morphological, immunohistochemical and molecular features of these new entities. The knowledge of key histologic and molecular characteristics may help pathologists in achieving a correct diagnosis thus leading to an adequate therapeutic approach.

Megaduodenum: an unusual presentation of amyloidosis?

Amyloidosis, a potentially fatal disease, is characterized by an abnormal deposition of autologous proteins. Heart, liver, kidneys, lung, thyroid, skin and the gastrointestinal tract can be involved; in this last case mucosal alterations or disturbances of the motility leading to pseudo-obstruction, bleeding, diarrhea and malabsorption can be present. However, the data concerning the possible gastrointestinal presentations of amyloidosis are scanty and heterogeneous. We report the case of a patient presenting severe gastrointestinal symptoms caused by a megaduodenum. The patient was thoroughly investigated and lesions appeared limited to the upper gastrointestinal tract in the absence of a systemic disorder. However, at follow up the patient developed cardiac dilatation and bioptic samples revealed the presence of amyloidosis.

[Clinicopathologic correlations in acute renal graft rejection]

Although the diagnostic and therapeutic outcome of renal transplantation has successfully improved during the last decades, acute graft rejection (AGR) is still an ongoing cause of concern being often associated with irreversible graft dysfunction. Renal biopsy remains a valuable tool in the initial assessment of the potential graft malfunction especially during the early post-transplant period. It is an accurate and sensitive means for detecting prognostically relevant microscopic abnormalities, and assisting in subsequent patient management. For long time, the histopathologic evaluation of AGR has suffered from an irreducible bias with poor interobserver rates. Nowadays, the classification schemes of AGR include the BANFF approach and the National Institute of Heath Collaborative Clinical Trials in Transplantation (NIH-CCTT) system: both have been originally designed in order to improve the diagnostic reproducibility of AGR among pathologists. Arteritis and tubulitis, along to clinical information, constitute the cardinal features of the BANFF classification. Distinguishing features of the traditional NIH-CCTT system includes microscopic criteria such as assessment of interstitial hemorrhage, extent and quality of inflammatory infiltrate, and acute glomerulitis, in addition to tubulitis and arteritis. The BANFF classification has apparently gained more popularity than the time-honored NIH-CCTT system since, if used in the appropriate clinical context, it allows a more accurate assessment of AGR, provides prognostically relevant information, and has a better reproducibility rate among pathologists. Nevertheless, the accuracy trend has not significantly improved during the last few years.

The Value of Fine Needle Aspiration Cytology in Breast Fibromatosis: Study of Two New Cases and Review of the Literature

We report two new cases of breast fibromatosis studied by needle aspiration cytology observed in a 32-year-old man and a 49-year-old woman. The lesions manifested as palpable, painless, and firm masses of the para-areolar breast soft tissues. Preoperative fine needle cytology revealed scant cellularity, featuring oval and spindle cells with bland nuclei and occasional larger polygonal cells with high nuclear:cytoplasmic ratio. Histologically, interwoven fascicles of spindle cells with bland nuclei, infiltrating the adjacent breast fat, were recognized. Based on available reports in the literature, we concluded that needle aspiration cytology, although not entirely specific, may be a source of important information in patients with breast fibromatosis. In particular, it confidently allows the exclusion of breast cancer and other more common diseases and is useful in planning a surgical approach to the lesion.

Aneurysmal bone cyst of the larynx presenting with hypoglottic obstruction

We report a new case of aneurysmal bone cyst of the larynx occurring in a 22-year-old man. The lesion manifested with progressive breathing discomfort and appeared as a polypoid pedunculated mass attached to the subglottic mucosa. Microscopically, it featured numerous mononuclear and multinucleated giant cells surrounding cavernous spaces filled with blood. Foci of proliferating spindle cells and mature osteoid tissue could be recognized. There was no apparent relationship with the cricoid perichondrium. Clinical follow-up was negative for local recurrence. Based on this report and a review of the literature, we conclude that aneurysmal bone cyst of the larynx is phenotypically comparable to its bone homologue; however, its microscopic recognition may be difficult, especially on small biopsy fragments. Since it can be confused with several lesions, including telangiectatic osteosarcoma, awareness of this rare appearance of aneurysmal bone cyst is important to avoid unnecessary radical surgery.

Aggressive fibromatosis of the larynx: report of a new case in an adult patient and review of the literature

We describe a case of aggressive fibromatosis of the larynx occurring in a 75-year-old man. The lesion manifested with voice hoarseness and swallowing difficulty. A computerized tomographic scan of the neck revealed distortion of the glottic profile. A malignant tumor was suspected. Although a laryngoscopy-driven biopsy was non-diagnostic, total laryngectomy was done, since the lesion was not deemed amenable to conservative therapy. Grossly, the glottic rim was infiltrated by a hard, grey-white tissue showing a tentacular outline. Tissue sections featured a moderately cellular lesion composed of spindle cells with bland, tapered nuclei, enmeshed in a variably collagenized ground substance. Delicate spindle cell fascicles surrounded the native submucosal seromucous glands and had invaded the thyroid cartilage and the thyroid gland as well. The spindle cells were immunopositive for actins and vimentin, and negative for keratins, epithelial membrane antigen, desmin, and S-100 protein. No further therapy was administered. Periodic follow-up visits were negative. The patient died 5 years after surgery of myocardial infarction with no clinical evidence of lesion recurrence. Based on the available literature, our data confirm that laryngeal fibromatosis in adult patients is a locally infiltrating and progressive disease. Total laryngectomy with clear margins is needed as to avoid the high risk of local recurrence.

Papillary thyroid carcinoma of the thyroglossal duct cyst: comparative cytohistologic and immunochemical study of 2 new cases and review of the literature

We report a cytohistologic and immunohistochemical study of 2 cases of papillary thyroid carcinoma occurring in a thyroglossal duct cyst. The patients were a 21-year-old woman and a 48-year-old man. Needle aspiration cytology smears were consistent with papillary thyroid carcinoma. The Sistrunk procedure was done. Papillary carcinoma was found within a thyroglossal duct cyst. In 1 case, the tumor spread outside the cyst. Follow-up was uneventful in both patients (2 and 9 years, respectively). Our results would indicate that papillary carcinoma of thyroglossal duct cyst, though indistinguishable from its thyroid homologue, has a more indolent course and could therefore be singled out as a clinicopathologic entity. Needle aspiration cytology reliably assists in planning patient management.

Role of fine-needle aspiration cytology in nonpalpable mammary lesions: a comparative cytohistologic study based on 308 cases

We retrospectively evaluated the accuracy of fine-needle aspiration cytology (FNAC) in nonpalpable breast lesions detected by imaging techniques between 1995-1997. A total number of 308 lesions was investigated: 273 had been studied by means of either FNAC obtained under ultrasound (175 cases) or stereotactic guidance (98 cases). The overall sensitivity rate was 87.8%; specificity was 95.3%; the positive predictive value was 76.6%; the negative predictive value was 97.8%. Our results confirm that FNAC is quite effective in the approach to patients with nonpalpable breast lesions. It is particularly accurate in diagnosing malignancy, although a lower yield may be encountered in tumor types producing a desmoplastic stroma (tubular carcinoma, infiltrating lobular carcinoma) or in noncomedonic in situ ductal carcinoma. Discrepancy between a suspicious cytology and a negative histology is more frequent with benign lesions usually because of sampling mistake or technically inadequate smears. In particular, when smears are adequate, FNAC safely assists in ruling out the malignant lesions.

Embryonal "Botryoid" rhabdomyosarcoma of the larynx: a clinicopathologic and immunohistochemical study of two cases

Two cases of embryonal rhabdomyosarcoma of the larynx are reported. The tumors occurred in a 16-year-old boy and in a 66-year-old man. They manifested clinically with nonspecific symptoms, including voice hoarseness and sense of throat fullness. Treatment consisted of total and partial laryngectomy, respectively. Grossly, both lesions had an exophytic growth pattern and microscopically featured a proliferation of small round to oval cells. Cell cytoplasms were occasionally stainable and fibrillary. Quite often, tumor cellularity was denser beneath the covering mucosa, recalling a "cambium layer" pattern. Tumor cells immunoreacted for desmin, actins, myoglobin, and sarcomeric actin; no immunostaining was noted for epithelial markers. No further antitumoral treatment was administered after surgery. There has been no recurrence of tumor at 2 and 10 years, respectively. Based on our series and the available literature, it seems that rhabdomyosarcoma of the larynx pursues a less-aggressive course than that seen in the homonimic juvenile or adult soft tissue lesion. Surgery alone appears to be a valid treatment option, especially when a polypoid, or "botryoid" gross pattern, coupled with the embryonal small cell histotype is encountered. In light of these findings, it is suggested that botryoid rhabdomyosarcoma of the larynx may deserve a specific consideration among the various laryngeal mesenchymal malignancies.

Pulmonary thromboembolism following calf cellulitis: report of an unusual complication of dog bite

We report a case of a 75-year-old woman who died of pulmonary thromboembolism following a dog bite to the calf. The bite caused laceration of the skin and gangrenous cellulitis of leg soft tissues. Six days after hospitalization, the patient died suddenly, despite early antibiotic and heparin administration. Postmortem examination revealed extensive thrombosis of the deep veins of the calf and massive thromboembolism of the main pulmonary arteries.

Pseudoangiomatous hyperplasia of the mammary stroma: true entity or phenotype?

We report the clinical and pathologic features seen in 14 cases of pseudoangiomatous hyperplasia of the mammary stroma. The lesion manifested as a discrete palpable lump in twelve women and two men. The excisional biopsy specimens showed firm, circumscribed grey-tan lesions measuring from 3 to 5.5 cm in largest dimension. Histologic study revealed diffuse, anastomosing, enlongated slits with open lumina, covered by spindle cells with bland nuclei and no mitotic activity. Strong reactivity for vimentin and CD34 was noted. Smooth muscle actin was focally noted in most cases. Immunostains for other markers, including CD31 and factor VIII related antigen was negative. Spindle cells from two cases expressed both estrogen and progesterone receptors. In all the cases, there was some degree of glandular hyperplasia accompanying the stromal changes. Fibroadenoma or fibrocystic disease were also common features. Our study confirms that pseudoangiomatous hyperplasia of mammary stroma represents a proliferation of local myofibroblasts, likely related to a hormonal stimulus. The wide range of associated changes of breast parenchyma further indicates that this lesion may represent a local, non specific change rather than a true clinico-pathologic entity.

Polypoid osteosarcoma of the left atrium: report of a new case with autopsy confirmation and review of the literature

We describe a new case of heart osteosarcoma manifesting as a large polypoid mass of the left atrium. Clinically, the lesion presented with dyspnea, syncopal attacks, and fever. Ultrasound scans of the heart were suggestive of a cardiac myxoma, although some imaging features could retrospectively indicate a malignant neoplasm. In particular, the lesion was relatively immobile, did not show the characteristic myxoma motion during the heart cycle, and extended into the left pulmonary veins. Exploratory thoracotomy showed a nonresectable polypoid mass of the left atrium widely infiltrating the myocardium and the epicardium, histological features of a polymorphic sarcoma. The patient died 5 months after presentation with diffuse metastases. At autopsy, a 5-cm polypoid tumor was seen protruding into the left atrium. Neoplastic infiltration of the atrial myocardium, pericardium, and pulmonary veins was evident. Extensive metastatic deposits were observed in numerous sites, including the skin, lung, liver, and brain. Microscopically, a spindle cell sarcoma forming malignant osteoid was seen, admixed with areas indistinguishable from myxoid and pleomorphic malignant fibrous histiocytoma. This case provides further evidence that although rare, osteosarcoma of the heart usually presents as a polypoid mass of the left atrium and is histologically characterized by conspicuous polymorphism. It is associated with a poor prognosis and rapid appearance of distant metastases. Although at echocardiography it may mimic a myxoma, subtle features such as tumor extension into pulmonary veins and main origin from nonseptal atrial walls suggest the presence of a nonmyxomatous tumor and a preoperatory diagnosis of aggressive malignant disease.

Gestational squamous cell carcinoma of the breast: an unusual mammary tumor associated with aggressive clinical course

We report two cases of squamous carcinoma of the breast detected during the gestational period. One woman was post-partum and lactating; one was in the first trimester of pregnancy. The lesions were clinically palpable, multifocal, and measured more than 5 cm in their largest dimension; both had a cystic appearance. They were treated with radical mastectomy. One patient received pre-operatory chemotherapy. Histologically, the tumors were poorly differentiated squamous cell carcinomas. No areas of ordinary duct differentiation were seen. Lymph nodes contained metastatic squamous carcinoma in both cases. Tumor cells were negative for estrogen and progesterone receptors. Also, they expressed a high proliferative index and several markers of tumor progression, including cErb-B2, p53 protein, bcl-2, and epidermal growth factor receptor. One patient died of tumor 5 months following breast surgery and had extensive metastases proven at autopsy. The other patient had evidence of pulmonary metastases: following cisplatin therapy, she underwent clinical remission. This study shows that squamous carcinoma of the breast may occur in pregnant or lactating women: it appears clinically distinguishable from the non-gestational type that is usually associated with a better prognosis and occurs in peri- or postmenopausal women.

Leiomyosarcoma of the female breast: report of two new cases and a review of the literature

We present the clinical, light microscopic, and immunohistochemical features of two new cases of leiomyosarcoma of the female breast. Both the patients were old (83 and 86 years) and were referred with a history of a long-standing breast lump. The results of the physical examination and the preoperative radiologic investigations suggested a phyllodes tumor. The patients were treated with mastectomy. The tumors measured 6 and 6.5 cm in the largest dimension, respectively, and were composed of fascicles of atypical, actively proliferating spindle cells, often intersecting at right angles. The axillary lymph nodes were free of tumor. Immunohistochemically, the tumor cells were positive for desmin, muscle-specific actin, and vimentin and negative for other markers, including keratins and hormone receptors. Focal rhabdomyoblastic differentiation was noted in one case. Follow up at 1 year is negative for metastases or local recurrences. Our study confirms that leiomyosarcoma of the breast is a locally invasive neoplasm and that it could represent a peculiar anatomic entity among mesenchymal tumors of the breast.

Pseudomesotheliomatous angiosarcoma: a pleuropulmonary lesion simulating malignant pleural mesothelioma

We report two cases of autopsy confirmed angiosarcoma in adult males, presenting as diffuse pleuropulmonary tumours and simulating malignant mesothelioma. Both the lesions grew along the serosal surfaces and were characterized by variably thick rinds of tissue encasing the lung. The pulmonary parenchyma showed diffuse, dark red, subpleural consolidations and multiple cavitations. Histologically, the lesions were composed by atypical spindle and polygonal, epithelioid cells showing rudimentary vascular differentiation and exhibiting strong positivity for factor VIII, CD31, CD34 and vimentin, We conclude that angiosarcoma may present with preponderant or exclusive involvement of pleura and peripheral lung and that it should be added to the list of tumours capable of simulating malignant mesothelioma.

Intrapericardial thymoma: report of two incidental autopsy cases and review of the literature

OBJECTIVES

To report the pathologic features of intrapericardial thymoma and discuss their possible clinical relevance.

DESIGN

Retrospective evaluation of autopsy cases and the available clinical records.

SETTING

A large autopsy population (>31,000 postmortem examinations between 1980 and 1995) in an Italian general hospital.

RESULTS

Two cases of thymoma showing an exclusive intrapericardial growth were retrieved from autopsy files. The patients were 61 and 82 years of age, both were women, and both were referred to the hospital with terminal conditions due to either neoplastic or chronic diseases. Myasthenia gravis and/or immunologic dysfunctions were not noted, although one of the patients had serum hypogammaglobulinemia. Roentgenography showed enlargement of mediastinal profiles and suggested cardiomegaly. At autopsy, tumors were bulky, noninvasive, and from 6 to 10 cm in largest dimension. Histologically, they were spindle cell "medullary" thymomas, frequently showing cell arrangement around microcystic spaces. They were strongly immunoreactive for epithelial markers.

CONCLUSIONS

This study confirms that thymomas may occur in the pericardium. Tumor-related symptoms may be overlooked owing to concomitant heart disease or equivocal instrumental features, especially in the absence of immune system disturbances. Based on these premises, they may deserve a specific distinction in the expanding chapter of ectopic thymomas.

Small cell carcinoma of the liver: a hitherto unreported variant of hepatocellular carcinoma

We report three cases of an unusual primary carcinoma of the liver composed of small cells. The patients were adult males (56 to 89 years) who presented with jaundice, weight loss and abdominal discomfort. Surgery was attempted in one case. Clinical evolution was rapid, with death ensuing between 1 and 5 months after diagnosis. Surgical (1 case) and autopsy (2) tissues were available for review. All three tumours arose in non-cirrhotic livers. They were composed of broad nests of small epithelial cells with little supporting tissue. They were positive for low-molecular weight keratins and alpha-fetoprotein. One case was immunoreactive for erythropoietin antigen. Expression of neuroendocrine markers was focal and erratic. No immunostaining was observed for carcinoembryonic antigen or S-100 protein. In one case ultrastructural investigation disclosed canaliculi surrounded by microvilli and junctional complexes. In the light of these features, it appears that small cell carcinoma represents a rare, but definite variant of hepatocellular carcinoma. Although it does not segregate in a peculiar clinical setting, it should be distinguished from metastatic pulmonary small cell carcinoma as well as from other malignancies featuring small cells.

Histopathology of the frozen prostate. The microscopic bases of prostatic carcinoma cryoablation

In the last few years percutaneous cryoablation surgery of the prostate has been re-introduced as an alternative means to treat prostatic carcinoma. Advantages of the technique include local effectiveness in eradicating tumors, minimal morbidity rate and lower costs when compared to radical surgery. We report a study documenting the histopathological changes seen in 317 biopsy specimens obtained from 30 patients (age range 59-83 years, median 73 years) treated with cryosurgical ablation for prostate cancer. Pre- and postoperatory assessment was inclusive of plain clinical, laboratory and instrumental data (digital rectal examination, transrectal ultrasound scan, serum prostatic specific antigen concentration) and systematic biopsies obtained from conventional and modified prostate sextants. Fifteen patients had tumors extending through the prostate capsule (pT3 and pT4). Six patients had stage PT1 tumors and 9 had stage pT2. Tissues were sampled at 3, 6 and between 12-18 months postoperatively. The histologic findings, in decreasing order of frequency, were: full core fibrosis, necrosis, granulation tissue, basal cell hyperplasia, cell swelling, hemosiderin deposits, chronic inflammation, thick nerves and prostatic hyperplasia. Necrosis was of the coagulative type, sometimes associated with nuclear debris, and seen at relatively short interval from cryotherapy. Fibrosis with hyaline qualities was seen especially at 12-18 month interval. The presence of necrosis, as well as granulation tissue, hemosiderin deposits and cell swelling, strongly correlate to intervals from cryosurgical ablation. Residual tumor tissue was focal (0.5-1 mm) and recognizable in 9 cores from 4 patients (13.3%) sampled especially from the prostatic apex. Incipient tumor necrosis was seen in 11 cores, without particular distribution. These findings indicate that cryosurgery results in distinctive changes in both tumoral and non-tumoral prostate tissue. Knowledge of the histopathologic patterns is important since it provides the clinicians with information on treatment efficacy or failure, and could assist in the selection of larger groups of patients eligible to cryosurgical ablation.

Inflammatory fibrosarcoma: another imitator of Hodgkin's disease?

We report a case of inflammatory fibrosarcoma occurring in a 49 year-old man, that manifested with distinct multinodular masses in the mesentery. Histologically, the lesion was characterized by spindle fibroblast-like cells, histiocytes, pool of lymphocytes and eosinophils, abundant fibrous to hyaline stroma, and numerous "ganglion" cells. Of special interest was the presence of large multinucleated tumor cells which displayed optically clear nuclei and prominent nucleoli, bearing a deceitful resemblance to the diagnostic Reed Sternberg cells of Hodgkin's disease. The differential diagnosis between the two conditions rests on the evaluation of the appropriate clinical background, as well as on an in-depth assessment of the basic pathologic features. Immunohistochemical reactivity of spindle and ganglion cells for actin along to complementary negativity for CD15, and CD30 further assists in separating the two conditions.

Small cell carcinoma of lung simulating pleural mesothelioma. Report of 4 cases with autopsy confirmation

Four cases of small cell carcinoma characterized by a striking involvement of the pleural sheets were investigated. The patients, four adult males with a long history of cigarette smoking, presented with symptoms common to pleural tumors, including cough and chest pain. Malignant cells were identified in pleural effusions of all cases and in the bronchial aspirate of one patient. Antitumoral treatments included chemo- and/or radiotherapy. Survival ranged from three to 17 months. At autopsy, the serosal sheets resulted to be extensively involved by thick tumor rinds, associated with massive hilar metastases. Histologically, the tumors were composed of small epithelial cells, expressing carcinoembryonic antigen and keratins and occasionally neuroendocrine markers. Our findings indicate that small cell carcinoma should be added to the group of pseudomesotheliomatous lung carcinomas and, above all, that it deserves distinction from ordinary mesothelioma, especially the small cell variant, because of its medico-legal implications and possible antitumoral treatment.

Effusion cytology of hepatocellular carcinoma

OBJECTIVE

To evaluate effusion cytology on routine smears in patients with hepatocellular carcinoma.

STUDY DESIGN

Filed smears from 106 patients with autopsy-proven hepatocellular carcinoma were retrospectively reviewed for the presence of malignant cells. Morphologic patterns, as well as immunochemical reactivity for a panel of antibodies, were analyzed when feasible.

RESULTS

Malignant cells were identified in 10 cases of ascites and 1 of pleural fluid. Positive smears were variably cellular, with paucicellular, round or linear aggregates of polygonal cells. The cytoplasm was usually evident and very stainable. The nuclei were hyperchromatic or vesicular, with inconspicuous nucleoli. Reactive changes were frequent. Malignant cells were positive for keratins (7/8) and erythropoietin (4/8) and negative for carcinoembryonic antigen (0/8). Concomitant cirrhosis was present in 103 cases (97.1%); all the noncirrhotic cases had malignant cells identifiable in the effusion. Antemortem clinical diagnosis of malignancy was made in 59 cases (55.7%); cytology was the only source of the morphologic diagnosis in most of them.

CONCLUSION

These results indicate that although the yield of hepatocellular carcinoma in effusion cytology is limited, it may be important in the initial assessment of the disease, given the ineligibility of most patients for invasive procedures and the equivocal features of instrumental investigations. Immunocytochemistry may further assist in differentiating doubtful cases.

Cervical cytopathology. An evaluation of its accuracy based on cytohistologic comparison

BACKGROUND

Although Papanicolaou cytology represents the most effective technique to prevent and detect precancerous conditions of the uterine cervix, its false-negative yield is still a reason of concern among pathologists and gynecologists.

METHODS

Because histologic control is one of the best ways to assess the accuracy of cytology diagnosis, the authors have investigated 1000 women who had cervical smears and tissue sampling obtained during the same colposcopic evaluation between 1987 and 1990.

RESULTS

Out of 1000 cases (average age, 34.6 years; range, 14-80 years), 918 had adequate, 62 had less than optimal, and 10 had unsatisfactory samples. Cytology unsatisfactory and less than optimal cases as well as inadequate histology cases have been disregarded from all calculations. After histologic comparison, confirmed negatives were 622 of 918 (67.8%). Cytologic diagnoses of cervical intra-epithelial neoplasia (CIN) I were 96, of CIN II were 44, of CIN III, inclusive of carcinoma in situ, were 39, and of invasive carcinoma were 2. Atypical cases were 56. The overall sensitivity was 76.3%, with group sensitivity rates increasing directly with CIN grade. Positive predictive value was 80.2%. Specificity was 93.0%, and negative predictive value was 91.3%. False-negatives were 59 of 681 (8.7%), basically due to sampling errors. Among true-positives, there was 1 category discrepancy in 30 cases (mostly undercalled or overcalled CIN II) and 2 category discrepancies in 4 cases.

CONCLUSIONS

Cervical cytology has an overall accuracy close to that reported in studies employing indirect control methods, such as patient follow-up. Higher sensitivity rates emerged for CIN II, CIN III, and cervical carcinoma. Our figures of sensitivity and specificity may represent a useful reference source for future studies dealing with quality control in cervical cytopathology.

Multicentric papillomavirus infection of the female genital tract. A study of morphologic pattern, possible risk factors and viral prevalence

We have investigated 103 biopsy specimens obtained from 50 women (average 28.1 years, range 16-66) with multicentric condylomatosis of the genital tract, including the uterine cervix (48 samples), the vagina (23), and the vulva (32). Each patient had at least 2 biopsies. A positive in situ hybridization for a Human Papilloma Virus (HPV) cocktail was observed in samples from 38 patients: in these multiplicity of lesions regarded the cervix and vulva (22 cases), cervix and vagina (12), vulva and vagina (1), cervix, vulva and vagina (3). Viral types 6,11 were more prevalent in simple condylomata. Both low- and high grade lesions of cervix, vagina, and vulva showed prevalence of types 16, 18 and 31, 33, 35. Signaling for more than one probe cocktail was detected in 14 (13.6%) samples. Partner's condylomatosis was referred to by a sizeable minority of patients. It is concluded that the spectrum of HPV infection in the female genital tract reflects a multiplicity of factors, including involved viral type and site, immunitary reaction of the host, perpetration or reactivation of latent infections.

The positive peritoneal effusion. A retrospective study of cytopathologic diagnoses with autopsy confirmation

The distribution of 215 malignant tumors responsible for peritoneal effusions was investigated with respect to cytohistologic correlation and autopsy features. In males, cancer of the gastrointestinal tract, pancreas and liver were the most frequently observed forms, whereas in females tumors at gynecologic sites far outnumbered other neoplasms, such as stomach, bowel, pancreas, gallbladder and liver cancer. Cells from extra abdominal tumors, consistently seen in positive ascitic effusions, were from pleural mesothelioma and breast carcinoma, respectively, in males and females. The first diagnosis of malignancy rested on cytologic material in about 57% of cases in both sexes. In females, however, cancers of the ovary were discovered only cytologically in about two-thirds of cases. Occasionally, cancers of the uterine cervix and endometrium were diagnosed initially on peritoneal fluid. Morphologic diagnosis of pancreatic cancer was rendered on a cytologic specimen in all cases. The results of this study are useful reference data for cytologists dealing with positive effusions, especially due to unknown primary neoplasms.

Association of breast cancer and meningioma. Report of 12 new cases and review of the literature

We report 12 new cases of female breast cancer associated with intracranial meningiomas, inclusive of autopsy study. At the time of death the patients' age ranged from 52 to 95 years (average 70.6 years). Breast carcinomas were documented ante mortem in 11 cases and at autopsy in 1. Meningiomas were diagnosed at autopsy (10 cases) or in vivo (2 cases). The diagnosis of meningioma antedated that of mammary carcinoma in only one patient. Histologically, the cancers were of ductal (11 cases) and lobular infiltrating (1 case) types and showed a variable malignancy grade. Widespread extracranial metastases were present at autopsy in 7 cases. Brain metastases were seen in 1 case. Neurologic signs were referred in 4 subjects. Four breast cancers and one meningioma showed immunoreactivity for progesterone receptors, whereas all the cases were negative for estrogen receptors. In one case, metastatic breast carcinoma tissue was present within a psammomatous meningioma. A brief review of the literature, which includes 14 similar observations, is reported. Although the association of breast cancer and meningioma is still difficult to explain, its clinical implications are important and deserve proper attention. A proper work up in patients with suspected intracranial metastases is recommended so that resectable meningiomas are not mistaken for metastases.

Cytopathology of malignant mesothelioma: a study of its patterns and histological bases

We have reviewed the effusion cytology of 51 cases of histologically proven malignant mesothelioma of the pleura (49 cases) and the peritoneum (2 cases). The patient group included 45 males and 6 females, aged 45-83 yr. A cytological diagnosis of malignancy had been rendered on 43 cases, and in 30 of them it was consistent with, or at least suggestive of, a mesothelioma. Diagnostic clues, especially evident in epithelial and biphasic tumors were hypercellularity and/or morular aggregates of malignant cells showing scalloped borders and nuclei with dense chromatin and evident nucleoli. Cytomegaly with multinucleation was also frequently observed. Reactive mesothelial cells were often present along with other non specific features such as red blood cells, fibrin, necrotic debris. In 13 cases, a diagnosis of malignancy was entertained but mesothelioma, although considered, was not reported out because of scantiness of material. In four cases, adenocarcinoma was erroneously diagnosed for the presence of deceptive cell vacuoles. In eight cases, no diagnostic cells were recovered in repeated effusions. The first diagnosis was a cytologic one in 37 patients, Tissue study was performed on autopsy (35 patients) and surgical material. The latter was the only source of histology in six cases. Immunocytochemical investigation was negative for carcinoembryonic antigen in all but one tested cases (1/21) and positive for human milk fat globulin in about one-half of the epithelial and biphasic tumors. In 18 of 21 cases, positivity for combined high- and low-molecular-weight keratins was detected.(ABSTRACT TRUNCATED AT 250 WORDS)

The positive pleural effusion. A retrospective study of cytopathologic diagnoses with autopsy confirmation

We performed an investigation focusing on the distribution of tumor types responsible for positive pleural effusions in 143 patients who died of malignancy and underwent autopsy. The principal malignant tumors were lung carcinoma (41 cases, 51.2%) and pleural mesothelioma (23 cases, 28.7%) in males and breast carcinoma (24 cases, 38.2%) and lung carcinoma (13 cases, 20.6%) in females. Histologically, most of the cases belonged to the adenocarcinoma category. The first morphologic diagnosis was a cytologic one in 86 cases (60.1%), especially regarding lung cancer. In breast cancer a positive pleural effusion always preceded recurrent disease with a rapidly progressive course, even a long time after the initial surgery. The results of this study, based on both cytomorphologic features and postmortem data on the tumor sites, may be a useful working framework for the cytologist dealing with a positive pleural effusion.

Cytology of transitional-cell carcinoma of the urinary bladder: diagnostic yield and histologic basis

The diagnostic yield of cytology in histologically proven transitional-cell carcinoma (TCC) of the urinary bladder has been studied in 100 cases. Cytohistologic correlation rates were 20 percent, 61.7 percent, and 92.8 percent, respectively, for grade 1, 2, and 3 tumors. When further evaluated, G2 cases were segregated into 2 subcategories, G2a and G2b, based on histologic preservation of nuclear polarity, pleomorphism, and other cellular irregularities. Correlation rates were rather low for G2a cases (6/18, 33%) and high for G2b cases, (23/29; 79%). The prevalence of atypical cells was 2 (11.1%) cases in G2a and 16 (55.2%) cases in G2b. The results of this study confirm that cytology has an extremely varying diagnostic yield in urinary bladder TCC. Greater cell exfoliation, increased atypia, and a tendency to infiltration of G2b and G3 cases probably account for the higher diagnostic yield detected in these groups.

Aggressive "breast-like" adenocarcinoma of vulva

A case of vulvar adenocarcinoma seen in a 42-year-old woman is reported. The tumor involved the right labium majus and diffusely spread into the surrounding soft tissues as well as the inguinal lymph nodes and was histologically composed of nests, cords, and tubular formations recalling an aggressive duct carcinoma of breast. Likewise, tumor cells exhibited positivity for common breast tumor markers, such as epithelial membrane antigen, carcinoembryonic antigen, and glandular keratins. The possible origin of the neoplasm from mammary ectopic tissue in vulva or from vulvar skin adnexa is briefly discussed.

Accuracy of bronchial aspiration cytology in typing operable (stage I-II) pulmonary carcinomas

The accuracy of bronchial aspiration cytology in typing resectable (stage I-II) lung cancer has been investigated in 100 cases, comparing preoperative cytologic features with pulmonary tumor histology seen at surgery. The accuracy has been 100% for small-cell carcinoma (two cases), 98.8% for squamous-cell carcinoma (86 cases), and 91.6% for adenocarcinoma (12 cases). The overall accuracy rate has been 98%. No case of undifferentiated large-cell carcinoma has been identified. It is suggested that the high accuracy in cytologic typing of operable lung cancer is basically related to adequate preservation of differentiation features, thus allowing for correct identification of most non-small-cell carcinoma. Moreover, the absence in this study of any large-cell carcinoma, compared with its frequency in advanced stage series, would indicate that such a histotype reflects excessive dedifferentiation of an original squamous or glandular form.

Intracranial metastases from malignant pleural mesothelioma. Report of three autopsy cases and review of the literature

We report three cases of brain metastases from malignant pleural mesothelioma that were seen at autopsy. We present a summarized review of 15 similar reports that were previously published. Our study included three aged male patients with a long occupational history of heavy asbestos exposure. In two patients, the metastases were discovered incidentally at autopsy, and there were no neurologic symptoms referred to before death. In the other patient, who had clinically occult mesothelioma, the intracranial tumor was discovered ante mortem: in this patient, the clinical features, as well as a computed tomographic scan, suggested a primary tumor of the brain. Interestingly, the histologic features of the latter case that were seen at autopsy depicted a spindle cell tumor that focally exhibited pseudopalisading, necrosis, vascular buds, which deceptively recalled a glioblastoma. All the three cases shared a basic sarcomatous pattern of malignant pleural mesothelioma in both primary and metastatic tumors. The immunohistochemical profile was consistent with such interpretation. It was concluded that metastases to the brain from malignant pleural mesothelioma, although rare, are not exceptional even if their clinical relevance is not prominent. They are seen concomitantly with high-grade tumors, and by mimicking a primary tumor on a clinical, instrumental, and histologic ground, they may occasionally represent a potential source of diagnostic pitfall.

Cytopathology of exocrine pancreatic carcinoma in effusions

The cytomorphologic features were analyzed in 26 fluid samples (18 peritoneal and 8 pleural fluids) obtained in vivo from 20 patients with pancreatic carcinoma. All tumors were ductal adenocarcinomas, as proven histologically on autopsy samples. The basic cytomorphologic pattern in the smears was that of a malignant glandular tumor, consisting of cell groups with various degrees of cohesiveness. The most prominent feature was a linear arrangement (the so-called "Indian file") of tumor cells showing nuclear molding; these aggregates were frequently closely associated with the flat round clusters of cells. Other nonspecific features of adenocarcinoma included eccentric hyperchromatic nuclei, abundant, often well-preserved vacuolated cytoplasm, a variable amount of fibrin and a reactive background. Review of the autopsy specimens also revealed the presence of an "Indian-file" pattern in most cases, especially when a conspicuous desmoplastic reaction was present. These findings suggest that pancreatic carcinoma should be included in the differential diagnosis of positive serous effusions showing these cytomorphologic features.

Metastatic tumors to the female breast. An autopsy study of 12 cases

Twelve cases of metastatic tumors to the female breast are reported. Ten of them were incidentally discovered at autopsy; two cases were diagnosed ante mortem but one was misinterpreted as primary. The patients' mean age was 58 years. The metastasizing tumors included cutaneous malignant melanoma (four cases); ovarian, renal and gastric adenocarcinoma (two cases each); and individual cases of pulmonary and pancreatic carcinoma. The patients with melanoma were younger than the others (49.7 vs. 62.7 years). The results of the present study indicate that breast metastases, although rare, are not exceptional especially in large autopsy series. Their recognition in surgical material would result in more adequate treatment against the primary tumor, thereby avoiding unnecessary radical surgery to the breast.

Cytological typing of primary lung cancer: study of 100 cases with autopsy confirmation

In order to assess the accuracy of bronchial aspiration cytology in typing lung cancer, tissue sections from 100 autopsy cases of lung cancer were compared with the cytology features observed in the same patients prior to death. There was 100% accuracy in the cytology of small-cell carcinoma; 90% in squamous-cell carcinoma; 70% in adenocarcinoma; and 50% in undifferentiated large-cell carcinoma. The observed discrepancies probably reflect intrinsic tumor properties rather than problems attributable to either the bronchial aspiration method or cytology interpretation, especially in cases involving advanced lung carcinoma. Because the highest accuracy rate was in detecting small-cell carcinoma, it is recommended that only the distinction between small-cell and non-small-cell forms be made on cytologic grounds and that further categorizations only be rendered in cases with unquestionable cytomorphological features.

Hodgkin's disease occurring in a Warthin's tumor: first case report

The case of a Warthin's tumor whose lymphoid component was totally replaced by a malignant lymphoma, Hodgkin's type, is reported. The disease was characterized by a rapid downhill course, with repeated medullary relapses and subsequent episodes of bone marrow failure. Death occurred 13 months after the initial diagnosis and was due to severe visceral involvement by Hodgkin's lymphoma, as confirmed at post mortem examination.

Myocardial ischemia in Vaquez's disease

The authors report a study performed on the ECG findings in patients affected by polycythemia rubra vera. Clinicopathological correlations are made on the basis of autopsic examinations of 11 of these patients (out of the 21 subjects studied). The clinical investigation was performed on the ECG findings according to the Minnesota Code; pathologic investigation pointed out some particular lesions of myocardial district, as myocardium sclerosis, acute infarction, post-infarction scars, vascular lesions of the macro- and microcirculation. The results showed that ECG and the pathological findings in polycythemia vera appear to have a physiopathologic background although the latter is not linked to a well-defined anatomopathologic picture.

Massive amyloidosis of mediastinal lymph nodes in a patient with multiple myeloma

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