Identification of Glandular (Acinar)/Tubule Formation in Invasive Carcinoma of the Breast: A Study to Determine Concordance Using the World Health Organization Definition

CONTEXT.—

The Nottingham Grading System (NGS) developed by Elston and Ellis is used to grade invasive breast cancer (IBC). Glandular (acinar)/tubule formation is a component of NGS.

OBJECTIVE.—

To investigate the ability of pathologists to identify individual structures that should be classified as glandular (acinar)/tubule formation.

DESIGN.—

A total of 58 hematoxylin-eosin photographic images of IBC with 1 structure circled were classified as tubules (41 cases) or nontubules (17 cases) by Professor Ellis. Images were sent as a PowerPoint (Microsoft) file to breast pathologists, who were provided with the World Health Organization definition of a tubule and asked to determine if a circled structure represented a tubule.

RESULTS.—

Among 35 pathologists, the κ statistic for assessing agreement in evaluating the 58 images was 0.324 (95% CI, 0.314-0.335). The median concordance rate between a participating pathologist and Professor Ellis was 94.1% for evaluating 17 nontubule cases and 53.7% for 41 tubule cases. A total of 41% of the tubule cases were classified correctly by less than 50% of pathologists. Structures classified as tubules by Professor Ellis but often not recognized as tubules by pathologists included glands with complex architecture, mucinous carcinoma, and the "inverted tubule" pattern of micropapillary carcinoma. A total of 80% of participants reported that they did not have clarity on what represented a tubule.

CONCLUSIONS.—

We identified structures that should be included as tubules but that were not readily identified by pathologists. Greater concordance for identification of tubules might be obtained by providing more detailed images and descriptions of the types of structures included as tubules.

The Peritumoral CD8 + /FOXP3 + Cell Ratio Has Prognostic Value in Triple-negative Breast Cancer

Compelling data has demonstrated the prognostic significance of tumor-infiltrating lymphocytes (TILs) in triple-negative breast cancer (TNBC), a subtype generally associated with a poor clinical outcome but highly heterogeneous in nature. There have been limited studies investigating the importance of subsets of T cells in TILs. Further, the significance of intratumoral versus peritumoral TILs remains controversial. We examined the prognostic value of tumor-associated CD8 + cytotoxic T cells and FOXP3 + regulatory T cells in 35 chemotherapy-naive TNBC cases with a tumor-host interface in the tissue sections. The CD8 + and FOXP3 + cell count was expressed by immunoreactive cells per high-power field in an average of 10 high-power fields. There was a wide range of CD8 + and FOXP3 + T cells within the peritumoral and intratumoral stroma. Both CD8 + and FOXP3 + TILs were significantly higher at the former location as compared with the latter ( P <0.0001 and 0.003, respectively). The numbers of CD8 + and FOXP3 + T cells, either within peritumoral or intratumoral stroma, were not significantly associated with distant relapse-free or disease-specific survival. However, the peritumoral CD8 + /FOXP3 + ratio of TILs was significantly associated with prolonged relapse-free survival ( P =0.04) and disease-specific survival ( P =0.02). This association was not observed with the CD8 + /FOXP3 + ratio of intratumoral TILs. These observations suggest that the immunologic balance in the tumor microenvironment might determine antitumor immunity. Further, the peritumoral TILs appear to play a more important role in the progression of TNBC when compared with the intratumoral TILs, thus reaffirming the necessity of revisiting the method for the assessment of TILs.

Breast Implant Capsule-Associated Squamous Cell Carcinoma: Report of 2 Patients

Breast implant augmentation is a low-risk procedure with few life-threatening complications. Capsular contracture and rupture/leakage of the implant are the most common complications encountered. Malignant breast implant augmentation-associated lesions are rare, with anaplastic large cell lymphoma being the most common. Squamous cell carcinomas associated with breast implant augmentation are exceedingly rare, with only eight patients reported. Breast implant capsule-associated squamous cell carcinoma occurs in patients with long standing breast implant augmentations (>11 years). We report two additional patients with breast implant capsule-associated squamous cell carcinoma. Review of the literature reveals that invasion beyond the breast implant capsule into the adjacent tissue by the squamous cell carcinoma appears to have negative prognostic implications, and possibly warrants close clinical follow-up.

Validation of the revised 8th AJCC breast cancer clinical prognostic staging system: analysis of 5321 cases from a single institution

The anatomic stage groups (ASG) have been arguably the most powerful in predicting breast cancer (BC) outcomes. Recognizing the prognostic influence of histologic grade and receptor status, the 8th AJCC mandates their incorporation into the newly established prognostic stage groups (PSG). This staging scheme was subsequently revised to provide pathological and clinical prognostic stage tables (PPSG/CPSG) due to its incapability to categorize a significant subset of BCs, with the former only used for patients having surgical resection as the initial treatment, and the latter for all patients. Given the increasingly used neoadjuvant therapy, PPSG cannot be assigned in a significant proportion of higher staged BCs. In this study, we validated the CPSG in a cohort of 5321 BCs. Compared to ASG, the application of CPSG resulted in assigning 16.1% and 27.2% of cases to a higher or a lower stage group in non-stage IV BCs, respectively. The changes were seen mostly frequently in ASG IB, followed by IIIC, IIB, IIA, IIIA, IIIB, and IA. In 7.9% of cases, the assigned CPSG changed more than one stage group from the ASG. CPSG provided an improved overall discriminating power in predicting BC-specific survival when compared to ASG. Pairwise comparison using the Cox proportional hazard model demonstrated further advantages for CPSG as the latter showed a significant difference in all categories when compared to their proximate groups, except IIA vs. IB and IIIA vs. IIIB. In contrast, a significantly different hazard was only seen when comparing IIB vs. IIA, IIIA vs. IIB, and IV vs. IIIC for ASG. Thus, the revised 8th AJCC CPSG provided a superior overall staging scheme for predicting prognostic outcomes in BC patients receiving standard of care treatment. Further validation using the available data with larger populations and longer follow-up may be needed to refine and improve this table.

Primary Clear Cell Sarcoma of the Breast: A Case Report

Casestudy: Clear cell sarcoma (CCS), also known as malignant melanoma of soft parts, is a primary soft tissue neoplasm exhibiting evidence of melanocytic differentiation. It is an uncommon aggressive tumor that arises in tendons and aponeuroses of the distal extremities. Here, we report the first case of primary CCS of the breast.

The patient was a 43-year-old female who presented with a left breast mass and underwent surgical resection at an outside hospital. No history of melanoma or any other malignancies was reported. Grossly, it was described as a 2 x 1.5 x 1.5 cm, well-demarcated, white nodular mass. Microscopic examination showed a malignant neoplasm composed of short spindle cells with ill-defined, eosinophilic cytoplasm and ovoid nuclei with finely stippled chromatin and exhibiting moderate pleomorphism. The lesional cells were arranged in short interlacing fascicles with abundant collagen, with brisk mitotic activity (&gt;15/10 HPF). The differential diagnosis included spindle cell carcinoma, myoepithelial carcinoma and melanocytic neoplasm. The tumor cells were immunoreactive for S-100 protein, SOX10, Mart-1, HMB45 and MiTF, but negative for multiple cytokeratins (including high and low molecular weight keratins), p63, EMA, CEA, Caldesmon, smooth muscle myosin, calponin, desmin, ERG, and CD31, thus confirming melanocytic origin. EWSR1 gene rearrangement was detected by fluorescence in situ hybridization analysis using break-apart probes. Overall, the histomorphology combined with the immunophenotype and cytogenetic characteristics, was most consistent with a CCS. To our knowledge, no primary CCS of the breast has been previously reported in the English language literature.

Pancreatic/Peripancreatic Spindle Cell Lesions Cytology: A 15-Year Review

Introduction/Objective

Spindle cell lesions (SCL) are diagnostically challenging, especially on cytology specimens where entities have overlapping features. Neoplastic and non-neoplastic SCL are uncommonly encountered in the pancreas/peripancreatic tissue. The sensitivity and specificity of EUS-FNA of pancreatic lesions both approach 95%. In this study, we assess the frequency of SCL found in pancreas/peripancreatic tissue on cytology specimens, the frequency of performing IHC stains and the most useful IHC panels. We also evaluate histology-cytology discrepancies and pitfalls.

Methods

A retrospective analysis of all pancreas/peripancreatic cytology specimen results between January 2004 - August 2019 was conducted. A total of 5,132 cases were identified. The number of spindle cell lesions was 27 (0.52%), with surgical pathology results available for 15 cases (55%). IHC stains were performed on 18 cell blocks (66%) and 9 surgical pathology specimens (60%).

Results

Of the 27 SCL identified, 22 lesions were neoplastic (81%), and 5 lesions were non-neoplastic (19%). The Neoplastic cases were: 10 GISTs (37%), 4 spindle cell lesions, NOS (14.8%), 2 metastatic sarcomas (7.4%), 1 pheochromocytoma (3.7%), 1 leiomyoma (3.7%), 1 schwannoma (3.7%), 1 malignant fibrous histiocytoma (3.7%), 1 granular cell tumor (3.7%), and 1 neuroendocrine carcinoma (3.7%). Of the neoplastic cases, 10 were lesions originating in a different organ with direct extension/distant metastasis to the pancreas (71%), with the most common organ being the stomach, 6 cases (60%). The non-neoplastic cases were: 4 granulomas (14.8%), and 1 accessory spleen (3.7%). IHC stains were performed on 18 cell blocks (66%), and attempted unsuccessfully on 2 cell blocks.

The most commonly utilized stains were: CD117, 15 cases (83%), SMA, 11 cases (61%), S-100, 9 cases (50%), CD34, 5 cases (27%) and Cytokeratin, 5 cases (27%). IHC stains assisted with proper classification in 9 cytology cases (50%). There was one interpretation error*, and the histology-cytology discrepancy rate was 6%.

Conclusion

Pancreatic and peripancreatic spindle cell lesions are uncommon (520/100,000), and are particularly challenging on cytology specimens. If neoplastic, the majority originate in an organ other than the pancreas. If non- neoplastic, the majority are granulomas. Immunohistochemical staining is required for proper classification. And in this small series, cytology is highly accurate for diagnosis (96%).

Anti-Rh alloimmunization after trauma resuscitation

The AABB recently posted a bulletin (19-02) regarding their recommendations for the use of group O red blood cells (RBCs) during trauma. Though group O Rh(D)-negative RBC units are considered the 'safest', the demand of such units often exceeds the supply. Therefore, O Rh(D)-positive units are often used during the first parts of a massive transfusion protocol (MTP) or patients with particularly severe hemorrhage are switched over from O Rh(D)-negative to O Rh(D)-positive RBC units in order to preserve the O Rh(D)-negative supply. In light of these limitations, it is important to understand the risk of such policies to the patient. The reported risk of alloimmunization after exposure to Rh(D)-positive RBCs ranges widely from 3 to 70%. In response, we performed a retrospective review of 1,198 patients in our institution that had a MTP activation due to trauma. Of those patients, we focused on Rh(D)-negative patients that received at least 1 unit of Rh(D)-positive RBCs. Seventy-two patients met the criteria for inclusion, accounting for 6% of the total population. Of the 72 Rh(D)-negative patients, we identified 17% that formed new Rh group antibodies after exposure to Rh(D)-positive RBCS. All 10 of our alloimmunized patients (two of which were females of childbearing age) formed anti-D, while 3 patients also formed either anti-E or anti-C. Since this was a retrospective review, we did not perform repeated antibody screens for the entire study period, but did review all records for the entire period. We did note that we were more likely to detect an novel alloantibody if more antibody screens were performed during the patient's initial stay and during follow-up visits. We conclude that providing Rh(D) negative patients Rh(D) positive RBC units is not without risk and policies regarding such provisions should be carefully considered. As RBC shortages continue to be a part of daily practice, such issues may continue to be a challenge for the blood bank community.