The histological subtype and grade work as prognostic indicators for platinum-based chemotherapy (CTX) of advanced ovarian carcinoma (AOC)

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Background: We previously reported the new histopathologic grading system applicable for all histological types of ovarian carcinoma (Cancer 82:893–901, 1998), which thereafter was reappraised by several investigators. The aim of the present study is to investigate the relationship of the histopathologic type and grade with the effect of CTX for AOC. Methods: Between 1/89 and 12/05, 272 consecutive patients (pts) with pT3 (FIGO stage III or IV) AOC pts received 6 cycles or more of cisplatin (70 mg/m2 for 1 cycle)-based CTX combined with aggressive debulking surgery consisting of hysterectomy, bilateral adnectomy, omentectomy, pelvic to paraaortic lymphadenectomy, with or without more extensive surgery including intestinal resections. Histological types and grade were diagnosed according to the WHO classification system and our system reported method, respectively. Results: Of the eligible 261 pts, response was achieved in 67% (CR: 21.8%, PR: 45.2%) of the pts. Response (CR+PR/total) by histological type was 86% (36+91/148) for serous, 97% (16+13/30) for transitional cell, 67% (5+13/27) for endometrioid, 4% (0+1/29) for mucinous, and 0% (0+0/27) for clear cell, respectively. Response (overall/CR) for chemo-sensitive histological types (serous/transitional cell/endometrioid) by grade (G) was 86%/52% for 21 G1, 90%/31% for 64 G2, and 83%/28% for 118 G3 (CR rate: G3 vs G1 + G2: p=0.02). Response duration (CR/PR) by G was not reached/30 months (mo) for G1, 85 mo/23 mo for G2, 40 mo/16 mo for G3. Response (overall/CR) to 2nd line CTX was 75%/38% for G1, 73%/17% for G2, and 47%/10% for G3. Conclusions: Histological type correlated with platinum-CTX sensitivity. CTX regimens should be designed based on the histological subtypes. New “non-platinum” regimens should be considered for both mucinous and clear cell carcinoma. Histological grade worked as an indicator for CR rate, response duration (thus, progression rate), and response rate to 2nd line CTX. Thus, the grade is considered to be a significant prognostic factor for platinum-sensitive AOC.

No significant financial relationships to disclose.

The validation of new aromatase monoclonal antibodies for immunohistochemistry--a correlation with biochemical activities in 46 cases of breast cancer

Intratumoral aromatase is a therapeutic target for the treatment of post-menopausal estrogen-dependent breast cancers. Therefore, reliable methods should be developed for routine application for the detection of intratumoral aromatase. Immunohistochemistry (IHC) is considered one of the most suitable methods in this regard. A multi-centre collaborative group has been established to generate and validate new aromatase monoclonal antibodies. We have selected two monoclonal antibodies, #677 against native aromatase protein and F2 against formalin-fixed protein for this purpose. With these two monoclonal antibodies 43 cases of invasive ductal carcinoma, which had been previously assayed for aromatase activity by product isolation methodology, were immunostained in three laboratories in UK, USA and Japan and independently evaluated by three pathologists (H.S., T.A. and S.G.S.). Staining of malignant epithelium, adipose tissue, normal/benign and stromal compartments of the tumors were assessed by estimating the proportion of positive staining cells and the relative intensity of staining in this fashion. Immunoreactivity could be detected in each component of the tissue specimens but a significant positive correlation with biochemical activity was detected only in malignant epithelium stained with 677 not in other components with #677 and not in any of the components. Staining using F2 as a primary antibody did not produce a positive correlation in any components with aromatase activity. These results suggest that we now have a monoclonal antibody against aromatase (#677) which may be used to stain archival materials. A methodology and scoring system is recommended whereby staining significantly correlates with aromatase activity of the resected tissue specimens of breast cancer.

Validation of new aromatase monoclonal antibodies for immunohistochemistry: progress report

Intratumoral aromatase is a potential therapeutic target for the treatment of postmenopausal estrogen-dependent breast cancers. Therefore, reliable methods should be developed for routine application for the detection of intratumoral aromatase. A multi-center collaborative group has been established to generate and validate new aromatase monoclonal antibodies (MAbs). A recombinant GST-aromatase fusion protein was expressed in baculovirus and the purified protein was used for immunization of mice either as a native or formalin-fixed antigen. Hybridomas were generated using standard techniques and screened biochemically prior to immunohistochemistry (IHC) evaluation in human placenta, ovary and breast cancer tissues. Twenty-three MAbs selected by biochemical assays were further evaluated by IHC of paraffin-embedded tissue sections including normal ovary, and placenta, and a small series of 10 breast carcinomas. Of the 23 MAbs, 2 (clones 677 and F2) were determined to specifically stain cell types known to express aromatase in normal tissues. In breast carcinomas staining of malignant epithelium, adipose tissue, normal/benign and stromal compartments was detected. IHC was performed and independently evaluated by three pathologists (HS, TJA and SGS), each using the same evaluation criteria for staining intensity and proportion of immunopositive cells. With these two MAbs, interpathologist and intralaboratory variations were minimal in comparison with differences which could be detected between tissue specimens and antibodies.

Metastatic breast lobular carcinoma involving tamoxifen-associated endometrial polyps: report of two cases and review of tamoxifen-associated polypoid uterine lesions

Two cases of lobular breast carcinoma metastatic to an endometrial polyp are described. Both patients had been treated with tamoxifen and presented with abnormal uterine bleeding. Histology of endometrial biopsy in both cases showed typical tamoxifen-associated endometrial polyps with focal subtle stromal infiltration by metastatic lobular breast carcinoma. This was confirmed by positive immunohistochemical staining with cytokeratin epithelial markers. Metastatic breast carcinoma may rarely involve tamoxifen-associated endometrial polyps. Because primary endometrial carcinomas may also arise within tamoxifen polyps, these should be extensively sampled. We briefly review polypoid uterine lesions that may occur secondary to tamoxifen therapy.

Computerized image analysis of p53 and proliferating cell nuclear antigen expression in benign, hyperplastic, and malignant endometrium

CONTEXT

The endometrium is an intrinsically dynamic tissue with great capability for regeneration and proliferation; consequently, there is some overlap between features seen in benign, premalignant, and malignant lesions. This leads to marked intrabiopsy, interbiopsy, and interobserver variability.

OBJECTIVE

We studied the specificity and sensitivity of computerized image analysis of molecular markers to evaluate its potential use as a diagnostic tool.

DESIGN

Specimens from 100 patients were examined and the following histologic diagnoses were assigned: proliferative endometrium (n = 10), secretory endometrium (n = 10), endometrial hyperplasia (n = 40; 30 with no atypia, 10 with atypia), and carcinoma (n = 40; 20 endometrioid, 10 serous, and 10 clear cell). All cases were evaluated immunohistochemically for p53 and proliferating cell nuclear antigen (PCNA) expression. Computerized image analysis was performed with a CAS 200 digital analyzer.

RESULTS

Expression of p53 was found only in carcinomas (65%) and endometrial hyperplasia with atypia (30%). Expression of p53 was higher in the poor prognostic categories (serous carcinoma and clear cell carcinoma) than in endometrioid carcinoma. In endometrioid carcinoma, p53 expression correlated with grade. Proliferating cell nuclear antigen showed a similar pattern of results to p53 in the various carcinoma subtypes and endometrioid carcinoma grades. Endometrial hyperplasia PCNA values were the lowest among all the groups. Both carcinomas and proliferative endometrium showed higher glandular and stromal PCNA values, significantly different from endometrial hyperplasia with atypia. In proliferative endometrium, stromal PCNA was the highest among all of the groups. The p53 and PCNA results correlated with each other for carcinoma.

CONCLUSIONS

Computerized image analysis correlates well with the established morphologic groups of endometrial pathology and yields results consistent with previous studies. Owing to its higher degree of sensitivity, computerized image analysis is of potential use in cases of diagnostic dilemmas and can help objectively allocate the case in the correct category (e.g., proliferative endometrium vs. endometrial hyperplasia, endometrial hyperplasia with atypia vs. endometrioid carcinoma). It is particularly useful in the evaluation of stromal changes.

"Thanatosomes": a unifying morphogenetic concept for tumor hyaline globules related to apoptosis

Hyaline globules (HG) have been observed in a large variety of unrelated categories of tumors and benign tissues. Different explanations for their formation have been proposed, varying according to tumor type and anatomic location. We have studied 80 tumor cases containing HG, by light microscopy, electron microscopy, immunohistochemical stains for various plasma proteins, and in situ DNA-end labeling for apoptosis. On light microscopy, HG were invariably related to areas of increased apoptosis and often contained apoptotic nuclear fragments. The HG stained as expected, with variable intensity with acidic stains. Most cells containing HG stained with immunohistochemical stains for all plasma proteins examined (alpha-1-antitrypsin, ferritin, C3, kappa and lambda light chains, and IgG), indicating an increased plasma membrane permeability. A morphologic change associated with the increased permeability was cytoplasmic blebbing. In the HG themselves, immunohistochemical stains for the plasma proteins were either diffusely positive or stained only the periphery of the larger HG. Double stains for apoptosis and plasma proteins confirmed the increased plasma membrane permeability to proteins of apoptotic cells in general and cells containing HG in particular. Free hyaline globules were often linked to the extracellular matrix by fibrin fibrils. Ultrastructurally, the HG appeared as phagosomes/secondary lysosomes or areas of cytoplasmic condensation surrounded by rough endoplasmic reticulum whorls. These were always associated with intense cytoplasmic blebbing. We conclude that HG reflect stages of cell injury, which in most instances relate to apoptotic cell death. They are specifically associated with the cytoplasmic blebbing and condensation typically seen in this form of cell death. These phenomena are accompanied by plasma protein influx (insudated plasma) and formation of distinct intracellular "hyalinized" cellular fragments. With cell fragmentation, the HG become extracellular and are likely to be ultimately disposed of by a process of "remodeling" and incorporation into the extracellular matrix, followed by collagenization. The latter process partly occurs by the initial linking of all components (HG, collagen fibers, cellular fragments, etc.) by a network of fibrin. The process of formation of HG follows a stereotypical pathway independent of cell type. Because it results mostly from apoptotic cell death, it is more pronounced in rapidly growing tumors or posttreatment. We propose the term thanatosomes for the entire spectrum of HG to emphasize their relationship to cell death. HUM PATHOL 31:1455-1465.

Distinct methylation patterns of two APC gene promoters in normal and cancerous gastric epithelia

The adenomatous polyposis coli (APC) tumor suppressor gene is mutationally inactivated in both familial and sporadic forms of colorectal cancers. In addition, hypermethylation of CpG islands in the upstream portion of APC, a potential alternative mechanism of tumor suppressor gene inactivation, has been described in colorectal cancer. Because a subset of both gastric and colorectal cancers display the CpG island methylator phenotype, we hypothesized that epigenetic inactivation of APC was likely to occur in at least some gastric cancers. APC exhibits two forms of transcripts from exons 1A and 1B in the stomach. Therefore, we investigated CpG island methylation in the sequences upstream of exons 1A and 1B, i.e., promoters 1A and 1B, respectively. We evaluated DNAs from 10 gastric cancer cell lines, 40 primary gastric cancers, and 40 matching non-cancerous gastric mucosae. Methylated alleles of promoter 1A were present in 10 (100%) of 10 gastric cancer cell lines, 33 (82.5%) of 40 primary gastric cancers, and 39 (97.5%) of 40 noncancerous gastric mucosae. In contrast, promoter 1B was unmethylated in all of these same samples. APC transcripts from exon 1A were not expressed in nine of the 10 methylated gastric cancer cell lines, whereas APC transcripts were expressed from exon 1B. Thus, expression from a given promoter correlated well with its methylation status. We conclude that in contrast to the colon, methylation of promoter 1A is a normal event in the stomach; moreover, promoter 1B is protected from methylation in the stomach and thus probably does not participate in this form of epigenetic APC inactivation.

E-Cadherin gene promoter hypermethylation in primary human gastric carcinomas

BACKGROUND

E (epithelial)-cadherin, the cell adhesion molecule also considered a potential invasion/metastasis suppressor, is mutationally inactivated in nearly half of all undifferentiated-scattered (diffuse-type) gastric carcinomas. In addition, silencing of E-cadherin by CpG methylation within its promoter region has been reported in several gastric carcinoma cell lines. We investigated the methylation status of the E-cadherin promoter region in 53 primary human gastric carcinomas.

METHODS

Hypermethylation of the E-cadherin promoter was determined by utilizing methylation-specific polymerase chain reaction (PCR)-single-strand conformation polymorphism (MSP-SSCP) analysis followed by direct sequencing of PCR products. Expression of E-cadherin was studied by western blot analysis. All statistical tests were two-sided.

RESULTS

Hypermethylation of the E-cadherin promoter was evident in 27 (51%) of 53 primary gastric carcinomas examined by MSP-SSCP. It occurred more frequently in carcinomas of the undifferentiated-scattered type (in 15 [83%] of 18) than in other histologic subtypes (in 12 [34%] of 35) (P =.0011, Fisher's exact test), and it was present at similar rates in early (in six [60%] of 10) versus advanced (in 21 [49%] of 43) carcinomas (P =.73, Fisher's exact test). Methylation occurring at all cytosine-guanosine sequences (CpGs) near the transcriptional start site was confirmed in six of six tumors examined by bisulfite-DNA sequencing, including two early gastric carcinomas. In addition, loss or diminished expression of E-cadherin was confirmed by western blotting in four of the six tumor tissues demonstrating hypermethylation.

CONCLUSIONS

The E-cadherin promoter frequently undergoes hypermethylation in human gastric cancers, particularly those of the undifferentiated-scattered histologic subtype. E-cadherin promoter hypermethylation is associated with decreased expression and may occur early in gastric carcinogenesis.

Mucosal epithelial proliferation of the fallopian tube: prevalence, clinical associations, and optimal strategy for histopathologic assessment

The prevalence and clinical significance of mucosal epithelial proliferation or hyperplasia of the fallopian tube are controversial in the few studies reported. Some authors have retrospectively examined "routine" sections (one or two submitted from each tube), whereas others have prospectively blocked the entire tubes. In the current study, we prospectively studied a total of 168 tubes from 98 women who had various indications for salpingectomy and compared the diagnosis in an initial single section (to simulate the usual practice) with that in the remainder of the entirely sectioned and submitted tube (mean total number of sections, 9.0). Some degree of mucosal epithelial proliferation was found in 83% of all tubes examined, with no difference between the tubes removed for routine tubal ligation and those in women who had benign ovarian lesions, malignant gynecologic tumors, uterine leiomyomata, or benign tubal lesions (salpingitis or ectopic pregnancy). Mucosal epithelial proliferation graded as more than mild, however, was seen in only 4.5% of the otherwise normal ligated tubes versus 35 to 46% of tubes associated with the other lesions. When the initial sections were compared with the subsequent ones, the diagnosis was identical in 96 tubes (57%). In the other 72 tubes (43%), the difference in diagnosis was never greater than one grade (no, mild, moderate, severe mucosal epithelial proliferation), with the diagnosis more often upgraded (50 tubes) than downgraded (22 tubes) in the additional sections. It is concluded that there is no reason to submit an entire tube for histologic examination to detect clinically significant lesions, and the usual practice of submission of one or two sections is clinically appropriate.

Problems in the differential diagnosis of endometrial hyperplasia and carcinoma

The differential diagnosis of endometrial hyperplasia and well-differentiated endometrioid adenocarcinoma is complicated not only by the resemblance of these lesions to each other, but also by their tendency to be overdiagnosed (particularly hyperplasia) on the background of polyps, endometritis, artifacts, and even normally cycling endometrium. Atypical hyperplasia may also be overdiagnosed when epithelial metaplastic changes occur in simple or complex hyperplasia without atypia. Low-grade adenocarcinomas are best recognized by architectural evidence of stromal invasion, usually in the form of stromal disappearance, desmoplasia, necrosis, or combinations of these findings between adjacent glands. Endometrioid adenocarcinomas are usually Type 1 cancers associated with manifestations of endogenous or exogenous hyperestrogenic stimulation and a favorable prognosis. Subtypes include adenocarcinomas with squamous differentiation and secretory, ciliated cell and villoglandular variants. Rules and pitfalls in the grading of endometrioid adenocarcinomas and the estimation and reporting of myometrial invasion are presented.

Secondary amenorrhea and infertility caused by an inhibin-B-producing ovarian fibrothecoma

OBJECTIVE

To report a case of secondary amenorrhea and infertility caused by an inhibin-B-producing ovarian fibrothecoma.

DESIGN

Case report.

SETTING

Academic medical center.

PATIENT

A 37-year-old woman with a 2-year history of secondary amenorrhea and infertility.

INTERVENTION(S)

Operative removal of a 5-cm ovarian fibrothecoma.

MAIN OUTCOME MEASURE(S)

Luteinizing hormone, FSH, E2, inhibin-B, TSH, and prolactin measured preoperatively and postoperatively. Immunostaining of tumor cells for inhibin and LH.

RESULT(S)

Preoperative hormone levels were as follows: FSH, 1.7 mIU/mL; LH, 23.4 mIU/mL; E2, 31 pg/mL; and inhibin B, 1,154 pg/mL. Three weeks postoperatively, the FSH was 1.5 mIU/mL, LH decreased to 7.1 mIU/mL, E2 increased to 276 pg/mL, and inhibin-B decreased to 17 pg/mL. The fibrothecoma did not stain for LH but was strongly positive for inhibin. Regular menstrual cycles resumed 28 days postoperatively.

CONCLUSION(S)

Inhibin-B produced by an ovarian tumor profoundly suppressed FSH levels and resulted in secondary amenorrhea and infertility. Use of sensitive and specific immunoassays for inhibin-A and -B may aid in the differential diagnosis of hormonally active ovarian tumors.

Histopathologic grading of ovarian carcinoma: a review and proposal

The histopathologic grade of ovarian epithelial carcinoma has generally been found to be of prognostic significance, but the grading system used has varied among published reports, and often has not been specified at all. The major proposed grading systems are reviewed, and a new system is proposed, which is modeled on the Nottingham system of breast cancer grading and is designed to be applied to all invasive epithelial carcinomas of the ovary. Results obtained in studies using this system are presented. When grading is compared with histopathologic typing of ovarian carcinoma, the latter is less valuable in predicting survival but better at predicting tumor responsiveness to chemotherapy, and can also suggest the chemotherapeutic agents to be used. Thus, both grade and type should be specified in the surgical pathology report for any ovarian carcinoma.

Oral contraceptives as risk factors for cervical adenocarcinomas and squamous cell carcinomas

To assess the hypothesis that oral contraceptives (OCs) increase the risk of cervical adenocarcinomas, we conducted a six-center case-control study of 124 patients with adenocarcinomas, 139 with squamous cell carcinomas, and 307 population controls. Women between the ages of 18 and 69 who were newly diagnosed with cervical adenocarcinomas between 1992 and 1996 were eligible. Healthy female controls and a second case group of incident cervical squamous cell carcinomas were matched to the adenocarcinoma cases. All participants were interviewed regarding OCs, other risk factors for cervical carcinoma, and utilization of cytological screening, and a PCR-based test determined HPV genotype of cervical samples for both case groups and controls. Use of OCs was positively and significantly associated with adenocarcinomas and positively but weakly associated with squamous cell carcinomas. Associations between OCs and invasive adenocarcinomas (n = 91), squamous cell carcinoma in situ (n = 48), and invasive squamous cell carcinomas (n = 91) disappeared after accounting for HPV infection, sexual history, and cytological screening, but a positive association remained between current use of OCs and cervical adenocarcinoma in situ (n = 33). This association persisted after stratification by screening and sexual history and after restriction according to HPV status, but small numbers made it difficult to exclude detection bias, selection bias, or residual confounding by HPV as potential explanations Current OC use was associated with cervical adenocarcinomas in situ, but we saw no other evidence that OCs independently increase the risk of cervical carcinomas.

Molecular diagnosis and prognosis in gynecologic oncology

Currently, molecular pathology plays a limited role in improving patient outcome in gynecologic oncology. However, molecular investigation is providing important insights into the epidemiology, pathogenesis, and progression of female genital cancers. Future roles should include prediction of poor outcome in low-risk cases, more accurate staging of multifocal tumors, identification of new precursor lesions, and prediction of response to specific therapeutic regimens. Gene therapy of some malignant tumors may become important in the near future. In the immediate future, however, the most significant role of molecular pathology may be in the screening and triage of putative cervical cancer precursors and in the possible prophylaxis of these lesions by means of a vaccine or vaccines against human papillomaviruses.

Tamoxifen-associated polyps (basalomas) arising in multiple endometriotic foci: A case report and review of the literature

We present a case of a 62-year-old G0P0 Caucasian woman who developed endometrial adenocarcinoma, FIGO grade 2, endometrioid type, after receiving tamoxifen for 2 years following a diagnosis of invasive carcinoma and ductal carcinoma in situ of the breast. An incidental finding in the hysterectomy specimen was numerous endometriotic foci involving the submucosa, subserosa, and serosa of the cervix; lower uterine segment serosa; and bilateral ovaries. Polypoid structures, similar to the endometrial polyps occurring in tamoxifen-treated patients, were observed to arise from endometriotic foci in the serosa of the cervix and bilateral ovaries. We have found only one similar report in the literature. Since these structures do not fit the definition of "polyp," we suggest "basaloma" as an alternative. We also review all cases of tamoxifen-associated endometriosis reported in the world literature and cases of polypoid endometriosis occurring in non-tamoxifen-treated patients. Of 12 reported cases of tamoxifen-associated endometriosis, 4 occurred in premenopausal women, 1 in a perimenopausal women, and 7 in postmenopausal women, of whom none had a known history of endometriosis. The endometriotic foci gave rise to a spectrum of lesions which included epithelial metaplasias, simple and complex hyperplasias, polypoid lesions, and 2 cases of endometrioid carcinomas.

Artifact in cervical LLETZ specimens: correlation with follow-up

The effect of cautery artifact on the ability to accurately diagnose dysplasia and predict abnormal follow-up in large loop excision specimens of the transformation zone (LLETZ) has not been adequately addressed in the pathology literature. One hundred consecutive conization specimens with cytologic and/or histologic follow-up were studied. Indications for the procedure were high-grade squamous intraepithelial lesion (on Pap smear and/or biopsy) in 64 cases, low-grade squamous intraepithelial lesion in 28, atypical squamous cells of unknown significance (ASCUS) in 3, atypical glandular cells of unknown significance in 2, adenocarcinoma in situ, squamous carcinoma in situ, and invasive squamous carcinoma in 1 each. Twenty-four specimens were cold-knife conizations (CKCs) and 76 LLETZs. All LLETZs had at least 1+ artifact, and in 46 cases (61%) it interfered with at least one aspect of evaluation. In 21 cases (28%), 1+ artifact interfered only with margin assessment. In 25 cases (33%), there was 2+ or 3+ artifact precluding not only margin assessment, but also diagnosis and grading of dysplasia. Of the 43 LLETZs received in more than one piece, 33 (77%) had interfering artifact, and in 21 (49%) it was 2+ or 3+, at least focally interfering with diagnosis and grading. In contrast, of 33 LLETZs received in a single piece, only 13 (39%) had interfering artifact, which was 2+ or 3+ in 4 (12%), (p < 0.05). Positive follow-up (including ASCUS, favor dysplasia, and ASCUS, not otherwise specified) was found in 6 of 7 CKCs with positive margins (86%), 10 of 16 LLETZs with positive margins (63%), and 4 of 7 LLETZs with unassessable margins (57%). In cases with negative cone margins, positive follow-up was found in 2 of 17 CKCs (12%), and 18 of 53 LLETZs (34%), p < 0.05; a higher frequency of interfering artifact (p < 0.05) was seen in these cases. LLETZ margin status and postprocedure endocervical curettage (ECC) specimens were not good predictors of residual disease, unlike margin status in CKC. Post-CKC ECC was a better predictor of subsequent abnormal follow-up than post-LLETZ ECC (p < 0.05). The presence of interfering artifact was only rarely mentioned in the original pathology report. In conclusion, the status of margins is a better predictor of abnormal follow-up in CKC than in LLETZ specimens. Fragmentation of the specimen is an additional factor, compounding the inevitable artifact. Postprocedure ECC is not a useful indicator of residual dysplasia. The pathologist should not hesitate to comment on specimen adequacy in surgical pathology reports.

Endocervical adenocarcinoma in situ of tubal type and its relation to atypical tubal metaplasia

Endocervical adenocarcinoma in situ (AIS) is currently classified as having endocervical, endometrioid, or intestinal differentiation or admixtures of these patterns. Tubal metaplasia (TM) of endocervical mucosa has been considered a benign lesion that may be confused with AIS but has no malignant potential. In recent years, an increasing number of cases in which TM not only coexists with AIS, but also possesses atypia with transitions between ordinary TM, atypical TM, and AIS with residual tubal morphology have been reviewed by the authors, largely in consultation material. The clinical and pathologic features of 11 cases showing tubal and other types of AIS arising in a background of TM are reported. It cannot be assumed that all ciliated tubal epithelium in the cervix is benign and possesses no premalignant potential. The relationship of atypical TM (dysplasia) to tubal-type AIS must be defined, and the latter pattern should be added to the known types of differentiation of cervical AIS.

Endometrial polyps: a comparison study of patients receiving tamoxifen with two control groups

Many reports describe an increased frequency and unusual features of endometrial polyps and carcinomas in women treated with tamoxifen (TMX) for breast cancer. Postmenopausal women with endometrial polyps were identified by computer search of pathology files from 1990 to 1996. Medical records were reviewed, and patients were divided into three groups: 28 receiving TMX for breast cancer, 23 receiving hormone replacement therapy (HRT), and 28 untreated controls (UC). Cumulative doses (CDs) of TMX were calculated. Histologic slides of polyps were reviewed blindly and evaluated for size, metaplasias, vascularity, fibrosis, and inflammation. Carcinomas were found in 3 TMX, no HRT, and 1 UC patient. Atypical hyperplasias were found in 1 TMX, 0 HRT, and 1 UC patient. Mean polyp size was larger in the TMX group (2.9 cm) than in the HRT (1.05 cm) and UC (1.35 cm) groups, and stromal fibrosis was more prominent in TMX-related and larger polyps. Mucinous metaplasias were observed more frequently in the patients receiving TMX. No other differences were noted. The two TMX patients in whom low-grade carcinomas developed and the one with atypical hyperplasia had independent risk factors. CDs for these patients were 32.9, 36.5, and 17.6 g, respectively. A high-grade carcinoma developed in a TMX patient without constitutional risk factors at a CD of 94.9 g. On the basis of a literature review and these results, low-grade carcinomas developing after relatively low CDs of TMX may be at least partially attributable to other risk factors. The association between poorly differentiated and nonendometrioid tumors with higher TMX CDs is still speculative, but the current study suggests that they may be related to TMX. A statistically significant increase in the frequency of thyroid replacement use by TMX patients is also noted.

Mammographic-histopathologic correlation of large-core needle biopsies of the breast

Large-core (14g) needle biopsy (CNB) of the breast is a new diagnostic modality increasingly being used to evaluate patients with mammographic abnormalities. Two hundred twenty-four CNBs were performed on 198 patients. Surgical follow-up was available in 64 cases (28.6%). Overall concordance rate was 93.8% (60 of 64 cases). Of the four discordant cases, two were diagnosed as atypical ductal hyperplasia (ADH) on CNB; on excision, these cases showed cribriform ductal carcinoma in situ (DCIS); two remaining cases, diagnosed on CNB as ADH versus DCIS, showed invasive carcinoma (DCIS with invasive component and infiltrating cribriform carcinoma, respectively) on excisional biopsy. Malignancy, primary (52) or metastatic (5), was identified in 57 cases (25.4%); 47 of these patients underwent surgical excision, and the diagnosis was confirmed in all of these cases. Of 51 cases with radiographic evidence of microcalcifications, 48 (94%) had microcalcifications in the CNB: 30 (62.5%) were benign, 11 (22.9%) were malignant, and 7 (14.6%) were diagnosed as ADH. In the remaining three cases (1.3%), only benign breast tissue without microcalcifications was seen, and the lesion was considered to have been missed. Biopsy specimens were obtained from 173 lesions because of the presence of a mass: 125 (72.3%) were benign, 45 (26%) were malignant, and 3 (1.7%) were diagnosed as ADH. Follow-up was available in 118 patients with benign lesions: all were mammographically stable or decreased at 6 or 12 months; no follow-up was available for the remaining patients. CNB of the breast is a highly sensitive (96.9%) and specific (100%) technique for management of patients with mammographic abnormalities. The histologic findings should be correlated with the mammographic appearance, and an attempt should be made to achieve a specific diagnosis in all lesions, particularly masses. The diagnosis of ADH should always prompt excisional biopsy because of a high frequency of false-negative results caused by sampling errors or underestimation.

Toward the development of a universal grading system for ovarian epithelial carcinoma. I. Prognostic significance of histopathologic features--problems involved in the architectural grading system

OBJECTIVE

Because there is no universally accepted grading system for ovarian epithelial carcinoma, we attempted to compare the prognostic utility of the individual components used in some systems--both architectural and cytologic features, as well as mitotic activity and histologic tumor type--to determine which of these components fit best with survival.

METHODS

We studied 461 patients with invasive ovarian carcinoma who had uniform treatment, complete clinical data including staging and follow-up, and slides available for review. Each tumor was assigned a histologic subtype, architectural grade (based on whether the predominant pattern was glandular, papillary or solid), nuclear grade, mitotic count, and FIGO grade (based on the system for endometrial carcinoma). These features were compared with each other and with tumor stage and survival.

RESULTS

The architectural grade, nuclear grade, and mitotic count were independent variables both in stage I/II and stage III/IV disease. Each of them correlated with survival for most combinations of histologic type and stage. By multivariate analysis, in stage I/II cancer, nuclear grade and architectural grade were significantly correlated with survival, mitotic count showed only a trend, and FIGO grade did not correlate. In stage III/IV disease, nuclear grade, architectural grade 3, and mitotic count were significant, and FIGO grade was not.

CONCLUSION

The new architectural grading system proposed worked better than the FIGO system in this study. Furthermore, it could be applied to all histologic subtypes of carcinoma. The nuclear grade and mitotic count were also independent of each other, correlated with survival, and could be utilized for all histologic types. These data support the development of a grading system which combines these architectural, nuclear, and mitotic features and can be applied regardless of the histologic type of carcinoma, modeled after the Nottingham system for grading of breast carcinoma.

Toward the development of a universal grading system for ovarian epithelial carcinoma: testing of a proposed system in a series of 461 patients with uniform treatment and follow-up

BACKGROUND

Most published series of ovarian carcinoma find a correlation between histologic grade and survival, but the grading system used commonly is not specified, and several different systems exist, some of which use different criteria for different histologic types. However, several studies have shown marked interobserver variability in distinguishing among the histologic types of ovarian carcinoma. The authors attempted to derive a universal grading system for all invasive ovarian carcinomas (IOC), based on the Nottingham system for grading all types of mammary carcinoma.

METHODS

The authors studied 461 patients with IOC of different histologic types and clinicopathologic stages who were treated in a uniform manner between 1980 and 1994 with surgery and cisplatin-based chemotherapy. All slides were reviewed and the tumors graded as follows: Architectural pattern (predominant): Glandular = 1, Papillary = 2, and Solid = 3; Nuclear pleomorphism: Slight = 1, Moderate = 2, and Marked = 3; Mitotic activity (mitotic figures per 10 high-power fields [1 HPF = 0.345 mm2]) in most active region: 0-9 = 1, 10-24 = 2, and > or = 25 = 3; Grade 1 = total score (adding three values obtained earlier) 3-5, Grade 2 = 6 or 7, and Grade 3 = 8 or 9.

RESULTS

Tumor grade correlated with survival in both early and advanced stage disease and for all major histologic types of IOC except clear cell carcinoma (CCC). Results for CCC approached but did not reach clinical significance. By multivariate analysis, only this tumor grade and performance status were significant in Stage I/II IOC. For Stage III/IV tumors, the new tumor grade also was significant, as were performance status, residual tumor size, response to chemotherapy, and mucinous (unfavorable) or transitional cell (favorable) histologic type. International Federation of Gynecology and Obstetrics grade (based primarily on architectural features) did not correlate significantly with survival except in Stage III/IV serous and Stage I/II mucinous carcinomas.

CONCLUSIONS

The new grading system reported is simple, reproducible (among the current study authors), and useful for all histologic types and clinical stages of IOC. Further testing for reproducibility and clinical utility is recommended.

Interobserver variability in the classification of proliferative breast lesions by fine-needle aspiration: results of the Papanicolaou Society of Cytopathology Study

This study evaluates the applicability of the published cytologic criteria in the categorization of proliferative breast lesions by assessing the diagnostic accuracy and interobserver reproducibility of a panel of experts. Twelve breast fine-needle aspiration (FNA) specimens of biopsy-proven nonproliferative breast lesion (NPL) (1 case), proliferative lesions without atypia (PL) (7 cases), proliferative lesion with atypia (PLA) (1 case), and low-nuclear grade ductal carcinoma in situ (DCIS) (3 cases) were selected. Six FNAs were Papanicolaou (PAP) and 6 were Diff-Quik-stained (DQ). Six expert cytopathologists classified the smears using a summary of published criteria as a guideline. All 6 participants rendered the same cytologic diagnosis in 2/12 (16%) cases. The agreement among the 6 raters was low (Kappa = 0.35). Cytohistologic correlation was achieved in 26/72 (36%) FNA diagnoses. The correlation of the PAP-stained cases was better than the DQ: 17/36 (47%) PAP and 9/36 (25%) DQ correlated. Improving the correlation was achieved by amalgamation of NPL and PL into "low risk" and PLA and DCIS into "high risk" categories: 47/72 (65%) FNA diagnoses then correlated with histology [29/36 (81%) PAP and 18/36 (50%) DQ]. We conclude that the cytologic criteria of proliferative breast lesions need to be further defined and assessed. Consideration should be given to minimizing the number of diagnostic categories and adopting a terminology that has a direct effect on patient management.

Immunolocalization of cyclins D and E and cyclin dependent kinase (cdk) 2 and 4 in human breast carcinoma

We studied the immunolocalization of cyclins D1 and E and their corresponding partner cyclin dependent kinases (cdk), cdk4 and cdk2 in 41 cases of human breast malignancy (21 invasive ductal carcinomas and 19 invasive lobular carcinomas) and examined the correlation of the labeling indexes among these cyclins, cdks, Ki67, estrogen receptor (ER) and progesterone receptor (PR). Cyclin D1 immunoreactivity was observed exclusively in the nuclei of tumor cells in 27/41 (65%) of the cases examined. Immunoreactivity for cyclin E and cdk2 was detected in all the cases and observed in the nuclei of both carcinoma and non-carcinoma cells. cdk4 immunoreactivity was detected in 39/41 (95%) cases and found in carcinoma and non-carcinoma cells. In all carcinomas examined, a significant correlation was observed only between Ki67 and cyclin D1 (p = 0.0037). However, when examining only invasive ductal carcinomas, a significant correlation was detected between Ki67 and cyclin D1 (p = 0.0069), Ki67 and cdk2 (p = 0.0043) and cyclin D1 and cdk4 (P = 0.0024). Only cyclin D1 correlated with the pathologic stages of the disease and histological grades of invasive ductal carcinoma. Among these cyclins and cdk, overexpression of cyclin D1 is considered to play an important role in the development of human breast malignancy through abnormal proliferation. No significant correlation was observed between steroid receptor status and any of cyclins and cdks examined. Cyclin D1 and cdk2 expression correlated with cell proliferation (Ki67) and cyclin D1 expression with expression of cdk4 in invasive ductal carcinoma but not invasive lobular carcinoma. Cyclin E expression did not correlate with cell proliferation, cyclin D1 or cdks possibly due to deregulation of its expression. These results also indicate different patterns of cyclin D1, cyclin E, cdk2 and cdk4 expression between invasive ductal and lobular carcinoma of human breast.

Telomerase expression in normal endometrium, endometrial hyperplasia, and endometrial adenocarcinoma

Telomerase activity has been detected in a broad range of human cancers and its expression could be an important step in tumor progression. Here, telomerase activity by the telomeric repeat amplification protocol in cases of benign endometrium, endometrial hyperplasia, and endometrial adenocarcinoma was tested. Telomerase expression was detected in 13 of 14 cases of proliferative phase endometrium, in 7 of 12 cases of secretory phase endometrium, but was not detected in any of 7 cases of atrophic endometrium. Three of three cases with evidence of luteal phase defect and one of four cases of chronic endometritis also expressed telomerase activity. Hyperplastic endometrium was positive for telomerase in 13 of 17 cases. Telomerase activity was detected in 40 of 48 cases of endometrial adenocarcinoma, which included 36 of 43 cases of endometrioid adenocarcinoma and four of five cases of papillary serous carcinoma. The detection of telomerase in endometrial adenocarcinoma was not associated with either architectural grade, myometrial invasion, or stage. There was statistically significant association, however, between telomerase activity in benign atrophic endometrium versus any endometrial abnormality in women 52 years of age or older.

Localization of mineralocorticoid receptor and 11 beta-hydroxysteroid dehydrogenase type II in human breast and its disorders

Mineralocorticoid receptors have been detected in the normal human breast and breast cancers. The expression of mineralocorticoid receptor (MR) and 11 beta-hydroxysteroid dehydrogenase type II (11sHSD2), which confers specificity on MR for aldosterone, was examined by immunohistochemistry in 114 samples from normal human breast and benign and malignant breast lesions in order to study its possible biological significance. MR and 11sHSD2 were immunolocalized in the ductal epithelium in 39/40 (98%) and 36/40 cases (90%) of normal breast, 21/22 (95%) and 15/22 cases (68%) of fibrocystic changes, and 11/11 (100%) and 8/11 (73%) cases of fibroadenoma, respectively. Cases positive for 11 sHSD2 also expressed MR but the patterns of expression varied greatly among examples of normal breast and benign breast diseases. There was a significant correlation between labeling indices of MR and 11sHSD2 in normal breast (p < 0.01) and in benign breast disease (fibrocystic change (p < 0.05) and fibroadenoma (p < 0.05)). In invasive carcinomas, immunoreactivity for MR and 11sHSD2 was detected in malignant cells in 32/41(78%) and 16/41(39%) cases. Both MR and 11sHSD2 labeling indices were significantly higher in invasive ductal carcinoma (22 cases) than invasive lobular carcinoma (19 cases) (p < 0.01). There was a significant correlation between labeling indices of MR and 11sHSD2 when analyzing all infiltrating carcinomas (p < 0.01), but not when assessing invasive lobular or invasive ductal carcinomas separately. These results indicate that the 11 sHSD2 enzyme generally colocalizes with the MR in the ductal epithelial cells of human breast, which may allow aldosterone to occupy its physiological receptor, and the expression of MR and 11sHSD2 appears to be related to ductal differentiation of breast carcinomas.

Loss of heterozygosity on chromosome 11q13 in lobular lesions of the breast using tissue microdissection and polymerase chain reaction

Demonstration of identical allelic loss on chromosome 11q13 in synchronous in situ (DCIS) and invasive ductal (IDC) breast carcinoma has provided molecular evidence of the progression of DCIS to IDC. We investigated loss of heterozygosity (LOH) at chromosome 11q13 in the spectrum of "marker/premalignant" and "malignant" lobular lesions of the breast, including atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), and infiltrating lobular carcinoma (ILC). Thirty-eight cases with various combinations of ALH, LCIS, and ILC were studied. Synchronous ductal lesions were present in 9 of 38 cases. Areas of interest were specifically isolated by tissue microdissection. The extracted DNA was amplified by polymerase chain reaction (PCR) and analyzed with two polymorphic markers for chromosome 11q13 (INT2 and PYGM). LOH at 11q13 was identified in ILC and LCIS in approximately one third of informative cases. LCIS in association with ILC showed a loss in 50% of cases, whereas pure LCIS in the absence of ILC had a much lower frequency of LOH, which was comparable to that of pure ALH. These results suggest that LOH on chromosome 11q13 may play an important role in development of ILC, similar to that of IDC from DCIS/ADH. Additionally, frequent LOH in ILC and LCIS associated with ILC and a significantly lower and comparable frequency of LOH in LCIS without ILC and ALH implies that genetic alteration(s) on chromosome 11q13 may be important in the transition of LCIS to ILC. LOH was detected in three of nine synchronous ductal lesions (one IDC and two DCIS), confirming our earlier findings and indicating that lobular and ductal neoplasia in the breast show some similar genetic changes. We hypothesize that LOH may help in separating morphologically similar yet genetically different subgroups of ALH and LCIS into one group with genetic changes and an increased potential to progress to invasive cancer and another group, the "marker" lesions of LCIS/ALH, that remain stable or possibly regress.

Advanced stage transitional cell carcinoma of the ovary

Primary transitional cell carcinoma (TCC) of the ovary has been recently recognized as a separate subtype of epithelial cancer. It has been proposed that recognition of such tumors is important on clinical grounds because of a favorable response to chemotherapy and an improved patient survival. The authors reviewed the histological and clinicopathologic findings of 58 patients with advanced stage (stages III and IV) ovarian cancer with a view to determining the frequency of TCC and confirming the favorable prognosis. Of these cases, 15 (26%) were reclassified as TCC; 13 were predominantly TCC, and 2 had a mixed pattern with approximately 50% of the tumor being TCC. TCC patients ranged in age from 44 to 70 years of age (mean, 57). Ten of the patients had stage III disease, and five were stage IV. The tumor was unilateral in 2 cases and bilateral in 11 (2 unknown). Tumor size varied between 3 and 23 cm. Of the stage III patients, five were optimally debulked, and five had residual disease. All patients received the same type of chemotherapy. The median overall survival was 28 months. There was no significant difference in the clinical outcome of patients with TCC compared with that of patients with serous carcinomas. These data suggest that TCC does not confer a favorable prognosis or better response rate to chemotherapy.

Aromatase and 17 beta-hydroxysteroid dehydrogenase type 1 in human breast carcinoma

The in situ formation of estradiol plays an important role in the development and biological behavior of human breast cancer Aromatase and 17 beta-hydroxysteroid dehydrogenase type 1 (17 beta-HSD type 1) are two principal enzymes involved in in situ estradiol production. We evaluated the expression of aromatase and 17 beta-HSD type 1 by immunohistochemistry in 41 cases of invasive breast carcinoma (19 lobular and 22 ductal). We then examined the correlation among the expression of these enzymes, estrogen (ER) and progesterone (PR) receptor status, Ki67 labeling index of carcinoma cells, age, and the clinical stage of the patients. Marked aromatase immunoreactivity was observed in stromal cells around carcinomatous glands in 32 of 41 cases (78%), and 17 beta-HSD type 1 immunoreactivity was detected in carcinoma cells in 23 of 41 cases (56%). There was a significant correlation observed between expression of 17 beta-HSD type 1 and aromatase in invasive lobular carcinoma (P = 0.0119), but not in invasive ductal carcinoma. There was an inverse correlation between aromatase and ER status in invasive ductal carcinoma (P = 0.0213), but not in invasive lobular carcinoma. No other correlations were observed among 17 beta-HSD type 1, aromatase, PR, ER, clinical stage, age, and Ki67 labeling indexes. Aromatase and 17 beta-HSD are not always expressed simultaneously in human breast carcinoma, but their simultaneous expression is more frequent in invasive lobular carcinoma than invasive ductal carcinoma. Consequently, different mechanisms may be involved in the regulation of expression of these two enzymes in human breast carcinoma.

K-ras point mutations in endometrial carcinoma: effect on outcome is dependent on age of patient

Mutations involving the K-ras proto-oncogene are believed to play an important role in the mechanism of tumorigenesis for many human cancers and occur in 10-30% of endometrial carcinomas. In the present study 221 cases of endometrioid endometrial carcinoma obtained from Japanese patients with average follow-up of 41 months were examined for point mutations in codon 12 of K-ras through use of the polymerase chain reaction. In 103 cases lymph node dissection had been performed. K-ras mutations were significantly associated with the presence of lymph node metastases (P < 0.04). Since endometrial carcinoma in premenopausal women generally behaves less aggressively than tumors of similar histologic grade arising in postmenopausal patients, we evaluated the effect of K-ras mutation on outcome in patients stratified into three different age categories (<53 years, premenopausal; 54-59 years, perimenopausal; >60 years, postmenopausal). In the postmenopausal age group (>60 years), the presence of K-ras mutations was statistically significantly associated with patients who died or experienced recurrence (41.2% vs 13.0%; P < 0.03). This was related to a dramatic (greater than eightfold; P = 0.011) increase in the likelihood of adverse outcome between the premenopausal and postmenopausal states for patients whose tumors contained mutant K-ras. These findings point to a possible role for K-ras activation in the mechanism(s) responsible for more aggressive clinical behavior of endometrioid endometrial cancer that is observed in postmenopausal patients.

Placental site nodule occurring in a fallopian tube

The placental site nodule (PSN), a recently described benign lesion of intermediate trophoblast, is usually an incidental finding in younger women. It is a well-circumscribed, round to oval lesion that is extensively hyalinized and immunohistochemically stains for cytokeratin, placental alkaline phosphatase (PLAP), human placental lactogen (HPL) and, focally, for human chorionic gonadotropin (HCG) and epithelial membrane antigen (EMA). Thus far, the cases reported have been found in endometrial curettage or hysterectomy specimens. The pathogenesis of PSN is yet to be ascertained; however, there is wide acceptance of the fact that it represents a remnant of the placental implantation site. If this is indeed the case, it should not be surprising to find PSN occurring at sites of ectopic gestation. We describe herewith a case in which PSN was found in a fallopian tube segment resected in a postpartum tubal ligation.

DNA analysis and S-phase fraction determination by flow cytometric analysis of infiltrating lobular carcinoma of the breast

Flow cytometric analysis was performed on 50 infiltrating labular carcinomas (ILCs) of the breast from 50 patients with clinical follow-up (average duration, 4.1 yr) who had been treated between 1976 and 1991. The patients were classified as alive with no evidence of disease, alive with disease, or dead of disease. Ploidy and S-phase fraction (SPF) were compared with clinical outcome, histologic pattern (classical versus variant patterns), nuclear grade 1 or 2, axillary lymph node status, tumor size, percentage of signet ring cells, and estrogen receptor status. There was no association between aneuploid or diploid ILC and disease recurrence (of those patients classified as alive with no evidence of disease plus dead of disease, 4 (40%) of 10 were aneuploid and 15 (38%) of 40 were diploid), survival (of those classified as alive with no evidence of disease plus alive with disease, 9 (90%) of 10 were aneuploid and 36 (90%) of 40 were diploid), or any of the other factors evaluated. However, ILCs with a high SPF were more likely to recur than those with a low SPF (a high SPF was found in 9 [56%] of 16; a low SPF was found in 9 [30%] of 30), but this relationship was not statistically significant (P = 0.08). When only diploid ILCs were considered, there was a statistically significant association between high SPF and recurrence (a high SPF was found in 9 [64%] of 14, a low SPF was found in 6 [24%] of 25, P = 0.033). After the stratification of the diploid ILCs by the stage of disease, this relationship persisted only in Stage 1 (recurrence: a high SPF was found in 3 [75%] of 4; a low SPF was found in 1 [9%] of 11, P = 0.033). There was no association between SPF and any of the other factors evaluated. Our study indicates that ILC is usually diploid and that SPF may be a prognostic indicator that is limited to Stage 1 disease.

Microinvasion in low malignant potential tumors of the ovary

The presence of microinvasion (Mi) has not previously been investigated in nonserous low malignant potential (LMP) tumors of the ovary. In serous LMP tumors (SLMP), Mi has not worsened the prognosis compared with usual SLMP in previous reports. In a retrospective clinicopathologic review of 126 cases of serous and mucinous LMP (MLMP) tumors of the ovary, the authors identified 14 cases with Mi: seven of 72 SLMP, four of 44 mucinous intestinal LMP (MILMP), and three of 10 mucinous müllerian LMP (MMLMP). Tumors with Mi resembled usual LMP histologically except for small foci (up to 0.2 cm) in the stroma consisting predominantly of single cells or small clusters of cells, sometimes in a cribriform pattern. In SLMP-Mi, the cells had eosinophilic cytoplasm, and the stromal reaction was minimal/absent. In MILMP-Mi and MMLMP-Mi, nuclear staining was paler; the stroma often showed a fibrous reaction or edema, especially in MILMP-Mi. All 14 patients had follow-up (2.2 to 18.6 years) and were without evidence of disease. Careful screening of both mucinous and serous ovarian LMP can show Mi. Mi foci should be distinguished from true stromal invasion, pseudoinvasion, endothelial cells, decidual cells and histiocytes, and pseudomyxoma in mucinous LMP. Mi does not seem to worsen prognosis in MLMP and SLMP tumors of the ovary.

Cytologic features of well-differentiated villoglandular adenocarcinoma of the cervix

OBJECTIVE

To evaluate the cytologic features of villoglandular adenocarcinoma of the cervix in cervical smears.

STUDY DESIGN

Eleven cervical smears from six patients with histologically proven villoglandular adenocarcinoma were reviewed.

RESULTS

All smears were positive for tumor upon retrospective evaluation and revealed similar cytologic features. The tumor cells were abundant and were shed in sheets, tight clusters and tissue fragments. Papillary projections, clusters with smooth borders and flattened cells at the periphery, strips with peripheral nuclear palisading and pseudostratification, and rosettes were present. Nuclear crowding and overlapping were prominent. The nuclei were small, ovoid and hyperchromatic. The chromatin was granular and evenly distributed. Nucleoli were absent or inconspicuous. Mitoses were present.

CONCLUSION

VGA may cause diagnostic difficulty because it shares some morphologic similarities with adenocarcinoma in situ, squamous cell carcinoma in situ involving endocervical glands, endometrial cells directly sampled with the Cytobrush and reactive endocervical cells. However, the above constellation of features should permit a cytologic diagnosis.

Proliferative activity of postmenopausal endometriosis: a histopathologic and immunocytochemical study

Histological features of 21 cases of postmenopausal endometriosis as well as the corresponding eutopic endometrium were studied. Immunocytochemical analysis of estrogen receptor (ER), progesterone receptor (PR), and Ki-67 nuclear antigen was also performed on the endometriotic lesions as well as the corresponding endometrium. All the cases studied were complicated by various other gynecologic diseases, making the preoperative diagnosis of endometriosis unlikely. Histologically, the endometriotic foci contained both epithelial and stromal components mostly lacking atrophic features in contrast to the corresponding eutopic endometrium. The endometriotic lesions and the corresponding endometrium exhibited immunoreactivity with ER in both the glands and stroma. The stromal cells of endometriotic lesions revealed positive PR staining, whereas those of the eutopic endometrium were either negative or weakly positive for PR, but the epithelial components of both were positive for PR. The positivity of Ki-67 antigen tended to be higher in the stroma of the postmenopausal endometriosis than in the eutopic endometrial stroma. Endometriotic lesions appear to remain biologically active, with proliferative activity as well as retained hormonal responsiveness, even in the low-estrogen milieu of the postmenopausal age.

An analysis of prognostic features in infiltrating lobular carcinoma of the breast

To establish prognostically useful pathologic features for infiltrating lobular carcinoma, histologic pattern, nuclear Grade 1 or 2, lymphatic invasion, the presence and extent of lobular carcinoma in situ, estrogen and progesterone receptor status, axillary lymph node status, tumor size, and pathologic stage were assessed as prognostic variables in 92 cases of infiltrating lobular carcinoma. Clinical follow-up was obtained (mean duration, 5.2 yr), and patients were classified as alive with no evidence of disease, alive with disease, or dead of disease. Recurrence (alive with disease and dead of disease) was associated with axillary lymph node metastases (P = 0.04), tumors measuring > 1.0 cm (P = 0.008), and pathologic Stage III/IV disease (P = 0.033). Survival (no evidence of disease and alive with disease) was associated with Stage I/II disease (P = 0.003). Statistically insignificant associations with disease recurrence or survival follow: infiltrative pattern (classical, alveolar, solid, mixed), nuclear grade, lymphatic vessel invasion, presence of lobular carcinoma in situ, extent of lobular carcinoma in situ (< 25% or > or = 25%), and hormone receptor status. Many of the prognostic features used in ductal carcinoma do not appear to be applicable to infiltrating lobular carcinoma. However, tumor size, axillary node status, and pathologic stage are prognostically useful in infiltrating lobular carcinoma.

Adenocarcinoma of the bilateral fallopian tube occurring after tubal sterilization

A case of bilateral tubal carcinoma occurring 22 years after tubal sterilization is presented. We believe that this is the first case report of bilateral tubal carcinoma that has arisen in ligated fallopian tubes. The possibility that tubal occlusion is one of the causative factors of tubal carcinoma is discussed.

Advances in endometrial pathology

In conclusion, the diagnosis of endometrial pathology is changing rapidly as our understanding of the pathogenesis of endometrial lesions expands. Increasingly, recognition of new lesions and further subclassification of well-described entities will become more important in patient care.

Ovarian mucinous tumors of low malignant potential: a clinicopathologic study of 54 tumors of intestinal and müllerian type

We have reviewed 44 mucinous intestinal (MI) and 10 mucinous mullerian (MM) tumors of low malignant potential (LMP) seen at The George Washington University Medical Center. As previously reported by Rutgers and Scully, MMLMP tumors occurred in younger women, were generally smaller and more frequently bilateral, had a papillary rather than multicystic appearance, and lacked goblet cells. All patients with MMLMP tumors were recurrence-free at last follow-up, including three whose tumors were microinvasive. Patients with MILMP tumors also all did well regardless of tumor grade, with the exception of a single patient with bilateral grade 1 ovarian tumors, an appendiceal villous adenoma, and pseudomyxoma peritonei. Microinvasion was also seen in four of these tumors, none of which recurred. Review of the literature suggests that MILMP tumors without stromal invasion but with either prominent cell stratification or marked nuclear atypia may have a worse prognosis than those lacking these features, but probably largely because of a correlation with higher stage disease. We believe that tumors of this sort should not be diagnosed as "noninvasive carcinomas," but should be sectioned more extensively for evidence of stromal invasion and subjected to careful staging. If the tumor is still noninvasive and in stage I after these procedures, the likelihood of treatment failure appears to be in the range of 1-3%.

Mucosal epithelial proliferation of the fallopian tube: a particular association with ovarian serous tumor of low malignant potential?

The presence or absence of tubal mucosal epithelial proliferation (MEP) and its degree of severity when present were investigated in 191 cases, including 49 ovarian serous tumors of low malignant potential (LMP), 33 nonserous (predominantly mucinous) LMP tumors, various other benign and invasive malignant female genital tract lesions, and 37 cases (73 fallopian tubes) of tubal ligation for sterilization. MEP including all degrees of severity was found to be an almost ubiquitous (83% of all cases) lesion of no clinical significance. On the other hand, MEP of moderate or marked degree was rarely seen (3% of cases) in normal tubes obtained for sterilization, but was identified in from 25% to > 40% of tubes accompanying a wide variety of nonneoplastic and neoplastic lesions. Thus, we recommend that only moderate to marked MEP be considered as a diagnosable lesion in the future. There was no tendency in this material for MEP to show any specific association with ovarian serous LMP tumors, as was previously reported. However, when MEP was present, it was more likely to be widespread and mitotically active when it accompanied an ovarian LMP tumor of any histologic type than when it was found with benign ovarian lesions, invasive gynecologic cancers, uterine leiomyomas, or tubal inflammatory lesions and ectopic pregnancies.

Microglandular hyperplasia of the cervix: a true "pill" lesion?

For many years, it has been assumed that microglandular hyperplasia (MGH) of the cervix occurs almost exclusively in women with endogenous (pregnancy) or exogenous (oral contraceptives) progestational stimulation, but this relationship has never been subjected to rigorous epidemiologic study. All available cases of MGH in our 1990 surgical pathology files were reviewed and clinical histories obtained. For each case of MGH, a control was chosen, consisting of a case in the same time frame of a woman of similar age who had undergone the same procedure (biopsy, conization, hysterectomy) for the same indication. A documented history of current oral contraception or pregnancy within the past 6 months was obtained in 57.9% (22 of 38) of the MGH cases and 47.4% (18 of 38) of the controls. This difference was not statistically significant by McNemar's test for paired data. The histologic features of the MGH lesions (lesion size, cytologic atypia, prominence of inflammation, and presence of solid component and of squamous metaplasia) were evaluated blindly without knowledge of the hormonal history. There were no statistically significant differences by the chi 2 test of association between cases with and without hormonal histories. This study provides no support for considering MGH or any of its constituent features. This study provides no support for considering MGH or any of its constituent features as causally related to oral contraception or other known hormonal perturbations.

Mature cystic teratomas of the ovary with intestinal wall structures harboring intestinal- type epithelial neoplasms

Mature cystic teratomas of the ovary frequently contain intestinal-type tissues, but these rarely organize into complete intestinal walls, including all layers, and even more rarely develop secondary neoplasms. The present report documents two mature teratomas with formation of complete segments of intestinal wall, one also containing a benign mucinous cystadenoma of the appendiceal type and the other an intestinal-type adenocarcinoma infiltrating into the neoplastic bowel wall but not the surrounding ovarian parenchyma. The latter patient is alive and well 5 years after surgery. These cases expand the repertoire of secondary neoplasms, benign and malignant, developing in mature cystic teratomas.

The significance of signet ring cells in infiltrating lobular carcinoma of the breast

To determine the prognostic significance of signet ring cells in infiltrating lobular carcinomas, the percentage of signet ring cells in 99 infiltrating lobular carcinomas was correlated with the patients' clinical outcomes (mean follow-up interval of 4.8 years). When the carcinomas were divided into those with 0%, 1-9%, and 10% or more signet ring cells, 57% (26/46) of patients with 10% or more signet ring cells had experienced recurrences or metastases compared with 40% (2/5) and 31% (15/48) with 0% and 1-9%, respectively. A similar analysis performed with breakpoints at 20% or 30% failed to yield any statistically significant associations. When patients were stratified by pathologic stage, patients with stage I disease and 10% or more signet ring cells were more likely to have recurrences or metastases than those patients with stage I tumors and fewer than 10% signet ring cells. There was no relationship between signet ring cells and disease progression in stages II, III, and IV. These results indicate that the presence of 10% or more signet ring cells represents a poor individual prognostic factor in stage I infiltrating lobular carcinomas.

Intraductal carcinoma (ductal carcinoma in situ) of the breast. A comparison of pure noninvasive tumors with those including different proportions of infiltrating carcinoma

BACKGROUND

Several studies have suggested that ductal carcinoma in situ (DCIS) of the comedo type (variably defined) is biologically more aggressive than other patterns of DCIS and more likely to progress rapidly to invasive carcinoma.

METHODS

Eighty-five pure DCISs were compared histopathologically with 64 carcinomas containing both intraductal and infiltrating ductal components (mixed DCIS/IDC).

RESULTS

Solid DCIS with and without necrosis was seen more frequently seen in the mixed DCIS/IDC series, especially in cases with less than 50% DCIS. Periductal stromal inflammation and multifocality also were seen more frequently in mixed DCIS/IDC than in pure DCIS. High nuclear grade and high mitotic activity were also more common in the DCIS component of the mixed cases and were well correlated with the intraductal and infiltrating components of the same tumors in most of the cases. The frequency of axillary lymph node metastases was correlated with the proportions of stromal invasion but not with the DCIS subtypes. When the criteria (solid growth pattern, high nuclear grade, and central necrosis) for the diagnosis of intraductal comedocarcinoma were analyzed separately, the first of these correlated most strongly with mixed DCIS/IDC compared with pure DCIS, the second less strongly, and the third not at all, although central necrosis has been considered the main or only diagnostic criterion for comedocarcinoma in several previous reports.

CONCLUSIONS

Solid growth pattern and high nuclear grade are the most important histopathologic features of DCIS used to predict progression to invasive carcinoma. No major changes between the intraductal and invasive elements of the same tumors were noted, but other studies have suggested that markers of aggressiveness either increase or decrease in the progression to invasion. These conflicting data require further investigation.

Immunohistochemical analysis of the peritoneum adjacent to endometriotic lesions using antibodies for Ber-EP4 antigen, estrogen receptors, and progesterone receptors: implication of peritoneal metaplasia in the pathogenesis of endometriosis

This study was designed to investigate whether or not the pelvic peritoneum exhibits a metaplastic process into müllerian-type epithelium using a marker for epithelial differentiation (Ber-EP4 antigen) and markers that indicate müllerian differentiation (estrogen receptors and progesterone receptors). The peritoneum and/or ovarian surface epithelium adjacent to endometriotic lesions were obtained from 24 patients with endometriosis at operation, and peritoneum and ovarian surface epithelium without any lesions were also obtained from control patients without endometriosis. The specimens were immunohistochemically analyzed using antibodies for epithelial antigen Ber-EP4, estrogen receptor (ER), and progesterone receptor (PR) on frozen sections. Normal peritoneal mesothelium showed negative staining for Ber-EP4, ER, and PR. The mesothelium of the peritoneum adjacent to the endometriotic lesions showed focal positivity for Ber-EP4, ER, and PR. Several cases of ovarian surface epithelium from normal control ovaries and ovaries adjacent to endometriotic lesions also showed focal positivity for Ber-EP4, ER, and PR. Stromal cells accompanying these foci were sporadically positive for ER and/or PR but negative for Ber-EP4. Focal expression of Ber-EP4, ER, and PR in the mesothelium of the peritoneum and the ovarian surface epithelium adjacent to endometriotic lesions suggests that mesothelium possibly acquires characteristics of epithelial as well as müllerian-type nature. These results support an existence of a metaplastic process of the peritoneal mesothelium in the pathogenesis of endometriosis. The more frequent Ber-EP4 positivity in normal ovarian surface epithelium compared to normal peritoneal mesothelium also suggests a fundamental difference in these tissues that may be related to the greater prevalence of epithelial neoplasms arising in ovarian tissue.