Mucocele-like lesions of the breast - A radiological and clinicopathological analysis

INTRODUCTION

Mucocele-like lesions (MLL) of the breast are rare entities which are considered to harbor uncertain malignant potential. Current UK guidelines recommend vacuum assisted excision (VAE) of all such lesions regardless of whether they display epithelial atypia. This study sought to review the key histological and radiological features of MLLs and compare their differing outcomes based on the presence of epithelial atypia.

METHODS

Pathology records of a single breast cancer screening center were retrospectively searched for all biopsy diagnosed MLLs over an 11-year period. Upgrade rates to malignancy (positive predictive values) were calculated by reviewing histology from the initial core biopsy and comparing with the corresponding excision specimen. Radiological images were simultaneously reviewed to provide radiological-pathological correlation.

RESULTS

Three of 11 patients (27.3%) with atypical MLLs on biopsy had malignant outcomes at excision, compared with only 1 of 36 patients (2.8%) with non-atypical MLLs. The majority of MLLs (93%) were identified as microcalcifications on mammographic imaging. No specific radiological features were predictive of malignancy.

CONCLUSIONS

Our data suggest that MLLs without atypia are potentially overtreated with current protocols and could be managed conservatively with radiological follow up. Radiological-pathological correlation is essential.

Hip-flask defense: An experimental study in the Hungarian population

Toxicology tests and medical expert opinions are part of routine work in drunk driving cases in both domestic and international practice. The greatest challenge to forming an opinion is that the perpetrator claims to have consumed alcohol after the act of driving. To determine the time of consumption, it is essential to establish whether the alcohol in the body was in the absorption phase or in the elimination phase when the sample was collected. In domestic practice, breath alcohol content can be measured several times, two blood samples can be collected, and both blood and urine samples can be taken almost simultaneously. A recent Swedish study showed that taking a single blood sample and two urine samples allows for a more accurate examination of consumption after the fact. This study aimed to examine the applicability of such model to the domestic environment. We conducted a controlled drinking experiment involving 15 Hungarian casual drinker volunteers aged 18-25 years who consumed different amounts of alcohol at specified times while providing regular breath alcohol measurements as well as blood and urine samples. These measurement results provided accurate information about the changes in alcohol metabolism compared to the time of drinking and allowed us to draw the necessary conclusions, offering further evidence that alcohol metabolism can vary significantly between different ethnic groups. The results showed that the absorption and excretion of ethyl alcohol in the volunteers were much faster than those in the current Hungarian standards used in practice. In conclusion, the comparison of blood and urine samples collected between 60 min and 120 min cannot be considered suitable for establishing the fact of drinking after driving in Hungarian practice, and a local model is needed.

Three-year Trends in Diagnosis of B3 Breast Lesions and Their Upgrade Rates to Malignant Lesions

BACKGROUND

B3 breast lesions are a heterogeneous group with uncertain malignant potential and, as such, provide a source of diagnostic difficulty. We calculated the prevalence of B3 lesions at our center along with the upgrade rates (positive predictive value) to in situ or invasive malignancy.

MATERIALS AND METHODS

We searched our pathology database over a 3-year period to include all B3 biopsies. The subsequent excision for each biopsy was reviewed, and the rate of upgrade was calculated by subtype. These results were compared against data published in large United Kingdom studies.

RESULTS

A total of 9206 breast biopsies were identified, of which 614 (6.7%) were classified as B3. Lesions displaying epithelial atypia were the most common subtype of lesion, with a prevalence of 39.6%. Lesions displaying epithelial atypia were upgraded to malignancy in 35.7% of cases. Among non-atypical cases, papillary lesions were the most common diagnosis (32.1%) with an upgrade rate of 2%. In situ lobular neoplasia (10.4%) was the third most frequently encountered diagnosis, and was upgraded to malignancy in 10.9% of cases. The upgrade rate in the remaining non-atypical lesions was invariably low (0%-2.6%).

CONCLUSIONS

Herein, we have shown an overall B3 rate in keeping with published data, whereas lesions displaying epithelial atypia showed upgrade rates to malignancy comparable with that of large United Kingdom studies. In our study, lesions without epithelial atypia showed very low rates of upgrade. A wide range of upgrade rates is seen in cases of lobular neoplasia, which highlights the need for uniformity of nomenclature and reporting within this subtype to accurately ascertain the true risk of upgrade associated with these lesions.

Time-dependent changes in kidney histopathology in ethylene glycol poisoning

Ethylene glycol (EG) may be acutely toxic following ingestion. In fatal cases, microscopic examination of urine and kidney specimens can establish a post-mortem diagnosis of EG poisoning. We describe the main renal histopathologic changes during different stages of EG poisoning, which might be helpful when dating the EG poisoning itself. A single-centre retrospective study conducted on all EG poisoning cases demonstrated that in an early stage of EG poisoning, fine dust-like crystals were deposited to the tubular cell basement membrane, followed by internalisation of calcium oxalate crystals into the epithelial cells. Later, the crystals formed larger aggregates within the epithelial cells. As the changes became advanced, pronounced tubular epithelial damage occurred, with detachment of epithelial cells from the basement membrane. In the final stage, coarse calcium oxalate crystals were recognised in the tubular lumen, with cellular debris from damaged epithelial cells. Our study shows that the time-dependent histological changes described follow the clinical stages of EG poisoning and may therefore provide a rough estimate of the time of EG ingestion before death.

A single-centre review of suspected sudden infant death cases

This study aimed to establish the number of deaths in infants under 1 year of age that were being reported for medico-legal examination at a single large academic centre in Hungary, as well as the method of these investigations with special emphasis on histopathology, ancillary techniques and the adherence of our current practice to international recommendations. A single-centre, retrospective audit was conducted on all suspected sudden infant death cases. After the review there were eight infectious background sudden infant death syndrome (SIDS) cases, infectious respiratory tract disease in 14 cases, cardiac septal tumour in one case, and hepatic, possibly metabolic, disorder in one case. Our study has highlighted that even in a single institution there is a huge heterogeneity of approaches which needs standardisation. A reclassification of infant cases according to the San Diego definition resulted in a decreased number of SIDS cases in our material. The San Diego definition and related international recommendations were found to be practical and the classification provides a guide to the standardisation of current practice.

Comparison of dual-color dual-hapten brightfield in situ hybridization (DDISH) and fluorescence in situ hybridization in breast cancer HER2 assessment

The most optimal method for assessing HER2 status is still subject to controversy as far as the type of assay used, the optimal method to perform, and the costs of each assay are concerned. The current study was done as a validation study prior to setting up a clinical HER2 testing service using the new commercial dual-color dual-hapten brightfield in situ hybridization (DDISH), but it was felt that our experience may be of interest to other laboratories considering setting up HER2 diagnostic facilities. One hundred and five patients diagnosed with invasive breast cancer were selected. PathVysion FISH and DDISH assays were carried out. Concordance correlation coefficients showed near perfect agreement in average HER2 and centromere-specific signal counts per cell and in HER2/CEN17 ratios between the PathVysion and the DDISH assays, and also the Kappa measure showed near perfect agreement between the two assays (Kappa=0.8712, P<0.0001). Statistical analysis confirmed that the two assays are comparable in terms of detection of HER2 gene amplification and suggests its utilization in routine HER2 diagnostics.

Comparison of Pathvysion and Poseidon HER2 FISH assays in measuring HER2 amplification in breast cancer: a validation study

Aims

The current study was done as a validation study prior to setting up a clinical HER2 testing service using the new commercial Poseidon HER2 fluorescence in situ hybridisation (FISH) assay. However, it was felt that the experience of the authors of this study may be of interest to other laboratories when considering setting up a HER2 diagnostic facility.

Methods

122 patients who had been diagnosed with invasive breast cancer were selected. Immunolabelling with HercepTest, PathVysion and Poseidon FISH assays were carried out using tissue microarray blocks.

Results

Concordance correlation coefficients showed near perfect agreement in average HER2 and centromere specific signal counts per cell and in the HER2/CEP17 ratios between the PathVysion and the Poseidon FISH assays. In addition, the κ measure showed perfect agreement (κ 0.9441, p<0.0001), and if only 2+ cases were considered there was substantial agreement (κ 0.7671, p=0.0006), between the two assays. The sensitivity and the specificity of the Poseidon FISH kit were calculated to be 95.2% and 100%, respectively, whereas the positive predictive value (PPV) and negative predictive value (NPV) were 100% and 99%, respectively. With regard to the ability to presume HER2 polysomy, the Poseidon FISH kit had a sensitivity of 93.3% and a specificity of 99.1%, with PPV and NPV of 93.3% and 99.1%, respectively, as assessed with PathVysion classification as the reference.

Conclusions

Statistical analysis confirmed that the two FISH assays are comparable in terms of detection of HER2 gene amplification. Proceeding from these findings, the genetic diagnoses obtained with the Poseidon kit can be considered to be as valuable as the results from the Food and Drug Administration approved PathVysion assay, and its utilisation in routine HER2 diagnostics is proposed.

Analysis of EGFR gene amplification, protein over-expression and tyrosine kinase domain mutation in recurrent glioblastoma

Gefitinib and erlotinib are both selective EGFR tyrosine kinase inhibitors (EGFR-TKIs) that have produced responses in a small subgroup of lung cancer patients. The strongest evidence for a role of EGFR in the biology of glioblastoma stems from clinical trials in which 15-20% of recurrent glioblastoma patients experienced significant tumour regression in response to these small-molecule EGFR kinase inhibitors. We examined the protein-kinase domain of the EGFR gene, EGFR protein expression and EGFR gene amplification in 20 cases of recurrent GBMs. EGFR protein over-expression was found in 65% of cases. EGFR protein over-expression was associated with EGFR gene amplification in 35% of cases, and with high polysomy in 15% of cases. No mutations were found in the TK domain of the EGFR gene. Our results confirm that mutations in the kinase domain are absent in recurrent GBM, and this might be a preponderant factor in the lack of major clinical responses of TKIs in GBM, recent studies have suggested that responsiveness to EGFR kinase inhibitors was strongly associated with coexpression of EGFRvIII and PTEN. Further prospective validation of EGFRvIII and PTEN as predictors of the clinical response to EGFR kinase inhibitors in recurrent GBM is strongly anticipated.

Immunohistochemical antibodies in breast cancer HER2 diagnostics. A comparative immunohistochemical and fluorescence in situ hybridization study

Overexpression and/or gene amplification of the HER2 oncogene predicts worse prognosis and altered sensitivity to chemotherapy. Trastuzumab is capable of improving prognosis of HER2-positive breast cancer, but for the success of treatment appropriate HER2 testing is essential. Our aim was to determine the value of immunohistochemical (IHC) screening prior to fluorescence in situ hybridization (FISH). We assessed five conventional IHC assays (NCL-CB11, Pathway CB11, CBE356, CBE1, HercepTest) and the novel rabbit monoclonal antibody, RM-4B5, combined with FISH on 199 invasive breast cancer cases. Taking FISH as the endpoint, we calculated sensitivity, specificity, positive and negative predictive values (PPV, NPV) and accuracy for all IHC assays with either taking both 2+/3+ cases or only 3+ cases as IHC positives. With 2+/3+ cases HercepTest showed 100% sensitivity and NPV, while the highest specificity, PPV and accuracy was associated with RM-4B5 (97.36, 80 and 95.34%, respectively). The second highest values belonged to either NCL-CB11 or Pathway CB11. When calculating only with 3+ cases, the results were reversed with increased specificity, PPV and accuracy. Our findings suggest that improving sensitivity by using two parallel IHC reactions might be beneficial; we recommend primarily HercepTest and Pathway CB11. Nevertheless, we may consider performing FISH analysis without prior IHC screening.

Tissue microarray technology in breast cancer HER2 diagnostics

Tissue microarrays (TMAs) as current medical research tools significantly lower the costs of immunohistochemical examinations (IHC) and fluorescence in situ hybridization (FISH) while enabling high levels of standardization and reliability. Taking HER2 testing of breast cancer into consideration, we assessed the routine applicability of TMAs. A hundred and seventy-four consecutive samples of invasive breast cancer cases were selected. TMAs were constructed in order to conduct double HER2 immunohistochemical analysis and FISH abreast using the conventional slide by slide method. Comparing the immunohistochemical data obtained from TMAs with the routinely processed large sections, we found a 94.5%/92.7%, 85.7%/88.9% and 91.2%/90% concordance at immunohistochemically HER2-negative, HER2 2+ and 3+ cases using the CB11/HercepTest, respectively. FISH performed on TMAs helped to determine Herceptin therapy suitability in all cases, and when discordance was found, we controlled FISH on "large sections". Being able to conduct FISH examinations at a reasonable price with or without prior immunohistochemical analysis, departments confronted with a certain frequency of breast cancer cases might extensively use the type of TMAs applied in our study. This is a relieve not only with regard to diagnostic work using microarrays, but this also allows to take new directions in research by shedding light on certain unusual cases.

Association between the Epstein-Barr virus and Hodgkin's lymphoma in the North-Eastern part of Hungary: effects on therapy and survival

This retrospective study included 109 patients with Hodgkin's lymphoma (HL; 45 females, 64 males). In 47 of the 109 HL patients (43%), immunohistochemical analysis of their formalin-fixed, paraffin-embedded histologic samples revealed Epstein-Barr virus (EBV) by latent membrane protein (LMP) 1. The highest virus association (50%) was found with the mixed cellularity histologic subtype, especially in patients aged 11-20 and >50 years. Virus positivity in nodular sclerosis was 35% (negative cases accumulated in patients aged 15-30 years). Regarding clinical stages, histologic subtypes, general symptoms, treatments employed and response to treatment, the EBV-positive group was not significantly different from the virus-negative group. During the mean follow-up time of 83 months (9-300 months), the overall or event-free survival of EBV-negative patients was more favorable than that of EBV-positive patients, although the difference was not significant (p = 0.16 and p = 0.24, respectively). EBV infection may be involved in the pathogenesis of HL in our Hungarian study cohort, but it does not significantly affect clinical symptoms, therapeutic results or complete and event-free survival of HL patients.

Transformed dermatofibrosarcoma protuberans: real time polymerase chain reaction detection of COL1A1-PDGFB fusion transcripts in sarcomatous areas

BACKGROUND

Recent cytogenetic studies have shown that reciprocal translocation t (17;22)(q22;q13) and a supernumerary ring chromosome derived from the translocation r(17;22) are highly characteristic of dermatofibrosarcoma protuberans (DFSP). The chromosomal rearrangements fuse the collagen type Ialpha1 (COL1A1) and the platelet-derived growth factor B-chain (PDGFB) genes. The COL1A1-PDGFB fusion transcript has been shown not only in conventional DFSP but also in a small series of DFSP with fibrosarcomatons areas (DFSP-FS) using reverse transcriptase-based conventional polymerase chain reaction. Nothing is known about the status of the COL1A1-PDGFB chimaeric gene in the pleomorphic areas of DFSP-PleoSarc (formerly known as DFSP-malignant fibrous sarcoma).

AIMS

To show the COL1A1-PDGFB fusion transcript in transformed malignant fibrous histiocytoma.

METHOD

A real-time polymerase chain reaction assay for the COL1A1-PDGFB fusion transcript in a series of DFSP containing sarcoma was conducted to determine whether the chimaeric gene could be identified in both components of DFSP-FS and DFSP-PleoSarc. Eight cases were analysed.

RESULTS

In seven cases, transcriptable RNA was detected, and in these cases, translocations were found between COL1A1 and PDGFB genes involving exons 27, 32, 34, 40 and 47 of the COL1A1 gene and exon 2 of the PDGFB gene.

CONCLUSIONS

From a diagnostic aspect, this assay can be particularly useful in confirming the diagnosis of sarcomatous DFSP. On the other hand, the COL1A1-PDGFB fusion gene was shown in three cases of DFSP containing pleomorphic sarcoma, which supports the theory of the common histogenesis.

Transformed dermatofibrosarcoma protuberans: a clinicopathological study of eight cases

BACKGROUND

Fibrosarcomatous (FS) or malignant fibrous histiocytomatous (MFH) transformation of dermatofibrosarcoma protuberans (DFSP) is a rare, but well known, entity. DFSPs with sarcomatous areas have questionable biological behaviour. Several studies suggest that they have a higher risk for local recurrence and distant metastases than ordinary DFSPs. One recent study described no difference in the behaviour of conventional and transformed DFSP.

AIMS

To investigate the biological behaviour of a series of transformed DFSPs.

METHODS

Eight transformed DFSPs were analysed clinicopathologically. Follow up ranged from four to 36 years.

RESULTS

The tumours involved the trunk (six cases) and lower extremity (two cases) and measured 3.5-8 cm (median, 4). Sarcomatous change presented de novo in all cases. The type of sarcomatous change was FS (five cases) and MFH (three cases). The estimated proportion of sarcomatous area in the tumour was 25-70% (median, 43.37%). Mitotic counts ranged from nine to 16 mitotic figures/10 high power fields in the FS and MFH areas (median, 12), and from one to three in the DFSP areas. Six patients were treated by wide local excision with histopathologically negative margins and two were treated by simple surgical excision with positive margins. Three patients developed recurrences and one developed metastasis during follow up. Of those treated by wide local excision, one developed recurrence. All tumours expressed CD34 in the DFSP component, but only three in the sarcomatous area.

CONCLUSIONS

Although DFSP containing sarcoma may be a more aggressive tumour, its behaviour can be influenced by surgical treatment.

Histiocyte-like cells expressing factor XIIIa do not belong to the neoplastic cell population in malignant fibrous histiocytoma

The term malignant fibrous histiocytoma (MFH) is widely used for pleomorphic soft tissue sarcomas without a specific line of differentiation. MFH is included in the category of fibrohistiocytic soft tissue tumors. MFH has a broad range of histological appearances, and it has several subtypes. All of these subtypes are composed of spindled fibroblast-like cells, undifferentiated cells, and histiocytic or histiocyte-like cells. A large number of fibroblast-like and pleomorphic cells express factor XIIIa in MFH. The cytological pleomorphism of factor XIIIa cells suggests that these cells may belong to the neoplastic population. It is equally possible that the factor XIIIa-positive cells are only activated stromal cells. The relation of factor XIIIa-positive cells to the neoplastic cell population in MFH is addressed in the present study. A morphometric approach compares the measure of nuclear pleomorphism of the factor XIIIa-positive cells with that of the factor XIIIa-negative tumor cells in high-grade MFH. The immunohistochemical approach compares the factor XIIIa-positive and -negative cell populations with regard to mutations of p53 tumor suppressor gene in p53-positive MFH cases. We selected 58 cases of soft tissue pleomorphic or storiform-pleomorphic MFH on the basis of histopathological examinations. A combination of incident light immunofluorescence for factor XIIIa and transmitted light examination for nuclear staining was used for morphometrical analysis. We found cytoplasmic factor XIIIa positivity in at least 2% of cells in 39 cases; the number of factor XIIIa-positive cells was under 0.5% in two cases, and the number of factor-positive cells ranged between 0.5% and 2% in 13 cases. Eighteen cases were analyzed with nuclear morphometry. We found that mean nuclear area and mean nuclear Ferret diameter in factor XIIIa-positive cells differed significantly from those of the tumor cells in all cases. The mean nuclear roundness factor differed significantly only in four cases. The latter finding showed that the microscopic polymorphism of factor XIIIa cells is measurable and is not merely a suspicion. The immunohistochemical positivity for p53 positivity can be accepted as the manifestation of a missense mutation of TP53 gene and as a marker of neoplastic cells. The simultaneous immunohistochemical detection of factor XIIIa and p53 in the same section revealed that factor XIIIa-positive cells were invariably p53 negative in MFH. This finding implies that the factor XIIIa cell population is non-neoplastic and belongs to the stromal component of MFH.

Estradiol is nephroprotective in the rat remnant kidney

BACKGROUND

Female sex hormones may influence the progression of renal diseases. We therefore evaluated the effects of estradiol on the development of glomerulosclerosis in a remnant kidney model.

METHODS

Ovariectomized or intact female Wistar rats underwent 5/6 nephrectomy. Ovariectomized animals were treated with vehicle, 17beta-estradiol alone or in combination with progesterone, intact rats received vehicle only. Twenty-four weeks after renal ablation, histological as well as molecular analysis were performed.

RESULTS

Vehicle-treated ovariectomized animals developed severe proteinuria and glomerulosclerosis as compared with vehicle-treated intact rats. In addition, renal mRNA levels of platelet-derived growth factor-A chain (PDGF-A) were increased. Estradiol replacement reduced proteinuria, which was paralleled by a diminished glomerular injury and reduced transforming growth factor-beta1 (TGF-beta1) and PDGF-A mRNA expression. In animals that received combined hormone treatment there were no significant differences in proteinuria, creatinine clearance, renal histopathology and growth factor mRNA levels compared with those measured in vehicle-treated ovariectomized rats. Serum cholesterol and triglyceride levels were comparable between all groups during the whole follow-up period.

CONCLUSIONS

The data suggest that estrogens protect against the development of glomerulosclerosis in the rat remnant kidney model.

Pseudoaneurysm and ilio-caval fistula caused by malignant fibrous histiocytoma of the aorta--CT diagnosis and angiographic confirmation

We report a case of a malignant fibrous histiocytoma (MFH) of the aortic bifurcation, which manifested as a pseudoaneurysm with the formation of an ilio-caval fistula, a complication about which, to our knowledge, nothing has been published previously. Spiral CT, catheter arteriography and venography were complementary in the diagnostic procedure.