Thyroid FNAC: Causes of false-positive results

In this paper, we aim to focus on false positive results in the evaluation of thyroid aspirations, covering cystic, inflammatory, follicular and oncocytic lesions, papillary carcinoma, and medullary carcinoma of thyroid. The recently described entity noninvasive follicular thyroid neoplasm with papillary-like nuclear features is also discussed detailing the impact of its introduction on the sensitivity and specificity of thyroid FNA, as well as the use of molecular tests for diagnostics. Medicolegal issues in relation to current practice in English law are also described.

Rapid on-site assessment of specimens by biomedical scientists improves the quality of head and neck fine needle aspiration cytology

OBJECTIVE

Immediate rapid on-site assessment (ROSA) of fine needle aspiration cytology (FNAC) specimens by biomedical scientists (BMS), the UK equivalent of cytotechnologists, or by pathologists may improve specimen quality and cellular adequacy rates for lymph node, head and neck and thyroid FNAC. The aim of this study was to evaluate the effect of introducing ROSA by BMS in an outpatient clinic setting.

METHODS

The adequacy rate and sensitivity of histological diagnosis for lymph node, thyroid and salivary gland FNAC samples were determined before and after the introduction of BMS ROSA. The additional financial costs and time required to perform this service were also estimated.

RESULTS

Thirty-one patients underwent ultrasound (US)-guided FNAC with ROSA and 151 without. ROSA reduced the number of FNAC insufficient in quality for diagnosis from 43% to 19% (P = 0.0194). The estimated additional cost for pathology per patient for ROSA was between £52.05 and £70.74, equivalent to €65.40/US $83.90 and €88.89/US $114.0, respectively, an increase of between 28% and 49% from the original cost. ROSA necessitated an additional 6 minutes clinic time per patient, reducing the number of patients that could be seen in an average clinic from 13 to 10 as well as requiring increased laboratory time for FNAC slide assessment.

CONCLUSION

ROSA by suitably trained biomedical scientists and with appropriate consultant pathologist support can improve the quality of FNAC sampling for head and neck lesions. Although ROSA resulted in both additional financial and time costs, these are more than likely to be offset by a reduction in patients returning to clinic for repeat FNAC or undergoing unnecessary surgery.

Thyroid FNAC cytology: can we do it better?

This article reviews recent developments in thyroid fine needle aspiration cytology (FNAC). While thyroid nodules are common, carcinoma is comparatively rare. Although histological assessment is used in most studies as the benchmark, the differential diagnosis on cytology or histology is not always reproducible. The literature shows wide variations in criteria for inadequate thyroid FNAC and study inclusion or exclusion criteria. In-clinic assessment of specimen adequacy and in-clinic reporting of thyroid FNAC has become popular although the costs and resource implications of in-clinic thyroid FNAC assessment and reporting are substantial. Many centres continue to use conventional techniques although liquid-based cytology and ultrasound-guided FNAC are gaining in popularity. Standardized categorical systems for FNAC reporting can make results easier to understand for clinicians and give clear indications for therapeutic action. Multidisciplinary case review is also essential, especially when there is diagnostic uncertainty. While currently of limited use, molecular pathology testing holds out some promise for the future.

Galectin-3 is not useful in thyroid FNA

INTRODUCTION

Previous studies have suggested that galectin-3 immunohistochemistry may be useful in the fine needle aspiration (FNA) diagnosis of thyroid carcinoma as it has been reported to selectively stain carcinomas and not adenomas or goitres.

METHODS

Fifty-one patients were included in a prospective study of galectin-3 in thyroid FNA; 88.2% were female and 11.8% male, mean age 53 years, range 25-87 years. Cell blocks were prepared and stained for galectin-3 if any cells were present in needle washings from the respective FNAs.

RESULTS

Twelve of 51 (23.5%) of cell blocks contained epithelial cells. One benign and one inadequate FNA were negative for galectin-3 staining. One of five non-diagnostic FNA cases, a papillary carcinoma on final histology showed positive staining. Four follicular neoplasm/suspicious of carcinoma cases showed negative staining. One malignant FNA case, a papillary carcinoma showed positive staining with galectin-3 but three further carcinomas, two papillary and one follicular were galectin-3 negative.

CONCLUSION

Galectin-3 immunohistochemistry does not appear to be a useful adjunct to diagnosis in thyroid FNA as it does not reliably distinguish malignant and benign lesions. Many thyroid aspirates are of low cellularity and are not suitable for cell block immunohistochemistry.

Prognostic relevance of extensive necrosis in renal cell carcinoma

AIMS

Evidence suggests that the presence of tumour necrosis is an adverse prognostic factor in renal cell carcinoma (RCC). However, it has also been shown that tumour regression, a microscopic feature associated with necrosis, may be a favourable short term prognostic factor in RCC.

METHODS

Pathology reports of 253 RCCs from 1992 to 2001 were reviewed, and identified 37 tumours with substantial macroscopic or microscopic necrosis. Microscopic pathology, TNM 1997 tumour stage, and clinical follow up were reviewed and correlated with pathological findings. Three cases were rejected because two were diagnosed at necropsy, and a third was the result of renal arterial embolisation.

RESULTS

Twenty of the 34 cases showed <50% necrosis, 10 showed 50-94% tumour necrosis, and four showed >95% tumour necrosis. Follow up data were unavailable in three cases. Nine of the remaining 31 tumours progressed; six were group 3 tumours showing <50% necrosis, three were group 2 tumours showing 50-94% necrosis, and none was a group 1 tumour showing >95% necrosis.

CONCLUSIONS

Extensive necrosis (>95% necrosis) is rare in RCC, accounting for only 1.6% of those diagnosed during eight years in this unselected hospital series. The microscopic pattern of necrosis was typical, requiring extensive tumour sampling for definitive tumour diagnosis. Although there were only four patients with extensive necrosis, none developed recurrent or metastatic carcinoma, or died from RCC. Although extensive (>95%) necrosis may imply better short term prognosis after adjusting for tumour pathological TNM stage, it is probably not a prognostic variable in RCC.

Are renal microgranulomas related to inflammatory tubular destruction?

Two cases of renal microgranuloma formation are reported, one in a patient with known Crohn's disease and another in a case of acute renal allograft rejection. In both cases, the microgranulomas arose as a result of inflammatory tubular destruction, in a manner analogous to that seen in patients with ulcerative colitis arising adjacent to ruptured epithelial crypts in the large intestine. Microgranulomas may occur at multiple anatomical sites in Crohn's disease, although renal microgranulomas are very rare. Non-specific inflammatory tubular destruction should be considered as a cause of renal microgranuloma formation, in addition to systemic granulomatous diseases, such as tuberculosis, sarcoid, or Crohn's disease, when granulomas are seen in the presence of inflammatory tubular destruction in renal biopsies.

Referrals for second opinion in surgical pathology: implications for management of cancer patients in the UK

OBJECTIVE

To compare patterns of outgoing referral practice from one large district general hospital histopathology (cellular pathology) laboratory to other pathology laboratories.

DESIGN

Referral cases for the relevant years were identified via hand searching of consultant referral files and from a central laboratory referral file. A comparison was made of the number and nature of pathology case referrals made to other laboratories in year 1990 with those made in year 1998.

SETTING

Large district general hospital pathology laboratory in the UK.

RESULTS

A statistically significant increase in the number of cases referred for a second opinion to an outside pathologist was noted, from 60 to 128 cases, representing an increase from 0.35 to 0.56% of total laboratory specimen workload (P=0.0034). In 36 (31.0%) of 116 cases from 1998 the diagnosis was altered, or a confident diagnosis was made where previously there was no definite diagnosis. Five cases with a benign in-house diagnosis had a malignant second opinion diagnosis and five cases with a malignant in-house diagnosis had a benign second opinion diagnosis. The largest single category of referred cases was for classification/grading of malignant lymphoma, comprising 27 (23%) of cases. The mean time delay between receipt of a specimen in the laboratory and issuing of the final report was 22 days (range 7-60 days). Only 25% of the referred cases were reported within 14 days.

CONCLUSIONS

Referrals are an important component of pathology practice. In the UK much of this activity is performed on a 'grace and favour' basis between laboratories despite the fact that referral cases are often complex and time consuming for the recipient pathologist and laboratory. Histopathology referrals do not seem to be adequately costed and accounted for in interinstitutional service level agreements within the UK National Health Service.

Pathology of ductal carcinoma in situ of the breast: current status

Ductal carcinoma in situ (DCIS) now accounts for around 20-25% of mammographically detected breast cancers. There is strong evidence to show that classification schemes for DCIS should be based primarily on nuclear grade and necrosis as these two features have been shown to be prognostically important as well as having high interobserver reproducibility among pathologists. Newer classifications of DCIS that employ these features, such as the Van Nuys DCIS Classification, are of prognostic importance in predicting recurrence of DCIS after breast conservation and show high levels of reproducibility. For treatment of DCIS via breast conservation a high pre-operative diagnostic rate is desirable, only achievable via needle-guided core biopsy. If local excision without radiotherapy is to be given there is strong evidence to support the requirement for a 10 mm tumour-free margin. Assurance that a margin is tumour-free requires sequential specimen processing which is both time consuming and costly, but which can be justified in cost and morbidity terms as radiotherapy may not be required for those patients with a 10 mm tumour-free margin. Other methods of specimen examination involve examination of mammographically directed tissue slices or alternative methods of excision margin assessment such as "onion skinning" of the specimen. Endocrine therapy will doubtless become more important for adjuvant therapy of DCIS as well as chemoprophylaxis in the future.

Colonic lymphoid hyperplasia in melanosis coli

We describe the case of a patient with Rett syndrome, a syndrome characterized by progressive infant encephalopathy, developmental delay, dementia, autism, ataxia, microcephaly, spastic paraparesis, and autonomic neuropathy with constipation. At colonoscopy, multiple foci of tiny white, sessile, polypoid lesions were seen throughout the colon and rectum, mimicking the appearances of small hyperplastic or adenomatous polyps, associated with generalized melanosis coli. This is the first case to our knowledge describing melanosis coli in a patient with Rett syndrome. As melanosis pigment deposition is characteristically not seen in lymphoid tissue, the lymphoid tissue was identifiable at endoscopy as multiple white nodules mimicking generalized colonic polyposis throughout the colon. We discuss the likely mechanisms of lymphoid hyperplasia and coexistent melanosis coli in Rett syndrome.

Method of specimen fixation and pathological dissection of colorectal cancer influences retrieval of lymph nodes and tumour nodal stage

INTRODUCTION

There is now evidence that meticulous specimen dissection may 'upstage' around one-quarter of colorectal cancers from node negative to node positive, although there is much debate as to how to achieve this: some authors prefer fat clearance techniques while others have opted for more conventional lymph-node retrieval with manual specimen 'breadknifing' and lymph-node palpation. While fat clearance is probably the optimum technique, it is time-consuming, costly and does not provide rapid diagnostic results.

METHODS

A prospective pathological study of 50 colorectal cancer resections was conducted with 100 comparison cases, the study group receiving at least an additional 24-h fixation of the mesocolonic or mesorectal fat in 10% aqueous formaldehyde prior to specimen dissection.

RESULTS

The percentage of node-negative colorectal cancer was significantly lower in the study group compared with the matched comparison group: (18) 36% compared with (55) 55% of comparison cases.

CONCLUSIONS

Effective lymph-node retrieval techniques require mesocolic/mesorectal fat to be adequately fixed prior to pathological dissection. This study suggests that satisfactory lymph-node retrieval is possible without fat clearance, provided the mesenteric fat is suitably fixed prior to colorectal cancer specimen dissection.

Fine-needle aspiration of the thyroid

BACKGROUND

Although fine-needle aspiration (FNA) of the thyroid is the key preoperative investigation of thyroid lesions, there are overlaps in the criteria for diagnosis of certain lesions, particularly important among which are those for follicular neoplasms. A proposal for a 5-category working system for thyroid FNA diagnosis is presented, devised using clearly defined diagnostic guidelines with a prospective 2-year evaluation in 1 center.

METHODS

The results of FNA of 156 patients with nodular thyroid lesions are presented. All patients were observed over a 2-year period in a multidisciplinary thyroid clinic. In some cases, the aspirates were repeated before excision of the lesion. The results of the FNA are classified by worst category for each patient, according to a 5-category scheme: THY1: inadequate; THY2: benign; THY3: indeterminate; THY4: suspicious lesion; THY5: malignant.

RESULTS

Seventy-five of the 156 patients (48.1%) proceeded to excision, of these 50 (67%) showed multinodular goiter or adenomatoid nodule within a goiter, 7 (9.3%) showed evidence of Hashimoto thyroiditis or lymphocytic thyroiditis alone, 1 (1.3%) showed evidence of Reidel thyroiditis, and 1 (1.3%) showed evidence of a parathyroid cyst. Eight patients (11%) showed evidence of follicular adenoma, and 5 patients (6.6%) showed papillary carcinoma; 1 (1.3%) showed follicular carcinoma, and 2 (2.7%) showed lymphoproliferative disease. There was a significant difference in the number of benign as compared with neoplastic thyroid lesions excised in the indeterminate (THY3) (2 of 13 [15%]) as compared with the suspicious categories (THY4) (10 of 24 [42%]), (P = 0.05). Although no false-negative FNAs were identified in this series, there was 1 false-positive (THY5) FNA.

CONCLUSIONS

The use of an indeterminate (THY3) category is helpful because it improves the diagnostic efficacy of thyroid FNA. The indeterminate (THY3) category is clinically useful and may markedly reduce or eliminate false-negative FNA in many patients with thyroid nodules. Cancer (Cancer Cytopathol)

The importance of skip lesions in temporal arteritis

AIM

To determine the frequency of skip lesions in an unselected series of temporal artery biopsies and compare the results with other series.

METHODS

The study was a retrospective review of 102 consecutive temporal artery biopsies taken in a five year period (1992-1997) in one large hospital.

RESULTS

35 cases (34.3%) showed evidence of active cranial vasculitis with pathological evidence of inflammation of the intima or media, with or without giant cells. Three of these cases (8.5%) showed apparent skip lesions: normal intima, media, and adventitia in one segment while in other segments there was clear evidence of active vasculitis. Immunocytochemical stains for leucocyte common antigen (LCA) and CD15 were helpful in identifying the absence of intimal or medial inflammatory cell infiltrates within skip lesions. Skip lesions have been described in up to 28.3% of cases in some series, while others have not found evidence of skip lesions or have identified them in a much smaller percentage of cases.

CONCLUSIONS

In this series skip lesions were relatively rare, accounting for 8.5% of cases of active vasculitis. The degree of inflammation in temporal arteritis is discontinuous. Immunostaining for inflammatory cells, for example LCA and CD15, may be helpful in identifying the presence of an inflammatory cell infiltrate in skip lesion segments of the temporal artery.

Spontaneous regression of renal cell carcinoma: a pitfall in diagnosis of renal lesions

Two cases of renal cell carcinoma, both of which underwent extensive spontaneous regression, are reported. The first occurred in a 56 year old man, forming a well circumscribed renal cortical nodule which contained only very occasional foci of viable renal cell carcinoma with areas of hyalinisation and calcification, and with metaplastic ossification. The second lesion was removed from an 82 year old man, comprising a cystic cavity containing necrotic debris with only occasional viable foci of classical renal cell carcinoma. Spontaneous regression of renal cell carcinoma is a rare but recognised entity. These two cases emphasise the important differential diagnoses: metastatic secondary carcinomas, xanthogranulomatous pyelonephritis, and infective granulomatous conditions of the kidney. The importance of adequate tissue sampling of all renal nodules cannot be overemphasised in the processing for examination of lesions within the kidney.

p53 and Rb1 protein expression: are they prognostically useful in colorectal cancer?

The expression of the p53 and Rb1 proteins was examined in an unselected consecutive series of 250 primary operable colorectal carcinomas with a mean follow-up of 4.3 years (range 43-77 months). The overall cancer-specific mortality was 34.8%, with 87 cancer deaths and 35 deaths as the result of other causes. Expression of p53 protein was identified in 152 of 250 (60.8%) cases, with expression of Rb1 protein in 207 of 250 (82.8%) cases. There was no association of p53 or Rb protein expression with patient age, sex, tumour site, tumour size, tumour type, tumour grade, peritumoral fibrosis, tumour lymphocytic infiltrate, nature of the tumour margin, extramural vascular invasion, number of lymph nodes or high apical lymph node involved or local peritoneal infiltration by tumour, Dukes' stage or Jass group. There was no difference in overall survival or recurrence-free survival for those cases that showed p53 expression or Rb1 protein expression compared with those cases showing absence of p53 or Rb1 protein expression, although patients with tumours showing aberrant (reduced) Rb1 protein expression demonstrated shorter recurrence-free survival and overall survival. The effect of 'aberrant' Rb1 protein expression and shorter recurrence-free and overall survival did not, however, achieve independent statistical significance. The results from this study would suggest that expression of p53 and Rb1 proteins does not appear be useful in determining the prognosis of operable colorectal cancer.

A prognostic index for ductal carcinoma in situ of the breast

BACKGROUND

There is controversy and confusion regarding therapy for patients with ductal carcinoma in situ (DCIS) of the breast. The Van Nuys Prognostic Index (VNPI) was developed to aid in the complex treatment selection process.

METHODS

The VNPI combines three significant predictors of local recurrence: tumor size, margin width, and pathologic classification. Scores of 1 (best) to 3 (worst) were assigned for each of the 3 predictors and then totaled to give an overall VNPI score ranging from 3 to 9. Three hundred thirty-three patients with pure DCIS treated with breast preservation (195 by excision only and 138 by excision plus radiation therapy) were studied with detection of local recurrence as the end point.

RESULTS

There was no statistical difference in the 8 year local recurrence free survival in patients with VNPI scores of 3 or 4, regardless of whether or not radiation therapy was used (100% vs. 97%; P = not significant). Patients with VNPI scores of 5, 6, or 7 received a statistically significant 17% local recurrence free survival benefit when treated with radiation therapy (85% vs. 68%; P = 0.017). Patients with scores of 8 or 9, although showing the greatest relative benefit from radiation therapy, experienced local recurrence rates in excess of 60% at 8 years.

CONCLUSIONS

DCIS patients with VNPI scores of 3 or 4 can be considered for treatment with excision only. Patients with intermediate scores (5, 6, or 7) show a 17% decrease in local recurrence rates with radiation therapy. Patients with VNPI scores of 8 or 9 exhibit extremely high local recurrence rates, regardless of irradiation, and should be considered for mastectomy.

C-erbB-3 in human breast carcinoma: expression and relation to prognosis and established prognostic indicators

A series of 346 patients with primary operable breast cancer and a series of 145 patients with advanced breast cancer were investigated for c-erbB-3 protein expression using the monoclonal antibody RTJ1. Formalin-fixed, paraffin-embedded tumour samples were stained using a standard immunochemical method and staining was assessed on a four-point scale. The study aimed to observe the expression of the c-erbB-3 protein and investigate any relationship between expression and established prognostic indicators and prognosis. In both the primary and advanced series breast tumour tissue was found to stain heterogeneously for c-erbB-3. The staining was observed to be predominantly cytoplasmic and the majority of tumours exhibited moderate positivity. However, 15% and 35% of cases in the primary operable and advanced series respectively displayed strong positive staining. No significant difference was found between the staining in the primary and advanced series. In the primary operable breast cancers, no significant associations were demonstrated with overall survival, disease-free interval, regional recurrence, the presence of distant metastases, age, menopausal status, oestrogen receptor status, histological grade, lymph node stage, vascular invasion and c-erbB-2 protein expression. However, a significant association was seen between the degree of c-erbB-3 immunoreactivity and both tumour size (P < 0.01) and tumour type prognostic group (P = 0.05). No overall association with local recurrence was seen when the four groups of c-erbB-3 expression were analysed (P = 0.12), but when those tumours showing no or weak staining were compared with those showing moderate and strong immunoreactivity it was seen that the latter were significantly more likely to develop local recurrence (P = 0.03). In the series of patients with advanced disease, no significant associations were demonstrated with survival, UICC criteria, age, menopausal status, oestrogen receptor status, histological grade, c-erbB-2 status or the presence of vascular invasion. In conclusion this study found variable expression of c-erbB-3 protein in human breast carcinoma and an association with some recognised prognostic factors in those patients with primary operable breast carcinoma. It seems, however, unlikely that c-erbB-3 protein expression will emerge as a powerful enough prognostic factor to be of value in clinical practice.

A prognostic index for ductal carcinoma in situ of the breast

BACKGROUND

There is controversy and confusion regarding therapy for patients with ductal carcinoma in situ (DCIS) of the breast. The Van Nuys Prognostic Index (VNPI) was developed to aid in the complex treatment selection process.

METHODS

The VNPI combines three significant predictors of local recurrence: tumor size, margin width, and pathologic classification. Scores of 1 (best) to 3 (worst) were assigned for each of the 3 predictors and then totaled to give an overall VNPI score ranging from 3 to 9. Three hundred thirty-three patients with pure DCIS treated with breast preservation (195 by excision only and 138 by excision plus radiation therapy) were studied with detection of local recurrence as the end point.

RESULTS

There was no statistical difference in the 8 year local recurrence free survival in patients with VNPI scores of 3 or 4, regardless of whether or not radiation therapy was used (100% vs. 97%; P = not significant). Patients with VNPI scores of 5, 6, or 7 received a statistically significant 17% local recurrence free survival benefit when treated with radiation therapy (85% vs. 68%; P = 0.017). Patients with scores of 8 or 9, although showing the greatest relative benefit from radiation therapy, experienced local recurrence rates in excess of 60% at 8 years.

CONCLUSIONS

DCIS patients with VNPI scores of 3 or 4 can be considered for treatment with excision only. Patients with intermediate scores (5, 6, or 7) show a 17% decrease in local recurrence rates with radiation therapy. Patients with VNPI scores of 8 or 9 exhibit extremely high local recurrence rates, regardless of irradiation, and should be considered for mastectomy.

Histological examination of clots from cytological specimens: is this a worthwhile procedure?

A comparison of conventional cytology and clot histology was made on 174 serous fluids, fine needle aspirates (FNA) and other non-gynaecological specimens. In eight cases (4.5%) this clot material contained malignant cells or cells suspicious of malignancy despite the absence of suspicious or malignant cells in conventionally prepared smears from the same specimen. In 11 cases (6.3%) the clot was negative, although conventional smears contained malignant or suspicious cells. A chi 2 test showed that there was no statistically significant difference between the number of positive diagnostic scores in each group with chi 2 of 0.223 (degree of freedom = 1), P = 0.637. Examination of clot material from serous fluids and FNA-aspirates is as effective as examination of conventional cytological preparations. Processing of clots from cytological aspirates for histological examination should be more widely adopted, and is applicable in all cytopathology laboratories.

Ten-year results comparing mastectomy to excision and radiation therapy for ductal carcinoma in situ of the breast

The 10-year results of 300 patients with ductal carcinoma in situ (DCIS) without microinvasion are reported; 167 treated with mastectomy and 133 treated with excision and radiation therapy. There was a significant difference in disease-free survival at 10 years, in favour of those treated with mastectomy, 98% versus 81% (P = 0.0004). Multivariate analysis confirmed nuclear grade as the only significant predictor of local recurrence (P = 0.02) or invasive local recurrence (P = 0.03) in patients with DCIS treated with excision and radiation therapy. There was no difference in breast cancer-specific survival or overall survival between the two treatment groups.

Prognostic classification of breast ductal carcinoma-in-situ

We present a new prognostic classification designated the Van Nuys classification for ductal carcinoma-in-situ (DCIS). The classification combines high nuclear grade and comedo-type necrosis to predict clinical recurrence. Three groups of DCIS patients were defined by the presence or absence of high nuclear grade and comedo-type necrosis: 1--non-high-grade DCIS without comedo-type necrosis, 2--non-high-grade DCIS with comedo-type necrosis, 3--high-grade DCIS with or without comedo-type necrosis. There were 31 local recurrences in 238 patients after breast-conservation surgery 3.8% (3/80) in group 1, 11.1% (10/90) in group 2, and 26.5% (18/68) in group 3. The 8-year actuarial disease-free survivals were 93%, 84%, and 61%, respectively (all p < or = 0.05). The Van Nuys classification defines three distinct and easily recognisable groups, each of which has a different likelihood of local recurrence if treated with breast conservation.

Cathepsin D in primary breast carcinoma: adverse prognosis is associated with expression of cathepsin D in stromal cells

The immunohistochemical expression of the aspartyl protease enzyme cathepsin D was examined in a consecutive series of 103 primary operable breast carcinomas with the polyclonal antibody NCL-CDp. Expression of cathepsin D was identified within the epithelial and stromal components of all tumours examined. No significant associations of increased cathepsin D expression in the epithelial tumour component with conventional prognostic indices such as tumour size, grade, lymph node stage, or patient survival were identified. However, significant associations of increased stromal cathepsin D expression and high tumour grade, chi 2 = 11.40 (df = 2), p = 0.003; increased tendency to local recurrence, chi 2 = 6.87 (df = 1), p = 0.009; regional recurrence, chi 2 = 7.44 (df = 1), p = 0.006; poorer disease free survival, chi 2 = 14.9 (df = 1), p = 0.0001; and poorer overall patient survival, chi 2 = 6.90 (df = 1), p = 0.0086, were identified. Cathepsin D expression is present in all breast tumours. Stromal cathepsin D expression is a neglected immunohistochemical prognostic parameter which could explain some of the previous apparently conflicting reports concerning the effect on patient prognosis of biochemical (i.e. total) and immunohistochemical estimations of cathepsin D in breast cancers.

Correlations between the mammographic features of ductal carcinoma in situ (DCIS) and C-erbB-2 oncogene expression. Nottingham Breast Team

PURPOSE

C-erbB-2 oncogene expression is found in 60% of DCIS cases. C-erbB-2 expression in DCIS has been shown to correlate with comedo subtype, large cell size, lymphoid infiltrate, nuclear pleomorphism, multinucleation and high mitotic rate. These findings have led to the suggestion that the subgroup of DCIS that expresses c-erbB-2 may be a biologically definable category with prognostic significance. The purpose of this study was to identify any differences in the mammographic appearances between DCIS which expresses c-erbB-2 and DCIS that does not express this oncogene.

MATERIALS AND METHODS

C-erbB-2 staining characteristics and preoperative mammograms were available for review in 126 patients with pure DCIS. All the mammograms were reviewed by a radiologist knowing the patient had DCIS but without any further pathological or immunohistochemical information.

RESULTS

C-erbB-2 positive DCIS showed the following features more commonly than c-erbB-2 negative disease: calcification (65 of 71 (92%) vs 28 of 39 (72%), P < 0.01), ductal distribution of calcification (51 of 65 (78%) vs 16 of 28 (57%), P < 0.05), rod-shaped calcification (53 of 65 (82%) vs 15 of 28 (54%), P < 0.01) and granular calcification (63 of 65 (97%) vs 24 of 28 (86%), P < 0.05). C-erbB-2 negative DCIS more commonly showed an abnormal mammogram without calcification than c-erbB-2 positive disease (11 of 39 (28%) vs 6 of 71 (8%), P < 0.01).

CONCLUSION

We have demonstrated significant differences in the mammographic features of c-erbB-2 positive and negative disease. As c-erbB-2 expression has been shown to correlate with aggressive histological features, the differences in the mammographic appearances between c-erbB-2 positive and c-erbB-2 negative DCIS may be of practical value.

Screening-detected and symptomatic ductal carcinoma in situ: mammographic features with pathologic correlation

PURPOSE

To compare the mammographic and pathologic features of screening-detected and symptomatic ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

The mammographic and pathologic features of 54 screening-detected and 77 symptomatic cases of DCIS were compared. Patients were aged 30-76 years (mean, 58 years).

RESULTS

Diffuse involvement was seen in 10 patients (13%) with symptoms but in none of the screening-detected group (P < .05). The disease was radiologically more extensive in the symptomatic group. Calcifications in the symptomatic group (n = 48) were less likely to have a ductal distribution than those in the screening-detected group (n = 48) (30 [63%] vs 40 [83%], respectively; P < .05). At histologic examination in some cases, the symptomatic group (n = 76) included eight (11%) patients with cribriform-micropapillary, large-cell tumors (P < .05) and less comedocarcinoma (20 [26%] vs 23 [45%], respectively; P < .05) compared with the screening-detected group (n = 51).

CONCLUSION

The results show differences in the radiologic and pathologic features of screening-detected and symptomatic DCIS.

Ideas in pathology. Ductal carcinoma in situ of the breast: a proposal for a new simplified histological classification association between cellular proliferation and c-erbB-2 protein expression

The diagnosis of ductal carcinoma in situ of the breast (DCIS) has become common with the advent of breast screening programs.

METHODS

Proliferation indices (S-phase fraction) were studied in 76 cases of pure DCIS. Tumors were classified according to conventional criteria and also according to a novel simplified classification based on cellular necrosis and morphology. This new classification defines three distinct tumor groups: pure comedo in 19 (25.0%) cases, DCIS with necrosis (non-pure comedo) in 21 (27.6%) patients, and DCIS without necrosis in 36 (47.4%) of cases, the latter group comprising largely classical cribriform or micropapillary architectural subtypes.

RESULTS

Flow cytometric DNA analysis showed a significantly higher S-phase fraction in comedo DCIS than in the subgroup of DCIS tumors without necrosis (P < 0.01 [anova]). A preliminary analysis of disease recurrence and disease-free survival in a large series of 391 cases of pure DCIS showed that of 181 cases of pure comedo DCIS there were 19 local recurrences at the 7-year stage (82% 7-year disease-free survival), with 5 local recurrences in 51 cases of DCIS with necrosis (non-pure comedo) (85% 7-year disease-free survival) and only 6 local recurrences in the 159 cases of the DCIS-without-necrosis subgroup (94% 7-year disease-free survival). The chi 2 value for the frequency of disease recurrence of all cases of DCIS with necrosis (i.e., combining the groups of comedo DCIS and DCIS with necrosis (non-pure comedo)) as compared to DCIS without histological evidence of necrosis was 5705 (df = 2; P = 0.0001), and the chi 2 for disease-free survival of types of DCIS with necrosis as compared to cases without necrosis was 178 (df = 2; P = 0.0001). This analysis indicates that the histological presence of necrosis appears to be a relatively powerful predictor of increased disease recurrence and poorer disease-free survival after treatment for DCIS.

CONCLUSIONS

Necrosis in DCIS in the absence of pure classical comedo morphology is a feature of more biologically aggressive in situ breast cancer with an intermediate proliferative fraction as compared with the high proliferative fraction of pure comedo DCIS and the low proliferative fraction of DCIS without necrosis. There was no significant difference in DNA ploidy (diploid or aneuploid) between the subgroups as assessed by chi 2 analysis. Further larger studies are required to establish if DCIS with necrosis (non-pure comedo) also shows a greater tendency to local recurrence after breast conservation treatment than do subtypes of DCIS without necrosis. DCIS with necrosis (non-pure comedo) should be adopted as a distinct histological subgroup of DCIS in future clinical studies of in situ mammary carcinoma.

Oestrogen receptor expression in ductal carcinoma in situ of the breast: relationship to flow cytometric analysis of DNA and expression of the c-erbB-2 oncoprotein

The expression of oestrogen receptor protein (ER) was examined in 151 cases of symptomatic or screening detected pure ductal carcinoma in situ (DCIS) of the breast by immunocytochemical assay (ERICA), in formalin-fixed paraffin-embedded tissue, with the monoclonal antibody H 222 (Abbott). Forty-eight tumours (31.8%) of cases were ER positive. Twenty-seven (17.9%) of cases showed high level ER expression and 21 (13.9%) of cases showed low level ER immunoreactivity. Significant associations of positive tumour ER immunoreactivity and non-comedo architecture chi 2 = 6.76; (d.f. = 1): P < 0.001, small cell size chi 2 = 4.49; (d.f. = 1): P = 0.034, higher S-phase fraction chi 2 = 4.71; (d.f. = 1): P = 0.03 and lack of c-erbB-2 protein overexpression chi 2 = 7.96; (d.f. = 1): P < 0.01 were identified. No significant associations of ER expression and patient age, histological grade of necrosis in DCIS, or DNA ploidy were found. ER expression is detectable in less than one third of symptomatic and screening detected cases of DCIS, implying that endocrine therapy of DCIS may be a more appropriate form of management for morphological subtypes of DCIS which show higher rates of oestrogen receptor expression, particularly those of non-comedo and small cell type.

Oncogenes and tumor morphology prediction

Oncogenes and oncoproteins have been shown to play an important role in the neoplastic progression of tumors. It is now evident that certain subsets of human tumors show preferential expression of specific oncogenes and oncoproteins that may in turn predict tumor morphology. The phenomenon of preferential oncogene or oncogene protein expression in certain morphologic types of tumor may help to better define the biologic behavior and aggressiveness of a given tumor, so leading to advances in the diagnosis, treatment, and understanding of human neoplasia.

p53 protein expression in mammary ductal carcinoma in situ: relationship to immunohistochemical expression of estrogen receptor and c-erbB-2 protein

The immunohistochemical expression of the p53 gene protein was examined in a consecutive series of 143 cases of pure ductal carcinoma in situ (DCIS) of the breast. Expression of wild-type and/or mutant p53 protein was detected in 36 (25.2%) of the cases examined, as evidenced by positive nuclear staining with the monoclonal antibody DO 7. Thirty-four (35.8%) of the large cell cases showed p53 protein expression compared with two (4.1%) of the small cell cases (chi 2 = 15.3 [df = 1], P < .001). p53 Protein expression also was associated with an increased histologic degree of necrosis, with a nearly significant association of negative tumor estrogen receptor status and p53 protein expression. No significant association of p53 protein expression and c-erbB-2 protein expression was seen. Immunohistochemical expression of p53 protein is present in approximately 25% of DCIS cases and is confined almost exclusively to large cell DCIS, a morphologic subtype of in situ breast carcinoma thought to be more biologically aggressive. Expression of p53 protein may be important in the neoplastic progression of DCIS, reflecting the acquisition of p53 gene mutations in large cell DCIS cases. Therefore, p53 may be implicated in mammary tumor evolution from in situ to invasive disease.

Mural bridging lesions in colonic Crohn's disease

A case of Crohn's colitis with mural bridging lesions is described. The bridging lesions comprised colonic-type mucosa, smooth muscle, nerve fibers, with foci of adipose tissue and fibrous connective tissue. The lesions arose from the muscularis propria proximal to colonic strictures and possibly due to diverticular outpouching of the colonic wall associated with increased intraluminal pressure, although the exact mechanism of their formation appears unclear. This entity has not been previously described in inflammatory bowel disease, to our knowledge. Bridging pseudopolyps are seen in ulcerative colitis and rarely in Crohn's disease but do not contain substantial amounts of smooth muscle and/or nerve fibers. We believe that the mural bridges described in this article represent residual muscularis propria at the site of diverticular formation due to long-standing Crohn's colitis. We speculate that the stricture formation seen distal to the site of the mural bridging lesions may have been an important factor in formation of the colonic diverticula and, hence, these lesions that we interpret as representing residual muscularis propria adjacent to sites of diverticular formation in long-standing Crohn's colitis.

Production and characterization of a polyclonal antibody to the c-erbB-3 protein: examination of c-erbB-3 protein expression in adenocarcinomas

A polyclonal rabbit antibody was raised to the c-erbB-3 protein using a synthetic peptide corresponding to amino acids 1229-1241 of the predicted protein sequence of c-erbB-3. In Western blot analysis this antibody detects a single band at approximately 165 kD in a c-erbB-3 transfected (293/HER-3) human cell line. c-erbB-3 protein expression was then examined in a variety of adenocarcinomas. Expression of c-erbB-3 protein was indicated by membrane and/or cytoplasmic tumour cell immunoreactivity in formalin-fixed, paraffin-embedded tissue sections. c-erbB-3 protein was detected in a series of 13 out of 14 primary breast carcinomas, 3 of 5 gastric adenocarcinomas, 8 of 9 colonic adenocarcinomas, 2 of 9 prostatic adenocarcinomas, 0 of 6 renal cell carcinomas, 1 of 4 primary lung adenocarcinomas, and 5 of 7 endometrial adenocarcinomas. Immunohistochemical expression of the c-erbB-3 protein appears to be a relatively common event in adenocarcinomas, and further studies are now warranted to establish the role of the c-erbB-3 protein in neoplasia.

Epidermal growth factor receptor expression in Barrett's esophagus

Six cases of known Barrett's esophagus were examined immunohistochemically for the presence of epidermal growth factor receptor. All cases showed expression of epidermal growth factor receptor in intestinal metaplastic Barrett's epithelium, the most common form of Barrett's change. Expression of epidermal growth factor receptor may be important in neoplastic transformation in Barrett's esophagus, possibly by an autocrine mechanism. Alternatively, epidermal growth factor receptor expression in intestinal metaplastic Barrett's epithelium may represent a nonneoplastic regenerative phenomenon as seen at other sites within the gastrointestinal tract. Further larger studies are required to assess the clinical significance of these findings.

p53 protein expression in human breast carcinoma: relationship to expression of epidermal growth factor receptor, c-erbB-2 protein overexpression, and oestrogen receptor

The expression of p53 protein, oestrogen receptor protein, epidermal growth factor receptor (EGFR) and overexpression of the c-erbB-2 oncoprotein was examined in a series of 149 primary symptomatic breast carcinomas. Expression of p53 was present in 62 of 146 cases (42.5%) of the invasive carcinoma and one of three cases (33.3%) of ductal carcinoma in situ (DCIS) examined. Statistical associations of tumour oestrogen receptor positivity and lack of p53 protein expression, chi 2 = 19.78 (d.f. = 1), P less than 0.001, positive tumour p53 status and poor tumour grade; chi 2 = 14.1 (d.f. = 2), P less than 0.001, EGFR expression chi 2 = 7.07, (d.f. = 1), P less than 0.01 and tumour c-erbB-2 protein overexpression; chi 2 = 4.61 (d.f. = 1), P = 0.032 were identified. Expression of p53 is rare in invasive lobular carcinoma of classical type (8.3% of cases examined) in contrast to other common types of mammary carcinoma. Non-significant trends of p53 protein expression and increased regional tumour recurrence; chi 2 = 3.20 (d.f. = 1), P = 0.074 and also poorer patient survival; chi 2 = 3.76 (d.f. = 1), P = 0.053 were identified. p53 protein expression is a common event in human breast cancer and is present in both DCIS and invasive mammary carcinoma. Abnormal expression of p53 protein is a feature of both in situ and invasive breast carcinoma, implying that the abnormal p53 protein expression may be implicated in the early stages of mammary carcinoma progression.

Nuclear and flow cytometric characteristics associated with overexpression of the c-erbB-2 oncoprotein in breast carcinoma

The overexpression of the c-erbB-2 oncoprotein is now thought by most authors to be associated with adverse prognosis in breast carcinoma. In this study, we investigate the relationship between overexpression of the c-erbB-2 oncoprotein and nuclear size by morphometry in a series of 150 human breast carcinomas, comprising 65 cases of ductal carcinoma in situ (DCIS) and 85 cases of invasive adenocarcinoma. The mean nuclear size for c-erbB-2 positive cases of DCIS was 54.8 micron 2 and invasive carcinoma was 52.1 micron 2 respectively, in contrast with 41.6 micron 2 and 42.5 micron 2 for c-erbB-2 negative cases of DCIS and invasive carcinoma respectively. Flow cytometric examination of DNA in a subset of 91 of these tumours showed no association between tumour cell aneuploidy and c-erbB-2 overexpression. S-phase fraction could be calculated on 20 cases of DCIS and 48 invasive carcinomas. There was a strong association between c-erbB-2 overexpression, S-phase fraction (p less than 0.001) and proliferative index (p less than 0.001) in 20 cases of DCIS. A weak association of S-phase fraction and c-erbB-2 overexpression was seen in 48 invasive carcinomas (p = 0.047). This study confirms the subjective impression that there is a relationship between large tumour cell nuclear size and an overexpression of the c-erbB-2 oncoprotein, and also shows an association with increased tumour cell proliferation.