Pathologic response and long-term follow-up in breast cancer patients treated with neoadjuvant chemotherapy: a comparison between classifications and their practical application

CONTEXT

Breast cancer is increasingly treated with neoadjuvant chemotherapy to improve surgical resectability and evaluate tumor response, which is assessed histopathologically. Several histopathologic classification systems have been previously described for assessment of treatment response.

OBJECTIVES

To test performance in a side-by-side comparison of several histopathologic classification systems after neoadjuvant chemotherapy with clinical outcome.

DESIGN

Sixty-two patients were enrolled in a randomized trial receiving sequential neoadjuvant chemotherapy with doxorubicin and paclitaxel. Histologic sections from the patients' tumors sampled before (core biopsy) and after treatment (excision or mastectomy) were reviewed. Histologic response was assessed following National Surgical Adjuvant Breast and Bowel Project protocol B18, Miller-Payne grading, Sataloff tumor and nodes, Residual Cancer Burden (RCB), and Residual Disease in Breast and Nodes (RDBN). Pathologic classification results were correlated with survival using Kaplan-Meier and Cox hazards regression with a median follow-up of 93 months.

RESULTS

RDBN was associated with distant disease-free survival by univariate and multivariate analysis (P = .01 and .004, respectively), as were lymph node metastases (P = .02 and .01, respectively). Five patients (8%) had complete pathologic response after neoadjuvant chemotherapy, and none of them relapsed during the study period. Survival was shorter among patients with higher Residual Cancer Burden scores, but the associations were not significant. Miller-Payne grading and Sataloff tumor scores were not correlated with survival.

CONCLUSIONS

Evaluation of breast specimens after neoadjuvant chemotherapy by the composite index RDBN correlates with long-term outcome. The residual disease in breast and nodes system is suitable for routinely processed pathology cases. This study confirms the importance of lymph node status after neoadjuvant chemotherapy and favorable outcome in patients with pathologic complete response.

A pilot study evaluating shaved cavity margins with micro-computed tomography: a novel method for predicting lumpectomy margin status intraoperatively

Microscopically clear lumpectomy margins are essential in breast conservation, as involved margins increase local recurrence. Currently, 18-50% of lumpectomies have close or positive margins that require re-excision. We assessed the ability of micro-computed tomography (micro-CT) to evaluate lumpectomy shaved cavity margins (SCM) intraoperatively to determine if this technology could rapidly identify margin involvement by tumor and reduce re-excision rates. Twenty-five SCM from six lumpectomies were evaluated with a Skyscan 1173 table top micro-CT scanner (Skyscan, Belgium). Micro-CT results were compared to histopathological results. We scanned three SCM at once with a 7-minute scanning protocol, and studied a total of 25 SCM from six lumpectomies. Images of the SCM were evaluated for radiographic signs of breast cancer including clustered microcalcifications and spiculated masses. SCM were negative by micro-CT in 19/25 (76%) and negative (≥2 mm) by histopathology in 19/25 (76%). Margin status by micro-CT was concordant with histopathology in 23/25 (92%). Micro-CT overestimated margin involvement in 1/25 and underestimated margin involvement in 1/25. Micro-CT had an 83.3% positive predictive value, a 94.7% negative predictive value, 83.3% sensitivity, and 94.7% specificity for evaluation of SCM. Evaluation of SCM by micro-CT is an accurate and promising method of intraoperative margin assessment in breast cancer patients. The scanning time required is short enough to permit real-time feedback to the operating surgeon, allowing immediate directed re-excision.

Occult Nipple Involvement in Breast Cancer: Clinicopathologic Findings in 316 Consecutive Mastectomy Specimens

Purpose

Although breast-conserving surgery is a standard approach for patients with breast cancer, mastectomy often becomes necessary. Surgical options now include nipple-sparing mastectomy but its oncological safety is still controversial. This study evaluates frequency and patterns of occult nipple involvement in a large contemporary cohort of patients with the retroareolar margin as possible indicator of nipple involvement.

Patients and Methods

Three hundred sixteen consecutive mastectomy specimens (232 therapeutic, 84 prophylactic) with grossly unremarkable nipples were evaluated by coronal sections through the entire nipple and subareolar tissue. Extent and location of nipple involvement by carcinoma was assessed with the tissue deep to the skin as potential retroareolar en-face resection margin.

Results

Seventy-one percent of nipples from therapeutic mastectomies showed no pathologic abnormality, 21% had ductal carcinoma in situ (DCIS), invasive carcinoma (IC), or lymphovascular invasion (LVI), and 8% lobular neoplasia (lobular carcinoma in situ). Human epidermal growth factor receptor 2 amplification, tumor size, and tumor-nipple distance were associated with nipple involvement by multivariate analysis (P = .0047, .0126, and .0176); histologic grade of both DCIS (P = .002) and IC (P = .03), LVI (P = .03), and lymph node involvement (P = .02) by univariate analysis. Nipple involvement by IC or DCIS was identified in the retroareolar margin with a sensitivity of 0.8 and a negative predictive value of 0.96. None of the 84 prophylactic mastectomies showed nipple involvement by IC or DCIS.

Conclusion

Nipple-sparing mastectomy may be suitable for selected cases of breast carcinoma with low probability of nipple involvement by carcinoma and prophylactic procedures. A retroareolar en-face margin may be used to test for occult involvement in patients undergoing nipple-sparing mastectomy.

Development and validation of a model predictive of occult nipple involvement in women undergoing mastectomy

Background

This prospective study aimed to build a predictive model using preoperative information to aid selection for nipple-sparing mastectomy.

Methods

Two hundred consecutive skin-sparing mastectomy specimens without overt nipple involvement were evaluated. Demographic, preoperative pathology and imaging information was collected. Nipple specimens (2 × 2 × 2 cm) were sectioned at 3-mm intervals. Haematoxylin and eosin-stained slides were examined by a breast pathologist for involvement by tumour. Logistic regression analyses of 65 therapeutic procedures identified factors associated with occult involvement and created a predictive model. This was tested on specimens from a further 65 therapeutic procedures.

Results

Occult nipple involvement was noted in 32 (24·6 per cent) of 130 mastectomy specimens. In the training set, imaging diameter of the lesion and its distance from the nipple predicted nipple involvement on univariable analysis (P = 0·011 and P = 0·014 respectively). The multivariable logistic regression model was validated in the test set. The areas under the receiver–operating characteristic curve were 0·824 and 0·709 for the training and test sets respectively.

Conclusion

Three-quarters of women undergoing mastectomy did not have occult nipple involvement. A clinical tool including tumour size and distance from the nipple has been developed to improve patient selection for nipple-sparing mastectomy.

Microscopic anatomy within the nipple: implications for nipple-sparing mastectomy

BACKGROUND

Precise anatomical relationships between ducts and vasculature within the nipple remain unknown. This study investigated nipple microvessels and their position relative to ducts.

METHODS

Nipple and duct bundle cross-sectional areas were measured in 48 specimens. Vessels located within the central duct bundle or within a peripheral rim were counted in 7 non-irradiated and 5 irradiated nipples.

RESULTS

Mean nipple diameter was 11.1 mm and duct bundle diameter 5.2 mm. A 2-mm and a 3-mm peripheral rim of nipple tissue would result in complete duct excision in 96% and 87% of sections, respectively. Twenty-nine percent of vessels are located in the duct bundle. A 2-mm rim contains 50%; a 3-mm rim contains 66%. Similar proportions were seen in irradiated nipples.

CONCLUSIONS

This study describes a strategy to balance duct removal with vascular preservation. Ducts can be excised leaving a rim of nipple tissue that contains a large proportion of microvessels.

Breast duct anatomy in the human nipple: three-dimensional patterns and clinical implications

BACKGROUND

The anatomy of the nipple has become clinically relevant. Diagnostic techniques access the breast through nipple ducts and surgeons offer nipple-sparing mastectomy. There is variation in the number of ducts reported and little is known about the spatial location of ducts, their size, and their relationship to orifices on the surface.

METHODS

Nipple specimens were taken from 129 consecutive mastectomies. Each was sectioned coronally into 3 mm blocks and one section was prepared from each block. The number of ducts and cross-sectional areas of nipple and duct 'bundle' were recorded. Three nipples were sectioned at 50 mum intervals and digitally reconstructed in three dimensions.

RESULTS

The median number of ducts was 23 (interquartile range 19-28). Reconstructions and summary data from 25 nipples show a central duct bundle narrowing to form a 'waist' as the ducts enter breast parenchyma. A three-dimensional reconstruction focusing on one nipple tip demonstrated 29 ducts arising from 15 orifices. Beneath the skin, most ducts are very narrow, gradually becoming larger deeper within the nipple.

CONCLUSIONS

This work demonstrates that many ducts share a few common openings onto the surface of the nipple, explaining the observed discrepancy between number of ducts and of orifices. Neither duct diameter nor position predicts whether a duct system will terminate close to the nipple or pass deeper into the breast. These new insights into nipple anatomy will be of use in considering the reliability of a ductal approach to diagnosis and in planning nipple-sparing mastectomy.

Solid papillary ductal carcinoma in situ versus usual ductal hyperplasia in the breast: a potentially difficult distinction resolved by cytokeratin 5/6

The solid papillary variant of ductal carcinoma in situ is an uncommon entity, which usually presents in the seventh or eighth decade and may be associated with invasive mucinous carcinoma. Solid papillary ductal carcinoma in situ (SP-DCIS) shares many morphological features with usual ductal hyperplasia (UDH) involving a papilloma: papillary architecture, solid growth, cellular streaming, and low-grade nuclear features. These similarities can make the distinction between these 2 entities challenging. Recent studies have demonstrated that immunohistochemical staining for cytokeratin 5/6 can distinguish UDH from conventional forms of ductal carcinoma in situ. Most of the epithelial cells of UDH express cytokeratin 5/6, but the tumor cells of ductal carcinoma in situ do not. We tested the hypothesis that the results of staining for cytokeratin 5/6 can distinguish UDH from the solid papillary variant of ductal carcinoma in situ. Immunohistochemical staining of 14 cases of SP-DCIS and 9 cases of UDH (4 involving papillomas) was performed using cytokeratin 5/6 antibody clone D5/16 B4. Strong cytoplasmic or membrane staining was considered positive. The hyperplastic cells in all cases of UDH showed strong staining for cytokeratin 5/6. The percentage of positive cells ranged from 50% to 80%. None of the SP-DCIS tumor cells stained for cytokeratin 5/6; however, many cases did show staining of occasional entrapped, benign epithelial, and myoepithelial cells. We conclude that the absence of strong cytokeratin 5/6 expression by SP-DCIS distinguishes it from its morphological mimic, UDH. Pathologists must guard against misinterpreting SP-DCIS as UDH in those cases in which the carcinoma cells engulf cytokeratin 5/6-expressing residual, native epithelial cells.

A brief historical perspective on the pathology of the breast: from cheatle to azzopardi and beyond

The modem pathological study of disorders of the breast begins with the intraoperative macroscopical examinations of such late-nineteenth-century American and British surgeons as Drs. John Collins Warren, Joseph Colt Bloodgood, and Sir George Lenthal Cheatle. Technical advances in the fields of microscopy and histology led to a shift in the nature and conduct of pathological studies in the first part of the twentieth century. Microscopical examination became the primary method of study, and pathologists assumed the leading role in this line of research. With the studies of Drs. Frank W. Foote, Fred W. Stewart, and Arthur Purdy Stout, pathologists began to explore the territory of breast pathology in detail, describing the microscopical features of breast lesions and developing theories regarding their pathogenesis. The spread of the use of biopsy procedures to establish diagnoses led pathologists of the mid-twentieth century to assume the new role of clinical diagnostician. Exemplified by the work of Dr. John G. Azzopardi, pathological research of the latter half of the twentieth century came to emphasize microscopical diagnostic criteria and differential diagnosis. With ever more sophistication and increasingly powerful techniques, this trend continues to this day.

Epithelial proliferations of ductal type

The diagnosis of ductal proliferations requires analysis of both architectural and cytological features. Architectural characteristics of conventional ductal hyperplasia include persistence of the duct lumen as peripheral, crescent shaped spaces; streaming of cells; formation of irregular, slit-like fenestrations; and "maturation." Hyperplastic ductal cells exhibit indistinct cell borders, irregular placement of nuclei, irregular nuclear shapes, granular chromatin, and uniform small nucleoli. The cells do not show polarization or dishesion. Low-grade ductal carcinoma in-situ exhibits both architectural and cytological atypicality. The architectural atypicality takes two forms: the formation of cribriform spaces or their variants and the regular arrangement of cells. The former reflects the polarization of the carcinoma cells and the latter their dishesion. Cytological atypicality includes distinct cell borders; smoothly contoured, oval or round nuclei; homogeneous chromatin; and inconspicuous nucleoli. Atypical ductal hyperplasia shows low-grade cytological atypicality but lacks the architectural atypicality of ductal carcinoma in situ. Proliferations lacking cytological atypicality do not merit the diagnosis of atypical ductal hyperplasia whatever their architectural characteristics. Although not usually necessary, immunohistochemical staining for high molecular weight keratin can help resolve difficult cases. Current evidence does not support the belief that conventional ductal hyperplasia represents an obligate precursor to ductal carcinoma in situ.

Noninvasive papillary proliferations

The diagnosis of noninvasive papillary tumors begins with categorization of the lesions as macropapillary or micropapillary. Macropapillary lesions include papilloma, papillary carcinoma, and papilloma harboring carcinoma. Papillomas consist of a few broad fronds, abundant stroma, and an epithelium containing both luminal and myoepithelial cells. Papillary carcinomas have many irregular fronds, small amounts of stroma, and a uniform population of malignant glandular cells. Papillomas can give rise to both conventional ductal hyperplasia and carcinomas. One analyzes proliferations on the surface of a papilloma as one would analyze those in a duct. Proliferations within the stalk of a papilloma require especially careful attention; one must observe large masses of cells demonstrating both cytological and architectural atypicality and devoid of intervening stroma to make the diagnosis of low-grade ductal carcinoma in-situ involving the stalk of a papilloma. Micropapillary proliferations represent either ductal hyperplasia or ductal carcinoma in situ. The former shows slight dilatation of ducts, micropapillae of similar size and shape, maturation of cells, lack of dishesion and necrosis, and lack of cytological atypicality. Micropapillary ductal carcinoma in situ exhibits extreme dilatation of ducts and lobules, micropapillae varying in size and shape, lack of maturation, dishesion and necrosis, and cytological atypicality.

Mammographic appearance of ductal carcinoma in situ does not reliably predict histologic subtype

Histologic subtypes of ductal carcinoma in situ (DCIS) have been correlated with disease prognosis. There are conflicting reports on whether the grade of DCIS can be predicted by the morphology of calcifications seen on mammography. We undertook this study to determine whether the grade of DCIS can be reliably and accurately determined by mammography prior to excisional biopsy. Ninety consecutive cases of DCIS from 1993 to 1996 were identified, of which 75 cases had mammograms available for review. Any lesion with invasion was excluded. The mammogram showed only a mass in 10 of 75 cases, a mass and calcifications in 3 of 75 cases, and calcifications alone in 62 of 75 cases. Three board-certified radiologists with special expertise in mammography reviewed and categorized the mammographic findings as well, intermediate or poorly differentiated DCIS without knowledge of the histologic diagnosis. Histologic grading was performed without knowledge of the mammographic finding. Receiver operating curves (ROCs) were computed for each of the radiologists. For microcalcifications, the ROC comparisons of the radiologists' opinions of tumor grade and random chance were not significantly different. In those cases with available magnification views, the grade assessment did not change significantly. If only a mass was present on mammography, well-differentiated DCIS was the predominant histologic subtype. A histologic grade of DCIS cannot accurately be determined prospectively based on the mammographic appearance of microcalcifications. However, if only a mass is present, this is more likely to represent well-differentiated DCIS.

Morphological observations regarding the origins of atypical cystic lobules (low-grade clinging carcinoma of flat type)

This study seeks to define the morphological pathogenesis of a form of cystic transformation of lobules referred to as atypical cystic lobule or low-grade clinging carcinoma of flat type. We collected 25 examples that seem to represent the early stages in the formation of atypical cystic lobules and made a careful study of their morphology. Our observations indicate that this lesion arises from pre-existing, structurally normal terminal duct-lobular units and that it seems to develop by the direct transformation of indigenous luminal cells. The transformed cells first become evident in the small duct or terminal ductule, where they appear as slightly enlarged columnar cells containing atypical nuclei. In more advanced examples, these alterations affect all luminal cells of the terminal duct-lobular unit, but the cells of the terminal ductule continue to show more pronounced changes than the cells lining the acini. The atypical cells within the lobule do not seem to displace the normal acinar cells. Instead, the cells form a continuum, making it impossible to define the point at which atypical cells and normal cells meet. Within the small duct, however, the atypical epithelium comes to an abrupt halt as the duct courses towards the nipple. Considering these observations, we ascribe the formation of atypical cystic lobules to the accumulation of atypical cells in pre-existing terminal duct-lobular units.

Atypical cystic lobules in patients with lobular neoplasia

We analyzed the frequency and anatomic distribution of atypical cystic lobules (ACLs) in patients whose index biopsy specimen contained lobular neoplasia (LN). Thirty of 54 patients (56%) had ACLs in their index biopsy specimen. Five of the patients whose index biopsy lacked ACLs underwent an additional biopsy, and 4 of these patients had ACLs in an additional specimen, bringing the total number of patients having both ACLs and LN to 34 of 54 (62.9%). ACLs involved both breasts with equal frequency and neither the extent of the involvement nor the anatomic location of the LN paralleled the distribution of the ACLs. The presence of ACLs in patients with LN might explain its increased risk for the development of ductal carcinomas and their bilateral distribution. Int J Surg Pathol 9(3):201-206, 2001

Solid low-grade in situ carcinoma of the breast: role of associated lesions and E-cadherin in differential diagnosis

Low-grade solid in situ carcinomas of the breast are difficult to classify. The authors investigated 12 cases of in situ carcinomas with equivocal features and correlated their histologic attributes with those of the associated invasive carcinomas as well as with E-cadherin expression in both in situ and invasive disease. E-cadherin-positive in situ lesions were invariably associated with invasive carcinomas of the ductal type. In situ carcinomas that were E-cadherin negative were associated with invasive carcinomas of the lobular type in five of six cases. In all cases, the invasive carcinomas showed the same pattern of E-cadherin reactivity as the in situ lesions. Sharply defined cellular membranes, necrosis, and occasional microacini were seen in both E-cadherin-positive and negative in situ carcinomas, whereas intracytoplasmic lumina and a noncohesive appearance were seen only in E-cadherin-negative lesions.

Collagenous spherulosis: an ultrastructural study

Ultrastructural findings are described in two cases of collagenous spherulosis associated with intraductal hyperplasia and sclerosing adenosis. The spherules showed a variable composition of basement membrane, banded collagen, and mineral deposition. Some spherules were connected to the periacinal stroma by a thin pedicle. The authors propose that spherules represent a peculiar form of stromal invagination that could be seen in a variety of breast lesions, rather than a form of intraductal hyperplasia.

Endocrine mucin-producing sweat gland carcinoma: a cutaneous neoplasm analogous to solid papillary carcinoma of breast

We describe two cases of a distinctive in situ and invasive cutaneous adnexal neoplasm occurring in the eyelid. Mucinous carcinoma represented the invasive portion of the tumor in one case, whereas the other infiltrated in small solid nests. The in situ component is identical to the recently described solid papillary carcinoma of the breast (endocrine ductal carcinoma in situ). Both tumors produced intra- and extracellular mucin, exhibited endocrine differentiation by immunohistochemistry and ultrastructural analysis, and were positive for estrogen and progesterone receptors.

Metaplastic carcinoma of the breast with melanocytic differentiation

We report the clinical and pathologic findings of a metaplastic carcinoma of the breast that exhibited melanocytic differentiation. The tumor possessed both in situ and invasive components. Lower grade regions of the infiltrating carcinoma had features of tubular, mucinous, and matrix-producing carcinomas. In the higher grade areas, conventional poorly differentiated ductal carcinoma merged with an anaplastic neoplasm that looked like malignant melanoma. The nonpigmented cells stained for keratin but lacked HMB-45 and S-100 proteins, whereas the cells containing melanin showed the opposite characteristics. Electron microscopic examination disclosed melanosomes in the neoplastic cells. We believe that these observations convincingly establish both the origin of the tumor from the mammary epithelium and the synthesis of melanin by the tumor cells. We propose the diagnosis of metaplastic carcinoma with melanocytic differentiation for this neoplasm and suggest that the phenomenon of melanocytic metaplasia might underlie the formation of primary melanomas of the breast.

High risk of breast carcinoma after irradiation of young women with Hodgkin's disease

BACKGROUND

Treatment-associated second neoplasms have emerged as a major threat to the continued survival of patients cured of Hodgkin's disease. In this study, the authors investigated the risk of breast carcinoma in an irradiated Hodgkin's disease population.

METHODS

One hundred and eleven women younger than 60 years presenting between 1964 and 1984 with Stage I and II Hodgkin's disease who received mantle irradiation were retrospectively analyzed and compared with an age specific population. Median follow-up was 18 years (range, 10-30 years), and the median age at initiation of therapy was 24 years. Kaplan-Meier actuarial risks, relative risks (RRs) (the ratio of the observed to the expected cases) with 95% confidence intervals (CIs), and the log rank test for trends were calculated.

RESULTS

Fourteen women developed breast carcinoma: 8 of 33 patients younger than 20 years at the time of irradiation, 5 of 48 patients age 20 to 29 years, and 1 of 30 patients age 30 years or older. Actuarial calculation predicted a 34.0% (CI, 14.2-53.8) risk of breast carcinoma at 25 years after therapy for the youngest group, 22.3% (CI, 4.1-40.5) for the group of intermediate age, and 3.5% (CI, 0-10.1) for the oldest group. The RR of breast carcinoma was 56 (CI, 23.3-107) for those 19 years or younger at the time of treatment, 7.0 (CI, 2.3-16.4) for those age 20-29 years, and 0.9 (CI, 0-5.3) for those 30 years and older. Excluding 1 patient who was age 38 years at the time of irradiation, the remaining 13 breast carcinomas were tightly clustered in women irradiated between the ages of 14 through 25, and were detected in years 11 through 25 after treatment, with 7 occurring in years 15 through 18.

CONCLUSIONS

Women younger than 30 years, particularly those younger than 20 years, who have received mantle irradiation for Hodgkin's disease require meticulous follow-up for breast carcinoma. The high incidence of breast carcinoma in this patient population should be considered when making treatment decisions in young women with early stage Hodgkin's disease.

Solid papillary carcinoma of breast: an ultrastructural study

Solid papillary carcinoma of the breast is a subset of papillary carcinoma, which occurs in older women and usually has a favorable prognosis. It is primarily intraductal but also is often associated with invasive carcinoma, especially mucinous carcinoma. Intracellular and extracellular mucin is also found in the in situ stage, in most tumors. In addition to forming solid papillary masses, the cells palisade around vessels in pseudorosettes and show minimal nuclear atypia. Some cells show neuroendocrine differentiation, based on argyophilia with Grimelius staining. Four examples of this neoplasm were studied electron microscopically. Myoepithelial cells were not found. Neoplastic cells had an ultrastructure that was generally similar to that of other types of mammary carcinoma. There were extracellular microlumens, but intracellular lumens and pseudolumens were few or absent. Secretory activity varied among cells, and those cells appearing active had a variety of granule types, including typical flocculent and "bull's-eye" mucinous granules, small dense-core granules, and large serous-like granules. Some of the dense-core granules were interpreted as neuroendocrine in nature, based on their abluminal or juxtavascular location, whereas others that were apical and subluminal were probably mucinous in type. The large serous-appearing granules were subluminal in some cells and diffuse in others and may also have represented a variant of mucinous granules. The results support earlier opinions that accurate interpretation of specific granular function at the electron microscopic level depends on cytochemical studies using uranaffin as a marker of neuroendocrine activity. Although mucinous granules are identified by their lack of staining with uranaffin, the nature of the serous-appearing granules would still not be answered by this method; that is, a negative reaction would not define whether the granules are truly serous, or simply another form of mucin. Regardless of limitations of this type, correlation and extrapolation of histochemical (Grimelius and Alcian blue) and immunohistochemical (chromogranin and synaptophysin) results with subcellular structure are still very useful in establishing cell type.

Cyclin D1 (PRAD1) alternative transcript b: full-length cDNA cloning and expression in breast cancers

The cyclin D1/PRAD1 protooncogene is a key regulator of the G1 phase of the cell cycle and has been incriminated in the pathogenesis of a variety of primary human tumors. Recently, part of a novel alternatively spliced cyclin D1 transcript, called transcript b, has been identified. This variant transcript showed a failure of splicing at the 3' end of exon 4 and as a result, the expected protein product is altered at its C-terminus. Because of similar transcript sizes, previous Northern analyses would not have been expected to distinguish the two variants, and the relative levels of the two cyclin D1 transcripts in human tumors is unknown. To elucidate the role of cyclin D1 transcript b, we have isolated cDNA clones of this variant transcript from human breast cancer cell lines and report the sequence of the entire coding region of the cDNA. The protein predicted from the cDNA sequence consists of 274 amino acid residues and lacks a PEST sequence in its C-terminus. Examination of the levels of the two alternative cyclin D1 transcripts in primary breast cancers and breast cancer cell lines by Northern blot analysis and reverse transcription-polymerase chain reaction (RT-PCR) assays showed that the variant transcript b is indeed expressed in primary breast cancers and breast cancer cell lines, but the level of transcript b is dramatically lower than that of the originally reported transcript a of the cyclin D1 gene. In breast cancers, oncogenic overexpression of cyclin D1 mRNA appears to consist overwhelmingly of transcript a, and the role of transcript b, if any, in oncogenesis remains to be established. Science Ireland Ltd.

Spindle cell endocrine carcinoma of the mammary gland

We report the pathological characteristics of a variant of mammary endocrine tumour, predominantly formed from cytologically bland spindle cells. This neoplasm grows as a red, well defined mass lacking the usual macroscopical characteristics of breast cancer. Within smoothly contoured aggregates arranged in an insular pattern, delicate capillaries and collagen bundles support the neoplastic epithelial cells. Most of the tumour cells possess a slender spindle shape and form a solid or fenestrated sheet, but a few appear cuboidal and create glands. Immunohistochemical studies demonstrate that the spindle cells and the glandular cells constitute a single population. Both types of cells stain for neuroendocrine markers (chromogranin, synaptophysin, and CD 57), carcinoembryonic antigen, keratin 8/18, S-100 protein, and receptors for oestrogen and progesterone. Many of the tumour cells possess argyrophilic granules, and electron microscopy may reveal dense core granules.

Smooth-muscle tumors of the vulva. A clinicopathological study of 25 cases and review of the literature

The clinical and pathological features of 25 smooth-muscle tumors of the vulva were analyzed. The patients ranged in age from 17 to 67 (mean, 37.6) years; two were pregnant. Twenty-three tumors were 1.5 to 16 (mean, 5.2) cm in greatest dimension; the size of two tumors was unknown. Microscopic examination showed that 16 tumors were circumscribed, six had focally infiltrative margins, and the margins could not be evaluated in three tumors. Fourteen tumors were composed mainly of spindle cells; two of these tumors had prominent myxoid stroma. Seven tumors were predominantly epithelioid and had a prominent hyalinized or myxoid stroma; often the cells had a plexiform pattern. Four tumors contained an approximately equal number of epithelioid and spindle cells. Ten tumors had mild, nine moderate, and six severe cytologic atypia. Mitotic figures ranged from 0 to 10 (average, 1.8) per 10 high-power fields (hpf). Immunohistochemically, all the tumors stained for one or more muscle markers. Thirteen of 17 tumors were positive for estrogen receptors, and 16 of 18 were positive for progesterone receptors. Follow-up information ranging from 1 month to 19 years (average, 5 years) was available in 19 cases. Four tumors recurred locally, and one patient with recurrent tumor died of metastases 7 months after the initial operation. We propose an expanded criteria to distinguish between leiomyomas and leiomyosarcomas of the vulva. Tumors that manifest three or all of the four following features should be considered sarcomas: > or = 5 cm in greatest dimension, infiltrative margins, > or = 5 mitotic figures per 10 hpf, and moderate to severe cytologic atypia. Those that have only one of these characteristics should be diagnosed as leiomyoma, and those that exhibit only two of these features should be considered benign but atypical leiomyomas. The sarcomas should be excised with widely negative margins; the leiomyomas and the atypical leiomyomas should be excised conservatively, with long-term, careful follow-up.

Involvement of collagenous spherulosis by lobular carcinoma in situ. Potential confusion with cribriform ductal carcinoma in situ

We describe five cases in which the cells of lobular carcinoma in situ seemed to form round, regular lumens similar to the cribriform spaces of ductal carcinoma in situ. After careful inspection, we concluded that the spaces indicate the presence of collagenous spherulosis and that this unusual pattern arises through the confluence of lobular neoplasia and spherulosis. We base this conclusion on three lines of evidence. First, attenuated myoepithelial cells, rather than carcinoma cells, form the spaces in question. Immunohistochemical staining for smooth-muscle actin and keratin 8/18 established the myoepithelial nature of these flattened cells because they express the former protein but lack the latter. These results also differentiate the myoepithelial cells from those of conventional in situ carcinomas, which do not contain smooth-muscle actin but virtually always possess keratin 8/18. Second, the material within the spaces looks like the deposits that characterize collagenous spherulosis. They consist of densely eosinophilic protein or radiating, fibrillar ground substances, and they differ in appearance from the disorganized, flocculent mucin and the cellular debris found in some in situ ductal carcinomas. Finally, the neoplastic cells display a loosely cohesive growth pattern that is more in keeping with the properties of lobular neoplasia than ductal carcinoma. Considered together, these three points should distinguish involvement of collagenous spherulosis by lobular neoplasia from cribriform ductal carcinoma in situ. Pathologists must remain alert to this form of mimicry because classification of in situ carcinoma of the breast carries important clinical implications.

Solid papillary carcinoma of the breast. A form of intraductal carcinoma with endocrine differentiation frequently associated with mucinous carcinoma

We report 20 examples of a distinctive form of intraductal papillary carcinoma frequently associated with both mucinous carcinoma and infiltrating ductal carcinoma, not otherwise specified. All the patients were in the seventh decade of life or older. The clinical presentation and macroscopic appearance suggested a benign lesion in most cases. The tumors grew in a solid papillary pattern and displayed low-grade cytological features as well as intracellular and extracellular mucin. Endocrine differentiation was demonstrated by the Grimelius stain in 11 of 17 cases and by the chromogranin immunohistochemical technique in eight of 14 cases. Lymph node metastases were not observed, but pulmonary metastasis occurred in one case. All the tumors were positive for estrogen receptors. We postulate that these lesions are the preinvasive counterpart of mucinous carcinomas with endocrine differentiation.

Cyclin D1 (PRAD1) protein expression in breast cancer: approximately one-third of infiltrating mammary carcinomas show overexpression of the cyclin D1 oncogene

Amplification of chromosome 11q13 has been observed in 10-20% of breast carcinomas and numerous other tumors, including squamous cell carcinomas of the head, neck, and esophagus; transitional cell carcinomas of the urinary bladder; and epithelial ovarian tumors. Cyclin D1/PRAD1 is a likely "driver" gene for this amplicon because of its role in cell cycle control and because it has been specifically implicated as an oncogene in parathyroid adenomas and B-cell lymphomas with 11q13 translocation breakpoints. We examined cyclin D1 protein expression in 48 consecutive cases of infiltrating mammary carcinoma using an affinity-purified polyclonal antisera to cyclin D1 and a microwave/citrate buffer antigen retrieval system. Staining data were correlated with clinicopathological features, protein detection by immunoblots, and 11q13 DNA amplification. Definite nuclear staining was seen in 17/48 (35%) tumors (16 infiltrating ductal carcinomas, predominantly grade 2/3, and one infiltrating lobular carcinoma). There was no nuclear staining of normal breast epithelium, fat cells, or admixed lymphocytes. Tumors with overexpression of cyclin D1 were estrogen receptor-positive (P < .005) and usually progesterone receptor-positive (P < .005) but otherwise were similar to other negative cases in the study group. Correlation between Western blot and immunostaining data was excellent (P < .01). Five of the 22 cases studied showed 11q13 DNA amplification as well as increased levels of cyclin D1 protein by Western blot and immunostaining. Four cases with increased cyclin D1 protein by both western blots and immunohistochemistry did not have detectable 11q13 amplification. Nuclear cyclin D1 protein can be detected in approximately one-third of infiltrating breast carcinomas using an immunohistochemical technique on formalin-fixed, paraffin-embedded tissue.(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinomas of the breast with endocrine differentiation: a review

The occurrence of endocrine differentiation in some mammary carcinomas seems well-established, but pathologists continue to debate its significance. Contemporary thinking suggests that endocrine tumours of the breast do not constitute a single clinicopathological entity with a consistent histogenesis but rather that endocrine differentiation represents a pathway of neoplastic development available to a range of breast cancers. This pattern of differentiation occurs in tumours with vastly different morphological appearances, such as: ductal carcinoma in situ, mucinous carcinoma, a variant of lobular carcinoma, and low grade invasive ductal carcinoma. Although such tumours share some characteristics with intestinal endocrine neoplasms, the typical pattern of intestinal carcinoid virtually never occurs in mammary lesions. Conventional microscopy permits the diagnosis in most cases. Specialized techniques (histochemistry, immunohistochemistry, and electron microscopy) can serve as the basis for diagnosis in the absence of the appropriate morphological features. Although the system of nomenclature proposed by the World Health Organization for use with endocrine tumours in other organs can be used for endocrine tumours of the breast, only a minority of lesions will fit the established criteria. Most lesions are classifiable in the conventional categories of mammary carcinomas. No special prognostic significance is attached to these tumours at the present time.

Progesterone receptor detection in paraffin sections of human breast cancers by an immunoperoxidase technique incorporating microwave heating

We sought to establish an easily interpretable and highly sensitive immunohistochemical method for detecting progesterone receptor protein in formalin-fixed, paraffin-embedded samples of breast carcinomas. Beginning with a conventional immunoperoxidase staining procedure, we incorporated microwave heating to compensate for the effects of conventional fixation and processing and then applied the method to 90 samples of primary breast carcinomas. We used the results of hormone binding assays as true values to establish the sensitivity, specificity, positive predictive value, and negative predictive value of the staining method. Our technique yielded good preservation of morphological detail and low nonspecific staining of background tissue. Comparisons of the results of staining and biochemical assays revealed that this progesterone receptor immunostaining procedure shows high sensitivity and acceptable specificity. We believe its performance characteristics make reliable study of small specimens and archival material possible.

Estrogen and progesterone receptor analysis in pregnancy-associated melanoma: absence of immunohistochemically detectable hormone receptors

The role of estrogen in the initiation and progression of melanoma remains unclear. Some findings that suggest a hormonal role in melanoma initiation or progression include the following: (1) melanomas arising during pregnancy are thicker than those in nonpregnant women, (2) pregnant women with stage II (regional nodal metastases) melanoma have a worse prognosis than nonpregnant women of similar stage, and (3) melanoma is rare prior to puberty. Although biochemical assays have shown that estrogen-binding proteins are present in malignant melanoma, studies using a sensitive and more specific immunohistochemical technique have not found estrogen receptors (ERs) in melanoma. In our laboratory an immunohistochemical technique using monoclonal antibody H222 can detect ER in tumors with receptor levels lower than 9 fmol/mg protein and detects ER in a variety of tissues and species. In addition, monoclonal antibody KD68 is used to detect progesterone receptors immunohistochemically. We studied 14 cases of pregnancy-associated melanoma. None of our cases, ranging from melanoma in situ to metastatic melanoma, showed positive nuclear staining for ER, nor did any of these cases show positive immunohistochemical staining for progesterone receptor. Despite the wide tissue and species distribution of ER detected by the monoclonal antibody H222, this immunohistochemical technique does not appear to be useful in the study of possible hormonal effects on the progression of malignant melanoma. The estrogen-binding proteins in melanoma detected by biochemical techniques in previous studies probably are distinct from the well-defined human ER.

pS2 protein and steroid hormone receptors in invasive breast carcinomas

We have used immunohistochemical and hormone-binding techniques to determine the presence of estrogen receptors, estrogen-receptor protein, progesterone receptors and pS2 protein in 97 invasive breast cancers. Our group of tumors displayed the same frequency of estrogen receptors and progesterone receptors as other comparable groups, but it contained more tumors containing pS2 protein. We also observed staining of morphologically normal cells in lobules adjacent to the tumors and in several fibroadenomas; both findings vary from some other reports. We attribute these variations to the use of a sensitive immunohistochemical method and choice of the lowest possible threshold to classify a tumor as pS2-positive. If we used a higher threshold, then about 95% of the tumors containing pS2 protein also contained estrogen receptor protein. Our results add further weight to the assertion that tumors containing pS2 protein also display estrogen receptors. The data also provide theoretical and indirect support to the clinical prediction that tumors containing pS2 protein are more likely to respond to hormonal therapy and may have a more indolent course than tumors lacking the molecule.

pS2 expression in primary breast carcinomas: relationship to clinical and histological features and survival

pS2 protein expression has been reported to have prognostic significance in human breast carcinomas and to correlate with estrogen receptor positivity, although these findings have not been confirmed by all investigators. pS2 positivity was compared to various clinical and histologic parameters in a retrospective study of 290 patients (median follow-up 7.2 years) and significantly correlated with tumor grade and estrogen receptor content (p = 0.001 and p = 0.0007, respectively). Significant associations between pS2 positivity and lymph node metastases, T stage, histologic tumor type, and patient age were not observed. Univariate and multivariate analyses (controlling for estrogen receptor content, T and N stage) of the patient population at large showed that pS2 positivity was not predictive of disease-free or overall survival. Univariate analysis of lymph node negative patients demonstrated that both pS2 and estrogen receptor positivity were significantly associated with a better outcome. Multivariate analysis of these patients, however, showed that only estrogen receptor data had independent prognostic significance. This study suggests that immunohistochemical analysis for pS2 protein expression will not contribute additional prognostic information if the estrogen receptor content is known.

Granular cell tumour of the breast

Eight cases of benign granular cell tumour of the breast are reported. Seven patients were women and one was male. The age at the time of the excision ranged from 17 to 73 (average 40.1) years. All tumours were positive for S-100 protein and negative for keratin, myoglobin and gross cystic disease fluid protein. In two cases ultrastructural studies revealed findings identical to those in the previously reported cases of granular cell tumours. None of these cases were diagnosed preoperatively. In six cases the clinical and mammographic findings, and in one case the frozen section, led to an erroneous diagnosis of malignancy. The clinico-pathological features of the cases are delineated in order to draw attention to a benign condition which closely simulates malignancy.

Spindle-cell argyrophilic mucin-producing carcinoma of the breast. Histological, ultrastructural, and immunohistochemical studies of two cases

We report two cases of neuroendocrine carcinomas of the breast displaying unusual histological features: numerous spindle cells and argyrophilic signet-ring cells. Both patients were older than 70 years, and both presented with a bloody nipple discharge. The tumor in both cases was predominantly intraductal. The tumor cells showed little pleomorphism or cytological atypia; because of the presence of spindle cells, benign diagnoses, such as ductal epithelial hyperplasia and intraductal papilloma, were considered for the in situ component. Recognition of the palisading arrangement of the peripheral cells, intracytoplasmic lumina, mitotic figures, and mucin permitted the diagnosis of intraductal carcinoma. Invasive nests composed of identical cells confirmed the diagnosis of malignancy in both cases. Our cases, along with those previously reported, suggest that neuroendocrine carcinoma with mucin production is a distinct breast tumor that usually occurs in older patients who experience bloody nipple discharge. The prognosis may be more favorable than that of the usual type of breast carcinoma. Common histological features include predominantly intraductal growth, an absence of desmoplasia, and low-grade atypia. Awareness of morphological variants of this tumor, such as those reported here, is necessary to avoid erroneous diagnoses.

pS2 expression and response to hormonal therapy in patients with advanced breast cancer

Seventy-two patients with advanced breast carcinoma (42% bone, 25% visceral, 5.5% soft tissue, and 27.5% multiple site metastases) were evaluated to determine the relationship between tumor expression of the estrogen-regulated protein pS2, estrogen receptor (ER) or progesterone receptor (PgR) content, and response to hormonal therapy. Twenty-nine % of tumors were pS2 positive, 64% were ER positive, and 29% were PgR positive. Of the ER-positive patients (n = 43), 15 (35%) had greater than 10% of the invasive carcinoma which immunostained for pS2 (these were considered pS2 positive). Only 3 of 24 ER-negative tumors were pS2 positive. A weak association between pS2 expression and ER content (P = 0.08) but not PgR content was observed. Of pS2-positive patients, 52% had a partial or complete response to hormonal therapy. In 24% of pS2-positive patients the disease stabilized with treatment. In contrast, 27% of pS2-negative patients had a partial or complete response. In 10% of these patients the disease stabilized. Similar associations between therapeutic response and ER or PgR were not observed. The odds of having a clinical response to hormonal therapy was greater for pS2-positive than for ER- or PgR-positive tumors. pS2 expression may define a subset of ER-positive tumors that are more likely to respond to hormonal treatment.

Mixed form, diffusely scattered calcifications in breast cancer with apocrine features

Diffusely scattered calcifications visible with mammography are almost always benign. Certain patterns, however, should arouse concern. For example, extensive comedocarcinoma is associated with large areas of mammographically visible calcium deposition. The authors identified 10 women in whom calcifications were visible throughout large volumes of breast tissue at mammography. The calcifications did not resemble those typical of extensive comedocarcinoma, yet they were associated with extensive breast cancer. Their mammographic pattern was characterized by a strikingly wild, chaotic appearance with profuse deposition of calcium. As in many cancers, the particles were heterogeneous, but unlike in most carcinomas, many deposits had a typically benign morphology. Histologic examination showed that even these typically benign calcifications were associated with malignant cells. The authors believe that the apocrine features displayed by many of the cancer cells in these 10 patients may explain the unusual profusion of calcium deposits.

Medullary carcinoma of the breast. Overdiagnosis of a prognostically favorable neoplasm

We reviewed 30 cases of breast cancer originally diagnosed as medullary carcinoma during a 10-year period. Of the 30, only 9 proved to be "typical medullary carcinoma" with the associated favorable prognosis. Seven of the remaining 21 cancers were reclassified as "atypical medullary carcinoma," and the remaining 14 were nonmedullary cancers. Overdiagnosis of medullary carcinoma could lead to inappropriately conservative therapy, since medullary carcinoma is a prognostically favorable neoplasm. Those involved with diagnosis and treatment of patients with breast cancer should be aware of this potential problem.

Analysis of c-erbB-2 expression in breast carcinomas with clinical follow-up

Various monoclonal antibodies reactive with protooncogene products or tumor-associated antigens have been utilized to investigate breast carcinoma biology or antigen expression with potential prognostic relevance. Murine monoclonal antibody TA1, generated by immunization of BALB/c mice with whole c-erbB-2 (neu) transformed NIH/3T3 cells, recognizes the extracellular domain of the c-erbB-2 protein and binds a Mr 185,000 protein by immunoprecipitation. Using avidin-biotin-peroxidase techniques and monoclonal antibody TA1, 313 archival primary adenocarcinomas of the breast were evaluated for c-erbB-2 overexpression; 290 of these were used for multiparametric statistical analysis. Historical, clinical (age, laterality), histological (nuclear grade, tumor size, lymph node status, lymphatic or blood invasion), and hormone receptor data as well as clinical outcome (minimal follow-up, 6 years; median follow-up, 8.5 years) were compared to TA1 staining. For these 290 patients Cox regression multivariate analysis showed the strongest correlation between lymph node status or estrogen receptor status and overall survival (P = 0.0001 and 0.049, respectively). TA1 staining did not significantly correlate with survival (P = 0.395). However, univariate analysis of certain patient subpopulations showed a significant correlation if the examined tumors were subdivided into negative or focally reactive and those with greater than or equal to 40% cellular reactivity. For T3, T4 patients, strong TA1 immunoreactivity correlated with a shortened disease-free survival (log rank P = 0.0018; Wilcoxon p = 0.0078) and overall survival (log rank P = 0.0002; Wilcoxon P = 0.0013). For these patients the overall survival at 6 years was markedly different between the strongly reactive tumors (0%) and the negative to weakly reactive tumors (55%). In lymph node-positive patients a trend between high TA1 reactivity and a worse overall survival was also noted (log rank P = 0.128; Wilcoxon P = 0.054), with a 6-year survival of 42% in the strongly reactive tumors (n = 16) and 65% in the negative to weakly reactive carcinomas (n = 105). No correlation between TA1 immunoreactivity and other historical, clinical, and histological features were noted. c-erbB-2 overexpression as measured by immunohistochemical techniques, therefore, may have clinical significance in certain patient subpopulations.

Treatment of intraductal carcinoma with limited surgery: long-term follow-up

Adequate therapy for ductal carcinoma in situ (DCIS) remains controversial. In spite of limited follow-up, recent studies advocate excision and postoperative radiotherapy as treatment. In an effort to provide long-term follow-up information, we evaluated retrospectively a group of 17 patients treated without mastectomy. Thirteen patients were treated with local excision, while four received excision and postoperative radiotherapy. Median follow-up is 100 months, with minimum follow-up 78 months. Five patients (29%) have recurred locally, at a median of 47 months following initial therapy. Three of the local recurrences were invasive carcinomas; two were DCIS. The patients recurring with invasive carcinoma progressed to disseminated disease and death, at a median of 131 months following their local recurrence. Of the eight patients followed for more than 9 years, four (50%) have recurred. Two patients have developed contralateral breast cancer, both treated by mastectomy. No recurrences have occurred in the group receiving radiotherapy. We conclude that long-term follow-up is required to accurately assess local recurrence rates in this disease, and that many recurrences will be invasive carcinomas. Since this lesion is virtually 100% curable by mastectomy, further analysis of long-term studies is warranted before recommending breast conservation to the majority of patients with DCIS.

The halo sign and malignant breast lesions

The halo sign, described as a complete or partial radiolucent ring surrounding the periphery of a breast mass, has long been considered a mammographic sign indicating a benign process. The phenomenon is most frequently seen with cysts and fibroadenomas. Over the past 8 years, 25 malignant breast lesions with a partial or complete halo on mammography have been identified in 19 women. These cases suggest that a halo sign does not guarantee a benign process.

Breast cancer metastasis to intramammary lymph nodes

Metastatic disease to the intramammary lymph nodes from breast cancer may be seen mammographically. In the four cases reviewed, the affected intramammary lymph nodes were enlarged (1 cm or greater in diameter), homogeneous, and well circumscribed. All lacked the lucent center or hilar notch characteristic of benign intramammary nodes. Differentiation of malignant from benign causes of intramammary lymph node enlargement, such as inflammation or hyperplasia, is impossible by mammography. Biopsy is recommended for all intramammary lymph nodes of 1 cm or greater that are not fat infiltrated unless the patient clearly has an associated dermatitis or mastitis. Metastatic disease to the intramammary lymph nodes may be the first clinical and/or mammographic sign of breast cancer and may significantly affect prognosis.

Progressive bulbar paresis in childhood

We present a case of progressive bulbar paresis in a 2-year-old child, with appropriate autopsy findings. A review of previously reported cases and a comparison with more extensive literature in Werdnig-Hoffmann disease suggest that Fazio-Londe disease is not unique, but belongs in the spectrum of progressive lower motor neuron disease.