Abstract P6-03-05: Risk of needle-track seeding with serial ultrasound guided biopsies in triple negative breast cancer

Background: Image-guided percutaneous needle biopsy of the breast is a common procedure. In breast cancer patients (pts) undergoing core biopsies and surgical resection on the same day, the rate of tumor cell displacement along the needle track has been reported to be up to 50%. However, the clinical significance of this finding in triple negative breast cancer (TNBC) patients (pts) undergoing serial biopsies while receiving neoadjuvant chemotherapy (NACT) is unknown. Here we report the incidence of needle-track seeding (NTS) in a cohort of TNBC pts enrolled on a molecular triaging protocol involving serial biopsies of the index breast lesion.

Methods: We reviewed the clinical records of 144 consecutive TNBC pts enrolled on a molecular triaging protocol at MD Anderson Cancer Center. Per protocol, all pts underwent a pre-treatment research biopsy and were initiated on anthracycline based NACT (AC). Pts with inadequate response to front-line NACT were encouraged to undergo additional biopsies of the index breast lesion prior to switching therapies. Serial breast ultrasound (US) was performed to monitor therapeutic response and incidental evidence of needle-track seeding noted on US was documented.

Results: Clinicopathological characteristics of the pts are summarized in Table 1. 89% (128/144) of pts had a diagnostic breast biopsy done at another center prior to presenting at MDACC. To date, we have performed 209 US guided biopsies of index breast lesions in 144 pts. 92% (193/209) of these biopsies were done mainly for research purposes. 1.4% (2/144) of pts were found to have evidence of NTS on follow up US. The first pt had a T1N0 (1.9cm), grade 3, invasive ductal carcinoma (IDC) at diagnosis. She underwent a diagnostic biopsy followed by a research biopsy before initiating AC. She was found to have NTS as well as progression of disease (PD) on follow up US after 2 cycles of AC. The second pt had a T2N0 (3cm), grade 3 IDC at diagnosis. She underwent a diagnostic biopsy at another center, followed by a research biopsy before initiating AC. Like the first pt, she was found to have NTS and PD on follow up US after 2 cycles of AC. Both pts are currently on neoadjuvant clinical trials of novel agents.

Conclusion: The rate of NTS detected on US in TNBC pts undergoing serial biopsies of index breast lesions while receiving NACT is low and further studies are needed to determine the impact of serial biopsies on long term outcomes in TNBC.

Table 1: Patient CharacteristicsCharacteristicN=144Age - Median (years, interquartile range)55 (46-62)Tumor Size Mean (cm, standard deviation)3.4 (2.2)T1 – n(%)35 (24)T2 – n(%)89 (62)T3 – n(%)19 (13)T4 – n(%)1 (1)Clinical Nodal Status Negative – n(%)74 (51)Positive – n(%)70 (49)Grade 1 – n(%)1 (1)2 – n(%)17 (12)3 – n(%)124 (86)Unknown – n(%)2 (1)Histologic Subtype Invasive ductal carcinoma – n(%)121 (84)Invasive lobular carcinoma – n(%)2 (1)Mixed ductal and lobular carcinoma – n(%)3 (2)Metaplastic carcinoma – n(%)13 (9)Not specified – n(%)5 (3)Laterality Right – n(%)72 (50)Left – n(%)72 (50)

Citation Format: Yam C, Santiago L, Candelaria RP, Adrada BE, Rauch GM, Hess KR, Litton JK, Piwnica-Worms H, Mittendorf EA, Ueno NT, Lim B, Murthy RK, Damodaran S, Helgason T, Huo L, Thompson AM, Gilcrease MZ, Symmans WF, Moulder SL, Yang W. Risk of needle-track seeding with serial ultrasound guided biopsies in triple negative breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-03-05.

Abstract P1-07-22: Androgen receptor positivity is associated with nodal disease in triple negative breast cancer

Background: Gene expression profiling (GEP) has identified several molecularly distinct subtypes of triple negative breast cancer (TNBC). Currently, GEP-based molecular diagnostics are not routinely used in clinical decision making due to the lack of proven benefit, costs involved and long turnaround time. However, two molecularly distinct subtypes of TNBC, the luminal androgen receptor (AR) and mesenchymal subtypes, have surrogate CLIA-certified immunohistochemical (IHC) markers, AR and vimentin (VM), respectively, which have the potential for application in the clinic. Here we report the rates of AR and VM positivity and their association with clinicopathological characteristics in a cohort of TNBC pts receiving NACT.

Methods: As part of an ongoing molecular triaging protocol, 144 pts with stage I-III TNBC underwent a pretreatment biopsy for molecular characterization (MC) prior to initiating neoadjuvant chemotherapy (NACT). IHC for AR and VM were performed using commercially available antibodies. AR+ and VM+ were defined as ≥10% and ≥50% staining, respectively. Pts were randomized 2:1 to know (intervention arm, n=93) and not know (control arm, n=51) the MC results. The charts of pts randomized to the intervention arm were reviewed. Categorical variables were analyzed using Fisher's exact test. Ordinal and continuous variables were analyzed using the Wilcoxon rank-sum test and Student's t test as appropriate.

Results: 31% (29/93) and 16% (15/93) of pts were AR+ and VM+, respectively. Only 4% (4/93) of pts were both AR+ and VM+. Clinicopathological characteristics are summarized in Table 1. AR+ pts were more likely to have clinically node positive disease as compared to AR- pts (66% vs 34%, p=0.007). There were no significant differences in clinical tumor size or grade between AR+ and AR- pts. VM+ and VM- pts had similar clinicopathological characteristics.

Conclusion: Pts with AR+ TNBC were more likely to have node positive disease. The impact of AR+ on long term outcomes should be investigated in prospective studies.

Table 1: Association between patient characteristics and AR/VM status AR  VM   AR+ (n=29)AR- (n=64)p-valueVM+ (n=15)VM- (n=78)p-valueAge - Median (years, interquartile range)58 (48-65)52 (46-61)0.05855 (48-64)56 (47-62)0.88Clinical Tumor Size      Mean (cm, standard deviation)3.5 (1.8)3.0 (1.8)0.2872.7 (1.7)3.3 (1.9)0.31T1 – n(%)5 (17)21 (33)0.2307 (47)19 (24)0.098T2 – n(%)21 (72)36 (56) 7 (47)50 (64) T3 – n(%)3 (10)7 (11) 1 (7)9 (12) Clinical Nodal Status      Negative – n(%)10 (34)42 (66)0.0078 (53)44 (56)1.00Positive – n(%)19 (66)22 (34) 7 (47)34 (44) Grade      2 – n(%)6 (21)5 (8)0.0763 (20)8 (10)0.293 – n(%)23 (79)59 (92) 12 (80)70 (90) 

Citation Format: Yam C, Huo L, Hess KR, Litton JK, Yang W, Piwnica-Worms H, Mittendorf EA, Ueno NT, Lim B, Murthy RK, Damodaran S, Helgason T, Thompson AM, Santiago L, Candelaria RP, Rauch GM, Adrada BE, Symmans WF, Gilcrease MZ, Moulder SL. Androgen receptor positivity is associated with nodal disease in triple negative breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-22.

Abstract OT3-02-05: NCI-2016-00367: A phase IIB study of neoadjuvant ZT regimen (enzalutamide therapy in combination with weekly paclitaxel) for androgen receptor (AR)-positive triple-negative breast cancer (TNBC)

BACKGROUND: Approximately 50% of TNBC expresses AR by immunohistochemical (IHC) staining. Luminal androgen receptor (LAR) subtype is heavily enriched in hormonally regulated genes, yet negative for ER by IHC. LAR is associated with low pCR rates and long survival. Preclinical data have shown that taxanes inhibit translocation of AR from the cytoplasm to the nucleus where AR is activated. Combining paclitaxel with enzalutamide may inhibit the AR pathway synergistically thereby increasing pCR rates. We hypothesized that patients with AR-positive TNBC who have chemo-insensitive disease (CID) after initial anthracycline-based chemotherapy treated with ZT would have higher RCB-0 and RCB-I rates than those who receive conventional taxane-based chemotherapy. Our team developed a clinical trial to identify patients with CID (ARTEMIS: A Randomized, TNBC Enrolling trial to confirm Molecular profiling Improves Survival). In the ARTEMIS trial, treatment-naïve patients with localized TNBC undergo a pretreatment biopsy and then begin anthracycline-based chemotherapy. Molecular testing results and radiographic response assessment are used to identify CID and will guide the second phase of neoadjuvant chemotherapy (NACT) to overcome CID.

PRIMARY OBJECTIVE: To determine RCB-0 and RCB-I rates of patients with TNBC who have CID to initial anthracycline-based chemotherapy and who received ZT.

TRIAL DESIGN AND STATISTICAL METHODS: Patients with CID from the ARTEMIS trial can enroll in the 12-week ZT (paclitaxel, 80 mg/m2 intravenously per week; enzalutamide, 160 mg orally per day). We will define pCR (RCB-0) or RCB-I as a response, using a Simon optimal 2-stage design with alpha=beta=10% and then setting the threshold for an acceptable pCR or RCB-I rate at 20%. We will enroll 12 patients into the first stage. If no patients experience pCR or RCB-I, we will stop the study after the first stage. If at least 1 patient experiences pCR or RCB-I, we will enroll 25 more patients for a total of 37 patients. We would declare the treatment worthy of further study if at least 4 of the 37 patients experience pCR or RCB-I. This design has a 54% probability of early termination after the first stage if the true pCR or RCB-I probability is 5%. Because patients with CID have a very low chance (5%) of achieving pCR with additional chemotherapy, improving pCR rates to 20% in this patient population would be clinically meaningful.

BRIEF ELIGIBILITY CRITERIA: Inclusion criteria: Primary invasive TNBC patients who have CID under the ARTEMIS trial; AR+ ≥1% nuclear staining by IHC; and adequate physical, organ, bone marrow, and cardiac functions. Exclusion criteria: Pregnant or lactating patients, history of colitis or absorption abnormality, known or suspected brain metastasis or leptomeningeal disease, or history of seizure.

CORRELATIVE SCIENCE: Enumeration of circulating tumor cells (CTCs) and expression of CTC-related gene transcripts will be measured to correlate CTC characteristics and/or gene profiles related to the AR pathway and treatment response to ZT.

Citation Format: Fujii T, Lim B, Helgason T, Hess KR, Gilcrease MZ, Willey JS, Tripathy D, Litton JK, Moulder S, Krishnamurthy S, Yang W, Reuben JM, Symmans WF, Ueno NT. NCI-2016-00367: A phase IIB study of neoadjuvant ZT regimen (enzalutamide therapy in combination with weekly paclitaxel) for androgen receptor (AR)-positive triple-negative breast cancer (TNBC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-02-05.

Metaplastic sarcomatoid carcinoma of the breast appears more aggressive than other triple receptor-negative breast cancers

Metaplastic sarcomatoid carcinoma (MSC) of the breast is usually triple receptor (ER, PR, and HER2) negative and is not currently recognized as being more aggressive than other triple receptor-negative breast cancers. We reviewed archival tissue sections from surgical resection specimens of 47 patients with MSC of the breast and evaluated the association between various clinicopathologic features and patient survival. We also evaluated the clinical outcome of MSC patients compared to a control group of patients with triple receptor-negative invasive breast carcinoma matched for patient age, clinical stage, tumor grade, treatment with chemotherapy, and treatment with radiation therapy. Factors independently associated with decreased disease-free survival among patients with stage I-III MSC of the breast were patient age > 50 years (P = 0.029) and the presence of nodal macrometastases (P = 0.003). In early-stage (stage I-II) MSC, decreased disease-free survival was observed for patients with a sarcomatoid component comprising ≥ 95% of the tumor (P = 0.032), but tumor size was the only independent adverse prognostic factor in early-stage patients (P = 0.043). Compared to a control group of triple receptor-negative patients, patients with stage I-III MSC had decreased disease-free survival (two-sided log rank, P = 0.018). Five-year disease-free survival was 44 ± 8% versus 74 ± 7% for patients with MSC versus triple receptor-negative breast cancer, respectively. We conclude that MSC of the breast appears more aggressive than other triple receptor-negative breast cancers.

Loss of myoepithelium is variable in solid papillary carcinoma of the breast

AIMS

Reports on the frequency of myoepithelial loss in solid papillary carcinoma (SPC) of the breast, an unusual variant of papillary carcinoma with a solid pattern of expansile growth, have been strikingly contradictory. The aim was to clarify the frequency of myoepithelial loss in cases of SPC diagnosed at our institution.

METHODS AND RESULTS

Eleven cases of SPC with available blocks or unstained slides were retrieved from the M. D. Anderson archives or obtained from outside contributors. Immunohistochemistry for smooth muscle actin (SMA) and p63 was evaluated on the circumscribed nests that appeared to be non-invasive by haematoxylin and eosin morphology. Three of the 11 cases (27%) were positive for both SMA and p63 at the periphery of all such foci, whereas eight cases (73%) lacked staining for both myoepithelial markers in at least one focus. Of these eight cases, one was diagnosed with only microinvasion, yet metastatic tumour resembling the circumscribed primary SPC was identified in two ipsilateral axillary lymph nodes.

CONCLUSIONS

SPC of the breast frequently lacks myoepithelial markers at the tumour-stromal interface in spite of a circumscribed non-invasive appearance. Metastases from such tumours are infrequent, but can occur in cases that lack myoepithelial marker expression by immunohistochemistry.

Expression of protease-activated receptor 1 in oral squamous cell carcinoma

Protease-activated receptor 1 (PAR-1) is a G-coupled membrane protein. In this study, we analyzed the expression of PAR-1 in oral squamous cell carcinomas (SCCs). PAR-1 was expressed in oral SCCs, but the level of PAR-1 protein was lower in non-metastatic cells than in metastatic cells. Thrombin stimulated the growth of metastatic cells, and both thrombin and thrombin receptor activation peptide (TRP) enhanced the adhesion of these cells to fibronectin, but had no effect on non-metastatic cells. Thrombin and TRP also induced matrix metalloproteinase (MMP)-2 and MMP-9 activities in metastatic cells. These results suggest that PAR-1 may contribute to the growth and invasive potential of oral SCC.

Adhesion of aspirated tumor cells to extracellular matrix proteins: a new methodology utilizing fine-needle aspiration

BACKGROUND

Cell adhesion molecules mediate the interactions of cells with other cells and with extracellular matrix components. Such interactions may be important in the development of tumor invasion and metastasis. This article describes a new approach to the evaluation of tumor cell-matrix interactions by utilizing fine-needle aspiration of resected tumors.

METHODS

Fine-needle aspiration was performed on 15 fresh surgical specimens of various types of carcinomas. After partial purification by isotonic Percoll centrifugation, tumor cell adhesion to collagen Type IV, laminin, and fibronectin was evaluated by counting cytologically malignant cells adhering to matrix-coated plastic substrates. Frozen tissue sections of the corresponding tumors were studied simultaneously for immunohistochemical expression of alpha-2, alpha-3, alpha-4, and alpha-5 integrin subunit expression. Results of the immunohistochemical staining then were compared with the adhesion data for particular tumors.

RESULTS

In general, the majority of the tumors exhibited little or no adhesion to collagen or laminin, but several tumors showed marked adhesion to fibronectin. Striking differences were noted between some tumors of the same histologic subtype. Competitive inhibition studies performed with two of the tumors (a large cell carcinoma and a renal cell carcinoma) showed decreased adhesion to fibronectin in the presence of anti-alpha-5, suggesting at least a partial role for the alpha-5-beta 1 fibronectin receptor in mediating the adhesion of these tumors to fibronectin. All the tumors examined exhibited strong immunohistochemical expression of the alpha-2 and alpha-3 integrin subunits, and all were negative for alpha-4. Three of the tumors showed weak expression of alpha-5, two of which (a squamous cell carcinoma and a renal cell carcinoma) were the tumors that showed the greatest adhesion to fibronectin.

CONCLUSIONS

Quantitative adhesion data can be obtained using cell suspensions prepared from fine-needle aspirates, and there are marked differences in adhesive properties between particular tumors. Although two of the tumors showed a correlation between adhesion to fibronectin and immunohistochemical expression of the alpha-5 integrin subunit, matrix adhesion does not necessarily correlate with immunohistochemical expression of adhesion molecule receptors. In the future, this methodology potentially could be of value in determining which patients may benefit from therapies aimed at modifying tumor cell-matrix interactions.

Extra-articular synovial chondromatosis of the temporomandibular joint: pitfalls in diagnosis

Synovial chondromatosis is a benign disease that only rarely affects the temporomandibular joint. When it does, disease is usually confined to the joint space itself but can occasionally extend beyond the joint capsule into the parotid gland, temporal bone, or cranium. The local clinical behavior, radiographic appearance, and histopathologic features can combine to create the appearance of a malignant lesion. We report a case of synovial chondromatosis that affected the temporomandibular joint and presented as an external auditory canal mass. The lesion was thought to be a chondrosarcoma prior to the definitive resection. Pitfalls in the diagnosis and management of synovial chondromatosis are discussed.

Correlation of CD44S expression in renal clear cell carcinomas with subsequent tumor progression or recurrence

BACKGROUND

Recent reports have shown altered expression of CD44 in renal cell carcinomas. However, to the authors' knowledge there are no data correlating CD44 expression in renal cell carcinomas with subsequent tumor progression or recurrence, nor is there information about the presence of particular splice variants of CD44 in these tumors.

METHODS

The authors examined the immunohistochemical expression of CD44S, the standard isoform of CD44, in renal cell carcinomas from 43 patients using 2 different monoclonal antibodies, Mab2137 and Hermes-3. In addition, they stained the renal cell carcinomas with antibodies to 2 splice variants of CD44, CD44v3 and CD44v6.

RESULTS

Increased staining of renal clear cell carcinomas with Mab2137 was observed in high grade versus low grade tumors (45% vs. 0%, P = 0.013), whereas increased staining of clear cell carcinomas with Hermes-3 was noted in high stage versus low stage tumors (40% vs. 0%, P = 0.006). Few tumors stained with antibodies to CD44v3. Although increased expression of the splice variant CD44v6 was noted in papillary versus clear cell carcinomas, and increased staining of papillary carcinomas with Mab2137 and with antibodies to CD44v6 was noted for low stage versus high stage tumors, these differences did not achieve statistical significance. Clinical follow-up of at least 43 months was available for 26 patients. Six of these patients (five with clear cell carcinoma and one with papillary carcinoma) developed progressive or recurrent disease. The primary tumors from all 5 patients with progressive or recurrent clear cell carcinoma showed staining with Mab2137, whereas the primary tumors from only 2 of the 15 patients with at least 43 months follow-up and no evidence of progressive or recurrent clear cell carcinoma (13%) showed staining with Mab2137 (P = 0.001). Alternatively, 5 of 7 clear cell carcinomas (71%) that stained with Mab2137 were from patients who subsequently developed recurrence or progression, compared with 0 of 13 clear cell carcinomas that did not stain. Similar findings were not observed for papillary carcinomas, which appeared to be biologically distinct from clear cell carcinomas.

CONCLUSIONS

CD44S staining with Mab2137 correlates with progression or recurrence of clear cell renal cell carcinoma. CD44S may, therefore, play a pathogenetic role in tumor progression.

Intrasellar adenoid cystic carcinoma and papillary mucinous adenocarcinoma: two previously undescribed primary neoplasms at this site

Most carcinomas involving the sella turcica are metastases. We report two previously undescribed carcinomas that appear to be primary at this site. The first occurred in a 44-year-old woman who presented with hemianopsia. A mass was noted by computed tomography to occupy the sella turcica, from which it appeared to originate. Transphenoidal biopsy showed the tumor to be an adenoid cystic carcinoma with a typical cribriform pattern. The patient died shortly after a subsequent attempt at tumor resection. The second tumor arose in a 55-year-old man who presented with diplopia. Computed tomography showed a mass in the sella turcica that was presumed to be a pituitary adenoma. However, transphenoidal resection revealed a mucinous adenocarcinoma composed of small papillae and glands lined by columnar epithelium. The tumor cells exhibited varying degrees of stratification with prominent interspersed mucin vacuoles. Focal solid areas showed a component of signet ring-type cells. In contrast to the apparent aggressive behavior of the adenoid cystic carcinoma, the papillary mucinous adenocarcinoma appeared much less aggressive, as the second patient was alive and without evidence of disease 5 years later. Both tumors may be derived from epithelial rests within the pituitary gland, either minor salivary gland rests or Rathke's cleft remnants.

Clear cell adenocarcinoma and nephrogenic adenoma of the urethra and urinary bladder: a histopathologic and immunohistochemical comparison

Because of histological similarities between nephrogenic adenomas and clear cell adenocarcinomas of the urinary tract, there is the potential for diagnostic confusion between these two entities. The histopathologic features of 13 nephrogenic adenomas and five clear cell adenocarcinomas of the urethra and urinary bladder are compared in this report, and detailed immunohistochemical staining profiles are provided for these tumors. Only 2 of the 13 nephrogenic adenomas contained clear cells, and these constituted less than 10% of the lesions. In contrast, four of the five clear cell adenocarcinomas contained prominent areas with clear cells. Nephrogenic adenomas generally showed only mild cytologic atypia, whereas four of the five clear cell adenocarcinomas showed severe atypia. A single mitotic figure was identified in only two of the nephrogenic adenomas, whereas the mitotic rate in the clear cell adenocarcinomas ranged from 2 to 14 per 10 high-power fields. None of the nephrogenic adenomas showed evidence of necrosis, but focal necrosis was noted in four of the five clear cell adenocarcinomas. In general, the nephrogenic adenomas and clear cell adenocarcinomas showed negative to weak staining with CK903 but strong staining with AE1, AE3, and Cam 5.2. Variable staining was observed with Brst-3 and antibodies to S-100, CEA (monoclonal and polyclonal), LeuM-1, and CA19.9. Nephrogenic adenomas and clear cell adenocarcinomas were all negative for prostate-specific acid phosphatase (PSAP), prostate-specific antigen (PSA), and estrogen and progesterone receptors (except for two nephrogenic adenomas, which showed only focal weak staining for estrogen receptor). Neither bcl-2 nor c-erbB-2 staining was able to discriminate between the tumors. However, strong staining for p53 was noted in each clear cell adenocarcinoma and in none of the nephrogenic adenomas. MIB-1 positivity in nephrogenic adenomas ranged from 0 to 13 (average of 5.5) per 200 cells, whereas the positive range for clear cell adenocarcinomas was 33 to 70 (average of 47) per 200 cells. In summary, histopathologic features that favor clear cell adenocarcinoma over nephrogenic adenoma include a predominance of clear cells, severe cytological atypia, high mitotic rate, necrosis, high MIB-1 positivity, and strong staining for p53.

Salivary duct carcinoma. Is a specific diagnosis possible by fine needle aspiration cytology?

OBJECTIVE

To review the cytomorphologic features of salivary duct carcinoma and to evaluate the likelihood of definitive diagnosis by fine needle aspiration.

STUDY DESIGN

The cytomorphologic features of two cases of salivary duct carcinoma, both occurring in the parotid gland in men over 80 years of age, were evaluated by fine needle aspiration and compared to cytologic features described in the literature. Additionally, previously reported diagnoses rendered by fine needle aspiration of salivary duct carcinomas were compiled from the cytology literature. The likelihood of arriving at a definitive diagnosis by fine needle aspiration was determined from the frequency of correct cytologic diagnoses reported in the literature.

RESULTS

The most characteristic features of salivary duct carcinoma by fine needle aspiration appear to be flat sheets with a cribriform pattern and tumor cells in a necrotic background with pleomorphic, eccentric nuclei and granular cytoplasm. However, no definitive diagnoses of salivary duct carcinoma by fine needle aspiration have been recorded in the cytology literature.

CONCLUSION

Because of the morphologic spectrum displayed by this tumor and the absence of definitive cytologic diagnoses in the literature to date, it is unclear whether a diagnosis of salivary duct carcinoma can be rendered by fine needle aspiration. Nevertheless, if cribriform groups are noted in a salivary gland aspirate, the diagnosis of salivary duct carcinoma should at least be considered.

Fine needle aspiration of signet-ring cell lymphoma. A case report with differential diagnostic considerations

BACKGROUND

Signet-ring cell lymphoma is an unusual morphologic variant of non-Hodgkin's lymphoma that, although well described histologically, is scarcely mentioned in the cytology literature. Its main significance lies in its potential for diagnostic confusion with more common lesions containing signet-ring cells.

CASE

A 50-year-old, white male presented with a two-month history of persistent cervical lymphadenopathy and fatigue. Fine needle aspiration of a 2-cm, left, submandibular lymph node revealed classic signet-ring cells among small and large lymphoid cells. Also noted were multivacuolated cells. The background of the smears showed many vacuolated structures analogous to the lymphoglandular bodies seen in lymphoid proliferations without signet-ring cells.

CONCLUSION

The differential diagnosis of signet-ring cell lesions by fine needle aspiration includes signet-ring cell lymphoma, sinus histiocytosis and metastatic adenocarcinoma, liposarcoma and melanoma. When confronted with such an aspirate, additional material should be obtained for immunocytochemical or flow cytometric analysis.

Testicular Sertoli cell tumor with a heterologous sarcomatous component: immunohistochemical assessment of Sertoli cell differentiation

OBJECTIVE

Immunohistochemical staining is reported to be useful in distinguishing ovarian Sertoli-stromal cell tumors from carcinosarcomas. To assess Sertoli cell differentiation in a rare malignant biphasic testicular tumor, we compared the immunophenotypic profile of the tumor with that of Sertoli cell nodules and adenomas and mullerian carcinosarcomas.

DESIGN

Immunohistochemical staining was performed on 6 testes (4 with hyperplastic Sertoli cell nodules, 2 with Sertoli cell adenomas) and 7 carcinosarcomas (6 involving the uterus, 1 involving the uterus and ovary) using primary monoclonal antibodies AE1/AE3, CAM 5.2, CA 19.9, and antibodies directed against epithelial membrane antigen, carcinoembryonic antigen (monoclonal and polyclonal), S100, placental alkaline phosphatase, and inhibin. These staining results were compared with those of the index case.

RESULTS

All testes showed positive staining for inhibin and vimentin in the Sertoli cells of the nodules and adenomas. One Sertoli cell nodule showed focal staining with AE1/AE3 and CAM 5.2. Both adenomas showed focal positive staining for S100. All nodules and adenomas were negative for epithelial membrane antigen, monoclonal and polyclonal carcinoembryonic antigen, CA 19.9, and placental alkaline phosphatase. In contrast, the carcinomatous areas of the carcinosarcomas were all negative for inhibin but exhibited positive staining for AE1/AE3, CAM 5.2, and epithelial membrane antigen. The carcinosarcomas showed variable expression of vimentin, S100, carcinoembryonic antigen, CA 19.9, and placental alkaline phosphatase. The epithelial component of the tumor from the index case showed strong diffuse staining for inhibin and vimentin and only very faint focal staining with AE1/AE3 and CAM 5.2. The epithelial component was negative for epithelial membrane antigen, monoclonal and polyclonal carcinoembryonic antigen, S100, CA 19.9, and placental alkaline phosphatase.

CONCLUSIONS

The immunohistochemical findings in the index case support the diagnosis of Sertoli cell tumor with a heterologous sarcomatous component over carcinosarcoma. Inhibin seems to be the best single marker for Sertoli cell differentiation. To our knowledge, only 1 other case of this rare testicular tumor has been reported in the literature.

Fine-needle aspiration of basaloid squamous carcinoma: a case report with review of differential diagnostic considerations

Basaloid squamous carcinoma is a distinct variant of squamous carcinoma with a particularly poor prognosis. To our knowledge, there are only two papers in the cytopathology literature which describe this entity. We report the fine-needle aspiration findings of an additional case of metastatic basaloid squamous carcinoma in a cervical lymph node and compare its cytomorphologic features to those observed on touch imprints of the subsequent surgical specimen. Smears of the aspirate showed a mixed lymphoid background with interspersed cohesive clusters of small cells roughly 3 times the size of small mature lymphocytes. Some cells were angulated and others exhibited irregular nuclear contours. The cells were generally hyperchromatic with evenly staining dense chromatin or irregularly distributed coarse chromatin. Focally there was evidence of nuclear molding. On Diff-Quik staining, irregular globules of magenta-stained extracellular dense material were noted within or adherent to the periphery of some clusters or as somewhat linear formations with small epithelial cells clinging to the edges. Abundant mitotic figures and clumps of necrotic tumor were more apparent on touch preps of the subsequent surgical specimen. The differential diagnosis by fine-needle aspiration includes adenoid cystic carcinoma, basal-cell adenocarcinoma, adenosquamous carcinoma, and small-cell carcinoma. If a fine-needle aspirate of a cervical lymph node shows the features described above and the primary tumor is unknown, suggesting the possibility of metastatic basaloid squamous carcinoma may aid clinicians in the search for a primary site, as basaloid squamous carcinoma occurs most frequently at the base of the tongue, hypopharynx, and supraglottic larynx.

Tyrosine-rich crystals associated with oncocytic salivary gland neoplasms

OBJECTIVE

Crystalloids have been identified ultrastructurally within the epithelial cells of Warthin's tumors, but there have been no studies characterizing crystals or crystalloids in Warthin's tumors by light microscopy. The finding of abundant needle-shaped crystals in a fine-needle aspirate of a cystadenoma of the parotid prompted us to examine the prevalence of crystals and crystalloids in oncocytic salivary gland neoplasms.

DESIGN

Ninety-seven oncocytic neoplasms (93 Warthin's tumors, 3 cystadenomas, and 1 oncocytoma) excised at our institution between 1950 and 1996 were examined, to identify crystals. Neoplasms with crystals were further characterized by means of a variety of histochemical stains and electron microscopy. Ninety-nine pleomorphic adenomas were similarly reviewed.

RESULTS

Seven cases with crystals were identified. Five of these were Warthin's tumors, 1 was a cystadenoma, and 1 was an oncocytoma. The crystals were noted within tumor cysts but were not limited to the neoplasms. The crystals were predominantly either needle-shaped or tabular, but some cases contained mixtures of both as well as intermediate forms. They stained pink with hematoxylin-eosin, although the tabular forms also exhibited a focal yellow hue. The crystals were not discernible under polarized light. They stained a red-brown color with Millon's reagent, which indicated the presence of tyrosine. Trichrome, periodic acid-Schiff stain with diastase, alcian blue (pH 2.5), and Congo red stains were negative. Electron microscopy revealed sharply defined, elongate, electron-dense structures with periodicity, both extracellular and within epithelial cells. No crystals or crystalloids were identified in any of 99 pleomorphic adenomas reviewed.

CONCLUSIONS

The findings indicate that tyrosine-rich crystals associated with several oncocytic salivary gland neoplasms are morphologically, histochemically, and ultrastructurally distinct from previously described tyrosine-rich crystalloids and collagenous crystalloids of pleomorphic adenomas. Although the crystals appear to form by the assembly of small units within epithelial cells, the exact mode of formation remains unclear.

Localized thymic Langerhans' cell histiocytosis and its relationship with myasthenia gravis. Immunohistochemical, ultrastructural, and cytometric studies

OBJECTIVE

It has been suggested that localized Langerhans cell histiocytosis may represent an exaggerated form of a proliferative process that has been reported in a few patients with myasthenia gravis. To evaluate the relationship between thymic Langerhans' cell proliferation and myasthenia gravis, we analyzed a rare case of localized thymic Langerhans' cell histiocytosis and examined thymic Langerhans' cell distribution in myasthenic and control patients.

DESIGN

Immunohistochemical, ultrastructural, and image cytometric DNA analyses were performed on the index case. Immunostaining for S100 was performed on 20 additional thymuses, 10 from patients with myasthenia gravis and 10 from control patients.

RESULTS

Immunohistochemical studies revealed no increase in Langerhans' cells in the surrounding thymic tissue of the index case. No difference was found between the number of Langerhans' cells in the remaining thymuses of myasthenia patients compared with the control group, and no micronodular proliferations were identified in either group.

CONCLUSIONS

Localized thymic Langerhans' cell histiocytosis is an unusual lesion that is associated with myasthenia gravis in some patients. In the few cases reported at present, however, the lesion does not appear to be related pathogenetically to myasthenia gravis.

Correlation of very late activation integrin and CD44 expression with extrarenal invasion and metastasis of renal cell carcinomas

Cell adhesion molecules mediate cell-cell and cell-matrix interactions, and they are thought to play an important role in tumor invasion and metastasis. Altered expression of integrins and CD44 in renal cell carcinoma has been recently demonstrated, but an association with invasive or metastatic behavior has not been reported. We examined very late activation (VLA) integrin and CD44 expression in 37 renal cell carcinomas and correlated adhesion molecule expression with multiple histological and clinical parameters. Most tumors exhibited positive staining for VLA3 (81%). Approximately one third of the tumors stained positively for VLA6 and CD44, and fewer (27%) were positive for VLA2. Only a few tumors were positive for VLA4 (8%) and VLA5 (14%). Most of the tumors exhibiting positive staining showed a combination of membranous and cytoplasmic staining patterns. Low-grade tumors positive for VLA6 showed a tendency for basilar staining of the tumor cells, whereas high-grade tumors exhibited diffuse cytoplasmic staining. All tumors exhibiting weak or strong positive staining for VLA4 or VLA5 showed extrarenal invasion or were known to have developed metastases at the time of nephrectomy. All tumors strongly positive for VLA2 or CD44 showed invasion beyond the renal capsule or metastases. In contrast to a previous study, no association was observed between positive staining and tumor grade. Nor were tumor size, architectural pattern, cell type, or DNA ploidy found to be associated with particular staining patterns. Although many of the invasive tumors showed no difference in VLA integrin or CD44 expression compared with tumors confined to the kidney, increased expression in some of them suggests that these cell adhesion molecules may contribute to the invasive or metastatic phenotype.

Somatic von Hippel-Lindau mutation in clear cell papillary cystadenoma of the epididymis

Papillary cystadenoma of the epididymis is an uncommon benign lesion that may occur sporadically or as a manifestation of von Hippel-Lindau (VHL) disease. Neither immunohistochemical studies nor molecular genetic analyses of the VHL gene have been reported previously for this lesion. The authors describe two cases of clear cell papillary cystadenoma of the epididymis, both of which were initially confused with metastatic renal cell carcinoma. Both lesions showed positive immunohistochemical staining for low and intermediate molecular weight keratins (Cam 5.2 and AE1/AE3), EMA, vimentin, alpha 1-antitrypsin, and alpha 1-antichymotrypsin. Each was negative for CEA. Because clear cell papillary cystadenoma is similar to renal cell carcinoma histologically, and because both occur as components of the von Hippel-Lindau disease complex, the authors analyzed both cases for the presence of mutations in the VHL gene. A somatic VHL gene mutation was detected in one of the two tumors by polymerase chain reaction followed by single-strand conformation polymorphism analysis. Direct sequencing revealed a cytosine to thymine transition at nucleotide 694, resulting in the replacement of an arginine with a stop codon after the sixth amino acid of exon 3. As the VHL gene is believed to function as a tumor suppressor gene, VHL gene mutations may play a role in the initiation of tumorigenesis in sporadic cystadenomas of the epididymis.

Yolk sac tumor identified at autopsy after surgical excision of immature sacrococcygeal teratoma

Although the predictive value of immature elements in sacrococcygeal teratomas in unclear, there are reports of malignant recurrence after surgical resection of immature sacrococcygeal teratomas. The recurrent tumors are presumed to arise from small residual malignant foci not identified at the time of surgical resection. In this report a premature female infant was delivered at 29 week's gestation with a large sacrococcygeal teratoma. The tumor weighed 1,350 g. It was largely cystic with a focal nodular and variegated appearance. Histologically, the tumor was a grade 1 immature teratoma with a predominance of neuroglial elements. No malignant elements were identified in any of 26 sections examined. The infant died intraoperatively of cardiovascular complications related to the large vascular supply of the tumor but had a grossly complete resection of tumor. At autopsy, a small microscopic focus of yolk sac tumor was identified adjacent to the sacrum anteriorly. Had the infant survived, this focus might well have been a source for malignant recurrence.

Secretion of a chemotactic substance(s) by AGE-stimulated human monocytes

Receptors for products of non-enzymatic glycosylation have been identified previously on activated human monocytes. In this study we have found that medium conditioned by activated human monocytes following stimulation with AGE-BSA elicited an almost 3-fold greater chemotactic response from other activated monocytes than conditioned medium obtained following stimulation with control BSA (44 +/- 13 and 16 +/- 4.6, respectively; n = 9, P less than 0.05). The response elicited from AGE-BSA alone was not statistically significant. It appears that stimulation of the cells via the AGE-receptor results in the secretion of increased levels of a chemotactic substance(s) for monocytes/macrophages. This mechanism may help to explain the pathogenesis of atherosclerosis in diabetes, as monocyte accumulation within the vessel wall is an important step in fatty streak development.

Human monocyte interactions with non-enzymatically glycated collagen

We have previously shown that receptors for advanced glycation end products are expressed on activated human monocytes. We now report that activated human monocytes exhibit increased adhesion to non-enzymatically glycated collagen substrates (+32% +/- 1, p less than 0.001), and the increased adhesion can be competitively inhibited with non-enzymatically glycated albumin. Non-activated monocytes, which do not express receptors for advanced glycation end products, exhibit decreased adhesion (-16% +/- 1, p less than 0.001). Similar results were observed with substrates of fibronectin and endothelial cell matrix proteins. As the presence of glycation adducts on collagen interferes with the normal binding of monocytes/macrophages, one possible role for advanced glycation adduct receptors on activated monocytes is to counterbalance such decreased adherence. Overcompensation for long periods of time may lead to pathological changes. Additionally, such receptors may play a role in monocyte-mediated remodelling of glycated matrix proteins, as we have observed increased degradation of non-enzymatically glycated collagen substrates by activated human monocytes at 2 h (+52% +/- 11, p = 0.01), 3 h (+49% +/- 10, 10, p = 0.01), and 4 h (+36% +/- 6, p less than 0.01) after adding activated monocytes to 125I-labelled substrates.

Examination of monocyte adherence to endothelium under hyperglycemic conditions

Increased nonenzymatic glycation of proteins has been implicated in the pathogenesis of diabetic vascular disease. The authors have shown by 3H-NaBH4 reduction of nonenzymatic glycation adducts that endothelial cell membrane proteins undergo increased nonenzymatic glycation in vitro when exposed to elevated concentrations of glucose. Increased nonenzymatic glycation also was found in vivo for microvascular endothelial cells isolated from streptozotocin-induced diabetic rats compared with control rats. Cultured monocytes have previously been reported to express receptors for certain nonenzymatic glycation adducts. The authors have further investigated whether monocyte interactions with endothelium are altered by the presence of nonenzymatic glycation adducts on endothelium. Adherence assays were performed in the presence of elevated concentrations of glucose with decreased NaCl levels to maintain normal osmolarity (as occurs physiologically). Although monocyte adherence to endothelium and levels of early nonenzymatic glycation adducts increased under these conditions, the increased adherence appears to be due to the altered NaCl levels. In fact, freshly isolated monocytes (in contrast to what has been found for macrophages and activated monocytes) were shown not to express appreciable numbers of receptors for nonenzymatic glycation adducts.

Neutrophil adhesion to endothelium following hyperosmolar insult

This study examined the effects of hyperglycemic/hyperosmolar conditions on neutrophil adhesion to endothelium. A 2.4-fold increase in neutrophil adhesion was observed following exposure of endothelial cells to 100 mM glucose for 24 hours (n = 9, p less than 0.001), and a 57% increase occurred following pre-incubation in 50 mM glucose for 24 hours (n = 8, p less than 0.01). Phase-contrast microscopy of endothelial monolayers following exposure to 100 mM glucose showed no gross morphological changes, and no differences in membrane permeability were detected. Electron microscopy, however, revealed that cells exposed to 100 mM glucose generally had more pseudopods, an increased density of cytoplasm, and more finely dispersed chromatin throughout the nucleus. Increased neutrophil adhesion to endothelium was also observed following exposure of endothelial cells to 100 mM mannitol, indicating that hyperosmolarity could account for the effect observed with high concentrations of glucose. However, the increase following mannitol treatment was 170% of control (n = 6), while glucose pre-treatment resulted in a 240% increase (n = 9, p = 0.01 for glucose compared to mannitol). The effect of high concentrations of glucose on neutrophil adhesion to endothelial cells was to some degree specific for endothelium, as the same effect was not observed with microvascular pericytes. As neutrophil adhesion to endothelium is an important early step in the acute inflammatory response, these findings may help to explain the increased incidence and severity of infections in diabetic patients.

Activated human monocytes exhibit receptor-mediated adhesion to a non-enzymatically glycosylated protein substrate

Non-enzymatic glycosylation of proteins is thought to play an important role in the development of diabetic vascular disease. Advanced glycosylation end products have been shown to accumulate on basement membranes and collagen in diabetes, and receptors for such adducts have recently been found on murine macrophages. We have observed that human monocytes activated by endotoxin express receptors for advanced glycosylation end products of similar affinity and number as has been previously reported for murine macrophages. In addition, there is an increased adherence of activated human monocytes to a non-enzymatically glycosylated albumin substrate, and such adhesion can be competitively inhibited up to 50% by soluble, non-enzymatically glycosylated albumin. We suggest that increased adherence of activated monocytes to non-enzymatically glycosylated proteins in the vessel wall may result in monocyte stimulation and/or local monocyte accumulation and thereby contribute to vascular disease in diabetes.