Ovarian non-Hodgkin's lymphoma: a clinicopathologic study of eight primary cases

Primary (localized) non-Hodgkin's lymphoma (NHL) of the ovary is rare. We studied eight cases of primary ovarian NHL to better understand the clinicopathologic and immunophenotypic features of these tumors. The patients ranged in age from 29 to 62 years (mean 47 years). Pelvic complaints were the most common symptoms; however, three of eight neoplasms were discovered incidentally. All tumors were unilateral and Ann Arbor stage I(E). The three incidental NHL were microscopic (largest 1.2 cm), whereas the grossly evident lesions ranged from 7.5 to 20 cm (mean 13.3). Each tumor was classified according to the World Health Organization Classification as follows: diffuse large B-cell lymphoma (three cases), follicular lymphoma (two cases), Burkitt lymphoma (one case), T-cell anaplastic large cell lymphoma (one case), and precursor T-lymphoblastic lymphoma (one case). Six tumors were of B-cell lineage, and two tumors were of T-cell lineage. All three diffuse large B-cell lymphomas were positive for BCL-6, two were positive for CD10, and two were positive for BCL-2. Estrogen and progesterone receptors were negative in all NHLs assessed. Patients were treated by various combinations of surgery, chemotherapy, and radiotherapy. Clinical follow-up ranged from 1.3 to 11.7 years (mean 5.2) and all patients were alive without disease at last follow-up. We conclude that most patients with primary ovarian NHL present with symptoms attributable to an ovarian mass, but in a subset of patients ovarian NHL may be detected incidentally. With appropriate therapy, patients appear to have a favorable prognosis although follow-up is short for some patients in this study.

Immunohistochemical analysis of clear cell carcinoma of the gynecologic tract

Clear cell carcinoma of the gynecologic tract has been defined in terms of its clinical and histologic features; however, its immunophenotypic profile has not been fully characterized. Seventeen cases of primary clear cell carcinoma from various sites within the female genital tract (11 ovary, 5 uterus, 1 vagina) were analyzed by immunohistochemistry. These tumors were assessed for the expression of cytokeratin 7 (CK7), cytokeratin 20 (CK20), low and high molecular weight cytokeratin, (CAM5.2 and 34 beta E12, respectively), carcinoembryonic antigen (CEA), Leu-M1, vimentin, estrogen receptor (ER), progesterone receptor (PR), bcl-2, p53, HER-2/neu, and CA-125. The characteristic immunoprofile for all sites was positivity for CK7, CAM5.2, 34 beta E12, CEA, Leu-M1, vimentin, bcl-2, p53, and CA-125; variably positivity for ER and HER-2/neu; and negativity for CK20 and PR. For comparison, two cases of urologic clear cell carcinoma (1 bladder, 1 urethra) were also studied, and their profile was found to be similar to the gynecologic cases. Aside from minor differences, clear cell carcinoma appears to have the same immunophenotype regardless of whether it originates in the endometrium, ovary, or genitourinary tract. Much of its profile is similar to other gynecologic adenocarcinomas, but some of the markers studied may be useful in the differential diagnosis of this tumor.

Uterine leiomyomas with Eosinophils: a clinicopathologic study of 3 cases

Although leiomyomas (LMs) of the uterus are common, hematopoietic components within these tumors are not. Lymphoid and other hematopoietic elements have been previously recognized, but eosinophilic infiltrates in LMs have received little attention in the literature. The clinical and pathologic features of 3 cases of uterine LM with eosinophilic infiltration were studied. The patients ranged in age from 35 to 62 years and presented with abdominal and/or pelvic pain and abnormal uterine bleeding. None had peripheral blood eosinophilia or clinical evidence of allergy or parasitic infection. One patient had a benign LM, and the other 2 patients had smooth muscle tumors of uncertain malignant potential. The tumors contained variable numbers of eosinophils and Giemsa stains showed variable numbers of mast cells in addition to the eosinophils. We also performed immunohistochemical and in situ hybridization studies to assess for interleukin-5 (IL-5) and eotaxin in these LMs. There was no consistent association between the presence of eosinophils and either IL-5 or eotaxin in smooth muscle cells, suggesting that mechanisms other than IL-5 or eotaxin production may account for the eosinophilia. Because eosinophils are believed to be involved in wound healing, tissue remodeling, and fibrosis, their presence within LMs may reflect a response to tissue injury produced by the neoplasm rather than intrinsic recruitment by chemotactic factors produced by the smooth muscle cells. Their presence, however, does not appear to have any clinical significance.

Non-Hodgkin's lymphoma involving the gynecologic tract: a review of 88 cases

Non-Hodgkin's lymphoma (NHL) involving the gynecologic tract is unusual and may cause confusion for the pathologist not familiar with its clinical and histologic features. The literature regarding this topic is also confusing, as modern NHL classification systems were not used or patients were not staged according to the Ann Arbor system in many prior reports. In addition, immunophenotypic data is not available for many cases, particularly in older studies. In the past year, there has been an interest in NHL involving the gynecologic tract and 88 cases have been collected. These cases were reviewed in the Pathology Department of M.D. Anderson Cancer Center during the past two decades, and many of these patients were treated at this hospital. In this review, these cases are reported using updated terminology and almost all cases were immunophenotyped using immunohistochemical methods or flow cytometric methods in a small subset of cases. These cases have also been segregated into two groups: 1) localized NHL, that presumably initially arose in the gynecologic tract and therefore are primary; and 2) NHL that involved the gynecologic tract as a part of systemic disease, and therefore most likely represent secondary involvement of the gynecologic tract. The differential diagnosis of NHL involving gynecologic organs is discussed.

Vulvar hypertrophy with lymphedema. A mimicker of aggressive angiomyxoma

We report the case of a 43-year-old quadriplegic woman with bilateral vulvar enlargement. The clinical impression was labial hypertrophy, but the microscopic features mimicked aggressive angiomyxoma because of the location, hypocellular proliferation of fibroblastic cells in an edematous-myxoid stroma, and vessels with perivascular collagen deposition, which simulated the thick-walled vessels of aggressive angiomyxoma. Since the lesion lacked true thick-walled vessels and contained ectatic tortuous lymphatics, the pathologic interpretation was lymphedema. This vulvar lesion should be recognized to prevent the misdiagnosis of aggressive angiomyxoma.

A micropapillary variant of transitional cell carcinoma arising in the ureter

A 79-year-old woman was evaluated for a ureteral stricture related to laser ablation of a tumor 6 months earlier at another institution. A ureteroscopic examination revealed an exophytic papillary tumor that was resected and examined histologically. The tumor was characterized by delicate papillae with thin stromal cores and numerous secondary micropapillae lined by small cuboidal to low columnar cells with uniform low-to-intermediate-grade nuclei, reminiscent of a serous borderline tumor of müllerian origin. The cell linings were 1 to 4 layers thick; mitotic figures were easily identified. The underlying stroma appeared edematous and contained scattered chronic inflammatory cells. No invasion was identified. After ascertaining that the patient had no known gynecologic neoplasm, the differential diagnoses considered included papillary nephrogenic adenoma, clear cell carcinoma, and the recently described entity of micropapillary transitional cell carcinoma. Because of the striking resemblance to serous carcinoma and the presence of significant mitotic activity, this case was felt to represent a case of micropapillary transitional cell carcinoma (World Health Organization grade 1 to 2) occurring in the ureter. To our knowledge, this tumor had some unique features (no areas of grade 3 nuclei or invasion) that have not been reported in tumors occurring in the urinary bladder. The transitional cell nature of the tumor cells was supported by the immunohistochemical staining pattern. The anatomic distribution of micropapillary transitional cell carcinoma is now expanded to include the ureter, and this tumor should be considered in the differential diagnosis for papillary lesions occurring in the ureter.

Non-Hodgkin's lymphoma involving the vulva

Non-Hodgkin's lymphomas (NHL) involving the vulva are rare. We report the clinicopathologic and immunohistochemical findings of six cases of vulvar NHL. The age of the patients ranged from 43 to 71 years (mean 60 years), and 5 presented with a vulvar mass. Two patients had neoplasms localized to the vulva, and two patients had a history of NHL that secondarily involved the vulva; in another patient the stage was unknown, and the sixth patient had stage IVA mycosis fungoides/Sezary syndrome involving the vulva. Each tumor was classified according to the revised European-American classification of lymphoid neoplasms: four were diffuse large B-cell lymphoma, one was peripheral T-cell lymphoma, and one was mycosis fungoides/Sezary syndrome. Two patients were treated with chemotherapy and radiotherapy, one patient received chemotherapy and phototherapy, one patient was treated with chemotherapy, and in two patients the treatment is unknown. Clinical follow-up, available for 4 cases, ranged from 7 months to 5 years. One patient with low-stage NHL responded to therapy, but relapsed and died of disease 2 years later. Two patients with generalized NHL that secondarily involved the vulva died of disease 7 months and 5 years, respectively, after the diagnosis of vulvar involvement was established. The patient with mycosis fungoides/Sezary syndrome is alive with disease at 4 years. The three patients in this study who died and our review of the literature indicate that NHL involving the vulva is usually an aggressive disease.

Malignant peripheral nerve sheath tumor with a t(X;18)

We describe an ankle tumor arising in a 16-year-old girl. The tumor demonstrated histology typical of a malignant peripheral nerve sheath tumor (MPNST), but exhibited a variant form of the (X;18) translocation associated with synovial sarcoma. Immunohistochemical stains were positive for vimentin, CD57, collagen type IV, and Bcl-2. Routine and molecular cytogenetic studies showed an unbalanced 3-way chromosomal translocation that involved chromosomes X, 18, and 1. Electron microscopic findings were noncontributory. This unusual tumor raises the following questions and possibilities: (1) As the t(X;18) suggests, could this tumor be a monophasic synovial sarcoma with the histologic features of an MPNST? (2) Or, as the histology suggests, is this tumor an MPNST that has a t(X;18)? (3) Finally, could MPNST histology, a t(X;18), and no defining immunohistochemical or electron microscopic features represent an as yet unrecognized part of a spectrum that spans from synovial sarcoma to MPNST or other spindle cell tumors?

Immunohistochemical determination of HER-2/neu expression in invasive breast carcinoma

Numerous methods exist for HER-2/neu assessment; however, technical and interpretive standardization is virtually absent. We evaluated 2 commercially available antibodies on routinely fixed paraffin-embedded tissue sections to establish our own guidelines. Thirty-three cases of infiltrating breast carcinoma were evaluated simultaneously with monoclonal and polyclonal antibodies. Only membranous staining, no matter how focal, was considered positive. An additional 32 tumors were studied subsequently using only the polyclonal antibody. Of all carcinomas, 13.0% showed immunohistochemical evidence of HER-2/neu overexpression. High-grade tumors were more often positive. There was no HER-2/neu gene expression in the benign epithelium that generally was present in the tissue section or in any of the well-differentiated tumors tested. The polyclonal antibody proved more sensitive than the monoclonal antibody. While true cytoplasmic staining was present occasionally, it did not create substantial difficulty in interpretation. The polyclonal antibody cost substantially less than the monoclonal antibody. Fluorescence in situ hybridization assay for HER-2/neu gene amplification performed on 32 of 65 cases showed concordant results in 31 cases. The immunohistochemical assay for HER-2/neu gene overexpression, using our methods, is accurate, economic, and easily integrated into the laboratory.

Non-Hodgkin's lymphoma involving the vagina: a clinicopathologic analysis of 14 patients

Non-Hodgkin's lymphomas (NHL) uncommonly involve the vagina. In this study, 14 NHL involving the vagina are reported. Eight cases were stage IE or IIE and are presumed to be primary. The mean age of these eight patients at presentation was 42 years (range, 26-66 yrs), and four of eight patients complained primarily of vaginal bleeding. Histologically, all eight neoplasms were diffuse large B-cell lymphoma (DLBCL). Clinical follow up ranged from 1.8 to 18 years. Six of eight patients were alive without evidence of disease at the last follow up (range, 2.8-21 yrs), one patient died of unrelated causes at 9 years, and one patient died from NHL at 1.8 years. In six patients vaginal involvement was part of systemic disease at diagnosis, either stage IIIE or IV. The mean patient age at the time vaginal involvement was detected was 65 years (range, 49-82 yrs). Four of six patients had vaginal bleeding. Five neoplasms were DLBCL and one tumor was B-cell small lymphocytic lymphoma/chronic lymphocytic leukemia. Clinical follow up for these patients ranged from 2 weeks to 13 years. Two patients were free of disease after treatment at 4.5 and 13 years, two patients were alive with progressive NHL, one patient died of NHL, and one patient was recently diagnosed. The authors conclude that low-stage (presumably primary) vaginal NHL are DLBCL, tend to occur in younger women, and cause vaginal bleeding. High-stage NHL involving the vagina are usually DLBCL, tend to affect older women, and are relatively more heterogeneous clinically and histologically, but also usually cause vaginal bleeding.

Endometrial carcinoma and non-Hodgkin's lymphoma involving the female genital tract: a report of three cases

The occurrence of both non-Hodgkin's lymphoma and carcinoma involving the female genital tract of the same patient is rare; we describe three such cases. In case 1, a 56-year-old woman with endometrioid endometrial carcinoma had synchronous follicular lymphoma of the uterus and ovary. In case 2, a 57-year-old woman with diffuse large B-cell lymphoma of the uterine cervix presented 5 years later with an endometrioid endometrial carcinoma. In case 3, a 69-year-old woman with an endometrioid endometrial carcinoma presented with a diffuse large B-cell lymphoma of the vagina 3 years later. In two patients, the non-Hodgkin's lymphoma was unsuspected clinically and would have been missed without biopsy and tissue diagnosis.

Primary vulvar and vaginal extraosseous Ewing's sarcoma/peripheral neuroectodermal tumor: diagnostic confirmation with CD99 immunostaining and reverse transcriptase-polymerase chain reaction

Two cases of extraosseous Ewing's sarcoma/peripheral neuroectodermal tumor arising in unusual, superficial sites are reported. One tumor involved the vaginal wall of a 35-year-old woman, and the other neoplasm arose in the dermis of the vulva in a 28-year-old woman. The tumors showed characteristic microscopic features of Ewing's sarcoma/peripheral neuroectodermal tumor with nodular monotonous proliferations of undifferentiated, small, round, hyperchromatic cells with a low mitotic index. Rare rosette-like formations were apparent only in the vulvar neoplasm. The tumors displayed intense immunoreactivity in a membranous pattern for CD99, the cell surface glycoprotein encoded by the MIC2 gene. Genetically, the tumors expressed the EWS/FLI-1 chimeric transcript, derived from the t(11;22)(q24;q12) chromosomal translocation. Both patients had localized disease treated with wide local excision; one received postoperative chemotherapy, and the other received chemotherapy and radiotherapy. To date, 18 and 19 months after diagnosis, neither patient has had clinical evidence of local recurrence or metastasis. To our knowledge, these are the first reported cases of vaginal and vulvar Ewing's sarcoma/peripheral neuroectodermal tumor, confirmed with molecular genetic analysis, in the English literature.

Granular cell tumor of intracranial meninges

BACKGROUND

Granular cell tumor (GCT) is a benign neoplasm composed of a proliferation of round or polygonal cells that contain eosinophilic granular cytoplasm. The most common locations are tongue and subcutaneous tissue, but a variety of other sites may be involved including the central nervous system (CNS). Most CNS GCT arise in the pituitary, but rare cases involving brain and leptomeninges have been described. Extracranial GCT are usually S-100-positive, but those of the CNS, as well as the congenital variant of GCT, can be S-100-negative.

CASE REPORT

We report an incidental autopsy finding of a 2.5 mm GCT that arose in the intracranial meninges overlying the anterior superior cerebellar vermis.

RESULTS

The neoplasm had abundant eosinophilic, granular cytoplasm that was PAS-positive and diastase-resistant. Immunohistochemical studies showed that the neoplasm was positive for CD68 and negative for S-100, GFAP, EMA, and keratin. Thus, the immunophenotype is consistent with non-neural origin.

CONCLUSION

Although this lesion in this circumstance was of no clinical significance, knowledge of the occurrence of GCT at this site broadens the differential diagnosis of eosinophilic lesions of the leptomeninges.

Non-Hodgkin's lymphomas involving the uterus: a clinicopathologic analysis of 26 cases

Non-Hodgkin's lymphomas (NHL) involving the uterus may be either low-stage neoplasms that probably arise in the uterus (primary) or systemic neoplasms with secondary involvement. In this study, 26 NHL involving the uterus are reported. Ten cases were stage I(E) or II(E) and are presumed to be primary. The mean age of patients at presentation was 55 years (range, 35 to 67 years), and abnormal uterine bleeding was the most frequent complaint (six patients). Nine of 10 tumors involved the cervix. Histologically, eight were diffuse large B-cell lymphoma (DLBCL); one was follicle center lymphoma, follicular, grade 1; and one was marginal zone B-cell lymphoma. At 5 years of clinical follow-up, five of six patients were alive after treatment. In 12 cases, uterine involvement was part of a systemic disease at diagnosis, either stage III(E) or IV. The mean patient age at the time that uterine involvement was detected was 58 years (range, 22 to 75 years); 6 of 12 had abnormal uterine bleeding. Six tumors involved both cervix and corpus, four corpus, and two cervix. Six were DLBCL; two were small lymphocytic lymphoma; three were follicle center lymphoma, follicular, grade 1 (two cases) or grade 2 (one case); and one was precursor T-cell lymphoblastic lymphoma. At 5 years of clinical follow-up, two of seven patients were alive after treatment. Four DLBCL arose in patients with incomplete clinical information; therefore, stage is unknown. We conclude that low-stage (presumably primary) uterine NHL are most commonly DLBCL, predominantly arise in the cervix, and cause abnormal uterine bleeding. High-stage NHL are a heterogeneous group of B-cell neoplasms that can involve the cervix or the corpus.

Pelvic abscess with fistula to the abdominal wall due to verrucous carcinoma

The case report of a 38-year-old woman with a pelvic abscess resulting from verrucous carcinoma of the uterine cervix is presented. This case is remarkable because the abscess formed a fistula through the anterior abdominal wall and because there was no visible lesion on the cervix. The patient underwent a total abdominal hysterectomy, left salpingectomy, fistulectomy, and removal of the abscess. Diagnosis was made on pathologic examination of the extirpated specimen. Genital tract verrucous carcinoma and genitocutaneous fistulae are reviewed.

Ectopic hidradenoma papilliferum: a case report and review of the literature

Hidradenoma papilliferum is a benign, cystic, papillary tumor that occurs almost exclusively in women on the skin of the anogenital region. Nonanogenital (ectopic) hidradenoma papilliferum are rare. We describe a 72-year-old white man with an enlarging nodule in the region of the right triceps muscle; microscopic examination showed a hidradenoma papilliferum. The median age of patients with ectopic hidradenoma papilliferum is between 1 to 2 decades older than the average age range of lesion onset in patients with anogenital hidradenoma papilliferum. In contrast to anogenital hidradenoma papilliferum, nearly one half of the patients with ectopic hidradenoma papilliferum are men. Ectopic hidradenoma papilliferum occurs most frequently (60%) in the head and neck region. Eighty-five percent of cases are 1.5 cm in the greatest diameter or smaller. The race, clinical features, pathologic features, treatment, and prognosis for hidradenoma papilliferum occurring in anogenital and ectopic locations are similar.