Arthur S. Patchefsky

Tubular carcinoma of the breast

Retrospective pathologic review of 636 breast carcinomas from 611 patients revealed twelve tumors which were pure low grade tubular carcinoma (TC) and nineteen tumors with features combining both low grade tubular carcinoma and invasive duct carcinoma (T&D). A control group of 23 cases consisted of invasive duct carcinoma with at least a third of the tumor surface area showing tubular formation, but without the low grade features of tubular carcinoma. Life table analysis at 15 years showed a 100%, 72%, and 33% survival for TC, T&D, and controls, respectively. Eight percent of TC and 21% of T&D had axillary metastases compared to 67% for controls. Axillary metastases had no detrimental effect on TC or T&D survival. There were no recurrences in the TC group. Patients with T&D with tumor diameter 1.0 cm or less or with 50% or greater low grade tubular carcinoma component are alive and well. The mean age of T&D was 7 years greater than TC. The combined TC and T&D group showed a significant incidence of multiple cancers in the ipsilateral breast and a significant trend toward bilateral cancers when compared to controls. Tubular carcinoma has an inherently low malignant potential with a histological and biological spectrum. Cancer 42:2334–2342, 1978.

Adenomatous and carcinomatous changes within hyperplastic colonic epithelium.

SummaryHyperplastic colonic polyps are benign, nonneoplastic proliferations; unlike tubular and villous adenomas, they do not predispose the patient to colonic cancer. Theoretically, these hyperplastic polyps, like normal colonic epithelium, should be able to undergo adenomatous transformation and possibly develop into cancer. In this report, we discuss an unusual case of a patient with numerous hyperplastic polyps, in which adenomatous changes occurred and cancer developed. We also discuss the significance of these changes as they relate to the polyp-cancer sequence.

Cloacogenic carcinoma of the anorectum in homosexual men: An observation of four cases

SummaryCloacogenic carcinoma of the anorectum is an uncommon neoplasm which arises from the transitional zone (cloacogenic) epithelium. The transitional zone epithelium is derived from the embryonic cloacogenic membrane as is the epithelium of the vagina and uterine cervix in the female. Four cases of cloacogenic carcinoma in male homosexuals who have engaged in longstanding receptive anal intercourse have been observed. This observation, along with the realization that the anorectal transitional zone shares a common embryologic origin with the uterine cervix, a site of cancer long known to be associated with factors related to sexual intercouse, leads to the serious question of the etiologic potential of receptive anal intercourse in the development of cloacogenic carcinoma.

Interobserver reproducibility of histopathological features in stage II breast cancer. An ECOG study.

SummaryEleven surgical pathologists studied microscopic sections from 45 mastectomy specimens of node positive breast cancer patients who had been entered into ECOG clinical trials. Inter-observer reproducibility for histoprognostic features was examined as a prerequisite before a subsequent evaluation of their possible clinical applicability could be undertaken. Histological type, nuclear grade, tubular formation, and lymphoid reactions were studied in the cancerous tissues. Lymph nodal responses (follicular and pulp prominence, sinus histiocytosis) were also examined in a manner that simulated slide review in routine surgical pathology practice. Numerous two-way comparisons of the pathologists findings resulted in low levels of agreement (usually ≪90%). The degree of inter-observer reliability is clinically unacceptable using customary slide review analysis. New ways of examining breast cancer tissues need to be explored in the search for prognostic features which can be applied to the clinical management of breast cancer patients.

Synovial sarcoma: a clinical, pathological, and ultrastructural study of 26 cases supporting the recognition of a monophasic variant.

Twenty-six cases of synovial sarcoma (14 biphasic, 12 monophasic) were subjected to a clinicopathological study that included electron-microscopic examination of six tumors. Monophasic tumors were composed predominantly of uniform, densely packed, small spindle cells with scant cytoplasm identical to those of the “stromal” elements of typical biphasic tumors. The arrangement of these cells into narrow interlacing fascicles, forming tight whorls and showing little collagenization, was distinctive for this tumor. Major clinical differences between the two types of synovial sarcoma were the tendency for monophasic tumors to arise in distal extremity locations (seven of 10), and the poorer prognosis of monophasic tumors, 30% surviving 5 years compared to 58% for biphasic tumors. At the ultrastructural level, monophasic tumors and the spindle-cell components of biphasic tumors were identical. Both were composed of spindle or polygonal cells attached by numerous desmosomes. Prominent Golgi, abundant RER, perinuclear microfilaments, and glycogen aggregates were characteristic. Intercellular spaces containing elongated cytoplasmic filopodia were observed consistently, as were fragments of basement membrane-like material. The EM findings concur with those described previously in normal and pathologic synovium, and support a synovioblastic origin for the monophasic variant of synovial sarcoma.

Intravascular fasciitis: a report of 17 cases.

Seventeen cases of intravascular fasciitis are reported from the files of the AFIP (14 cases) and the Pathology Department, Thomas Jefferson University Hospital (three cases). It is characterized by the histologic features of nodular fasciitis but with intraluminal, intramural, and extramural involvement of small to medium-sized veins and arteries and multinodular or serpentine growth along the course of affected blood vessels. A painless, slowly growing mass was most common. Fourteen patients (82%) were under age 30 (range 1/2–57 years); the sex ratio was about equal. Seven cases were located on the upper extremity (three hand, two wrist or forearm, two shoulder), three on the ankle or lower leg, five on the head and neck, and two in the chest wall and breast. Most cases were small with a mean diameter of 1.5 cm, but two were elongated masses measuring 4–5 cm in length. At surgery, four cases showed intimate association with large veins or arteries. This type of fasciitis is rare and has been found in only one of 14 consecutive cases of nodular fasciitis operated at this university hospital between 1969 and 1978. Six of 15 consultation cases were originally confused with sarcoma. Intravascular fasciitis is benign. Seven patients were free of disease from 2.5 to 20 years (mean 9.5 years); two patients had local recurrences.

Bronchoalveolar cell carcinoma of the lung.

A multivariable analysis was performed of all patients registered and confirmed to have bronchoalveolar cell carcinoma of the lung in the Tumor Registry of Thomas Jefferson University Hospital between 1969 and 1983. These 122 patients were reviewed for age, sex, smoking history, occupational exposure, symptoms, radiographic findings, methods of diagnosis, clinical and pathologic staging, methods of treatment, survival, and complications of treatment. No correlation could be found in this series between a patients age, sex, smoking history, or occupational exposure and the incidence or outcome of the disease. Seventy-one of the 122 patients in this series were asymptomatic, and the carcinoma was discovered in them by routine chest roentgenogram. Of these asymptomatic patients, 50 were seen with pathologic stage I disease. Of the 51 symptomatic patients, 32 (65%) were seen with stage IIIm0 or IIIm1 disease. Despite medical evaluations, 77% of the T1 and T2 lesions required thoracotomy for diagnosis. The overall five-year survival rate was 42.3%, ranging from 75% for those with stage I disease to 8.7% for those with stage IIIm1 disease.

Staging and treatment of clinically occult breast cancer

Five hundred fifty‐seven biopsies were performed for clinically occult mammary lesions, detected by mammography as clustered calcifications or nonpalpable masses within the breast. One hundred seventy‐five cancers were demonstrated within this group, including 106 invasive carcinomas, 10 microinvasive carcinomas, 45 in situ ductal carcinomas, and 14 lobular carcinomas in situ (lobular neoplasia). No patient with in situ or microinvasive carcinoma had evidence of axillary node metastases in 33 specimens studied. However, a disturbingly high proportion of those patients with invasive carcinomas, approximately 35%, had histologically confirmed axillary node metastases, despite the small size of the primary tumors. These observations suggest that the use of the term “minimal” cancer is misleading when applied to invasive carcinoma. Staging systems for breast cancer have been imprecise when referring to nonpalpable lesions. Cancers detected as clustered calcifications only or as areas of parenchymal distortion without an accompanying mass are properly considered as T‐0 cancers, with a suggested T‐0(m) to indicate that the lesion was detected by mammography. However, when the mammogram indicates the presence of a mass that proves to be malignant, although the clinical examination may have been negative, the cancer should be staged according to the size of the mass on the mammogram, with the notation that it was detected by mammography, e.g., T‐1(m), T‐2(m), etc. The incidence of axillary node metastases even in these so‐called occult cancers is significant, so that recommendations for treatment for any invasive cancer, regardless of its size, must take these observations into account. Similarly, the incidence of multifocal sites of cancer within the breast, even in the noninvasive cancers encountered, must be remembered when treatment is suggested. Cancer 53:1379‐1384, 1984.

The pathology of breast cancer detected by mass population screening.

Breast cancer was detected in 156 of 17,526 asymptomatic women, (8.9/1000), aged 45‐64 years, screened by mammography, thermography, and physical examination. Twenty‐six percent of 149 pathologically reviewed cases metastasized to axillary nodes. Thirty‐six percent of tumors were in situ, minimally invasive, or low grade tubular carcinomas, none of which metastasized. Increased rates of detection were shown for intraductal and tubular types. Frankly invasive ductal and lobular carcinomas had a mean diameter of 2.3 cm., 46% of which had axillary lymph node metastases. Seventy‐percent of these were to only one to three nodes, however. Multicentricity with intraductal and lobular carcinoma in situ was frequently observed. Metastatic potential was related to tumor size, degree of stromal invasion, lymphatic permeation, and histologic grade. Few histological parameters other than size could be considered favorable. Forty‐two percent of tumors were not palpable, the majority being in situ, minimally invasive, and tubular types. Only five nonpalpable invasive carcinomas metastasized. While the initial results of mass screening appear favorable, prolonged follow‐up is needed to determine its impact on the population at risk.

Benign clear cell tumor of the lung. An Ultrastructural Study

The ultrastructural features of a benign clear cell tumor of the lung are reported. The tumor cells showed monogranular, rosette, and membrane‐bound glycogen which appears unique to this tumor. Many tumor cells were surrounded by basement membrane material, and were in close association with endothelial cells. The cytoplasmic membrane of the cells showed electron‐dense deposits alternating with pinocytotic vesicles. Many cells showed intracytoplasmic filaments. The ultrastructural features suggest a smooth muscle or pericytic origin for this neoplasm.