Benjaporn Chaiwun

Metaplastic carcinoma of the breast: a clinicopathological review

Background: Mammary metaplastic carcinoma encompasses epithelial-only carcinoma (high-grade adenosquamous carcinoma or pure squamous cell carcinoma), biphasic epithelial and sarcomatoid carcinoma and monophasic spindle cell carcinoma. Aim: To evaluate the clinicopathological features of a large series of 34 metaplastic carcinomas. Methods: 10 epithelial-only, 14 biphasic and 10 monophasic metaplastic carcinomas were assessed for nuclear grade, hormone receptor status, HER2/neu (cerbB2) oncogene expression, Ki-67 and p53, lymph node status and recurrence on follow-up. Results: Intermediate to high nuclear grade were assessed in most (33/34) tumours. Oestrogen and progesterone receptors were negative in 8 of 10 epithelial-only, all 14 biphasic, and 9 of 10 monophasic tumours, cerbB2 was negative in 7 of 10 epithelial-only, all 14 biphasic and 8 of 10 monophasic tumours. Ki-67 was found to be positive in 6 of 10 epithelial-only, 6 of 14 biphasic, and 7 of 10 monophasic tumours, whereas p53 was positive in 6 of 10 epithelial-only, 7 of 14 biphasic, and 8 of 10 monophasic tumours. Lymph node metastases were seen in 7 of 7 epithelial-only, 7 of 11 biphasic, and 3 of 7 monophasic tumours. Recurrences were seen in 4 of 7 epithelial-only, 8 of 9 biphasic, and 4 of 9 monophasic tumours. Conclusions: All three subtypes of metaplastic carcinoma are known to behave aggressively, and should be differentiated from the low-grade fibromatosis-like metaplastic carcinoma, which does not metastasise. Oncological treatment options may be limited by the frequently negative status of hormonal receptor and cerbB2.

p63 is useful in the diagnosis of mammary metaplastic carcinomas

Aims: p63 has been recently reported to be expressed in sarcomatoid/metaplastic carcinoma of the breast, in addition to its role as a myoepithelial marker. A large series of 34 metaplastic carcinomas, including cases with pure epithelial component (squamous cell and adenosquamous carcinomas), biphasic tumours with carcinomatous and sarcomatoid components and monophasic tumours with only spindle cell component, were evaluated for p63 expression with respect to the different cellular components. Methods: All of the metaplastic carcinomas were assessed for p63 and conventional epithelial and mesenchymal markers of AE1/3, CAM5.2 and vimentin by immunohistochemistry. Results: All of the different categories of metaplastic carcinomas showed similar clinico‐pathological features (patient age, tumour size, nuclear grade, mitotic activity, lymph node status and hormonal receptor status). For metaplastic carcinoma with epithelial component only, p63 was only expressed in the squamous cell component, but not the adenocarcinoma component. Eight of the 10 tumours were positive for p63. For the tumours with sarcomatoid component, either singly or together with carcinomatous component, p63 was positive in 14 of 24 cases. Pure sarcomas and carcinomas were all negative for p63 staining by immunohistochemistry, thus rendering p63 staining highly specific for diagnosing metaplastic carcinoma. Conclusions: Using p63 for diagnosis of metaplastic carcinoma gives a sensitivity of 65%, a specificity of 96%, a positive predictive value of 96%, and a negative predictive value of 66% and an accuracy of 78%. p63 may be used as an adjunct marker in the diagnosis of metaplastic carcinoma.

Detection of occult metastases in lung carcinomas: Progress and implications for lung cancer staging

The ability to detect occult regional and systemic metastases in patients with operable lung carcinoma could have a significant impact on the management of the disease. Here, we review the literature, including studies from our own laboratory, regarding the clinical significance of the presence of occult metastases in patients with lung cancer. The accumulated evidence strongly suggests that the detection of occult regional and systemic metastases is an important predictor of disease progression. The use of this method should be considered in the future design of lung cancer clinical trials, at the very least. The detection of occult metastases should have an impact on lung cancer mangement; to reflect this, we propose a change in the TNM staging system to indicate the presence or absence of occult regional (lymph node) and systemic (bone marrow) metastases. The proposed change is TNnMm, where n and m are occult nodal and bone marrow metastases status. J. Surg. Oncol. 1998;69:265–274.

Spectrum of Papillary Lesions of the Breast: Clinical, Imaging, and Pathologic Correlation

OBJECTIVE Papillary lesions of the breast are a heterogeneous group of lesions that are difficult to diagnose as benign or malignant. The purpose of this article is to review clinical presentation, imaging features, and pathologic correlation of papillary lesions of the breast and to discuss the prognosis and management of these lesions. CONCLUSION Recognition of the variety of benign and malignant papillary lesions of the breast will facilitate diagnosis and proper management.

Fine needle aspiration for evaluation of breast masses

Purpose of review Fine needle aspiration has been used for many years as a diagnostic tool for breast lesions, with high sensitivity and specificity. There is controversy as to whether this technique should be replaced by other diagnostic procedures such as core biopsy. This review aims to re-evaluate the usefulness of breast fine needle aspiration. Recent findings During the past 10 years many institutions have replaced fine needle aspiration by core biopsy and related techniques such as vacuum-assisted core biopsy and advanced breast biopsy instrument action. Other institutions continue to use fine needle aspiration as a first line of investigation for breast lesions. This technique is especially useful in radiologically benign lesions and when combined with image guidance. The use of the ‘triple test’ (combined cytologic, clinical and radiologic findings) decreases false-negative and false-positive results. Summary Fine needle aspiration continues to be an acceptable and reliable procedure for the preoperative diagnosis of breast lesions, particularly in developing countries, and when used as part of the ‘triple test’. Accurate diagnosis requires experience in both aspiration technique and specimen interpretation. Clinicians should be mindful of the limitations of the technique. The choice between fine needle aspiration and core biopsy should be individualized for the patient.

Lymphadenopathy due to Penicillium marneffei infection: Diagnosis by fine needle aspiration cytology

Penicillium marneffei is an opportunistic fungal infection that usually causes disseminated disease, mainly in immunocompromised individuals, especially those with HIV infection. Untreated cases are usually fatal. Diagnosis is traditionally made by biopsy and/or culture; successful diagnosis by fine needle aspiration (FNA) has only been reported once. We present eight cases of HIV-infected patients with lymphadenopathy caused by P. marneffei infection, in which the diagnosis was made by FNA. In all cases, intracellular and extracellular yeast forms were visualized, and the characteristic cross-septation of P. marneffei was highlighted by GMS staining. All diagnoses were confirmed by culture. Anti-fungal treatment for P. marneffei was initiated, resulting in marked clinical improvement. We conclude that a diagnosis of lymphadenopathy caused by P. marneffei can reliably be made by FNA. The diagnosis is more rapid than biopsy or culture, allowing rapid institution of therapy, particularly important in immunocompromised patients. In all our cases, not only were lymphoma and other causes of lymphadenopathy ruled out, but also the necessity for an open surgical biopsy was obviated. This can be especially beneficial to patients (e.g., three in our study) in which lymphadenopathy is confined to deep intra-abdominal nodes.

Fine needle aspiration cytology of papillary lesions of the breast - how accurate is the diagnosis?

Background: Cytological diagnosis of mammary papillary lesions is difficult. Aim: To review the previous cytology diagnosis of 23 papillomas and 11 papillary carcinomas and specific cytological features that may assist in differentiating these entities. Methods: The cytology preparations were reviewed for: (i) overall cellularity; (ii) epithelial cell ball devoid of fibrovascular cores; (iii) background single cells; and (iv) papillary fragments and their morphology. Results: The overall diagnostic accuracy was 59%, atypical rate was 24%, and the error (combined false positive and negative) rate was 17%. For overall cellularity, 6, 14 and 3 cases of papillomas, and 6, 3 and 2 cases of papillary carcinomas showed low, moderate and high cellularity, respectively. Cell balls were present in mild to moderate number in 20 papillomas and 10 papillary carcinomas. The background single cells were absent, or present in low or moderate to high numbers in 7, 10 and 6 papillomas, and 3, 3 and 5 papillary carcinomas, respectively. Papillary fragments were absent, or present in small, moderate or large quantities in 9, 4, 8 and 2 papillomas, and 6, 3, 1 and 1 papillary carcinomas, respectively. There was no demonstrable quantitative difference between papilloma and papillary carcinoma for all these parameters. Qualitatively, the cell balls and single cells showed a higher degree of atypia in papillary carcinoma, and the papillary fragments were more elaborate and slender. Conclusion: Cytological diagnosis of papillary lesions shows a significant error rate with overlapping features. Cellular atypia and fragments with long and slender papillae with ramifying edges favour papillary carcinoma.

Fine-needle aspiration cytology of metaplastic carcinoma of the breast

Background: Metaplastic carcinoma of the breast encompasses a heterogeneous group of tumours with variable components of sarcomatoid, squamous or poorly differentiated carcinomas. Aim: To review a series of 19 cytological preparations of metaplastic carcinomas to assess diagnostic cytological features. Methods: 17 cases of fine-needle aspirates of histologically proven metaplastic carcinomas (4 monophasic spindle cell carcinomas, 4 squamous cell carcinomas and 11 biphasic tumours) were reviewed, with an emphasis on the presence of poorly differentiated carcinoma, squamous cell carcinoma, atypical spindle cells, benign stromal fragments and necrosis. Results: All cases were diagnosed as malignant, with 68% of cases showing moderate to high cellularity, and 47% showing necrosis. If the tumours were analysed according to the constituting components histologically, 7, 15 and 8 cases, respectively, possess poorly differentiated carcinoma cells, sarcomatoid malignant cells and squamous carcinoma cells, whereas these components were cytologically identified in 11, 10 and 7 cases, respectively. Dual tumour populations were identified in only 5 of the 11 biphasic carcinomas in the cytological preparations; and the stromal material was cytologically identified in the only case with chondroid stroma. Conclusions: Identification of metaplastic carcinoma in cytology remains problematic. There seems to be morphological overlap between various components. The identification of dual components, unequivocal squamous carcinoma cells and chondroid stroma is helpful for diagnosis, but it is uncommon. The presence of poorly differentiated carcinoma cells with a suggestion of focal spindle morphology is another clue to the suggestion of metaplastic carcinoma.

Breast cancer in the elderly: A histological assessment

Aims:  To understand the correlation between the expression status of different biological markers in breast cancers in the elderly.

Multiple Bilateral Giant Fibroadenomas Associated with Cyclosporine a Therapy in a Renal Transplant Recipient

A 31-year-old woman developed a right breast mass following cyclosporine A therapy after a renal transplant. Several large breast masses continued to grow bilaterally. Mammography and ultrasonography showed features of giant fibroadenomas. The diagnosis was confirmed by biopsy of one of the masses. Awareness of the association between cyclosporine A therapy and fibroadenoma development in renal transplant recipients is highlighted.