Joseph Houghton

Metastatic breast lobular carcinoma involving tamoxifen-associated endometrial polyps: report of two cases and review of tamoxifen-associated polypoid uterine lesions

Two cases of lobular breast carcinoma metastatic to an endometrial polyp are described. Both patients had been treated with tamoxifen and presented with abnormal uterine bleeding. Histology of endometrial biopsy in both cases showed typical tamoxifen-associated endometrial polyps with focal subtle stromal infiltration by metastatic lobular breast carcinoma. This was confirmed by positive immunohistochemical staining with cytokeratin epithelial markers. Metastatic breast carcinoma may rarely involve tamoxifen-associated endometrial polyps. Because primary endometrial carcinomas may also arise within tamoxifen polyps, these should be extensively sampled. We briefly review polypoid uterine lesions that may occur secondary to tamoxifen therapy.

Composite cervical adenocarcinoma composed of adenoma malignum and gastric type adenocarcinoma (dedifferentiated adenoma malignum) in a patient with Peutz Jeghers syndrome

An unusual cervical adenocarcinoma is reported in a 50-year-old woman with a history of Peutz Jeghers syndrome. The carcinoma contained two morphologically distinct and spatially separate components, one comprising typical well differentiated adenoma malignum and the other a moderately differentiated neoplasm, in keeping with gastric type adenocarcinoma. Both components were positive for HIK1083 and MUC6 and negative for p16, and did not contain human papillomavirus. It is believed that such a composite tumour has not been described in the literature. It is believed that the component of gastric type adenocarcinoma arose through a process of dedifferentiation within adenoma malignum and we provide circumstantial molecular evidence in support of the interpretation that both components may be clonally related in that they displayed an extra copy of chromosome 7. This raises the possibility of a relationship between these two uncommon types of cervical adenocarcinoma, both of which are thought to exhibit gastric differentiation.

Concordance between digital pathology and light microscopy in general surgical pathology: A pilot study of 100 cases

Aim (1) A pilot study to determine the accuracy of interpretation of whole slide digital images in a broad range of general histopathology cases of graded complexity. (2) To survey the participating histopathologists with regard to acceptability of digital pathology. Materials and methods Glass slides of 100 biopsies and minor resections were digitally scanned in their entirety, producing digital slides. These cases had been diagnosed by light microscopy at least 1 year previously and were subsequently reassessed by the original reporting pathologist (who was blinded to their original diagnosis) using digital pathology. The digital pathology-based diagnosis was compared with the original glass slide diagnosis and classified as concordant, slightly discordant (without clinical consequence) or discordant. The participants were surveyed at the end of the study. Results There was concordance between the original light microscopy diagnosis and digital pathology-based diagnosis in 95 of the 100 cases while the remaining 5 cases showed only slight discordance (with no clinical consequence). None of the cases were categorised as discordant. Participants had mixed experiences using digital pathology technology. Conclusions In the broad range of cases we examined, digital pathology is a safe and viable method of making a primary histopathological diagnosis.

A simple method for the prevention of endometrial autolysis in hysterectomy specimens

Aims: Uteri are among the most common surgical pathology specimens. Assessment of the endometrium is often difficult because of pronounced tissue autolysis. This study describes a simple method to prevent endometrial autolysis and aid in interpretation of the endometrium. Methods: Sixty uteri were injected with formalin using a needle and syringe directed alongside a probe, which was inserted through the external cervical os into the endometrial cavity. Injection was performed on the same day as removal of the uterus. As controls, 60 uteri that were not injected with formalin were examined. The degree of endometrial autolysis was assessed on a four point scale (0–3), with a score of 0 representing no or minimal autolysis and a score of 3 representing extensive autolysis, such that histological interpretation of the endometrium was impossible. Results: In the injected group, the number of cases with scores of 0, 1, 2, and 3 was 42, 13, four, and one, respectively. The corresponding values for the control group were 17, 23, eight, and 12, respectively. This was highly significant (p < 0.001) Conclusions: There was significantly less endometrial autolysis in uteri injected with formalin. The use of this simple procedure should be encouraged in hysterectomy specimens.

Histopathologists’ approach to keratoacanthoma: a multisite survey of regional variation in Great Britain and Ireland

Introduction This survey examines regional variation in the diagnosis of keratoacanthoma (KA). Methods Twenty-three departments from Great Britain and Ireland were invited. The number of cases coded as KA or cutaneous SCC in the previous 12 months was retrieved. An SCC: KA ratio was calculated. Participants also provided free text responses. Results Seventeen departments replied. A total of 11 718 cases were included with a breakdown of 998 KA and 10 720 SCC. The mean SCC:KA ratio was 10.7:1, range (2.5:1 to 139:1). Free text responses are presented. Discussions An extreme variation in approach is highlighted by this survey. We believe a multidisciplinary team approach to the diagnosis of KA is essential. There seems to be a need for a carefully considered clinicopathological study, backed up by molecular studies, to better understand the natural biology of this diagnosis.

Digital pathology imaging offers more benefits than glass slides and microscopes

The study by Elmore and colleagues entailed the assessment of glass slides.1 The potential benefits of digital pathology images were briefly mentioned in the article, and we would like to make …

Pyoderma gangrenosum of the abdominal wall.

A 60-year-old woman presented with a large painful haemorrhagic ulcer of her left lower abdomen. Her medical history included ulcerative colitis, breast cancer, stroke and atrial fibrillation for which she was on warfarin. On examination she had a 15×6 cm large necrotic haemorrhagic ulcer of the left lower abdomen (figure 1). The border appeared violatious and undermined and the …

Diagnostic dilemma of ectopic notochord tissue in the nasopharynx

Sir: This is a case report of a 28-year-old male with a probable diagnosis of ectopic notochord tissue in the nasopharynx. It is important to highlight this entity, as there is a paucity of published literature describing this lesion. This is a ‘benign’ developmental abnormality which can easily be misdiagnosed as a chordoma (a malignant tumour). The notochord is an embryonic structure that organizes chondrification and segmentation of vertebral body mesenchyme and influences development of the floor plate. Although it usually regresses by the age of 3 years, notochord remnants are relatively common and have been described in a variety of sites. The most common sites are the base of the skull (ecchordosis physaliphora), the odontoid process of the axis and in the coccyx. Less commonly they have been reported in the nasopharynx. Chordomas which account for <4% of primary bone tumours arise from these remnants. Chordomas are slow growing, locally destructive malignant tumours which metastasize in up to 20% of cases and the 5-year survival is 68%. Unfortunately for the pathologist, notochord remnants and chordomas are indistinguishable histologically. Notochord remnants could therefore be described as pseudotumours. The need to be aware of this entity is omitted in a number of major pathology reference books. A 28-year-old male patient with a history of Down’s syndrome presented to Ear, Nose, Throat (ENT) outpatients. He had a 7-month history of retching and gagging, and his mother thought that food might be stuck in the back of his throat. Examination of the patient revealed a smooth-walled cystic mass in the nasopharynx at the level of the body of C2. The clinical suggestion was a possible Thornwaldt cyst (a developmental abnormality related to the notochord). We received two pieces of soft tissue measuring 26 · 16 · 6 mm and 8 · 8 · 4 mm. Histological examination showed ciliated and squamous mucosa, reactive lymphoid tissue and a proliferation of sheets of clear cells with single and multiple vacuoles (Figure 1). AE1 ⁄ AE3 (Figure 2), S100 and epithelial membrane antigen (EMA) were positive. Carcinoembryonic antiogen (CEA) was negative. The suggested differential diagnosis was (i) notochord remnant and (ii) chordoma. These could not be distinguished histologically. The investigation of choice was a magnetic resonance imaging scan, but the patient could not tolerate this and instead had a computed tomography scan of the head and neck, which showed no evidence of a tumour and, in particular, no evidence of a destructive bony lesion. At 6 months’ follow-up he was asymptomatic and there was no evidence of recurrence. We felt that the probable diagnosis in this case was a notochord remnant rather than a chordoma. No further active treatment was recommended and the patient is being followed up carefully. The notochord is a flexible, rod-shaped body found in embryos of all chordates. It is composed of cells derived from the mesoderm and defines the primitive axis of the embryo. In lower vertebrates, it persists throughout life as the main axial support of the body, whereas in higher vertebrates it is replaced by the vertebral column. The notochord is found on the ventral surface of the neural tube. Evolutionists believe that notochords were advantageous to primitive ‘fish ancestors’ Figure 1. H+E.

Precancerous lesions are more accurately termed "dysplasia"

Precancerous lesions, often detected by cancer screening programmes, fascinate histopathologists. Microscopic examination shows some of the architectural and cytological features of malignancy but no invasion of surrounding healthy tissue. As a practising histopathologist, I have always felt uncomfortable that patients with these conditions, such as ductal carcinoma in situ of the breast, are often told …