Robert R. Rickert

Adenomatous lesions of the large bowel: an autopsy survey.

A comprehensive autopsy survey of the large bowel showed that adenomas were very common lesions occurring in about one‐half of the 518 cases studied. The great majority were small adenomatous polyps (tubular adenomas), 86.7% measuring less than 10 mm in diameter. Adenomas with a more complex tubulo‐villous pattern were larger with a mean diameter of 19.0 mm. There was no apparent increase in mean size of adenomas with age. Nineteen clinically unsuspected cancers were discovered. Fourteen (8 in situ and 6 invasive) cancers had areas of residual benign adenoma. Five invasive cancers had no residual benign component. No in situ carcinomas or small (<10 mm) invasive cancers not containing residual adenoma were found. The results suggest that, although adenomas of the large bowel are very common, the vast majority are simple adenomatous polyps which do not undergo progressive growth and malignant change. Conversely, it appears that cancers may arise from benign adenomas which have the characteristics of large size and a more complex villous architecture.

Endoscopically removed malignant colorectal polyps: Clinicopathologic correlations

BACKGROUND/AIMS Treatment options for patients with endoscopically removed malignant colorectal polyps are polypectomy alone vs. polypectomy followed by surgery. The aim of this study was to define histopathologic parameters that can be used for clinically relevant treatment decisions. METHODS Five pathologists evaluated 140 polyps for the presence or absence of unfavorable histology. Unfavorable histology was tumor at or near (< or = 1.0 mm) the margin and/or grade III and/or lymphatic and/or venous invasion. Adverse outcome was recurrent and/or local cancer and/or lymph node metastasis. RESULTS Adverse outcome was 19.7% (14 of 71), 8.6% (2 of 23), and 0% (0 of 46) when unfavorable histology was present, indefinite (lack of agreement), and absent, respectively (P < 0.0005, present vs. absent). Four patients with cancer > 1.0 mm from the margin had an adverse outcome (2 with lymphatic invasion and 2 indefinite for lymphatic invasion). Four patients with negative resections later developed distant metastases. Eight patients (6.3%) died of disease, and 2 of 69 without unfavorable histology (both indefinite for lymphatic invasion) had an adverse outcome. Interobserver strength of agreement was substantial to almost perfect for margin, grade, and venous invasion and fair to substantial for lymphatic invasion. CONCLUSIONS This system is usable clinically. Patients with unfavorable histology are probably best managed by resection postpolypectomy, whereas in the absence of unfavorable histology, they probably can be treated by polypectomy only.

Familial Juvenile Polyposis Coli A Clinical and Pathologic Study of a Large Kindred

A kindred with familial juvenile polyposis coli is described. Of 92 family members, 26 have had symptoms consistent with polyposis, and a definite diagnosis of polyposis has been made in 19. Two family members have developed colorectal carcinoma before age 40 yr. The lesion of juvenile polyposis is a characteristic nonneoplastic polyp that is distinct from the neoplastic lesion of adenomatous polyposis. Patients with this disorder develop symptoms at an earlier age than those with adenomatous polyposis. Both variants of polyposis appear to have a dominant pattern of inheritance. Patients with juvenile polyposis who present in infancy are likely to have severe symptoms and complications. Although the premalignant potential of the juvenile polyp remains in doubt, there may be an increase risk of gastrointestinal cancer in these patients and their families.

Indurative mastopathy: A benign sclerosing lesion of breast with elastosis which may simulate carcinoma

Five cases of a benign sclerosing lesion of breast are described. The lesion is characterized by a stellate, indurated zone of sclerosis and elastosis in a region of benign ductal proliferation. Because of the stellate configuration and frequently retracted cut surface, the lesion may grossly resemble scirrhous carcinoma. Microscopically, there is often entrapment of benign but distorted ducts at the sclerotic margin, which may further cause confusion with cancer. Of special interest is the radiographic appearance, which may be indistinguishable from scirrhous carcinoma. The term “indurative mastopathy” is a descriptively valid designation for these lesions.

Pigmented villonodular synovitis of the temporomandibular joint.

A 39-year-old woman had a large asymptomatic left parotid mass that she had apparently not noticed. The clinical appearance suggested a parotid tumor. Aspirated tissue revealed numerous giant cells, histiocytes, and hemosiderin pigment. At surgical exploration a tumor was found deep to the facial nerve involving the temporomandibular joint, which had a brown-stained roughened synovial membrane. The resected specimen histologically was a proliferative lesion composed of epithelioid histiocytes, spindle cells, and multinucleated giant cells. The appearance was typical of the family of lesions that includes pigmented villonodular synovitis, bursitis, and tenosynovitis (giant cell “tumor” of tendon sheath). In view of the origin from the temporomandibular joint, reinforced by a characteristic radiologic appearance, we interpret this as a case of pigmented villonodular synovitis. This is the fifth case reported from this site.

The CD117 immunohistochemistry tissue microarray survey for quality assurance and interlaboratory comparison: a College of American Pathologists Cell Markers Committee Study.

CONTEXT We have developed tissue microarray-based surveys to allow laboratories to compare their performance in staining predictive immunohistochemical markers, including proto-oncogene CD117 (c-kit), which is characteristically expressed in gastrointestinal stromal tumors (GISTs). GISTs exhibit activating mutations in the c-kit proto-oncogene, which render them amenable to treatment with imatinib mesylate. Consequently, correct identification of c-Kit expression is important for the diagnosis and treatment of GISTs. OBJECTIVE To analyze CD117 immunohistochemical staining performance by a large number of clinical laboratories. DESIGN A mechanical device was used to construct tissue microarrays consisting of 3 x 1-mm cores of 10 tumor samples, which can be used to generate hundreds of tissue sections from the arrayed cases, suitable for large-scale interlaboratory comparison of immunohistochemical staining. RESULTS An initial survey of 63 laboratories and a second survey of 90 laboratories, performed in 2004 and 2005, exhibited >81% concordance for 7 of 10 cores, including all 4 GIST cases, which were immunoreactive for CD117 with >95% staining concordance. Three of the cores achieved less than 81% concordance of results, possibly due to the presence of foci of necrosis in one core and CD117-positive mast cells in 2 cores of CD117-negative neoplasms. CONCLUSIONS There was good performance among a large number of laboratories performing CD117 immunohistochemical staining, with consistently higher concordance of results for CD117-positive GIST cases than for nonimmunoreactive cases. Tissue microarrays for CD117 and other predictive markers should be useful for interlaboratory comparisons, quality assurance, and education of participants regarding staining nuances such as the expression of CKIT by nonneoplastic mast cells.

Pathologic Changes in the Stomach at the Site of Silicone Gastric Banding

Silicone gastric banding procedures for severe obesity have been done on 303 patients; 214 as primary operations and 89 as revisions of different types of gastric restriction operations. Twenty-five bands were removed, and in 16 of these cases full thickness gastric wall biopsies were done at the banding site. The pathologic changes at the banding site in these 16 patients consisted of variable local tissue responses consistent with constriction due to the banding process. The most significant finding, seen in only one patient, was full thickness fibrous replacement of the muscular wall. Ten patients had only serosal fibrosis at the banding site and four had both serosal fibrosis and patchy fibrous replacement of the muscularis propria. One biopsy specimen showed no pathologic changes. Notably absent in all cases were evidence of ischemia and evidence of penetration of the gastric wall by the band.

Simultaneous occurrence of renal cell adenocarcinoma and urothelial carcinoma of the renal pelvis in the same kidney diagnosed by preoperative angiography.

An unusual case of dissimilar histologic neoplasms in the same kidney is presented. An 86‐year‐old man had renal cell carcinoma and urothelial carcinoma in the same kidney eight years after therapy for urinary bladder carcinoma. These two different types of neoplasms were identified preoperatively by angiography. A peculiar hamartoma was also found in the same kidney.

Granular-cell tumors (myoblastomas) of the anal region.

SummaryThree cases of granular-cell tumor of the perianal region are reported. The clinical and pathologic features of these tumors are reviewed. Their precise histogenesis remains uncertain. The association with pseudoepitheliomatous hyperplasia of the overlying epithelium, which was well illustrated in two of the three cases, is discussed. The lesions are nearly always benign, and the treatment of choice is local excision.

Malignant Parapharyngeal Schwannoma (Neurilemmoma)

A malignant parapharyngeal neurilemmoma developed in a 45-year-old woman who had had a benign solitary neurilemmoma removed from the same area nine years previously. Incomplete excision was achieved through a mandibulotomy approach. Malignant schwannoma usually is associated with neurofibromatosis and has a poor prognosis, spreading along the nerve of origin or by blood stream. Small localized tumors should be treated aggressively by surgery. The possibility that a previously benign schwannoma underwent malignant transformation must be considered.