Roshni Chinoy

Multicentricity of breast cancer: whole-organ analysis and clinical implications

We studied the spatial relationship within the breast between multicentric foci (MCF) and the primary tumour in 30 modified radical mastectomy specimens using Egans correlated pathological-radiological method using 5 mm slices of the whole breast. The relative positions within the breast of the primary tumour and MCF were used to calculate the relative distribution of primary tumour and MCF in the four quadrants of the breast and the per cent breast volume that would be required to be excised to include all MCF. Nineteen (63%) breast harboured MCF. The relative distribution of primary tumour and MCF in the four breast quadrants was significantly different (P = 0.034). MCF were present beyond the index quadrant (25% of breast volume including the tumour) in as many as 79% (15/19) of breasts that harboured MCF; and in half the cases (15/30) when all breast were considered. This is in variance with the suggestion put forward previously that MCF are contained within the index quadrant in 90% of cases. Although the number of patients in the present series is small, the probability of our finding being due to play of chance is 1 in 1500. In a large series of breast conservation studies > 90% of early breast recurrences have been found to occur in the index quadrant. Our finding, that in half the patients (15/30) MCF are present in quadrants other than the index quadrant, suggests that MCF do not give rise to early breast recurrence.

Prediction of nipple and areola involvement in breast cancer

AIMS To find a pre-operative test for nipple and areola involvement in breast cancer. METHODS Areola-tumour distance was measured in 140 consecutive patients (median age 45, range: 23-83) undergoing a mastectomy. We analysed whether nipple and areola correlated with areola-tumour distance, tumour size, nodal status, perinodal involvement and lymphatic embolization. RESULTS The nipple was involved in 22 (16%) cases and this correlated with tumour size, number of lymph nodes, perinodal extension and presence of lymphatic emboli. In all these 22 cases, the tumour was within 2.5 cm of the areola. Tumour size, however, could not predict nipple involvement in tumours within 2.5 cm of the areolar edge. CONCLUSIONS In the one-fifth of cases where the tumour is over 2.5 cm from the areola, preserving the nipple and areola for reconstruction may be worthwhile. In remaining cases, some other predictive test for nipple involvement would be necessary.

Giant cell tumor of the tendon sheath: A retrospective study of 28 cases

Background and Objectives: Giant cell tumor of the tendon sheath (GCTTS) is a lesion of uncertain etiology. To better interpret pathogenesis and aid in the differentiation of GCTTS from other similar pathological processes we reviewed the literature and analyzed the available information.

Hormone receptors over the last 8 years in a cancer referral center in India: what was and what is?

This study was carried out to observe the trend in hormone receptors over the last 8 years in a tertiary cancer center in India. A total of 11,780 tumors analyzed for hormone receptors over the last 7 years were compared with the results of hormone receptor expression in a prior published study on 798 cases of breast cancer from the same institute. The patients ages ranged from 18 to 102 years, Sixty percent of the patients were in the age group of 31-50 years. Seventy percent of the tumors were grade III tumors. The percentage of hormone receptor expression in breast cancer in the last 8 years varied from 52 to 57%. The overall receptor expression in the last 8 years shifted within a 5% range, confirming that the hormone receptor expression in Indian patients with breast cancer is low. However, there was redistribution within the pattern of estrogen receptor (ER) and progesterone receptor (PR) expression among tumors showing hormone receptor expression. Breast cancers showing only PR expression reduced dramatically from 21% in the year 1999 to in the year 2006, with a parallel increase in breast cancers showing combined ER and PR positivity (from 25 to 41.8%) and only ER expression (from 7.4 to 10.6%). The hormone receptor expression in breast cancers in India is and continues to be low but the high incidence of only PR-positive tumors in our population reported earlier was misrepresented.

Clinicopathological features with outcomes of a series of conventional and proximal-type epithelioid sarcomas, diagnosed over a period of 10 years at a tertiary cancer hospital in India

Epithelioid sarcoma (ES) is an uncommon sarcoma. Lately, its variants, including proximal-type ES, have been recognized. The present study highlights clinicopathological features of 26 (65%) conventional and 14 (35%) cases of proximal-type ES. Thirty-eight percent of cases were seen in 21–30-year age group, including 77.5% cases in men. Extremities were the commonest sites in both the subtypes. Histologically, conventional-type ES displayed nodular tumor aggregates with necrosis, while proximal-type showed solid arrangement of large, “rhabdoid-like” cells. More cases (64.2%) of the proximal type were of grade 3. A range of differential diagnoses was considered. Most important immunohistochemical markers were vimentin, epithelial membrane antigen, cytokeratin, CD34, and desmin. Maximum (72.5%) cases were treated surgically. Recurrences and metastasis were observed more in the proximal type. The 7-year disease-free survival was 19.4% in the conventional and nil in the proximal subtype (p = 0.06). The overall survival rate was also lower in the proximal (31.3%) than conventional type (90.2%; p < 0.001). Other unfavorable parameters were deeper location, larger size, and higher tumor stage. This unusual sarcoma, with characteristic growth patterns, merits a proper histological evaluation, as it has many mimics. Proximal-type ES is rather a morphological subtype, associated with an aggressive course.

Changes in the Tumor Grade and Biological Markers in Locally Advanced Breast Cancer after Chemotherapy – Implications for a Pathologist

Abstract:  There is insurgence of literature evaluating prognostic and predictive factors in breast carcinomas treated with chemotherapy, with a parallel need to develop guidelines for the pathologist interpreting such excisions. Prechemotherapy gun biopsy and postchemotherapy excision specimens from 78 women with locally advanced breast cancer were analyzed for histological changes in the tumor, changes in the tumor grade, hormone receptors, cerb2, and bcl2 and their impact on disease‐free survival (DFS). An unusually prominent granulomatous response to tumor was seen in three cases. The tumor grade changed in five patients, estrogen receptor (ER) expression was altered in 10 cases, progesterone receptor detection changed in 16 cases, cerb2 in one case and bcl2 in 16 cases. Fixation of the gun biopsy in Bouin’s fluid and severe damage of nuclei after chemotherapy were the reasons for shift in the expression of hormone receptors. A low‐grade tumor was associated with better response to chemotherapy. In the Kaplan–Meier analysis the ER expression and a low‐grade tumor (grade I and II) significantly affected DFS. None of the factors evaluated impacted the overall survival of patients. To conclude there is a change in the tumor grade, bcl2, cerb2 and hormone receptors after chemotherapy. A pathologist interpreting specimens of breast cancer after chemotherapy must always record the postchemotherapy grade as it is an indicator of better response to chemotherapy and survival.

Accuracy of concurrent visual and cytology screening in detecting cervical cancer precursors in rural India

The high burden of cervical cancer and inadequate/suboptimal cytology screening in developing countries led to the evaluation of visual screening tests, like visual inspection with acetic acid (VIA) and Lugols iodine (VILI). We describe the performance of VIA, VILI and cytology, carried out in a multinational project called “Screening Technologies to Advance Rapid Testing” in 5,519 women aged 30–49 years, in detecting cervical intraepithelial neoplasia (CIN). VIA, VILI and cytology were positive in 16.9%, 15.6% and 6.1% women, respectively. We found 57 cases of CIN2, 55 of CIN3 and 12 of cervical cancer; 90% of CIN3 and 43% CIN2 cases were positive for p16 overexpression and high‐risk HPV infection, indicating a high validity of histological diagnosis. The sensitivity of VIA, VILI and cytology to detect high‐grade CIN were 64.5%, 64.5% and 67.7%, respectively; specificities were 84.2%, 85.5% and 95.4%. A high proportion of p16 positive CIN 3 (93.8%) and 2 (76.9%) were positive on cytology compared with visual tests (68.8% and 53.8%, respectively) indicating a higher sensitivity of cytology to detect p16 positive high‐grade CIN. However, the immediate availability of the results from the visual tests permits diagnosis and/or treatment to be performed in the same sitting, which can potentially reduce loss to follow‐up when women must be recalled following positive cytology. Organizing visual screening services in low‐resource countries may facilitate the gradual building of an infrastructure committed to screening allowing the eventual introduction of more sensitive, highly objective, reproducible and affordable human papillomavirus screening tests in future.

Utility of the thromboplastin-plasma cell-block technique for fine-needle aspiration and serous effusions

(I) To assess the feasibility of thromboplastin‐plasma (TP) method for cell block, (II) to concentrate the minimal cellular material from effusions and needle‐rinses by block preparation and improve visual details, (III) to compare conventional cytological smears with cell blocks for final assessment, and (IV) to assess utility of immunocytochemistry (ICC) for diagnostic accuracy.

An analysis of 46 static telecytology cases over a period of two years

We analysed 46 telecytology cases sent from two rural hospitals about 500 km from a tertiary cancer centre. The cases were submitted for second opinion over a period of two years and evaluated using a static store and forward telecytology approach. A total of 715 digital images were studied (average 15 per case). Forty-one of the 46 cases (89%) were reported within 3 days and 54% of cases were reported within one working day. The aspiration smears and images were found to be of diagnosable quality in 89 and 93% of the cases, respectively. The diagnostic concordance was assessed by comparing the telecytology diagnosis, glass slide diagnosis and final histopathology diagnosis (when available). A clinically useful diagnosis was rendered in 91% cases with 74% complete concordance. Five out of 46 cases (11%) were deferred for glass slide review. Store and forward telecytology using the Internet is a rapid and effective method of providing expert diagnosis in cytology.

Presence of a Micropapillary Pattern in Mucinous Carcinomas of the Breast and its Impact on the Clinical Behavior

Abstract:  Infiltrating micropapillary carcinomas (IMPC) of breast are highly angioinvasive tumors with poor prognosis. This study is based on the observation that a similar micropapillary pattern is also observed in mucinous carcinomas of breast. About 102 mucinous carcinomas were evaluated for the presence and impact of this micropapillary pattern on the clinical behavior. Of these, 68 were mucinous carcinomas with a micropapillary pattern (MUMPC), 20 had MUMPC mixed with an infiltrating duct carcinoma component, two were solid variants of papillary carcinoma with mucin (SVPCMU), five had collision of the MUMPC and SVPCMU patterns and seven were mucinous carcinomas with signet ring cells (MUS). The factors negatively affecting overall survival (OAS) and disease‐free survival (DFS) included the histological type of mucinous carcinoma, nodal metastases, an irregular tumor border, <50% mucin and an IMPC type of local recurrence or metastases. In the multivariate analysis, the histologic type of mucinous carcinoma and an irregular tumor border were most significant for OAS and DFS. Thus, 86% of mucinous carcinomas in this study were mucinous variants of the angioinvasive infiltrating micropapillary carcinomas. These tumors can produce IMPC type of metastases and thus should be treated aggressively.