Shabnam Jaffer

Lobular neoplasia on core needle biopsy does not require excision

Lobular neoplasia (LN), encompassing atypical lobular hyperplasia (ALH) and lobular carcinoma in situ (LCIS), is often an incidental finding on core needle biopsies (CNBs) performed in instances of radiologic densities and/or calcifications. Because LN is generally considered a risk factor for breast carcinoma, the utility of subsequent excision is controversial.

Predictors of nonsentinel lymph node metastasis in breast cancer patients

BACKGROUND In order to define a future subset of breast cancer patients in whom the axilla may be staged by sentinel lymph node biopsy alone, the conditions under which nonsentinel axillary lymph node metastases occur must be delineated. METHODS A prospective database including 212 breast cancer patients who underwent sentinel lymph node biopsy followed by completion axillary dissection at our institution was reviewed. A multivariate, logistic, stepwise regression was performed to evaluate the relationship between nonsentinel lymph node metastasis and patient age, primary tumor size, presence of lymphatic invasion, use of radioisotope to identify the sentinel node and degree of metastasis in the sentinel node. RESULTS Tumor size greater than 2 cm, lymphatic invasion of the primary tumor, macrometastasis in the sentinel node, and use of radioisotope all positively correlated independently with metastasis in the nonsentinel lymph node (P = 0.0001, P = 0.0483, P = 0.0008, P = 0.0271, respectively). CONCLUSIONS Predictors of nonsentinel axillary node metastasis exist and are important in defining those patients in whom a sentinel lymph node biopsy alone may not be adequate.

Epithelial Displacement in Breast Lesions: A Papillary Phenomenon

CONTEXT Displacement of epithelial cells (DE) in the breast may occur after various types of needling procedures. OBJECTIVE To determine if specific lesions or entities in the breast are more prone to displacement than others. DESIGN A review of our computer files from January 1994 to June 2004 yielded 53 cases with DE. Clinical information, including the age of the patient, specific reason for the biopsy, and type of biopsy, was gathered. Histologic review of all hematoxylin-eosin-stained slides (core biopsies and excisions) was performed. RESULTS Needling procedures included 1 or more of the following: ultrasound-guided core biopsy (24 cases), mammotome core biopsies (16), fine-needle aspiration (8), anesthetic injection (3), suture placement (5), and wire localization (1). Procedures were performed in order to investigate a mass (34 cases), calcifications (15), both (3), or nipple discharge (1). The time from needling to surgical procedure yielding a specimen with DE ranged from minutes to 47 days. Displacement of epithelial cells occurred in the following sites: biopsy tract (42 cases), lymphatic channels (5), both biopsy tract and lymphatic channels (4), and breast stroma (2). The diagnoses included intraductal papilloma (6 cases) and intraductal carcinoma (DCIS) (45; 15 with invasive carcinoma). The remaining 2 cases were invasive carcinoma (colloid and papillary types) devoid of DCIS. Of the DCIS cases, either pure or with invasive carcinoma, the pattern was micropapillary in 23, intraductal papilloma involved by DCIS in 32, and both features in 12. The remaining 2 cases of DCIS included comedo DCIS and cribriform DCIS involving a cyst. CONCLUSIONS With the exception of 3 cases, DE was associated with 1 or more underlying papillary lesions, including pure intraductal papilloma, DCIS involving intraductal papilloma, micropapillary DCIS, and invasive carcinoma. Other etiologies included mucinous carcinoma and cystic lesions, with only 1 case in which a mechanism for DE could not be postulated.

Excision is indicated for intraductal papilloma of the breast diagnosed on core needle biopsy

Although it has been accepted that intraductal papillomas with atypia or malignancy diagnosed on core needle biopsy require surgical excision, the management of pure intraductal papillomas has been controversial. Because some series reported a small but definite incidence of atypia or malignancy, whereas others claimed that radiologic follow‐up was adequate, this study evaluated results of excision of all pure intraductal papillomas diagnosed on core needle biopsy at this institution.

N-cadherin Expression in Breast Cancer: Correlation with an Aggressive Histologic Variant – Invasive Micropapillary Carcinoma

SummaryUpregulation of N-cadherin in epithelial tumor cells has been shown to contribute to the invasive/metastatic phenotype. It remains however to be determined whether N-cadherin is increased in human breast cancers with enhanced malignant potential. We examined a large number of invasive breast cancer specimens (n=114) for N- and E-cadherin. These specimens compared invasive duct carcinomas (IDCs) of varying histologic grades with an aggressive subtype, invasive micropapillary carcinoma of the breast (MPAP), which has a high propensity for lymphatic invasion and lymph node metastasis. Staining scores for N- and E-cadherin were compared between non-MPAP and MPAP IDCs, and between the invasive and ductal carcinoma in situ (DCIS) of each IDC using statistical analysis. We found that N-cadherin was expressed in 76% of MPAP and 52% of non-MPAP carcinomas, and E-cadherin in 57% of MPAP and 36% of non-MPAP tumors. More MPAP (25%) compared to non-MPAP (5%) tumors expressed both cadherins. Of the two cadherins, N-cadherin was significantly associated with MPAP tumors (p=0.033) compared to E-cad (p=0.171). Moreover, in the majority of tumors that were positive for N-cadherin, the staining scores were increased in the IDC relative to intraductal components, and this effect was more dramatic in the MPAP carcinomas. This difference for N-cadherin was greater than the corresponding difference for E-cadherin in the MPAP group (p=0.005), whereas such changes were not significant in the non-MPAP group (p=0.10). Thus, N-cadherin is associated with tumor aggressiveness and metastatic potential and may contribute to tumor progression.

Upgrade of high-risk breast lesions detected on mammography in the Breast Cancer Surveillance Consortium

BACKGROUND Upgrade rates of high-risk breast lesions after screening mammography were examined. METHODS The Breast Cancer Surveillance Consortium registry was used to identify all Breast Imaging Reporting and Data System category 4 assessments followed by needle biopsies with high-risk lesions. Follow-up was performed for all women. RESULTS High-risk lesions were found in 957 needle biopsies, with excision documented in 53%. Most (n = 685) were atypical ductal hyperplasia (ADH), 173 were lobular neoplasia, and 99 were papillary lesions. Upgrade to cancer varied with type of lesion (18% in ADH, 10% in lobular neoplasia, and 2% in papillary lesions). In premenopausal women with ADH, upgrade was associated with family history. Cancers associated with ADH were mostly (82%) ductal carcinoma in situ, and those associated with lobular neoplasia were mostly (56%) invasive. During a further 2 years of follow-up, cancer was documented in 1% of women with follow-up surgery and in 3% with no surgery. CONCLUSIONS Despite low rates of surgery, low rates of cancer were documented during follow-up. Benign papillary lesions diagnosed on Breast Imaging Reporting and Data System category 4 mammograms among asymptomatic women do not justify surgical excision.

Incidental intraductal papillomas (<2 mm) of the breast diagnosed on needle core biopsy do not need to be excised.

Most authors recommend excision of intraductal papillomas diagnosed on core needle biopsy. This leads to the question of whether or not excision is necessary for incidental intraductal papillomas on core needle biopsy as opposed to those corresponding to imaging findings. Using the pathology computerized data base we retrospectively identified 46 incidental intraductal papillomas diagnosed on core needle biopsy from 1/2000 to 12/2008. Clinical, radiologic, and pathologic information was gathered and correlated. All core needle biopsies were reviewed to confirm the diagnosis of incidental intraductal papillomas, and excision specimens reviewed when available. Of the 46 patients, follow‐up information was available in only 38. The age of the patients ranged from 39 to 82 years (mean = 48 years). Most incidental intraductal papillomas were diagnosed by mammotome core needle biopsy (36 cases). A total of 33 cases were performed for calcifications with the following indications: clustered = 21, new = 4, pleomorphic = 3, increasing = 3, indeterminant = 2. The correlating diagnoses included the following: fibrocystic changes with calcium phosphate = 18 or calcium oxalate = 10, fibroadenoma with calcifications = 5. The three masses were: two cases of cystic papillary apocrine metaplasia (I Ultrasound and 1 MRI) and 1 fibroadenoma (Ultrasound). In all cases, the intraductal papillomas were ≤0.2 cm, were not associated with calcifications, and were incidental to them or the underlying mass. A total of 14 patients underwent excision, whereas the remaining 24 have remained radiologically stable for over 12 months. The excision specimen findings were: fibrocystic changes = 8 and intraductal papilloma = 6. With the exception of one case, all the intraductal papilloma remained incidental to imaging findings. In this solitary case, the calcifications were described as pleomorphic and corresponded to fibrocystic changes calcifications on core needle biopsy. However, on excision, residual pleomorphic calcifications on mammogram correlated with both fibrocystic changes and intraductal papilloma. No cases were upstaged on excision to atypical duct hyperplasia or intraductal or invasive carcinoma. With the exception of one case, all incidental intraductal papillomas diagnosed on core needle biopsy were either completely excised or remained incidental. The exception occurred due to sampling error and accounted for the change from an incidental intraductal papillomas on core needle biopsy to one that was associated with calcifications on excision. Given the complete lack of upstaging, it is difficult to recommend excision of incidental intraductal papillomas diagnosed on core needle biopsy provided the index lesion has been adequately sampled and radiologic follow‐up is maintained.

Imprint cytology of metastatic sialoblastoma. A case report.

BACKGROUND Sialoblastoma is a rare, aggressive and potentially malignant perinatal/congenital tumor that recapitulates the developing salivary gland. There is only 1 brief description of the cytologic findings of metastatic sialoblastoma and 1 poorly documented case of lung metastasis in the literature. CASE A 75-month-old girl with a history of recurrent sialoblastoma initially diagnosed at 21 months and treated with multiple incomplete surgical excisions, chemotherapy and radiation presented with a solitary lung nodule. Imprint smears and frozen section of the mass were diagnostic of metastatic sialoblastoma. CONCLUSION Cytologic features of sialoblastoma showed complete concordance with histology and included the presence of variably arranged, tight, solid clusters of atypical-appearing, basaloidlike cells in a background of dispersed epithelial and myoepithelial cells. The clusters contained admixed benign ductal cells and dense, metachromatic, magenta hyaline globular material with smooth, rounded outlines. The differential diagnoses include neoplasms composed of either basaloid cells and/or admixed hyaline matrix material and included pleomorphic adenoma, basal cell adenoma and adenoid cystic carcinoma. All these neoplasms affect patients in the first 2 years of life, whereas sialoblastoma usually occurs in the first 2 decades of life.

Mesenteric paraganglioma: a case report and review of the literature.

Approximately 5% to 10% of paragangliomas occur in extra-adrenal sites, which can extend from the upper cervical region to the pelvis, parallel to the autonomic nervous system. This distribution corresponds to the embryologic development of the paraganglia from neural crest cells. Rarely, extra-adrenal paragangliomas can also occur aberrantly outside this distribution. We report such a case of extra-adrenal paraganglioma occurring in the anterior mesentery in a 76-year-old man. Two case reports exist in the literature describing extra-adrenal paragangliomas in the posterior mesentery. Normal paraganglionic tissue has been described at the roots of the superior and inferior mesenteric arteries, theoretically explaining the origin of the posterior mesenteric paragangliomas. Our case can best be attributed to the ventral migration of paraganglionic tissue through these vessels to reach the anterior mesentery, where they could potentially give rise to paragangliomas in this site.

gC1qR Expression in Normal and Pathologic Human Tissues Differential Expression in Tissues of Epithelial and Mesenchymal Origin

The gC1qR (i.e., gC1q receptor, gC1q binding protein, p32, p33) is a multifunctional cellular protein that interacts with components of the complement, kinin, and coagulation cascades and select microbial pathogens. Enhanced gC1qR expression has been reported in adenocarcinomas arising in a variety of organs. The present study compared gC1qR expression in normal, inflammatory, dysplastic, and malignant tissue of epithelial and mesenchymal origin. gC1qR expression was visualized in tissue sections by immunohistochemistry using the 60.11 monoclonal antibody (i.e., IgG1 mouse monoclonal antibody directed against gC1qR) and the UltraVision LP Detection System. Sections were counterstained with hematoxylin and examined by light microscopy. Strongest gC1qR expression was noted in epithelial tumors of breast, prostate, liver, lung, and colon, as well as in squamous and basal cell carcinoma of the skin. However, increased gC1qR staining was appreciated also in inflammatory and proliferative lesions of the same cell types, as well as in normal continuously dividing cells. In contrast, tumors of mesenchymal origin generally stained weakly, with the exception of osteoblasts, which stained in both benign and malignant tissues. The data suggest that increased gC1qR expression may be a marker of benign and pathologic cell proliferation, particularly in cells of epithelial origin, with potential diagnostic and therapeutic applications.