Tanja Leniček

Primary ovarian leiomyoma associated with endometriotic cyst presenting with symptoms of acute appendicitis: a case report

BackgroundOvarian leiomyoma is a rare benign tumor that accounts for 0.5 to 1% of all benign ovarian tumors. It probably arises from smooth muscle cells in the ovarian hilar blood vessels but there are other possible origins including cells in the ovarian ligament, smooth muscle cells or multipotential cells in the ovarian stroma, undifferentiated germ cells, or cortical smooth muscle metaplasia. Additionally, smooth muscle metaplasia of endometriotic stroma, smooth muscle present in mature cystic teratomas, and smooth muscle in the walls of mucinous cystic tumor may explain their occurrence in the ovary in some cases.Case presentationA 31-year-old woman was admitted to our surgical emergency service with a one-day history of appendicitis-like symptoms. Upon laparotomy, there was a solid, oval left-sided ovarian tumor located behind the uterus. The tumor was sent to the pathology department. A diagnosis of primary ovarian leiomyoma associated with an endometriotic cyst was established.ConclusionThe origin of ovarian leiomyoma is still unresolved. In our case, the tumor probably arose from smooth muscle cells derived from myofibroblasts that originate from metaplastic ovarian stromal cells present in the rim of the endometriotic cyst. Despite its rarity, ovarian leiomyoma should be considered in the differential diagnosis of ovarian spindle cell tumors. Appropriate diagnosis may require additional immunohistochemical analysis in some cases.

Expression of growth hormone receptor, plakoglobin and NEDD9 protein in association with tumour progression and metastasis in human breast cancer

Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer-related deaths among female population worldwide. Metastases are the common cause of morbidity and mortality in breast cancer and can remain latent for several years after surgical removal of the primary tumour. Thus, the identification and functional characterisation of molecular factors that promote oncogenic signalling in mammary tumour development and progression could provide new entry points for designing targeted therapeutic strategies for metastatic breast cancer. In the present study, we investigated the expression of proteins involved in cell signalling (growth hormone receptor (GHR) and NEDD9) and cell-cell adhesion (plakoglobin) in epithelial and stromal compartments of primary ductal invasive breast carcinomas and their axillary lymph node metastases versus non-metastatic tumours. Obtained data revealed remarkable increase in the expression levels of GHR and NEDD9 proteins in both epithelial and stromal components of axillary lymph node metastases in comparison with those of non-metastatic tumours, suggesting that the expression of these two proteins may provide biomarkers for tumour aggressiveness.

CD138-positive plasmacytoid urothelial carcinoma of urinary bladder with focal micropapillary features

Both the plasmacytoid and micropapillary types of urothelial carcinoma of the urinary bladder are uncommon, distinct clinical and pathological findings. To date, several reports in the English medical literature have been published on either of these variants. CD138 is commonly used as a marker for tumors of plasma cell origin. However, few authors have described positive immunoreactivity of plasmacytoid cells in urothelial carcinoma. Mixed histological differentiation is thought to be a phenotype of locally aggressive and advanced urothelial carcinoma. Therefore, a precise histopathological diagnosis should be made and awareness of all the entities is crucial. We report a case of CD138-positive plasmacytoid urothelial carcinoma of the bladder with focal micropapillary features. To our knowledge this is the first case of these two rare subtypes of urothelial carcinoma combined in a single cystectomy specimen.

Pleomorphic ductal carcinoma of the breast with predominant micropapillary features

An 83‐year‐old woman with long‐standing chronic ischemic cardiac and obstructive pulmonary disease, presented with a painless tumor in her right breast. Microscopically the tumor consisted of micropapillary formations and loosely cohesive nests and strands of large, highly pleomorphic cells. Micropapillary formations were surrounded by peritumoral retraction clefting, and the papillae lacked a true fibrovascular core. Multinucleated giant and bizarre tumor cells were also present and numerous. Within the tumor a high‐grade intraductal component with the same cell morphology and necrosis and mucin production was found. Micropapillary pattern occupied approximately 60% of the tumor mass, loosely cohesive nests and strands approximately 20% and an intraductal component was noted in approximately 20% of the tumor mass. On immunohistochemistry the tumor cells were positive for pan‐cytokeratin, epithelial membrane antigen (EMA), S100 protein and E‐cadherin while estrogen and progesterone receptors, HER2‐neu and Bcl2 were negative. EMA staining was diffuse and observed in the outer and inner margins of neoplastic nests. The diagnosis of pleomorphic breast carcinoma with predominant micropapillary features was established. In summary, micropapillary carcinoma can be distinguished from other types of breast carcinoma with micropapillary growth pattern on the basis of reverse cell polarity, which is easily confirmed on immunohistochemistry.

Peritumoral Retraction Clefting Correlates with Advanced Stage Squamous Cell Carcinoma of the Esophagus

The present study was designated to analyze correlation between the presence and extent of peritumoral retraction clefting and various clinicopathologic features in esophageal squamous cell carcinoma (ESCC), and to possibly establish the significance of this phenomenon in ESCC. Fifty-four consecutive patients with advanced ESCC were included in the study. The presence of peritumoral retraction clefting was classified on the basis of the proportion of tumor nests exhibiting this phenomenon. Tumors with clefts that affected up to 25% of tumor nests were classified as group I; with clefts that affected >25% to 50% of tumor nests as group II; with clefts that affected >50% to 75% of tumor nests as group III; and tumors with clefts that affected more than 75% of tumor nests were classified as group IV. Statistical analysis showed a correlation between presence and extent of peritumoral clefting and lymph node metastasis. T3 tumors and tumors with lymph node metastasis had significantly more pronounced peritumoral clefting compared with T2 tumors and tumors without lymph node metastasis. The presence of peritumoral clefting was not associated with the number of affected lymph nodes. There was no correlation between the presence and extent of peritumoral clefting with patient age and sex, and tumor location, diameter and grade. The association of peritumoral retraction clefting in ESCC with local invasiveness and lymph node metastasis indicated that peritumoral clefting could be a simple and useful morphological feature of tumor aggressiveness and may contribute to the pathological and clinical assessment of patients with ESCC.

Primary osteosarcoma of bladder diverticulum mimicking intradiverticular calculus: a case report

There is a well-documented relationship between urinary bladder diverticula and intradiverticular neoplasms. The great majorities of these tumors are urothelial carcinomas, but may also be of glandular or squamous type. Sarcomas occurring within bladder diverticula are exceptionally rare and highly malignant lesions, with only 20 well documented cases published in the literature to date (including carcinosarcomas). We report a case of osteosarcoma of the bladder diverticulum in a 68-year old man, which clinically mimicked intradiverticular calculus. To our knowledge, this is the second case described in the literature to date, and the first in English literature.Virtual SlidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/5205089355246060.

Periacinar retraction clefting and d2-40 expression in prostatic adenocarcinoma.

Retraction clefting is known to appear in various types of tumors, but it has only recently been recognized as a specific histological phenomenon. Previously, it was considered merely a laboratory procedure artifact, but lately, there have been some assumptions that peritumoral retractions actually represent lymphatic spaces. In our study, we analyzed neoplastic glands in 52 specimens of prostatic adenocarcinoma. Immunohistochemical analysis was performed using D2-40 antibody, to highlight lymphatic endothelium and thereby differentiate actual lymph vessels or lymphovascular invasion from periacinar retractions. Our results showed that the number of lymph vessels was significantly lower in tumorous tissue compared to adjacent normal prostatic tissue. On the other hand, the number of lymph vessels in tumorous tissue was significantly higher than the number of lymph vessels mimicking periacinar retractions. Overall, the number of lymph vessels mimicking periacinar clefts was particularly low. These results are in accordance with our previous studies, which had shown that periacinar clefting appears due to lack of basal cells and stromal changes around tumorous acini. Also, these results support our hypothesis that retractions do not represent lymph vessels but should be considered a distinct entity, which is proven to be helpful both as diagnostic and predictive factor.

Intrarenal ectopic adrenal tissue associated with renal angiomyolipoma.

To the Editor: Developmental anomalies of the adrenals are divided into three groups: true adrenal heteropias, adrenal–renal fusion and ectopic adrenal tissue. The latter has been reported in multiple anatomical sites. Intrarenal location has mostly been described as an incidental finding in autopsy or surgical specimens. Even though the clinical significance of this location is usually minimal, in certain situations it appears interesting enough to be described in view of the encountered diagnostic difficulties. We report a case of ectopic adrenocortical tissue that was incidentally discovered during surgical removal of a benign renal tumor. A 46-year-old female patient underwent a routine medical check-up. Her previous personal and family history was non-contributory and she had no complaints. An abdominal ultrasound revealed a mass on the right upper pole of the right kidney. An abdominal CT scan revealed a contrast enhancing, well defined, heterogeneous mass measuring 2.0 ¥ 1.5 cm, originating from the right upper pole with cystic and solid areas. There was no evidence of renal vein or caval thrombus or embolus. A partial nephrectomy was performed. Surgical specimen revealed a cortical, encapsulated, dark red tumor with gray and yellow–white areas measuring 2.0 ¥ 1.5 ¥ 0.8 cm, which was resolved as angiomyolipoma (AML) on frozen section. On microscopic examination, the tumor was composed of islands of mature lipid cells, tortuous thick-walled blood vessels without elastic lamina, bundles of smooth muscle and perivascular epithelioid cells (Fig. 1a). On immunohistochemistry (all antibodies from Dako; Copenhagen, Denmark) tumor cells were positive for HMB-45 (dilution 1:75), SMA (dilution 1:100) and melan-A (dilution 1:75) (Fig. 1b–d). Underneath the AML, in the cortical part of the kidney, a small area consisting of large clear cells with distinct membranes arranged in cords, with numerous small lipid vacuoles in the cytoplasm and small round nuclei without nucleoli resembling zona fasciculata cells, was found (Fig. 2a). Renal tubules were entrapped between the cells. There was no mitotic activity. Immunohistochemistry for cytokeratins (AE1/3, dilution 1:50), CD10 (dilution 1:80) and epithelial membrane antigen (EMA, dilution 1:100) were negative in this area, but some cells were positive for inhibin (dilution 1:50) and calretinin (dilution 1:100), which confirmed the adrenal origin (Fig. 2b–d). The postoperative course was uneventful and the patient was discharged a few days later. Ectopic adrenal tissue was first reported by Morgagni in 1740, when he described yellowish nodules adjacent to the main adrenal gland. Since then, this phenomenon has been reported in various locations, most commonly related to the kidney, pelvic structures such as the spermatic cord and in structures around the testis. They are thought to occur in almost 50% of newborns, but usually atrophy and vanish within a few years. Morphologically, ectopic adrenal tissue situated further away from the adrenal gland is, in most cases, composed of a varying number of, or all three of, the adrenal cortical layers. Those that are closer to the gland can include medullary tissue as well. In our case, only cells from the zona fasciculata were found in the renal cortex. Between these cells, a few entrapped renal tubules were noted. Clinical significance of ectopic adrenal tissue in the kidney is usually minimal. However, at intraoperative frozen section, a histological differential diagnosis with clear cell renal cell carcinoma (RCC) can be difficult. Normal corticoadrenal spongiocytes can be mistaken for the clear cells of RCC, Fuhrman nuclear grade 1. The correct diagnosis is then usually made on the permanent paraffin sections of the nephrectomy specimen. Several authors have reported yellowish nodules that were initially assumed to be RCC. In our patient, partial nephrectomy was performed because of the well circumscribed AML. The small focus of adrenocortical tissue was incidentally found on the nephrectomy specimen. The distinction of clear-cell RCC from normal adrenal tissue was resolved by histological and immunohistochemical findings that were also reported by other authors. To the best of our knowledge, this is the first case of renal AML and ectopic intrarenal adrenal tissue published in the written English literature. So far, the relationship between those two entities is not explained. It is known that the adrenal cortex develops from mesoderm as well as mesenchymal tissues. We can speculate that the same factors that induce development of AML can cause the development of ectopic adrenal cortex from pluripotent stem cells. Conversely, intrarenal adrenal tissue can be a coincidental finding with an AML. In conclusion, ectopic adrenal tissue is a rare finding with distinct morphologic features. Together with immunohistochemical analysis, the right diagnosis can be made. The possibility of making a mistake and diagnosing it as a neoplasm should be excluded. Pathology International 2011; 61: 778–780 doi:10.1111/j.1440-1827.2011.02724.x

The Fetal Human Testis

At our pathology department, all spontaneously aborted fetuses are routinely autopsied and analyzed. During fetal autopsy, the position of the testes is assessed and noted, and both testes are taken for routine histopathologic analysis. They are fixed in 10 % buffered formalin, embedded in paraffin and routinely processed, cut in 5-μm sections, and stained with hematoxylin and eosin (H&E). If the microscopic features are within the normal limits for gestational age, the microscopic appearance is not described in detail in the autopsy report. If there is any deviation from the appearance expected for gestational age, it is described in detail. Although immunohistochemical (IHC) analysis is not done routinely, for the purpose of this chapter and for a better understanding of fetal development, certain markers were used (see the figures).