February 2006
Interobserver Reproducibility in the
Diagnosis of Flat Epithelial Atypia of the Breast
O'malley FP, Mohsin SK, Badve S, Bose et al.
Columnar cell lesions (CCLs) of the
breast with low-grade/monomorphic-type cytologic atypia are being identified
increasingly in biopsies performed owing to mammographic microcalcifications.
The WHO Working Group on the Pathology and Genetics of Tumours of the Breast
recently introduced the term 'flat epithelial atypia' (FEA) for these lesions.
However, the ability of pathologists to reproducibly diagnose FEA and to
distinguish it from CCLs without atypia has not been previously evaluated.
Eight pathologists with an interest in breast pathology participated in a study
to address this issue. The study reference pathologist provided the other seven
study pathologists with a Powerpoint tutorial that included written criteria
for, and representative images of, FEA and CCLs without atypia (ie, columnar
cell change and columnar cell hyperplasia). Following review of the tutorial,
the study pathologists examined images in Powerpoint format from 30 CCLs and
were instructed to categorize each as either 'FEA' or 'not atypical'. Overall
agreement among the eight pathologists was 91.8% (95% CI, 84.0-96.9%), and the
multi-rater kappa value was 0.83 (95% CI, 0.67-0.94), which is within the
'excellent agreement' range. Agreement was slightly better for determining
absence of FEA (92.8%: 95% CI, 84.1-97.4%), than for determining its presence
(90.4%: 95% CI, 79.9-96.7%). Authors conclude that the diagnosis of FEA and its
distinction from CCLs without atypia is highly reproducible with the use of
available diagnostic criteria.
Modern Pathology, Feb. 2006, 19(2), 172-179.
Atypical Reactive Proliferation of Endocervix:
A Common Lesion Associated with Endometrial Carcinoma and Likely Related to
Prior Endometrial Sampling
Scott M, Lyness RW, McCluggage WG.
Authors describe a common, but hitherto not well described, reactive change of
the endocervical surface epithelium, commonly seen in association with
endometrial carcinoma, and which we term 'atypical reactive proliferation'.
This lesion, especially when florid, has the potential to be misinterpreted as
a manifestation of a stage 2A endometrial cancer (endocervical glandular
involvement). Authors examined the cervical sections in 80 consecutive
hysterectomy specimens of endometrial cancer. In 22 cases (27.5%), there was
cervical involvement by tumour and these cases were excluded from further
analysis. Of the remaining cases, atypical reactive proliferation involved the endocervical
surface in 40 of 58 (69%) cases, although the degree of abnormality varied
widely between individual cases. Histological features characteristic of
atypical reactive proliferation (not all features were present in each case)
included nuclear stratification and multilayering with short micropapillary
processes, squamoid change, hobnail cells and mild cytological atypia. Other
features present in some cases were surface erosion, clearing of the cytoplasm,
fibrin deposition, an inflammatory cell infiltrate and fibrosis of the subepithelial
tissue. In 20 control cases, comprising hysterectomy specimens for benign
conditions, similar changes were not seen. Vimentin immunohistochemistry was
undertaken in eight cases in which atypical reactive proliferation was
particularly florid. Five cases were completely negative and three exhibited
very focal positivity. Atypical reactive proliferation involving the endocervical
surface is commonly seen in association with endometrial cancer and has the
potential to be misinterpreted as endocervical involvement by tumour. Although
this could represent a reactive change associated with the presence of an
endometrial cancer, we feel atypical reactive proliferation is most likely a
reactive/reparative response to recent endometrial biopsy or curettage. The vimentin-negative
immunophenotype may be of value in cases where the uterine carcinoma is endometrioid
in type as these neoplasms are generally vimentin positive.
Modern Pathology advance online publication, 27 January 2006; doi:10.1038/modpathol.3800556.
Usefulness of Touch Preparation Cytology in Postmortem Diagnosis: A Study from The University Hospital of The West Indies
Shirley, Suzanne E., Escoffery, CaRlos T.
Touch preparation or imprint cytology has been shown to be of value in the diagnosis of surgical pathology specimens and a few studies have also suggested a role in postmortem examination. The use of the technique in postmortem diagnosis has not been previously reported from a developing country. We prospectively examined 40 autopsy cases (M:F ratio 1.2:1, mean age 50.7 +/- 22.3 years) at the University Hospital of the West Indies with touch preparation cytology in addition to routine histology. A total of 120 specimens were obtained from a wide range of organs with the cytologic diagnosis being malignant in most cases (75 %); the overall concordance between cytologic and histologic diagnoses was 92.2%. Touch preparation cytology proved to be an accurate, simple, fast and relatively inexpensive method of postmortem diagnosis, and is likely to be of particular value in areas where cost-containment is critical.
The Internet Journal of Pathology, 2005, Volume 3 Number 2
The Value of Immunohistochemistry as a Diagnostic Aid in Ovarian Neoplasia: A Review
Recently, immunohistochemistry has come to the fore as a diagnostic aid in gynecological pathology. In this review, the value of markers in the diagnosis of ovarian neoplasia is reviewed with an emphasis on recent advances. Topics covered include the distinction between a primary and secondary ovarian adenocarcinoma and the categories of ovarian sex cord–stromal neoplasms and small round cell tumors. Markers of value in the distinction between ovarian serous carcinoma and uterine serous carcinoma and in typing of an ovarian carcinoma are also discussed. The use of immunohistochemistry in distinguishing between an epithelial and a mesothelial proliferation is reviewed. Finally, antibodies of value in the diagnosis of female adnexal tumor of Wolffian origin and ovarian germ cell tumors are covered.
In the last decade, there has been an explosion of interest regarding the value of immunohistochemistry as a diagnostic aid in gynecological pathology, most of the literature relating to gynecological neoplasms. In this review, the value of immunohistochemical markers in the diagnosis of ovarian neoplasms is discussed. There have been some significant recent advances in this field, such as the advent of differential cytokeratin (CK) staining and other markers, which assist in the distinction between a primary and secondary ovarian adenocarcinoma and the development of markers of ovarian sex cord–stromal tumors. It is stressed that immunohistochemistry should always be used as an adjunct to morphology and that no antibody is totally specific or sensitive for a given neoplasm. In general, panels of antibodies should be employed when immunohistochemistry is used to distinguish between various neoplasms in the differential diagnosis.
DISTINCTION BETWEEN PRIMARY AND SECONDARY OVARIAN ADENOCARCINOMA
The ovary is a common site for a metastatic tumor. The most common secondary neoplasm to involve the ovary is colorectal adenocarcinoma. Presentation may be with an ovarian mass in the absence of a known primary, and the primary neoplasm within the colorectum may not manifest itself for some time. In general, metastatic colorectal adenocarcinomas within the ovary mimic primary ovarian endometrioid or mucinous adenocarcinomas. Especially with a metastatic adenocarcinoma with mucinous features (including metastatic mucinous carcinomas from other organs such as the pancreas, appendix, biliary tree, and endocervix), extremely bland foci may be present such that these may be misinterpreted as preexisting areas of benign and borderline mucinous tumor, suggesting an ovarian primary. Indeed, on occasions the whole tumor may be bland, mimicking a primary ovarian mucinous borderline tumor or even a mucinous cystadenoma.
In the distinction between a primary ovarian endometrioid adenocarcinoma and a metastatic colorectal adenocarcinoma with an endometrioid appearance, immunohistochemistry is extremely useful. Primary ovarian endometrioid adenocarcinomas are almost always diffusely positive for CK7 and CA125 and negative for CK20 and carcinoembryonic antigen (CEA). The converse immunophenotype is the rule with a metastatic colorectal adenocarcinoma with an endometrioid appearance, ie, diffuse positivity for CK20 and CEA and negative staining for CK7 and CA125. The situation is more complicated with a metastatic colorectal adenocarcinoma mimicking a primary ovarian mucinous tumor. This is because primary ovarian mucinous adenocarcinomas often exhibit intestinal differentiation and may be positive for CK20 and CEA. Conversely, some mucinous colorectal adenocarcinomas may exhibit CK7 positivity. Although many exceptions occur, primary ovarian mucinous neoplasms are usually diffusely positive with CK7 and negative or focally positive with CK20, while metastatic colorectal adenocarcinomas with a mucinous appearance usually exhibit diffuse CK20 and focal CK7 positivity. However, in general, differential CK staining is less useful than in cases with an endometrioid appearance.
Other markers are of value in the distinction between a primary ovarian carcinoma and a metastatic colorectal adenocarcinoma. In general, as with differential CK staining, these are of more value in a neoplasm exhibiting an endometrioid appearance since primary ovarian mucinous adenocarcinomas not uncommonly express markers of intestinal differentiation. Markers that may be of use include CDX2, villin and [beta] catenin. These are more likely to be positive in metastatic colorectal adenocarcinomas than in primary ovarian adenocarcinomas. CDX2 and [beta] catenin staining should be nuclear to be of diagnostic value. Membranous positivity with [beta] catenin is the norm in epithelial cells, benign and malignant. Some ovarian endometrioid adenocarcinomas exhibit nuclear [beta] catenin positivity since these may be associated with mutation in the [beta] catenin gene, similar to colorectal adenocarcinomas.
Differential CK staining (along with molecular studies) has shed light on the origin of pseudomyxoma peritonei (PMP) in women with coexistent ovarian and appendiceal mucinous neoplasms. In most cases of PMP, the appendiceal (or more rarely colorectal) neoplasm, the omental and peritoneal disease, and the ovarian mucinous neoplasm are diffusely positive with CK7 and negative or focally positive with CK20. This suggests that in almost all cases, the appendix is the origin of PMP and the ovarian disease represents secondary implantation.
Metastatic pancreatic adenocarcinoma in the ovary may closely mimic a primary ovarian mucinous neoplasm, even of benign or borderline type. In general, differential CK staining is of little value in this diagnostic scenario since both pancreatic and ovarian mucinous neoplasms are most commonly CK7 positive and CK20 negative or focally positive. Markers such as mesothelin, fascin, and CA 19.9 may be of value in that they are more likely to be positive in a primary pancreatic adenocarcinoma than an ovarian mucinous neoplasm. However, there is significant immunohistochemical overlap. An absence of Dpc4 staining may be of value. Primary ovarian mucinous neoplasms are usually positive with this marker, while approximately 50% of pancreatic adenocarcinomas exhibit loss of expression due to mutation in the gene that encodes for this protein. Thus, negative staining assists in confirming a primary pancreatic adenocarcinoma.
A panel of markers assists in distinguishing between a primary ovarian clear cell carcinoma and a metastatic clear cell carcinoma within the ovary, most commonly from the kidney. RCC marker and CD10 are usually positive in metastatic renal clear cell carcinoma, while CK7, CK20, and 34[beta]E12 are generally negative. Primary ovarian clear cell carcinoma usually exhibits CK7 and 34[beta]E12 positivity, while CK20, RCC marker, and CD10 are usually negative, although CD10 may be positive in some cases. Rare colorectal adenocarcinomas metastatic to the ovary exhibit a clear cell appearance. The panel of antibodies discussed previously which is of value in distinguishing between a primary ovarian endometrioid adenocarcinoma and a metastatic colorectal adenocarcinoma is also of value here.
Metastatic endocervical adenocarcinomas in the ovary may closely mimic a primary ovarian mucinous or endometrioid neoplasm. p16 Staining may assist in this regard. Metastatic endocervical adenocarcinoma usually exhibits diffuse p16 staining, which in these neoplasms is a surrogate marker of the presence of high-risk human papillomavirus (HPV). Most primary ovarian mucinous and endometrioid neoplasms would be expected to be negative, although this has not been well studied. Molecular methods, such as in situ hybridization, to detect HPV may also be of value.
Other markers which may be of value in the distinction between a primary ovarian neoplasm and a secondary tumor include TTF1 (positive in some metastatic lung carcinomas), gross cystic disease fluid protein-15 (GCDFP15) (positive in metastatic breast carcinoma), and uroplakin III (positive in metastatic urinary transitional cell carcinoma). It is stressed that a CK7 positive/CK20 negative immunophenotype is not specific for an ovarian primary. Mesotheliomas exhibit this pattern of differential CK staining, as do many primary adenocarcinomas of the cervix, uterus, stomach, breast, lung, pancreas, and biliary tree. The main value of differential CK staining is confirmation or exclusion of a primary colorectal adenocarcinoma.
MARKERS OF OVARIAN SEX CORD–STROMAL TUMORS
There have been significant recent developments in this area. Ovarian sex cord–stromal tumors have a varied morphologic appearance and are often mistaken for other neoplasms, especially adenocarcinomas of endometrioid type. Recently described markers of ovarian sex cord–stromal tumors include [alpha] inhibin, calretinin, melan A, CD99, relaxin-like factor, and mullerian inhibiting substance. Of these, the 2 most useful are [alpha] inhibin and calretinin, and these should be used in combination. In most, but not all, studies, calretinin has been shown to be a slightly more sensitive marker of ovarian sex cord–stromal tumors but [alpha] inhibin is much more specific. It can be summarized that [alpha] inhibin is the most useful marker of ovarian sex cord–stromal tumors. Most morphologic subtypes are positive, except for fibromas and some sarcomatoid granulosa cell tumors and poorly differentiated Sertoli-Leydig cell tumors. However, it should be cautioned that occasional classic granulosa cell tumors are [alpha] inhibin negative, and this should not detract from the diagnosis. In other cases, staining is focal. Almost all ovarian adenocarcinomas are [alpha] inhibin negative, although occasional cases have exhibited focal weak positivity. In the distinction between a sex cord–stromal tumor and an ovarian endometrioid adenocarcinoma, a panel of markers should be used, including [alpha] inhibin, calretinin, CK7, and epithelial membrane antigen (EMA). It is unusual for an ovarian sex cord–stromal tumor to be positive for CK7 or EMA, although focal EMA positivity has recently been described in ovarian juvenile granulosa cell tumors. In contrast, anti-CK antibodies are not uncommonly positive in ovarian sex cord–stromal tumors, especially of Sertoli cell but also of granulosa cell type. Therefore anti-CK antibodies are of limited value. Sex cord–stromal markers, such as [alpha] inhibin and calretinin, are of value in diagnosing a late recurrence or metastasis of an ovarian granulosa cell tumor since metastatic and recurrent neoplasms usually maintain their immunoreactivity. [alpha] Inhibin and calretinin also stain nonneoplastic luteinized ovarian stromal cells, which are commonly present as a reaction to any mass lesion within the ovary. Therefore, there should be close correlation between the morphology and the immunohistochemistry. Other markers which may be positive in ovarian sex cord–stromal tumors include vimentin, S100, CD10, and WT1.
ANTIBODIES OF VALUE IN TYPING OVARIAN CARCINOMA
With a well-differentiated ovarian carcinoma, ascertaining the morphologic subtype is nonproblematic. However, with a poorly differentiated carcinoma, typing may be difficult, especially the distinction between a serous and an endometrioid adenocarcinoma. In general, there is diffuse nuclear positivity with WT1 (antibody against N-terminal) in ovarian serous carcinomas, while most endometrioid adenocarcinomas are negative. Most poorly differentiated nonmucinous ovarian adenocarcinomas are also WT1 positive, suggesting they may be serous in type.
Primary ovarian transitional cell carcinomas are also usually WT1 positive. Primary ovarian transitional cell carcinomas exhibit a mullerian rather than a urothelial immunophenotype. They are positive for CK7 but usually negative for CK20 and urothelial markers such as thrombomodulin and uroplakin III. In contrast, ovarian Brenner tumors often exhibit positivity with urothelial markers, providing evidence for true urothelial differentiation.
DISTINCTION BETWEEN OVARIAN SEROUS CARCINOMA AND UTERINE SEROUS CARCINOMA
With a disseminated serous carcinoma involving the uterus and 1 or both ovaries, it may be difficult to ascertain the site of primary. This is of importance in that adjuvant therapy may differ between an ovarian and a uterine primary. The question of synchronous independent neoplasms as part of a “field change” effect may also arise. WT1 (antibody against N-terminal) may be of value. As discussed, most ovarian serous adenocarcinomas exhibit diffuse nuclear staining with WT1. The literature regarding WT1 immunoreactivity in uterine serous carcinoma is slightly contradictory, but these are much less likely to be WT1 positive than ovarian serous carcinomas, and those cases which are positive usually exhibit focal staining. It can be summarized that diffuse intense WT1 positivity is in keeping with a primary ovarian serous carcinoma, while negative staining is against an ovarian origin. Primary tubal and peritoneal serous carcinomas are also WT1 positive.
OVARIAN SMALL ROUND CELL TUMORS
Ovarian tumors which are composed of small round cells have a wide differential diagnosis. Many of these neoplasms occur predominantly in young patients. The immunophenotype of some of the neoplasms in this group, such as granulosa cell tumor, has already been discussed. The immunophenotype of other tumors in the small round cell category, such as neuroblastoma, lymphoma, and rhabdomyosarcoma, are well known and will not be detailed further. Rather, the immunophenotype of several neoplasms in this group will be discussed.
Ovarian small cell carcinoma of hypercalcemic type (OSCCHT) is an enigmatic tumor, the histogenesis of which remains unknown. Recent studies have shown that almost all cases exhibit diffuse intense nuclear positivity with an antibody against the N-terminal of WT1. Many cases are also positive with EMA and anti-CK antibodies, although usually focally so. Other markers which may be positive include CD10, calretinin, and p53. WT1 may be extremely useful in diagnosis in that most of the other neoplasms in the differential diagnosis are negative. Juvenile granulosa cell tumor (JGCT) (which is probably the closest morphologic mimic of OSCCHT since both neoplasms characteristically contain follicle-like structures) may exhibit WT1 positivity, but this is usually focal and weak in my experience. Moreover, JGCT is positive with [alpha] inhibin, which has been negative in all OSCCHT studied to date.
Intraabdominal desmoplastic small round cell tumor (IADSRCT) most commonly occurs in males but in females often mimics a primary ovarian neoplasm with widespread metastatic spread. IADSRCT is characterized by positivity with a variety of epithelial, mesenchymal, and neural markers. In particular, desmin is positive in almost all cases, often with punctate cytoplasmic staining. IADSRCT is characteristically positive with an antibody against the C-terminal of WT1.
Ovarian small cell carcinoma of pulmonary type is a rare neuroendocrine type small cell carcinoma which is usually positive with neuroendocrine markers, although often focally so. Some cases may be negative since, similar to their pulmonary counterparts, the tumor cells are often sparsely granulated. Anti-CK markers are usually positive.
Primitive neuroectodermal tumors (PNETs) uncommonly occur within the ovary and may mimic many of the other small round blue cell tumors. PNETs are usually positive with CD99 and FLI-1. However, it should be cautioned that some other ovarian neoplasms, including sex cord–stromal tumors, may be CD99 positive.
Malignant melanoma involving the ovary (most commonly metastatic) may be composed of small round cells. The 3 most widely used markers of malignant melanoma are S100, melan A, and HMB45. One of the main categories of tumor in the differential diagnosis of malignant melanoma is the sex cord–stromal group. It should be cautioned that many ovarian sex cord–stromal tumors are positive for S100 and melan A. In addition, HMB45, which is widely regarded as the most specific melanoma marker, may be positive in ovarian steroid cell tumors. When one considers that occasional metastatic malignant melanomas in the ovary may be [alpha] inhibin positive, the potential for confusion is obvious.
EPITHELIAL VERSUS MESOTHELIAL PROLIFERATION
Serous proliferations involving the ovary and peritoneum may closely mimic mesothelial proliferations. Reactive mesothelial hyperplasia around the ovary is often florid and may mimic an ovarian serous carcinoma. In distinguishing between an epithelial and a mesothelial proliferation, a panel of antibodies should be used, including markers of both epithelial and mesothelial lineage. The most useful epithelial marker is Ber EP4, which is positive in most serous proliferations in the ovary but is generally negative in mesothelial cells. CEA is of no value in that most primary ovarian epithelial neoplasms are negative. Markers of mesothelial lineage include calretinin, CK5/6, HBME1, CD44H, and thrombomodulin. Probably the most useful mesothelial marker is calretinin. It is stressed that calretinin staining should be nuclear, in addition to cytoplasmic, to be sufficiently specific for mesothelial cells.
MISCELLANEOUS
Placental alkaline phosphatase (PLAP) and OCT4 are of value in the diagnosis of an ovarian dysgerminoma. OCT4 is a recently described marker of testicular seminoma and ovarian dysgerminoma. Nuclear positivity is required. Almost all ovarian dysgerminomas are OCT positive, while most other primary ovarian neoplasms which have been studied are negative. However, a small number of clear cell carcinomas are positive. Since clear cell carcinoma may enter into the differential diagnosis of a dysgerminoma, this may result in diagnostic difficulties. [alpha] Fetoprotein and [beta] human chorionic gonadotropin assist in confirming a diagnosis of yolk sac tumor or choriocarcinoma, respectively, within the ovary.
Female adnexal tumor of Wolffian origin (FATWO), which is most commonly located within the broad ligament but may rarely occur in the ovary, generally expresses CKs and vimentin and may be positive for calretinin, CD10, and androgen receptor. EMA and CEA are usually negative. In addition, [alpha] inhibin is often positive, although staining is usually focal and weak, in contrast to the diffuse positivity characteristic of most ovarian sex cord–stromal tumors. However, since some ovarian sex cord–stromal tumors may be only focally positive, the potential for misdiagnosis is obvious. The immunophenotype of FATWO and ovarian sex cord–stromal tumors overlaps considerably. The immunophenotype of FATWO is similar to that of mesonephric remnants around the ovary and elsewhere in the female genital tract, providing evidence for a mesonephric origin for this neoplasm.
Pathology Case Reviews, Volume 11(1), January/February 2006, pp 31-37
BOTTOM LINE
Normal Fasting Plasma Glucose Levels and Type 2 Diabetes in Young Men
Amir Tirosh, M.D., Iris Shai, R.D., Dorit Tekes-Manov et al
Background The normal fasting plasma glucose level was recently defined as less than 100 mg per deciliter (5.55 mmol per liter). Whether higher fasting plasma glucose levels within this range independently predict type 2 diabetes in young adults is unclear.
Methods Authors obtained blood measurements, data from physical examinations, and medical and lifestyle information from men in the Israel Defense Forces who were 26 to 45 years of age.
Results A total of 208 incident cases of type 2 diabetes occurred during 74,309 person-years of follow-up (from 1992 through 2004) among 13,163 subjects who had baseline fasting plasma glucose levels of less than 100 mg per deciliter. A multivariate model, adjusted for age, family history of diabetes, body-mass index, physical-activity level, smoking status, and serum triglyceride levels, revealed a progressively increased risk of type 2 diabetes in men with fasting plasma glucose levels of 87 mg per deciliter (4.83 mmol per liter) or more, as compared with those whose levels were in the bottom quintile (less than 81 mg per deciliter [4.5 mmol per liter], P for trend <0.001). In multivariate models, men with serum triglyceride levels of 150 mg per deciliter (1.69 mmol per liter) or more, combined with fasting plasma glucose levels of 91 to 99 mg per deciliter (5.05 to 5.50 mmol per liter), had a hazard ratio of 8.23 (95 percent confidence interval, 3.6 to 19.0) for diabetes, as compared with men with a combined triglyceride level of less than 150 mg per deciliter and fasting glucose levels of less than 86 mg per deciliter (4.77 mmol per liter). The joint effect of a body-mass index (the weight in kilograms divided by the square of the height in meters) of 30 or more and a fasting plasma glucose level of 91 to 99 mg per deciliter resulted in a hazard ratio of 8.29 (95 percent confidence interval, 3.8 to 17.8), as compared with a body-mass index of less than 25 and a fasting plasma glucose level of less than 86 mg per deciliter.
Conclusions Higher fasting plasma glucose levels within the normoglycemic range constitute an independent risk factor for type 2 diabetes among young men, and such levels may help, along with body-mass index and triglyceride levels, to identify apparently healthy men at increased risk for diabetes
New England Journal of Medicine, Volume 353:1454-1462 October 6, 2005, Number 14.