Apocrine poroma of the breast

Abstract: Poromas are sweat gland tumors classically reported to be of eccrine origin. However, it is now recognized that poromas may also be derived from apocrine glands. There are no prior reports of either type of poroma arising on the breast. We report the first case of a poroma of the breast. The lesion was localized to the areola of a 70-year-old woman and mimicked an underlying neoplasm of the breast. Because the histopathology demonstrated apparent continuity of a benign poroma with the infundibula of hair follicles, the diagnosis of apocrine poroma was made. The poroma in this case is of apocrine derivation. This report demonstrates that apocrine poromas should be considered in the clinical differential of acquired lesions on the areola, suggesting an underlying breast tumor. Apocrine poromas that are only partially biopsied may recur. Moreover, since apocrine poromas may potentially develop into apocrine porocarcinomas, analogous to eccrine poromas sometimes transforming into eccrine porocarcinomas, apocrine poromas should be completely excised.     

Sentinel Lymph Node Biopsy for Atypical Melanocytic Lesions with Spitzoid Features

Introduction Sentinel lymph node biopsy (SLNB) is routinely used as a staging procedure for melanomas, however may also assist in understanding the biology of atypical and controversial spitzoid melanocytic skin lesions.Methods Five hundred and forty-nine sentinal lymph node excisions were performed over a 5-year period. Fourteen patients with controversial melanocytic lesions were identified and of these ten underwent SLNB. The histology of the primary skin lesion and corresponding sentinal lymph nodes were evaluated and correlated with outcome.Results Thickness of the primary melanocytic lesion ranged from 1.22 to 4 mm. Fifty percent of patients were less than 17 years of age. Ten patients underwent SLNB and three cases (30%) displayed metastatic disease in the SLNB specimen. All three patients were under 17 years of age and all underwent completion axillary dissection. One completion axillary dissection had an additional node with metastasis on routine H&E and immunohistochemical staining. No capsular invasion was seen. All three cases with metastatic disease received adjuvant systemic therapy and remain disease free at 29, 49 and 57 months follow-up. All patients with a negative SLNB remain disease free at mean follow-up of 28.1 months (range: 13–40 months).Conclusion Our results confirm that some of these spitzoid lesions metastasize to regional lymph nodes and SLNB is a valuable adjunct tool in staging these lesions. However, molecular studies and a prolonged follow-up are needed to determine whether these lesions, especially those occurring in children are comparable to stage matched overt melanoma in adults.     

Apocrine carcinoma of the breast —A case report

A case of apocrine carcinoma of the breast is reported herein. Apocrine carcinoma is a rare tumor characteristically composed of large cells with eosinophilic cytoplasm. This case involves a 34-year old woman who underwent a modified radical mastectomy and is now doing well with no evidence of recurrence, 10 months after her surgery.     

Flat Epithelial Atypia and Atypical Ductal Hyperplasia: Carcinoma Underestimation Rate

Abstract: This study was carried out to determine the underestimation rate of carcinoma upon surgical biopsy after a diagnosis of flat epithelial atypia and atypical ductal hyperplasia and 11‐gauge vacuum‐assisted breast biopsy. A retrospective review was conducted of 476 vacuum‐assisted breast biopsy performed from May 2005 to January 2007 and a total of 70 cases of atypia were identified. Fifty cases (71%) were categorized as pure atypical ductal hyperplasia, 18 (26%) as pure flat epithelial atypia and two (3%) as concomitant flat epithelial atypia and atypical ductal hyperplasia. Each group were compared with the subsequent open surgical specimens. Surgical biopsy was performed in 44 patients with atypical ductal hyperplasia, 15 patients with flat epithelial atypia, and two patients with flat epithelial atypia and atypical ductal hyperplasia. Five cases of atypical ductal hyperplasia were upgraded to ductal carcinoma in situ, three cases of flat epithelial atypia yielded one ductal carcinoma in situ and two cases of invasive ductal carcinoma, and one case of flat epithelial atypia/atypical ductal hyperplasia had invasive ductal carcinoma. The overall rate of malignancy was 16% for atypical ductal hyperplasia (including flat epithelial atypia/atypical ductal hyperplasia patients) and 20% for flat epithelial atypia. The presence of flat epithelial atypia and atypical ductal hyperplasia at biopsy requires careful consideration, and surgical excision should be suggested.     

Alterations of the Cell Cycle Regulators Cyclin D1, Cyclin A, p27, p21, p16, and pRb in Apocrine Metaplasia of the Breast

Abstract:  G1/S transition defects have been a proposed requirement for tumor development. Apocrine metaplasia (APM) in the breast has been held as a sign of benignity. Yet, a number of studies have reported the presence of molecular abnormalities in some forms of APM suggesting a possible oncogenic potential for some of these lesions. We currently investigate the role of some of the cell cycle proteins, previously reported to be de-regulated in breast cancer, in an attempt to assess their significance in APM. Using immunohistochemistry, the expression of cyclin D1, cyclin A, p27, p21, p16, pRb and Ki-67 was examined in 93 cases of APM. The cases were divided into nonpapillary (NAPM) (30 cases) and papillary metaplasia (PAPM) (63 cases). PAPM was further subdivided into simple papillary (SPAPM) (29 cases), complex papillary (28 cases) and highly complex papillary (six cases). For statistical analysis, the last two groups were merged together (CPAPM). The results showed that increased histological complexity was associated with significant increase of proliferative capacity and alterations of the cell cycle control. The median Ki-67 index was 1.5% in SPAPM and 4.8% in the CPAPM. Also, alterations of the cell cycle regulators were significantly higher in the CPAPM than in the SPAPM. NAPM was generally similar to normal breast epithelium. Apocrine cells were negative for p16 while pRb was expressed in all cases. These findings suggest that in complex forms of APM, there is a considerable degree of cellular unrest. This may contribute to increased susceptibility to carcinogenesis.     

Androgen Receptor Expression Along with Loss of bcl-2, ER, and PR Expression in Benign and Malignant Apocrine Lesions of the Breast: Implications for Therapy

Abstract: Apocrine lesions of the breast are not uncommon. Limited studies have suggested that apocrine cells may be under the influence of an androgenic, rather than an estrogenic, regulatory system. Furthermore, a recent study has shown that metaplastic apocrine cells of the breast lack expression of bcl-2, a B-cell leukemia/lymphoma gene protein whose expression in the breast is believed to be regulated by estrogen. This study was undertaken to immunohistochemi-cally assess the status of expression of estrogen receptor (ER), progesterone receptor (PR), bcl-2, and androgen receptor (AR), in a series of mammary apocrine lesions ranging from simple metaplasia to metastatic carcinoma, and to determine whether there is any possible interrelationship or correlation between the expression of these hormone receptors and that of bcl-2. Among 102 apocrine lesions (68 benign and 34 malignant) evaluated, 100 (98%) were ER and PR negative; only two intraductal carcinomas (IDCA, 2%) were weakly positive for ER and PR. Bcl-2 was detectable only in these two IDCA, but not in any of the other apocrine lesions. In contrast, AR positivity was evident in 15 of 16 (94%) benign apocrine lesions and 18 of 25 (72%) cancerous apocrine lesions (13 of 16 IDCA, 5 of 8 invasive carcinomas, and 0 of 1 metastatic carcinoma) evaluated; all 7 AR negative cancerous lesions (3 IDCA, 3 invasive carcinomas, and 1 metastatic carcinoma) were poorly differentiated with pronounced atypia. These results suggest that apocrine differentiation appears to be associated with retention of AR positivity and a reversal of the usual mammary hormone receptor expression profile for ER, PR, and bcl-2 oncoprotein. These findings warrant exploration of the value of androgenic hormone manipulations in management of AR-positive apocrine carcinomas.?     

Apocrine Adenocarcinoma of the Nipple: a Case Report

Apocrine adenocarcinoma of the skin is a rare and, most of the time, clinically misdiagnosed malignant adnexal tumour.

A 66-year-old female patient presented with an asymptomatic swelling of the left nipple that on pathological evaluation was confirmed as an apocrine adenocarcinoma.

Surgery is to be considered as the mean treatment for such a lesion and the diagnosis is always difficult to establish. To our best knowledge, this is only the second reported apocrine adenocarcinoma arising from a nipple and the first presenting with Paget’s phenomenon.     

Atypical fibroxanthoma of the scalp

BACKGROUND: Atypical fibroxanthoma occurs most frequently in the head and neck region of the elderly. Previous reports have identified that the condition usually arises at the following sites: the nose, cheeks, forehead, and the ears; its development at other sites is unusual. METHOD: We report a series of 10 cases with lesions all occurring at an apparently unusual site, the scalp, over a 10-year period. We compared the clinical and histologic appearances and behavior of this series with the existing reports of these lesions elsewhere in the head and neck region to investigate whether there were differences with those occurring at a conventional site. RESULTS: Despite the identification of a range of clinical and histologic findings in our cases, we were unable to find any significant differences with those arising at a conventional site. CONCLUSION: This clustering of cases at an apparently unusual site leads us to propose that this condition occurs more commonly on the scalp than current literature suggests. The possibility of its development at this site should be remembered by head and neck surgeons in their differential diagnosis of exophytic lesions of the scalp.     

Papillary and sclerosing lesions of the breast detected and biopsied by MRI: Clinical management,upgrade rate,and association with apocrine metaplasia

Benign papillary and sclerosing lesions of the breast (intraductal papillomas, complex sclerosing lesions, radial scars) are considered high‐risk lesions due to the potential for upgrade to carcinoma on subsequent surgical excision. Optimal clinical management of such lesions remains unclear due to variable reported upgrade rates. Apocrine metaplasia is a common finding in breast tissue and its role in MRI enhancing lesions is increasingly being recognized. The purpose of this study was to investigate the MRI features of papillary and sclerosing lesions of the breast, evaluate the clinical management and upgrade rate of such lesions, and examine the contribution of apocrine metaplasia to the imaging findings. A 13‐year retrospective review of MRI‐guided biopsies identified 70 MRI‐detected and ‐biopsied papillary and sclerosing lesions. Sixteen lesions without atypia underwent surgical excision; only one case (6%) was upgraded to pleomorphic lobular carcinoma in situ. The majority (64%) of biopsies contained apocrine metaplasia either within or adjacent to the targeted lesion. We found that half of MRI‐detected lesions had T2 hyperintense foci (2‐5 mm) or masses (>5 mm) adjacent to the lesion. Histologic correlation showed apocrine cysts were likely responsible for this imaging finding in 56% of these cases.     

Atypical Histological Features as Risk Factors for Recurrence in Newly Diagnosed WHO Grade I Meningioma

The significance of atypical histological features (AHF) as risk factors for recurrence in benign meningioma is not well understood. This study examined risk factors of World Health Organization (WHO) Grade I meningioma (GIM) recurrence, focusing on AHF. We investigated 150 consecutive newly diagnosed GIM patients who had more than one year of follow-up after resection in our hospital between January 2007 and March 2018. The following factors were reviewed retrospectively: age, sex, tumor location, extent of resection, MIB-1 index, mitotic figures, number and distribution of AHF, and recurrence. The patients were grouped according to the presence or absence of recurrence and comparatively examined. Recurrence was observed in 10 cases (6.7%). Univariate analysis showed that patients with recurrence had a significantly higher MIB-1 index (2.0 vs. 4.3; p = 0.006) and a significantly higher proportion of male patients (21.4% vs. 70.0%; p = 0.002) and patients with sheet-like growth (6.42% vs. 30.0%; p = 0.04). In multivariate analysis, skull base location (odds ratio [OR] 31.424; 95% confidence interval [CI] 1.74–569), gross total resection (OR 0.130; 95% CI 0.0189–0.897), and MIB-1 index (OR 1.939; 95% CI 1.19–3.15) were significantly associated with recurrence. Our study revealed that skull base location, subtotal resection, and high MIB-1 index were independent risk factors for recurrence. Only the presence of sheet-like growth had a significantly higher incidence in patients with recurrence in univariate analysis of AHF. Multivariate analysis found no significant association. Sheet-like growth may be involved in malignancy and recurrence of benign meningioma.     

Imaging and Histopathologic Features of BI‐RADS 3 Lesions Upgraded during Imaging Surveillance

To evaluate imaging and histopathologic differences between screen‐detected benign and malignant upgraded lesions initially assessed as BI‐RADS 3 at diagnostic evaluation. An IRB approved retrospective review of the mammography data base from January 1, 2004 to December 31, 2008 identified 1,188 (1.07%) of 110,776 screening examinations assessed as BI‐RADS 3 following diagnostic evaluation at our academic center (staffed by breast specialists) or our outpatient center (staffed by general radiologists), 1,017 with at least 24 months follow‐up or biopsy. Sixty (5.9%) BI‐RADS 3 lesions were upgraded to BI‐RADS 4 or 5 during imaging surveillance (study population). Prospective reports, patient demographics, and clinical outcomes were abstracted from the longitudinal medical record. Mean patient age was 54.1 years (range 35–85). Lesions consisted of 7 masses, 12 focal asymmetries and 41 calcifications. Fifteen (25%) of 60 lesions upgraded from initial BI‐RADS 3 assessment were malignant (1.47% of total; 15/1,017 BI‐RADS 3 studies). Malignancy rates by upgraded lesion type showed no significant difference: Thirty‐three (73.3%) of 45 benign upgraded lesions were calcifications compared to 8 (53.3%) of 15 malignant upgraded lesions (p = 0.202). Twelve (26.7%) of 45 benign upgraded lesions were masses or focal asymmetries, compared to 7 (46.7%) of 15 upgraded malignant lesions (p = 0.202). Six (85.7%) of 7 malignant upgraded masses/focal asymmetries had no US correlate at initial BI‐RADS 3 assessment compared to 7 (58.3%) of 12 benign upgraded masses/focal asymmetries (p = 0.33). Breast‐imaging specialists interpreted 21 studies, 3 (14.3%) malignant; general radiologists interpreted 39 studies, 12 (30.8%) malignant (p = 0.218). There was no significant difference in malignancy rate among different types of upgraded mammographic lesions, nor depending on subspecialty interpretation versus nonsubspecialist interpretation. Although calcifications made up a majority of upgraded lesions, most were benign, suggesting that decreased surveillance of calcifications may be appropriate.     

Secretory Carcinoma of the Breast in an Elderly Woman: Report of a Case

(Received for publication on Apr. 30, 1996; accepted on Jan. 7, 1997)     

腹腔镜诊治早期不典型输卵管妊娠临床分析

目的 探讨腹腔镜对早期不典型输卵管妊娠的诊疗价值. 方法 38例均因早期或不典型输卵管妊娠行腹腔镜手术.明确看到输卵管有蓝紫色妊娠物或发现一侧输卵管局部略增粗并呈紫色而未见明显妊娠肿物,均行输卵管切开取胎术＋输卵管缝合修补术.双侧输卵管外观均未见任何异常者,暂无生育要求,则先行诊断性刮宫,确诊输卵管妊娠后,于双侧输卵管壶腹部各注入甲氨蝶呤（MTX）30 mg;有生育要求则不行诊断性刮宫. 结果 术前误诊5例,误诊率13%.腹腔镜误诊3例,误诊率8%.腹腔镜下输卵管切开取胎术＋输卵管缝合修补术30例,输卵管注射MTX保守治疗4例,均成功,术后血β-hCG降至正常时间（4.2±3.1）d. 结论腹腔镜是早期不典型输卵管妊娠诊治的最佳选择.     

Treatment of Pituitary Carcinomas and Atypical Pituitary Adenomas: A Review

Atypical pituitary adenomas (APAs) are aggressive tumors, harboring a Ki-67 (MIB-1) staining index of 3% or more, and positive immunohistochemical staining for p53 protein, according to the World Health Organization (WHO) classification in 2004. Pituitary carcinomas (PC) usually develop from progressive APAs and predominantly consist of hormone-generating tumors, defined by the presence of disseminations in the cerebrospinal system or systemic metastases. Most of the cases with these malignant pituitary adenomas underwent surgeries, irradiations and adjuvant medical treatments, nevertheless, the therapies are mainly palliative. Recently, the efficacy of temozolomide (TMZ), an orally administered alkylating agent, has been reported as an alternative medical treatment. However, some recent studies have demonstrated a significant recurrence rate after effective response to TMZ. Further clinical and pathological researches of malignant pituitary adenomas will be required to improve the outcome of patients with these tumors.     

Breast Imaging: Understanding How Accuracy Is Measured When Lesions are the Unit of Analysis

Abstract: Medical imaging tests of breast cancer patients can be used to detect and provide information on the location of multiple malignant lesions within a patient. Within this context, it is often the case that one needs to evaluate the accuracy of an imaging test for finding the multiple lesions in a patient rather than simply detecting that a patient has disease. A natural way to approach this task is to estimate the accuracy of the test using a lesion‐level analysis. Sensitivity, specificity, and receiver operating characteristic (ROC) curves are analytic measures that are frequently used to quantify the accuracy of medical tests. When the test or radiologist must first locate the lesions, however, it is not possible to directly estimate the specificity or an ROC curve keeping the individual lesions as the unit of analysis. The goal of this study is to demonstrate to clinicians conducting or reviewing studies evaluating breast imaging tests what measures of accuracy can and cannot be calculated in different types of studies and to describe in detail the difficulty with calculating specificity and ROC curves in a lesion‐level analysis.     

A Model to Predict the Risk of Upgrade to Malignancy at Surgery in Atypical Breast Lesions Discovered on Percutaneous Biopsy Specimens

Background

When any atypical feature is identified on a percutaneous biopsy specimen of a suspicious breast lesion, surgical excision is mandatory, leading to unnecessary surgeries in 70–90 % of the cases. The purpose of this study was to develop a model to predict the presence of cancer at surgery that would be applicable to all atypical lesions.

Methods

We collected complete clinical, radiological, and double-reading histological data concerning all patients with a diagnosis of a pure atypical lesion on image-guided biopsy performed at the One-Stop Breast Care Unit between 2004 and 2011.

Results

Among the 204 eligible patients, 49 cancers (24 %) had been diagnosed at definitive surgery (20 ductal carcinoma in situ, 20 invasive ductal, and 9 invasive lobular carcinoma). The univariate analysis retrieved age (p = 0.03), the focus size in mm (p = 0.02), the number of biopsy cores (p = 0.02), the disappearance of radiological anomalies after biopsy (p = 0.05), the mean number of atypical foci (p = 0.05) and the percentage of atypical lobules and ducts for lobular neoplasia (p = 0.04) as factors associated with cancer at surgery, whereas neither Ki67 nor ALDH1 expression was significantly correlated. The final most informative nomogram comprised information on patient age, the disappearance of radiological anomalies after biopsy and a focus size >15 mm. For the optimal threshold (risk of cancer = 21 %), sensitivity, specificity, positive predictive value, and negative predictive value were 78, 66, 36, and 90 %, respectively.

Conclusions

After validation, this model could help to identify a subset of patients with premalignant disease who could be spared surgery.     

SLAP Lesions of the Shoulder

A specific pattern of injury to the superior labrum of the shoulder was identified arthroscopically in twenty-seven patients included in a retrospective review of more than 700 shoulder arthroscopies performed at our institution. The injury of the superior labrum begins posteriorly and extends anteriorly, stopping before or at the mid- glenoid notch and including the “anchor” of the biceps tendon to the labrum. We have labeled this injury a “SLAP lesion” (Superior Labrum Anterior and Posterior). There were 23 males and four females with an average age of 37.5 years. Time from injury to surgery averaged 29.3 months. The most common mechanism of injury was a compression force to the shoulder, usually as the result of a fall onto an outstretched arm, with the shoulder positioned in abduction and slight forward flexion at the time of the impact. The most common clinical complaints were pain, greater with overhead activity, and a painful “catching” or “popping” in the shoulder. No imaging test accurately defined the superior labral pathology preoperatively. We divided the superior labrum pathology into four distinct types. Treatment was performed arthroscopically based on the type of SLAP lesion noted at the time of surgery. The SLAP lesion, which has not been previously described, can be diagnosed only arthroscopically and may be treated successfully by arthroscopic techniques alone in many patients.