Bone marrow biopsy: interpretive guidelines for the surgical pathologist

Ideally, the bone marrow core biopsy should be reviewed with knowledge of the clinical history, complete blood count, and findings in the peripheral blood and bone marrow aspirate smears. However, for a variety of reasons, the pathologist may receive the core biopsy and aspirate clot section without all of this information. Although this approach is not optimal, a great deal of valuable information can be generated from these specimens. Over the past 20 years, there has been considerable progress in the fields of flow cytometric analysis, immunohistochemistry, and molecular diagnostic studies that can be performed on smears or extracted DNA from paraffin embedded tissue. These modalities have augmented and refined diagnostic criteria formerly ascertained by light microscopy, cytochemistry, and cytogenetics. This is particularly true of some myeloid and lymphoreticular neoplasms where a collaborative and multidisciplinary approach to the diagnosis has become necessary. Despite this growing complexity and dependence on newer methodologies, the traditional role of histopathology in evaluating the bone marrow biopsy remains as important as it has been in the past. In this review, we focus on contemporary practices and expectations for interpreting bone marrow biopsies and clot sections.     

Subclassification of renal cell neoplasms: an update for the practising pathologist

The classification of renal cell neoplasms has been extensively studied in the last decade, and a standardized nomenclature adopted. Although this system is based on a combination of genetic, histological and immunohistological features, in most cases accurate classification can be based on histological features alone. This review summarizes the key features of the tumours included in this system, and then focuses on diagnostic difficulties that can arise when using this system, as well as reviewing several recently characterized tumours that are not yet included.     

An update regarding the effects of hormones on the endometrium: practical considerations for the surgical pathologist

The endometrium displays a unique physiology characterized by its cyclical response to steroid hormones, which results in morphological changes that contribute to a pathologist's interpretation of proper endometrial function. Distinctive changes are also observed during times of physiological hormonal shifts (such as during pregnancy), pathological hormonal imbalances (such as certain functioning ovarian tumours) and iatrogenic hormonal imbalances (such as hormone therapy). The ubiquity of these states, particularly in conjunction with the widespread use of oral contraceptives, hormone replacement therapy, and intrauterine devices, requires that the pathologist be familiar with both the complete patient history and the histologic patterns specific to each entity in order to obtain an accurate and practical diagnosis for the clinician. Furthermore, some endometrial changes may mimic more worrisome lesions, and vigilance is necessary to accurately distinguish among these histologic patterns when evaluating endometrial samples.     

Epstein Barr virus-associated tumours: an update for the attention of the working pathologist

Epstein-Barr virus (EBV) is a herpesvirus associated with approximately 1% of tumours worldwide. EBV is the epitome of B lymphotropic viruses, but the spectrum of tumours it is associated with extends to T lymphocyte and NK cell malignancies, various types of carcinomas and smooth muscle tumours. Ubiquitous EBV infection in humans implies that most individuals carry EBV-infected cells. Therefore, mere detection of the virus in individuals with a tumour is not sufficient for establishing a causal relationship between both events, but instead requires unequivocal detection of viral nucleic acids or viral proteins in the tumour cells. Recent controversies about EBV infection in several carcinomas mainly resulted from such technical issues. The gold standard remains in situ EBER detection, but detection of EBNA1 would be an interesting alternative. EBV detection can be helpful for diagnostic, prognostic and therapeutic purposes. The rate of EBV association with entities such as NK/T cell tumours of the nasal type is so high that absence of detection of the virus in such a lesion should cast doubt of the accuracy of the diagnosis. Similarly, diagnosis of EBV-associated follicular pseudo-tumour obviously requires detection of the virus. EBV-positive common gastric adenocarcinomas seem to have a better prognosis than their EBV-negative counterparts and identification of the virus in B cell lymphoproliferations in immunocompromised individuals will guide therapeutic options. In conclusion, EBV-associated tumours are common enough to be relevant for the pathologist in everyday practice, but there is a need to facilitate detection of the virus (eg EBNA1 antibody).     

Histologic changes after stereotactic 11-Gauge directional vacuum assisted breast biopsy for mammary calcification: experience in 31 surgical specimens

II Gauge directional large core vacuum assisted biopsy has been used recently in the etiological diagnosis of microcalcifications. The objective of our work was to summarize the histological modifications resulting from vacuum biopsies observed on 31 surgical specimens issuing from a series of 109 biopsies performed over a 15-month period for malignant and borderline lesions. Histological modifications attributable to vacuum biopsies, scar tissue and displacements, were searched for in all cases. Scar tissue was seen as granulations, inflammation and hemorrhagic tissue associated or not with fat necrosis and/or foreign body giant-cell reaction. Displacements were seen as movements of injured tissue generally in the vicinity of scar tissue or vascular channels. Scar tissue was identified in all cases, presenting as star-shaped tissue measuring 12.8 mm on the average. Five displacements of either benign or malignant epithelia or of lymphovascular channels were observed (16% of the specimens). Scar tissue seen on surgical specimens indicates the location of the mammotome cut and confirms correctly directed surgery. It is particularly important to identify scar tissue because the lesions are nonpalpable and difficult to localize, or may have been totally removed at the initial biopsy. Displacements can be mistaken for infiltrating carcinoma or lymphatic invasion and must be carefully localized. They seem to be less frequent after vacuum biopsy.     

Vulvar inflammatory dermatoses for the non-dermatopathologist: an approach for the practising surgical pathologist

Recognition of tissue patterns of injury will help the non-dermatopathologist when confronted with biopsies of vulvar inflammatory dermatoses. This review defines and discusses the most common inflammatory patterns including spongiotic, psoriasiform, interface and vesiculobullous; providing a brief overview of the clinical, histologic and differential diagnoses of the more common lesions to affect the vulva. Also included are entities with specific predilection for the female gynaecologic tract including Zoon's vulvitis and Behçet's disease. A comprehensive review of this topic is beyond the scope of this mini-symposium. However, we hope to provide an approach to the diagnosis of vulvar inflammatory dermatitis which will be of practical use to the surgical pathologist.     

Vulvar inflammatory dermatoses for the non-dermatopathologist: an approach for the practising surgical pathologist

Recognition of tissue patterns of injury will help the non-dermatopathologist when confronted with biopsies of vulvar inflammatory dermatoses. This paper defines and discusses the most common inflammatory patterns including: spongiosis, psoriasiform, interface and vesiculobullous, providing a brief overview of the clinical, histologic and differential diagnoses of the more common lesions to affect the vulva. Also included are entities with specific predilection for the female gynaecologic tract including Zoon’s vulvitis and Behcet’s disease. A comprehensive review of this topic is beyond the scope of this mini-symposium. However we hope to provide an approach to the diagnosis of vulvar inflammatory dermatitis which will be of practical use to the surgical pathologist.     

Atypical ductal hyperplasia diagnosis by directional vacuum-assisted stereotactic biopsy of breast microcalcifications. Considerations for surgical excision

In 824 patients who underwent directional vacuum-assisted biopsies (DVABs) of breast microcalcifications, 61 (7.4%) showed atypical ductal hyperplasia (ADH). The 42 who subsequently underwent excision were the subjects of this study. Cases were evaluated for the mammographic characteristics of the lesion, the percentage of lesion removed according to mammography, and histologic findings (including number of large ducts and/or terminal duct-lobular units involved with ADH) in DVAB specimens. Pathologic findings in the surgical specimens in the area of the biopsy site also were recorded. In the DVAB specimens, ADH was confined to an average of 1.5 large ducts or lobular units and was associated with microcalcifications in all of the patients. Surgical specimens showed ADH in 15 cases, no residual lesion in 24 cases, and ductal carcinoma in situ in 3 cases. We found that microcalcifications that contain ADH in less than 3 lobules or ducts and/or that are removed completely by DVAB do not reveal higher-risk lesions on excision; thus, removal is unnecessary. When assessing microcalcifications with ADH, clinicians should consider the percentage of microcalcifications removed by DVAB and the extent of lobular involvement to better assess the need for excision.     

Placental pathology for the surgical pathologist

Pathologic examination of the placenta is of clinical importance in the evaluation of pregnancies with a less than perfect outcome. Morphologic alterations of the placenta can mirror disorders of the fetus and the mother and evaluation of the placenta can identify clinically significant lesions, allow understanding of a child's disability and may have a role in resolving medical-legal disputes. Pathologic findings in the placenta can provide information on the pathogenesis of cerebral palsy, mental retardation, or neurodevelopmental disorders. This review will cover a variety of frequently encountered, clinically important, and morphologically distinct disorders of the placenta. The current understanding of the clinical implications of lesions for the mother, infant, and for future pregnancies will also be considered.     

How stereotactic core-needle biopsy affected breast fine-needle aspiration utilization: an 11-year institutional review

To determine the effect of stereotactic core-needle biopsy (SCNB) on the utilization of breast fine-needle aspirate (FNA) biopsy, we retrospectively reviewed 1,568 cases of breast FNAs that were obtained from 1,188 patients between the years 1990 and 2000. There were 378 positive and atypical cases and 497 negative and unsatisfactory cases in the pre-SCNB group (between 1990 and 1996; 7 years); and 225 positive and atypical cases and 468 negative and unsatisfactory cases in the post-SCNB group (between 1997 and 2000; 4 years). The average number of cases per year in the pre- and post-SCNB groups was 125 and 173, respectively. While the average positive/atypical cases per year in both groups remained relatively constant, the average negative/unsatisfactory cases per year were significantly increased in the post-SCNB group (117 in the post-SCNB vs. 71 in the pre-SCNB). The increase in this group was due to a true increase in the negative diagnoses, since unsatisfactory rate decreased in the post-SCNB group (12.6% in the post-SCNB vs. 9.3% in the pre-SCNB). The sensitivity, specificity, positive predictive value, and negative predictive value were 90%, 79%, 92%, and 82% in the pre-SCNB group and 93%, 86%, 91%, and 90% for the post-SCNB group, respectively. In conclusion, the implementation of SCNB did not result in a decrease in the total number of breast FNAs; however, the distribution of cases changed. FNA is increasingly used to complete the triple test in clinically and radiographically negative cases.     

Why I became a surgical pathologist with interest in breast disease

Factors that influenced my decision to become a surgical pathologist are presented below. Early childhood experience shaped my interest in epidemiology and public health. Formal education at Johns Hopkins Medical School cemented my decision to become a surgical pathologist and elective time with pioneers in the field of surgical pathology sealed my career choice. As a mentor, I have tried to teach residents and fellows how to practice pathology, not merely how to make a diagnosis.