Anatomic Pathology Selected Abstracts, 8/13

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Anatomic pathology abstracts editors: Michael Cibull, MD, professor and vice chair, Department of Pathology and Laboratory Medicine, University of Kentucky College of Medicine, Lexington; Rouzan Karabakhtsian, MD, attending pathologist, Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; and Thomas Cibull, MD, dermatopathologist, Evanston Hospital, NorthShore University HealthSystem, Evanston, Ill.

Endometrium as a primary site of origin of pelvic high-grade serous carcinoma in BRCA1 or BRCA2 mutation carriers

Serous endometrial intraepithelial carcinoma has been proposed to be a potential precursor lesion of pelvic high-grade serous carcinoma. If true, an increased incidence of uterine papillary serous carcinomas would be expected in BRCA1 and BRCA2 mutation carriers, who are at high risk of developing pelvic high-grade serous carcinoma. The authors conducted a study in which they explored the occurrence of uterine papillary serous carcinoma, as well as other endometrial cancers, following risk-reducing salpingo-oophorectomy in women with a BRCA1 or BRCA2 germline mutation who were treated at a tertiary multidisciplinary clinic in the Netherlands. A consecutive series of women with a BRCA1 or BRCA2 mutation who had undergone risk-reducing salpingo-oophorectomy without hysterectomy at the University Medical Center Groningen from January 1996 until March 2012 were followed prospectively. They were crossed with the histopathology list of endometrial cancer diagnoses reported by the Dutch nationwide pathology database PALGA. To assess the risk of endometrial cancer, a standardized incidence ratio was calculated comparing the observed with the expected number of endometrial cancer cases. Overall, 201 BRCA1 and 144 BRCA2 mutation carriers who were a median age of 50 years (range, 32–78 years) were analyzed. After a median followup of six years after risk-reducing salpingo-oophorectomy, two cases of endometrial cancer were diagnosed, whereas the expected number was 0.94 cases (standardized incidence ratio, 2.13; 95 percent confidence interval, 0.24–7.69; P=.27). Both endometrial cancer cases were of the endometrioid histological subtype. The authors showed that the incidence of endometrial cancer following risk-reducing salpingo-oophorectomy, especially uterine papillary serous carcinoma, in women at high risk of developing pelvic high-grade serous carcinoma is not increased. On the basis of these data, the hypothesis of serous endometrial intraepithelial carcinoma being an important precursor lesion of pelvic high-grade serous carcinoma seems unlikely. The authors concluded that it is not necessary to add a prophylactic hysterectomy to risk-reducing salpingo-oophorectomy in BRCA1 or BRCA2 mutation carriers.

Reitsma W, Mourits MJ, de Bock GH, et al. Endometrium is not the primary site of origin of pelvic high-grade serous carcinoma in BRCA1 or BRCA2 mutation carriers. Mod Pathol. 2013;26:572–578.

Correspondence: H. Hollema at h.hollema@umcg.nl

Criteria and pitfalls in diagnosis of lymphovascular invasion in prostatectomy specimens

Lymphovascular invasion is an independent prognostic factor in prostate cancer. The authors conducted a study to describe reliable morphologic features for identifying lymphovascular invasion in prostatectomy specimens and avoiding misinterpretation of its mimickers. A total of 364 foci of lymphovascular invasion were analyzed in 264 slides from 170 prostatectomies. The average tumor volume was 25.5 percent. Tumor emboli were seen inside the tumor (eight percent), at the front edge of the tumor (30 percent), separated from the tumor (32 percent), and distant from the tumor (30 percent). Tumor emboli were more frequent per case and more often in an extraprostatic location in lymph node-positive cases (P<.05). One hundred thirty-four emboli were in a single thin-walled vessel; 227 were in a thin-walled vessel next to an artery; and three were inside an artery. Twenty-eight tumor emboli were attached to a vessel wall; 18 had proteinaceous material in the vascular lumen; and 14 were surrounded by erythrocytes. The following mimickers were seen: retraction artifact and perineural invasion—all cases; cancer impinging upon vascular space—45 foci; tangential sections of endothelium—10 foci; displacement of benign and collapsed malignant glands—16 and 27 foci, respectively; retraction with erythrocytes—three cases; intravascular degenerating tumor cells—3 foci; malignant glands in atrophic ducts—four foci; and myofibroblastic proliferation in thrombosed vessels—two foci. In 50 stained blocks, CD31 and D2-40 immunostaining studies confirmed all lymphovascular invasions diagnosed by hematoxylin-and-eosin staining and demonstrated emboli in 47 lymphatic and 16 blood vessels. This study identifies features of true lymphovascular invasion and how to distinguish them from mimickers on routine hematoxylin-and-eosin sections.

Kryvenko ON, Epstein JI. Histologic criteria and pitfalls in the diagnosis of lymphovascular invasion in radical prostatectomy specimens. Am J Surg Pathol. 2012;36(12):1865–1873.

Correspondence: Dr. Jonathan I. Epstein at jepstein@jhmi.edu