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Anatomic Pathology Selected Abstracts, 3/15

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Editors: Michael Cibull, MD, professor emeritus, 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; Thomas Cibull, MD, dermatopathologist, Evanston Hospital, NorthShore University HealthSystem, Evanston, Ill.; and Rachel Stewart, DO, resident physician, Department of Pathology and Laboratory Medicine, University of Kentucky.

Histopathologic spectrum of thecoma of the ovary: a report of 70 cases

Diagnostic criteria for ductal adenocarcinoma of the prostate: interobserver variability

Surgeon influence on use of needle biopsy in patients with breast cancer

Müllerian precursor lesions in serous ovarian cancer patients

Loss of 5-hydroxymethylcytosine and increasing morphologic dysplasia in melanocytic tumors

Frequent CCNE1 amplification in endometrial intraepithelial carcinoma and uterine serous carcinoma

Tubal origin of ovarian endometriosis

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Histopathologic spectrum of thecoma of the ovary: a report of 70 cases

The authors evaluated 70 cases of thecoma of the ovary to ascertain their histopathologic spectrum. The tumors occurred over a wide age range (average, 49.6 years). Presentation in the form of pelvic or abdominal pain was uncommon, but postmenopausal bleeding was relatively frequent. All the tumors were unilateral, ranging up to 22.5 cm (average, 4.9 cm) in greatest dimension. They were typically intact, uniformly solid, and yellow. Microscopic examination usually showed a predominant diffuse growth but was altered to varying degrees by hyaline plaques (37 cases), nodular growth (20 cases), calcification (20 cases), and keloid-like sclerosis (12 cases). Forty percent of the tumors had a minor component of fibroma. Reticulin stains typically showed an investment of single cells. The tumor cells characteristically had ill-defined cytoplasmic membranes and distinctive pale gray cytoplasm. Two tumors had degenerative so-called bizarre atypia, and 15 tumors had nuclear grooves, but they were rarely conspicuous. The differential diagnosis is primarily with other sex cord-stromal neoplasms, particularly sclerosing stromal tumor, microcystic stromal tumor, steroid cell tumor, and adult granulosa cell tumor. The nodules of sclerosing stromal tumors have a more heterogenous morphology than the uniform cell type of thecomas, and microcystic stromal tumors are distinguished because of microcysts and the differing character of the tumor cells. Steroid cell tumors also have contrasting cytoplasmic features. Granulosa cell tumor with a prominent thecomatous component is the most clinically important differential diagnosis and is largely solved by thorough sampling. The authors’ experience indicates that thecomas have a relatively distinctive appearance, which contrasts with the lipid-rich character often emphasized in the literature. Awareness of this finding and a spectrum of other findings should enable the accurate interpretation of an almost invariably benign tumor.

Burandt E, Young RH. Thecoma of the ovary: a report of 70 cases emphasizing aspects of its histopathology different from those often portrayed and its differential diagnosis. Am J Surg Pathol. 2014;38:1023–1032.

Correspondence email not provided.

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Diagnostic criteria for ductal adenocarcinoma of the prostate: interobserver variability

Ductal adenocarcinoma of the prostate is clinically important because its behavior may differ from that of acinar adenocarcinoma. The authors investigated the interobserver variability of this diagnosis among experts in uropathology and defined diagnostic criteria. For the study, photomicrographs of 21 carcinomas with ductal features were distributed among 20 genitourinary pathologists from eight countries. Ductal adenocarcinoma of the prostate (DAC) was diagnosed by 18 observers (mean, 13.2 cases; range, 6–19). In 11 (52 percent) cases, a two-thirds consensus was reached for a diagnosis of DAC, and in five (24 percent) there was consensus against such a diagnosis. In DAC, the respondents reported papillary architecture (86 percent), stratification of nuclei (82 percent), high-grade nuclear features (54 percent), tall columnar epithelium (53 percent), elongated nuclei (52 percent), cribriform architecture (40 percent), and necrosis (seven percent). The most important diagnostic feature reported for DAC was papillary architecture (59 percent), whereas nuclear and cellular features were considered to be most important in only two percent to 11 percent of cases. The most common differential diagnoses were intraductal prostate cancer (52 percent), high-grade prostatic intraepithelial neoplasia (37 percent), and acinar adenocarcinoma (17 percent). The most common reason for not diagnosing DAC was lack of typical architecture (33 percent). The authors concluded that papillary architecture was the most useful diagnostic feature of DAC, and nuclear and cellular features were considered to be less important.

Seipel AH, Delahunt B, Samaratunga H, et al. Diagnostic criteria for ductal adenocarcinoma of the prostate: interobserver variability among 20 expert uropathologists. Histopathology. 2014;65:216–227.

Correspondence: Lars Egevad at lars.egevad@ki.se

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Surgeon influence on use of needle biopsy in patients with breast cancer

Use of needle biopsy is a proposed quality measure in the diagnosis and treatment of breast cancer, yet literature documents underuse. From a national perspective, little is known about the contribution of a patient’s surgeon to needle biopsy use, and knowledge regarding the downstream impact of needle biopsy on breast cancer care is incomplete. In a national Medicare study using 2003 to 2007 nationwide Medicare data from 89,712 patients with breast cancer and 12,405 surgeons, logistic regression was employed to evaluate the following outcomes: surgeon consultation before versus after biopsy, whether needle biopsy was used, and number of surgeries for cancer treatment. Multilevel analyses were adjusted for physician, patient, and structural covariates. The study found that needle biopsy was used in 68.4 percent (n=61,353) of all patients and only 53.7 percent (n=32,953/61,312) of patients seen by a surgeon before biopsy. Patient factors associated with surgeon consultation before biopsy included Medicaid coverage, rural residence, residence more than 8.1 miles from a radiologic facility performing needle biopsy, and no mammogram within 60 days before consultation. Among patients with surgeon consultation before biopsy, surgeon factors such as absence of board certification, training outside the United States, low case volume, earlier decade of medical school graduation, and lack of specialization in surgical oncology were negatively correlated with receipt of needle biopsy. Risk of multiple cancer surgeries was 33.7 percent for patients that underwent needle biopsy compared with 69.6 percent for those who did not (adjusted relative risk, 2.08; P<0.001). The authors concluded that needle biopsy is underused in the United States, resulting in a negative impact on breast cancer diagnosis and treatment. Surgeon-level interventions may improve needle biopsy rates and, accordingly, quality of care.

Eberth JM, Xu Y, Smith GL, et al. Surgeon influence on use of needle biopsy in patients with breast cancer: a national Medicare study. J Clin Oncol. 2014;32:2206–2216.

Correspondence: Dr. Benjamin D. Smith at bsmith3@mdan derson.org

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