Turkish Journal of Pathology - 2013; 29(3)

Editorial

Alp USUB�T�N — 2013-09-01

Editorial

Alp USUB�T�N — 2013-09-01

The Cell Block Method Increases the Diagnostic Yield in Exudative Pleural Effusions Accompanying Lung Cancer

2013-09-01

Objective: Thoracentesis is the first investigation to be performed in a patient with lung cancer and pleural effusion. The diagnostic yield of conventional smear studies varies in the first thoracentesis. In this study, we aimed to investigate if the cell block method increases the diagnostic yield in exudative pleural effusions accompanying lung cancer. Material and Method: Forty patients with lung cancer and exudative pleural effusions were included. Ten mililiters of fresh pleural fl uid was obtained by thoracentesis from all patients in the initial evaluation. The pleural fluid sample was divided into two equal parts. One part was subjected to conventional smear and the other to the cell block method. Conventional smears were stained with May-Gr�nwald-Giemsa and Hematoxylin-Eosin. Cell block sections were stained with Hematoxylin-Eosin and mucicarmine. Conventional smear findings were grouped as “benign cytology” or “malignant cytology”. Th e cell block sections were evaluated for the presence of single tumor cells, acinary or papillary pattern, solid islands and staining with mucicarmine. Results: There were 20 patients each in the benign and malignant conventional smear group. In the benign group, adding the cell block method to conventional smear provided a diagnosis of malignancy in 4 more patients and the diagnosis of malignant effusion was increased by a ratio of 10% (4/40). In the malignant group, adding the cell block technique provided the subtyping of lung cancer as adenocarcinoma in 7 patients (7/20, 35%). Conclusion: Our study confirms that the cell block method combined with conventional smear increases the diagnostic yield in exudative pleural effusions accompanying lung cancer.

Predictive Value of Micronucleus Count in Cervical Intraepithelial Neoplasia and Carcinoma

Marie Moses AMBROISE, Kanchana BALASUNDARAM, Manjiri PHANSALKAR — 2013-09-01

Objective: A micronucleus is a small additional nucleus formed due to chromosomal loss or fragmentation. The aim of this study was to assess the utility of micronucleus count as a screening tool in cervical cancer. Material and Method: A total of 132 cases consisting of 42 pre-neoplastic and neoplastic cases and 90 non-neoplastic cases were studied. Only routine Papanicolaou-stained cervical smears were used. In each smear, the number of micronucleated cells and binucleated cells were counted under oil immersion and expressed as a count per 1,000 cells. The micronucleated and binucleated cell counts in pre-neoplastic, neoplastic and non-neoplastic categories were compared for statistical significance. The counts were also correlated with age, duration of marital life, number of pregnancies and abortions. Results: The micronucleus count and the binucleated cell count were significantly higher in the high -grade squamous intraepithelial lesion (HSIL) and invasive carcinoma categories compared to low -grade squamous intraepithelial lesion (LSIL) and non-neoplastic cases. Receiver operating characteristic (ROC) curve analysis revealed that micronucleus count and binucleated cell count possess a high degree of sensitivity and specificity for identifying HSIL and invasive carcinoma. Conclusion: Our results reveal that micronucleus evaluation in routine Pap smears is a very useful biomarker in cervical cancer screening. The binucleated cell count increases the predictive value of this simple test.

Patients with Epithelial Cell Abnormality in PAP Smears: Correlation of Results with Follow-Up Smears andCervical Biopsies

2013-09-01

Objective: Cervical carcinoma has been included in the preventable diseases category ever since the use of cervical cytology in routine practice. The Pap test is an efficient screening test. We aimed to compare the cervical cytology diagnosis with biopsy and smear follow up results in our institution. Material and Method: We aimed to compare the diagnosis of cytology material examined in our institution during the 2009-2012 period with their biopsy and smear follow ups. The diagnoses were compared with the follow up smears and/or cervical biopsies. Results: 13610 Pap tests were examined during September 2009-July 2012. Among these cases, there were 370 atypical squamous cells of undetermined significance (ASCUS), 29 atypical squamous cells-high grade intraepithelial lesions cannot be excluded (ASC-H), 155 low grade squamous intraepithelial lesion (LSIL), 33 high grade squamous intraepithelial lesion (HSIL), and 5 atypical glandular cell (AGC) diagnoses. The ratio of atypical squamous cell (ASCUS and ASC-H) to squamous intraepithelial lesions was 2.12. Squamous intraepithelial lesion was verified in 47 of 91 ASCUS cases. Among patients who had a cervical biopsy, 52 of 64 LSIL cases and all of the 21 HSIL cases had biopsy-proven SIL. Conclusion: Atypical squamous cell (ASC) is the most common diagnosis in abnormal cervical cytology. As it is indefinite, ASC is used as a quality assurance parameter and the aim is to decrease its use. As the ratio of epithelial cell abnormality is variable in different populations, the ASC/SIL is a more definite variable to be used for quality assurance. The efficiency in clinical use of the cervical cytology screening test is determined by biopsy verification. Our epithelial cell abnormality, ASC/SIL ratio and cytology-histology correlation values were parallel to the literature, proving that the methods are used reliably at our institution.

Comparison of Growth Hormone Receptor, Igf-1r and Igfbp-3 Between Tumoral and Non-Tumoral Areas in Non-Melanoma Skin Cancers

�zge G�ND�Z, �zay G�K�Z, G�l ERK�N, T�lin AKAN — 2013-09-01

Objective: A relationship between the pathogenesis of some cancers and growth hormone, insulin-like growth factor-1 and insulin-like growth factors binding protein-3 has been shown. Our aim was to evaluate the expression of growth hormone receptor, insulin-like growth factor-1 receptor and insulin-like growth factors binding protein-3 in actinic keratosis, basal cell carcinoma and squamous cell carcinoma, and to compare the expression patterns of tumoral areas with normal epidermis and skin appendages. Material and Method: The formalin-fixed, paraff in-embedded tissues of 40 patients which were diagnosed as 15 actinic keratosis, 15 basal cell carcinoma and 15 squamous cell carcinoma were analyzed for growth hormone receptor, insulin-like growth factor-1 receptor and insulin-like growth factors binding protein-3 with the immunohistochemical method using the streptavidin-biotin-peroxidase technique. Results: There was no difference between tumoral areas of actinic keratosis, basal cell carcinoma and squamous cell carcinoma in expression of growth hormone receptor and insulin-like growth factors binding protein-3 (P>0.05). However, a significantly higher expression of insulin-like growth factor-1 receptor was observed in tumoral areas of squamous cell carcinoma (P<0.01). In basal cell carcinoma, a significantly lower intensity of immunostaining with growth hormone receptor, insulin-like growth factor-1 receptor and insulin-like growth factors binding protein-3 in tumoral areas than skin appendages was seen (P <0.01). In squamous cell carcinoma, higher expressions of growth hormone receptor, insulin-like growth factor-1 receptor and insulin-like growth factors binding protein-3 in tumoral areas than peritumoral epidermis was found (P =0.06, P <0.01 and P =0.02, respectively). Conclusion: Our study points out that, growth hormone receptor, insulin-like growth factor-1 receptor and insulin-like growth factors binding protein-3 have a role in the pathogenesis of non-melanoma skin cancers, especially squamous cell carcinoma.

Assessment of Maturation Status of Tumor-Infiltrating Dendritic Cells in Invasive Ductal Carcinoma of the Breast: Relation with Vascular Endothelial Growth Factor Expression

Nevine M. F. EL DEEB, Radwa A. MEHANNA — 2013-09-01

Objective: Poor immunogenicity has been described in breast carcinoma although dendritic cells, the major antigen presenters, are known to infiltrate the tumor. Vascular endothelial growth factor has been proposed to reduce local immune response in tumors. We investigated the maturation status of dendritic cells in invasive ductal carcinoma of the breast in relation to vascular endothelial growth factor expression and clinicopathological parameters. Material and Method: Fifty invasive ductal carcinomas of the breast were immunostained with CD1a (marker of immature dendritic cells); CD83 (marker of mature dendritic cells), vascular endothelial growth factor, estrogen receptor and progesterone receptor. Results: Mature dendritic cells were detected in 36 cases (72%), and correlated with smaller tumor size, negative lymph nodes, positive steroid receptor status, and lower grade (P<0.001). Immature dendritic cells were found in 100% of cases and correlated only with negative steroid receptor expression (estrogen receptor and progesterone receptor) (P=0.006 and 0.020 respectively). Vascular endothelial growth factor expression was detected in 44 cases (88%), and correlated directly with positive nodal metastases (P=0.014), correlated inversely with mature dendritic cell count (P=0.005); and did not correlate with immature dendritic cell count (P=0.104). Conclusion: Mature dendritic cell count correlates with good prognostic features in invasive ductal carcinoma of the breast, suggesting their role in initiating primary anti-tumor immune response. Vascular endothelial growth factor expression may play a role in inhibition of dendritic cell maturation sequence in the tumor microenvironment.

The Approaches of Physicians Working in the Field of Pathology Regarding Forensic Pathology Practice and the Training Process

2013-09-01

Objective: Forensic autopsies are performed by the forensic medicine department and the microscopic examination processes by pathology specialists within the forensic medicine practice in Turkey. This disconnection in the process raises problems in the training of both branches. The aim of this study was to determine the awareness of pathology staff on forensic medicine practices and responsibilities and their opinion on the pathology training model in the forensic medicine specialty and to discuss the matter within the framework of the present situation and global applications. Material and Method: A 15-item questionnaire form distributed to the participant physicians during registration at the 21st National Pathology Congress held in 2011 was evaluated. Results: 94 participants responded. A negative opinion was expressed by 72% about the interest in the general post-mortem process. The view that pathology specialists should undergo a separate training to perform autopsies was predominant and there was a general lack of interest in all kinds of autopsy processes. The percentage who said they knew the legal responsibility of a pathology specialist regarding forensic autopsies correctly was 37%. The questions “what are the necessary factors to contribute to the pathology training in forensic medicine” and “if anything is required, which of them would take priority” were respectively answered as “for me to be interested (46%)” and “a system guaranteeing that training will always be given by pathology specialists (67%)”. Despite the possibility of becoming a forensic medicine specialist in two years, the mean answer score of the participants to the phrase “I do not consider becoming a forensic medicine specialist” was 4.1 (out of 5). Conclusion: A reluctance among the pathologists in our country was seen regarding forensic medicine specialists being able to perform post-mortem microscopic examination. However, despite their legal responsibilities, their interest in forensic pathology practice was low. There seems to be rational factor that would increase this interest in the near future. Cooperation is necessary to enable forensic medicine specialists to perform post-mortem pathology procedures. This cooperation should be based on improving the training of pathology research assistants.

HPV Types in Turkey: Multicenter Hospital Based Evaluation of 6388 Patients in Turkish Gynecologic Oncology Group Centers

2013-09-01

Objective: To evaluate the prevalence of HPV DNA and cervical cytological abnormalities, to compare cervical cytology results and HPV DNA and to define HPV types distribution in a large series of Turkish women who have undergone HPV analysis in hospitals that are members of the Turkish Gynecological Oncology Group. Material and Method: Between 2006 and 2010, a total of 6388 patients’ data was retrospectively evaluated at 12 healthcare centers in Turkey. Demographic characteristics, cervical cytology results, HPV status and types were compared. Results: The mean age of the patients was 38.9�10.2. Overall, 25% of the women were found to be HPV positive. Presence of HPV-DNA among patients with abnormal and normal cytology was 52% and 27%, respectively. There was significant diff erence with respect to decades of life and HPV positivity (p < 0.05). HPV was positive in (within the HPV (+) patients) 37%, 9%, 27%, 20%, 22%, and 41% of the ASCUS, ASC-H, LSIL HSIL, glandular cell abnormalities, and SCC cases respectively The most common HPV types in our study were as follows; HPV 16 (32%), HPV 6 (17%), HPV 11 (9%), HPV 18 (8%), HPV 31 (6%), HPV 51 (5%), HPV 33 (3%). Conclusion: In this hospital based retrospective analysis, HPV genotypes in Turkish women with normal and abnormal cytology are similar to those reported from western countries. Further population based prospective multicenter studies are necessary to determine non-hospital based HPV prevalence in Turkish women.

Cystic Solitary Fibrous Tumor of the Liver: A Case Report

2013-09-01

Solitary fibrous tumors are unusual neoplasms that are rarely found in the liver parenchyma. They are usually described as hard, grayish white, well-defined lesions. Predominant cystic change in a solitary fibrous tumor is an unexpected finding, with only a few previous cases reported in the literature, two of which are localized in the head and neck region. Herein, we report a unique case of solitary fibrous tumor of the liver in a 38-year-old female with predominant multiloculated cystic appearance, and discuss the histopathologic differential diagnosis.

Spindle Cell Rhabdomyosarcoma Displaying CD34 Positivity: A Potential Diagnostic Pitfall; Report of Two Pediatric Cases

Ayper KA�AR, Hac� Ahmet DEM�R, Haydar DURAK, Serg�len DERV��O�LU — 2013-09-01

Spindle cell rhabdomyosarcoma is a rare subtype of rhabdomyosarcoma mainly seen in children. Occasional aberrant staining with a variety of immunohistochemical markers has been noted. The aberrantly expressed markers include alpha-smooth muscle actin, cytokeratin, S100, neurofilaments, CD20, immunoglobins, and CD117. We report herein two pediatric cases displaying strong CD34 positivity and one with additional focal CD117 positivity, causing considerable difficulty in distinction from solitary fibrous tumor and extra-gastrointestinal stromal tumor. To our knowledge, CD34 staining has been merely reported in rhabdomyosarcoma. Spindle cell rhabdomyosarcoma has to be considered in the differential diagnosis of childhood spindle cell tumors. Post-chemotherapy specimens should be evaluated in caution, since chemotherapy can cause considerable changes in tumor antigen expression. Since CD117 and CD34 are stem cell markers, their positivity in pediatric tumors should be interpreted with caution. Even if the morphology is not supportive, a wide immunohistochemical panel should be applied in childhood malignant solid tumors.

Primary Low Grade Intratesticular Leiomyosarcoma: Case Report and Review of the Literature

Samir ABDULLAZADE, �nder KARA, B�lent AKDO�AN, Dilek ERTOY BAYDAR — 2013-09-01

A 49-year-old male presented with a painful mass in the left scrotum. An inguinal orchiectomy was performed. Pathological examination revealed a well-differentiated leiomyosarcoma completely located inside the testicular parenchyma. We report this unusual case because primary leiomyosarcoma of the testis proper is extremely rare; our patient being the 19th case recorded thus far in the medical literature. It can lead to significant clinical and diagnostic difficulty due to its wide differential diagnosis and extreme rarity.

Bilateral Breast Metastasis from Mucinous Adenocarcinoma of the Rectum: A Case Report and Review of the Literature

2013-09-01

Metastatic breast carcinoma is rarely seen in clinical practice. It has been reported that lymphoma-leukemia, melanoma and sarcomas can metastasize to the breast. Bilateral metastases to the breast are rare and commonly have been seen to originate from ovarian carcinoma. Adenocarcinoma of rectum metastasizing to breast is an extremely rare clinico-pathological situation. We report a 28-year-old female who presented with bilateral breast metastasis 9 months after abdomino-perineal resection and total meso-rectal excision for a locally advanced mucinous adenocarcinoma of the rectum. A few case reports of a mucinous adenocarcinoma of rectum presenting with bilateral breast metastasis have been seen in the world literature and we hereby report this case who till now is the youngest patient reported.

Oral Focal Mucinosis: A Case Report and Review of the Literature

Merva SOLUK TEKKE��N, Mustafa YILMAZ, Vakur OLGA� — 2013-09-01

Oral focal mucinosis is a rare clinicopathological entity that represents the mucosal counterpart of cutaneous focal mucinosis or cutaneous myxoid cyst. The aetiology is unknown. Oral focal mucinosis is most common in young adults. The gingiva is the most common site and the hard palate is the second most common location. A 19-year-old male patient presented with a 2 cm painless mass localized to the palatal side. An excisional biopsy was taken and sent for histopathologic evaluation to our department. Histopathologic findings were a well-circumscribed lesion composed of myxomatous connective tissue that contained bipolar, fusiform or stellate shaped fibroblasts. The aim of this study was to bring oral focal musinosis diagnosis to the attention of clinicians and pathologists when considering the differential diagnosis of gingival and palatal nodules.

Multiloculated Epidermoid Cyst of Spleen: A Case Report

2013-09-01

Splenic epidermoid cyst is a rare cystic disease of spleen. Primary cysts of the spleen lined by epithelium or endothelium are usually seen in young adults. A 23-year-old woman with abdominal distension presented at the surgery outpatients of our hospital. Splenomegaly was detected on physical examination and elective surgery was performed. The multiloculated cyst was 10x6 cm on macroscopic examination and creamy material was drained. Immunohistochemical examination of the cyst lined with epithelium was Cytokeratin and CEA positive and calretinin, BerEP4, HBME-1 and F8 negative and it was reported as ‘epidermoid cyst'. We discussed the etiopathogenesis of our case in light of the theories regarding its development.

“Pure” Primary Large Cell Neuroendocrine Carcinoma of the Urinary Bladder

Teresa PUS�OL, Maria Grazia ZORZI, Doriana MORICHETTI — 2013-09-01

“Pure” Primary Large Cell Neuroendocrine Carcinoma of the Urinary Bladder

Ay�eg�l SARI — 2013-09-01