Turkish Journal of Pathology - 2017; 33(2)

Intraductal Neoplasms of the Pancreas: An Update

G�k�e A�KAN, Pelin BA�CI, Bahar MEM��, Olca BA�T�RK — 2017-05-01

With improvements in imaging to detect silent pancreatic lesions and increases in the number of centers now performing pancreatic surgery, more surgeries have been performed for indications other than invasive carcinoma. This has enormously added to our knowledge of the intraductal neoplasms of the pancreas. In addition, our understanding of the genetics of these lesions has expanded with the introduction of routine molecular genetic analyses. In this review, we provide an update into the most common intraductal neoplasms, namely intraductal papillary mucinous neoplasm and intraductal tubulopapillary neoplasm. We first focus on their clinicopathologic and molecular features of relevance to the practicing pathologist and then discuss their differential diagnoses.

TERT Expression in Pituitary Adenomas

2017-05-01

Objective: Although pituitary adenomas have benign histomorphological features, some of them may present in an aggressive manner. To predict the behaviour of these tumours, telomerase reverse transcriptase (TERT) activity in pituitary adenomas has been the subject of a few studies with contradictory results. This study aims to investigate whether immunohistochemical expression of TERT differs in neoplastic and nonneoplastic pituitary tissues and aims to investigate whether TERT expression is related to clinicopathological features of pituitary adenomas. Material and Method: The study included 48 patients who had been diagnosed with pituitary adenomas and had clinical follow-ups. Nonneoplastic pituitary tissues were obtained from autopsy specimens (n=20). Immunohistochemistry for TERT antibody was performed. Both the nuclear and cytoplasmic expression of TERT antibody was noted, and total combined TERT staining was evaluated according to nuclear and cytoplasmic stainings. Results: TERT expression did not differ between neoplastic and nonneoplastic pituitary tissues. Neither total (combined nuclear and cytoplasmic) TERT nor nuclear TERT expression revealed any statistically significant relationship with any of the clinicopathological features. Higher cytoplasmic TERT expression was observed in adenomas with recurrence than adenomas without recurrence (p=0.035). Conclusion: This study introduces the notion that immunohistochemical expression of TERT does not differ in neoplastic and nonneoplastic pituitary tissues. Pituitary adenomas with cytoplasmic immunohistochemical expression of TERT have significantly higher rates of recurrence. Further studies, including combined methods of immunohistochemistry and molecular analyses in larger groups, may reveal applicable results for the clinical significance of TERT in pituitary adenomas.

The Role of EGFR, Hepatocyte Growth Factor Receptor (c-Met), c-ErbB2 (HER2-neu) and Clinicopathological Parameters in the Pathogenesis and Prognosis of Chordoma

Zeynep TOSUNER, S�heyla UYAR BOZKURT, T�rker KILI�, Baran YILMAZ — 2017-05-01

Objective: Chordoma is a rare malignant bone tumor with a poor outcome. Although radiotherapy and gamma knife surgery have been used for treatment, providing a cure for the tumor is not easy, because of the frequent recurrences. Molecular targeted therapy against tyrosine kinases has been effective in the treatment of malignancies such as breast and lung cancers and brain tumors. We aimed to analyse the histopathological features of chordomas and the immunoexpression profiles of the three receptor tyrosine kinases of EGFR, c-Met and c-Erb-B2 in chordomas. We have correlated these results with recurrence and overall survival status of the patients. Material and Method: We studied 49 chordoma patients in order to evaluate the histopathological features and immunohistochemical stainings by EGFR, c-Met and c-ErbB2 antibodies. Of the 49 patients, follow up data was available for 40 patients. Clinical data of the patients were correlated with histopathological features and survival analysis was performed. Results: The immunostaining rate by EGFR and c-Met was 73.5% and 12.2% respectively. None of the cases showed immunoreactivity by c-ErbB2 (0%). Of the 40 cases, 17 cases showed recurrences. EGFR expression was detected in 14 recurrent (14/17) and 17 non-recurrent cases (17/23). Four of the 17 recurrent cases (4/17) were positive by c-Met, while none of the non-recurrent cases (0/23) were positive by this antibody. Significantly, all cases with positive c-Met expression showed recurrences (p<0.05). Conclusion: Our study indicates that EGFR expression is detected in the majority of chordoma cases. c-Met expression can be used as a prognostic indicator for chordoma.

Correlation of FOXL2 with Inhibin and Calretinin in the Diagnosis of Ovarian Sex Cord Stromal Tumors

Ruchi RATHORE, Deepshikha ARORA, Sarla AGARWAL, Sonal SHARMA — 2017-05-01

Objective: Alpha-inhibin and calretinin have been traditionally used as immunomarkers for sex cord stromal tumors. However, the variation in their immunoreactivity and their lack of specificity for sex cord stromal tumor makes the search for a more sensitive and specific immunohistochemical marker essential in routine diagnosis of sex cord stromal tumor. This study was conducted to correlate the diagnostic utility of FOXL2 with inhibin and calretinin in the diagnosis of sex cord stromal tumors of ovary. Material and Method: The study was conducted in the department of pathology. 31 cases of sex cord tumors received in past eight years (2002-2010) were included in this study. Immunostaining for inhibin, calretinin and FOXL2 was performed and compared on the basis of staining intensity and percentage positivity on all the cases. Results: Calretinin was found to be positive in 29/31 sex cord stromal tumors with variable intensities and was negative in two cases of sex cord stromal tumors, inhibin was positive in 28/31 and only three cases had no cytoplasmic staining. All the 31 cases included in this study were positive for FOXL2 with variable staining intensities and percentage positivity. Ten cases of each surface epithelial and germ cell tumors were also negatively stained with FOXL2. Conclusion: In contrast to inhibin and calretinin, FOXL2 had a sensitivity and specificity of 100% for all the cases of sex cord stromal tumors included in this study.

Clinicopathological Features of Bone Marrow Infiltration in Hodgkin Lymphoma. Should Bone Marrow Staging Be Done Only in High Risk Patients?

2017-05-01

Objective: The frequency of bone marrow infiltration by Hodgkin lymphoma is low and varies from 3 to 18%. Hence there exists a dilemma whether bone marrow staging should be done only in the high risk cases. This study aims to study the clinicopathological features and the histomorphology of bone marrow infiltration by Hodgkin Lymphoma. Material and Method: Bone marrow aspirates and biopsies from cases of Hodgkin lymphoma diagnosed between 2007 and 2015 were studied. Immunohistochemistry with CD15 and CD30 were done in necessary cases. Bone marrow infiltration was correlated with various clinicopathological parameters. Results: Ten of the 81 cases (12.3%) studied showed infiltration by Hodgkin lymphoma in the bone marrow biopsy sections. All the aspirates were negative. Bone marrow in the involved cases showed Reed-Sternberg cells and/or mononuclear Hodgkin cells positive for CD30 in a polymorphous inflammatory background. Cases of lymphocyte depleted subtype (66%) and those with leucopenia/ thrombocytopenia (100%) were frequently associated with bone marrow infiltration. B-symptoms, anemia and mixed cellularity were the other risk factors. However none of these risk factors were noted in two out of the ten cases with bone marrow infiltration. Conclusion: As the role of bone marrow aspirate is minimal in the staging of Hodgkin lymphoma, bone marrow biopsy should be the method of choice. Immunohistochemistry helps in the doubtful cases. Bone marrow involvement was frequent but not confined to the high risk groups. Our findings suggest that bone marrow staging should not be restricted to the high risk cases alone.

What does the Data of 354,725 Patients from Turkey Tell US About Cervical Smear Epithelial Cell Abnormalities? - The Epithelial Cell Abnormality Rate is Increasing - Quality Control Studies and Corrective Activity are Musts

2017-05-01

Objective: There is no other screening program close to the success rate of PAP test. Cervical cytology constitutes a large workload so that quality control in cervical cytology is important for the quality assurance of pathology laboratories. Material and Method: In this study, we collected the cervical cytology results from all over Turkey and discussed the parameters influencing the quality of the PAP test. The study was conducted with Turkish gynaecopathology working group and 38 centers (totally 45 hospitals) agreed to contribute from 24 different cities. The study was designed to cover the cervical cytology results during 2013. The results were evaluated from the data based on an online questionnaire. Results: The total number of Epithelial Cell Abnormality was 18,020 and the global Epithelial Cell Abnormality rate was 5.08% in the total 354,725 smears and ranging between 0.3% to 16.64% among centers. The Atypical squamous cells /Squamous intraepithelial lesion ratios changed within the range of 0.21-13.94 with an average of 2.61. When the centers were asked whether they performed quality assurance studies, only 14 out of 28 centers, which shared the information, had such a control study and some quality parameters were better in these centers. Conclusion: There is an increase in the global Epithelial Cell Abnormality rate and there are great differences among centers. Quality control studies including the Atypical squamous cells/Squamous intraepithelial lesion ratio are important. Corrective and preventive action according to quality control parameters is a must. A cervical cytology subspecialist in every center can be utopic but a dedicated pathologist in the center is certainly needed.

Comparison of Three Different New Bipolar Energy Modalities and Classic Bipolar in Vivo for Tissue Thermal Spread

2017-05-01

Objective: The aim of this study was to compare three different new bipolar energy modalities and classic bipolar in vivo for tissue thermal spread. Material and Method: This prospective, randomized, single-blind study was conducted between Septemsber 2012 and July 2013. Eighteen patients aged 40-65 years undergoing hysterectomy and bilateral salpingectomy for benign etiology were included in the study. Before the hysterectomy operation began, it was marked nearly distal third cm started from uterine corn and proximal close third cm started from fimbrial bottoms by visualizing both fallopian tubes. The surgery was performed using one 5 mm applicator of PlasmaKinetics�, EnSeal�, LigaSure� or classic bipolar energy modality. The time each device was used was standardized as the minimum time of the audible warning of the device for tissue impedance and as tissue vaporization on classic bipolar. Tissues were dyed by both H&E and Masson's Trichrome in the pathology laboratory. Thermal spread was compared. Results: Evaluation of the damage on the uterine tubes by each device used revealed that LigaSure� was associated with increased thermal injury compared to PlasmaKinetics� (p=0.007). Apart from PlasmaKineticsTM (p=0.022), there was no statistically significant difference between the three devices in terms of thermal damage spread in the distal and proximal fallopian tubes. Conclusion: To reduce lateral thermal damage, Plasmakinetics� may be preferable to Ligasure� among the three different new bipolar energy modalities.

Bioprotective Efficacy of Erucin Against 7,12-Dimethylbenz(α)anthracene-Induced Microstructural Changes in Male Wistar Rats

2017-05-01

Objective: Environmental pollutants are responsible for inducing a number of biochemical and physical changes in the various organs of an organism. The most potent pollutants is7,12-dimethylbenz(α)anthracene (DMBA) (a genotoxic carcinogen), a polyaromatic hydrocarbon. It is known to induce a number of genetic changes including the formation of DNA adducts. These genotypic changes in turn are responsible for inducing microstructural changes in the vital organs viz. kidneys, stomach and lungs of an organism. These changes in turn cause biochemical alterations in an animal and hence alter the normal functioning. Synthetic drugs provide a sigh of relief but a large number of side effects in addition to the growing resistance has made it necessary to find an efficient alternative. Plant secondary metabolites, especially glucosinolate hydrolytic products, are known for their high bioprotective activity. The current study was therefore designed to analyze the bioprotective role of erucin against DMBA-induced microstructural changes in kidneys, lungs and stomach of male Wistar rats using histological analysis. Material and Method: The bioprotective efficacy of erucin was evaluated in male Wistar rats against DMBA induced microstructural changes. The rats were divided into five groups where group I was untreated control, group II was DMBA treated and group III-V were treatment (DMBA + erucin) groups. Results: Erucin was able to protect the rats against DMBA-induced histopathological changes in the lungs and stomach. No changes were observed in the kidney following treatment with DMBA or erucin. Conclusion: Erucin has bioprotective activity against genotoxic carcinogen.

Phyllodes Tumor of Anogenital Mammary-like Glands with Diffuse Pseudoangiomatous Stromal Hyperplasia

2017-05-01

Anogenital mammary-like glands may give rise to various pathologic lesions identical to those known in mammary pathology. Tumor occurring in the anogenital region is extremely rare. The histogenetic origin of this tumor is controversial as it is being debated whether such lesions evolve from ectopic breast tissue and most recently, anogenital mammary-like gland. We report a 28-year-old girl who presented with a painless mass in the anogenital region, which was subsequently excised. Microscopic examination revealed morphologic pattern characteristic of benign phyllodes tumor with pseudoangiomatous stromal hyperplasia. We present this case to emphasize the importance of recognizing this uncommon lesion occurring at an extremely unusual site. We also discuss the histogenesis of phyllodes tumor and related lesions occurring in the anogenital region in light of the current literature along with a brief review of the previously reported cases of anogenital mammary-like glands.

A Rare Diagnosis in the Neck During Childhood: Congenital Chondrolipoma

Fulya �ZER, Nebil BAL — 2017-05-01

Chondrolipomas are mesenchymal tumors that found as mature cartilage tissue in a fat tissue. A 2-year-old boy was seen with a complaint of a mass of the neck. On physical examination of the child, there was a one-centimeter mass above the sternocleidomastoid muscle on the lateral neck. Pathological examination of this mass after excision was reported as chondrolipoma. Chondrolipomas are seen mostly in the breast and in the adult. They are rare tumors of the head and neck area and seen mostly the in oral cavity here. This is the first case of chondrolipoma with this age and localization combination in the literature. Chondrolipoma should therefore also be considered in the differential diagnosis of congenital masses located at lateral cervical area.

Pancreatoblastoma, a Rare Childhood Tumor: A Case Report

Asuman ARGON, Ahmet �EL�K, Haldun �N�Z, Geylani �ZOK, Funda YILMAZ BARBET — 2017-05-01

Pancreatoblastoma, rarely encountered in the literature, is a malignant exocrine tumor seen in the pancreas. A 5-year-old boy suffering from abdominal pain was sent to our institute for further examination and treatment. Clinical examination was normal but for a palpable abdominal tumor mass. Abdominal Doppler ultrasonography showed a mass with well-defined margins within the body of the pancreas. Laboratory tests, including lactic dehydrogenase, alpha-fetoprotein and cancer antigen 125 were abnormal. The tumor invading the splenic vein and transverse colon was removed totally. We observed a hypercellular tumor in histopathological examination. The tumor had epithelial acinar cells and squamoid morules (corpuscles) separated by stromal bands. Adjuvant chemotherapy was used after surgery. However, the patient died 14 months later. All data about pancreatoblastoma have to be collected in order to choose the treatment to elucidate the molecular pathogenesis of the tumor, to diagnose it early and to develop target-specific treatments.

Malignant Melanoma Presenting as a Mediastinal Malignant Melanoma Presenting as a Mediastinal Unknown Primary Origin?

2017-05-01

The most common site of primary malignant melanoma is the skin, however, virtually any organ system may be involved. Metastatic melanoma of unknown primary origin accounts for approximately 2-6% of all melanoma cases. The mediastinum as the site for malignant melanoma is extremely rare, both as a primary or metastatic lesion. Primary malignant melanoma of mediastinum is very rare with only a handful of reports in the literature. We hereby report a rare case of malignant melanoma of mediastinum in a 31 year old male who was initially misdiagnosed on fine needle aspiration cytology as adenocarcinoma for which he received chemotherapy with clinical deterioration. Even on extensive meticulous search, no primary was discovered.

Hydatid Cyst of Parotid Gland: An Unusual Case Diagnosed by Fine Needle Aspiration Biopsy

2017-05-01

Hydatid disease is a zoonotic disease caused by the parasite Echinococcus granulosus. This infection frequently infects the liver and the lung and even in endemic regions rarely occurs in the head and neck region. This is also true for the parotid gland. The diagnosis relies on imaging techniques and the medical history. Another method that is helpful in the diagnosis is serological tests. Fine-needle aspiration biopsy is usually not recommended due to the potential risk of anaphylactic shock or spreading of daughter cysts. The preferred treatment method of hydatid cysts in the salivary gland is surgical excision. We introduce a rare case of hydatid cyst in the parotid gland diagnosed preoperatively by fine-needle aspiration biopsy and discuss the differential diagnosis.

Intra-Articular Glomus Tumor� A Rare Presentation

Ritesh SACHDEV, Ishani MOHAPATRA, Shalini GOEL, Smeeta GAJENDRA — 2017-05-01