Excisional Biopsy Specimen Research Articles

Evaluation of automated silver-enhanced in situ hybridization (SISH) for detection of HER2 gene amplification in breast carcinoma excision and core biopsy specimens

Evaluation of automated silver-enhanced in situ hybridization (SISH) for detection of HER2 gene amplification in breast carcinoma excision and core biopsy specimens

Bacillary Angiomatosis as an Initial Presentation in an HIV-Positive Man

0196-4399/00 (see frontmatter) © 2009 Elsevier Clinical Microbiology Newsletter 31:19,2009 Introduction A 26-year-old man presented with fever, malaise, scrotal skin lesions, and inguinal lymphadenopathy. An excisional biopsy specimen from an inguinal lymph node demonstrated a florid vascular proliferation. AWarthin-Starry stain, an immunoperoxidase stain, and PCR studies confirmed the presence of Bartonella henselae. The diagnosis of bacillary angiomatosis secondary to B. henselae infection was established. Bacillary angiomatosis is a vascular proliferative disease most often reported in patients with human immunodeficiency virus (HIV) infection (1) and less frequently in patients with other causes of immunosuppression. Because of the high correlation between HIV and Bartonella infection, we recommended that the patient be tested for HIV infection, whereupon he was found to be positive for HIV. We recommend that all patients with bacillary angiomatosis and unknown immune status undergo HIV studies.

Perinatal Tuberculosis in a 73-Day-Old Infant

A 73-day-old female infant presented with cough and fever. A chest roentgenogram showed a pneumonic patch, but empirical antibiotic treatment failed. The pathology of an excisional biopsy specimen confirmed pulmonary tuberculosis. We emphasize that tuberculosis should be considered for neonates or infants with unresponsive pneumonia because delayed diagnosis is associated with a fatal outcome.

Comparison of fluorescent in situ hybridization HER-2/neu results on core needle biopsy and excisional biopsy in primary breast cancer

HER-2/neu status is critical for the therapy for breast carcinoma. Fluorescent in situ hybridization for gene amplification and immunohistochemical stains for protein expression are widely used methods to detect HER-2/neu status. Multiple studies have shown fluorescent in situ hybridization and immunohistochemical stain results to have high concordance rates. To our knowledge, a comparison between fluorescent in situ hybridization results for core needle biopsy and the subsequent excisional biopsy specimens has not yet been studied. We retrospectively evaluated the fluorescence in situ hybridization and immunohistochemical results in both the breast core needle and the excisional biopsy of 125 patients with invasive breast carcinoma from 2002 to 2005. There was complete concordance with respect to both immunohistochemical and fluorescence in situ hybridization results for core needle biopsy and excisional biopsy specimens in 87% of the patients evaluated. Comparison of fluorescent in situ hybridization results of the 129 core needle biopsies to the 131 excisional biopsies of all 125 patients showed a concordance rate of 92%. The immunohistochemical stain results of the same core needle and excisional biopsies showed a concordance rate of 98%. Comparison of the immunohistochemical stain results with the fluorescent in situ hybridization results for all 260 cases examined showed 95% concordance. On the basis of our study, we observed that repeating HER-2/neu testing by immunohistochemical stain and/or fluorescent in situ hybridization methods on excisional biopsy is not unreasonable, in particular in cases of intratumoral heterogeneity, indeterminate/borderline HER-2/neu results and after neoadjuvant chemotherapy.

Haemangiosarcoma in the uterine remnant of a spayed female dog

A 11-year-old, female, spayed greyhound was presented with a haemorrhagic discharge from the vulva. Clinical examination, vaginoscopy and a computed tomography scan showed an irregular egg-sized mass in the region of the cervix and uterine stump. An endoscopic grab biopsy (incisional) suggested a malignant mesenchymal tumour. Following this, surgical excision of the cranial vagina, cervix and the uterine remnant was performed. The final diagnosis of haemangiosarcoma was based on histological examination of the larger excisional biopsy specimen and was confirmed by positive immunolabelling of the neoplastic endothelial cells for the von Willebrand factor.

Tuberculous cervical lymphadenitis in a patient with laryngeal carcinoma

We report an extremely rare presentation of concomitant tuberculous cervical lymphadenitis in a patient with carcinoma of the larynx. A 66-year-old man presented with a nine-month history of hoarseness. He was found to have an exophytic lesion over the posterior half of the right vocal fold. He also had a palpable right jugulodigastric node. Biopsy of the vocal fold lesion revealed invasive squamous cell carcinoma. Histological analysis of an excision biopsy specimen from the lymph node was highly suggestive of tuberculosis. On further assessment of the slides, one acid-fast bacillus was seen. The patient was treated with radiotherapy to the larynx and concomitant anti-tuberculosis chemotherapy. Five months following treatment, there was no sign of laryngeal cancer recurrence; however, the patient continued to have a productive cough and night sweats. To our knowledge, this is the first report of a laryngeal carcinoma with concurrent tuberculous cervical lymphadenitis. In the face of an unhelpful fine needle aspiration cytology examination, an assumption of metastatic neck disease could have been made. Subsequent surgical and/or oncological intervention would have been highly inappropriate, with potentially catastrophic effects. This case highlights the importance of proper diagnosis, and emphasises the fact that tuberculosis should always be borne in mind in the differential diagnosis.

Optimal Use of Re-Excision in Patients Diagnosed with Early-Stage Breast Cancer by Excisional Biopsy Treated with Breast-Conserving Therapy

The goal of the current study is to help refine guidelines for the need for re-excision and the appropriate amount of breast tissue to re-excise in patients with early breast cancer following excisional breast biopsy when treated with breast-conserving therapy (BCT). The study population consisted of 441 patients derived from a dataset of 607 consecutive cases of stage I and II breast cancer treated with BCT, in which patients underwent primary excisional diagnostic biopsy and subsequent re-excision prior to the initiation of radiation therapy (RT). A single pathologist reviewed all specimens. Re-excision was indicated because tumor was found close to or involving the resection margin. In 333 of the 441 cases, it was possible to measure the extension of carcinoma into the re-excision specimen. Margins were classified as negative (carcinoma>4.2 mm from the margin), near (<4.2 mm from the margin) or positive. Any carcinoma identified near the final margin was quantified by width of invasive carcinoma and number of ductal carcinoma in situ (DCIS) ducts near the margin and subdivided into three distinct groups: least, intermediate, and greatest amount. These factors were then analyzed to determine the likelihood and extent of residual carcinoma in re-excision specimens. Statistical analysis was performed using Systat version 10 (SPSS Inc., Chicago, IL). The quantity of carcinoma near the initial biopsy margin and the invasive carcinoma-to-specimen dimension ratio demonstrated a significant association with increasing amounts of residual carcinoma at re-excision. Combination of these two variables allowed for a statistically significant (P<0.001) calculation of risk index for identifying significant residual invasive carcinoma or DCIS in the adjacent breast parenchyma at re-excision, and yielded stratification into low- (6%), intermediate- (27%), and high-risk (44%) groups. In re-excision specimens, the observed distance of carcinoma extension into adjacent breast tissue was associated with a statistically significant decrease in the ratio of the initial excisional biopsy specimen dimensions and invasive carcinoma dimensions. Combining the initial margin status with the specimen-to-invasive carcinoma maximum dimension ratio yielded an accurate predictor of the maximum distance of tumor extension. Evaluation of the initial excisional biopsy margin status in correlation with the invasive carcinoma-to-specimen maximum dimension ratio may be helpful for (1) identifying patients who require re-excision prior to RT and (2) predicting the quantity of additional breast tissue to excise to ensure adequate surgical margins with BCT.

Primary breast lymphoma treated with r-chop chemotherapy

Primary breast lymphoma is rare disease which is treated with surgery, radiotherapy and chemoterapy. There is little experience of rituximab treatment is in breast lymphoma. Here we present a case of primary breast lymhoma treated with rituximab and chemotherapy combination. A 58-year-old woman referred for left breast mass. Radiologic imaging showed a mass of 4 cm in diameter. Pathologic examination of excisional biopsy specimen revealed Diffuse Large B Cell Lymphoma with CD20 positivity. The patient was stage IE (Ann Arbor). Mastectomy, lumpectomy or axillary dissection were not performed. Six courses of R-CHOP (CHOP plus rituximab) chemotherapy and radiotherapy were given. The complete response was obtained. The patient has been followed for 36 months with no evidence of disease recurrence. This is one of the first cases treated with rituximab. She has been followed for more than 36 months without relapse.

Evaluation of automated silver‐enhanced in situ hybridization (SISH) for detection of HER2 gene amplification in breast carcinoma excision and core biopsy specimens

To validate the use of the silver-enhanced in situ hybridization (SISH) technique in assessing HER2 status of breast carcinoma in excision biopsy specimens, and to assess its reliability in determining HER2 status in core biopsy specimens. Routinely processed paraffin sections of 65 excised breast carcinomas and 56 available preoperative core biopsy specimens from the same patients were selected from the archives for testing with the SISH technique using the automated Ventana Benchmark XT machine. For each case, two sections were used, one for the assessment of HER2 gene amplification and the other for assessment of chromosome 17. Of the 65 excision specimens tested, sections of 53 cases were also available for fluorescence in situ hybridization (FISH) examination. HER2 gene amplification was detected by SISH in 14 (21%) out of 65 excision specimens and in eight (14%) out of 56 core biopsy specimens. The results of SISH and FISH were identical in 50 (94%) out of the 53 excision cases examined by the two techniques. Two cases were SISH-, FISH+, and one case was the other way round. SISH results of core biopsy specimens and corresponding excision biopsy specimens were identical in 50 (89%) out of 56 cases. Four cases (7%) were SISH- in cores but positive in excision specimens, whereas two cases were the other way round. The results validate the use of the SISH technique for assessing HER2 status of excised breast carcinoma tissue sections. The results are comparable to those obtained with FISH, but SISH has the advantage of having a permanent end result that can be visualized by an ordinary light microscope. There is a reasonable 89% concordance between SISH results obtained in core and excision biopsy specimens. However, it may be prudent to postpone doing SISH, if possible, until sections of the resected specimen are available, as these seem to be more reliable.

A Case of Atypical Granuloma Annulare Involving Both Ears

We report a rare case of granuloma annulare (GA), affecting both ear antihelixes, in a 28-year old male patient that presented with a 1-year history of non-tender, firm, skin-colored, 1~5 mm papules on both ear antihelixes. There was no history of trauma. An excisional biopsy specimen taken from one of the lesions of the right ear revealed infiltration of histiocytes and lymphocytes around a zone of collagen alteration in the dermis. Based on the clinical and pathological findings, the patient was diagnosed with a rare case of bilateral GA of both antihelixes; this is the first report in the Korean dermatology literature.

Coincidence of Mammary and Sentinel Lymph Node Papilloma

This report describes an unusual case of mammary intraductal papillomas coexistent with sentinel lymph node papilloma. A 47-year-old Japanese female underwent 5 needle manipulations and 2 surgical biopsies for recurring papillomas in the right breast over 5 years before having a simple mastectomy. During the mastectomy, the ipsilateral sentinel node was found to be extensively occupied by completely benign papilloma that measured 6 mm in its greatest dimension. The clinical history led us to put forward the working hypothesis that the nodal papillary lesion may develop from the epithelial cells that are displaced from the mammary papillomas during needle procedures and mechanically transported to the sentinel lymph node. To test the hypothesis, we retrieved surgical biopsies (dochectomy and excisional biopsy), mastectomy, and sentinel lymph node specimens for histopathologic, immunohistochemical, and molecular studies. The presence of myoepithelial layer in each papillary tumor was confirmed by immunostains with specific myoepithelial markers, p63 and CD10. The excisional biopsy specimen exhibited displaced fragments of benign epithelial cells within granulation tissue at the needle manipulation site, indicating that iatrogenic epithelial cell displacement did occur in this case. However, loss of heterozygosity at 16p13 and 16q21 was only observed in the papillomas of the dochectomy and the excisional biopsy; no loss of heterozygosity was detected in the papillomas of the mastectomy and the sentinel lymph node. It remains undetermined whether the nodal papilloma was derived from the papilloma of the mastectomy or if it arose de novo from the breast tissue inclusion of the sentinel node.

Sinonasal Neuroendocrine Carcinoma: A Case Report

Neuroendocrine carcinoma (NEC) is rare. We report a case of probable sinonasal NEC in a 73-year-old man who had presented with a history of right nasal obstruction, nasal discharge, and recurrent epistaxis. On examination, a red, friable, gelatinous, polypoid mass with a tendency to bleed was seen in the right nasal cavity. Computed tomography revealed that the lesion was confined to the right nasal cavity; coincidental or reactive opacification was seen in the adjacent sinuses. The final histologic evaluation of the excised biopsy specimens yielded a diagnosis of an invasive, poorly differentiated NEC, probably a large-cell variant, with the differential diagnosis lying at a point somewhere between poorly differentiated large-cell NEC and high-grade olfactory neuroblastoma. The patient underwent a right lateral rhinotomy and medial maxillectomy followed by adjuvant radiotherapy. At 20 months of follow-up, he exhibited no sign of recurrence.

Suspected penile cancer: a method to improve handling of pathology specimens

BACKGROUND A major problem encountered by the supranetwork team managing new cases of penile cancer is inadequate tissue preparation for pathological evaluation of specimens. The histological examination of a circumcision or wide local excision specimen, when there is a clinical suspicion of malignancy, relies on receiving an orientated and pinned-out specimen [1]. When a foreskin is placed directly into formalin the specimen immediately contracts. After fixation it is not possible to stretch the specimen to identify the dorsal slit, or to take representative sections for a histological assessment of surgical margins. Similarly, excision-biopsy specimens might be difficult to orientate. We describe a method that enables a foreskin and excision-biopsy specimens to be pinned and orientated using material readily available in any operating theatre. METHODS In combination with the pathologist, we have developed a method that maintains the integrity of the specimen and allows orientation (Figs 1 and 2). The pathologist can then identify the dorsal slit, which is not a true surgical margin. The distal (glans) and proximal (shaft) margins can be identified and marked by using two colours of ink. The specimen is sliced sagittaly and the location of each sample identified using a block code. This block code must appear in the text of the pathology report, as these specimens are often reviewed in a distant cancer centre which will not have access to any block code written on the form at the time of sectioning. DISCUSSION About 80% of penile carcinomas arise from the foreskin and/or glans [2]. The aim of surgical management is to achieve control of disease without compromising functional or cosmetic results; hence organ-sparing procedures are increasingly favoured. Traditionally, a surgical margin of 20 mm has been advised. However, one study examined men who had conservative treatment for carcinoma of the penis [3]; the surgical resection margin was <10 mm in 48% of patients and <20 mm in 90% of patients. After a median follow-up of 26 months, 4% were found to have recurrence. This suggests that surgical margins within a few millimetres of microscopic tumour are sufficient. To accurately identify surgical margins, a clear orientation of the specimen is vital; the above technique describes a simple and cost-effective method.

Spectral waveform analysis of intranodal arterial blood flow in abnormally large superficial lymph nodes in dogs

To evaluate pulsed-wave Doppler spectral parameters as a method for distinguishing between neoplastic and inflammatory peripheral lymphadenopathy in dogs. 40 superficial lymph nodes from 33 dogs with peripheral lymphadenopathy. 3 Doppler spectral tracings were recorded from each node. Spectral Doppler analysis including assessment of the resistive index, peak systolic velocity-to-end diastolic velocity (S:D) ratio, diastolic notch velocity-to-peak systolic velocity (N:S) ratio, and end diastolic velocity-to-diastolic notch velocity ratio was performed for each tracing. Several calculation methods were used to determine the Doppler indices for each lymph node. After the ultrasonographic examination, fine needle aspirates or excisional biopsy specimens of the examined lymph nodes were obtained, and lymphadenopathy was classified as either inflammatory or neoplastic (lymphomatous or metastatic) via cytologic or histologic examination. Results of Doppler analysis were compared with cytologic or histopathologic findings. The Doppler index with the highest diagnostic accuracy was the S:D ratio calculated from the first recorded tracing; a cutoff value of 3.22 yielded sensitivity of 91%, specificity of 100%, and negative predictive value of 89% for detection of neoplasia. Overall diagnostic accuracy was 95%. At a sensitivity of 100%, the most accurate index was the N:S ratio calculated from the first recorded tracing; a cutoff value of 0.45 yielded specificity of 67%, positive predictive value of 81%, and overall diagnostic accuracy of 86.5%. Results suggested that noninvasive Doppler spectral analysis may be useful in the diagnosis of neoplastic versus inflammatory peripheral lymphadenopathy in dogs.

Periodontal Management of Gingival Enlargement Associated With Sturge‐Weber Syndrome

Sturge-Weber syndrome (encephalotrigeminal angiomatosis) is a rather uncommon congenital condition that is characterized by a combination of venous angioma of leptomeninges over the cerebral cortex and ipsilateral angiomatous lesions of the face and sometimes of the skull, jaws, and oral soft tissues. It is commonly referred to as Sturge-Weber syndrome after Sturge and Weber who first described this affliction in 1879. This article presents a case of Sturge-Weber syndrome associated with severe gingival enlargement, its management, and follow-up results. A 15-year-old male patient was referred to the Department of Periodontics, Government Dental College and Hospital, for severe gingival enlargement. A detailed dental and medical history, clinical examination, and investigations confirmed the diagnosis of Sturge-Weber syndrome. This report reveals a classic presentation of the syndrome with emphasis on its oral manifestations. Periodontal management included thorough scaling and root planing followed by periodontal flap surgery to treat the gingival enlargement. Histopathologic examination of the excisional biopsy specimen revealed features suggestive of fibrous gingival enlargement. Reevaluation of the patient after 2 years showed remarkable (90%) reduction of the gingival enlargement in the maxillary arch and complete diminution (100%) in the mandibular arch. However, a slight recurrence was noted in the maxillary right quadrant. Sturge-Weber syndrome is clinically important to the periodontist because of its associated gingival vascular features and their complicating manifestations. Periodic systemic and oral examinations are recommended to identify and prevent any complications from the cranial and oral lesions.

Pyogenic granuloma and pemphigus vulgaris: An unusual association

To the Editor: A 45-year-old African American man with a 3-year history of oral pemphigus vulgaris (PV) presented with new-onset smooth, broad-based, well-defined, red, ulcerated nodules on the right buccal mucosa, right lateral border of the tongue, and left back aspect of the tongue developing during a 5-week period (Fig 1). The patient's oral pemphigus, which had initially led to a 60-lb weight loss, has been refractory to a number of aggressive combination immunosuppressive therapies of oral prednisone, azathioprine, cyclophosphamide, cyclosporine, mycophenolate mofetil, and intravenous immunoglobulin and methylprednisolone, with concomitant use of several topical corticosteroids, tacrolimus, and antihistamine-anesthetic rinses. At the time of the development of the oral nodules, the patient was taking prednisone and mycophenolate mofetil. The excisional biopsy specimen of the lesions showed a peculiar histologic picture–the nodule was a combination of a vasoformative tissue proliferation of a pyogenic granuloma (PG) with overlying epithelial changes of PV (Fig 2). After a year of follow-up, the patient has not experienced recurrence of the excised nodules.

Touch Imprint and Fine Needle Aspiration Cytology of Giant Cell Tumor of Tendon Sheath: A Case Report

Giant cell tumor of the tendon sheath (GCTTS) is a slowly growing, benign soft tissue tumor. The tumors occur predominantly on the hands and feet. Although the clinical and histopathologic features are well-defined, only a few reports have described the cytologic appearance of this entity. A 26-year-old woman presented with a gradually developing circumscribed soft tissue mass near the proximal phalanx of her left little finger for one year. Imprint and fine needle aspiration (FNA) smears were obtained from the excisional biopsy specimen. The imprint smears were composed of predominantly singly dispersed bland mononuclear cells and several giant cells. The mononuclear cells were polygonal to round, and they showed a histiocyte-like appearance. Osteoclast-type multinucleated giant cells of various sizes were randomly scattered throughout the smears, and these cells contained 3 to 50 nuclei. Nuclear atypia and pleomorphism were absent in both the single and giant cells. Loose aggregates of hemosiderin-laden macrophages and binuclear stromal cells were also seen. The cytologic features of the FNA smears were similar with those of the imprint, Additionally, the FNA smears contained several clumps of densely collagenous stromal tissue that were seldom noted in previously reported cytologic material. The cytologic features were well-correlated with the concurrent histologic findings and the diagnosis of GCTTS was made. When the clinical and radiologic datas are integrated, the diagnosis of GCTTS can be strongly suggested, based on the pre-operative cytologic specimen.

Plexiform fibrohistiocytic tumor

Plexiform fibrohistiocytic tumor is an uncommon mesenchymal tumor that can cause difficulty in diagnosis and surgical management. On clinical and histologic examination, these tumors can potentially be misdiagnosed as sebaceous/epidermal cysts. We report a case of plexiform fibrohistiocytic tumor in a young female, which on initial clinical evaluation was diagnosed as sebaceous cyst. The tumor was deeply invasive, with positive margins on two excisional biopsy specimens. The importance of recognition of this entity, potential pitfalls and prognosis are discussed and the literature is reviewed.

Langerhans cell histiocytosis of the caruncle

A 37-year-old man presented with the complaint of a small non-tender mass growing steadily on the left caruncle for 3 months. This was a soft, reddish-yellow tumour, occupying the whole left caruncular area without impinging on the conjunctiva. Histopathological evaluation of the excisional biopsy specimen showed that the tumour was largely composed of Langerhans cells mixed with eosinophils and mature lymphocytes. There were strong CD1a and S-100 positivity on immunohistochemical studies. Langerhans cell histiocytosis is an exceedingly rare tumour of the caruncle in the adult and this lesion cannot be distinguished from other amelanotic lesions on clinical grounds alone. Simple excision of the lesion provided a 4-year disease-free period.

Atypical Ductal Hyperplasia: Improved Accuracy with the 11-Gauge Vacuum-Assisted versus the 14-Gauge Core Biopsy Needle

Percutaneous stereotactic core needle biopsy (CNB) has become the primary diagnostic modality for evaluating nonpalpable, mammographically detected breast lesions. Atypical ductal hyperplasia (ADH) uncovered by CNB confers a significant risk of harboring an occult malignancy in the excisional biopsy specimen; therefore, we sought to determine the benefits of upsizing biopsy needles from 14- to 11-gauge. Patients with isolated ADH diagnosed by CNB were included for analysis in this retrospective review. Mammographic description, number of needle passes, pathology results, and follow-up data were analyzed and compared to our previously published institutional results with the 14-gauge needle. From June 1996 until July 2006, 4,579 CNBs were performed at our tertiary level medical facility. Seventy eight of 88 patients (89%) diagnosed with ADH on CNB with an 11-gauge vacuum-assisted needle underwent open surgical excision. Of these patients, nine (11%) were upgraded to ductal carcinoma in-situ (DCIS) while five (6%) had invasive cancer (IC), giving a total underestimation rate of 17%. These results differ from our previously published series of 14-gauge CNB which revealed an underestimation rate of 36%. Mean number of passes obtained at time of biopsy, mean age of patients, and characteristic radiographic abnormalities were similar for malignant and benign diagnoses. 11-gauge CNB technique reduces sampling error and improves accuracy, but does not eliminate the risk of missing an underlying malignancy. Surgical excision of ADH identified by CNB is required for definitive diagnosis.