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Nakamura S, Suchi T 1991 A clinicopathologic study of nodebased, low-grade, peripheral T-cell lymphoma. Some cells possess dark round nuclei, indistinguishable from normal small lymphocytes. Immunocytochemistry Immunostaining for parathyroid hormone is helpful for confirming the parathyroid nature of nonfunctioning or ectopic parathyroid carcinomas. Scattered throughout are the characteristic hyaline-vascular lymphoid follicles, which are follicles with regressed germinal centers surrounded by concentric rings of small lymphocytes and penetrated by one or more hyalinized venules. In some follicular lymphomas, a plasma cell population staining for the same Ig light chain as the neoplastic follicles is present in the interfollicular areas or within the follicles. The peak incidence of cervical sarcoma botryoides typically is in the second or third decade, although occasional cases have occurred in infants and in women in their fifth decade. B, the large nodule shows Reed-Sternberg cell variants in a background of lymphocytes and plasma cells. Vimentin and bcl-2 are the only immunohistochemical markers that are consistently expressed, but neither is specific. Small lymphocytes are admixed with lymphoplasmacytoid cells and maturelooking plasma cells. Evaluation of this is usually straightforward, although sometimes cautery artifact, marked inflammation, and fragmentation of the specimen may make it difficult. The differential diagnosis of acinar cell carcinoma is primarily versus pancreatic neuroendocrine tumors, which they can mimic histologically. The tumor is firm, bulges from the cortical surface, and is composed of whitish tissue. A, the infiltrate in the red pulp of the spleen is diffuse, and the white pulp is lost. Currently the gold standard for assessment of response to anti-Helicobacter therapy is still histologic rather than molecular study. Histologic Appearances the best illustrated and best documented renal carcinomas associated with neuroblastoma contain majority populations of cells with abundant finely granular eosinophilic cytoplasm, growing in papillary and solid patterns. Feakins R M, Lowe D G 1997 Basal cell carcinoma of the vulva: a clinicopathologic study of 45 cases. Dermatofibrosarcoma protuberans is a fibroblastic tumor that arises only occasionally in the vulva,188-197 being more commonly located on the trunk (see Chapter 23). Outcome of patients with stage I papillary serous adeno carcinoma of the cervix does not appear to be different from those with conventional adenocarcinoma. Cytologically, the cells may resemble those found in typical hairy cell leukemia, with fine cytoplasmic projections, but they also commonly demonstrate distinct nucleoli and may have more convoluted nuclear contours. Distant metastatic spread occurs when carcinoma invades into lymphovascular spaces. Some cases show cystic degeneration, necrosis, hemorrhage, hyalinization, and calcification. Leukemia Granulocytic sarcoma involves the female genital tract, rarely, where it may represent either the first clinical manifestation of the disease or relapse of acute myeloid leukemia. In type 2, the cells are usually larger and often have abundant eosinophilic cytoplasm. Although most patients present with generalized lymphadenopathy, some show simultaneous or exclusive extranodal involvement. Klimstra D S, Rosai J, Heffess C S 1994 Mixed acinar-endocrine carcinomas of the pancreas. Robboy S J, Scully R E 1970 Ovarian teratoma with glial implants on the peritoneum: an analysis of 12 cases. Kini S R, Miller J M 1986 Infarction of thyroid neoplasms following aspiration biopsy.

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These cytoplasmic processes can be difficult to see because of their delicate nature and are best appreciated with phase-contrast microscopy. Thus, whenever the results contradict the histologic findings, further workup by immunohistochemical staining on paraffin-embedded tissues is recommended. Hofmann W J, Momburg F, Moller P 1988 Thymic medullary cells expressing B lymphocyte antigens. Clinical Features Most small adenomas and serrated polyps of the appendix are discovered incidentally by the pathologist on exami nation of an appendectomy specimen. Kaminski P F, Tavassoli F A 1984 Plexiform tumorlet: a clinical and pathologic study of 15 cases with ultrastructural observations. The small cytoplasmic volume, papillary structures, and psammoma bodies bring this to mind. Macroscopic Appearances Appendiceal carcinoid tumors are usually localized to the tip of the appendix. Immunostaining is required to distinguish it from follicular dendritic cell proliferative lesion. Newman D M, Brown J R, Jay A C, Pontius E E 1968 Squamous cell carcinoma of the bladder. This stain is generally not required for diagnosis, but may be useful in fragmented and scanty biopsy specimens in which a differential diagnosis between reactive and neoplastic serous epithelium is under consideration. Extravillous trophoblast cells are medium to large-sized mononuclear or multinucleated cells with marked nuclear atypia. Organ-confined tumors (pathologic stage T2) are subdivided into pT2a, T2b, and T2c depending on the extent of tumor involvement (half of one lobe or less, more than half of one lobe but not both lobes, and both lobes, respectively). The nucleus is round to oval and has a degree of moderate chromatin condensation, intermediate between that of a mature lymphocyte and a blast. This field depicts the striking proliferation of thymic epithelium that accompanies the tumor and can potentially lead to an erroneous diagnosis of thymoma. Uterine inflammatory myofibroblastic tumors range in size from 1 to 12 cm (median 5 cm, mean 6 cm); this mean size at presentation is similar to that of extrauterine inflammatory myofibroblastic tumors. The stroma is composed of spindle-shaped fibroblastic cells and collagen in varying proportions. Stabile B E, Morrow D J, Passaro E Jr 1984 the gastrinoma triangle: operative implications. A, the tumor infiltrates within a desmoplastic stroma in irregular islands but still with some vague resemblance to the lobulation seen in thymoma. Extensive sampling may be helpful because these tumors frequently have foci, albeit sometimes small, of typical renal cell carcinoma, which make the correct diagnosis obvious. Disseminated Peritoneal Leiomyomatosis cytogenetic analysis of two cases has shown the presence of a derivative chromosome-der(14)t(12;14)(q15;q24)- frequently found in uterine leiomyomas, supporting uterine origin. Abraham S C 2002 Sporadic fundic gland polyps with epithelial dysplasia: evidence for preferential targeting for mutations in the adenomatous polyposis coli gene. At the periphery is a dense zone of inflammatory cells comprising predominantly lymphocytes and plasma cells. A large, soft tumor, resembling cerebral cortex in color and consistency, dwarfs the kidney in which it has arisen. These atypical cells are often easier to find in the deeper portions of the biopsy, away from the ulcerated surface. A, Large and small, simple and complex glands are embedded in spindle cell stroma of variable cellularity. The extent of bone marrow involvement is variable; patchy involvement is most common, but occasionally diffuse marrow replacement is seen. Cysts ranging from a few millimeters to centimeters in diameter are present in approximately a third of cases.

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Rare medullary carcinomas are composed of small cells arranged in sheets and packets, histologically similar to small cell carcinoma of lung. Histologically, preferential involvement of the marginal zone of the white pulp and fibrous trabeculae is seen, but other areas of the spleen can be involved. Fibroepithelial stromal polyps127-138 are hormonally responsive lesions that arise from cells residing in the distinctive subepithelial zone of the distal female genital tract. They are usually small and round to oval but may be convoluted, resembling collecting ducts or convoluted tubules of the kidney. Ngan B, Warnke A, Cleary M L 1989 Variability of immunoglobulin expression in follicular lymphoma. The tube is lined by stratified atypical columnar cells that show loss of polarity and tufting. Chen Z M, Wang H L 2004 Alteration of cytokeratin 7 and cytokeratin 20 expression profile is uniquely associated with tumorigenesis of primary adenocarcinoma of the small intestine. They possess bland-looking nuclei with fairly dense chromatin and indistinct nucleoli. Tsang W Y, Chan J K, Ng C S 1993 Epstein-Barr virus and Reed-Sternberg-like cells in chronic lymphocytic leukemia. Paraganglioma Clinical Features the rare paragangliomas that occur within the thyroid gland are thought to arise from the inferior laryngeal paraganglia, which are sometimes located within the thyroid capsule. Tumors more commonly involve vulvar mucosa than skin and are usually deeply pigmented; however, amelanotic tumors are not uncommon, representing 30% of vulvar melanoma in one large series. Lymphoblastic lymphomas, some cases of blastic plasmacytoid dendritic cell neoplasms, and some examples of blastic follicular lymphoma are TdT positive, whereas blastoid mantle cell lymphoma is always TdT negative. McMahon J T, Hart W R 1988 Ultrastructural analysis of small cell carcinomas of the ovary. Hawk W A, Hazard J B 1976 the many appearances of papillary carcinoma of the thyroid. The degree of architectural atypia at the top of the field with back-toback glands amounts to early intramucosal adenocarcinoma. If histiocytes are not found, the endothelial cell nuclei can be used instead as the "ruler," although they are less satisfactory because of their ovoid or elongated shape. Cancer 38: 22172221 Hammar S, Sale G 1975 Multiple hormone producing islet cell carcinomas of the pancreas. Compared with the neoplastic cells within the follicles, they are often smaller and show a more rounded overall nuclear contour. Perrone T, Steeper T A, Dehner L P 1987 Alpha-fetoprotein localization in pure ovarian teratoma: an immunohistochemical study of 12 cases. The acini are lobular, but can be infiltrative and may be architecturally mistaken for adenocarcinoma. Nodules of benign-appearing glial tissue are covered by peritoneum in this grade 0 implant. The standard treatment is hysterectomy and bilateral salpingo-oophorectomy, but unilateral salpingooophorectomy is adequate treatment for a young woman. Stage I also requires evaluation of the renal capsule, but this is often difficult because, as a renal neoplasm grows, it sequentially is surrounded by an intrarenal pseudocapsule, the renal capsule, a pseudocapsule external to the kidney, Gerota fascia, and the ultimate limits of the specimen. Lopez A, Mendez F, Puras-Baez A 2003 Extramedullary plasmacytoma invading the bladder: case report and review of the literature. The cytoplasm is amphophilic to basophilic, and a paranuclear pale hof is often present. Histologic risk factors and clinical outcome in colorectal malignant polyp: a pooleddata analysis. Meissner W A, Adler A 1958 Papillary carcinoma of the thyroid, a study of the pattern in 226 patients. Young R H, Scully R E 1983 Ovarian tumors of probable Wolffian origin: a report of 11 cases. Small vacuolar spaces and apoptotic remnants of lymphocytes are typically present. Most of the carcinomas found in prophylactic salpingo-oophorectomy specimens are of serous type, measure only a few millimeters in diameter, and are of high grade. Young R H, Kurman R J, Scully R E 1990 Placental site nodules and plaques: a clinicopathologic analysis of 20 cases. The young age of the patient should provide the most important clue to the correct diagnosis.

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Am J Clin Pathol 138: 132-139 Abboudi Z, Patel K, Naresh K N 2009 Cyclin D1 expression in typical chronic lymphocytic leukaemia. Therefore the presence of carcinoma in situ is not necessarily bona fide evidence of primary seminal vesicle carcinoma. Tumors that do not have a p53 mutation generally show staining in at least some tumor cell nuclei, a finding that contrasts with the patterns seen in tumors with a mutation. Inverted Urothelial Papilloma Inverted papilloma occurs much less commonly in the renal pelvis and ureter than in the urinary bladder. The main disadvantages are (1) requirement of fresh tissue; (2) lack of direct correlation with topography or cytology; for example, a thymoma can potentially be mistaken for T-lymphoblastic lymphoma because the tumor sample is rich in T cells with an immature phenotype; and (3) that the neoplastic population might be underrepresented in the cell suspension because of sclerosis or low tumor cell viability. Note the typical coarse chromatin, multiple distinct nucleoli, and frequent mitoses. The hyperplastic rests are macroscopically visible and may contain blastemal, embryonic, or sclerosing areas. They occur almost exclusively (>95%) in women, usually in the fourth to fifth decades, and are found, in more than 90%, in the tail or body of the pancreas (see Table 11-8). Most appear as a raised, well-demarcated lesion with a waxy appearance; pigmentation is not uncommon. Bergholm U, Bergstrom R, Ekbom A 1997 Long-term follow-up of patients with medullary carcinoma of the thyroid. Papillary clear cell carcinomas are occasionally mistaken for other types of tumor, especially for borderline serous tumors. The majority of the cases in men have involved the fossa navicularis, but the prostatic urethra, bulbous urethra, pendulous urethra, and meatus may also be the primary sites. Most examples are secondary neoplasms arising in a benign cystic teratoma; this kind of ovarian squamous cell carcinoma is discussed in the section on teratomas. The tumor typically has mixed histology with sinusoidal, solid, papillary, and cavernous growth patterns. Isaacson P G, MacLennan K A, Subbuswamy S G 1984 Multiple lymphomatous polyposis of the gastrointestinal tract. It occurs during the reproductive age range (similar to its uterine counterpart) and usually measures less than 5 cm. Similarly, pigmentation of the epithelium and melanin deposition in the stroma and within stromal macrophages may be pronounced, corresponding to clinically apparent pigmented areas. Agaimy A, Hahn T, Schroeder J, Elhag A 2012 Follicular thyroid adenoma dominated by spindle cells: report of two unusual cases and literature review. The tumor is composed of long fascicles of spindle cells with ovoid or tapering nuclei, vesicular chromatin, small nucleoli, and indistinct cytoplasm, usually within a collagenous stroma. The stroma between the neoplastic glands often, but not always, shows a desmo plastic or inflammatory response. Selby D, Stocker J, Ishak K 1992 Angiosarcoma of the liver in childhood: a clinicopathologic and follow-up study of 10 cases. Fadare O, Zheng W 2009 Insights into endometrial serous carcinogenesis and progression. Carney J A, Ryan J, Goellner J R 1987 Hyalinizing trabecular adenoma of the thyroid gland. The cut surface may appear bright yellow or golden yellow throughout or have irregular mottled areas of dark pigmentation. The large lymphoid cells do not constitute a monotonous population but appear to show transition to plasmablasts and plasma cells. Leiomyoma Symptomatic renal leiomyomas are rare,201 but they rarely are large masses weighing as much as 37 kg202; small ones are usually found incidentally at autopsy. Shaha A R, Shah J P, Loree T R 1996 Risk group stratification and prognostic factors in papillary carcinoma of thyroid. Basement membrane material surrounds tumor cell nests and fills the central spaces within the nests, forming the hyaline cores seen by light microscopy. Chen H, Udelsman R 1998 Papillary thyroid carcinoma: justification for total thyroidectomy and management of lymph node metastases. Lymphoplasmacytic lymphoma is a diagnosis by exclusion; this diagnosis should not be made if features of other lymphoma types are found. Second-look operations performed after chemotherapy in patients with incompletely resected immature teratoma can reveal residual immature teratoma, no residual tumor, small glial implants, or bulky nodules of mature teratoma.

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Patients usually present with vaginal bleeding, and clinical examination typically reveals a polypoid, friable mass that may mimic sarcoma botryoides. Most cases pursue a benign clinical course with a low risk of pelvic recurrence or distant metastasis, most commonly to the lung. The pancreatic tissue can show both exocrine and endocrine components, and, rarely, acute pancreatitis with hemorrhage and fat necrosis can develop. Histologically, tumors may appear to be in direct continuity with the epidermis and appear morphologically similar to an enteric adenocarcinoma. Nolan L P, Heatley M K 2001 the value of immunocytochemistry in distinguishing between clear cell carcinoma of the kidney and ovary. Most women with a granulosa cell tumor have a palpable unilateral adnexal mass; bilateral tumors are uncommon. Smith N L, Baird D B, Strausbauch P H 1997 Endometrial involvement by multiple myeloma. Patients have an unfavorable prognosis, because adenoid cystic carci noma is frequently associated with local recurrence or metastatic spread. ReedSternberg cells and variants are found in a background of lymphocytes, eosinophils, and plasma cells. Yolk sac tumor is present in the upper left part of the field and dysgerminoma in the lower right. Arch Pathol Lab Med 107: 633-637 Boggs L K, Kimmelstiel P 1956 Benign multilocular cystic nephroma: report of two cases of so-called multilocular cyst of the kidney. Facchetti F, Jones D M, Petrella T 2008 Blastic plasmacytoid dendritic cell neoplasm. This lesion has been designated a variety of names, such as inflammatory pseudotumor, pseudosarcoma, and inflammatory myofibroblastic tumor. In this example, the diagnosis of malignancy is based on presence of vascular invasion (not shown). Ljungberg O, Tibblin S 1979 Perioperative fat staining of frozen sections in primary hyperparathyroidism. Histologically, anastomosing vascular channels, spindle cell fascicles, papillary formations, and solid areas are seen. The tumor may result from bidirectional differentiation in a tumor of presumed glandular origin; occasionally, ultrastructural evidence of squamous and glandular differentiation may be found within a single tumor cell. Examination of a bone marrow biopsy sample and aspirate smear is necessary to make this clinically important distinction. In some cases the gross appearance is quite characteristic of this disease, consisting of large fleshy white masses, but, occasionally, lesscharacteristic sessile lesions with thickening of the bladder wall are present. In approximately 20% of cases, focal epithelialrich areas compatible with B3 thymoma are seen; such cases should be diagnosed as thymoma with B2 and B3 components (with estimation of the percentage of area occupied by the respective components). Lauriola L, Erlandson R A, Rosai J 1998 Neuroendocrine differentiation is a common feature of thymic carcinoma. Loh K C 1997 Familial nonmedullary thyroid carcinoma: a meta-review of case series. It may not be possible to find mucin in many malignant glands, and overt mucin production is not necessary to make the diagnosis of well-differentiated adenocarcinoma. Ordonez N G 2000 Value of thyroid transcription factor1 immunostaining in distinguishing small cell lung carcinomas from other small cell carcinomas. It is not uncommon to encounter thymomas with mixed features, that is, features of both B1 and B2, or features of both B2 and B3, or even features of all three types. This type of carcinoma comprises 5% to 12% of ovarian cancers in North America and other Western countries, with the highest percentages reported most recently. Springer, New York Staging and Grading Renal Cell Carcinoma the extent of spread of renal cell carcinoma is the dominant factor in prognosis. Friesen S R, Tomita T 1981 PseudoZollingerEllison syndrome: hypergastrinemia, hyperchlorhydria without tumor. Myxoid change in the stroma can be seen and may be prominent,515 but nuclear atypia is minimal and mitoses are infrequent. These lesions may rarely recur locally, particularly if incompletely excised or there is continued hormonal stimulation. Consideration is restricted primarily to neoplasms, but in both the urinary bladder and urethra a wide variety of nonneoplastic lesions are encountered that may mimic neoplasms grossly and/or microscopically, and accordingly some of these are also illustrated.

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Clear cell carcinomas of the endometrium differ slightly from serous tumors by the presence of two features, one of which is glands or papillae lined by a single layer of polyhedral cells with uniform nuclei and prominent nucleoli. Int J Gynecol Pathol 27: 161-174 McCluggage W G 2008 My approach to and thoughts on the typing of ovarian carcinomas. In contrast, among group 2 patients, 170 (90%) who had more than 50% decline in parathyroid hormone level after resection of a single parathyroid adenoma were cured. Exophytic papillae lined by neoplastic cells that have a combination of squamous and transitional features. Besides lymphadenopathy, presentation in extranodal sites, such as skin, bone, soft tissue, and gastrointestinal tract, can also occur. Ruck P, Harms D, Kaiserling E 1990 Neuroendocrine differentiation in hepatoblastoma: an immunohistochemical investigation. These myeloid precursor forms include cells destined to contribute to mature neutrophilic, eosinophilic, and basophilic granulocytic lineages, as well as the monocytic, erythroid, and megakaryocytic lineages. They have granular eosinophilic or amphophilic cytoplasm and uniform, round central nuclei with a distinctive chromatin pattern. A single biopsy may shows areas with typical morphology and areas with blastoid appearance. Residual islands of thymic epithelium can be infiltrated by the lymphoma cells, can show reactive proliferation, or can undergo cystic change with formation of multiple cysts. Fadare O 2009 Recent developments on the significance and pathogenesis of lymph node involvement in ovarian serous tumors of low malignant potential (borderline tumors). Most tumors range in size from 2 to 10 cm; the weight of individual tumors varies considerably, but most of the clinically benign pheochromocytomas weigh 50 to 100 g. All patients have been treated solely with surgery; no recurrence has been reported. Lane Z, Epstein J I 2008 Polypoid/papillary cystitis: a series of 41 cases misdiagnosed as papillary urothelial neoplasia. Chen J S, Lai G M, Hsueh S 1998 Malignant thyroid teratoma of an adult: a long-term survival after chemotherapy. Well-differentiated tumors show a pseudoacinar or thin trabecular pattern and mild nuclear atypia. Cellular angiofibroma150-152 is a benign mesenchymal neoplasm that most commonly occurs in the vulvovaginal region. Schmid K W, Mesewinkel F, Bocker W 1996 Hyalinizing trabecular adenoma of the thyroid-morphology and differential diagnosis. Electron Microscopy the neoplastic cells of thymoma possess multiple interdigitating elongated cell processes connected by desmosomes. The most common morphologic appearance of the bone marrow in cases with t(8;21) is acute myeloblastic leukemia with maturation beyond the blast stage. Joshi V V, Beckwith J B 1989 Multilocular cyst of the kidney (cystic nephroma) and cystic, partially differentiated nephroblastoma, terminology and criteria for diagnosis. The child died of neonatal herpes simplex and this cortical rest as well as cortex in eutopic adrenal glands showed prominent necrosis with typical herpetic nuclear inclusions. DiGiuseppe J A, Sauvageot J, Epstein J I 1997 Increasing incidence of minimal residual cancer in radical prostatectomy specimens. They are either pure squamous carcinoma or squamous carcinoma admixed with adenocarcinoma (adenosquamous carcinoma). Minor foci of cell types other than the predominant one can be ignored, but when significant amounts (>10%) of several cell types are present, the tumor is best classified as a mixed epithelial tumor. The changes appear to begin at the base of the crypt as branches or buds; these glands assume a lobular arrangement, mimicking the architecture of the gastric antrum or pylorus. Histologic progression often manifests as an increase in the proportion of large cells.

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Deligdisch L, Hirschmann S, Altchek A 1997 Pathologic changes in gonadotropin releasing hormone agonist analogue treated uterine leiomyomas. Semin Hematol 36: 139-147 Isaacson P G 1999 Gastrointestinal lymphomas of T- and B-cell types. Histologic Appearances the architecture is predominantly papillary or tubulopapillary in more than 90% of papillary renal cell carcinomas. A, Paraimmunoblasts and prolymphocytes are typically intimately intermingled with the major population of small lymphocytes, which show round nuclear contour, condensed chromatin, and scanty cytoplasm. Architecturally, interconnecting meshworks of epithelial cells form the scaffolding and milieu for habitation by the lymphocytes. Undifferentiated carcinomas lack gland formation and may show giant cell, spindle cell, small cell (nonneuroendocrine), and nodular types. The small size of some tumors may make detection difficult in the intact gland, but transverse sectioning reveals a tumor that is round to ovoid and often bright yellow (or canary yellow). Tumors expressing Ig with high sugar content sometimes have red- or crimson-tinged cytoplasm, an appearance referred to as a flame cell. The situation is further complicated by the rare occurrence of true dysplasia or even frank adenocarcinoma developing in large hyperplastic polyps, usually at the tip. This inci dence differs from tumors that arise in the vagina, which typically affect infants and young children. From a practical viewpoint, cases showing marked treatment effect should not be graded. Because type A thymoma is a glandular neoplasm, at least focal evidence of glandular differentiation should be present to support this diagnosis in a spindle cell neoplasm. The spindle cells show focal weak or negative staining for cytokeratin and epithelial membrane antigen, are positive for vimentin, and show inconsistent staining for actin. A, Note the focal expansion and coalescence of the white pulp corpuscles, producing a large pale-staining nodule. Ferry J A, Scully R E 1988 "Adenoid cystic" carcinoma and adenoid basal carcinoma of the uterine cervix: a study of 28 cases. The nucleus to cytoplasm ratio is increased relative to that seen in a serous cystadenoma, and focal stratification of the nuclei is present. In the case of verrucous carcinoma, unequivocal invasion is seldom demonstrable in superficial biopsies, and clinicopathologic correlation is often vital in reaching the correct diagnosis. Remick D G, Kumar N B 1984 Benign polyps with prostatic-type epithelium of the urethra and the urinary bladder: a suggestion of histogenesis based on histologic and immunohistochemical studies. Grainger R, Gikas P W, Grossman H B 1990 Urothelial carcinoma occurring within an inverted papilloma of the ureter. The cells of prostatic-type urethral polyp are usually small with extremely bland cytology, and the glands show two cell layers. Glassy Cell Carcinoma Glassy cell carcinoma118122 is a rare tumor that is consid ered a variant of adenosquamous carcinoma because some examples may exhibit focal squamous or glandular differentiation by microscopic examination, whereas others demonstrate a biphasic appearance by electron microscopy. Diagnostic Reed-Sternberg cells are large cells (20-30 mm) with morphologic hallmarks of polyploidy (double, multiple, or multilobed nuclei) and do not always show the mirror-image double nuclei often portrayed in textbooks. Most benign and borderline epithelial tumors are serous tumors,1089 although a Brenner tumor has also been reported. The lymphoid cells between the epithelial nodules are predominantly B cells, which are admixed with some mature T cells. In this example, many signet ring cells are interspersed among the spindled tumor cells. A subset of these tumors, including cases in the vulva, exhibit higher-grade fibrosarcomatous change, which is most often characterized by a herringbone pattern of growth in combination with increased cellularity and mitoses. It can be recognized by the presence of hypercalcemia, endocrine-type vasculature, clear cells (if present), and expression of neuroendocrine markers. Eventually, dissemination to regional lymph nodes occurs; in the later stages, tumor may be borne hematogeneously to the lungs, liver, bones, and other organs.

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Most frequent are leiomyosarcoma129 and malignant peripheral nerve sheath tumor, followed by liposarcomas and unclassified pleomorphic sarcomas (so-called malignant fibrous histiocytomas). Keith T A, Cousar J B, Glick A D 1985 Plasmacytic differentiation in follicular center cell lymphomas. Solid clusters of cells and individual neoplastic cells represent more than half of the tumor. The disease pursues a highly aggressive course, with poor response to treatment, early relapse, and early death. The lymphoid component comprises predominantly immature T lymphocytes, which have been shown by genotypic studies to be nonclonal. Markers shown within the circles (cells) are expressed in the cytoplasm (c-) or nucleus, whereas markers shown outside the circles are expressed on the cell surface (s-). The central portion of the node often suffers from delayed fixation, which results in blowing up of the nuclei and clearing of the chromatin. B, this biopsy shows the typical changes of lymphoma regression after anti-Helicobacter therapy. An adipocytic variant characterized by interspersed groups of mature adipose cells has also been described. Cerar A, Dolenc-Strazar Z, Bartenjev D 1996 Infantile hemangioendothelioma of the liver in a neonate: immunohistochemical observations. It should be noted, however, that in postmenopausal patients or patients who are being given treatment with hormones, the stroma may be atrophic and not discernible around every gland. Gynecol Oncol 42: 4853 Wong W S, Ng C S, Lee C K 1990 Verrucous carcinoma of the cervix. Gran ulocytic sarcoma involving the female genital tract has the same morphologic characteristics and immunophe notypic profile as its counterpart in extramedullary tissues elsewhere (see Chapter 22). Among a survey of genitourinary pathologists, features that were considered to be pathognomonic for cancer were glomeruloid bodies (58%), collagenous micronodules (64%), circumferential perineural invasion (84%), and glands in fat (36%). Fibromas occur in patients 20 to 80 years of age, with an average age of more than 50 years, whereas patients with cellular fibromas appear to be somewhat younger, with an average age of 40 to 50 years. On the basis of the growth pattern, adenomas can be tubular, papillary, or tubulopapillary. The presence of a trabecular pattern, colloid material, or true glandular spaces renders a diagnosis of paraganglioma most unlikely. This is best achieved by carefully assessing the nuclear morphology of the cells; macrophages have rather open vesicular nuclei with one or more small nucleoli and fine heterochromatin, whereas the nuclei of signet ring cell carcinoma cells are larger, more hyperchromatic, and pleomorphic with coarse, dispersed chromatin and occasional mitoses. B, Immunostaining shows that the perivascular space is surrounded by cytokeratin-positive epithelial cells. The degree of nuclear atypia and loss of stratification is highly variable; some authors report the grade of superimposed squamous intraepithelial neopla sia, but this is inconsistent. Exceptionally, islands and trabeculae of tumor cells are accompanied by abundant extracellular mucin. However, more recently a case was reported of pigmented adrenocortical carcinoma that demonstrated atypical histologic features and evidence of local recurrence and metastatic disease. The cellular composition and pattern of growth can vary greatly from case to case and even from lobule to lobule within the same tumor. Hallgrimsson J, Scully R E 1972 Borderline and malignant Brenner tumours of the ovary: a report of 15 cases. The verrucous variant of squamous cell carcinoma37 is characterized by broad papillae of well-differentiated keratinizing squamous epithelium showing minimal cytologic atypia; these invade the underlying tissues over a broad front in the form of well-demarcated bulbous epithelial tongues. Spry C J 1982 the hypereosinophilic syndrome: clinical features, laboratory findings and treatment. Am J Surg Pathol 13: 490-499 Suster S, Moran C A 2005 Primary synovial sarcomas of the mediastinum: a clinicopathologic, immunohistochemical, and ultrastructural study of 15 cases. Aggressive systemic mastocytosis-characterized by progressive infiltration of various organs by mast cells, which often exhibit cytologic atypia, but lacking an associated clonal hematologic disorder. Interstitial amphophilic materials representing bacterial aggregates are the histologic hallmark of bacillary angiomatosis, which can be highlighted by silver stain such as Warthin-Starry or immunostaining for Bartonella henselae. The mucin can partly or completely organize, with ingrowth of fibroblasts and blood vessels. Foci of squamous differentiation or heterologous elements in the form of bone, cartilage, or striated muscle may be found.

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Lewandrowski K, Warshaw A, Compton C 1992 Macrocystic serous cystadenoma of the pancreas: a morphologic variant differing from microcystic adenoma. Although this is generally a benign tumor, rare malignant examples have been reported. Tumors with epithelioid features may mimic epithelial tumors of the kidney, and the possibility should be considered when examining an epithelial-like renal tumor that is hard to classify, particularly if the patient has tuberous sclerosis. Immature teratomas are exceptional in older or 13 Tumors of the Female Genital Tract 715 postmenopausal women. They usually have moderate amounts of palely eosinophilic cytoplasm, but sometimes the cytoplasm is more abundant and lightly eosinophilic. Benign Neoplasms Vestibular Papilloma (Vestibular Papillomatosis, Micropapillomatosis Labialis, and Physiologic Papillomatosis) Clinical Features. The qualifier "tumor of uncertain malignant potential" may be used for lesions in which histologic malignancy is not clearly evident. Given the limited experience with these tumors, most authors favor making a diagnosis of leiomyosarcoma in tumors with moderate nuclear atypia, even a few mitotic figures, or an infiltrative growth pattern. Cytogenetic Studies Specific chromosomal translocations have been identified in some lymphoma types. The malignant cells lining the glands and cysts stratify or grow in cartwheel, garland, or cribriform patterns with foci of segmental epithelial necrosis. Staining in the perinuclear space is also indicative of cellular immunoglobulin synthesis (not shown). Cholangiocarcinoma is less common, and metastatic adenocarcinoma is rare in cirrhotic liver. In one study, cystic tumors were more likely to be diagnosed at an early stage, to be associated with endometriosis, to exhibit a papillary growth pattern, and to have a more favorable outcome than solid adenofibromatous tumors334; in another study, adenofibromatous tumors were more likely to be low stage at diagnosis and to have a more favorable prognosis. Further, mitotic figures are rare in metanephric adenoma, and blastema is not present. The tumor shares with enteropathyassociated T-cell lymphoma (classic type) the genetic alterations of +9q31. For diffuse disease or persistent disease, rituximab and combination chemotherapy have to be given. Rywlin A M 1982 Mastocytic eosinophilic fibrohistiocytic lesion of the bone marrow. Patients are usually younger than 40 years of age and present with abnormal vaginal bleeding. The background small lymphocytes have small dark round nuclei, or appear mildly atypical, with irregular or elongated nuclei. C, Composite pheochromocytoma shows spindle cell schwannian stroma admixed with pheochromocytoma. Compared with B-lymphoblastic leukemia, these cells are larger, demonstrate more nuclear hyperchromasia, and show prominent cytoplasmic vacuolization. This tumor, which typically occurs in middle-aged women, is usually polypoid, and symptoms are generally related to a mass lesion and include dyspareunia and bleeding. The granulosa cells in juvenile granulosa cell tumors differ from those seen in adult granulosa cell tumors. It is therefore important to determine whether an ovarian choriocarcinoma is of gestational or germ cell type. Young R H, Perez-Atayde A R, Scully R E 1984 Ovarian SertoliLeydig cell tumor with retiform and heterologous components: report of a case with hepatocytic differentiation and elevated serum alpha-fetoprotein. Histologically, they consist of welldifferentiated endometrial stromal cells with a plexiform capillary network. A few tiny clusters of cells and single cells have penetrated into the superficial lamina propria. The 5-year survival for resectable tumors with negative margins is 20% to 40%, and the operative mortality is 10%. Pallesen G 1981 Neoplastic Paneth cells in adenocarcinoma of the urinary bladder: a first case report. Normal portal tracts are typically not found within the lesion, although a bile duct of intermediate or large caliber can be found in the central fibrous zone in rare cases.

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It occurs over a wide age range, but predominantly in the fourth and fifth decades, typically presenting as a painless, well-circumscribed subcutaneous mass that is usually less than 3 cm. The most common presenting complaints are abdominal pain, abdominal enlargement, or an abdominal mass. Dexeus F, Logothetis C, Hossan E, Samuels M L 1986 Carcinoembryonic antigen and beta-human chorionic gonadotropin as serum markers for advanced urothelial malignancies. Iwasa Y, Fletcher C D 2004 Distinctive prepubertal vulval fibroma: a hitherto unrecognized mesenchymal tumor of prepubertal girls-analysis of 11 cases. We have seen examples where this mimics a germinal center, and at low power the first impression is of follicular cystitis. Histologically it is composed of irregularly shaped glands, some of which may exhibit papillary infoldings, and a leaflike architecture surrounded by smaller rounded glands, imparting a lobular appearance. Li S, Zimmerman R L, Livolsi V A 1999 Mixed malignant germ cell tumor of the fallopian tube. Macroscopically, this is an exophytic tumor in the lower third of the esophagus (A). In contrast to extragenital melanoma, which has a peak incidence in patients around the fourth decade, vulvar melanoma typically occurs in older women, with most patients in their sixth to eighth decades. The Nature of Reed-Sternberg Cells the histogenesis of Reed-Sternberg cells has been controversial. In the prepubertal age group, teratoma and yolk sac tumor account for practically all cases, whereas in the postpubertal age group all the various types of germ cell tumor can occur. They are lined by low columnar to cuboidal cells with scanty cytoplasm and oval hyperchromatic nuclei. McKenney J K, Balzer B L, Longacre T A 2006 Lymph node involvement in ovarian serous tumors of low malignant potential (borderline tumors): pathology, prognosis, and proposed classification. Foci of limited stromal invasion are identified occasionally in a borderline serous tumor. Histologic Appearances Microscopically, small stellate cells lie in a faintly basophilic loose stroma, reminiscent of the stroma of the renal medulla. Coyne J D, Kealy W T, Annis P 1987 Seminal vesicle epithelium in prostatic needle biopsy specimens. Some cases have been accompanied by raised serum levels of chorionic gonadotropin, which also can be demonstrated immunohistochemically within the trophoblastic cells. Parathyroid adenoma can be mistaken for thyroid follicular adenoma, in particular when it shows a follicular pattern or predominance of oxyphilic cells, or when it is situated in the thyroid. The cellular organization is largely maintained, but nuclear crowding may be seen. The sex cord cells are polygonal and have uniform nuclei and small amounts of cytoplasm; they resemble indifferent sex cord cells or granulosa cells. In some cases, the cytoplasm is plasmacytoid, with a pale juxtanuclear Golgi zone. These lesions are benign and typically do not recur even after incomplete excision. The urothelium is thickened, and variable nuclear enlargement and hyperchromasia are present. Brainard J A, Hart W R 1998 Adenoid basal epitheliomas of the uterine cervix: a reevaluation of distinctive cervical basaloid lesions currently classified as adenoid basal carcinoma and adenoid basal hyperplasia. The position paper from the International Thymic Malignancy Interest Group provides further details on the application of the staging system. They are usually asymptomatic, being detected at colonoscopic screening for colorectal cancer. Feinberg S M, Leslie K O, Colby T V 1987 Bladder outlet obstruction by so-called lymphomatoid granulomatosis (angiocentric lymphoma). Patients complain of pelvic or abdominal pain, abdominal swelling, or a palpable abdominal mass. Strahlenther Onkol 185: 184-189 Herbst A L, Ulfelder H, Poskanzer D C 1971 Adenocarcinoma of the vagina: association of maternal stilbestrol therapy with tumor appearance in young women. The stroma is the most distinctive and morphologically variable component, ranging from hypocellular to hypercellular and containing cells that range from bland spindle-shaped cells with indistinct cytoplasm to cells with markedly enlarged hyperchromatic nuclei and abundant eosinophilic cytoplasm52. Hyperplasia of mucus acini is common, and pseudopyloric metaplasia may be present.