"Ovarian thecal metaplasia" (OTM), a spindle cell proliferation in the adrenal gland, is a rare lesion that is predominantly found in postmenopausal women. Here we present 5 patients with OTM in adrenalectomy specimens resected for adrenal and nonadrenal tumors in women aged 42 to 80 years old. Extended immunohistochemical analysis was performed using contemporary markers, which revealed expression of desmin (DES), HHF35 (ACTA1), inhibin alpha (INHA), SF1, and WT1. Histologic recognition of this lesion and knowledge of its expression can aid in identification and prevent misclassification.

AIMS:Standardizing pathology reporting protocols through peer consensus review is critical for the best quality of care metrics. Reporting heterogeneity due to discrepancies among professional societies and practice patterns may lead to heterogeneous management and treatment approaches. This issue prompted a multi-institutional survey of pathologists to address potential similarities or differences in trends and practice patterns in prostate pathology reporting worldwide. METHODS AND RESULTS:A REDCap survey was distributed among 175 pathologists worldwide, recruited through invitations and social media. The response rate among invited pathologists was 83%. The practice locations were as follows: North America (USA, Canada, and Mexico, 62%), Europe (17%), Australia/New Zealand (3%), Central/South America (2%), Asia (13%), and Africa (2%). Most pathologists practiced for <5 years (28%). A genitourinary (GU) pathology fellowship was completed by 37%, 58% practiced in a subspecialized setting, and 43% in academia. Reporting includes (63%) or subtracts (37%) intervening benign tissue. Both Gleason score and Grade Groups (GG)s were reported by 96% of responders, whereas 94% report percent pattern 4 (%4). Aggregate grading and volume estimation in undesignated cores with different grades in the same jar are reported by 73% and 54% for systematic biopsies, and 83% and 62% for targeted biopsies, respectively. Cribriform morphology was reported by 81%. For presumed intraductal carcinoma (IDC), 89% use basal cell markers when isolated (iIDC), 82% with GG1 cancer, and 37% with ≥GG2. iIDC or IDC associated with GG1 or with ≥GG2 was not graded by 90%, 78%, and 70%, respectively. In radical prostatectomies, 90% report %4, but only 53% report it if the overall grade is ≥7. A tumour with Gleason 3 + 3 = 6 and <5% pattern 4 was graded as GG2 by 64%. A <5% cutoff for defining tertiary pattern was used by 74%, and 80% report >5% pattern 4 or 5 as a secondary pattern. Grading was assigned based on the dominant nodule by 59%. Finally, reporting practices were significantly associated with demographic characteristics. CONCLUSIONS:Although most issues are agreed upon, significant discordance is identified among societies and pathologists in different practice settings. We hope this survey will serve as the basis for future studies and new collaborative approaches to more standardized reporting practices.

OBJECTIVES:Testicular germ cell tumors are susceptible to tumor displacement artifact (TDA), which produces pseudo-lymphovascular invasion (LVI) and confounds the identification of true LVI. Our study aimed to evaluate tumor displacement artifact and pseudo-LVI in testicular germ cell tumors and determine if prolonged fixation improves histological quality. METHODS:A retrospective search identified 121 orchiectomies with slides that were reviewed to assess TDA and pseudo-LVI. RESULTS:Seminoma had more TDA (68% vs 45%, P = .01) and pseudo-LVI (53% vs 19%, P < .001) than mixed germ cell tumor. Seminoma and mixed germ cell tumor with TDA and pseudo-LVI were larger than those without. Mixed germ cell tumor with ≥50% composition of seminoma had a higher rate of TDA (89% vs 38%, P = .008) and pseudo-LVI (44% vs 15%, P = .06) than those with less. TDA was reduced in seminoma with >1 night fixation compared to no fixation (50% vs 82%, P = .046), with a similar trend in mixed germ cell tumor (31% vs 60%, P = .15). A trend in reduction of pseudo-LVI was seen with >1 night fixation compared to no fixation in seminoma (64% vs 39%, P = .12). CONCLUSIONS:Seminomas and larger germ cell tumors were more prone to TDA and pseudo-LVI. Prolonged formalin fixation improved histological quality in testicular germ cell tumors. Based on these data, we recommend fixation for at least 2 nights before sectioning orchiectomy specimens, particularly for larger tumors.

Adenoid cystic carcinoma (ACC) is a rare tumor, accounting for 1% of all head and neck cancers, with an aggressive nature characterized by local recurrence, delayed metastasis, and survival of less than 50% at 10 years. This is a case of biopsy-proven ACC to the kidney, 1 of 29 known occurrences, managed by metastasectomy by robotic-assisted nephrectomy, with plans for resection of lung metastasis. Thirteen years after diagnosis of sinonasal ACC treated with resection, the patient presented with shortness of breath. This prompted a CT scan of the chest, which led to the incidental finding of left renal mass and pulmonary lesion. Literature suggests improved disease-specific survival in locoregional recurrence treated with surgery versus radiation; in patients with metastasis to the lung, metastasectomy offers greater survival benefit than supportive therapy. But, this is not significantly better than chemotherapy or radiation alone. While the optimal therapeutic approach remains to be identified in distant metastatic ACC, metastasectomy remains a viable option for patients who have potentially completely resectable metastatic tumors, appropriate performance status, and adequate affected-organ function. Preoperative counseling should include discussion on partial nephrectomy with prioritization of nephron-sparing but potential for increased perioperative risk versus radical nephrectomy to ensure negative margins and expedite timeline to systemic therapy.

To the Editor.—The pathology job market in the United States has been a source of concern, controversy, and confusion. There is a paucity of data on the job market, with information predominately from surveys of graduating trainees and pathologists in practice. In response to the recently published article by Gross et al1 using the 2021 College of American Pathologists Practice Leader Survey to evaluate the job market, we reviewed the job advertisements for pathologists posted at www.PathologyOutlines.com during the 5-year time period from 2018 to 2022 and compared this with our analysis2 of jobs posted from the prior 5-year time period of 2013 to 2017. Postings for locum tenens, residency, fellowship, and nonpathologist positions were excluded. Our results are consistent with the increase in hiring identified in 2021 compared with 2017 described by Gross et al.1Comparing the time periods of 2013–2017 and 2018–2022, the number of job postings more than doubled (2013–2017 total, 2330 [range per year, 267–660]; 2018–2022 total, 5438 [range per year, 788–1522]) (Figure 1). In 2018–2022, there was an increase in job postings in all years but 2020. Not surprisingly, there was job market contracture in 2020 (n = 788) during the height of the COVID-19 pandemic. However, in 2020 there were still a greater number of posted jobs than in any year between 2013 and 2017. The contracture in 2020 was followed by a large increase in jobs posted in 2021 (n = 1359) and 2022 (n = 1522), more than double compared with any year between 2013 and 2017.More jobs were posted in the fourth quarter (October–December) (689 of 2330; 29.6%) during 2013–2017, followed by the third quarter (July–September) (615 of 2330; 26.4%). This was reversed in 2018–2022, with more jobs posted in the third quarter (1523 of 5438; 28.0%) than the fourth quarter (1383 of 5438; 25.4%), suggestive of greater competition acquiring candidates who were still in training, earlier in the academic year.For 2018–2022, 5104 of 5438 job advertisements (93.9%) were for positions within the United States and 287 of 5438 (5.3%) were for positions in Canada, similar proportions to 2013–2017 (2153 of 2330 [92.4%]; 154 of 2330 [6.6%]). The location of job openings within the United States was very stable between 2013–2017 and 2018–2022. For example, the Midwest had 22.7% (489 of 2153) of job openings in the former and 22.6% (1152 of 5104) in the latter time period. Proportional changes in job market in all geographic regions were less than 1%. The region with the most job openings was the South for both time periods (2013–2017, 659 of 2153 [30.6%]; 2018–2022, 1588 of 5104 [31.1%]).In both time periods, about half of jobs were posted for academia and about half were for private practice. Although there were slightly more jobs in academia in 2013–2017 (1229 of 2330; 52.7%) than in private practice (1101 of 2330; 47.3%), this was reversed in the 2018–2022 time period (2534 of 5438 [46.6%]; 2904 of 5438 [53.4%]) (Figure 2). The posted job ads may still be an overrepresentation of the academic setting as the proportion is higher compared with 38% of survey respondents who accepted an academic position per Gratzinger et al.3In both time periods, most jobs ads stated that anatomic pathology (AP) or AP/clinical pathology (CP) was required (2013–2017, 1807 of 2330 [77.6%]; 2018–2022, 4080 of 5438 [75.0%]). From 2013 to 2017, the proportion of jobs requiring combined AP/CP was stable (857 of 2330 [36.8%]; range, 33.7%–39.6%). However, a substantial increase in the requirement of combined AP/CP was noted starting in 2019 (2018, 304 of 845 [36.0%]; 2019, 421 of 924 [45.6%]; 2020, 459 of 788 [58.2%]; 2021, 680 of 1359 [50.0%]; 2022, 808 of 1522 [53.1%]). With more job openings, this suggests a greater need for newly hired pathologists to do a broader range of clinical duties. The increase was observed in both private and academic job postings. From 2013 to 2017, most private jobs required combined AP/CP (715 of 1101; 64.9%), whereas few academic jobs (142 of 1229; 11.6%) did. Analyzing 2019 quarters 3 and 4 through 2022 showed a slight increase in AP/CP required in the private setting (1526 of 2213; 69.0%) and a large increase in the academic setting (657 of 1947; 33.7%). Few posted jobs required CP only in both time periods (2013–2017, 201 of 2330 [8.6%]; 2018–2022, 333 of 5438 [6.1%]).The percentage of job ads that did not require a subspecialty (beyond surgical pathology) was variable but was below 30% for most of the past decade (2013, 38 of 267 [14.2%]; 2014, 87 of 351 [24.8%]; 2015, 127 of 482 [26.3%]; 2016, 101 of 570 [17.7%]; 2017, 73 of 660 [11.1%]; 2018, 74 of 845 [8.8%]; 2019, 180 of 924 [19.5%]; 2020, 204 of 788 [25.9%]) (Figure 3). However, an increase was observed in the past 2 years (2021, 519 of 1359 [38.2%]; 2022, 620 of 1522 [40.7%]). This may indicate more competition for candidates and subsequently less emphasis on the specific background of the candidate.During both time periods, the 3 most frequent subspecialties listed in job ads were cytopathology (2013–2017, 344 of 2330 [14.8%]; 2018–2022, 1059 of 5438 [19.5%]) and hematopathology (325 of 2330 [13.9%]; 1064 of 5438 [19.6%]), followed by gastrointestinal pathology (263 of 2330 [11.3%]; 809 of 5438 [14.9%]) (Table). The next 4 most frequently requested subspecialties in descending order during 2013–2017 were dermatopathology, molecular pathology, breast pathology, and gynecologic pathology. These were the next 4 during 2018–2022 as well, but the order changed to breast pathology, gynecologic pathology, dermatopathology, and molecular pathology.In conclusion, during the past 5 years within the United States, inclusive of before, during, and after the COVID-19 pandemic, our analysis supports a strong pathology job market. We found a markedly increased demand for pathologists compared with the prior 5-year period and in particular during 2021 and 2022. Practices that are hiring should be aware of the increase in demand and that job openings are now more frequently posted earlier in the academic year. Of relevance to trainees, more practices may emphasize general skills and combined board certification.

The 5th edition WHO Classification of Urinary and Male Genital Tumours (2022) introduced many significant changes relevant to urologic daily practice, mainly to renal tumors which was covered in the What’s New newsletter in September 2022. In this newsletter, we summarize the notable changes to bladder, prostate, testis, and penis based on the 5th edition of the WHO.

Adenoid cystic carcinoma (AdCC) metastasis to kidney is rare. We identified 10 patients with metastatic AdCC in multi-institutional collaboration. Core needle biopsy was the most common specimen ( n = 6). Patients were predominately female ( n = 7) with a median age of 48 years (35–62 years). The most common primary location of the AdCC was head and neck ( n = 6, among them parotid gland = 4), followed by lung ( n = 2), breast ( n = 1), and vulva ( n = 1). Median lapse between primary AdCC and renal metastasis was almost 13 years (154 months, range 1–336 months). Moreover, all but one patient had unilateral kidney metastasis. The majority of metastatic AdCC within the kidney demonstrated mixed growth patterns, frequently cribriform, and tubular morphology. Follow-up available for 8 patients showed 6 alive with disease and 2 died of disease (the longest survival was 4 years past the diagnosis of renal metastasis). A systematic literature review including 29 patients revealed that kidney metastasis by AdCC is usually a late event, is typically unilateral, and is usually composed of one to three foci, and thus has clinical features which mimic a primary renal tumor.

The 3rd-7th edition of the American Joint Committee on Cancer had 3 categories for positive lymph nodes (pN1-3) in upper urinary tract carcinomas. The 8th edition removed pN3, defining pN1 as one lymph node with a tumor deposit <2 cm and pN2 as a node with a tumor deposit >2 cm or me-tastases in multiple nodes. The aim of this study was to assess if the current pN categories impact sur-vival in renal pelvic and ureteral carcinomas. Nephroureterectomies performed at our institution for primary upper urinary tract carcinomas between 2010 and 2019 were reviewed. Lymphadenectomy was performed in 73.3% of cases (151/206, median Z 9 nodes). Eighty-one (53.6%) patients were deceased at the last review (pN0, 53 [44.5%]; pN1-2, 28 [87.5%]). There was no difference in overall or recurrence-free survival between pN1 and pN2 with 5-year overall survival (95% confidence inter -val) of pN0, 60.7% (52.0-70.8%); pN1, 15.4% (4.3-35.2%); and pN2, 21.1% (8.8-40.3%). The met-astatic deposit size threshold of 2 cm, the number of positive lymph nodes, as well as extranodal extension did not correlate with overall or recurrence-free survival. As such, pN1 and pN2 were group -ed together with a 5-year overall survival of 18.8% (9.12-28.6%). The current stratification of upper urinary tract carcinomas into pN1 and pN2 does not provide prognostic information, and both yield a stage IV classification, regardless of pT or pM category. Therefore, we recommend further simplifica-tion of pN classification into one category for regional lymph node metastasis, irrespective of the lymph node deposit size or number of positive lymph nodes.(c) 2023 Elsevier Inc. All rights reserved.

According to the American Joint Cancer Committee, pT3 renal pelvic carcinoma is defined as tumor invading the renal parenchyma and/or peripelvic fat and is the largest pT category, with notable survival heterogeneity. Anatomical landmarks within the renal pelvis can be difficult to discern. Using glomeruli as a boundary to differentiate renal medulla invasion from renal cortex invasion, this study aimed to compare patient survival of pT3 renal pelvic urothelial carcinoma on the basis of the extent of renal parenchyma invasion and, thereafter, determine whether redefining pT2 and pT3 improves pT correlation with survival. Cases with primary renal pelvic urothelial carcinoma were identified through a review of pathology reports from nephroureterectomies completed at our institution from 2010 to 2019 (n = 145). Tumors were stratified by pT, pN, lymphovascular invasion, and invasion of the renal medulla versus invasion of the renal cortex and/or peripelvic fat. Overall survival between groups was compared using Kaplan-Meier survival models and Cox regression multivariate analysis. pT2 and pT3 tumors had similar 5-year overall survival, with multivariate analysis demonstrating an overlap between hazard ratios (HRs) for pT2 (HR, 2.20; 95% CI, 0.70-6.95) and pT3 (HR, 3.15; 95% CI, 1.63-6.09). pT3 tumors with peripelvic fat and/or renal cortex invasion had a 3.25-fold worse prognosis than pT3 tumors with renal medulla invasion alone. Furthermore, pT2 and pT3 tumors with only renal medulla invasion had similar overall survival, whereas pT3 tumors with peripelvic fat and/or renal cortex invasion had a worse prognosis (P = .00036). Reclassifying pT3 tumors with only renal medulla invasion as pT2 yielded greater separation between survival curves and HR. Thus, we recommend redefining pT2 renal pelvic carcinoma to include renal medulla invasion and restricting pT3 to peripelvic fat and/or renal cortex invasion to improve the prognostic accuracy of pT classification.

The American Joint Cancer Committee pT categorization in renal pelvic carcinoma defines pT3 as invasion of renal parenchyma, invasion of peripelvic fat, or both. However, survival heterogeneity within the pT3 category has been demonstrated. This investigation sought to compare survival between pT categories of renal pelvic urothelial carcinoma and identify modifications to improve correlation with survival. Pathology reports from nephroureterectomies performed at our institution from 2010 to 2019 were analyzed to identify primary renal pelvic urothelial carcinoma (n = 146). Tumors were stratified based on pT, pN, and invasion of renal parenchyma vs invasion of peripelvic fat with or without renal parenchyma invasion. Kaplan-Meier survival curves and Cox regression multivariate analysis were used to compare overall survival between groups. Similar survival curves were observed for pT2 and pT3 tumors. Multivariate analysis confirmed overlapping hazard ratios (HRs) for pT2 (HR = 2.64, 95% confidence interval [CI] = 0.69, 10.06) and pT3 (HR = 4.42, 95% CI = 2.08, 9.37). pT3 tumors with peripelvic fat invasion, regardless of renal parenchyma involvement, had a 3.3-fold worse overall survival than pT3 tumors with only renal parenchyma involvement. Additionally, pT3 tumors with only renal parenchyma invasion had similar survival compared to pT2, while pT3 tumors with peripelvic fat invasion had worse overall survival (p = 0.00091). Reclassifying renal parenchyma invasion as pT2 yielded greater survival curve separation and greater difference in HRs. For renal pelvic urothelial carcinoma, modifying the pT3 category to only include tumors with peripelvic fat invasion and expanding the pT2 category to include renal parenchyma invasion may improve pT correlation with overall survival.

Scrotal leiomyosarcoma arises from the subcutaneous smooth muscle layer and is an exceptionally rare disease process with only six patients in the largest reported case series. This rarity creates uncertainties regarding diagnosis, surgical management, and clinical outcomes. Our purpose was to retrospectively describe our institutional experience with scrotal leiomyosarcoma from 2010 to 2022. Slides were reviewed with case inclusion requiring both nuclear atypia and mitotic activity. Ten patients with scrotal leiomyosarcoma were identified. Clinical impression included scrotal cyst in nine cases. The median age at diagnosis was 52 years (range 29-75 years). Mean tumor size was 1.6 cm (range 0.4-3.7 cm). Margins were positive in three cases and close in one case, prompting four re-excisions. Mean mitotic rate was 2.3 per 10 high power field (range 1-11) with mean Ki67 of 4.6% (range 1-15%). Nine of the tumors were grade 1, while 1 was grade 2. Four patients had disease specific follow-up. The remaining six patients have not had disease specific surveillance. None of the ten patients have shown evidence of recurrence (median follow-up 75 months, range 0-116 months). Our series demonstrates that scrotal leiomyosarcoma has a deceptive clinical presentation with a wide age range and small tumor size. With complete surgical resection, scrotal leiomyosarcoma has an excellent prognosis and rigorous follow-up or adjuvant treatment is not likely to be necessary. Cases with unusual clinical or pathologic findings, such as large tumor size or high mitotic rate, may merit more intensive disease specific surveillance.

Few medical schools have required experience in surgical pathology during the clinical years. After introducing a pilot and preliminary surgical pathology clinical experience into the curriculum, we initiated a required 3rd-year medical student surgical pathology clinical experience that consisted of a one hour introductory lecture; one hour gross room, histology, and immunohistochemistry laboratory introduction; and one hour of one-on-one case sign-out preceptorship with a subspecialty surgical pathologist within the surgery and obstetrics/gynecology block. Concepts that were covered included specimen processing, intraoperative frozen section consultation, completing specimen requisitions, interpreting synoptic reports, and pTNM staging. Students evaluated the surgical pathologist from 1 to 5 (1 "poor/unhelpful," 2 "marginal," 3 "neutral," 4 "good," 5 "excellent/useful"). Ten multiple-choice questions (included as part of a perioperative services exam) and attendance were incorporated into students' perioperative services rotation grade. From 2014 to 2018, 757 students participated in the required 3rd-year surgical pathology clinical experience. Thirty academic subspecialty pathologists acted as preceptors with an average of nine sessions per preceptor per year. Evaluation data from 316 students from 2015 to 2018 showed a mean preceptor rating of 4.8/5 (range 4.0-5.0). Students scored an average of 81% on the surgical pathology portion of the exam (range 21-99% for each question). We successfully implemented a required medical student surgical pathology clinical experience. At the clerkship's conclusion, students demonstrated understanding of key concepts and rated their preceptorship experience highly.