Malignant melanoma of the vulva in childhood is a rare neoplasm. Lichen sclerosus of the vulva in childhood is also a rare disease. The association of these two rare lesions in the vulva of young girls is extremely rare. We present a 10-year-old white girl with malignant melanoma associated with lichen sclerosus of the vulva. She had dark pigmentation of both the labia minora and posterior fourchette. The inner labia majora and fourchette showed whitish, glistening areas of skin. Histologic examination found mostly an in situ lentiginous/mucosal melanoma with focal invasion to a depth of 0.44 mm in the left upper labium majus. All specimens showed evidence of lichen sclerosus. Partial vulvectomy was performed, and no metastases were detected at the time of treatment. The patient has been disease free for the 12 months after treatment. It is critical for physicians to realize that melanoma can occur in children, and although rare, can occur in the vulva. We feel that lichen sclerosus in this instance may represent a pattern of host immune response to melanoma.

We report a primary uterine sarcoma with classic histologic, immunohistochemical, and ultrastructural features of a malignant extrarenal rhabdoid tumor (MERT). It arose in a 71-year-old woman who presented with postmenopausal bleeding, ascites, and a right pelvic mass. Malignant cells with rhabdoid morphology were identified by cytologic examination of the peritoneal fluid. Exploratory laparotomy revealed a 10-cm right adnexal mass and disseminated peritoneal tumor. Pathologic study showed diffuse expansion of the endometrial stroma by rhabdoid-like cells with transmural infiltration of the myometrium and extensive involvement of uterine serosa and right ovary by tumor. Neoplastic cells were immunoreactive for vimentin, cytokeratin, and epithelial membrane antigen, and cytoplasmic whorls of intermediate filaments were observed by electron microscopy. Fluorescence in situ hybridization (FISH) studies with chromosome 22–specific probes showed no loss of the INI1 gene, and no coding sequence mutation was identified. HUM PATHOL 32:884-886. Copyright © 2001 by W.B. Saunders Company

OBJECTIVE:We reviewed consecutive cases classified as benign cellular changes (BCC) over a four-month period.STUDY DESIGN:Cases classified as BCC were retrieved from the cytology files. A search was carried out to identify the previous Pap smears and concomitant cervical biopsies.RESULTS:One thousand one hundred three cases (23% of our gynecologic smears) were classified as BCC. Ninety-two patients (8.3%) underwent concurrent cervical biopsies. Specific infections accounted for 8% of BCC cases; reactive changes accounted for 92%. Of the biopsy specimens, 8.3% had no significant pathologic change. The most common biopsy diagnoses were cervicitis (31.5%), immature squamous metaplasia (16.3%) and reserve cell hyperplasia (10.8%). Miscellaneous benign diagnoses accounted for 21.7%. Cervical intraepithelial neoplasia (CIN) 1/human papillomavirus (HPV) was present in 14% of cases. All patients with biopsy diagnoses of CIN 1 had at least two previous abnormal Pap smears. Previous biopsy reports were available for review in 127 (12%) of the 1,103 patients. Of these 127 cases, 53.5% had a previous diagnosis of CIN/HPV; 9.4% had invasive carcinoma. A benign diagnosis was reported in 36.5%.CONCLUSION:The majority of BCC cases are due to reactive and inflammatory processes. In patients with a previous history of CIN, BCC may be of some significance. In patients with no significant prior cervical abnormalities, a Pap smear classified as BCC represents a reactive process.

OBJECTIVE:To evaluate the qualification of a Pap smear classified as atypical squamous cells of undetermined significance (ASCUS) favor reactive or neoplasia as recommended by the Bethesda System.STUDY DESIGN:The smears from 105 concurrent patients with a cytologic diagnosis of ASCUS not otherwise qualified were reviewed and subclassified as ASCUS favor reactive, low grade squamous intraepithelial lesion (LSIL) or high grade squamous intraepithelial lesion (HSIL) based on the Bethesda System criteria. The cervical biopsy diagnoses were correlated.RESULTS:Of the 105 cases classified as ASCUS, 37 were subclassified as favor reactive, 51 as favor LSIL and 17 as favor HSIL on cytologic review. In the ASCUS favor reactive group, 19 (51%) had reactive changes on biopsy, 17 (46%) had cervical intraepithelial neoplasia (CIN) 1, and 1 (2%) had CIN 3. A total of 48% patients had CIN. In the favor LSIL group, there was CIN 1 in 28 cases (55%), CIN 2 or 3 in 12 (23%) and benign changes in 11 (22%) on biopsy. Seventy-eight percent had CIN. In the 17 cases classified as ASCUS favor HSIL group, all had CIN.CONCLUSION:Of the total 105 cases of ASCUS, 71% had CIN, 29% had reactive changes on follow-up biopsies, and 48% of patients in the ASCUS favor reactive group had CIN. Qualifiers of ASCUS have questionable utility in patient management.

OBJECTIVES:We set out to examine our use of the squamous intraepithelial lesion (SIL) category, compare our SIL rate to rates reported by others, and determine the corre-lation between SIL and histologically proven cervical intraepithelial neoplasia (CIN) in our population.MATERIALS AND METHODS:Reports from all Papanicolaou smears and associated histological specimens interpreted by the University of Florida Department of Pathology between 1992 and 1996 were reviewed.RESULTS:Of 39,484 Papanicolaou smears, 2,101 (5.3%) were classified as low-grade squamous intraepithelial lesion (LGSIL) and 1,366 (3.5%) were classified as high-grade (HGSIL). Of the LGSIL cases, 972 (46.3%) underwent timely biopsy: Findings were benign in 29.9%; 41.7% had CIN1,20.9% had CIN2, and 7.5% had CIN3. Of the HGSIL cases, 932 (68.2%) underwent timely biopsy: Findings were benign in 12.3%; 17.1% had CIN1, 26.7% had CIN2, 42.2% had CIN3, and 1.6% showed squamous cell carcinoma. Condusions. Our LGSIL rate is similar to reported rates, but our HGSIL rate of 3.5% is higher. We found good correlation between SIL on Papanicolaou smear and CIN on biopsy (70.1% for LGSIL and 86% for HGSIL).

OBJECTIVES:We set out to determine our rate of atypical glandular cells of undetermined significance (AGUS) classification, to compare our AGUS rate to rates reported by others, and to determine the correlation between AGUS and histological abnormalities in our population.MATERIALS AND METHODS:Reports from all Papanicolaou (Pap) smears and associated histological specimens interpreted by the University of Florida Department of Pathology between 1992 and 1996 were reviewed.RESULTS:A total of 462 (1.2%) of 39,484 Pap smears were classified as epithelial cell abnormality-glandular cell, with 328 (0.83%) AGUS, 102 (0.26%) endometrial cells out of phase or in a postmenopausal woman, and 32 (0.08%) adenocarcinoma. A total of 146 (45%) of the AGUS cases had timely biopsies: 95 (65.1%) had benign findings, 27 (18.5%) had cervical intraepithelial neoplasia, 14 (9.6%) had adenocarcinoma (10 endometrial, 2 endocervical, 2 extrauterine), 9 (6%) had endometrial hyperplasia, and 1 (0.7%) showed endocervical glandular cell dysplasia.CONCLUSIONS:AGUS on Pap is associated with a clinically significant histological abnormality in a moderate percentage of patients. Both squamous and glandular lesions are seen, supporting the need for aggressive evaluation of the cervix, endocervix, and endometrium when AGUS is reported.

BACKGROUND:Surgical implantation of silicone breast prostheses has been conducted and considered safe for over 30 years. Some implant recipients, however, complain of a group of symptoms similar to those observed in connective tissue disorders, rheumatoid arthritis, systemic lupus erythematosus, or polymyositis. To date, immunologic sequelae have not been confirmed and remain controversial.OBJECTIVE:To examine an autoimmune-like basis for the "silicone associated disease" reported by some women with silicone breast prostheses.METHODS:Proliferative responses of peripheral blood mononuclear cells against a panel of control and connective tissue proteins and to compounds common to silicone prostheses were measured in 26 women who received silicone breast implants (with implants in place an average of 166.4 [standard deviation (SD) 58.3] months), and 23 age-matched and sex-matched healthy controls.RESULTS:The frequency and intensity of cellular immune responses against collagen I, collagen III, fibrinogen, and fibronectin were significantly increased in silicone breast implant recipients versus controls. In implant subjects, the highest frequency of immune reactivity was directed against collagen I (11/26, 42%) with collagen III being the most immunostimulatory self-antigen with a mean stimulation index (SI) of 8.2 [95% confidence interval (95% CI) 3.2]. In addition, 10/26 (39%) of the implant recipients responded to more than one of the connective tissue antigens versus 0/23 (0%, P = .0007) healthy controls. Immunologic reactivities to other antigens, including silicone-based compounds, were remarkably similar.CONCLUSIONS:The identification of self-reactivity towards these connective tissue antigens may provide important information for attempts at associating silicone breast implants with disease.

Tenenbaum and colleagues1Tenenbaum SA Rice JC Espinoza LR et al.Use of antipolymer antibody assay in recipients of silicone breast implants.Lancet. 1997; 349: 449-454Summary Full Text Full Text PDF PubMed Scopus (51) Google Scholar suggest that an assay for antipolymer antibodies (APA) is useful in the assessment of patients with silicone breast implants (SBI). The paper does not clearly state the chemical nature of the polymer; the referenced abstract2Tenenbaum SA Cuellar ML Citera G et al.Identification of a novel antigen recognized by silicone breast implant recipients.Arthr Rheum. 1993; 36: S118Google Scholar shows that it is polyacrylamide, a chemical functionally and structurally unrelated to silicone and not having any in-vivo distribution. Nor are we provided with evidence that immunoglobulin binding to the polymer is specific. There are no competition experiments, there is no evidence for Fab fragment binding, and there are no control polymers. The data presented do not suggest that this test on polyacrylamide is indicative of reaction with other related or unrelated polymers. The authors should provide details of the method used to generate the antigen and of the assay itself sufficient to allow other laboratories to confirm their results. Specificity for individuals with silicone breast implants is open to question. 48% of non-SBI patients with fibromyalgia were APA positive3Gluck OS Tesser JRP Tenenbaum SA et al.Development of a laboratory marker for fibromyalgia.Arthr Rheum. 1996; 39 (abstr): 381Google Scholar and even 19% of osteoarthritis patients had such antibodies. Were the controls in the blinded study1Tenenbaum SA Rice JC Espinoza LR et al.Use of antipolymer antibody assay in recipients of silicone breast implants.Lancet. 1997; 349: 449-454Summary Full Text Full Text PDF PubMed Scopus (51) Google Scholar matched for age and medications; was there a difference in serum storage that might account for increased binding to polyacrylamide; and why were fibromyalgia controls not used? The utility of such a test in distinguishing highly symptomatic from modestly symptomatic patients is open to question. Was the functional classification of patients done before the assay results were obtained? Is it not artificial to assign patients with mild symptoms and functional class IV (severely disabled and incapacitated) to a less severe disease subgroup while patients with moderate symptoms and functional class I (no incapacity) are assigned to a more severe subgroup? Was there a relation between antibody titre and symptom severity? The authors should be directly challenged as to: (1) why they did not make clear which antigen was used in their assay (but instead allowed the inference that silicone was used); and (2) why they did not reference their own data on non-implant fibromyalgia patients which would lead a reader to draw very different conclusions. Both are serious omissions. I have served as a consultant and expert witness on matters related to SBI. Antipolymer antibodies, silicone breast implants, and fibromyalgiaAuthors' reply Full-Text PDF

OBJECTIVES:We set out to develop a benchmark for our use of the term atypical squamous cells of undetermined significance (ASCUS), to compare our ASCUS rate to rates reported by others, and to determine the correlation between ASCUS and histologically-proved cervical intraepithelial neoplasia (CIN) in our population.MATERIALS AND METHODS:All Papanicolaou (Pap) smears and associated cervical biopsies or endocervical curettages interpreted by the University of Florida Department of Pathology between 1992 and 1995 were reviewed.RESULTS:Of 28,494 Pap smears; 17% were classified as "epithelial cell abnormality, squamous," with 7.4% ASCUS, 5.6% low-grade squamous intraepithelial lesion, and 4.0% high-grade squamous intraepithelial lesion. Of the 2,100 ASCUS cases, 753 had timely biopsies; 45.8% were benign, 53.8% showed CIN, and 0.4% showed carcinoma. Of the CIN cases, 39.2% were CIN1, 8.1% were CIN2, and 6.5% were CIN3.CONCLUSIONS:Our 7.4% ASCUS rate is similar to published rates. Our high rate of neoplasia associated with ASCUS (54.2%) and our low ASCUS-squamous intraepithelial lesion ratio (0.77) indicate that we do not overuse the ASCUS classification.

A method to measure gel bleed from intact silicone gel-filled breast implants was developed. This nondestructive technique permits accurate and reproducible serial measurements of silicone bleed from smooth wall breast implants (n = 10) under simulated physiologic conditions in vitro. Gel bleed rates from new low bleed gel-filled implants and intact explants (unbarriered, low bleed, double lumen) were determined. These results demonstrate the reliability of this method to quantify silicone gel bleed and may permit a meaningful comparison of bleed rates from implants in the future.

In order for silicone from breast implants to have an effect on the immune system, it must be demonstrated that cells with the potential for immune system function have access to silicone. It had long been thought that the fibrous capsule surrounding breast prostheses functioned as an effective barrier between the biomaterial and the host. Implants that ruptured were thought to be innocuous to the host as long as the fibrous tissue capsule surrounding the implant was intact. This was termed “contained rupture.” Thus, the capsule was thought to prevent the egress of foreign material (Bingham et al. 1988)

Silicone gel is known to escape from clinically intact breast prostheses, through a process known as gel bleed through the elastomer shell. Multiple observers report the presence of silicone in regional lymph nodes of patients with ruptured or clinically intact breast prostheses. The mechanism of transport of silicone droplets away from the prosthesis to lymph nodes is described.Using a data base of more than two hundred explanted breast prostheses and their associated capsular tissues, the path of silicone droplets has been observed. Silicone droplets are picked up by macrophages in the lumen of the capsule. The macrophages become incorporated into the capsule, where mobility of the cell is unimpeded due to the absence of a basement membrane. Macrophages move deep into collagen layers of the capsule and aggregate in deep soft tissues in perivascular locations. Macrophages containing droplets of silicone are observed in regional lymph nodes draining the prosthesis sire. The observation of silicone in sites distant from the prosthesis was confirmed using microscopically guided Fourier Transform Infrared Spectroscopy (FTIR).The authors conclude that at least some of the silicone found distant to breast prostheses arrives chemically unchanged at regional lymph nodes, carried in droplets by tissue macrophages. This process occurs in patients with clinically unruptured prostheses as well as in those with ruptures.

A new method for diagnosis of ruptured silicone gel-filled implants was developed. The method uses a recently described technique for insertion of a catheter into an implant capsule. This allows irrigation with saline and recovery of cells for cytopathologic diagnosis. Cytopathologic diagnosis was both sensitive (94 percent) and specific (95 percent) in the detection of intracellular foreign material accompanying ruptured implants. The intracellular material has been positively identified as silicone. This laboratory study included 42 samples obtained at three time intervals on 5 rabbits, each of which had one "ruptured" and one intact implant for a total of 10 implants.

Citing evidence that breast implant-related capsules resolve uneventfully, surgeons have elected to leave the capsules in place when implants are removed because capsulectomy adds both morbidity and expense to the procedure. However, recent clinical and histopathologic evidence suggests that uneventful resolution is not always the case, and several potential problems may arise from retained capsules after removal of the implant. Retained implant capsules may result in a spiculated mass suspicious for carcinoma, dense calcifications that obscure neighboring breast tissue on subsequent imaging studies, and cystic masses due to persistent serous effusion, expansile hematoma, or encapsulated silicone filled cysts. Furthermore, retained capsules are a reservoir of implant-related foreign material in the case of silicone gel-filled implants and textured implants promoting tissue ingrowth. To avoid complications from retained capsules, total capsulectomy or postoperative surveillance should be offered to patients.