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Pathology (January 2013) 45(1), pp.

8099

CORRESPONDENCE
Obtaining expert opinions in diagnostically
difficult cases
Sir,
Klebe et al.1 describe their experience with expert review of
difficult mesothelial proliferations. They found only 57%
complete concordance between the expert and referring pathologists diagnosis, with some 9.5% of cases having significant disagreement (benign versus malignant, or mesothelioma
versus another tumour type). Whilst disturbing, this will come
as no surprise to those of us with subspecialty interests in other
rare tumour types such as sarcoma or GIST, and no doubt in
other organ systems as well.
These figures are in line with similar studies performed
overseas; for example, in their review of 349 soft tissue specimens, Thway and Fisher2 reported minor diagnostic discrepancy in 15.7% and major discrepancy in 10.9%, including a
difference of benign versus malignant in 5%. Similarly, in a
review of 266 referred soft tissue lesions for which a primary
diagnosis had been offered by the referring pathologist, there
were major discrepancies (e.g., benign versus malignant, nonmesenchymal tumour) in 25% of cases, and minor discrepancies in 7%.3 Numerous other such studies from a variety of
countries support the value of timely expert review of rare and
difficult cancers,47 with diagnostic discrepancies reportedly as
high as 45% or more in some series.6,7
This is more than simply an intellectual exercise: delayed or
incorrect diagnosis can lead to profound impacts on the patient
who undergoes inappropriate or unnecessary surgery, chemoor radiotherapy, or who is denied potentially life-saving
therapy. A review of 1996 musculoskeletal tumours in one
specialist unit8 found a diagnostic error in 87 cases, 54 of
which (2.7%) resulted in a significant change to the patients
management. In the case of aggressive cancers, even relatively
short delays in accurate diagnosis can impact on patient survival.9 Even if the correct diagnosis is reached, errors in grading
or risk stratification can also impact on clinical decision-making, e.g., neoadjuvant radiotherapy versus up-front surgery in
various types of soft tissue sarcoma; adjuvant imatinib versus
observation in GIST; wait and see versus treatment, or choice
of treatment modality, in gastroenteropancreatic neuroendocrine tumour (GEP-NET).
It is clear, therefore, that timely expert review of difficult and
rare entities is in the best interests of the patient; however, for
many pathologists working in non-specialist centres, there are
difficulties in obtaining such review. Not only does the referring laboratory incur a cost in terms of packaging and sending
the slides (and hopefully a paraffin block or two!) to the
expert, but the receiving laboratory incurs a significant cost
in terms of handling the incoming material, making the diagnosis and issuing an opinion (which is often complex). This
brings its own rewards in that the cases are often interesting,
and expertise is only accrued through exposure to difficult and
unusual cases, but the cost must be borne somewhere. Many of
us choose not to charge a fee for this work, but this is only
sustainable if the number of referrals is relatively small (and
with the indulgence of our heads of department), and some
institutions insist on a fee of perhaps several hundred dollars
a cost which most referring laboratories cannot meet. This
Print ISSN 0031-3025/Online ISSN 1465-3931

means that the fee is most often passed on to the patient, an


added stress at the very time that they are facing a potentially
devastating diagnosis. Surely our patients access to accurate
diagnosis and grading, and subsequent management, should be
independent of their personal wealth?
There is clearly a need for timely and appropriate referrals of
difficult cases for expert review, and this should be funded in an
equitable fashion. The relatively small cost of these referrals
would be more than compensated by avoiding unnecessary and
inappropriate treatment based on an incorrect diagnosis or
tumour grade; for example, only one incorrect diagnosis of
high risk GIST will cost in excess of AU$45 000 per annum10 in
drug costs alone, for adjuvant imatinib which will not benefit
the patient. Therefore, funding of expert opinion referrals
would not only be good medicine, but would be cost effective.
The Royal College of Pathologists of Australasia (RCPA) has
prepared two applications to the Medical Services Advisory
Committee (MSAC) to fund retrieval of tissues and such expert
opinions, which would help the situation at least in Australia,
and this initiative should be strongly supported by pathologists
and clinicians alike.
Patients with rare cancers deserve the same expert diagnosis
and management that is afforded to those with common
tumours, and that can only be achieved through timely referral
for expert advice when it is needed.
Chris Hemmings
ACT Pathology, Canberra, Australian National University, and
Australasian Sarcoma Study Group, Canberra, ACT, Australia
Contact Dr C. Hemmings.
E-mail: Christine.Hemmings@act.gov.au
1. Klebe S, Greiggs K, Ely M, Henderson D. Is there a need for expert
opinion for biopsy diagnosis of difficult cases of malignant mesothelioma?
Pathology 2012; 44: 5623.
2. Thway K, Fisher C. Histopathological diagnostic discrepancies in soft
tissue tumours referred to a specialist centre. Sarcoma 2009; May 27: (Epub
ahead of publication).
3. Arbiser Z, Folpe A, Weiss S. Consultative (expert) second opinions in soft
tissue pathology: analysis of problem-prone diagnostic situations. Am J
Clin Pathol 2001; 116: 4736.
4. Lehnhardt M, Daigeler A, Hauser J, et al. The value of expert second
opinion in diagnosis of soft tissue sarcomas. J Surg Oncol 2007; 97:
403.
5. Amant F, Moerman P, Cadron I, et al. The diagnostic problem of
endometrial stromal sarcoma: report on six cases. Gynecol Oncol 2003;
90: 3743.
6. Lurkin A, Ducimetiere F, Vince D, et al. Epidemiological evaluation of
concordance between initial diagnosis and central pathology review in a
comprehensive and prospective series of sarcoma patients in the RhoneAlpes region. BMC Cancer 2010; 10: 150.
7. Sharif M, Hamdani S. Second opinion and discrepancy in the diagnosis of
soft tissue lesions at surgical pathology. Indian J Pathol Microbiol 2010; 53:
46670.
8. Grimer R, Carter S, Spooner D, Sneath R. Diagnosing musculoskeletal
tumours. Sarcoma 2001; 5: 8994.
9. Kim M, Lee S, Cho W, et al. Prognostic effects of doctor-associated
diagnostic delays in osteosarcoma. Arch Orthop Trauma Surg 2009;
129: 14215.
10. Australian Government, Department of Health and Ageing. Australian
Pharmaceutical Benefits Scheme. Cited Oct 2012. www.pbs.gov.au.

DOI: 10.1097/PAT.0b013e32835baec7

2012 Royal College of Pathologists of Australasia

Copyright Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.

CORRESPONDENCE

Rapidly fatal post-allogeneic stem cell


transplant lymphoproliferative disorder
presenting with skin and bone
marrow involvement
Sir,
Post-transplant lymphoproliferative disorders (PTLD) are an
uncommon complication of both solid organ and allogeneic
blood or bone marrow transplants (BMT). Early PTLD almost
invariably results from uncontrolled proliferation of Epstein
Barr virus (EBV) infected donor derived B cells in these
immunosuppressed patients who are unable to mount an
EBV specific cytotoxic T-cell response. The main risk factors
for developing PTLD are the duration and intensity of immunosuppression and recipient EBV seronegativity at the time of
transplant. Additional risk factors in recipients of allogeneic
BMT include degree of mismatch between the donor and
recipient and T-cell depletion of the graft.1,2 The 2008 World
Health Organization Classification3 charts the heterogeneous
spectrum of PTLD disorders ranging from infectious mononucleosis-type polyclonal proliferations, which generally
resolve with reduction in immunosuppression, to monomorphic
PTLD which may present as an aggressive lymphoma and
require chemotherapy. Patients who have received lung, small
bowel or multiple organ transplants are reported to be at the
highest risk of PTLD, with rates of approximately 5%.2 By
contrast, the rate of PTLD following allogeneic BMT is
reported to be lower, with an overall risk of approximately 1%.1
This report describes a patient who developed a highly
aggressive PTLD within 2 months of a second allogeneic
BMT for relapsed acute myeloid leukaemia (AML). Clinical
progression was rapid and the patient died one week after
presentation. Such a fulminant presentation is extremely rare
with only three similar reported cases.46
A 45-year-old EBV IgG positive Caucasian male with a
background of Crohns disease was diagnosed with AML in
August 2007. Despite an adverse cytogenetic profile (monosomy 5, del7q and multiple additional anomalies) a complete
morphological and cytogenetic remission was documented
following induction chemotherapy with high dose cytarabine
and idarubicin. After two cycles of consolidation chemotherapy
he underwent a matched sibling peripheral blood stem cell
transplant in January 2008 with cyclophosphamide and total
body irradiation conditioning. A bone marrow biopsy on day
60 showed evidence of a cytogenetic relapse which was
successfully managed with withdrawal of immunosuppression.
Three years post-transplant a routine bone marrow demonstrated a cytogenetic relapse (1/40 metaphases demonstrating
the complex karyotype noted at diagnosis), and 1 month later he
was in a morphological relapse with 30% bone marrow myeloblasts. Following two cycles of salvage chemotherapy
morphological and cytogenetic remission was again documented. The patient then underwent a fully matched (HLA-A, -B,
-C, and -DRB1 by molecular typing) unrelated donor BMT
with fludarabine, busulphan and thymogloblulin conditioning
(total dose thymoglobulin 4.5 mg/kg). The EBV status of the
donor was unknown. Post-transplant immunosuppression was
with methotrexate and cyclosporin. The patient engrafted on
day 14 and simultaneously developed a rash and deranged
liver function tests. A skin biopsy was consistent with graft
versus host disease and he was successfully treated with topical

81

hydrocortisone and 40 mg oral prednisone. A rising cytomegalovirus polymerase chain reaction (PCR) titre on day 35
was effectively treated with oral valganciclovir.
The patient was readmitted on day 71 with a 1 week history
of progressive nausea, vomiting and diarrhoea with associated
fever with rigors. Multiple blood cultures were negative
although stool Clostridium difficile toxin PCR and norovirus
enzyme immunoassay were both positive. His IgG level was
low at 3.32 g/L and treatment with metronidazole and intravenous immunoglobulin was commenced. His clinical condition
deteriorated with the development of abdominal pain, oliguria
and severe lactic acidosis with a lactate of 7.7 mmol/L. A
computed tomography (CT) scan showed wall thickening of
the descending colon along with intra-abdominal lymph nodes
measuring up to 3 cm. An exploratory laparotomy and colonoscopy, performed due to concern of possible ischaemic bowel,
showed only mild inflammation of the colon. Cytological
analysis of peritoneal fluid demonstrated a small number of
atypical cells. On day 76 a skin rash developed and was
biopsied. Simultaneously the patient developed pancytopenia
with Hb 103 g/L, WCC 2.7  109/L and platelets 22  109/L
and a bone marrow biopsy was performed. The patient died
from progressive multiorgan failure on day 78 before the
results of these investigations were available.
The skin biopsy demonstrated an abnormal perivascular
infiltrate of large, morphologically abnormal lymphoid cells
with polymorphic nuclei and prominent nucleoli (Fig. 1A). The
abnormal cells were positive for CD20/CD79a/EBER/MUM-1/
PAX-5 and Bcl-2 but negative for CD10/CD30/CD138 and
Bcl-6 (Fig. 1B). Occasional plasmacytoid lymphoma cells were
noted in the peripheral blood. The bone marrow biopsy was
hypocellular with an abnormal infiltrate of similar lymphoid
cells (Fig. 2A). Flow cytometry of the bone marrow showed an
abnormal population of large CD19 and lambda positive cells.
Immunohistochemistry of the trephine showed small clusters of
large cells with strong immunoreactivity for EBER (Fig. 2B)
and relative lambda light chain restriction. Cytogenetic analysis
was normal. Whilst the lymphoma cells showed significant
pleomorphism, the clinical picture and immunostains were
consistent with monomorphic PTLD, most likely a non-germinal centre diffuse large B-cell lymphoma.
Only one previous case has been reported of simultaneous
multifocal skin and bone marrow involvement in a patient with
PTLD. This developed in a 14-month-old EBV seronegative
recipient of a combined small bowel and liver transplant from
an EBV seropositive donor.4 The patient presented with
cutaneous PTLD associated with circulating lymphoma cells
5 months post-transplant and died rapidly from multiorgan
failure.
Two other cases of similarly fulminant PTLD have been
reported. The first occurred in an EBV seronegative recipient of
a renal transplant from an EBV seropositive donor.5 The second
developed in an EBV seropositive recipient of a non-myeloblative allogeneic BMT for relapsed anaplastic large cell
lymphoma.6 The donor had a positive IgM titre for EBV viral
capsid antigen (VCA) in the pre-transplant specimen, consistent with recent infection. ln each of these previous cases the
aggressive presentation of the disease was attributed either to
the recipient being EBV seronegative or to recent EBV infection in the donor. In our case the recipient was EBV seropositive and we presume the development of PTLD was instead
related to the intensive immunosuppression as a result of his
previous treatments. Although only a relatively low dose of

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82

Pathology (2013), 45(1), January

CORRESPONDENCE

A
A

B
B
Fig. 1 Skin biopsy. (A) Medium power view showing dermal perivascular
infiltrate of lymphoma cells (H&E). (B) EBER staining is strongly positive.

Fig. 2 (A) High power view of two lymphoma cells seen in the bone marrow
aspirate with deep blue markedly vacuolated cytoplasm (MGG). (B) Immunohistochemistry of the bone marrow trephine shows a hypocellular marrow with
an abnormal infiltrate of strongly EBER positive lymphoma cells.

may allow improved risk stratification and hence individualisation of patient immunosuppressive regimens.
thymoglobulin was used in his conditioning regimen, the
T-cell depletion associated with this therapy is a known risk
factor for the development of PTLD.3 It is also possible that the
history of Crohns disease is relevant, although his inflammatory bowel disease had been inactive with no specific therapy
since his initial diagnosis of AML. Patients with inflammatory
bowel disease who are treated with thiopurines are known to
have an increased risk of lymphoma which is often EBV
positive.7
PTLD is a rare complication of allogeneic stem cell transplant.1 The disease is often extranodal at presentation which
may result in a delay in diagnosis.8 Historically the prognosis
for patients with PTLD has been poor with survival rates of
around 30%.9 The cornerstone of treatment for PTLD postsolid organ transplant is withdrawal of immunosuppressive
therapy. However, this is rarely useful post-BMT because
the defect is delayed EBV-memory cytotoxic T cell recovery,
not suppression of their function.10 Treatment with monoclonal
antibodies such as rituximab, chemotherapy or ex vivo generated EBV cytotoxic T cells are resulting in improved outcomes.11 Some groups have advocated serial monitoring of
EBV viral load in high risk patients to aid early detection and
treatment.12 This case demonstrates the unique clinical and
pathological features of an early onset highly aggressive disseminated variant of PTLD post-BMT, highlighting the need
for early and ongoing vigilance in high risk patients. Further
research into the pathogenesis of this devastating complication

Conflicts of interest and sources of funding: The authors state


that there are no conflicts of interest to disclose.
Robin Gasiorowski*
John Gibson{
Geoff Watson
Judith Trotman{
Stephen Larsen{
ANZAC Research Institute, and {Department of Haematology,
Concord Repatriation General Hospital, Concord, zInstitute of
Haematology, Department of Anatomical Pathology, Royal
Price Alfred Hospital, Camperdown, NSW, Australia
Contact Dr R. Gasiorowski.
E-mail: robin.gasiorowski@sydney.edu.au
1. Curtis RE, Travis LB, Rowlings PA, et al. Risk of lymphoproliferative
disorders after bone marrow transplantation: a multi-institutional study.
Blood 1999; 94: 220816.
2. Dharnidharka VR, Tejani AH, Ho PL, Harmon WE. Post-transplant lymphoproliferative disorder in the United States: young Caucasian males are at
highest risk. Am J Transplant 2002; 2: 9938.
3. Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumours
of Haematopoietic and Lymphoid Tissues. 4th ed. Lyon: IARC Press, 2008.
4. Apichai S, Rogalska A, Tzvetanov I, Asma Z, Benedetti E, Gaitonde S.
Multifocal cutaneous and systemic plasmablastic lymphoma in an infant
with combined living donor small bowel and liver transplant. Pediatr
Transplant 2009; 13: 62831.

Copyright Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.

CORRESPONDENCE

5. Mathur RV, Kudesia G, Suvarna K, McKane W. Fulminant post-transplant


lymphoproliferative disorder presenting with lactic acidosis and acute liver
failure. Nephrol Dial Transplant 2004; 19: 191820.
6. Zamkoff KW, Bergman S, Beaty MW, Buss DH, Pettenati MJ, Hurd DD.
Fatal EBV-related post-transplant lymphoproliferative disorder (LPD) after
matched related donor nonmyeloablative peripheral blood progenitor cell
transplant. Bone Marrow Transplant 2003; 31: 21922.
7. Beaugerie L, Brousse N, Bouvier AM, et al. Lymphoproliferative disorders
in patients receiving thiopurines for inflammatory bowel disease: a prospective observational cohort study. Lancet 2009; 374: 161725.
8. Nalesnik MA, Jaffe R, Starzl TE, et al. The pathology of posttransplant
lymphoproliferative disorders occurring in the setting of cyclosporine
A-prednisone immunosuppression. Am J Pathol 1988; 133: 17392.
9. Savage P, Waxman J. Post-transplantation lymphoproliferative disease.
QJM 1997; 90: 497503.
10. Gross TG, Steinbuch M, DeFor T, et al. B cell lymphoproliferative
disorders following hematopoietic stem cell transplantation: risk factors,
treatment and outcome. Bone Marrow Transplant 1999; 23: 2518.
11. Heslop HE. How I treat EBV lymphoproliferation. Blood 2009; 114: 40028.
12. Stevens SJ, Verschuuren EA, Pronk I, et al. Frequent monitoring of EpsteinBarr virus DNA load in unfractionated whole blood is essential for early
detection of post transplant lymphoproliferative disease in high-risk
patients. Blood 2001; 97: 116571.

DOI: 10.1097/PAT.0b013e32835b5de4

Familial haemophagocytic
lymphohistiocytosis in twin infants
Sir,
Haemophagocytic lymphohistiocytosis (HLH) is an uncommon
entity comprising a constellation of symptoms and laboratory
findings that together form the clinical inflammatory syndrome. HLH encompasses two separate conditions: a primary
hereditary form (familial haemophagocytic lymphohistiocytosis, FHL) and a secondary/acquired form (secondary HLH,
sHLH).1 sHLH may follow a variety of stimuli including viral,
bacterial, and fungal infections, as well as a number of malignant diseases, notably T-cell lymphomas. FHL is generally
inherited in an autosomal recessive or x-linked manner, presents during infancy or early childhood, and is uniformly fatal if
left untreated. Here we present an interesting case of FHL
presenting in a pair of identical twins in the immediate postnatal period.
The patients were diamnionic-dichorionic identical twins
born at 35 weeks gestation. Twin 1 was born via normal
spontaneous vaginal delivery, while twin 2 was born via
emergent caesarean section due to placental abruption. The
initial post-natal clinical course was uncomplicated, and the
patients were discharged home without complication. At
2 months of age both twins were hospitalised for fever with
neutropenia, and severe thrombocytopenia. Liver ultrasound
showed hepatomegaly. Laboratory studies (Table 1) showed
many abnormalities, including low fibrinogen, elevated
D-dimers, and prolonged coagulation times, indicating likely
disseminated intravascular coagulation. Blood cultures at this
time were negative in both twins. Simultaneous bone marrow
aspirates were obtained on both twins. While the bone marrow
aspirate from twin 2 showed non-specific findings due to
markedly haemodilute aspirate smears (i.e., predominantly
mature lymphocytes similar to peripheral blood), the bone
marrow aspirate from twin 1 showed significantly increased
haemophagocytic histiocytes on the smear (Fig. 1) in addition
to erythroid hyperplasia and relative decrease in myeloid cells.

83

Megakaryocytes were unremarkable. Additional laboratory


studies (Table 2) showed elevated alanine aminotransferase
(ALT), elevated aspartate aminotransferase (AST), increased
triglycerides and increased soluble interleukin-2 receptor
(CD25) in both twins. Studies for NK-cell functional activity
were non-contributory due to technical reasons in twin 1 and
not decreased significantly in twin 2.
Twin 1 met the following criteria for the diagnosis of
haemophagocytic lymphohistiocytosis: (1) fever, (2) fibrinogen level less than 1.5 g/L, (3) increased haemophagocytic
lymphohistiocytosis on bone marrow aspirate smear, (4) ferritin
level more than 500 ng/mL, and (5) elevated soluble interleukin-2 receptor (soluble CD25) level of more than 2400 U/mL.
Twin 2 met the following diagnostic criteria for the diagnosis of
haemophagocytic lymphohistiocytosis: (1) fever, (2) cytopenias (haemoglobin less than 9 g/dL and platelet count less than
100 k/mL), (3) fibrinogen level less than 1.5 mg%, (4) ferritin
level more than 500 ng/mL, and (5) soluble interleukin-2
receptor (soluble CD25) level more than 2400 U/mL. A diagnosis of haemophagocytic lymophohistiocytosis was made on
both the twins, based on these findings (see Table 3).2 Due to
the fact that these were identical twins, FHL was considered
and subsequent perforin-1 (PRF1) gene mutation analysis
showed identical mutations, i.e., homozygous for 50delT
(L17fsX50), confirming the diagnosis of FHL type 2 in both
the twins. Both patients were started on chemotherapy consisting of dexamethasone, etoposide, and cyclosporine according to the HLH-2004 protocol. Twin 2 progressively
deteriorated, developing respiratory and hepatic failure, fungaemia, and worsening coagulopathy, with death occurring 8
days after the start of chemotherapy. Twin 1 did well on
chemotherapy and was eventually discharged 4 months
after admission.
FHL is a rare condition, most often presenting in infancy,
with a peak age of presentation between 1 and 6 months.1 The
reported incidence ranges from 0.12 per 100 000 cases in
studies conducted in Sweden3 to 7.5 per 10 000 among
hospitalised patients in Turkish studies.4 The high rate of
FHL in the Turkish population may be due to the high rate
of consanguineous marriage, fitting with the autosomal recessive inheritance patterns seen in most genetically elucidated
types of FHL. In addition, as the incidence of FHL varies
amongst people of different ethnic backgrounds, so too do the
genetic defects that give rise to the HLH phenotype.
The mechanism of immune impairment leading to the syndrome is unclear; however, it is clear that the mechanism
involves the release of inflammatory cytokines, T-cell and
histiocyte activation, and NK-cell impairment. This leads to
the defining clinical and laboratory findings, including fever,
splenomegaly, multiple cytopenias, hypertriglyceridaemia
Table 1

Results of laboratory studies on both twins

Test (normal range)

Twin 1

Twin 2

Haemoglobin (1015 g/dL)


WBC (514 k/mL)
Absolute neutrophil count (27 k/mL)
Platelet count (150400 k/mL)
D-dimer (<1100 ng/mL FEU)
Fibrinogen (181456 mg%)
Prothrombin time (10.011.7 s)

9.2
5.2
1.2
100
3660.00
<50
140

8.9
4.2
1.1
34
3780.00
<50
30.5

FEU, fibrinogen equivalent units, WBC, white blood cell.

Copyright Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.

84

Pathology (2013), 45(1), January

CORRESPONDENCE

Fig. 1 May-Grunwald Giemsa; multiple haemophagocytic histocytes.

and/or hypofibrinogenaemia, haemophagocytosis in the bone


marrow, spleen, or lymph nodes, low/absent NK-cell activity,
hyperferritinaemia, and increased soluble IL-2 receptor
(soluble CD25), in the absence of malignancy (Table 3). Five
of the eight criteria are necessary for a diagnosis of HLH,
though a diagnosis may still be made if there is molecular
evidence consistent with HLH.2 Diagnostic work-up includes
complete blood count and blood smear analysis, liver function
tests, blood chemistry, triglyceride and cholesterol levels,
ferritin, and coagulation tests. Bone marrow biopsy and aspirate
may be initially negative, and should be repeated over time to
see if evidence of haemophagocytosis appears; biopsies from
other organs can help demonstrate haemophagocytic histocytes
or evidence of chronic persistent hepatitis in more uncommon
instances.2
Microscopic features are identical in the familial and
acquired forms. The main histological feature is diffuse infiltration by T-lymphocytes and histiocytes. The organs most
frequently examined are the bone marrow, spleen, liver, and
central nervous system, and so are the most frequently
described; however, almost no organ is spared, and the characteristic findings may be seen in almost any organ. Perhaps most
frustrating is the fact that the characteristic haemophagocytic
histiocytes (showing phagocytosis of nucleated cells as well as

Table 2

red blood cells) may be absent in some organs, or infrequent at


best, thus necessitating repeated biopsies for histological
confirmation. Histological findings in the liver, which may
be the second most common organ biopsied after the bone
marrow, shows a pattern of sinusoidal dilatation, congestion
and hyperplasia of Kupffer cells. Haemophagocytic histiocytes
are not seen in the portal inflammatory infiltrate, but characteristically in the dilated sinusoids.5 The immunophenotype of
the phagocytic histiocytes are also unique. They express common macrophage-associated antigens, S100 protein and also
may express CD1a (which are more commonly seen in
Langerhans cells or interdigitating dendritic cells).6
Five distinct genetic subtypes of FHL have been identified to
date. FHL type 1 has been mapped to chromosome 9 (9p21),
although the exact protein and gene remain unknown.7 This
mutation is believed to account for 10% of all FHL. FHL type 2
has been mapped to the perforin gene located on chromosome
10 (10q2122).8 Perforin gene mutations cause either a nonfunctional form or markedly reduced/absent form of the perforin protein (PRF1), resulting in decreased granzyme mediated
toxicity by NK cells and cytotoxic T-cells. Missense mutations
of PRF1 result in a non-functional form of the protein through
conformational changes that inhibit proteolytic processing of
the protein precursors; nonsense mutations result in absent

Results of additional laboratory studies on both twins

Test (normal range)


Triglycerides (3385 mg/dL)
Ferritin (322468 ng/mL)
ALT (230 IU/L)
AST (1643 IU/L)
Soluble interleukin-2 receptor; CD25 (<970 U/mL)
NK-cell activity; NK-cell functional assay (8170 LU30)
Perforin-1 gene mutation analysis

Twin 1

Twin 2

125
11460
437
384
>6500
Non-contributory
Homozygous for 50 del T(L17fsX50) mutation

140
11057
435
1704
>6500
15
Homozygous for 50 del T(L17fsX50) mutation

ALT, alanine aminotransferase; AST, aspartate aminotransferase.

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CORRESPONDENCE

Table 3 Revised diagnostic criteria for haemophagocytic


lymphohistiocytosis2
The diagnosis of HLH can be established if either 1 or 2 below is fulfilled:
1. A molecular diagnosis consistent with HLH
2. Diagnostic criteria for HLH fulfilled (5/8 criteria below)
Initial diagnostic criteria:
1. Fever
2. Splenomegaly
3. Cytopenias (affecting 2 or more of 3 lineages in the peripheral blood)
a. Haemoglobin <90 g/L (in infants <4 weeks of age:
hemoglobin <100 g/L)
b. Platelets <100  109/L
c. Neutrophils <1.0  109/L
4. Hypertriglyceridaemia and/or hypofibrinogenaemia:
a. Fasting triglycerides 3.0 mmol/L (265 mg/dL)
b. Fibrinogen 1.5 g/L (150 mg/dL)
5. Haemophagocytosis in bone marrow, spleen, or lymph nodes
6. No evidence of malignancy
New diagnostic criteria:
1. Low or absent NK-cell activity (according to local
laboratory reference)
2. Ferritin 500 mg/L
3. Soluble CD25 (soluble IL-2 receptor) 2400 U/mL
Additional comments:
1. If haemophagocytic activity is not proven, further search for
haemophagocytic activity, including additional biopsies from other
organs and serial aspirates over time may be helpful
2. Supportive evidence may be for the diagnosis:
a. Spinal fluid pleocytosis (mononuclear cells) and/or elevated spinal
fluid protein
b. Liver biopsy with findings of chronic persistent hepatitis
3. Other clinical and laboratory findings that may support the diagnosis:
cerebromeningeal symptoms, lymphadenopathy, jaundice, oedema,
skin rash, hepatic enzyme abnormalities, hypoproteinaemia,
hyponatraemia, increased VLDL, decreased HDL
HDL, high density lipoprotein; HLH, haemophagocytic lymphohistiocytosis;
VLDL, very low density lipoprotein.

protein production.9,10 Further, the type of mutation affects the


clinical presentation with missense mutations having a later age
of onset than nonsense mutations.11 Mutations in PRF1 account
for 2040% of FHL. While there have been over 50 different
PRF1 mutations identified, a subset of mutations have been
found to be more prevalent in certain ethnicities. The
1122G!A (W374X) mutation appears to be more prevalent
in Turkish cohorts, while the 272C!T (A91 V) mutation
appears to dominate in Italian populations.11 The 50delT
mutation, also seen in our described patients, is interestingly
the single mutation seen in African/African American individuals. FHL type 3 is traced to the hMunc134 gene, encoding
the
Munc134 protein, which is involved in vesicle
priming.12 The granules containing perforin and granzymes
A and B are normal, however priming prior to release is
abnormal, resulting in the abnormal FHL phenotype. FHL type
4 results from abnormalities in the Syntaxin 11 (STX11)
gene,13 found only in patients of a Turkish/Kurdish background
thus far. Syntaxin 11 is also involved in vesicle priming. FHL
type 5 has been mapped to chromosome 19p, which encodes the
STXBP2 gene encoding Munc182 protein (syntaxin binding
protein 2).14 This protein is involved in intracellular trafficking
and granule exocytosis. Regardless of the mutated protein, or
specific type of mutation, patients with FHL tend to have a
clinically similar disease.
Prior to the use of cytotoxic chemotherapy FHL was
uniformly fatal, with patients succumbing to infection and
multi-organ failure. With the use of chemotherapeutic agents,
including etoposide, anti-thymocyte globulin, and CSA, as well
as steroids, the majority of patients were able to show

85

symptomatic improvement; however, a true cure was not


obtained without haematopoietic stem cell transplantation.
The regimen currently in use, as produced by the 2004 revision
of the Histiocyte Society consensus study protocol (HLH2004), uses etoposide, dexamethasone, cyclosporine, and
intrathecal methotrexate.4
In conclusion, haemophagocytic lymphohistiocytosis
is a rare disease that may present in a phenotypically
indistinguishable acquired or familial form. The familial
form is a genetically heterogeneous and phenotypically homogeneous disease, of which five genetically distinct subtypes
have been described. Diagnosis rests on a combination of
clinical and histological features, and chemotherapy along with
haematopoietic stem cell transplant is the mainstay of therapy.
Conflicts of interest and sources of funding: The authors state
that there are no conflicts of interest to disclose.
Bryce Higa
Milind Velankar
Department of Pathology, Loyola University Medical Center,
Maywood, IL, USA
Contact Dr B. Higa.
E-mail: bhiga@lumc.edu

1. Henter JI, Samuelsson-Horne AC, Arico M, et al. Treatment of hemophagocytic lymphohistiocytosis with HLH-94 immunotherapy and bone marrow transplantation. Blood 2002; 100: 236773.
2. Henter J, Horne A, Arico M, et al. HLH-2004: Diagnostic and therapeutic
guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer
2007; 48: 12431.
3. Henter J, Elinder G, Soder O, Ost A. Incidence in Sweden and clinical
features of familial hemophagocytic lymphohistiocytosis. Acta Paediatr
Scand 1991; 80: 42835.
4. Gurgey A, Gogus S, Ozyurek E, Aslan E, et al. Primary hemophagocytic
lymphohistiocytosis in Turkish children. Pediatr Hematol Oncol 2003; 20:
36771.
5. de Kerguenec C, Hillaire S, Molinie V, Gardin C, et al. Hepatic manifestations of hemophagocytic syndrome: a study of 30 cases. Am J Gastroenterol
2001; 96: 8527.
6. Herlin T, Pallesen G, Kristensen T, Clausen N. Unusual immunophenotype
displayed by histiocytes in haemophagocytic lymphohistiocytosis. J Clin
Pathol 1987; 40: 14137.
7. Ohadi M, Lalloz M, Sham P, et al. Localization of a gene for familial
hemophagocytic lymphohistiocytosis at chromosome 9p21.322 by homozygosity mapping. Am J Hum Genet 1999; 64: 16571.
8. Stepp S, Dufourcq-Lagelouse R, Le Deist F, et al. Perforin gene defects in
familial hemophagocytic lymphohistiocytosis. Science 1999; 286: 19579.
9. Risma KA, Frayer RW, Filipovich AH, Sumegi J. Aberrant maturation of
mutant perforin underlies the clinical diversity of hemophagocytic lymphohistiocytosis. J Clin Invest 2006; 116: 18292.
10. Molleran S, Villanueva J, Sumegi J, et al. Characterization of diverse
PRF1 mutations leading to decreased natural killer cell activity in
North American Families with hemophagocytic lymphohistiocytosis.
J Med Genet 2004; 41: 13744.
11. Trizzino A, Stadt U, Ueda I, Risma K, et al. Genotype-phenotype study of
familial hemophagocytic lymphohistiocytosis due to perforin mutations.
J Med Genet 2008; 45: 1521.
12. Feldmann J, Callebaut I, Raposo G, et al. Munc13-4 is essential for
cytolytic granules fusion and is mutated in a form of familial hemophagocytic lymphohistiocytosis (FHL3). Cell 2003; 115: 46173.
13. Glolam C, Grigoriadou S, Gilmour KC, Gaspar HB. Familial hemophagocyt5ic lymphohistiocytosis: advances in the genetic basis, diagnosis and
management. Clin Exp Immunol 2011; 163: 27183.
14. Cote M, Menager MM, Burgess A, et al. Munc18-2 deficiency causes
familial hemophagocytic lymphohistiocytosis type 5 and impairs cytotoxic
granule exocytosis in patient NK cells. J Clin Invest 2009; 119: 376573.

DOI: 10.1097/PAT.0b013e32835b5db2

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86

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A novel oncocytoid papillary renal cell


carcinoma, type 2, with aberrant
cytogenetic abnormalities

Sir,
Renal cell carcinoma is classified by the World Health Organization (2004)1 on the basis of histological patterns correlated
with cytogenetic, genetic and both familial and sporadic cases.
Papillary renal cell carcinoma (PRCC) is usually multifocal,
comprises 1015% of renal cell carcinomas, and is postulated
to arise from the intercalated cells of the distal tubule.14
Benign oncocytoma accounts for 515% of surgically resected
renal tumours and is believed to arise from the intercalated cells
of collecting ducts. There are case reports of hybrid tumours
oncocytoma/chromophobe RCC,2,4,5 but only four cases of
combination or hybrid tumour oncocytoma/PRCC have been
reported,2,46 of which three cases are <5 mm and would
qualify as adenomas. The present case is the second case to
qualify as a hybrid tumour oncocytoma/PRCC.
A 64-year-old man, with a known medical history of autoimmune haemolytic anaemia, hypertension and hepatitis B,
presented with an incidental finding of a right lower pole renal
mass during an ultrasound scan performed for his hepatitis. A
subsequent computed tomography (CT) scan demonstrated a
66  63  47 mm complex renal mass and multiple small cysts
scattered in both kidneys. There was no evidence of hydronephrosis or hydroureter. There was no extension of tumour into
veins and no lymphadenopathy was seen.
The patient had no history of hereditary polycystic kidney
disease. A core biopsy of the renal mass showed a PRCC. Due
to other medical conditions, a partial nephrectomy was not
performed until a year later, and the partial nephrectomy
measured 72  50  47 mm and a separate piece of perinephric
fat 65  50  45 mm. Part of two simple cysts were seen at the
resection margin, and measured 30  23 mm and 32  25 mm
each. On sectioning, there was a circumscribed tumour measuring 72  50  46 mm. The tumour was protuberant and had two
distinct areas: one area had a tan/fleshy appearance and was
multicystic at one edge, and the other area was haemorrhagic
and with a red-brown colour and areas of golden-yellow. The
tumour was situated 1 mm from the closest resection margin,
and showed attenuation, but no invasion through the renal
capsule.
Microscopically, the tumour showed two distinct morphological features corresponding to the macroscopic appearance.
The darker brown/haemorrhagic areas showed papillary tubulopapillary and cystic growth pattern with fibrovascular stalks

covered by pseudostratified cells with irregular vesicular nuclei,


small nucleoli and abundant eosinophilic cytoplasm. Aggregates
of foamy macrophages were present within the stalks as well as in
cystic spaces, and psammoma bodies within the papillary cores
and adjacent desmoplastic stroma (Fig. 1A). There were focal
areas of haemorrhage in the neoplasm. These features supported
PRCC, type 2, and comprised approximately 50% of the entire
renal tumour. The tan/fleshy area showed tubulocystic architecture lined by cuboidal cells with uniform round vesicular nuclei
with well defined nucleoli and granular or eosinophilic cytoplasm (Fig. 1B). The intervening stroma was oedematous and
myxoid. Microcysts, some filled with red blood cells were
present. These features supported oncocytoma and comprised
the other 50% of the renal tumour. There were also areas of clear
demarcation between the two components: the PRCC and the
oncocytoma (Fig. 1C). The PRCC component showed positive
staining for CK7, vimentin (Fig. 2A) and CD10 (Fig. 2B), and
was negative for CD117 (Fig. 2C). The oncocytoma component
showed positive staining for CD117 (Fig. 2C) and negative for
CK7, vimentin and CD10. Electron microscopy showed the
fleshy part of the tumour to be composed of tubules with a
single layer of epithelial cells, central lumen and few scattered
microvilli on the epithelial surface. The cytoplasm was filled
with enlarged, swollen mitochondria and well-defined cristae,
and other organelles and microvesicles were scanty. There was a
continuous basal lamina and cell junctions, features which were
characteristic of an oncocytoma (Fig. 3A).7
The PRCC component showed the epithelial cells with
mitochondria admixed with other cell organelles (Fig. 3B).
Fluorescence in situ hybridisation (FISH) with centromeric
probes for chromosomes X, Y, 1, 7 and 17 was carried out on
formalin fixed, paraffin embedded tumour sections from areas
with each type of morphology. Areas with an oncocytoma-like
morphology showed gains of chromosome 1 (30% of interphase
nuclei) and low level gain of chromosome 7 (8% of nuclei) as
well as low level loss of chromosome 17 (32% of nuclei). Areas
with papillary morphology showed a similar pattern but with
significantly more nuclei showing 7 (50%) and 17 (58%). No
alterations to sex chromosome numbers were seen in either area.
To our knowledge, there are only four reported cases of hybrid
oncocytoma/PRCC. PRCCs are grossly well-circumscribed, and
areas of haemorrhage, necrosis and cystic degeneration are
frequently present. There are two morphological types based
on the nuclear features and growth pattern. Type 1 is composed of
small cells with scanty, pale basophilic cytoplasm arranged in a
single layer covering papillary cores, and in Type 2 there are
larger papillae with pseudostratification of higher nuclear grade
and abundant eosinophilic cytoplasm. In our case the PRCC
showed positivity for CD10, vimentin and CK7, and was

Fig. 1 (A) The heterogeneous part of the renal tumour shows features of a PRCC with well-formed papillae, interstitial foam cells and plentiful calcified psammoma
bodies (H&E). (B) The fleshy tumour area shows the typical features of oncocytoma with rounded nuclei and plentiful eosinophilic cytoplasm. There are also myxoid
areas (H&E). (C) The renal tumour shows a well demarcated zone between the PRCC (left) and the oncocytoma (right) (H&E).

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CD10

Vimentin

87

C-kit

Fig. 2 Immunohistochemistry. The PRCC (left) shows positive staining for (A) vimentin and (B) CD10. The oncocytoma (right) is negative for these markers.
(C) CD117 stain is positive for the oncocytoma and negative for the PRCC.

negative for CD117. The electron microscopy showed mitochondria admixed with other cell organelles and microvesicles.
The one component of the renal tumour showed all the immunohistological features of a PRCC, type 2.
Oncocytomas are benign well-circumscribed neoplasms
which may have a central, stellate scar of hyalinised connective
tissue and are mahogany brown. Haemorrhage and cystic
degeneration may be present, but tumour necrosis is not a
feature. They are arranged in nests, tubules, cords or microcysts
and the tumour cells have dense eosinophilic cytoplasm, round
nuclei and small nucleolus. Onocytomas are positive for
CD117, variable positivity for CD10, and are negative for
CK7 and vimentin. Electron microscopy showed a mitochondria rich cytoplasm and scanty other organelles. The second
component of the renal tumour in our case supported the
features of an oncocytoma.

A
10 m

B
10 m
Fig. 3 Electron microscopy. (A) The fleshy area of the tumour shows the
features of oncocytoma: a tubular structure with plentiful mitochondria and a
well formed basal lamina (6000). (B) The PRCC shows cells with variably
sized luminal microvilli resting on a basal lamina. The cytoplasm contains
variable numbers of mitochondria and other cell organelles (6000).

The papillary carcinoma component in the four cases


reported as hybrid tumour were small in size and in two were
reported to be a small focus6 and numerous small nests2 and
in the other two were reported to be 1.5 mm4 and 7 mm.5 The
oncocytoma component of these tumours ranged in size from
15 mm to 36 mm.
As three of the four reported cases were <5 mm they should
be classified as papillary adenomas rather than papillary
carcinomas. The tumour in our case was 72 mm in maximum
dimension, with approximately equal proportions of PRCC
and oncocytoma, and is the largest of the hybrid tumours,
and qualifies as a hybrid or combined oncocytoma/PRCC,
type 2.
In the three cases2,4,5 the papillary component was small and
was found within the larger oncocytoma. In the case reported by
Vasuri and Fellegara,6 the two tumours were found adjacent to
each other, whereas our case showed the PRCC and oncocytoma as a mixed tumour, both within and adjacent to each other.
Vasuri and Fellegara6 believed these neoplasms were two
distinct colliding neoplasms, and Rowsell et al.5 postulated
that their case represents divergent differentiation of either
oncocytoma into papillary RCC or papillary RCC into oncocytoma. Al-Saleem et al.2 demonstrated gains of chromosome
7 in the oncocytoma part of their tumour, which was a feature of
PRCC, and hypothesised that this was a secondary event
leading to the evolution of PRCC within the oncocytoma.
The cytogenetic patterns seen in our case were not characteristic of any common renal tumour, particularly not of oncocytoma in which loss of a sex chromosome and loss of chromosome
1 are the common cytogenetic changes, or for PRCC in which
trisomy 7 and 17 are the most common abnormalities.1,8,9 The
gain of chromosome 1 and loss of chromosome 17 are not
characteristic of either renal oncocytoma or PRCC and gain
of chromosome 7 is not common in oncocytoma. The close
relationship between the cytogenetic abnormalities detected in
the two differing morphological areas of tumour strongly
suggests a common origin with the increasing proportion of
cells with trisomy 7 in the papillary component suggesting
tumour progression. The unusual pattern of cytogenetic abnormalities but more consistent histological patterns seen suggests we
may be dealing with a novel tumour entity, an oncocytoid PRCC,
type 2, with aberrant cytogenetic expression.
These reports of mixed tumours with oncocytoma and PRCC
components, and also the hybrid morphology between oncocytoma and chromophobe RCC,10 indicate that further studies
are needed to show that different tumours have different
molecular pathways, and the possible evolution of a subset
of oncocytomas to papillary and chromophobe RCC has diagnostic and therapeutic implications.

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88

Pathology (2013), 45(1), January

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Conflicts of interest and sources of funding: The authors state


that there are no conflicts of interest to disclose.
Rajalingam Sinniah*
Angeline Teo*
Ashleigh Murch{
*Department of Anatomical Pathology, PathWest Laboratory
Medicine, Royal Perth Hospital, Wellington Street, Perth, and,
and {Cytogenetics Department, Path West Laboratory
Medicine, King Edward Memorial Hospital, Subiaco, WA,
Australia
Contact Professor R. Sinniah.
E-mail: Rajalingam.sinniah@health.wa.gov.au
1. Eble JN, Sauter G, Epstein JI, Sesterhenn IA, editors. World Health
Organisation Classification of Tumours. Pathology and Genetics of
Tumours of the Urinary System and Male Genital Organs. Lyon: IARC
Press, 2004.
2. Al-Saleem T, Balsara BR, Liu Z, et al. Renal oncocytoma with loss of
chromosomes Y and 1 evolving to papillary carcinoma in connection with
gain of chromosome 7. Coincidence or progression? Cancer Genet Cytogenet 2005; 163: 815.
3. Murphy WM, Girgnon DJ, Perlman EJ. Atlas of Tumour Pathology.
Tumours of the Kidney, Bladder, and Related Urinary Structures. 4th series,
fascicle 1. Washington DC: AFIP, 2004; 16474.
4. Floyd MS Jr, Javed S, Pradeep KE, De Bolla AR. Composite
oncocytoma and papillary renal cell carcinoma of the kidney treated by
partial nephrectomy: a case report. Scientific World Journal 2011; 11:
11737.
5. Rowsell C, Fleshner N, Marrano P, Squire J, Evans A. Papillary
renal cell carcinoma within a renal oncocytoma: case report of an
incidental finding of a tumour within a tumour. J Clin Pathol 2007;
60: 4268.
6. Vasuri F, Fellegara G. Collision renal tumours. Int J Surg Pathol 2009; 17:
3389.
7. Erlandon RA, Shek TW, Reuter VE. Diagnostic significance of mitochondria in four types of renal epithelial neoplasms: an ultrastructural study of
60 tumours. Ultrastruct Pathol 1997; 21: 40917.
8. Linehan WM, Walther MM, Zbar B. The genetic basis of cancer of the
kidney. J Urol 2003; 170: 216372.
9. Yang XJ, Tan MH, Kim HL, et al. A molecular classification of papillary
renal cell carcinoma. Cancer Res 2005; 65: 562837.
10. Tickoo SK, Reuter VE, Amin MB, et al. Renal oncocytosis, a morphologic
study of fourteen cases. Am J Surg Pathol 1999; 23: 1094101.

DOI: 10.1097/PAT.0b013e32835b682e

internal surfaces, the latter with adherent aggregates of


hair. No solid or papillary areas were seen. Microscopic
examination showed a multilocular cyst with constituent tissues from the three embryonic layers including adipose tissue,
skeletal muscle, bone, cartilage with keratinising squamous
epithelium and associated skin adnexal structures, pseudostratified ciliated respiratory type epithelium and ciliated ependymal cells with associated choroid plexus lining the cystic
spaces. Focally the choroid plexus tissue formed a well demarcated, non-invasive papillary tumour characterised by complex branching fibrovascular structures lined by mildly
crowded, elongated and focally stratified columnar ependymal
cells without nuclear atypia or mitotic activity. The features
were diagnostic of a choroid plexus papilloma (WHO Grade I)
(Fig. 1).
The basic components of the choroid plexus are glomerular vascular tufts derived from the vascular leptomeninges
that are covered by a cobblestoned secretory ependymal
epithelium.1 Small nests of meningothelial cells are native
constituents of the choroid plexus and can give origin to
psammoma bodies.1 Choroid plexus papillomata are rare
primary central nervous system tumours that grossly appear
as a circumscribed, cauliflower-like mass within ventricles.2,3 Microscopically, columnar non-ciliated cells that
show nuclear crowding and stratification are arranged in
an orderly fashion around delicate well formed fibrovascular

Choroid plexus papilloma arising in a mature


cystic teratoma of a 32-year-old female
Sir,
Herein, to the best of our knowledge, we report the third
published case of a choroid plexus papilloma arising in a
mature cystic teratoma. The female patient, aged 32 years,
presented with a 6 month history of left loin pain post-partum.
She underwent investigation with pelvic ultrasound and computed tomography (CT) of the abdomen revealing a 10 cm
complex mass arising from the left ovary with a large cystic
component and elements of fat, all consistent with a dermoid
cyst. The affected ovary was removed and submitted for
pathological examination.
Macroscopically the specimen consisted of an opened
cyst, 80  30 mm when laid flat, with smooth external and

B
Fig. 1 Choroid plexus papilloma in a mature cystic teratoma. (A) Low power
view of a circumscribed papillary lesion with delicate, well formed fibrovascular
stalks projecting into a cystic space. (B) A high power view shows the
fibrovascular stalks are lined by non-ciliated columnar cells that show nuclear
crowding and stratification.

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CORRESPONDENCE

stalks.2,3 Calcified bodies are often seen in the stroma of


papillomas.3 An atypical papilloma is defined by the presence of mitoses >2 per 10 high power fields (HPF) and two
or more of increased cellularity, nuclear pleomorphism, solid
growth and areas of necrosis.3
There are only two other reports of choroid plexus papillomata arising in mature cystic teratomas in the literature. In one
report a choroid plexus papilloma developed in the wall of an
ovarian dermoid in a 14-year-old female.4 In the other, an
atypical choroid plexus papilloma with cytologic atypia, focal
necrosis and mitoses up to 3/10 HPF, was described arising in
the wall of a dermoid in a 26-year-old female.5 Follow-up is
limited in both cases.
Usual WHO grade I choroid plexus papillomata arising in the
central nervous system are considered benign and complete
excision in these cases is considered curative. By extrapolation,
the oophrectomies performed to remove the teratoma in the
current case and the other reported cases are considered
curative.
Importantly, choroid plexus papillomata can be confused
with other ovarian papillary epithelial neoplasms that may
mimic primary or metastatic tumours including serous, clear
cell or endometroid tumours, especially if associated with
psammomatous calcifications.68 Metastasis from lung adenocarcinoma, papillary thyroid carcinoma, urothelial carcinoma
and malignant mesothelioma would also enter the differential
diagnosis.9
In conclusion, we describe another example of the rare
phenomenon of a choroid plexus papilloma arising in a mature
cystic teratoma of the ovary. Pathologists need to be aware of
this entity so as not to confuse this with other well differentiated
ovarian papillary epithelial neoplasms that may be primary
or metastatic.
Conflicts of interest and sources of funding: The authors state
that there are no conflicts of interest to disclose.
Benjamin F. Dessauvagie*{
Sukeerat Ruba*{
Peter D. Robbins{
*Histopathology Department, PathWest, King Edward
Memorial Hospital, Subiaco, and {Division of Tissue
Pathology, PathWest, QEII Medical Centre, Nedlands, WA,
Australia
Contact Dr B. Dessauvagie.
E-mail: ben.dessauvagie@health.wa.gov.au
1. Sternberg S. Histopathology for Pathologists. 2nd ed. Philadelphia: Lippincott Raven, 1997; 2713.
2. Tena-Suck T, Salinas-Lara C, Rembao-Bojorquez D, Castillejos M.
Clinicopathologic and immunohistochemical study of choroid plexus
tumours: single-institution experience in Mexican population. J Neurooncol
2010; 98: 53765.
3. Nelsen J, Mena H, Parisi J, Schochet S. Principles and Practice
of Neuropathology. 2nd ed. Oxford: Oxford University Press, 2003;
3324.
4. von Gunten M, Burger H, Vajtai I. Choroid plexus papilloma developing in a
dermoid cyst of ovary. Histopathology 2006; 49: 2045.
5. Quadri A, Ganesan R, Hock Y, Karim S, Hirschowitz L. Malignant
transformation in mature cystic teratoma of the ovary: three cases
mimicking primary ovarian epithelial tumors. Int J Surg Pathol 2011;
19: 71823.
6. Terada T. Immature teratoma of ovary composed largely of choroid plexus.
Int J Gynecol Cancer 2010; 20: 11012.

89

7. Robboy S, Mutter G, Prat J, Bentley R, Russell P, Anderson M. Robboys


Pathology of the Female Reproductive Tract. 2nd ed. London: Churchill
Livingstone, 2009; 74954.
8. Crum C, Nucci M, Lee K. Diagnostic Gynecologic and Obstetric Pathology.
2nd ed. Philadelphia: Elsevier Saunders, 2011; 9057.
9. Ikota H, Tanaka Y, Yokoo H, Nakazato Y. Clinicopathological and
immunohistochemical study of 20 choroid plexus tumours: their
histological diversity and the expression of markers useful for differentiation from metastatic cancer. Brain Tumor Pathol 2011; 28:
21521.

DOI: 10.1097/PAT.0b013e32835b6855

Metastatic papillary thyroid carcinoma to the


kidney: report of two cases mimicking
primary renal cell carcinoma and review of
the literature
Sir,
Papillary carcinoma of the thyroid is the most common subtype,
accounting for up to 86% of thyroid cancers. Mean age at
diagnosis ranges from 31 to 49 years, with a female to male
ratio between 2:1 and 3:1. The main pattern of spread is to
cervical lymph nodes, with distant metastases occurring
uncommonly and having an adverse impact on survival. Distant
metastases from papillary carcinoma of the thyroid can occur at
any time during the course of the disease: initial presentation of
metastatic disease has been reported in 112% of differentiated
thyroid tumours, being less frequent in papillary (2%) than in
follicular (10%) thyroid carcinoma, whereas cumulative
incidence, including metastatic disease following initial treatment, varies between 10 and 35%, depending upon the
histology, again being least in well-differentiated papillary
thyroid carcinoma.1 Increasing age and primary size, male
sex, extrathyroidal extension, and histological subtypes, including tall-cell, columnar-cell, diffuse sclerosing and solid variants, have been associated with adverse prognosis.2 When
haematogenous spread occurs, it is usually to bone, brain,
lungs and soft tissue. Metastasis to the kidney is found in
2.83.8% and 620% of thyroid papillary and follicular cancer
cases, respectively, but clinically detectable differentiated
thyroid cancer metastatic to the kidney is exceedingly rare.3
Herein we report two cases of papillary thyroid carcinoma
metastatic to the kidney. The literature on metastatic thyroid
tumours to the kidney is also reviewed and differential diagnoses are discussed.
Case 1 was a 63-year-old man who presented in February
1995 with gastrointestinal symptoms, 10 lb weight loss and
dizziness. He had a history of papillary thyroid carcinoma
status post-thyroidectomy (1980), radical neck dissection and
bilateral lung metastases (1982), iodine-131 treatment (1986),
as well as chemotherapy (1991) and radiation therapy (1992).
On admission, abdominal computed tomography (CT) scan
showed a partially cystic mass in the right abdomen. The patient
underwent angio-infarction and subsequent (5 months later)
resection of a large right kidney mass eroding into the duodenum and forming a pyelo-duodenal fistula.
Grossly, most of the kidney was involved by a partially solid,
cystic and extensively necrotic neoplastic process, 13 cm in
largest dimension. Microscopically, the lesion showed a papillary architecture and characteristic nuclear changes (Fig. 1).

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90

Pathology (2013), 45(1), January

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Fig. 1 Papillary carcinoma of the thyroid, tall-cell variant, metastatic to the kidney (H&E). (A) Neoplastic papillae are characterised by a central fibrovascular stalk of
loose connective tissue and thin-walled vessels, and (B) in some cases show abundant acellular hyaline material. The papillae are lined by cells that often show abundant
eosinophylic cytoplasm and are at least twice as tall as large. The nuclei (A, C, D) sometimes conform the elongated cells in which they are contained, and show the
characteristic abnormalities of papillary thyroid carcinoma: optical clearing (arrows), indentations, folds and grooves (arrowhead).

Papillae showed a central fibrovascular stalk lined by neoplastic epithelium. The better developed papillae were long with a
complex arborising pattern. Some were straight and slender,
arranged in a parallel, regimented fashion; others were short
and stubby. The papillary stalk was mainly composed by loose
connective tissue and variously sized thin-walled vessels; in
some cases, it was swollen by oedematous fluid or occupied by
an abundant acellular hyaline material. Occasionally, it was
infiltrated by lymphocytes or clusters of foamy or haemosiderin-laden macrophages. The neoplastic cells lining the papillae often showed tall cell features; they were at least twice as
long (tall) as wide, with large eosinophilic cytoplasm and round
to slightly oval nuclei. Nuclear contour appeared smooth on
superficial examination, although closer inspection revealed
subtle irregularities in the form of indentations, folds, and
grooves. Another peculiar feature of neoplastic nuclei was the
empty appearance of the nucleoplasm, which seemed almost
totally devoid of chromatin strands. These nuclei were similar to
the ones previously described as pale, optically clear, watery,
empty, ground glass, or Orphan Annies eyes. No psammoma
bodies or other concretions were noted. Immunohistochemically,
neoplastic epithelial cells showed positive staining for cytokeratin (CK)19, CK7, CD57, thyroglobulin, and thyroid transcription factor-1 (TTF-1) (Fig. 2AD). Cells did not react with
CK20, racemase, HMWCK, p63, CD10, and RCC marker.
The histological and immunohistochemical findings supported the diagnosis of metastatic papillary thyroid carcinoma,
tall-cell variant. The patient was lost to follow-up.
Case 2 was a 56-year-old woman who presented in December 2008 with haematuria and left flank pain due to an enlarging
left lower pole renal mass. Her past medical history included
metastatic papillary carcinoma of the thyroid, follicular variant
to the brain (resected), thyroidectomy, resection of liver
metastasis, and metastatic disease to the left arm treated

by external beam radiation therapy. At ultrasound, a


7.9  7.6  6.0 cm heterogeneous mass was identified at the
inferior pole of the left kidney.
Needle biopsy of the renal mass showed variably-sized
neoplastic follicles generally filled with homogeneous eosinophilic colloid. Follicles were lined by cuboidal epithelial cells
with overlapping irregular nuclei that focally harboured characteristic changes of papillary thyroid carcinoma, such as grooves
and intranuclear pseudoinclusions. No psammoma bodies or
true papillations were identified. By immunoperoxidase staining, performed to further evaluate the lesion, the tumour cells
showed positive reactivity for CK7, thyroglobulin, TTF-1,
and CD57.
In view of the previous diagnoses the findings were considered consistent with metastatic papillary thyroid carcinoma,
follicular variant. The patient underwent microsphere embolisation of the renal mass and died of disease, 7 years after her
first diagnosis.
Metastatic disease to the kidney is observed frequently at
autopsy, but is rarely found clinically in living patients.3
Although there are no modern autopsy series devoted to
kidney metastases, studies performed in the past have
reported that renal metastases outnumber primary renal
tumours by 4:1, and that up to 12.6% of cancer patients
had metastatic disease to the kidney, with frequencies of
bilaterality and multiplicity being as high as 7181%. By
contrast, primary renal cell carcinomas are rarely bilateral.
Renal metastasis should be suspected whenever there is a
known primary, even in cases of unilateral solitary renal
masses. Although, theoretically, all solid tumours may give
rise to renal metastasis, secondary lesions to the kidney occur
more commonly in patients with lung and breast cancer,
melanoma, gastric carcinoma and lymphoma. Reports in the
literature suggest rates of epithelial (non-lymphoma) renal

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CORRESPONDENCE

CK7

Thyroglobulin

CD57

TTF-1

91

Fig. 2 Papillary carcinoma of the thyroid metastatic to the kidney (immunohistochemistry). Tumour cells show strong positivity for (A) CK7, (B) CD57,
(C) thyroglobulin and (D) TTF-1.

metastases of 1.51.8% of the general population.4 Imaging


features are rarely pathognomonic.
Metastasis to the kidney of differentiated thyroid cancer is an
uncommon event; in an autopsy series of 161 fatal primary
malignant thyroid tumours, only four (6%) differentiated thyroid tumours metastasised to the kidney, whereas 35 (54%) and
40 (61%) metastasised to the lungs and bones, respectively.5 In
another autopsy study, Silliphant et al. found that six of 44
(14%) differentiated papillary and follicular thyroid cancers
metastasised to kidney, compared to 22 (50%) and 17 (26%)
cases metastasising to the lungs and bones, respectively.6 On
the other hand, thyroid cancer represents only 1.02.5% of
primary tumours metastasising to the kidneys.3
Detection of thyroid carcinoma with clinically apparent
kidney metastases is very rare, with less than 30 cases reported
in the literature so far (21 of them referenced in Malhotra
et al.).712 Clinical and pathological features were only accessible in a subset of cases (n 28) (Table 1). Of the 28 cases of
renal metastases associated with differentiated thyroid carcinoma, 13 were from papillary carcinoma (7 of which were
follicular-variant papillary carcinomas), and 15 were from
follicular carcinoma. In five cases there was bilateral involvement. In three patients the disease was discovered incidentally
during intravenous pyelography or ultrasound. In the vast
majority of cases, patients had known thyroid tumours at the
time the renal metastases were identified. However, in some
instances, metastases to the kidney preceded the knowledge of
the primary thyroid neoplasm and were treated surgically as
primary renal tumours. Ruggiero et al. reported a case of a
25-year-old woman who underwent radical nephrectomy for a
right renal mass.7 The tumour was diagnosed as papillary
thyroid carcinoma, follicular variant. The patient had no
previous history of thyroid disease. During subsequent evaluation, metastatic disease was also identified in the patients
lungs. More recently, Gupta et al.10 reported a case of metastatic papillary thyroid carcinoma that presented with flank

pain and haematuria and was treated by radical nephrectomy as


a primary renal malignancy. The patient had neither history nor
signs and symptoms of thyroid disease. Later work-up of the
patient for thyroid disease revealed a nodule of 0.6 cm in the
right lobe of the thyroid, which was confirmed as a papillary
thyroid carcinoma by ultrasound-guided fine needle aspiration.
No other metastatic sites were identified.
Herein we describe two cases of thyroid papillary carcinoma,
a tall-cell variant and a follicular variant, metastatic to the
kidney. The former (Case 1) to our knowledge is the first case of
tall-cell variant papillary thyroid carcinoma metastatic to the
kidney described to date. Although both patients initially
presented with disseminated disease, the renal metastasis presented as a unilateral, large heterogeneous mass located at the
lower pole of the kidney.
The differential diagnoses for tall-cell variant papillary
thyroid carcinoma metastatic to the kidney include primary
papillary renal cell carcinoma, particularly type 2, micropapillary urothelial carcinoma of the upper urinary tract, and metastasis of papillary carcinomas from other organs. Papillary renal
cell carcinoma comprises approximately 10% of renal cell
carcinomas. The male to female ratio ranges between 1.8:1
and 3.8:1. Papillary renal cell carcinoma frequently contains
areas of haemorrhage, necrosis and cystic degeneration. A
pseudo-capsule may be identified. Bilateral and multifocal
tumours are common. Neoplastic cells typically form varying
proportions of papillae and tubules. Papillae contain a delicate
fibrovascular core and aggregates of foamy macrophages;
cholesterol crystals may be present. Calcified concretions are
common in papillary cores and adjacent desmoplastic stroma.
Papillary renal cell carcinoma has been subclassified into two
morphological variants, types 1 and 2. Papillary renal cell
carcinoma type 2 is composed of tall cell with eosinophilic
cytoplasm and less frequently shows microcalcifications.
Neoplastic cells exhibit large and spherical nuclei, prominent
nucleoli, and varying degrees of nuclear pseudostratification,

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92

Pathology (2013), 45(1), January

CORRESPONDENCE

Table 1

Clinical and pathological features of renal metastases from differentiated thyroid carcinoma

Reference

Sex/Age

Tumour type

Presentation

Years after detection

Site

Takayasu et al., 19687


Davis et al., 19797
Johnson et al., 19827
Marino et al., 19917
Sardi et al., 199212
Tur et al., 19947
Ro et al., 19957
Graham et al., 19957
Lam et al., 199611
Benchekroun et al., 19997
Garcia-Sanchis et al., 19997
Gamboa-Dominguez et al., 19999
Muller et al., 20007
Smallridge et al., 20017
Smallridge et al., 20017
Abe et al., 20027
Ferrer Garcia et al., 20027
Moudouni et al., 20027
Insabato et al., 20037
Matei et al., 20037
Iwai et al., 20057
Liou et al., 20057
Ruggiero et al., 20057
Kumar et al., 20057
von Falck et al., 20077
Gupta et al., 200810
Malhotra et al., 20107
Borde et al., 20118
Present cases:
Case 1
Case 2

F/44
F/49
F/66
F/
M/53
F/72
F/47
M/75
F/91
M/56
F/65
F/50
F/58
F/53
F/61
M/37
F/58
M/62
F/64
F/78
F/76
F/50
F/25
F/66
F/64
M/50
M/30
M/56

Follicular
Follicular
Follicular
Follicular
Papillary
PTC-FV
Follicular
PTC-FV
Follicular
Papillary
Follicular
PTC-FV
Follicular
PTC-FV
PTC-FV
Papillary
Follicular
Follicular
Follicular
Follicular
Follicular
PTC-FV
PTC-FV
Follicular
Follicular
Papillary
Papillary
Papillary

Abdominal mass
Incidental finding (IVP)
Gross haematuria
Neck nodule
Haematuria
No complaints; liver mass
Haematuria
Gross haematuria
Incidental autopsy finding
Low back pain
Neck and sternal mass
Haematuria and flank pain
Dyspnoea
Back pain
Upper back mass
Incidental finding (US)
Lumbalgia
Left upper abdominal discomfort
Incidental finding (US)
Microscopic haematuria and flank pain
Haematuria and flank pain
Low back pain
Abdominal/flank pain
Scalp mass
Constant increase in serum thyroglobulin levels
Flank pain and haematuria
Low backache radiating to the lower limbs
Post radioiodine-131 treatment scanning

3
18
37
23
7
3
7
No
No
3
No
No
11
No
No
No
5
9
35
10
13
No
No
No
20
No
20
No

Bilateral
Bilateral
Left kidney
Right kidney
Right kidney
Right kidney
Right kidney
Left kidney
Left kidney
Left kidney
Left kidney
Left kidney
Bilateral
Right kidney
Left kidney
Left kidney
Left kidney
Left kidney
Right kidney
Right kidney
Right kidney
Right kidney
Right kidney
Left kidney
Left kidney
Right kidney
Bilateral
Bilateral

M/63
F/56

Papillary
PTC-FV

Nausea, vomiting, easy satiety


Haematuria and flank pain

15
6

previous history*
previous history
previous history
previous history*
previous history
previous history
previous history*

previous history
previous history*
previous history
previous history*
previous history

Right kidney
Left kidney

Treated surgically as primary renal cell tumour.


IVP, intravenous pyelogram; PTC-FV, papillary thyroid carcinoma - follicular variant; US, ultrasound.

although typical nuclear changes of papillary thyroid carcinoma are not present. Papillary renal cell carcinomas typically
express CK7, CK8, CK18, CK19, CAM 5.2, RCC marker,
CD10, and racemase (Table 2). Micropapillary urothelial carcinoma of the upper urinary tract is a rare variant of urothelial
carcinoma. There is a male predominance (M:F 3.2:1).
Almost all the reported cases occur in the urinary bladder,
but it may also involve the renal pelvis and the ureter. It consists
of slender, delicate fine papillary and filiform processes, with
central fibrovascular cores. Papillae are lined by high nuclear
grade cells with eosinophilic cytoplasm. Psammoma bodies are
infrequent. Micropapillary carcinomas are immunoreactive for
CK7, EMA, CK20, Leu M1, and CEA.
The main differential diagnosis for the follicular variant of
papillary thyroid carcinoma metastatic to the kidney is a
Table 2 Immunohistochemical comparison between papillary thyroid
carcinoma and papillary renal cell carcinoma

TTF-1
Thyroglobulin
CK17
CD57
Racemase
CD117
RCC marker
CD15
CK7
CK19
EMA

PTC

PRCC

/


/






/

PRCC, papillary renal cell carcinoma; PTC, papillary thyroid carcinoma.

recently described entity called primary thyroid-like follicular


carcinoma of the kidney. Other primary renal cell tumours,
including oncocytoma, papillary renal cell carcinoma with
tubular architecture, and metanephric adenoma should also
be considered, although the presence of inspissated colloidlike material and/or follicular architecture is rare and patchy in
these tumours.
First reported in 2004, thyroid-like follicular carcinoma of
the kidney is an extremely rare variant of renal cell carcinoma
with only eight accepted cases described in the literature. This
tumour shows a slight female predominance (M:F 1:2).
Histologically, these tumours are well circumscribed with a
distinct fibrous capsule, a striking follicular architecture with
micro- and macro-follicles filled with inspissated colloid-like
material. The cells lining the follicles have moderate to scant
amphophilic to eosinophilic cytoplasm. Nuclei are round to
oval, with uniform chromatin and inconspicuous nucleoli.
Although these tumours are usually incidentally detected, have
a relatively small size, and a predominantly indolent behaviour,
a distinct malignant potential is supported by reported metastatic disease in two patients. Thyroid-like follicular carcinomas of the kidney lack key histological features of
papillary carcinoma of thyroid, such as papillary architecture
and classic nuclear changes. Immunohistochemically, tumour
cells are negative for classical markers of thyroid neoplasms
such as thyroglobulin, TTF-1 and CD57. Pax2, RCC marker,
CD10, WT1, Ksp-cadherin, racemase, vimentin, and CD56
have been reported to be negative. In a case recently diagnosed
at the authors institution, thyroid-like follicular carcinoma of
the kidney showed strong nuclear staining for PAX8 (unpublished data, personal communication).

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CORRESPONDENCE

In conclusion, thyroid carcinoma should be considered in the


differential diagnosis of a renal mass, particularly in patients
with a high serum thyroglobulin level, even if the mass is
solitary and unilateral, or no history of thyroid cancer is present.
The overlapping profile between papillary renal cell carcinoma
and metastatic papillary thyroid carcinoma highlights the
importance of clinicopathological correlation, and demonstrates the importance of using a panel of antibodies in differentiating these tumours.
Conflicts of interest and sources of funding: The authors state
that there are no conflicts of interest to disclose.
Sara M. Falzarano*{
Deborah J. Chute*
Cristina Magi-Galluzzi*{
*Pathology and Laboratory Medicine Institute, and {Glickman
Urological and Kidney Institute, Cleveland Clinic, Cleveland,
OH, United States; zDepartment of Pathology and Human
Oncology, University of Siena, Siena, Italy
Contact Dr C. Magi-Galluzzi.
E-mail: magic@ccf.org
1. Mihailovic J, Stefanovic L, Malesevic M. Differentiated thyroid carcinoma
with distant metastases: probability of survival and its predicting factors.
Cancer Biother Radiopharm 2007; 22: 2505.
2. Clark JR, Lai P, Hall F, et al. Variables predicting distant metastases in
thyroid cancer. Laryngoscope 2005; 115: 6617.
3. Patel U, Ramachandran N, Halls J, et al. Synchronous renal masses in
patients with a nonrenal malignancy: incidence of metastasis to the kidney
versus primary renal neoplasia and differentiating features on CT. Am J
Roentgenol 2011; 197: W6806.
4. Pascal RR. Renal manifestations of extrarenal neoplasms. Hum Pathol
1980; 11: 717.
5. Heitz P, Moser H, Staub JJ. Thyroid cancer: a study of 573 thyroid tumors
and 161 autopsy cases observed over a thirty-year period. Cancer 1976; 37:
232937.
6. Silliphant WM, Klinck GH, Levitin MS. Thyroid carcinoma and death. A
clinicopathological study of 193 autopsies. Cancer 1964; 17: 51325.
7. Malhotra G, Upadhye TS, Sridhar E, et al. Unusual case of adrenal and
renal metastases from papillary carcinoma of thyroid. Clin Nucl Med 2010;
35: 7316.
8. Borde C, Basu S, Kand P, et al. Bilateral renal metastases from papillary
thyroid carcinoma on post 131I treatment scan: flip-flop sign, radioiodine
SPET, 18F-FDG PET, CECT and histopathological correlation. Hell J Nucl
Med 2011; 14: 723.
9. Gamboa-Dominguez A, Tenorio-Villalvazo A. Metastatic follicular variant
of papillary thyroid carcinoma manifested as a primary renal neoplasm.
Endocr Pathol 1999; 10: 25668.
10. Gupta R, Viswanathan S, DCruz A, et al. Metastatic papillary carcinoma of
thyroid masquerading as a renal tumour. J Clin Pathol 2008; 61: 143.
11. Lam KY, Ng WK. Follicular carcinoma of the thyroid appearing as a
solitary renal mass. Nephron 1996; 73: 3234.
12. Sardi A, Agnone CM, Pellegrini A. Renal metastases from papillary thyroid
carcinoma. J La State Med Soc 1992; 144: 41620.

DOI: 10.1097/PAT.0b013e32835b5dcc

Somatostatin receptor expression in prostate


carcinoma: the urological pathologists role in
the era of personalised medicine
Sir,
Somatostatin (SST) is known to inhibit the secretion of a
wide range of hormones, exocrine glands, and gastrointestinal

93

motility. Among other actions, SST has revealed an antiproliferative potential, reversing the impact of mitogenic signals
delivered by substances such as epidermal growth factor. The
actions of SST are mediated by membrane-associated receptors
that comprise five distinct subtypes (termed SSTR1 to 5).
Frequently multiple subtypes coexist in the same cell.
After binding their ligand, SSTR-ligand complexes undergo
cellular internalisation with intracytoplasmic and intranuclear
translocation. Reubi et al.1 showed that the degree of internalisation, i.e., the ratio of internalised SSTR2 to membranous
SSTR2, varied greatly from one patient to the other. Although
generally found in endosome-like structures, internalised SSTR2
were also identified to a small extent in lysosomes, as seen in colocalisation experiments. Very recently Waser et al.2 showed that
phosphorylated SSTR2 was present in most gastrointestinal
neuroendocrine tumours from patients treated with octreotide
but that a striking variability existed in the subcellular distribution of phosphorylated receptors among such tumours.
Cloning of the five SSTRs has led to the development of
subtype-selective ligands.3 In the era of personalised medicine
and targeted therapies, SSTR profiling is an important prerequisite for successful in vivo somatostatin receptor targeting
for imaging or therapeutic purposes in an individual patient.
Therefore, localisation and expression of the five SSTRs in a
tumour must be determined to decide whether the patient is
eligible for these applications. Several methods have been used
to determine the expression of SSRTs.
Tissue somatostatin receptors can be measured directly
in vivo by performing a OctreoScan or 68 Ga-DOTATOC
positron emission tomography/computed tomography scan.
Molecular techniques such as in situ hybridisation histochemistry and autoradiography have been used in a limited number
of studies.4 The former basically investigates SSTR mRNA
expression in cryostat sections. The latter also utilises cryostat
sections and is based on radioligands, i.e., 125I-labelled somatostatin ligands, such as octreotide. Previous studies have dealt
with only some of the subtypes, therefore information is
limited. The type of information obtained using these two
techniques is not always comparable to that obtained with
immunohistochemical analysis in formalin fixed, paraffin
embedded (FFPE) tissue, in which the architecture and the
cytology in the background are well preserved. In addition, the
immunohistochemical technique is widely available, and faster,
easier and cheaper to apply than in situ hybridisation histochemistry and autoradiography. It can be used even retrospectively on archival material.
We read with great interest the recent publication by Korner
et al.5 This study was performed on neuroendocrine tumours
from various gastrointestinal and extragastrointestinal sites and
in a small group of non-neuroendocrine tumours. The aim of the
investigation was to correlate FFPE-based immunohistochemistry using the monoclonal anti-somatostatin receptor subtype
2A antibody UMB-1 (Biotrend Chemikalien, Germany; or
Epitomics, USA), with the gold standard in vitro method
quantifying somatostatin receptor levels in tumour tissues.
The results obtained by comparing the UMB-1 immunohistochemistry with tumoural in vitro 125I-[Tyr3]-octreotide binding site levels allowed recommendations for the use of SSTR
immunohistochemistry in daily diagnostics for optimally tailored patient management.
Data on the immunohistochemical patterns of the five SSTRs
in prostate cancer (PCa), its precursor high-grade prostatic
intraepithelial neoplasia (HGPIN) and normal prostatic

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94

CORRESPONDENCE

epithelium were obtained by our group in FFPE archival tissue


material.69 Data were collected separately for the luminal/
secretory and basal epithelial cells, for the latter when present,
as well as for the smooth muscle cells of the stroma and for the
endothelial cells (Fig. 1).
For the secretory or luminal cells, differences were found
between normal, HGPIN and PCa (Fig. 2A), and between
incidentally-detected and clinically-detected acinar PCa, therefore between insignificant or indolent and significant or aggressive cancers.9 Typical patterns in terms of localisation and
expression of the five SSTRs in PCa with neuroendocrine
differentiation,8 PCa following complete androgen ablation
(CAA)6 and hormone refractory PCa7 were identified, with
differences among these three groups and from untreated acinar
adenocarcinoma9 (Fig. 2B).
For the basal cells in normal prostate and HGPIN,
immunoreactivity was primarily detected in the cytoplasm
in all the five subtypes. In subtypes 1 and 3 the mean proportions of positive cells were higher than in the other three
subtypes. The proportions were higher in normal prostate
compared with HGPIN. Immunoreactivity for the five SSTRs
in the groups of cases with neuroendocrine tumours was

Pathology (2013), 45(1), January

similar in terms of expression and localisation to that seen


in the group of untreated HGPIN. The values in the patients
under complete androgen ablation were lower than in the
untreated patients.
For the smooth muscle and endothelial cells, there were no
cases with a distinct positivity in the cell membrane. Subtype
1 showed a strong immunoreactivity in the cytoplasm in the
majority of the smooth muscle cells and the endothelial cells.
Nuclear staining was seen only with subtypes 4 and 5.
Neuroendocrine differentiation in PCa well as CAA and
hormone refractory PCa did not affect SSTR expression
and localisation in the in the endothelial and smooth muscle
cells.
The limitation of our study was that the immunohistochemical results were not compared with data obtained with a
molecular technique or with a gold standard in vitro method
quantifying somatostatin receptor levels in tissues, as was in the
case of the Korner paper.5 However, specificity of the antibodies used in our studies (Rabbit polyclonal anti-SSTR subtype antibodies from Chemicon International, USA) was
assessed. Western blot experiments on a prostate tissue extract
were performed. Western blot analysis of prostate tissue

Fig. 1 Immunoreactivity for (A) SSTR4 in the luminal and basal cells in normal prostate, (B) SSTR3 in untreated HGPIN, (C) SSTR4 in untreated PCa, (D) SSTR4 in
prostate cancer with neuroendocrine differentiation, (E) SSTR4 in complete androgen ablated prostate cancer, and (F) for SSTR4 in hormone refractory prostate cancer.

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CORRESPONDENCE

95

15

10
Nep
HGPIN
PCa
5

0
SSTR1

A
%

SSRT2

SSRT3

SSTR4

SSTR5

100
90
80
70
60
50

Membrane

40

Cytoplasm

30

Nucleus

20
10
0

GS 6 PCa

GS 8 PCa

PCa NE

CAA PCa

HR PCa

Fig. 2 (A) Mean percentages of intensely immunostained luminal (secretory) cells in the cytoplasm for the five SSTR subtypes in normal epithelium (Nep), high-grade
prostatic intraepithelial neoplasia (HGPIN) and prostate cancer (PCa) from untreated patients. (B) Mean percentages of immunostained luminal cells for SSTR4 in PCa,
separately for cell membrane, cytoplasm and nucleus from all groups. The mean values of SSTR expression in the cytoplasm, membrane and nuclei of the epithelial cells
of hormone refractory PCa are lower than in the cancer areas of the PCa of the other two groups. The highest values are seen in the cytoplasm, the difference being
significant. (GS 6, Gleason score 336; GS 8, Gleason score 448; NE, NE differentiation; CAA, PCa following complete androgen ablation; HR, hormone
refractory PCa.)

performed with the panel of five polyclonal anti-SSTR antibodies yielded single bands as previously described by Helboe
et al.10
We agree with Korner et al.5 that the type of antibodies can
have an influence on the result to the point that the cytoplasmic
and nuclear localisation, i.e., cellular internalisation, of the
SSTRs can be seen intriguing and controversial. For instance,
the immunohistochemical expression at the cell level of the five
SSTRs in normal and pathological prostate tissue was also
investigated by Dizeyi et al.11 There were differences between
our investigation and that by Dizeyi et al., probably due to the
types of antibodies used (in Dizeyis investigation the antibodies were from a private source and not commercially
available).
In conclusion, our data showed that SSTR profiling in an
individual patient with HGPIN and the multifaceted PCa is
feasible. Even though there is no clinical application for a
somatostatin-based diagnostic test for prostate pathology at
present, as opposed to neuroendocrine tumour, this should
be of relevance to better tailor somatostatin analogue-based

diagnostic or therapeutic procedures in neoplasms other


than neuroendocrine tumours.12 This is particularly important in the era of personalised medicine and targeted
therapies.
Rodolfo Montironi*
Marina Scarpelli*
Liang Cheng{
Antonio Lopez-Beltran
Francesco Montorsi{
Ziya Kirkalijj
*Section of Pathological Anatomy, Polytechnic University of
the Marche Region, School of Medicine, United Hospitals,
Ancona, and {Department of Urology, University VitaSalute, Scientific Institute H San Raffaele, Milan, Italy;
zDepartment of Pathology and Laboratory Medicine,
Indiana University School of Medicine, Indianapolis, IN,
USA; Department of Surgery, Cordoba University Medical
School, Cordoba, Spain; jjDepartments of Urology, School of

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96

CORRESPONDENCE

Medicine, Dokuz Eylul University, Izmir, Turkey; these


authors contributed equally to this work
Contact Professor R. Montironi.
E-mail: r.montironi@univpm.it
1. Reubi JC, Waser B, Cescato R, et al. Internalized somatostatin receptor
subtype 2 in neuroendocrine tumors of octreotide-treated patients. J Clin
Endocrinol Metab 2010; 95: 234350.
2. Waser B, Cescato R, Liu Q, et al. Phosphorylation of sst2 receptors in
neuroendocrine tumors after octreotide treatment of patients. Am J Pathol
2012; 180: 19429.
3. Hofland LJ, van der Hoek J, Feelders R, et al. Pre-clinical and clinical
experiences with novel somatostatin ligands: advantages, disadvantages
and new prospects. J Endocrinol Invest 2005; 28: 3642.
4. Montironi R, Cheng L, Mazzucchelli R, et al. Immunohistochemical
detection and localization of somatostatin receptor subtypes in prostate
tissue from patients with bladder outlet obstruction. Cell Oncol 2008; 30:
47382.
5. Korner M, Waser B, Schonbrunn A, et al. Somatostatin receptor subtype 2A
immunohistochemistry using a new monoclonal antibody selects tumors
suitable for in vivo somatostatin receptor targeting. Am J Surg Pathol 2012;
36: 24252.
6. Mazzucchelli R, Morichetti D, Santinelli A, et al. Immunohistochemical
expression and localization of somatostatin receptor subtypes in androgen
ablated prostate cancer. Cell Oncol (Dordr) 2011; 34: 23543.
7. Mazzucchelli R, Morichetti D, Scarpelli M, et al. Somatostatin receptor
subtypes in hormone-refractory (castration-resistant) prostatic carcinoma.
Asian J Androl 2011; 13: 2427.
8. Morichetti D, Mazzucchelli R, Santinelli A, et al. Immunohistochemical
expression and localization of somatostatin receptor subtypes in prostate
cancer with neuroendocrine differentiation. Int J Immunopathol Pharmacol
2010; 23: 51122.
9. Morichetti D, Mazzucchelli R, Stramazzotti D, et al. Immunohistochemical
expression of somatostatin receptor subtypes in prostate tissue from
cystoprostatectomies with incidental prostate cancer. BJU Int 2010; 106:
107280.
10. Helboe L, Mller M, Nrregaard L, et al. Development of selective
antibodies against the human somatostatin receptor subtypes sst1-sst5.
Brain Res Mol Brain Res 1997; 49: 828.
11. Dizeyi N, Konrad L, Bjartell A, et al. Localization and mRNA expression of
somatostatin receptor subtypes in human prostatic tissue and prostate
cancer cell lines. Urol Oncol 2002; 7: 918.
12. Mazzucchelli R, Scarpelli M, Lopez-Beltran A, et al. Immunohistochemical expression and localization of somatostatin receptors in normal prostate, high grade prostatic intraepithelial neoplasia and prostate cancer and
its many faces. J Biol Regul Homeost Agents 2012; 26: 18192.

DOI: 10.1097/PAT.0b013e32835bae76

Reticular and microcystic schwannoma of the


parotid gland
Sir,
Reticular and microcystic schwannoma is a recently described,
rare, distinctive variant of schwannoma with a predilection for
visceral organs, particularly the gastrointestinal tract.1,2 Fewer
than 20 cases have been described in the literature and involvement of the head and neck has not been reported.16 Herein we
report a case of reticular and microcystic variant of schwannoma in the parotid gland and discuss its unique histomorphological features and the relevant differential diagnoses in this
location. Microcystic/reticular variant of schwannoma demonstrates similar biological behaviour to usual schwannoma and
must be distinguished from other parotid gland tumours that
may recur aggressively if incompletely excised.
A 59-year-old woman presented with a small pre-auricular
swelling. She did not have any stigmata of neurofibromatosis

Pathology (2013), 45(1), January

(NF) type I or II. Fine needle aspiration smears showed loosely


cohesive aggregates of cytologically bland spindle shaped cells
admixed with myxoid stroma (Fig. 1A). The cellular aggregates
showed swirling patterns (Fig. 1B) and occasional cells showed
intracytoplasmic vacuoles (Fig. 1C). The cytological features
were of a benign lesion and a diagnosis of pleomorphic
adenoma was made on cytology. At surgery, the tumour was
found closely associated with facial nerve and was resected
with nerve preservation.
The surgical specimen comprised a portion of the parotid
gland with a macroscopically well circumscribed nodule
measuring 28  20  16 mm. On cut section, the tumour
appeared pale grey, firm and had a gelatinous texture
(Fig. 2A). Histologically, the tumour was well demarcated,
but unencapsulated with entrapped ductal structures at the
periphery (Fig. 2B). Occasional lymphoid aggregates were also
seen at the periphery (Fig. 2C). The tumour was composed of
slender spindle shaped cells arranged in an anastomosing
lattice-like pattern amidst myxoid stroma. Microcystic and
reticular formations were seen (Fig. 2D). The cells showed
cytoplasmic vacuolation and uniform slender spindle shaped to
ovoid nuclei (Fig. 2E). Foci of extravasated red blood cells
were seen. Focally, the extravasated red blood cells overlying
cytoplasmic vacuoles appeared reminiscent of intracytoplasmic
lumina with red blood cells (Fig. 2F).
The lesion displayed relatively uniform cellularity and hypoand hypercellular areas, or areas with nuclear palisading were
not seen. Hyalinised, thick walled blood vessels were absent.
Degenerative changes, cyst formation, haemorrhage, or foamy
macrophages were not seen. Epithelial elements, other than the
peripheral entrapped ducts, were not identified within the
tumour. Cytological atypia, mitoses or necrosis were not
present. Special stains with periodic acid-Schiff reagent, with
and without diastase digestion, and mucicarmine did not show
any intracytoplasmic glycogen or mucin.
Immunohistochemical staining of the tumour showed diffuse
and strong nuclear and cytoplasmic immunoreactivity with
S100 (Fig. 3A). The tumour also showed immunoreactivity
for GFAP (Fig. 3B) and CD34. The tumour lacked immunoreactivity with multiple epithelial markers including Pan CK,
AE1/AE3, EMA, Cam5.2, mCEA, and CK7. The tumour also
lacked immunoreactivity with myoepithelial markers such as
smooth muscle actin (SMA), p63, calponin, smooth muscle
myosin heavy chain (SMMHC) and vascular markers such as
CD31, D240 and factor VIII. The tumour did not demonstrate
immunoreactivity with desmin and myogenin.
Electron microscopy performed on formalin fixed, paraffin
embedded tissue showed scattered elongated spindle cells in an
amorphous matrix with thin cellular processes, scant cytoplasmic organelles and focal basal lamina-like material
(Fig. 3C). Epithelial, myoid or endothelial differentiation
was lacking.
Schwannomas are generally benign, non-recurring tumours
that can show a plethora of histological appearances and several
variants are well described in the literature. Liegl et al. have
recently described reticular and microcystic variant of schwannoma in visceral organs.1 As observed in the current case, these
tumours show a predilection for women in the seventh decade
and tend to be relatively small in size.2 The tumours are
typically well circumscribed and show spindle shaped cells
embedded in myxoid matrix as seen in this case.1,2 The current
case also showed extensive lattice-like patterns with cribriform
microcystic areas as described in the literature.1,2 Areas with

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CORRESPONDENCE

97

Figure 1 (A) Fine needle aspiration smears showed loosely cohesive aggregates of cytologically bland spindle shaped cells admixed with myxochondroid matrix
(DiffQuik). (B) Swirling pattern within the cellular aggragates (PAP). (C) Intracytoplasmic vacuoles (PAP).

extravasated red blood cells were also present. An unusual


feature observed in the current case and not described previously in literature was the presence of intracytoplasmic
vacuoles within most of the spindle shaped cells. These
vacuoles could also be observed in the fine needle aspiration
material.
A high index of suspicion and awareness of the histological
features of this variant are essential for accurate diagnosis as the
tumour lacks several typical features seen in a usual schwannoma. Visceral examples of microcystic and reticular variant of
schwannomas lack encapsulation and may show entrapment of
normal structures at the periphery as seen in the current case.1 A

peripheral cuff of lymphoid aggregates, as seen in the current


case, may be helpful when present; however, Liegl et al.
observed this feature in only about 10% of their cases.1 The
tumours also generally lack the classic organisation into Antoni
A and Antoni B areas, and thick walled hyalinised vessels may
be rare.1,2,4 Immunohistochemistry is of diagnostic utility as
microcystic and reticular variant of schwannoma demonstrates
immunoreactivity for S100, GFAP and occasionally for CD34,
as is the usual case in schwannomas. As expected, the tumours
lack immunoreactivity for all epithelial, myoepithelial, muscle
and vascular markers such as a broad panel of cytokeratins, p63,
calponin, SMA, desmin, CD31, D240 and factor VIII.

Figure 2 (A) Parotid gland with a well circumscribed nodule measuring pale grey, firm tumour with a gelatinous texture. (B) Well demarcated, but unencapsulated
tumour with entrapped ductal structures at the periphery (H&E). (C) Lymphoid aggregates at the periphery (H&E). Slender spindle shaped cells arranged in a
anastomosing lattice-like pattern amidst myxoid stroma with formation of microcystic and reticular areas (H&E). Spindle shaped cells with cytoplasmic vacuolation
(H&E). Foci of extravasated red overlying cytoplasmic vacuoles reminiscent of intracytoplasmic lumina with red blood cells (H&E).

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98

Pathology (2013), 45(1), January

CORRESPONDENCE

Figure 3 (A) Diffuse nuclear and cytoplasmic immunoreactivity with S100. (B) Immunoreactivity with GFAP. (C) Electron micrograph showing schwannian features
such as slender, elongated interdigitating cell processes covered by a thin, continuous layer of basement membrane material and scant cytoplasmic organelles.

The histopathological appearance of these tumours raises a


wide spectrum of differential diagnoses, particularly in the
salivary gland where extratemporal schwannomas arising from
the intraparotid facial nerve are very rare.7 The differential
diagnostic considerations in this location include pleomorphic
adenoma and myoepithelial neoplasms. Given the remarkable
overlap in the histopathological features of these three entities,
the lack of immunoreactivity for cytokeratins and myoepithelial markers such as calponin, p63, and SMA, as would be
expected in pleomorphic adenoma and myoepithelial tumours,
aids in making the distinction. The present case of microcystic
and reticular schwannoma showed cord-like arrangement of
cells and extensive cytoplasmic vacuolation. Artefactual overlapping of extravasated red blood cells in some areas (Fig. 2)
was reminiscent of intracytoplasmic vascular lumina, raising
the differential diagnosis of epithelioid haemangioendothelioma. The presence of cords and nests of cells with extensive
cytoplasmic vacuolation were also suggestive of a parachordoma, a rare and unusual entity in the salivary gland. Lack of
immunohistochemical reactivity for several vascular markers
and cytokeratins can aid in excluding these unusual entities.
The constellation of the clinical, histological and immunohistochemical features are generally sufficient for accurate diagnosis without resorting to electron microscopy, which shows
features including long slender interdigitating cell processes
and basement membrane material, in keeping with schwannian
differentiation as seen in the present case.
Preservation of the facial nerve is an important consideration
during parotid surgery, potentially leading to incomplete resection of the lesion. Schwannomas, including the microcystic and
reticular variant, are benign tumours that generally do not recur
even after incomplete resection. Thus, accurate distinction of
schwannoma from other benign entities such as pleomorphic
adenoma is important, as the latter shows propensity for
multiple and multifocal recurrences that are difficult to control
surgically following incomplete resection.8
In summary, we describe microcystic and reticular variant
of schwannoma in the parotid gland with an emphasis on some
of its unusual histopathological features warranting a high

index of suspicion and ancillary techniques for accurate


diagnosis.
Jia-Min Pang*
Annabelle Mahar*
Kerwin Shannon{
James Kench*
Charles Chan{
Ruta Gupta*
*Tissue Pathology and Diagnostic Oncology, Royal Prince
Alfred Hospital, Camperdown, {Sydney Head and Neck
Cancer Institute, Royal Prince Alfred Hospital,
Camperdown, zElectron Microscopy Unit, Anatomical
Pathology, Concord Hospital, and Discipline of Pathology,
the University of Sydney, Sydney, NSW, Australia
Contact Dr R. Gupta.
E-mail: rutagupta@gmail.com
1. Liegl B, Bennett MW, Fletcher CD. Microcystic/reticular schwannoma: a
distinct variant with predilection for visceral locations. Am J Surg Pathol
2008; 32: 10807.
2. Chetty R. Reticular and microcystic schwannoma: a distinctive tumor of the
gastrointestinal tract. Ann Diagn Pathol 2011; 15: 198201.
3. Agaimy A, Markl B, Kitz J. Peripheral nerve sheath tumors of the gastrointestinal tract: a multicenter study of 58 patients including NF1-associated
gastric schwannoma and unusual morphologic variants. Virchows Arch 2010;
456: 41122.
4. Lee SM, Goldblum J, Kim KM. Microcystic/reticular schwannoma in the
colon. Pathology 2009; 41: 5956.
5. Kienemund J, Liegl B, Siebert F, Jagoditsch M, Spuller E, Langner C.
Microcystic reticular schwannoma of the colon. Endoscopy 2010; 42 (Suppl 2):
E247.
6. Liegl B, Bodo K, Martin D, Tsybrovskyy O, Lackner K, Beham A.
Microcystic/reticular schwannoma of the pancreas: a potential diagnostic
pitfall. Pathol Int 2011; 61: 8892.
7. Eisele DW, Johns ME. Salivary gland neoplasms. In: Bailey BJ, editor. Head
and Neck SurgeryOtolaryngology. Philadelphia: Lippincott Williams and
Wilkins, 2001; 127997.
8. Witt RL. The significance of the margin in parotid surgery for pleomorphic
adenoma. Laryngoscope 2002; 112: 214154.

DOI: 10.1097/PAT.0b013e32835be3ec

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CORRESPONDENCE

99

Predominance of VREfm ST203 subgroup


in Queensland

Table 1

Correlation of MelT with ST

MelT

Possible ST*

CC

Sir,
The molecular epidemiology of Enterococcus faecium in an
Australian setting has recently been described for the first
time.1 Johnson et al. described the epidemiology of 85 E.
faecium isolates in blood culture over a 12 year period at a
single institution in Victoria, Australia (Austin Health,
Melbourne).1 This comprised 34 vancomycin resistant E.
faecium (VREfm) and 51 vancomycin susceptible E. faecium
(VSEfm) isolates. They defined 17 different sequence types
(STs) amongst 85 E. faecium isolates using multilocus
sequence typing (MLST) and found three dominant STs
(ST17, ST252 and ST203). Amongst the VREfm isolates, all
but one carried the resistance gene, vanB.1 ST17, the putative
founder of clonal complex 17 (CC17), was stable and predominated in VREfm and VSEfm for the first 10 years of the
12 year study period. From 2007 to 2009, a significant increase
in VREfm bacteraemia was identified.1 The predominant ST
was ST203, accounting for 76% and 81.8% of VREfm bacteraemia isolates in 2007 and 2009, respectively. ST203 is a
double-locus variant of ST17 and both STs belong to CC17.
We have investigated 765 VREfm isolates (39 clinical and
726 screening isolates) from hospitalised patients across 26
hospitals in Queensland, collected from January to November
2010. Van genotyping was performed on all isolates. A total of
758 isolates (99.1%) had a vanB genotype while seven isolates
were positive for vanA. Ninety-one vanB VREfm were selected
to study molecular epidemiology using repetitive polymerase
chain reaction (PCR) (DiversiLab; bioMerieux, France), comprising both clinical (n 39) and screening (n 62) specimens.
Results revealed that the majority of isolates from Queensland
(n 88) were very closely related (>92% similarity).
Fourteen isolates from this major group were further analysed by high resolution melting (HRM) genotyping as
described.2 Four melting types (MelTs) were identified,
MelT11 (n 1), MelT34 (n 1), MelT121 (n 11) and one
novel MelT. MelT11, MelT34 and MelT121 represent STs
which are clustered in CC17. MelT11 and MelT121 include
various STs from each subgroup founded by ST17 and ST203,
respectively. MelT34 incorporated multiple subgroups of CC17
as well as the singleton ST51 (Table 1). MLST was performed
in all 14 isolates as previously described;3 of these, 12 isolates
were ST203. The results from MLST were correlated with
HRM genotyping except the novel MelT that was identified as
ST203 (Table 1).
In conclusion, our results indicate that 88 of 91 isolates
(97%) were closely related. HRM genotyping and MLST of
representative isolates from this cluster revealed that ST203
was predominant. This suggests that ST203 may be responsible
for VREfm in Queensland. These findings correspond with
what was found by Johnson et al. The same ST causing
outbreaks in two geographically non-contiguous states suggests

11

17, 63, 103, 180, 187, 234, 267, 295, 307, 308, 357, 460,
475, 480, 538, 543, 554, 578, 584
49, 51, 177, 232, 341, 547, 548, 556
203, 365, 412, 478, 483, 577

17

34
121

17
17

*
Generated by Enterococcus faecium MLST and MelT key as described by
Tong et al.2 and found at http://menzies.edu.au/node/43174.
Bold type indicates ST identified by MLST.
CC, clonal complex; MelT, melting type; MLST, multilocus sequence
typing; ST, sequence type.

that other regions in Australia may be similarly affected. ST203


has also been reported in Korea, Japan China, Germany, Denmark, The Netherlands and Serbia (http://efaecium.mlst.net/).
Interestingly, ST203 isolates reported from these countries
almost entirely possessed the vanA gene. On the contrary,
the majority of isolates from Victoria and Queensland possessed vanB. This highlights that CC17, especially ST203, has a
great ability for hospital adaptation. CC17 has caused outbreaks
in multiple continents including Australia.4 Further study and
surveillance of this subgroup is necessary to understand its
persistence in the hospital environment.
Conflicts of interest and sources of funding: The authors state
that there are no conflicts of interest to disclose.
Witchuda Kamolvit*
Hanna E. Sidjabat*
Graeme R. Nimmo*{
Snehal N. Anuj{
Haakon Bergh{
Leisha J. Richardson*
David L. Paterson*{
*The University of Queensland Centre for Clinical Research,
Herston, Brisbane, and {Division of Microbiology, Pathology
Queensland Central Laboratory, Brisbane, Qld, Australia
Contact Dr W. Kamolvit.
E-mail: witchuda.kamolvit@uqconnect.edu.au
1. Johnson PD, Ballard SA, Grabsch EA, et al. A sustained hospital outbreak of
vancomycin-resistant Enterococcus faecium bacteremia due to emergence of
vanB E. faecium sequence type 203. J Infect Dis 2010; 202: 127886.
2. Tong SY, Xie S, Richardson LJ, et al. High-resolution melting genotyping of
Enterococcus faecium based on multilocus sequence typing derived single
nucleotide polymorphisms. PloS ONE 2011; 6: e29189.
3. Homan WL, Tribe D, Poznanski S, et al. Multilocus sequence typing scheme
for Enterococcus faecium. J Clin Microbiol 2002; 40: 196371.
4. Willems RJ, Top J, van Santen M, et al. Global spread of vancomycinresistant Enterococcus faecium from distinct nosocomial genetic complex.
Emerg Infect Dis 2005; 11: 8218.

DOI: 10.1097/PAT.0b013e32835b68d2

Copyright Royal College of pathologists of Australasia. Unauthorized reproduction of this article is prohibited.