486
Correspondence
I I . Sullivan JL. Medveczky P. Forman SJ, rt al. Epstein-Barr virus induced lymphoproliferations. N. Engl I. Med. 1984: 31 1: 1 16 31167. 12. Sodorski J , Rosen C. Wong-Staal F rt d . Trans acting transcriptional regulation of human T-cell leukaemia virus type Ill long
terminal repeat. Srioicr 1985: 227: 171-173. 1 3 . Vogel j , Hinrichs SH. Kay Reynolds K. Luciw PA and Jay C. The
HIV tut gene induces dermal lesions resembling Kaposi's sarcoma in transgenic mice. Nature 1988; 3 3 5 : 606-61 1. 14. 13lumenfeld W. and Beckstaed JH. Angioimmunohlastic lymphadenopathy with dysproteinaemia in homosexual nien with acquired immune deficiency syndrome. Arch. P d i o l . Lob. Mcd. 1983: 107; 567-5159. 1 5 . Weiss LM. Strikler JG. Dorfnian RF of cil. Clonal T-cell populations in angioimmunoblastic lymphadenopathy and angioimmunoblastic-like lymphoma. Ant. I. Pnthol. 1986: 122: 392-397. 1 0 . Salahuddin SZ. Nakaniura S. Bibefield P et nl. Angiogenic properties of Kaposi's sarcoma derived cells after long term culture in vitro. Aiericc 1988: 242: 430-433. 17. Janier M. Flageeul 8. Drouet L c't (11. Cutaneous and plasma values of von Willehrand factor in AIDS. I. Ir7vest. Ilurn~itol. 1988: 90: 703-707, 18. Costa J. Rabson AS. Generalised Kaposi's sarcoma is not a neoplasm. Lm7cet I98 3: i: 58. 19. Vogcl FS. Enhanced susceptibility of proliferating endothelium to salivary gland virus under naturally occurring and experimental conditions Ant. /. Prrfhol. 1958: 34: 1069-1079.
Sir: We wish to thank Dr Slater, Dr Francis and Professor Henry for their review of the recent literature on the association between HIV infection and peripheral T-cell lymphomas. Our computer literature search has clearly let us down, but we would point out that many of the papers cited have been published since preparation and submission of our manuscript. The recent number of publications on the subject serves to emphasise the need to identify and report cases which initially appear to be unusual and contrary to the accepted dogma. It is only through case reports such as ours and the others cited that rare associations such as this can be recognized. Despite the apparent increase in recognition of cases of T-cell non-Hodgkin's lymphoma in association with HIV infection, the published literature clearly supports our view that the vast majority of lymphomas presenting in association with AIDS are of B-cell origin. Indeed, a recent review editorial on HIV and opportunistic cancers states that HIV associated non-Hodkin's lymphomas are all of the B-cell phenotype I . We would also point out that T-cell non-Hodgkin's lymphoma is not a recognized CDC criterion for the diagnosis of AIDS. Unfortunately we do not have information on the HTLV-I status of our patient. Only data from large series, perhaps pooled from several centres, will give a clear indication of the true frequency of T-cell lymphoma and allow identification rather than speculation on its pathogenesis. The level of frequency reported to date
could be due to chance or ti3 unidentified indirect associations with HIV infection. K.Shorrock 1.O.Ellis R.G.Finch PathoJogg Drpnrtrrrrtit. Lricestrr Royal lrgrrtiwy, Lricester LE2 7 1 X llk'
Reference 1 . Lowry WS. Editorial review: The human immunodeticiency viruh and opportunistic cancers. / t i t . /. STU. A I M 1990: 1: 83-85,
Fine needle biopsy Sir: In his commentary 'Fine needle cytology wrsus histology', Dr Rode stated that the complication rate of his biopsy method was low. with a major morbidity of 0. So/,'. If 'major' means 'serious' complications, then 0.5% is not a low figure for a diagnostic technique that is to be used widely. In the literature, the major complication rate for abdominal fine needle aspiration biopsy is of the order of 1 in 20001,as opposed to 1 in 2 0 0 in Rode's series. I do not think a biopsy tl-chnique with a major morbidity rate of 0.5% should be undertaken lightly. especially when a n alternative method is available. At our hospital, we use the ijpproach suggested by Hall-Craggs and Lees'. Diagnosis is first obtained by tine needle cytology and only when the latter fails to providc an answer or more information 'IS required for nianagcment decision, is a properly planned histological biopsy is carried out. Whenever feasible. we also prepare blocks from fine needle (22-gauge) aspirates.
K.C.Suen Lkpn r t 111c t I t of' Pn t holo~gy, Vancouver Geriprril Hospittrl. Viincorrver, HC'. Cll I rnrlrc
References 1 . Rode J. Fine needle cytology w s u s histology. Histr)i,trtltolo!lII~l[~~j~~ 1 9 X 9
1 5 : 435-439. 2. Livraghi T. Ilamascelli B. Lombardi C, :Spagnoli I. Risk in fine-ncedlc abdominal biopsy. /. C h i . Ultrasourid. 1983: 11: 77-81, 3 . Hall-Craggs MA, Lees WR. Fine needle biopsg cytology. histology. or both? Gut 1987: 28; 233-2 36.
Choriocarcinomatous features in mammary mucoid carcinoma Sir: It is always dangerous to say that something 'has not been previously described'. Dr Green reports an intorest-
Correspondence
ing case of mucoid carcinoma of the breast, in which one of the axillary lymph nodes was infiltrated by tumour having the appearance of choriocarcinoma' , and comments that 'differentiation of breast carcinoma to frank choriocarcinoma has not been previously described'. Whilst this is extremely rare, Saigo & Rosen reported such a case in 1981l. They described a 55-year-old woman, treated 1 3 years previously for invasive ductal carcinoma of the right breast, who presented with a new lesion in the left breast. Histology showed a moderately well differentiated infiltrating ductal carcinoma which merged with areas of more anaplastic tumour having the histological pattern of choriocarcinoma. Immunohistochemistry showed that positive staining with hCG-P localized exclusively to that area of the tumour which resembled choriocarcinoma. The patient died 7 months later with widespread, histologically anaplastic and necrotic pulmonary and nodal metastases which also stained positively with hCG-P.
48 7
Saigo & Rosen commented that 'the rare appearance of choriocarcinomatous differentiation in breast cancer with the appropriate hormone limited solely to that portion makes this tumour distinctly unusual'. This is, perhaps, safer than saying that the lesion has not previously been described.
R.R.Millis ZCRF Cfinicul Oncofogy Unit, Guy's Hospital, London SEI 9RT. U K
References 1. Green DM. Mucoid carcinoma of the breast with choriocarcinoma in its metastases. Histopathology 1990: 16: 504-506. 2. Saigo PE. Rosen PP. Mammary carcinoma with 'choriocarcinomatous' features. A m . /. Surg. Pathol. 19x1: 5: 7 7 3 - i i 8 .
Correspondence
I I . Sullivan JL. Medveczky P. Forman SJ, rt al. Epstein-Barr virus induced lymphoproliferations. N. Engl I. Med. 1984: 31 1: 1 16 31167. 12. Sodorski J , Rosen C. Wong-Staal F rt d . Trans acting transcriptional regulation of human T-cell leukaemia virus type Ill long
terminal repeat. Srioicr 1985: 227: 171-173. 1 3 . Vogel j , Hinrichs SH. Kay Reynolds K. Luciw PA and Jay C. The
HIV tut gene induces dermal lesions resembling Kaposi's sarcoma in transgenic mice. Nature 1988; 3 3 5 : 606-61 1. 14. 13lumenfeld W. and Beckstaed JH. Angioimmunohlastic lymphadenopathy with dysproteinaemia in homosexual nien with acquired immune deficiency syndrome. Arch. P d i o l . Lob. Mcd. 1983: 107; 567-5159. 1 5 . Weiss LM. Strikler JG. Dorfnian RF of cil. Clonal T-cell populations in angioimmunoblastic lymphadenopathy and angioimmunoblastic-like lymphoma. Ant. I. Pnthol. 1986: 122: 392-397. 1 0 . Salahuddin SZ. Nakaniura S. Bibefield P et nl. Angiogenic properties of Kaposi's sarcoma derived cells after long term culture in vitro. Aiericc 1988: 242: 430-433. 17. Janier M. Flageeul 8. Drouet L c't (11. Cutaneous and plasma values of von Willehrand factor in AIDS. I. Ir7vest. Ilurn~itol. 1988: 90: 703-707, 18. Costa J. Rabson AS. Generalised Kaposi's sarcoma is not a neoplasm. Lm7cet I98 3: i: 58. 19. Vogcl FS. Enhanced susceptibility of proliferating endothelium to salivary gland virus under naturally occurring and experimental conditions Ant. /. Prrfhol. 1958: 34: 1069-1079.
Sir: We wish to thank Dr Slater, Dr Francis and Professor Henry for their review of the recent literature on the association between HIV infection and peripheral T-cell lymphomas. Our computer literature search has clearly let us down, but we would point out that many of the papers cited have been published since preparation and submission of our manuscript. The recent number of publications on the subject serves to emphasise the need to identify and report cases which initially appear to be unusual and contrary to the accepted dogma. It is only through case reports such as ours and the others cited that rare associations such as this can be recognized. Despite the apparent increase in recognition of cases of T-cell non-Hodgkin's lymphoma in association with HIV infection, the published literature clearly supports our view that the vast majority of lymphomas presenting in association with AIDS are of B-cell origin. Indeed, a recent review editorial on HIV and opportunistic cancers states that HIV associated non-Hodkin's lymphomas are all of the B-cell phenotype I . We would also point out that T-cell non-Hodgkin's lymphoma is not a recognized CDC criterion for the diagnosis of AIDS. Unfortunately we do not have information on the HTLV-I status of our patient. Only data from large series, perhaps pooled from several centres, will give a clear indication of the true frequency of T-cell lymphoma and allow identification rather than speculation on its pathogenesis. The level of frequency reported to date
could be due to chance or ti3 unidentified indirect associations with HIV infection. K.Shorrock 1.O.Ellis R.G.Finch PathoJogg Drpnrtrrrrtit. Lricestrr Royal lrgrrtiwy, Lricester LE2 7 1 X llk'
Reference 1 . Lowry WS. Editorial review: The human immunodeticiency viruh and opportunistic cancers. / t i t . /. STU. A I M 1990: 1: 83-85,
Fine needle biopsy Sir: In his commentary 'Fine needle cytology wrsus histology', Dr Rode stated that the complication rate of his biopsy method was low. with a major morbidity of 0. So/,'. If 'major' means 'serious' complications, then 0.5% is not a low figure for a diagnostic technique that is to be used widely. In the literature, the major complication rate for abdominal fine needle aspiration biopsy is of the order of 1 in 20001,as opposed to 1 in 2 0 0 in Rode's series. I do not think a biopsy tl-chnique with a major morbidity rate of 0.5% should be undertaken lightly. especially when a n alternative method is available. At our hospital, we use the ijpproach suggested by Hall-Craggs and Lees'. Diagnosis is first obtained by tine needle cytology and only when the latter fails to providc an answer or more information 'IS required for nianagcment decision, is a properly planned histological biopsy is carried out. Whenever feasible. we also prepare blocks from fine needle (22-gauge) aspirates.
K.C.Suen Lkpn r t 111c t I t of' Pn t holo~gy, Vancouver Geriprril Hospittrl. Viincorrver, HC'. Cll I rnrlrc
References 1 . Rode J. Fine needle cytology w s u s histology. Histr)i,trtltolo!lII~l[~~j~~ 1 9 X 9
1 5 : 435-439. 2. Livraghi T. Ilamascelli B. Lombardi C, :Spagnoli I. Risk in fine-ncedlc abdominal biopsy. /. C h i . Ultrasourid. 1983: 11: 77-81, 3 . Hall-Craggs MA, Lees WR. Fine needle biopsg cytology. histology. or both? Gut 1987: 28; 233-2 36.
Choriocarcinomatous features in mammary mucoid carcinoma Sir: It is always dangerous to say that something 'has not been previously described'. Dr Green reports an intorest-
Correspondence
ing case of mucoid carcinoma of the breast, in which one of the axillary lymph nodes was infiltrated by tumour having the appearance of choriocarcinoma' , and comments that 'differentiation of breast carcinoma to frank choriocarcinoma has not been previously described'. Whilst this is extremely rare, Saigo & Rosen reported such a case in 1981l. They described a 55-year-old woman, treated 1 3 years previously for invasive ductal carcinoma of the right breast, who presented with a new lesion in the left breast. Histology showed a moderately well differentiated infiltrating ductal carcinoma which merged with areas of more anaplastic tumour having the histological pattern of choriocarcinoma. Immunohistochemistry showed that positive staining with hCG-P localized exclusively to that area of the tumour which resembled choriocarcinoma. The patient died 7 months later with widespread, histologically anaplastic and necrotic pulmonary and nodal metastases which also stained positively with hCG-P.
48 7
Saigo & Rosen commented that 'the rare appearance of choriocarcinomatous differentiation in breast cancer with the appropriate hormone limited solely to that portion makes this tumour distinctly unusual'. This is, perhaps, safer than saying that the lesion has not previously been described.
R.R.Millis ZCRF Cfinicul Oncofogy Unit, Guy's Hospital, London SEI 9RT. U K
References 1. Green DM. Mucoid carcinoma of the breast with choriocarcinoma in its metastases. Histopathology 1990: 16: 504-506. 2. Saigo PE. Rosen PP. Mammary carcinoma with 'choriocarcinomatous' features. A m . /. Surg. Pathol. 19x1: 5: 7 7 3 - i i 8 .
