Invasive breast carcinoma - IARC

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Fig. 5.08 Keratinizing squamous cell carcinoma. Note the partly spindle-shaped cells with eosinophilic cytoplasm and hyperchromatic nuclei. Fig. 5.09 Non-keratinizing squamous cell carcinoma. There is a syncytium with anisokaryosis, irregular distributed coarsely chromatin and nucleoli. c - m y c . c - m y c amplification has been demonstrated in CIN and invasive cervical carcinoma {110,666,2004} suggesting that it is important in early cervical carcinogenesis. Moreover, c-myc overexpression correlates with high risk HPVpositive neoplasia and with cellular proliferation {666}. It has been claimed that an increased level of c-myc transcripts is strongly indicative of a poor prognosis in early stage cervical carcinoma {1314} but not in late stage disease {2823}. the Swedish Family-Cancer Database {1184}. The relative risk when the mother or a daughter was affected by cervical cancer was 2. An aggregation of tobacco-related cancers and cancers linked with HPV and immunosuppression was found in such families. Thus, familial predisposition for cervical cancer is likely to imply genes which modulate immune response, e.g. human leukocyte antigen (HLA) haplotypes {2524} and/or shared sexual or lifestyle factors in family members. Prognosis and predictive factors Clinical criteria The clinical factors that influence prognosis in invasive cervical cancer are age, stage of disease, volume, lymphatic spread and vascular invasion {370,663, 673,818,970,1506,2525,2672,2782}. In a large series of cervical cancer patients treated by radiation therapy, the frequency of distant metastases (most frequently to the lung, abdominal cavity, liver and g a s t rointestinal tract) was shown to increase with increasing stage of disease from 3% in stage IA to 75% in stage IVA {818}. Radiotherapy and surgery produce similar results for early invasive cancer (stages IB and IIA). More advanced lesions (IIB to IV) a re treated with a combination of extern a l radiotherapy and intracavitary radiation. Randomized phase III trials have shown a significant overall and disease free survival advantage for cisplatin-based therapy given concurrently with radiotherapy {1063, 2908}. A significant benefit of chemoradiation on both local (odds ratio 0.61) and distant re c u r rence (odds ratio 0.57) has been observed. The absolute benefit with combined therapy on overall survival was 16%. Based on this evidence, c o n c u r rent chemotherapy with radiotherapy is emerging as the new standard of c a re for advanced cervical cancer. Histopathological criteria Among histopathological variables based on histological findings and not included in the staging system for cervical cancer {1532}, the grading of tumours does not seem to be a strong predictive factor {3233}. In non-squamous cell carcinomas the only histological type of cervical cancer of prognostic significance is small cell carcinoma {68}. There is some evidence that women with a d e n o c a rcinoma and adenosquamous carcinoma have a poorer prognosis than those with squamous cell carc i n o m a after adjustment for stage {2314}. Genetic predictive factors T P 5 3 . The prognostic value of TP53 immunoreactivity in cervical carcinoma is controversial. Some have found no association between p53 overexpression or the presence of mutant p53 protein and clinical outcome {1267,2251}, whilst others have reported that TP53 expression identifies a subset of cervical carcinomas with a poor prognosis {2969}. c-erbB. Frequent amplification of c-erbB- 2 has been documented in cervical carcinoma {2634}, and c-erbB-2 immunostaining has been found to be significantly associated with poor survival and was considered to be a marker of high risk disease {1998}. Additionally, c-erbB-2 immunostaining was found to be an important prognostic factor for predicting tumour recurrence in cervical carcinomas treated by radiotherapy {1967, 2026}. On the other hand, overexpression of c-erbB-3 oncoprotein in squamous, adenosquamous and adenocarcinomas of the cervix showed no association with clinical outcome {1267} Squamous tumours and precursors Definition Primary squamous epithelial tumours of the uterine cervix, either benign or malignant. ICD-O codes Squamous cell carcinoma 8070/3 Keratinizing 8071/3 Non-keratinizing 8072/3 Basaloid 8083/3 Verrucous 8051/3 Warty 8051/3 Papillary 8052/3 Lymphoepithelioma-like 8082/3 Squamotransitional cell 8120/3 Microinvasive squamous 8076/3 cell carcinoma Cervical intraepithelial neoplasia 3 8077/2 squamous cell carcinoma in situ 8070/2 Squamous papilloma 8052 / 0 Squamous cell carcinoma Definition An invasive carcinoma composed of squamous cells of varying degrees of differentiation. Macroscopy Macroscopically, squamous cell carcinoma may be either predominantly exophytic, in which case it grows out from the surface, often as a papillary or polypoid excrescence, or else it may be mainly endophytic, such that it infiltrates into the surrounding structures without much surface growth. 266 Tumours of the uterine cervix
Histopathology There have been few recent developments in the histological diagnosis of frankly invasive squamous cell carcinoma of the cervix {362,1201}. They vary in their pattern of growth, cell type and degree of differentiation. Most carcinomas infiltrate as networks of anastomosing bands with intervening stroma and appear as irregular islands, sometimes rounded, but more usually angular and spiked. Often, particularly in small tumours, CIN may be found on the surface and at the edge of the invasive tumour, and, occasionally, difficulty may be encountered in distinguishing between invasive islands and CIN involving crypts. Similarly, invasion cannot be excluded when neoplastic squamous epithelium shows features of CIN 2 or 3 but underlying stroma is not present. A number of histological grading systems have been proposed that depend upon the type and degree of differentiation of the predominant cell {2794}. A simpler classification is a modification of the four grades of Broders {350} and subdivides the tumours into well differentiated (keratinizing), moderately differentiated and poorly differentiated types. Approximately 60% are moderately differentiated, and the remaining tumours are evenly distributed between the well and poorly differentiated groups. A simple two-tiered classification is recommended, keratinizing and non-keratinizing, to avoid nosological confusion with small cell carcinoma, a term that should be reserved for tumours of neuroendocrine type. The cervical stroma separating the islands of invasive carcinoma is usually infiltrated by a variety of cell types, mainly lymphocytes and plasma cells. A markedly eosinophilic stromal response {262} or a foreign body type giant cell reaction is occasionally seen. A variety of histological types of squamous cell carcinoma have been described. Keratinizing These tumours contain keratin pearls composed of circular whorls of squamous cells with central nests of keratin. Intercellular bridges, keratohyaline granules and cytoplasmic keratinization are usually observed. The nuclei are usually large and hyperchromatic with coarse chromatin. Mitotic figures are not frequent and are usually seen in the lesswell differentiated cells at the periphery of the invasive masses. In cytological preparations the cells usually have bizarre shapes with mostly eosinophilic cytoplasm and large, irregul a r, hyperc h romatic nuclei. Necro t i c debris is present. Non-keratinizing These tumours are composed of generally recognizable polygonal squamous cells that may have individual cell keratinization and intercellular bridges, but keratin pearls are absent. Cellular and nuclear pleomorphism is more obvious than in the well differentiated tumours, and mitotic figures are usually numerous. In cytological preparations the cells are solitary or arranged in syncytia and show anisokaryosis. The nuclei are relatively large with unevenly distributed, coarsely granular chromatin and may have irregular nucleoli Basaloid Basaloid squamous cell carcinoma is composed of nests of immature, basal type squamous cells with scanty cytoplasm that resemble closely the cells of squamous carcinoma in situ of the cervix. Some keratinization may be evident in the centres of the nests, but keratin pearls are rarely present. In the vulva this tumour has been associated with HPV infections, predominantly type 16 {1541,2936}. This underrecognized variant of squamous cell carcinoma is an aggressive tumour with basaloid features {1057}. This tumour along with adenoid cystic carcinoma is at one end of the spectrum of basaloid tumours of the cervix. At the opposite end are low grade lesions such as adenoid basal carcinoma. To avoid confusion in the diagnosis of a cervical tumour with basaloid features, the term "basaloid carcinoma" should be avoided {1057}. Verrucous Verrucous carcinoma is a highly diff e re n- tiated squamous cell carcinoma that has a hyperkeratotic, undulating, warty surface and invades the underlying stro m a in the form of bulbous pegs with a pushing bord e r. The tumour cells have abundant cytoplasm, and their nuclei show minimal atypia. Features of HPV infection a re not evident. Verrucous carc i n o m a s Fig. 5.10 Schematic representation of the FIGO definition of stage 1A carcinoma of the cervix. A: Depth of invasion no greater than 5 mm; B: Horizontal spread 7 mm or less. have a tendency to recur locally after excision but do not metastasize. They a re distinguished from condyloma by their broad papillae that lack fibro v a s c u- lar cores and the absence of koilocytosis. Verrucous carcinoma is distinguished from the more common types of squamous cell carcinoma in that it shows no more than minimal nuclear a t y p i a . Warty This lesion is defined as a squamous cell carcinoma with a warty surface and cellular features of HPV infection {720, 1541,2936}. High risk HPV-DNA is typically detected {2936}. It is also referred to as condylomatous squamous cell carcinoma. Papillary This is a tumour in which thin or bro a d papillae with connective tissue stro m a a re covered by epithelium showing the f e a t u res of CIN. Whilst a superf i c i a l biopsy may not reveal evidence of invasion, the underlying tumour is usually a typical squamous cell carc i n o m a {345,2333}. Such tumours are positive for HPV type 16. Papillary squamous cell carcinoma differs from warty squamous carcinoma by the inconspicuous keratinization and lack of cellular feat u res of HPV infection and from transitional cell carcinoma by its squamous cell diff e rentiation {345}. Lymphoepithelioma-like H i s t o l o g i c a l l y, lymphoepithelioma-like c a rcinoma is strikingly similar to the n a s o p h a ryngeal tumour of the same name. It is composed of poorly defined islands of undiff e rentiated cells in a background intensely infiltrated by lym- Epithelial tumours 267
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Previous volumes in this series Kle
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World Health Organization Classific
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Published by IARC Press, Internatio
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CHAPTER 1 Tumours of the Breast Can
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TNM classification of carcinomas of
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Invasive breast carcinoma I.O. Elli
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Rapid growth and greater adult heig
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tives, administrative and clerical
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Grade 1 - well differentiated: 3-5
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ent and this is occasionally extens
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Most melanotic tumours of the breas
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A Fig. 1.22 A Classic invasive lobu
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yet others at 90% {97,2147}. For pr
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Fig. 1.27 Medullary carcinoma. The
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myoepithelial cells in fibro a d e
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A Fig. 1.33 Neuroendocrine carcinom
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Macroscopy Fisher et al. reported t
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Fig. 1.39 Apocrine carcinoma. Note
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cells contain intracytoplasmic lume
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A Fig. 1.50 Carcinosarcoma. A Two a
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A B C Fig. 1.75 Lobular neoplasia.
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Intraductal proliferative lesions F
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A B absence of either microcalcific
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Fig. 1.83 Atypical ductal hyperplas
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A B Fig. 1.88 Large excision biopsy
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unusual variants as well. Using thi
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esemble those identified in invasiv
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A B Fig. 1.97 Microinvasive carcino
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A Papilloma may be subject to morph
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A B C Fig. 1.103 Papillary intraduc
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colour measuring from 0.5 to 12 cm.
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Immunoprofile The cases studied by
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Glycogen-rich, clear cell carcinoma
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Differential diagnosis There may be
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quality metaphase spreads from an i
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Fig. 1.67 Lobular carcinoma of brea
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detectable distant metastasis displ
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detected at a late stage as small t
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Extent of ductal carcinoma in situ
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Benign epithelial proliferations G.
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Fig. 1.112 Microglandular adenosis.
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A Apocrine adenoma ICD-O code 8401/
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A B Fig. 1.128 Adenomyoepithelioma,
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Mesenchymal tumours M. Drijkoningen
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1113,1275}. There is a complex patt
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A B Fig. 1.137 A Lipoma. Intraparen
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Fig. 1.141 Angiosarcoma after breas
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A Fig. 1.144 Mammary osteosarcoma.
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Fibroepithelial tumours J.P. Belloc
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aged women (average age of presenta
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lished data suggests a 21% rate of
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A Fig. 1.157 Syringomatous adenoma
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Malignant lymphoma and metastatic t
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used. Inflammatory conditions in th
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male population both in the USA and
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CHAPTER 2 Tumours of the Ovary and
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Polyembryoma 9072/3 Non-gestational
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Surface epithelial-stromal tumours
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A Fig. 2.04 A Serous borderline tum
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A Fig. 2.06 Serous borderline tumou
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A Fig. 2.10 Invasive peritoneal imp
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Fig. 2.15 Mucinous carcinoma with i
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Fig. 2.20 Mucinous endocervical-lik
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A Fig. 2.28 Mucinous cystic tumour
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early secretory endometrium {2605}.
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IV, 6% {2233}. Patients with grade
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A Fig. 2.37 A This polypoid intracy
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Fig. 2.40 Endometrioid cyst with at
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1 tumours are extremely rare. Almos
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Fig. 2.50 Borderline Brenner tumour
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express thrombomodulin and have bee
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serous and transitional cell carcin
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is yellow to tan with a variable ad
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Genetic susceptibility JGCTs may pr
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Clinical features F i b romas may b
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distinguishes this tumour from the
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A Fig. 2.77 A Retiform Sertoli-Leyd
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Mean ages of 21 and 38 years and me
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Tumours unassociated with PJS form
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mal origin without crystals of Rein
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Germ cell tumours F. Nogales A. Tal
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cases, anisokaryosis has no prognos
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ation may coexist in the same neopl
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Table 2.06 Grading of ovarian immat
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A B Fig. 2.102 A Mature cystic tera
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Diagnostic procedures Elevated urin
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associated with mature teratomas sh
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atives intimately admixed. The germ
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Fig. 2.113 Mixed germ cell-sex cord
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A Fig. 2.116 A Adenomatous hyperpla
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Fig. 2.117 Small cell carcinoma, hy
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Clinical features Adenoid cystic-li
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Histopathology This epithelial tumo
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sis. Corpus luteum of pregnancy has
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Lymphomas and leukaemias L.M. Roth
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Secondary tumours of the ovary J. P
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Occasionally, the colonic adenocarc
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Peritoneal tumours S.C. Mok J.O. Sc
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A B Fig. 2.140 Cystic adenomatoid m
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whelmingly poor {1038,1547,2310}. H
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CHAPTER 3 Tumours of the Fallopian
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TNM and FIGO classification of carc
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Endometrioid adenocarcinoma Endomet
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Two examples of adenofibroma of bor
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A Fig. 3.11 Adenomatoid tumour. A T
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Clinical features Patients range in
Page 216 and 217: Fig. 3.16 Uterus-like mass. The cys
Page 218 and 219: CHAPTER 4 Tumours of the Uterine Co
Page 220 and 221: TNM and FIGO classification of non-
Page 222 and 223: Epithelial tumours and related lesi
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Page 226 and 227: fers from the prototypical type I e
Page 228 and 229: the ovary and bladder. Unlike prima
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Page 232 and 233: Table 4.03 Altered gene function in
Page 234 and 235: Mesenchymal tumours and related les
Page 236 and 237: areas are limited to less than 30%
Page 238 and 239: A B C Fig. 4.30 Leiomyosarcoma. A T
Page 240 and 241: e used sparingly and is reserved fo
Page 242 and 243: A B Fig. 4.38 Leiomyoma with perino
Page 244 and 245: cytological atypia, tumour cell nec
Page 246 and 247: Mixed epithelial and mesenchymal tu
Page 248 and 249: Prognosis and predictive factors Th
Page 250 and 251: tumours may superficially invade th
Page 252 and 253: A Fig. 4.46 A Gestational choriocar
Page 254 and 255: A Fig. 4.49 A Classic complete hyda
Page 256 and 257: Sex cord-like, neuroectodermal and
Page 258 and 259: Secondary tumours of the uterine co
Page 260 and 261: WHO histological classification of
Page 262 and 263: Epithelial tumours M. Wells J.M. Ne
Page 264 and 265: Fig. 5.04 Mechanisms of human papil
Page 268 and 269: in their Asian population {2957}. I
Page 270 and 271: have a strong association with high
Page 272 and 273: e red by squamous epithelium {380}.
Page 274 and 275: endometrioid adenocarcinoma of the
Page 276 and 277: metrial epithelium. In some cases t
Page 278 and 279: with distinct cell borders and a gr
Page 280 and 281: Mesenchymal tumours M.L. Carcangiu
Page 282 and 283: {781}, liposarcoma {2840,3016}, ost
Page 284 and 285: Mixed epithelial and mesenchymal tu
Page 286 and 287: Fig. 5.44 Wilms tumour. The tumour
Page 288 and 289: A Fig. 5.47 Implant of endometrial
Page 290 and 291: CHAPTER 6 Tumours of the Vagina Alt
Page 292 and 293: Epithelial tumours E.S. Andersen A.
Page 294 and 295: Aetiology The fact that both VAIN a
Page 296 and 297: Fig. 6.10 Fibroepithelial polyp.A m
Page 298 and 299: er of mitoses varies but is usually
Page 300 and 301: ICD-O codes Adenosquamous carcinoma
Page 302 and 303: A C Fig. 6.17 Sarcoma botryoides. A
Page 304 and 305: 1-11 cm. They may arise anywhere in
Page 306 and 307: elsewhere in the female genital tra
Page 308 and 309: A Fig. 6.24 Yolk sac tumour. A The
Page 310 and 311: g rowing in sheets. Some may have s
Page 312 and 313: WHO histological classification of
Page 314 and 315: Epithelial tumours E.J. Wilkinson M
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even with additional sectioning, it
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type) is a highly diff e rentiated
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Clinical features Bartholin gland c
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glandular elements surrounded by fi
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Mesenchymal tumours R.L. Kempson M.
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Table 7.03 Differential diagnosis o
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Prognosis and predictive factors A
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Table 7.04 Clark levels of cutaneou
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A Fig. 7.23 Vulvar peripheral primi
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Familial aggregation of cancers of
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BRCA1 syndrome Definition Inherited
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dispose individuals to the developm
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Fig. 8.05 To assess whether wild-ty
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Fig. 8.07 Factors that modify risk
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BRCA2 syndrome R. Eeles S. Piver S.
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tubal or ovarian carcinomas. Howeve
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in typical nuclear foci that may re
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Breast tumours Frequency Breast can
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Fig. 8.14 Codon distribution of som
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Breast tumours Age distribution and
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Hereditary non-polyposis colon canc
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essary in the evaluation of the pat
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Age distribution and penetrance Mos
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Contributors Dr Vera M. ABELER** De
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Dr Carlo LA VECCHIA Laboratory of E
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Dr Manuel TEIXEIRA Department of Ge
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02.100 Dr. A. Ostor 02.101 Dr. F.A.
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52. Akhtar M, Robinson C, Ashraf Al
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180. Bapat K, Brustein S (1989). Ut
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307. Bolis GB, Maccio T (2000). Cle
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436. Chang J, Sharpe JC, A'Hern RP,
Page 378 and 379:
562. Costa MJ, Ames PF, Walls J, Ro
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689. Di Domenico A, Stangl F, Benni
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820. Falck J, Petrini JH, Williams
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943. Gad A, Azzopardi JG (1975). Lo
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1067. Grimes MM (1992). Cystosarcom
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1197. Herod JJ, Shafi MI, Rollason
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1323. Jacques SM, Qureshi F, Ramire
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1449. Khalifa MA, Mannel RS, Harawa
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1564. Lagios MD (1977). Multicentri
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1687. Loman N, Johannsson O, Kristo
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1807. McCluggage G, McBride H, Maxw
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1937. Mukai M, Torikata C, Iri H (1
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2056. Norris HJ, Taylor HB (1967).
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2180. Park JS, Jones RW, McLean MR,
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2304. Puls LE, Hamous J, Morrow MS,
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2 4 3 4 . Rosen PP, Groshen S, Saig
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2559. Schlesinger C, Silverberg SG
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2686. Silverberg SG (1999). Protoco
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2806. Stutz JA, Evans AJ, Pinder S,
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2942. Tornos C, Silva EG, Ordonez N
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3061. Wargotz ES, Norris HJ (1990).
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3189. Yoshioka T, Tanaka T (2000).
Page 422 and 423:
References 425
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Biphasic teratomas, 168 BLM, 341, 3
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G GADD45, 343, 353 GCDFP-15, 25, 33
Page 428 and 429:
MPNST, see Malignant peripheral ner
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Small cell / oat cell carcinoma, 32
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Invasive breast carcinoma - IARC

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