Histopathology 1992, 21, 597-601

Correspondence Solitary fibrous tumour arising at unusual sites Sir: In the recent very informative article by Goodlad & Fletcher’ the authors refer to a fibrous tumour (case 6) in the anterior superior mediastinum which was infiltrating and inoperable with mitotic activity. Yet the patient survived 1 9 years without recurrence and died from radiation induced pulmonary fibrosis. I wonder if the authors did consider the possibility of sclerosing mediastinitis’ in this case. We have recently reviewed 19 cases3 from our files in which the patients presented with large infiltrating lesions in the anterior superior mediastinum on chest X-ray and the mass was considered inoperable in all cases. Histological features similar to that described, with spindle cell proliferation, occasional mitoses and hyalinized collagen bundles were seen in several of our cases without evidence of granulomatous inflammation or chronic inflammatory cells including plasma cells. Our cases also stained for smooth muscle actin and were negative for keratin. A retrospective history of pulmonary tuberculosis was obtained in nine cases while one case also had a history of histoplasmosis. Follow-up of our cases showed that the disease is usually stable with no progression. However, some can progress locally with lung destruction and death: this occurred in three of our cases. No extramediastinal spread has been described for this lesion which is believed to be due to a hypersensitivity reaction to previous infection/trauma/ radiation. Did the case reported have any previous significant history to suggest that the process could be that of sclerosing mediastinitis and not a neoplastic lesion as suggested?

M .N.Sheppard Department o$ Lung Pathology, Royal Brompton. National Heart and Lung Hospital, Sydney Street, London SW3 6NP, U K

References 1. Goodlad JR. Fletcher CDM. Solitary fibrous tumour arising in

unusual sites: analysis of a series. Histopathology 1991; 19; 5 1 5522. 2. Schowengerdt CG. Suyemoto R. Main FB. Granulomatous and fibrous mediastinitis. J. Thorac. Cardiovasc. Surg. 1969; 57; 365379. 3. Molle TM, Sheppard MN. Sclerosing mediastinitis in the UK (Abstract).Am. Rev. Resp. Dis. (In press).

Sir: We appreciate Dr Sheppard’s comments on our paper and are interested to hear of her large series of

cases of sclerosing mediastinitis. We had indeed considered the latter as a diagnostic possibility in our case 6 but had excluded it for the following reasons: 1 the patient was entirely asymptomatic; 2 the mass was radiologically discrete/circumscribed (albeit not so surgically); 3 the lesion was virtually devoid of inflammatory cells; and 4 this case belonged in the cellular category of solitary fibrous tumour with haemangiopericytoma-like vessels and bore no resemblance to sclerosing mediastinitis of either infective or idiopathic type. The fact that the patient survived for 19 years simply attests further to the well-known fact that the clinical behaviour of solitary fibrous tumour is unpredictable and does not correlate reliably with the histological appearances.

J.R.Goodlad C.D.M.Fletcher Depurtment of Histopathology, St. Thomas’s Hospital, London S E l 7 E H , UK

Histopathology for minor surgery Sir: We read with interest the commentary by Drs Cotton and Stephenson on the role of histopathology for minor surgery] and would like to support their call for the continuation of histopathological examination of routinely excised skin biopsies, whether originating from hospital or general practice. We conducted a review of 3 years’ experience in a surgical histology laboratory where material derived solely from hospital practice was examined. In all cases where the clinical diagnosis of ‘sebaceous cyst’ was provided ( n= 2 30),the histology was reviewed. In 185 of these cases, the presence of a cyst of either epidermal (118; 5 1.3%)or pilar/trichilemma1 (67; 29.1%) type was confirmed. In 11 instances, there was evidence only of non-specific inflammation and fibrosis (4.8%). Thirty-four other cases (14.8%) yielded a variety of diagnoses, mainly of inflammatory conditions or of benign adnexal and mesenchymal tumours. However, in four cases (1.7%), the final pathological diagnosis was of a malignant condition: a basal cell carcinoma from the shoulder, a sebaceous carcinoma from the axilla, a squamous carcinoma from the upper arm and a metastatic squamous carcinoma of oesophagus presenting as a cysticdower chest wall mass. This last lesion was the first unsuspected sign of recurrent disease in a 64-year-old man 18 months after oesophagectomy. All of these lesions had been treated adequately by wide excision, possibly reflecting the 597

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hospital based nature of our surve:y,and most of the nonneoplastic and benign lesions identified were of little significance in their own right. Nevertheless, the lack of correlation between the clinical innpression and the true histopathological diagnosis suggests that, if such apparently trivial lesions are discarded important clinical conditions will be missed in a significant proportion of cases (in our study, between 1.7’ and 14.8%). Recent studies suggest that this proportion may be higher in the hands of general practitioners2 and further reinforces Cotton and Stephenson’s contention that routine histopathology of these and other similar lesions is necessary. As they suggest we, as histopathologists, should be informing our clinical colleagues of the value of clinicopathological correlation in training and audit at all possible opportunities. C.M.Manson R .F.T.McMahon Division of Histopathology, Department of Pathological Sciences, University of Manchester, Stopford Building, Oxford Road, Marichester M 1 3 9PT, UK

References 1 . Cotton DWK, Stephenson TJ. Histopathology for minor surgery. Histopathology 1992: 20: 455-456. 2. McWilliam LJ. Knox F, Wilkinson N, (logarah P. Performance of skin biopsies by general practitioners. Br. Med. 1. 1991: 303: 1 1 771179.

Sir: Presumably due to unfortunate timing, possibly the most important reference relating to minor surgery in general practice has not been included by Drs Cotton and Stephenson’. This comprises the recent guidelines issued by The General Medical Services Committee and The Royal College of General Practitioners’. Here, it is 6rmly stated that ‘all lesions removed during minor surgery should be sent for histological examination’. This is fortunate as, ironically, a different Sheffield University department has seriously queried the ‘expensive and time consuming option of sending all specimens for histopathological e ~ amin atio n ’~ This . view, however, does emphasise that we cannot forget the new ‘internal market’ and that general practitioners will be looking for the most cost-effective laboratory to report their specimens. Also, the guidelines and the general practitioner’s ‘red h a n d b ~ o kserve ’ ~ as timely reminders that, to date,

minor surgery histopathology has not been viewed on the same scale of importance as, for example, the national breast and cervical cytology screening programmes. The clinical importance of melanocytic lesions alone, makes this illogical in view of the rising incidence of melanoma and the necessity to correctly diagnose and treat early melanoma and its precursors. It is revealing that the only collaboration acknowledged in the guidelines is that with The Royal College of Surgeons. Similarly, perusal of the minor surgery list in the ‘red handbook’ suggests minimal histopathological contribution to its national formulation. It would appear imperative, as emphasized by Drs Cotton and Stephenson, that this situation is improved by histopathologists assuming a higher profile. D.Slater Department of Histopathology, Rot herham District Hospital, Moorgate Road, Oakwood, Rotherham S60 2UD, UK

References 1 . Cotton DWK, Stephenson TJ.Histopathology for minor surgery. Histopathology 1992: 20: 455-456. 2. Minor Surgery in General Practice. Guidelines by The General Medical Services Committee and The Royal College of General Practitioners. Department of Health. 1991: 1-5. 3. Brazier JE, Lowy A. Performance of skin biopsies by general practitioners. Br. Men. 1. 1991: 303: 1472. 4. Statement of fees and allowances. National Health Service General Medical Services. Heywood Storrs. 1992; 115-1 16. 5. O‘Cathain A, Brazier JE. Milner PC. Fall M. Cost effectiveness of minor surgery in general practice: a prospective comparison with hospital practice. Br. 1. Gen. Pruc. 1992: 42: 13-1 7. 6. Slater D.Performance of skin biopsies by general practitioners. Br. Med. 1. 1991; 303: 1472.

Sir: We are grateful for the comments from Drs Manson, McMahon and Slater and gratified to see that their experience and views correspond with our own. We feel that the argument for routine histopathological examination of all surgically resected specimens is overwhelming from the ethical, clinical, medico-legal and academic points of view: we are less sanguine that these considerations will prevail over financial arguments. We agree with Dr Slater on the importance of the recent guidelines issued by The General Medical Services Committee and The Royal College of General Practitioners which was not to hand a t the time of going to press. It is gratifying to see that other histopathologists

Histopathology for minor surgery.

Histopathology 1992, 21, 597-601 Correspondence Solitary fibrous tumour arising at unusual sites Sir: In the recent very informative article by Goodl...
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