Endoscopic follow-up of low-grade precancerous bronchial lesions in high-risk patients: long-term results of the SELEPREBB randomised multicentre trial.

BACKGROUND: 3-9% of low-grade preinvasive bronchial lesions progress to cancer. This study assessed the usefulness of an intensive bronchoscopy surveillance strategy in patients with bronchial lesions up to moderate squamous dysplasia. METHODS: SELEPREBB (ClinicalTrials.gov NCT00213603) was a randomised study conducted in 17 French centres. After baseline lung computed tomography (CT) and autofluorescence bronchoscopy (AFB) to exclude lung cancer and bronchial severe squamous dysplasia or carcinoma in situ (CIS), patients were assigned to standard surveillance (arm A) with CT and AFB at 36 months or to intensive surveillance (arm B) with AFB every 6 months. Further long-term data were obtained with a median follow-up of 4.7 years. RESULTS: 364 patients were randomised (A: 180, B: 184). 27 patients developed invasive lung cancer and two developed persistent CIS during the study, with no difference between arms (OR 0.63, 95% CI 0.20-1.96, p=0.42). Mild or moderate dysplasia at baseline bronchoscopy was a significant lung cancer risk factor both at 3 years (8 of 74 patients, OR 6.9, 95% CI 2.5-18.9, p<0.001) and at maximum follow-up (16 of 74 patients, OR 5.9, 95% CI 2.9-12.0, p<0.001). Smoking cessation was significantly associated with clearance of bronchial dysplasia on follow-up (OR 0.12, 95% CI 0.01-0.66, p=0.005) and with a reduced risk of lung cancer at 5 years (OR 0.15, 95% CI 0.003-0.99, p=0.04). CONCLUSION: Patients with mild or moderate dysplasia are at very high risk for lung cancer at 5 years, with smoking cessation significantly reducing the risk. Whereas intensive bronchoscopy surveillance does not improve patient outcomes, the identification of bronchial dysplasia using initial bronchoscopy maybe useful for risk stratification strategies in lung cancer screening programmes.

Molecular predictive factors for progression of high-grade preinvasive bronchial lesions.

RATIONALE: The outcome of precancerous bronchial lesions is not well known, and their management is subject to controversy. Many molecular alterations are present in preinvasive lesions, but none has been assessed to predict the evolution of the lesions. OBJECTIVES: To analyze the outcome of high-grade precancerous lesions according to their molecular profile. METHODS: Twenty-three severe dysplasia and 31 carcinoma in situ (CIS) lesions in 37 patients were monitored using repeated autofluorescence bronchoscopy over a 12-year period. Microdissection and polymerase chain reaction analysis were performed on paraffin tissue sections to assess loss of heterozygosity (LOH) and microsatellite instability on chromosome 3p, 5q, and 9p. Histology and molecular status at baseline were compared between 7 lesions that became invasive, 11 that relapsed after treatment, 17 that were eradicated with local treatment, and 19 that spontaneously regressed. MEASUREMENTS AND MAIN RESULTS: Ninety-four percent of lesions that progressed or relapsed were CIS at baseline, whereas 79% of spontaneously regressing lesions were severe dysplasia (P < 0.0001). 3p and 9p LOH was more frequent in CIS than in severe dysplasia (P = 0.03). In the whole group of lesions as well as in the CIS group, 3p LOH was strongly associated with progression (P < 0.0001 and P = 0.02, respectively). Microsatellite instability was not associated with the outcome of the lesions. A therapeutic strategy based on the presence of 3p or 9p LOH would have led to overtreatment of six lesions but would have missed only 1 among the 18 progressing lesions. CONCLUSIONS: Baseline histology and 3p LOH analysis appear to be useful in predicting the outcome of high-grade precancerous lesions.

[Cytokeratins 7 and 20 immunohistochemistry in ampullary carcinomas]. / Expression immunohistochimique des cytokératines 7 et 20 dans les carcinomes ampullaires.

UNLABELLED: Ampullary carcinomas (AC) account for 33% of all surgically operable pancreatoduodenal tumors. The 5-year relative survival rate is 50% and tumoral stage is the main prognostic factor. However, among the three AC histological subtypes (intestinal, pancreatobiliary and mixed), a favorable prognostic has been reported for the intestinal subtype. BACKGROUND: The aims of this study were to determine the prognostic impact of AC histologic subtype and of cytokeratins (CK) 7 and 20 immunostaining profile in these tumors. PATIENTS AND METHODS: Clinical data of 54 AC were obtained retrospectively. Macroscopic and histologic documents were reviewed and immunostainings for CK7 and CK20 were performed. RESULTS: The classification of tumors, according to histological subtype, was: intestinal 26%, pancreatobiliary 65% and mixed 9%. No correlation was found between histological subtype and tumor stage. The 5-year survival rate varied from 100% for intestinal subtype to 35% for pancreatobiliary subtype. A strong correlation (p < 0.0001) was found between histological subtype and CK7/CK20 immunostaining profile. The 5-year survival rate varied from 100% for CK7-/CK20 + AC to 40% for CK7 + /CK20- AC. CONCLUSION: In our study, the intestinal histological subtype had a favorable prognostic value. CK7/CK20 immunostaining profile was helpful for the identification of histological subtype and appears to provide additional prognostic information.

SMAD4-related Familial Juvenile Polyposis Syndrome with Colon Cancer.

BACKGROUND: Juvenile polyposis syndrome (JPS) is a rare autosomal dominant disorder characterized by the development of multiple hamartomatous polyps in the gastrointestinal tract with an increased risk of malignancy. SMAD4 germline mutations account for about a third of JPS. PATIENTS AND METHODS: We describe, in the same family, the morphological and genetic aspects of two cases of JPS with colon cancer in one patient. RESULTS: Both cases were characterised by diffuse colorectal and gastric involvement by typical juvenile polyps as well as "atypical" multilobulated and densely epithelial polyps with some dysplastic areas. A germline mutation of SMAD4 was demonstrated in both cases. SMAD4 protein and DNA analyses were performed on the colonic adenocarcinoma showing a lack of expression of SMAD4 protein and loss of heterozygosity at the SMAD4 locus. CONCLUSION: These two exceptional familial cases underline the fact that the morphological features of JPS associated with SMAD4 mutations are different from those found in non SMAD4 mutated cases: polyps are more widespread in the upper GI tract with massive gastric polyposis and they have a dense epithelial component. This study also confirmed that SMAD4 genetic analysis is useful for the diagnosis of JPS and may be predictive of an increased risk of malignancy through inactivation of both alleles of SMAD4.

[Retrorectal cystic hamartomas. Report of one case]. / Hamartome kystique rétrorectal. A propos d'une observation.

Retrorectal cystic hamartomas (RCH) are rare congenital lesions of the presacral space, of which 68 cases are reported under different terms. Clinicopathologic features are usually constant and similar to the present case. A 23-year-old woman complained of abdominal and perineal pains for several months. Physical examination revealed a nodular mass in the posterior part of the rectum. A pelvic MRI showed a 5.5 cm cystic retrorectal mass compressing the rectum. The patient underwent surgical resection. Pathologic examination found an ill-defined nodular mass, composed by numerous cysts surrounded by fibroadipose tissue. Cysts were lined by different epithelia: keratinized and non keratinized squamous, transitional, ciliated and mucus-producing columnar epithelia. Few mucinous glands were noted, connected to some cysts. These epithelial structures were surrounded by connective tissue in which well-differentiated bundles of smooth muscle fibers were present without well-formed muscularis. The RCH differential diagnosis includes principally congenital cysts: epidermal cysts, cystic teratomas, dermoid cysts, anal gland cysts and rectal duplications. An embryologic origin of RCH from remnants of the postanal gut is currently accepted. Loco-regional inflammatory process frequently complicates this lesion and can cause perirectal fistulae. RCH also possesses a malignancy potential, with development of adenocarcinomas. To avoid these complications, complete excision is recommended.

[Recurring bone epithelioid hemangioma]. / Hémangiome épithélioïde osseux récidivant.

Bone vascular tumors are very rare. Epithelioid types are described according to their architecture, their degree of vascular differentiation, and their cytonuclear atypia. The include epithelioid hemangioma, epithelioid hemangioendothelioma, and angiosarcoma. We report a case of L4 corpus vertebral bone epithelioid hemangioma. The patient was a 25-year-old man with a tumor that recurred twice. The lesion was characterized by a vascular lumen lined by cells with regular nuclei and inflammatory infiltrates. Capillaries were lined by prominent epithelioid endothelial cells, associated with CD31+ and cytokeratin-.

Smoking status, occupational asbestos exposure and bronchial location of lung cancer.

The objective of this study was to determine the factors associated with central airway versus peripheral bronchial location of lung cancer. All patients diagnosed with lung cancer from 1997 through 2000 in the Respiratory Disease Department of Rouen University Hospital were prospectively interviewed about their smoking and occupational history using a standardized questionnaire. All patients underwent white-light bronchial endoscopy using a 4.5 mm flexible endoscope. Tumors were classified as central when they were accessible and visible using this technique. Out of 217 cases of lung cancer included in this study, 155 (71%) were central. Histological type of lung cancer was strongly associated with bronchial location as central location was observed in 48, 82 and 92% of Adenocarcinoma (AC), Squamous Cell (SqC), and Small Cell Carcinoma (SCC), respectively (P<0.0001). Among non asbestos-exposed patients, location varied little with smoking status, with central location frequency ranging from 74 to 80%. In contrast, lung cancer was recorded central in 41% of long-term (> or =10 years) ex-smokers, 67% of short-term (<10 years) ex-smokers and 75% of current smokers (P=0.04) among patients exposed to asbestos, suggesting an interaction between duration of smoking cessation and occupational asbestos exposure with respect to lung cancer location. These findings were confirmed after adjustment for sex, age and histologic type in multivariate analysis. These results suggest that individually-tailored multimodality screening strategies relying on various combinations of low-dose CT scan, sputum analysis and fluorescence endoscopy according to each patient's profile may be more effective than standard strategies based on a single approach for all patients.

PAS inclusions, immunoreactive tenascin and proliferative activity in low-grade chondrosarcomas.

To distinguish between chondrosarcoma (grade 1--borderline histology) and enchondroma, we examined six chondrosarcomas (grade 1--borderline histology) which looked like benign lesions. Their diagnosis, albeit based on clinical, radiologic and pathologic examinations, was not easily reached. Moreover, we examined six enchondromas and 11 chondrosarcomas, the diagnoses of which were straightforward. All cartilaginous tumors were studied, placing emphasis on PAS-positive intracytoplasmic globules. Anti-Ki67 proliferation-associated nuclear antigen antibody and tenascin antibody were applied. The following features were observed in low-grade chondrosarcomas: (1) masses of hyalin and/or myxoid cartilage invading spaces around the tumor, (2) host lamellar bone trabeculae surrounded by cartilage on all sides, (3) tumoral resorption of bone trabeculae. Intracytopasmic hyalin globules (ICG) were more frequently found in malignant than in benign neoplasm (p = 0.042). Moreover, tenascin matrix immunoreactivity was more likely to be observed in benign than in malignant neoplasm (p = 0.029). Ki67 immunoreactivity was more frequent in characterized than in low-grade chondrosarcomas or in enchondromas, where it was null (p = 0.0044).

[Detection of HHV8 latent nuclear antigen by immunohistochemistry. A new tool for differentiating Kaposi's sarcoma from its mimics]. / Détection de l'antigène LNA1 de l'HHV8 par immunohistochimie.

UNLABELLED: The purpose of this work was to study the value of HHV8 latent nuclear antigen 1 detection by immunohistochemistry in Kaposi sarcoma and its mimics. MATERIALS AND METHODS: : We used the mAB LNA53 against the latent nuclear antigen 1 of HHV8 to study its expression by immunohistochemistry in paraffin embedded biopsy of Kaposi and its mimics. We also performed in vitro PCR for HHV8 DNA, extracted from the same paraffin embedded biopsies. We studied characteristic lesions of 26 Kaposi sarcoma; 20 cutaneous lesions raising problems of differential diagnosis. We also studied 11 biopsies of skin, mucosa, or lymph nodes of patients infected by HHV8 but without Kaposi sarcoma, and 22 lesions initially classified by histological analysis as uncertain Kaposi sarcoma . RESULTS: : In all cases of Kaposi, HHV8 was detected in the majority of tumor cells, with no expression in other adjacent cells. In these biopsies HHV8 DNA, was identified by in vitro PCR. None of the 20 Kaposi sarcoma mimics and the 11 lesions of patients infected by HHV8 but without any Kaposi sarcoma, were HHV8+ on immunohistochemistry sections or by PCR. From the 22 cases of uncertain Kaposi sarcoma, only the 14 lesions HHV8 PCR+ and with a clinical evolution in accordance with a Kaposi sarcoma, were HHV8+ on immunohistochemistry. In contrast, the 8 cases negative for HHV8 on immunohistochemistry were also PCR- and had a self-healing evolution in accordance with the diagnostic of pyogenic granuloma. CONCLUSION: : Detection of the latent nuclear antigen 1 of HHV8 by immunohistochemistry is a specific and sensitive diagnostic tool for differentiating Kaposi sarcoma from its mimics.

Aberrant methylation of the CDKN2a/p16INK4a gene promoter region in preinvasive bronchial lesions: a prospective study in high-risk patients without invasive cancer.

Among the identified factors involved in malignant transformation, abnormal methylation of the CDKN2A/p16(INK4a) gene promoter has been described as an early event, particularly in bronchial cell cancerization. Precancerous bronchial lesions (n = 70) prospectively sampled during fluorescence endoscopy in a series of 37 patients at high risk for lung cancer were studied with respect to the methylation status of the CDKN2A gene. Methylation-specific polymerase chain reaction was performed on DNA extracted from pure bronchial cell populations derived from biopsies and detection of p16 protein was studied by immunohistochemistry on contiguous parallel biopsies. Aberrant methylation of the CDKN2A gene promoter was found in 19% of preinvasive lesions and its frequency increased with the histologic grade of the lesions. Methylation in at least 1 bronchial site was significantly more frequent in patients with cancer history, although there was no difference in the outcome of patients with or without methylation in bronchial epithelium. The other risk factors studied (tobacco and asbestos exposure) did not influence the methylation status. There was no relationship between CDKN2A methylation and the evolutionary character of the lesions. Our results confirm that abnormal methylation of the CDKN2A gene promoter is an early event in bronchial cell cancerization, which can persist for several years after carcinogen exposure cessation, and show that this epigenetic alteration cannot predict the evolution of precancerous lesions within a 2-year follow-up.