A multicentre validation of Metasin: a molecular assay for the intraoperative assessment of sentinel lymph nodes from breast cancer patients.

AIMS: Treatment strategies for breast cancer continue to evolve. No uniformity exists in the UK for the management of node-positive breast cancer patients. Most centres continue to use conventional histopathology of sampled sentinel lymph nodes (SLNs), which requires delayed axillary clearance in up to 25% of patients. Some use touch imprint cytology or frozen section for intraoperative testing, although both have inherent sensitivity issues. An intraoperative molecular diagnostic approach helps to overcome some of these limitations. The aim of this study was to assess the clinical effectiveness of Metasin, a molecular method for the intraoperative evaluation of SLNs. METHODS AND RESULTS: RNA from 3296 lymph nodes from 1836 patients undergoing SLN assessment was analysed with Metasin. Alternate slices of tissue were examined in parallel by histology. Cases deemed to be discordant were analysed by protein gel electrophoresis. There was concordance between Metasin and histology in 94.1% of cases, with a sensitivity of 92% [95% confidence interval (CI) 88-94%] and a specificity of 97% (95% CI 95-97%). Positive and negative predictive values were 88% and 98%, respectively. Over half of the discordant cases (4.4%) were ascribed to tissue allocation bias (TAB). CONCLUSIONS: Clinical validation of the Metasin assay suggests that it is sufficiently sensitive and specific to make it fit for purpose in the intraoperative setting.

Primary extrarenal papillary type II renal cell carcinoma presenting as a pelvic mass: a case report and review of the literature.

We report a case of a 57 years old woman with a solitary mass located in the pelvis diagnosed as an extrarenal papillary renal cell carcinoma, in the absence of a primary renal cancer. The diagnosis was based on cytomorphological features and further confirmed by immunochemistry findings following surgical excision. The hypothesis of a tumor developing in a supernumerary or ectopic kidney was excluded, since no normal renal tissue could be identified in the specimen and in the preoperative computed tomography and MRI images.

Metasin-an intra-operative RT-qPCR assay to detect metastatic breast cancer in sentinel lymph nodes.

Nodal status is one of the most important prognostic factors in breast cancer. Established tests such as touch imprint cytology and frozen sections currently used in the intra-operative setting show variations in sensitivity and specificity. This limitation has led to the development of molecular alternatives, such as GeneSearch, a commercial intra-operative real-time quantitative Polymerase Chain Reaction (RT-qPCR) assay that allows the surgeon to carry out axillary clearance as a one-step process. Since GeneSearch has been discontinued, we have developed the replacement Metasin assay, which targets the breast epithelial cell markers CK19 and mammaglobin mRNA and identifies metastatic disease in sentinel lymph nodes. The optimised assay can be completed within 32 min (6 min for RNA preparation and 26 min instrument run time), making its use feasible in the intraoperative setting. An analysis by Metasin of 154 archived lymph node homogenates previously analysed by both parallel histology and GeneSearch showed concordance for 148 cases. The sensitivity and specificity of Metasin compared with GeneSearch were 95% (CI 83%-99%) and 97% (CI 91%-99%) respectively; compared with histology they were 95% (CI 83%-99%) and 97% (CI 91%-99%), respectively. The sensitivity and specificity of GeneSearch compared with histology were 90% (CI 77%-96%) and 97% (CI 93%-99%) respectively. The positive predictive value of Metasin was 90% and negative predictive value was 98% for both histology and GeneSearch. The positive predictive value of GeneSearch was 92% and the negative predictive value was 97% compared to histology. The discordance rates of Metasin with both GeneSearch and histology were 3.89%. In comparison, the discordance rate of GeneSearch with histology was 4.5%. Metasin's robustness was independently evaluated on 193 samples previously analysed by GeneSearch from the Jules Bordet Institute, where Metasin yielded comparable results.

Collision tumor of malignant tumors of the skin: dermal squamomelanocytic tumor coexisting with basal cell carcinoma-a rare case.

Collision tumors are neoplasms coexisting in the some anatomical area. The most common combination is melanocytic nevus with basal cell carcinoma. Melanocytic nevus with basal cell carcinoma constitutes the most common cutaneous combination. Co-existence of two malignant neoplasms is extremely rare. We describe the case of a 69-year-old man who was admitted to our hospital with a nodular mass on the back. We performed an excisional biopsy that revealed collision tumor, consisting of basal cell carcinoma along with mixed melanosquamous carcinoma. Subsequently, wide excision with sentinel node biopsy was performed. The sentinel node was negative. The patient did not receive any ongologic therapy.

Primary squamous cell carcinoma of the ovary. Review of the literature.

PURPOSE: Primary squamous cell carcinoma (SCC) of the ovary is rare. Most cases arise from a cystic teratoma or less frequently from Brenner tumor or endometriosis. We reviewed 36 cases of primary ovarian SCC reported in the literature including a case diagnosed and treated in our institution. METHODS: Data was collected by using the key-words "primary squamous cell carcinoma" and "ovary" on Google Scholar and PubMed in April 2018. All reviewed cases were analyzed according to diagnosis, surgical approach, adjuvant therapy and outcome. RESULTS: To date 23 articles presenting 36 cases of primary ovarian SCC are reported. Nine patients had stage I, 8 stage II, 11 stage III and 5 stage IV disease, whereas 3 patients had in situ carcinoma. All patients underwent surgery (mainly hysterectomy with bilateral salpingo-oophorectomy). Adjuvant therapy was reported in 24 patients, 15 of which received chemotherapy, 6 radiotherapy and 3 a combination of both. Chemotherapy regimens were similar to the ones used in ovarian carcinoma (more often platinum plus paclitaxel). Follow-up period was in general short and survival varied between 9 days and 14 years, depending on the stage at diagnosis. CONCLUSIONS: Primary ovarian SCC is a rare entity with poor prognosis, compared to serous carcinoma. Treatment is usually extrapolated from classical ovarian carcinoma algorithms, including surgical management combined with adjuvant chemotherapy with or without radiotherapy. Further investigations are needed to define optimal treatment, such as chemotherapy regimens and the role of radiotherapy and lymph node dissection.

Prognostic impact of lymphangiogenesis and lymphatic invasion (CD105 expression) in small cell lung carcinoma.

BACKGROUND: Lymphangiogenesis, an essential process in the metastasis of malignant tumors, has not been thoroughly studied. The possibility of using it to define subsets of patients with different prognosis in cancer could be of vital clinical importance. MATERIALS AND METHODS: Fifty patients (5 women, 45 men; mean age, 64.47 years) with SCLC were retrospectively studied. Tumor specimens were stained for CD105, and intratumoral lymphatic microvessel density (ILMVD) and lymphatic invasion were determined. RESULTS: Twenty-five patients were diagnosed with limited and 25 with extensive SCLC. All patients received chemotherapy and 32.7% radiation therapy. A direct association between ILMVD (CD105 expression) and lymphatic invasion was observed (p<0.046). CD105 expression was significantly associated with the stage of the disease (p=0.004) and the presence of metastasis (p=0.05). CONCLUSION: CD105 expression and lymphatic invasion correlated significantly with the clinical parameters and patient outcome, therefore, constituting an important prognostic role in SCLC.

Immunohistochemical expression of cell-cycle proteins in gastric precancerous lesions.

BACKGROUND: The early indicator for the subject predisposed to gastric cancer is abnormal proliferation of gastric epithelial cells, such as atrophic gastritis (AG), intestinal metaplasia (IM), and dysplasia, which have been considered as precancerous lesions of gastric cancer. To determine whether p53 protein, cyclins D1, and D3, and p27(kip1) play a role in the carcinogenesis pathway of gastric cancer, we performed an immunohistochemical study of their expression in gastric precancerous lesions. METHODS: A total of 1 45 endoscopic gastric biopsy specimens of AG, IM, and gastric dysplasia were studied. These molecular markers were localized by immunohistochemistry. RESULTS: P53 was expressed in 15% of cases with gastric dysplasia and not in the pre-dysplastic stages of the gastric mucosa. All cases were concerning high-grade dysplasia. Cyclin D1 protein was almost undetectable in the precancerous lesions of gastric cancer. Cyclin D3 protein overexpression was seen in 10% of biopsies with IM, and 50% of biopsies with gastric dysplasia. High expression of p27(kip1) protein was demonstrated in all cases of chronic gastritis. As atrophy, IM, and dysplasia develop, expression of p27(kip1) protein is suppressed. In total, 15% of dysplastic cases showed no expression of p27(kip1) protein. CONCLUSIONS: (i) P53 mutation must be a late event during the development of gastric cancer. (ii) Cyclin D1 protein overexpression may not play a role in the progression from normal to neoplastic gastric mucosa, while overexpression of cyclin D3 is an earlier event during gastric carcinogenesis, and its role must be further evaluated. (iii) Reduced expression of p27(kip1) is a rather early event in gastric tumorigenesis, before dysplastic changes occur.

Association of liver cirrhosis related IgA nephropathy with portal hypertension.

A high incidence of IgA nephropathy has been reported in patients with liver cirrhosis, though, clinically evident nephrotic syndrome is very uncommon. Impaired hepatic clearance of circulating IgA immune complexes and subsequent deposition in renal glomeruli has been considered principally in the pathogenesis of liver cirrhosis associated IgA nephropathy. Here we report on a patient with cryptogenic liver cirrhosis and splenic vein thrombosis, who presented with nephrotic syndrome. Renal biopsy showed findings consistent with IgA nephropathy. Lower endoscopy showed features of portal hypertensive colopathy. Following initiation of propranolol and anticoagulant treatment to reduce portal pressure, a gradual decrease of proteinuria and hematuria to normal range was noted. The potential pathogenetic role of portal hypertension in the development of IgA nephropathy in cirrhotic patients is discussed.

Assessment of algorithms for mitosis detection in breast cancer histopathology images.

The proliferative activity of breast tumors, which is routinely estimated by counting of mitotic figures in hematoxylin and eosin stained histology sections, is considered to be one of the most important prognostic markers. However, mitosis counting is laborious, subjective and may suffer from low inter-observer agreement. With the wider acceptance of whole slide images in pathology labs, automatic image analysis has been proposed as a potential solution for these issues. In this paper, the results from the Assessment of Mitosis Detection Algorithms 2013 (AMIDA13) challenge are described. The challenge was based on a data set consisting of 12 training and 11 testing subjects, with more than one thousand annotated mitotic figures by multiple observers. Short descriptions and results from the evaluation of eleven methods are presented. The top performing method has an error rate that is comparable to the inter-observer agreement among pathologists.

Estrogen receptor beta (ERbeta) is expressed in brain astrocytic tumors and declines with dedifferentiation of the neoplasm.

PURPOSE: Estrogen receptor beta (ERbeta) is the second identified receptor mediating the effects of estrogen on target tissues. The role of ERbeta in cancer pathobiology is largely unknown, because specific antibodies have not been available until recently. Initial studies have shown that ERbeta expression declines in breast, ovarian, prostatic, and colon carcinomas. Tamoxifen, a synthetic anti-estrogen compound that is a mixed agonist/antagonist of estrogen receptor alpha (ERalpha) and a pure antagonist of ERbeta, has moderate beneficial effects in human astrocytic neoplasms. However, most published studies agree that glial tumors do not express ERalpha. The purpose of this study was to explore the expression of ERbeta in astrocytic neoplasms. METHODS: ERbeta expression was monitored immunohistochemically in 56 cases of astrocytomas of all grades (grade I-IV) and in adjacent non-neoplastic brain tissue. RESULTS: Moderate or strong nuclear immunopositivity was obtained in non-neoplastic astrocytes and in low-grade astrocytomas, whereas the majority of high-grade tumors were immunonegative or displayed weak immunoreactivity. The progressive decline in ERbeta expression paralleled the increase in tumor grade. CONCLUSIONS: In as much as ERbeta is possibly the only ER expressed in astrocytes, its decreased expression may play an important role in astrocytic tumor initiation and in the potential response of glial neoplasms to tamoxifen.

Expression of mismatch repair proteins in invasive and in situ carcinoma of the breast.

BACKGROUND: Genetic instability is a characteristic feature of familial and sporadic breast carcinomas. It is not clear whether defects in the mismatch repair system accompany this instability. The purpose of this study was to explore the expression of two of the proteins encoded by the DNA mismatch repair genes, namely MLH1 and MSH2, in sporadic in situ and invasive breast carcinomas of various types and grades occurring in Greek patients. MATERIALS AND METHODS: MLH1 and MSH2 expression was monitored immunohistochemically in 60 breast carcinomas (20 in situ and 40 invasive). RESULTS-CONCLUSION: Although we did not detect loss of MLH1 or MSH2 expression, we do believe that our data will contribute to a better understanding of the role of the mismatch repair (MMR) system in breast cancer.

The usefulness of p63 as a marker of breast myoepithelial cells.

The identification of an outer layer of myoepithelial cells is a valuable clue in the differential diagnosis of breast lesions. Myoepithelial cells can usually be appreciated with standard hematoxylin-eosin stains, however in pathology practice one encounters difficult cases, particularly in core biopsy specimens. There are several reported markers for the immunohistochemical detection of myoepithelial cells. Smooth muscle specific proteins, such as smooth muscle actin, smooth muscle myosin heavy chain, calponin and h-caldesmone are utilized to highlight myoepithelium. Smooth muscle actin is the most commonly used and has been established as a specific and sensitive marker. However, sometimes the staining can not be interpreted, since actin stains stromal fibroblasts and vascular smooth muscle cells as well. S100 protein and specific cytokeratins (keratins 5,7,14 and 17) also stain myoepithelial cells, but the staining is not specific and is not optimally sensitive. Maspin and CD10 are relatively new and promising markers. The nuclear protein p63 has attracted much attention in recent reports. p63-positive myoepithelial cells have been shown to surround benign epithelial lesions and form a consistent, although discontinuous, rim around epithelial cells in carcinomas in situ. No staining has been noted in infiltrative carcinomas. p63-immunostaining is nuclear and so it is easily appreciated, even in cytologic preparations. It is also highly specific since neither stromal fibroblasts nor vascular smooth muscle cells are stained. In conclusion, it appears that p63 is a sensitive and specific myoepithelial marker and may be included in immunohistochemical panels aiming at identifying myoepithelial cells in problematic breast lesions.

Expression of vascular endothelial growth factor (VEGF) and association with microvessel density in benign prostatic hyperplasia and prostate cancer.

BACKGROUND: Tumor angiogenesis is an absolute requirement for tumor growth and a prognostic factor for various malignant neoplasms. Recent reports in the literature have addressed the importance of the VEGF system in benign prostatic hyperplasia (BPH) and adenocarcinoma, however the results are controversial. The aim of the present study was to determine and compare the levels of VEGF expression and vascularity in BPH and prostate carcinoma. MATERIALS AND METHODS: We examined 60 prostate adenocarcinomas and 64 benign prostatic hyperplasias. Angiogenesis was estimated by determining microvessel counts (MVC), with the use of anti-CD31 and anti-CD34 antibodies. Expression of VEGF was also evaluated immunohistochemically. RESULTS AND CONCLUSION: Our data showed that angiogenesis was more prominent in carcinomas than in BPH. Furthermore, increased MVC was significantly associated with high-grade carcinomas. Angiogenesis was correlated with VEGF expression and it was, at least in part, mediated by the latter. Thus, prostate adenocarcinoma may represent a suitable neoplasm for antiangiogenic treatment in combination with conventional therapies.

Immunohistochemical expression of vascular endothelial growth factor (VEGF) and C-KIT in cutaneous melanocytic lesions.

Vascular endothelial growth factor (VEGF) and C-KIT are involved in tumor progression in several human neoplasms. The aim of the present study has been to investigate their immunohistochemical expression in melanocytic lesions. We examined 11 compound nevi, 12 dysplastic nevi, and 18 melanomas. Immunostaining for VEGF was observed only in melanomas; c-kit expression was detected in melanomas (higher in radial than in vertical growth phase) and in nevi (predominantly in the junctional component). Our data indicate that assessment of VEGF expression might aid in the differential diagnosis between dysplastic nevi and melanomas. Moreover, VEGF might be a candidate for targeted therapy. The loss of c-kit expression might contribute to melanoma progression.

Variations in sentinel node isolated tumour cells/micrometastasis and non-sentinel node involvement rates according to different interpretations of the TNM definitions.

Breast cancers with nodal isolated tumour cells (ITC) and micrometastases are categorised as node-negative and node-positive, respectively, in the tumour node metastasis (TNM) classification. Two recently published interpretations of the TNM definitions were applied to cases of low-volume sentinel lymph node (SLN) involvement and their corresponding non-SLNs for reclassification as micrometastasis or ITC. Of the 517 cases reviewed, 82 had ITC and 435 had micrometastasis on the basis of one classification, and the number of ITC increased to 207 with 310 micrometastases on the basis of the other. Approximately 24% of the cases were discordantly categorised. The rates of non-SLN metastases associated with SLN ITCs were 8.5% and 13.5%, respectively. Although the second interpretation of low-volume nodal stage categories has better reproducibility, it may underestimate the rate of non-SLN involvement. The TNM definitions of low-volume nodal metastases need to be better formulated and supplemented with visual information in the form of multiple sample images.

Estrogen receptor beta (ERbeta) protein expression correlates with BAG-1 and prognosis in brain glial tumours.

Estrogen receptor beta (ERbeta) is an important mediator of estrogen function in a variety of tissues. Its expression declines in breast, ovarian, prostatic and colon carcinomas as well as in astrocytic tumours. BAG-1 is a multifunctional protein with an important role in neoplasia and is possibly regulated by estrogen receptors. One of the direct targets of BAG-1 is HSP70. The purpose of this study was to analyse the expression pattern of these proteins in two distinct types of glial neoplasms, to investigate their possible correlation and probe their impact on prognosis. ERbeta, BAG-1 and HSP70 protein expression was monitored immunohistochemically in 66 cases of astrocytomas and 20 oligodendrogliomas. In astrocytic tumours low ERbeta expression correlated significantly with high grade (P < 0.001), higher expression of cytoplasmic BAG-1 (P < 0.001) and worse survival (log rank P = 0.02). Multivariate analysis revealed that ERbeta expression had a prognostic value for overall survival in these patients (Cox P = 0.03), which was not dependent on grade. There was also statistically significant association of BAG-1 nuclear expression with HSP70 cytoplasmic expression. Our results strengthen the hypothesis that ERbeta, BAG-1 and HSP70 play an important role in the pathogenesis and progression of glial neoplasms. Moreover, ERbeta expression in astrocytic tumors might be an important prognostic factor for survival.