Carcinogenesis in heterotopic respiratory epithelium in canine subcutaneous bronchial autografts.

Short bronchial segments obtained by pneumonectomy were implanted, 9-12 per dog, in the subcutaneous tissues of the back of seven dogs. These subcutaneous bronchial autografts (SBA) became vascularized, and they contained viable, histologically normal respiratory epithelium 4 wk after implantation. From 1-3 mo after implantation, 10% methylcholanthrene in steroid suspension medium was instilled into 21 SBAs, and 10% methylcholanthrene in a silicone polymer sustained release implant was placed in 22 SBAs. Ten SBAs were left carcinogen free as controls. SBA contents were examined cytologically at 3-mo intervals. Biopsies were done from 2-32 mo after carcinogen implantation. Progressive preneoplastic changes were noted in all five dogs which received carcinogen. Curetments of five SBAs after 14-mo exposure to methylcholanthrene yielded 10(4)-10(5) cells from each SBA; 40-70% of the cells obtained were at the same stage of atypical squamous metaplasia. At least one SBA in each dog yielded cancer cells by cytological criteria by 19-29 mo after instillation. Biopsy of a grossly abnormal SBA revealed well-differentiated epidermoid carcinoma at 32 mo. The multiple SBA method provides isolated portions of canine respiratory epithelium for the study of chemical carcinogenesis and for the production of sizable preneoplastic cell populations.

Pseudosarcoid granulomas in Hodgkin's disease.

The sarcoid-like granulomas encountered in lymph nodes, spleens, and hepatic biopsy specimens removed from patients being "staged" in the course of Hodgkin's disease and, in lower incidence, in non-Hodgkin's lymphomas may, at least in part, be due to reactions to the oily radiographic contrast medium used in lymphangiography. They are seen more often following lymphangiography than when no contrast medium is used. The granulomas in patients who have not undergone lymphangiographic procedures are attributed to the many agents inciting pseudosarcoid lesions. It is speculated that the granulomas seen in Hodgkin's disease after lymphangiography may be the result of a combination of lipogranulomatous reaction and the effects of an immune adjuvant.

Intraoperative cytodiagnosis of lung tumors by needle aspiration.

Rapid-stain cytologic evaluation of needle aspirates are a recent adjunct to diagnosis and staging of lung neoplasms. The benefits of this approach include ease of sampling from deep and remote lesions and the fact that the results are generally available within 10 minutes. In the past 2 years, we did 187 needle aspirations for cytopathological evaluation in 70 patients at 51 thoracotomies and 21 mediastinoscopies. The cytologic findings from aspirates of lymph nodes, mediastinal masses, and intrapulmonary lesions were compared with diagnosis obtained by histopathological techniques. Quick-stain cytopathological evaluation discriminated cancer among all 55 lung masses from which aspirates were taken; specific diagnosis as to the type of neoplasm, lymphoproliferative disorder, or infection was achieved in 60 of 70 patients (85%). We conclude that intraoperative needle aspirations for cytologic evaluation facilitates the practice of modern general thoracic surgery.

Endobronchial carcinogenesis in dogs.

A canine model of squamous cell lung cancer has been developed through studies with 110 dogs exposed by 11 focal endobronchial regimens to chemical carcinogens: benzo(a)pyrene, nitrosomethylurea, methylcholanthrene, and dimethylbenzanthracene. A combination of nitrosomethylurea and benzo(a)pyrene caused the first invasive cancer after 5.5 years. Toxic side-effects resulted from either nitrosomethylurea or high-dose dimethylbenzanthracene given by bronchial submucosal injection and from adjuvant immunosuppression with azathioprine and corticosteroids. Four regimens in 58 dogs caused 31 cancers, including five T1-2 N0 M0 cancers, 17 metastasizing carcinomas, and nine carcinomas of lesser stages. The following regimens caused cancers: sequential benzo(a)pyrene, nitrosomethylurea, and yttrium 91; benzo(a)pyrene and topical nitrosomethylurea; low-dose dimethylbenzanthracene; high-dose methylcholanthrene. The most suitable regimen to date has been 30 mg of methylcholanthrene given by submucosal injection every 2 to 3 weeks; this produced cancers at preselected sites within 2 years of first exposure in eight of 10 dogs. The neoplastic continuum has followed a predictable, reproducible sequence that regularly began with epithelial hyperplasia. Squamous metaplasia occurred in 6 to 18 weeks; it was followed by progressive squamous atypia. The interval until invasive cancer developed varied with the regimen employed; it was about 20 months with methylcholanthrene. Serial cytologic specimens, studied by image analysis, revealed progressive increase in mean total cellular deoxyribonucleic acid content from diploid in normal cells to greater than tetraploid in cancer cells (p less than 0.01). We have recently been successful with serial passage of four canine lung cancers from four to twelve transplant generations in nude mice. There is now a predictable large animal model of squamous cell lung carcinoma at preselected site(s) that closely resembles human lung cancer. The preneoplastic period is short enough to be fiscally defensible, but long enough to permit study of the biologic changes during endobronchial carcinogenesis.

Non-small cell lung cancer in autogenous subcutaneous bronchial grafts in dogs.

The progression of preneoplasia into lung cancer can be serially studied in a new canine model that is simpler and more cost effective than previously reported methods of orthotopic endobronchial carcinogenesis. Short segments of bronchus, obtained by pneumonectomy, were placed on the back of 10 dogs in the form of subcutaneous bronchial autografts. These autografts (12 to 14 per dog) became vascularized and lined with normal respiratory epithelium. Four to 12 weeks after autograft implantation, 10% methylcholanthrene in crystalline form was put into 57 autografts and 10% methylcholanthrene in a silicone polymer sustained-release implant was placed into 54 autografts. Ten autografts without carcinogen (one per dog) served as controls. Serial samplings of each autograft during 9 to 97 weeks of carcinogen exposure showed the neoplastic progression from normal bronchial cells to invasive cancer through stages such as atypical squamous metaplasia and carcinoma in situ. To date, cancers have been histologically proved in 60 autografts; 36 were induced by implants and 24 by the crystalline form. Thirty-nine cancers were epidermoid, and the remainder were either adenocarcinomas (n = 3) or poorly differentiated spindle cell cancers (n = 18). The sustained-release implant method resulted in larger autografts with a greater tendency to progress to cancer than the crystalline carcinogens (p greater than 0.025). Therefore, the sustained-release implant is now considered the preferred method. Measurement of nuclear deoxyribonucleic acid by image analysis of nine histologic cancers demonstrated hyperploidy. Deoxyribonucleic acid from the L1 repeated sequence family was demonstrably hypomethylated in spindle cell tumors. Curettement of individual autografts yielded sheets of respiratory epithelium from which 43.5 to 409.5 micrograms of deoxyribonucleic acid was isolated. For the first time, deoxyribonucleic acid from each stage of the neoplastic progression in non-small cell lung cancer is available in adequate quantities for serial biochemical and therapeutic analysis.

Surgical management of lymphomas involving the chest.

The efficacy of surgical judgments in the management of thoracic lymphoma was studied through review of 34 patients with primary mediastinal lymphomas, 30 patients who needed one or more thoracic operations after treatment of extrathoracic lymphomas, and 5 patients with primary lymphocytic infiltrates (PLI) of the lung. In all patients with primary lymphocytic infiltrates of the lung, thoracotomies were required in order to establish the correct diagnosis. Patients with primary mediastinal lymphoma required 74 surgical procedures (2.2 per patient) to establish the correct diagnosis. In retrospect, 40 operations were not beneficial. The procedures that provided diagnostic samples were 15 anterior mediastinotomies, 8 full thoracotomies, 3 median sternotomies, and 8 lesser procedures such as mediastinoscopy. Patients who needed thoracic procedures after treatment of extrathoracic lymphomas had 41 thoracic operations (1.37 per patient). Five operations were needed to manage complications of thoracic lymphoma or its therapy. To evaluate new radiographic findings, there were 35 operations (1.3 per patient) at a mean interval of 5.0 years following initial treatment; the findings were recurrent lymphoma in 62% and new lesions in 38% of patients. Among new lesions, there were 2 bronchogenic cancers; 9 enlarging mediastinal-pleural masses were not caused by lymphoma. The accurate diagnosis of thoracic lymphoma or new thoracic lesions in patients with lymphomas usually requires enough tissue for immunophenotyping. Providing adequate tissue samples and treating new lesions that are not lymphomas often require major thoracomediastinotomies for immunophenotyping.

A family of epidermoid lung cancer models.

A method of sustained release implantation has been developed whereby Silastic cylinders, impregnated with benzo[alpha]pyrene (BP) or methylcholanthrene (MCA) each at 2% (low dose) and 10% (high dose) concentrations, were inserted into the bronchus intermedius of hamsters. High-dose BP and MCA, and low-dose MCA had first-order exponential release rates: the half-time of release was 40 days for high-dose BP, 30 days for high-dose MCA, and 165 days for low-dose MCA. Release rate of low-dose BP was a second-order function: half-time of release was 40 days. Atypical squamous metaplasia was noted by 4 weeks in more than 65% of hamsters after insertion of each high-dose carcinogen but in less than 30% with the low-dose carcinogens. Carcinoma in situ was noted approximately 8 weeks after high-dose BP and 19 weeks after low-dose BP. At about 15 to 17 weeks after a high-dose carcinogen, 64% of animals had invasive epidermoid cancer, whereas after a low-dose carcinogen, only 21% did. After 25 weeks of exposure to a high-dose carcinogen, more than 85% of hamsters had invasive epidermoid cancer; up to 52 weeks were required for invasive epidermoid cancer to develop in 30% after a low-dose carcinogen. Measured by image analysis, nuclear deoxyribonucleic acid content of cells with severe atypical squamous metaplasia was greater than tetraploid (mean +/- standard deviation [SD], 3.77 +/- 1.4), whereas cells with invasive epidermoid cancer were suprahexaploid (mean +/- SD, 6.48 +/- 3.6). These differences are significant (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

A clinically relevant canine lung cancer model.

Research on early human lung cancer is difficult; we have sought a canine correlate. Regimens included endobronchial submucosal injections and topical focal applications of benzo[a]pyrene, nitrosomethylurea, dimethylbenzanthracene, and methylcholanthrene, singly or in combinations. Sustained-release discs were placed into lung parenchyma or sutured into major bronchi. Tracheal segments were isolated as cervical pedicle grafts. Gross and histological evolution was reproducible. Columnar and basal hyperplasia and squamous metaplasia were early changes. Atypia occurred within 6 weeks and was found in all dogs within 16 to 18 weeks. Invasive cancers occurred within 8 to 65 months. No tracheal graft developed cancer. Of 15 dogs with parenchymal sustained-release implants, 1 to date has developed cancer in 8 months. Four endobronchial regimens have produced 16 cancers in 56 lungs at risk for 18 to 65 months. No cancers developed in 23 lungs at risk from eight other regimens. Of 10 dogs at risk for unilateral endobronchial cancer, 5 have had cancer. Of 23 dogs with both lungs at risk, 9 developed cancer. We have shown focal carcinogenesis with well-defined pathogenesis and an extended preneoplastic period at predictable sites in a lung cancer model.

The significance of cutaneous metastasis from visceral tumors diagnosed by fine-needle aspiration biopsy.

Cutaneous metastases from various visceral organs were studied in 43 patients. The morphologic diagnosis in each case was established by fine-needle aspiration cytodiagnosis. There were 28 males and 15 females, with median ages of 62 and 61 yr, respectively. The most common primary tumor in men was carcinoma of the lung (35%), followed by malignant melanoma (21%) and carcinoma of the oropharynx (14%). In women, the most frequent primary cancers were carcinoma of the colon (59%) and lung (20%). Metastatic cutaneous lesions were more frequent in the back (23%), upper extremities (21%), and scalp (12%). Median survival from onset of cutaneous metastasis was shortest in primary lung cancer at 3 mo followed by colon at 5 mo and oropharynx at 5.5 mo. Our study confirms that cutaneous metastasis represents a terminal manifestation of the disease due to either hematogenous or lymphatic spread. This study also reiterates the clinical usefulness of needle aspiration biopsy as an alternative diagnostic tool in establishing the presence of cutaneous metastasis.

Thymoma diagnosed by transthoracic fine needle aspiration.

The cytologic diagnosis of a thymoma by transthoracic fine needle aspiration is described. A 64-year-old female was found toi have a left hilar mass following an episode of hemoptysis. Fine needle aspiration of the lesion demonstrated an intimate admixture of two cell types: epithelial and lymphoid. On the basis of the biphasic cytomorphology, the diagnosis of thymoma was suggested; this was confirmed by light and electron microscopic examination of tissue obtained at thoracotomy. Because of the paucity of cytologic descriptions of thymoma in the literature, pertinent morphologic features are emphasized, differential diagnostic possibilities are discussed, and the value of ultrastructural studies is confirmed.

Rapid staining techniques employed in fine needle aspirations of the lung.

Fifty-two consecutive patients ranging in age from 22 to 90 years underwent percutaneous transthoracic fine needle aspiration biopsy under fluoroscopic guidance. A quick staining and rapid interpretation technique was used on samples from the 37 most recent cases. Rapid staining was accomplished within five minutes, and interpretation was available less than 15 minutes after obtaining the specimen. Successful diagnosis was obtained in 36 of 37 patients (97%). Standard methods utilizing a single aspiration sample yielded a successful diagnosis in 13 of 15 patients (86%). The improved rate of successful diagnosis following the rapid stain technique reflects the advantage of being able to determine the adequacy of specimens before releasing patients from the procedure room.

Granulocytic sarcoma of the cervix as a primary manifestation: case without overt leukemic features for 26 months.

A case of granulocytic sarcoma involving the uterine cervix as primary manifestation without evidence of leukemia is presented. It was followed by neurological symptoms 19 months later and a right breast mass 26 months after the initial cervical lesion, but still with no evidence of leukemia. Two years and four months after onset, soft tissue and skin nodules developed and rare blastic cells appeared on peripheral blood smear. The patient terminally developed acute granulocytic leukemia with a rapidly downhill course. The differential diagnosis of granulocytic sarcoma and histiocytic lymphoma is discussed. The literature is reviewed with emphasis on the clinical and pathological problems that arise when the tumor presents in an unusual location without peripheral blood manifestation of leukemia.

Glassy cell carcinoma of the cervix. Cytologic and clinicopathologic analysis.

A clinicopathologic analysis of 15 patients with glassy cell carcinoma confirmed that this is a rare disease, having an incidence of 1.2%. It is a rapidly progressive and biologically aggressive disease with early extrapelvic metastasis. The five-year survival and the median survival in our series were 28% and 14 months, respectively. The majority of patients (87%) were understaged, which may have played a role in the poor prognosis. Four of 12 patients (33%) were initially diagnosed as having a benign disease (false-negatives). Defining of cytologic characteristics and differential features of this tumor may facilitate an early and more accurate diagnosis to improve prognosis.

Quantitative DNA determinations by image analysis. I. Application to human pulmonary cytology.

A description is made of the application of image analysis to quantitative deoxyribonucleic acid (DNA) determinations in a variety of cells. Optical density of the video signal from Feulgen-stained material was integrated across the area of the nucleus and values obtained related to values derived from known diploid cells. Analysis was performed on three classes of material: (1) biological material with known haploid, diploid and tetraploid nuclear DNA (standards), (2) metaplasias of the bronchial epithelium and (3) bronchogenic carcinomas. Results obtained with image analysis corresponded with expected data for the biologic standards and with microspectrophotometric data obtained for metaplasia and epidermoid carcinoma of the bronchial system. Application of this and other quantitative methods to cancer screening and biology is discussed.

Hepatic metastasis in granulosa cell tumor of the ovary.

Hepatic metastases occur rarely in epithelial ovarian carcinoma and also appear to be unusual in malignant stromal tumors of the ovary (granulosa cell tumors). Recently two patients with extensive hepatic metastasis from this primary tumor, were treated. Review of the experience at the City of Hope National Medical Center provided three additional patients with a confirmed diagnosis of granulosa cell tumor of the ovary, one of whom is alive and disease-free. A review of clinical and pathologic data revealed that both of the other patients died of their disease and had hepatic metastases proven at autopsy. Hemorrhagic events complicating the clinical course of these patients were frequent. It is believed that the frequency of hepatic metastasis in granulosa cell tumor of the ovary may be higher than has been appreciated in the past, and that the cystic-hemorrhagic nature of these lesions contributes to the morbidity and mortality associated with granulosa cell tumors of the ovary.

Quantitative DNA determination by image analysis. II. Application to human and canine pulmonary cytology.

Comparative DNA measurements in human and canine preneoplastic and neoplastic tracheobronchial cells were made with the application of computerized image analysis. Canine studies demonstrated that the sequence of cellular events that precede epidermoid lung cancer simulates precisely the progression observed in humans. DNA studies concomitantly confirmed that there is a stepwise increase in DNA content with advancing nuclear atypia in metaplastic respiratory cells in both species. All carcinomas, regardless of histologic type, were significantly hyperploid to aneuploid (4c to 6c). Small-cell carcinoma exhibited a narrow modal distribution in the 4c region. The uniformity of the cytologic and quantitative DNA changes among these disparate species tends to confirm that humans and canines share biologic characteristics in bronchogenic carcinogenesis. The quantitative DNA measurements provide an objective cellular marker and may be used clinically for diagnostic purposes.

Bronchopulmonary Kulchitzky cell carcinomas. A new classification scheme for typical and atypical carcinoids.

Typical and atypical carcinoids constitute less than 5% of lung tumors. They and small cell undifferentiated lung cancers (SCLC) belong to the same family of apudomas arising from bronchopulmonary Kulchitzky cells. To reflect the overlap among these cancers, the authors suggest calling them Kulchitzky cell carcinomas (KCC); to indicate their spectrum of aggressiveness, the authors suggest calling typical carcinoids KCC-I, atypical carcinoids KCC-II, and small cell cancers KCC-III. One hundred fifty-six KCCs were reviewed: 115 were KCC-I and 41 were KCC-II. The ratio of women to men equals 2:1. At time of initial diagnosis, all patients with KCC-I, except one patient, were in Stage I. Among patients with KCC-II, 16 (39%) were in Stages II or III at time of presentation. The incidence of carcinoid syndrome was 1.9%. Treatment was lobectomy in 112 (72%) of patients, the remainder having lesser resections or pneumonectomy in approximately equal distribution. Our data cannot support the use of radical resection in the treatment of KCC because none of the patients died of local recurrence. The mean diameters of KCC-I and -II tumors were 1.5 and 2.8 cm, respectively. Increased mitotic activity and tumor necrosis were reliable criteria for diagnosing KCC-II. Electron microscopic examination did not help in differentiating KCC-I and KCC-II. Thorough sampling of the entire tumor was found to be mandatory for precise diagnosis and for differentiation from KCC-III (SCLC). Measurement of nuclear DNA was done using integrated optical density (IOD) by image analysis. The IODs of KCC-I, -II and -III were 1.36, 1.55 and 1.94, respectively. These significant differences (P less than 0.001) correlated with the aggressiveness of the cancers. Of patients with KCC-I, 1.7% succumbed to KCC; this included one patient reported to have died of KCC-III (SCLC). Of 41 patients with KCC-II, 11 (27%) died of KCC; this includes at least 3 deaths from KCC-III.

Quantitative DNA. Comparative studies of a cellular marker for bronchogenic carcinoma.

During the course of induction of bronchogenic carcinoma in a colony of standard-bred beagles, serial cytologic and biopsy material was obtained under direct bronchoscopy. Cytological changes followed the sequence from metaplasia to carcinoma, closely simulating those features observed in humans, but with subtle differences characterized as species variations. Quantitative DNA done by image analysis correlated directly with the severity of cytologic atypia and also corresponded well with data obtained from humans. Equivalent studies in human bronchogenic carcinoma have shown similar results and strongly suggest that graded hyperploidy accurately reflects atypia in the lung and qualifies as an interspecies tumor marker.