Double contrast-enhanced ultrasound for the preoperative gross classification of gastric cancer: a comparison with multidetector computed tomography.

PURPOSE: To compare the diagnostic performance of double contrast-enhanced ultrasound (DCEUS) and multi-detector row computed tomography (MDCT) in the gross classification of gastric cancer (GC) preoperatively. METHODS: 54 patients with histology proved GC were included in this retrospective study. The sensitivity and specificity of DCEUS and MDCT for the gross classification of GC was calculated and compared. The area under the curve (AUC) from a receiver operating characteristic curve analysis was used to evaluate the difference of the diagnostic performance between these two methods. RESULTS: There were no significant differences between DCEUS and MDCT in terms of AUC for early gastric cancer (EGC), Borrmann I, II, III and Borrmann (III + IV) (P = 0.248, 0.317, 0.717, 0.464 and 0.594, respectively). The accuracy of DCEUS in diagnosing EGC, Borrmann I, II and Borrmann (III + IV) was higher than that of MDCT (96% vs 92%; 96% vs 94%; 87% vs 80%; 83% vs 73%), while in determining Borrmann III and IV, that of DCEUS was lower than that of MDCT (72% vs 74%; 89% vs 96%). CONCLUSION: Considering the revolution in clinical decision, prognosis evaluation, safety and non-invasion aspects, DCEUS can be used as the main alternative method for Borrmann classification of GC preoperatively.

Preoperative Tumor Staging of Gastric Cancer: Comparison of Double Contrast-Enhanced Ultrasound and Multidetector Computed Tomography.

OBJECTIVES: The purpose of this study was to compare the sensitivity and specificity of double contrast-enhanced ultrasound (CEUS) and multidetector computed tomography (MDCT) in the preoperative tumor staging of gastric cancer (GC) to stratify patients for suitable treatment. METHODS: Fifty-four patients with GC proved by histologic findings were included. The sensitivity and specificity of double CEUS and MDCT for tumor staging were calculated and compared. The differences between these methods were evaluated by using the area under the curve (AUC) from a receiver operating characteristic curve analysis. RESULTS: There were no significant differences in AUC values for T1 and T2 stages between double CEUS and MDCT (P = .190 and .256, respectively). However, the sensitivity of double CEUS in the detection of the T1 stage was higher than that of MDCT (88% versus 75%). The AUC values of MDCT for T3 and T4 stages were 0.833 and 0.905, which were both significantly higher than those of double CEUS (0.759 and 0.696; P < .05). The sensitivities of double CEUS and MDCT for the T3 stage were both 89%, but the accuracy and specificity of double CEUS were lower than those of MDCT (76% versus 83% and 63% versus 78%). The specificities of double CEUS and MDCT for the T4 stage were both 98%, but the accuracy and sensitivity of double CEUS were lower than those of MDCT (85% versus 94% and 42% versus 83%). CONCLUSIONS: Multidetector CT is superior to double CEUS for T3 and T4 GC, and double CEUS may be regarded as an important complementary method to MDCT.

[Adult-onset generalized autoimmune enteropathy involving small intestine and colon: report of a case and review of literature].

OBJECTIVE: To investigate the clinicopathologic features of adult-onset autoimmune enteropathy (AIE). METHODS: A case of adult-onset AIE was described along with a literature review. RESULTS: A 41-year-old male patient was admitted for intractable diarrhea for more than three months despite of any dietary restriction or anti-inflammatory therapy. Fat globule was observed by stool examination and Sudan III staining of the stool was positive. Enteroclysis showed weak movement and few plica of small intestine, while colonoscopy appeared normal. Small bowel biopsies revealed villus atrophy and increased crypt apoptotic bodies and lymphocytic infiltration in deep crypt. Although without significant surface intro-epithelial lymphocytosis, there were a large number of monocytes, lymphocytes, plasmacytes and neutrophilic granulocytes infiltrating in the lamina propria. Morphologically, the colonic mucous was similar to the small intestine although cryptitis and crypt abscess were significant in the former. Serum IgG anti-goblet cell antibody was demonstrated by indirect immunofluorescence. Other causes of diarrhea were excluded on the base of medical history, histopathology and other accessory examinations before the diagnosis of AIE was made. The patient had a complete remission after steroid treatment without recurrence for eight months during the follow-up even after steroid withdrawal for five months. CONCLUSIONS: AIE is exceedingly rare and timely diagnosis is important for successful therapy. Histological differential diagnoses should include ulcerative colitis, celiac disease, lymphocytic colitis, etc. The final diagnosis should be based on histological examination combined with the patient history, clinical manifestation, endoscopy finding and serological testing.

[Value of detection of DNA mismatch repair proteins deficiency by immunohistochemistry in predicting tumor microsatellite status].

OBJECTIVE: To evaluate the sensitivity and specificity of immunohistochemical (IHC) staining of DNA mismatch repair (MMR) protein for the screening of microsatellite instability (MSI) colorectal cancer (CRC). METHODS: A total of 255 CRC cases were studied, including 140 cases of routine paraffin-embedded tissue samples and 115 cases constructed on tissue microarray. Expressions of 4 MMR proteins including MHL1, MSH2, MSH6 and PMS2 were investigated by IHC. Negative protein expression was defined as complete absence of nuclear staining within tumor cells in the presence of positively labeled internal non-neoplastic cells. Focal staining was defined as the presence of staining in < 5% of the tumor cells. CRCs showing negative staining for any MMR proteins were interpreted as MMR deficient tumors. PCR-genescan MSI analysis was performed in each case by a five marker panel including Bat26, Bat25, NR-21, NR-24 and MONO-27. RESULTS: Among the 140 CRCs with routine formalin-fixed paraffin embedded tissue sections, concordance rate between IHC and PCR-genescan was 98.6% (138/140), the sensitivity and specificity of IHC in detecting MSI tumors were 94.9% (37/39) and 100.0% (101/101), respectively. The 2 disconcordant cases showed focal staining in at least one of the MMR proteins but were confirmed to be MSI-H CRCs by PCR-genescan assay. On tissue microarray, 91.3% (105/115) of the cases had informative results. The concordance rate between IHC and PCR-genescan was 100.0% (105/105). Both the specificity and sensitivity of IHC in detecting MSI tumors on available tissue microarray samples were 100.0%. Ten cases were inclusive due to the presence of negative stains of MMR proteins in both the tumor and internal control cells. CONCLUSIONS: Detection of 4 MMR proteins expression by IHC is reliable for identifying MSI CRCs and is recommended for routine practice. Tumors with focal MMR protein staining are highly suspected for the presence of MSI-H and PCR-genescan based MSI analysis should be performed to confirm.

Epigenetic modification facilitates proline synthase PYCR1 aberrant expression in gastric cancer.

BACKGROUND & AIMS: Pyrroline-5-carboxylate reductase 1 (PYCR1) upregulation contributes to the progression of gastric cancer (GC) and indicates poor survival. However, PYCR1 expression profile in GC subtypes and the mechanism behind its upregulation are not well-studied. METHODS: PYCR1 expression profiles in GC subtypes and different stages of gastric carcinogenesis were assessed in different GC cohorts. Genetic alterations and epigenetic modulation in PYCR1 regulation were further investigated using bioinformatics analysis and in vitro experiments. RESULTS: PYCR1 expression was significantly higher in intestinal-type GC and associated molecular subtypes in TCGA and ACRG GC cohorts. During the cascade of intestinal-type GC, PYCR1 was continuously increased from normal gastric tissues through to atrophic gastritis, to intraepithelial neoplasia, and to GC. Copy number alterations in PYCR1 were associated with PYCR1 transcript expression. One CpG island was observed in PYCR1 promoter region, and the hypomethylation occurred at this region could contribute to PYCR1 transcriptional activation in GC. Besides, H3K27ac combination was found in PYCR1 promoter, and acetyltransferase p300 induced H3K27ac could promote PYCR1 expression in GC. CONCLUSIONS: PYCR1 expression varies across GC subtypes, with intestinal-type GC and associated molecular subtypes having the highest expression. Hypomethylation at CpG sites and p300-induced H3K27ac modification within PYCR1 promoter could contribute to maintaining PYCR1 overexpression in GC. These results provide us with a new insight into epigenetic modulation in mitochondrial proline metabolism.

PathNarratives: Data annotation for pathological human-AI collaborative diagnosis.

Pathology is the gold standard of clinical diagnosis. Artificial intelligence (AI) in pathology becomes a new trend, but it is still not widely used due to the lack of necessary explanations for pathologists to understand the rationale. Clinic-compliant explanations besides the diagnostic decision of pathological images are essential for AI model training to provide diagnostic suggestions assisting pathologists practice. In this study, we propose a new annotation form, PathNarratives, that includes a hierarchical decision-to-reason data structure, a narrative annotation process, and a multimodal interactive annotation tool. Following PathNarratives, we recruited 8 pathologist annotators to build a colorectal pathological dataset, CR-PathNarratives, containing 174 whole-slide images (WSIs). We further experiment on the dataset with classification and captioning tasks to explore the clinical scenarios of human-AI-collaborative pathological diagnosis. The classification tasks show that fine-grain prediction enhances the overall classification accuracy from 79.56 to 85.26%. In Human-AI collaboration experience, the trust and confidence scores from 8 pathologists raised from 3.88 to 4.63 with providing more details. Results show that the classification and captioning tasks achieve better results with reason labels, provide explainable clues for doctors to understand and make the final decision and thus can support a better experience of human-AI collaboration in pathological diagnosis. In the future, we plan to optimize the tools for the annotation process, and expand the datasets with more WSIs and covering more pathological domains.

Neutrophils may be a vehicle for viral replication and dissemination in human H5N1 avian influenza.

The mechanism of systemic spread of H5N1 virus in patients with avian influenza is unknown. Here, H5N1 nucleoprotein and hemagglutinin were identified by immunohistochemistry in the nucleus and cytoplasm of neutrophils in the placental blood of a pregnant woman. Viral RNA was detected in neutrophils by in situ hybridization and enhanced real-time polymerase chain reaction. Therefore, neutrophils may serve as a vehicle for viral replication and transportation in avian influenza.

H5N1 infection of the respiratory tract and beyond: a molecular pathology study.

BACKGROUND: Human infection with avian influenza H5N1 is an emerging infectious disease characterised by respiratory symptoms and a high fatality rate. Previous studies have shown that the human infection with avian influenza H5N1 could also target organs apart from the lungs. METHODS: We studied post-mortem tissues of two adults (one man and one pregnant woman) infected with H5N1 influenza virus, and a fetus carried by the woman. In-situ hybridisation (with sense and antisense probes to haemagglutinin and nucleoprotein) and immunohistochemistry (with monoclonal antibodies to haemagglutinin and nucleoprotein) were done on selected tissues. Reverse-transcriptase (RT) PCR, real-time RT-PCR, strand-specific RT-PCR, and nucleic acid sequence-based amplification (NASBA) detection assays were also undertaken to detect viral RNA in organ tissue samples. FINDINGS: We detected viral genomic sequences and antigens in type II epithelial cells of the lungs, ciliated and non-ciliated epithelial cells of the trachea, T cells of the lymph node, neurons of the brain, and Hofbauer cells and cytotrophoblasts of the placenta. Viral genomic sequences (but no viral antigens) were detected in the intestinal mucosa. In the fetus, we found viral sequences and antigens in the lungs, circulating mononuclear cells, and macrophages of the liver. The presence of viral sequences in the organs and the fetus was also confirmed by RT-PCR, strand-specific RT-PCR, real-time RT-PCR, and NASBA. INTERPRETATION: In addition to the lungs, H5N1 influenza virus infects the trachea and disseminates to other organs including the brain. The virus could also be transmitted from mother to fetus across the placenta.

[Clinical and molecular characteristics of a child with familial adenomatous polyposis].

OBJECTIVE: To explore the clinical features and molecular mutation of early-onset familial adenomatous polyposis(FAP) in childhood. METHOD: The clinical features, endoscopic findings, pathology and therapeutic effect of sulindac during 11 years follow-up in a child with FAP were retrospectively reviewed . Adenomatous polyposis coli (APC) gene mutation analysis was performed by PCR and first generation sequencing. RESULT: This 6-year-old girl was admitted for intermittent bloody stool during the last one and a half years. Colonoscopy showed hundreds of polyps in the rectum and colon. Pathological examination revealed tubular adenomas with high grade dysplasia. During the follow-up period of 11 years, the child presented intermittent mucous bloody stool. Endoscopy showed the number of polyps in colon and rectum increased to thousands, and found multiple polyps in gastric fundus and body.She was treated with sulindac at the age of 13. Then the number of polyps and the grade of pathology showed a slight improvement and no carcinoma was seen on biopsy. She has not accepted surgery until now. Gene sequencing of this child revealed 5 bp deletion at codon 1,309 of exon 15 (c.3927_3931delAAAGA) of tumor suppressor gene, whereas none of her parents had the same mutation. And no polyps were found on her parents colonoscopy. CONCLUSION: This child with FAP had an early onset of this disease, and clinical conditions were exacerbated with age. Sulindac was partially effective in controlling size and number of polyps. The site of mutation in this case was consistent with classic FAP, and without family history, the mutation may be a sporadic one.

KRAS and BRAF gene mutations and DNA mismatch repair status in Chinese colorectal carcinoma patients.

AIM: To investigate gene mutations and DNA mismatch repair (MMR) protein abnormality in Chinese colorectal carcinoma (CRC) patients and their correlations with clinicopathologic features. METHODS: Clinical and pathological information for 535 patients including 538 tumors was reviewed and recorded. Mutation analyses for exon 2 of KRAS gene and exon 15 of BRAF gene were performed by Sanger sequencing except that in 9 tumors amplification refractory mutation system PCR was used. Expression of MMR proteins including MHL1, MSH2, MSH6 and PMS2 was evaluated by immunohistochemistry. Correlations of KRAS and BRAF mutation status and the expression status of MMR proteins with age, gender, cancer stage, location, and histology were analyzed. Correlations between KRAS or BRAF mutations and MMR protein expression were also explored. RESULTS: The overall frequencies of KRAS and BRAF mutations were 37.9% and 4.4%, respectively. KRAS mutations were more common in patients ≥ 50 years old (39.8% vs 22% in patients < 50 years old, P < 0.05). The frequencies of BRAF mutants were higher in tumors from females (6.6% vs males 2.8%, P < 0.05), located in the right colon (9.6% vs 2.1% in the left colon, 1.8% in the rectum, P < 0.01), with mucinous differentiation (9.8% vs 2.8% without mucinous differentiation, P < 0.01), or being poorly differentiated (9.5% vs 3.4% well/moderately differentiated, P < 0.05). MMR deficiency was strongly associated with proximal location (20.5% in the right colon vs 9.2% in the left colon and 5.1% in the rectum, P < 0.001), early cancer stage (15.0% in stages I-II vs 7.7% in stages III-IV, P < 0.05), and mucinous differentiation (20.2% vs 9.2% without mucin, P < 0.01). A higher frequency of MLH1/PMS2 loss was found in females (9.2% vs 4.4% in males, P < 0.05), and MSH2/MSH6 loss tended to be seen in younger (<50 years old) patients (12.0% vs 4.0% ≥ 50 years old, P < 0.05). MMR deficient tumors were less likely to have KRAS mutations (18.8% vs 41.7% in MMR proficient tumors, P < 0.05) and tumors with abnormal MLH1/PMS2 tended to harbor BRAF mutations (15.4% vs 4.2% in MMR proficient tumors, P < 0.05). CONCLUSION: The frequency of sporadic CRCs having BRAF mutation, MLH1 deficiency and MSI in Chinese population may be lower than that in the Western population.

A modified GEWF solution is cost-saving and effective for lymph node retrieval in resected colorectal carcinoma specimens.

Lymph node (LN) retrieval is important for proper staging of colorectal carcinoma. Although various assistant techniques were recommended to facilitate LN identification, most of them were unavoidably time-consuming, resource intensive and costly. We prepared a modified GEWF solution (RE-GEWF) by use of recycled alcohol and a familiar dye, eosin and investigated its efficacy on 55 colorectal carcinoma specimens. Of the 55 studied cases, 33 of them with <12 LNs (Group A) and 22 with ≥12 LNs were detected (Group B) before RE-GEWF treatment. All were subsequently treated with RE-GEWF for 14-16h and were inspected again for LNs. The number of LNs revealed before and after RE-GEWF treatment was 539 and 476 respectively. The mean number of LNs per cases increased from 9.80±6.27 to 18.43±8.77. Twelve accessory LN metastases were found in 9 cases. Upgrade of pN stage was only present in 7 of the Group A cases. The results show that RE-GEWF is as effective as other reported LN revealing solutions. Use of RE-GEWF not only can assure the quality of LN detection, but also minimize the cost and reduce the release of waste.

Immunoglobulin G is present in a wide variety of soft tissue tumors and correlates well with proliferation markers and tumor grades.

BACKGROUND: The traditional view that immunoglobulin (Ig) is produced only by B lymphocytes has been challenged, because it has been demonstrated that Ig genes and proteins are expressed in epithelial cancer cells. However, whether Ig expression in nonlymphoid cells is limited to epithelial cells is unclear. Because sarcomas differ distinctly from carcinomas in their biologic and clinical features, the authors investigated the question of nonlymphoid IgG expression in soft tissue lesions. METHODS: Immunohistochemistry, in situ hybridization, and polymerase chain reaction (PCR) were used to demonstrate IgG expression in 80 soft tissue lesions. The correlation between Ig expression and proliferation markers (proliferating cell nuclear antigen [PCNA], Ki-67, and cyclin D1) in sarcomas was investigated by immunohistochemical and statistical analyses. RESULTS: Igkappa was identified in 97.4% of sarcomas and in 31.7% of benign lesions by immunohistochemistry. The difference was statistically significant (P < .01). Messenger RNA from the IgG1 heavy-chain constant region was also detected by in situ hybridization. Variable-diversity-joining recombination sequences of both heavy and light chains were obtained by PCR and sequencing. Moreover, the labeling index of PCNA, Ki-67, and cyclin D1 was much higher in sarcomas with high Igkappa expression than in sarcomas with low Igkappa expression (P < .01 for PCNA and cyclin D1; P < .001 for Ki-67). There were more grade 3 sarcomas with high Igkappa expression compared with grade 1 and 2 sarcomas (P < .05). CONCLUSIONS: IgG was identified in a wide variety of soft tissue tumors and correlated well with proliferation markers and tumor grades. IgG may be a useful marker for cell proliferation in sarcomas.

Molecular pathology in the lungs of severe acute respiratory syndrome patients.

Severe acute respiratory syndrome (SARS) is a novel infectious disease with disastrous clinical consequences, in which the lungs are the major target organs. Previous studies have described the general pathology in the lungs of SARS patients and have identified some of the cell types infected by SARS coronavirus (SARS-CoV). However, at the time of this writing, there were no comprehensive reports of the cellular distribution of the virus in lung tissue. In this study, we have performed double labeling combining in situ hybridization with immunohistochemistry and alternating each of these techniques separately in consecutive sections to evaluate the viral distribution on various cell types in the lungs of seven patients affected with SARS. We found that SARS-CoV was present in bronchial epithelium, type I and II pneumocytes, T lymphocytes, and macrophages/monocytes. For pneumocytes, T lymphocytes, and macrophages, the infection rates were calculated. In addition, our present study is the first to demonstrate infection of endothelial cells and fibroblasts in SARS.