Are the uterine serous carcinomas underdiagnosed? Histomorphologic and immunohistochemical correlates and clinical follow up in high-grade endometrial carcinomas initially diagnosed as high-grade endometrioid carcinoma.

Histologic subclassification of high-grade endometrial carcinomas can sometimes be a diagnostic challenge when based on histomorphology alone. Here we utilized immunohistochemical markers to determine the immunophenotype in histologically ambiguous high-grade endometrial carcinomas that were initially diagnosed as pure or mixed high-grade endometrioid carcinoma, aiming to determine the utility of selected immunohistochemical panel in accurate classification of these distinct tumor types, while correlating these findings with the clinical outcome. A total of 43 high-grade endometrial carcinoma cases initially classified as pure high-grade endometrioid carcinoma (n=32), mixed high-grade endometrioid carcinoma/serous carcinoma (n=9) and mixed high-grade endometrioid carcinoma/clear cell carcinoma (n=2) were retrospectively stained with a panel of immunostains, including antibodies for p53, p16, estrogen receptor, and mammaglobin. Clinical follow-up data were obtained, and stage-to-stage disease outcomes were compared for different tumor types. Based on aberrant staining for p53 and p16, 17/43 (40%) of the high-grade endometrial carcinoma cases initially diagnosed as high-grade endometrioid carcinoma were re-classified as serous carcinoma. All 17 cases showed negative staining for mammaglobin, while estrogen receptor was positive in only 6 (35%) cases. The remaining 26 cases of high-grade endometrioid carcinoma showed wild-type staining for p53 in 25 (96%) cases, patchy staining for p16 in 20 (77%) cases, and were positive for mammaglobin and estrogen receptor in 8 (31%) and 19 (73%) cases, respectively, thus the initial diagnosis of high-grade endometrioid carcinoma was confirmed in these cases. In addition, the patients with re-classified serous carcinoma had advanced clinical stages at diagnosis and poorer overall survival on clinical follow-up compared to that of the remaining 26 high-grade endometrioid carcinoma cases. These results indicate that selected immunohistochemical panel, including p53, p16, and mammaglobin can be helpful in reaching accurate diagnosis in cases of histomorphologically ambiguous endometrial carcinomas, and can assist in providing guidance for appropriate therapeutic options for the patients.

c-Abl and Arg induce cathepsin-mediated lysosomal degradation of the NM23-H1 metastasis suppressor in invasive cancer.

Metastasis suppressors comprise a growing class of genes whose downregulation triggers metastatic progression. In contrast to tumor suppressors, metastasis suppressors are rarely mutated or deleted, and little is known regarding the mechanisms by which their expression is downregulated. Here, we demonstrate that the metastasis suppressor, NM23-H1, is degraded by lysosomal cysteine cathepsins (L,B), which directly cleave NM23-H1. In addition, activation of c-Abl and Arg oncoproteins induces NM23-H1 degradation in invasive cancer cells by increasing cysteine cathepsin transcription and activation. Moreover, c-Abl activates cathepsins by promoting endosome maturation, which facilitates trafficking of NM23-H1 to the lysosome where it is degraded. Importantly, the invasion- and metastasis-promoting activity of c-Abl/Arg is dependent on their ability to induce NM23-H1 degradation, and the pathway is clinically relevant as c-Abl/Arg activity and NM23-H1 expression are inversely correlated in primary breast cancers and melanomas. Thus, we demonstrate a novel mechanism by which cathepsin expression is upregulated in cancer cells (via Abl kinases). We also identify a novel role for intracellular cathepsins in invasion and metastasis (degradation of a metastasis suppressor). Finally, we identify novel crosstalk between oncogenic and metastasis suppressor pathways, thereby providing mechanistic insight into the process of NM23-H1 loss, which may pave the way for new strategies to restore NM23-H1 expression and block metastatic progression.

Association of number of positive nodes and cervical stroma invasion with outcome of advanced endometrial cancer treated with chemotherapy or whole abdominal irradiation: a Gynecologic Oncology Group study.

OBJECTIVE: To determine whether the number of positive pelvic nodes (PPN), cervical stromal involvement (CSI), and/or lymphovascular space involvement (LVSI) were prognostic factors among women with advanced endometrial carcinoma treated with adriamycin plus cisplatin (AP) or whole abdominal irradiation (WAI). METHODS: Data were abstracted from records of patients treated with adjuvant WAI or AP in a GOG randomized trial. Cox proportional hazards models were used to estimate the association of CSI and PPN with differences in PFS and OS while adjusting for treatment and previously studied factors. RESULTS: WAI was randomly allocated to 202 and AP to 194 eligible patients. CSI (n=93 total) was associated with a 44% increase in risk of progression and a 33% increase in risk of death. There was a trend for increasing number PPN being associated with a 7% per positive node increase in risk of progression/death. For CSI, the estimated unadjusted treatment hazard ratios (HRs) were: PFS 0.85 (0.53, 1.38); OS 0.81 (0.50, 1.33). For metastatic disease limited to a single PPN (n=25), the unadjusted HRs were: PFS 0.96 (0.34, 2.74); OS 0.73 (0.24, 2.18). The test of homogeneity of treatment effect (ie., AP vs WAI) across subgroups (CSI, number of positive pelvic nodes) was not statistically significant for either endpoint, thus supporting the superiority of chemotherapy as reported in the original manuscript. CONCLUSIONS: The presence of CSI and increasing number of PPN were associated with poor prognosis. On average, patients with CSI experienced improved PFS and OS when treated with AP relative to WAI.

Infection of an esophageal cyst following endoscopic fine-needle aspiration.

In this report, we describe an unusual presentation of an esophageal cyst. Esophageal cysts are generally benign and are frequently asymptomatic until progressive enlargement leads to symptoms of obstruction. Incidental discovery usually warrants excision. In the described case, a patient presented with signs of enlargement and concerns for infection after an attempted endoscopic biopsy of the lesion. After admission and initial management with antibiotics she was taken to the operating room for resection via a thoracotomy. We review the literature and underscore the conventional practice of operative management of esophageal cysts without the use of invasive diagnostic evaluations.

Should Histologic Grade Be Incorporated into the TNM Classification System for Small (T1, T2) Node-Negative Breast Adenocarcinomas?

Prognosis of invasive ductal carcinoma (IDC) strongly correlates with tumor grade as determined by Nottingham combined histologic grade. While reporting grade as low grade/favorable (G1), intermediate grade/moderately favorable (G2), and high grade/unfavorable (G3) is recommended by American Joint Committee on Cancer (AJCC) staging system, existing TNM (Primary Tumor/Regional Lymph Nodes/Distant Metastasis) classification does not directly incorporate these data. For large tumors (T3, T4), significance of histologic grade may be clinically moot as those are nearly always candidates for adjuvant therapy. However, for small (T1, T2) node-negative (N0) tumors, grade may be clinically relevant in influencing treatment decisions, but data on outcomes are sparse and controversial. This retrospective study analyzes clinical outcome in patients with small N0 IDC on the basis of tumor grade. Our results suggest that the grade does not impact clinical outcome in T1N0 tumors. In T2N0 tumors, however, it might be prognostically significant and relevant in influencing decisions regarding the need for additional adjuvant therapy and optimal management.

Cryopreservation of composite tissue transplants.

Composite tissue allotransplantation holds great promise for upper extremity reconstruction but is limited by donor part availability. Cryopreservation may increase the availability of donor parts and even reduce antigenicity. The purpose of the study was to evaluate the viability of cryopreserved composite tissues and to demonstrate the feasibility of microvascular isotransplantation of cryopreserved composite flaps. Twenty epigastric flaps were harvested from Lewis rats. Ten flaps were analyzed fresh. Ten flaps were perfused with dimethyl sulfoxide (DMSO)/trehelose cryoprotectant agent (CPA), frozen by controlled cooling to -140 degrees C, and stored for 2 weeks. Flaps were evaluated by factor VIII endothelial staining and MTT tetrazolium salt assay. For the in vivo phase, 30 flaps were harvested. Ten were transplanted fresh to isogenetic recipient animals, ten were perfused with CPA and transplanted, and ten were cryopreserved for 2 weeks, thawed, and transplanted. All cryopreserved samples displayed intact vascular endothelia on factor VIII staining. On MTT analysis, the epithelial viability index for the cryopreserved samples was not significantly different from fresh controls (p = 0.12). All freshly transplanted flaps (10/10) were viable at 60 days. Nine of ten flaps in the perfused/transplanted group were viable at 60 days. Survival of cryopreserved/transplanted flaps ranged from 5 to 60 days. The skin and vascular endothelial components of composite tissue flaps appear to retain their viability after cryopreservation. The in vivo studies demonstrate that the long-term survival of cryopreserved composite tissue transplants is feasible and support an indirect injury, rather than direct injury from freezing or cryoprotectant agents, as the mechanism of flap loss.

Size of sentinel node tumor deposits and extent of axillary lymph node involvement: which breast cancer patients may benefit from less aggressive axillary dissections?

BACKGROUND: In most breast cancer series, nearly 30% to 40% of all patients are sentinel node positive; however, in a large proportion of these, the disease is limited to three or fewer positive nodes. On the basis of these observations, the object of this study is to identify a subset of patients who might benefit from a less aggressive axillary dissection, without compromising staging or local disease control. We reviewed known clinicopathologic variables associated with a higher risk for axillary metastasis in 467 patients who underwent sentinel node mapping at our institution. We then compared the incidence of these variables in patients with N1a versus N2-3 stage disease. RESULTS: Although the presence of lymphvascular invasion in the primary tumor and extracapsular extension of tumor in the sentinel node were statistically significantly different between N1a and N2-3 patients (P < .025 and P < .01, respectively), the variable that most reliably separated N1a from N2-3 patients was the size of the tumor deposits in the sentinel node (P < .001). All patients with sentinel node tumor deposits

Ultrasound-guided fine-needle aspiration of clinically negative lymph nodes versus sentinel node mapping in patients at high risk for axillary metastasis.

BACKGROUND: Sonographically directed fine-needle aspiration is a less invasive and less costly alternative to sentinel node (SN) mapping in breast cancer patients at high risk for metastatic disease but with clinically negative axillae. METHODS: Radiographic, cytological, and histological diagnostic data on breast primary tumors from 114 consecutive SN candidates were prospectively assessed for clinicopathologic variables associated with an increased incidence of axillary metastases. Patients in whom these variables were identified underwent sonographic examination of their axillae followed by fine-needle aspiration when abnormal nodes were detected. SN mapping was performed in patients with normal axillary sonogram results or negative cytological results. Patients with positive cytological results proceeded to complete axillary dissection. Final axillary histological outcomes from patients not meeting the high-risk criteria were recorded. Additionally, a cost analysis was performed in which the costs of ultrasonography and ultrasound-guided fine-needle aspiration of the axilla were compared with those of SN mapping. RESULTS: According to our selection criteria, a third of the patients with clinically negative axillae (37 of 114; 32%) were considered at high risk for axillary metastases. Fifty-nine percent of these patients (22 of 37) had metastatic disease on final histological analysis. Forty percent (15 of 37) of high-risk patients were spared SN mapping, with a reduction in health care costs of 20% in this patient population. Eighty-seven percent of patients not meeting high-risk criteria were SN negative. CONCLUSIONS: This study suggests that in patients at increased risk for axillary metastases, the use of sonographic evaluation of the axilla in combination with fine-needle aspiration is not only clinically justified, but also cost-effective.

The fate of cryopreserved adipose aspirates after in vivo transplantation.

BACKGROUND: Successful long-term preservation of adipose tissues may have an important impact on future clinical application of autologous fat transplantation. Our group has recently developed an optimal cryopreservation method for possible long-term preservation of adipose aspirates. OBJECTIVE: The purpose of this study was to evaluate the fate of previously cryopreserved adipose aspirates after in vivo administration in an established nude mouse model. METHODS: Adipose aspirates were collected from a cosmetic lipoplasty of the patient's abdomen after centrifugation. In the fresh control group (n = 20), fresh adipose aspirates were injected into the posterior scalp of a nude mouse. In the optimal cryopreservation group (n = 20), adipose aspirates after the optimal cryopreservation were injected. In the simple cryopreservation group (n = 20), adipose aspirates after the simple cryopreservation were injected. All animals in each group were observed for gross appearance of maintained fat grafts over their posterior scalps for up to 16 weeks. The final volume and weight of maintained fat grafts and their histology were evaluated at the end of the study. RESULTS: More maintained volume, weight, and fatty tissue structure of injected free grafts were found in the optimal cryopreservation group compared with the simple cryopreservation group, but the results were still less satisfactory than those in the fresh control group. CONCLUSIONS: Based on this in vivo study, we believe that an optimal cryopreservation method developed in our laboratory provides reasonably good long-term preservation of adipose aspirates. However, further studies may still be warranted to refine our method for optimal cryopreservation of adipose tissues.

The viability of fatty tissues within adipose aspirates after conventional liposuction: a comprehensive study.

This study was conducted to evaluate the viability of fatty tissues within adipose aspirates after conventional liposuction and to examine their potential role as a source of donor material for possible future autogenous fat grafting. Samples of adipose aspirates (group I, n = 8) were obtained from adult female patients who underwent a conventional liposuction of the abdomen. Samples of fresh fatty tissues obtained from adult female patients who underwent an abdominoplasty (group II, n = 8) were cut into small pieces and served as a control. All samples were spun at 50 x g for 10 minutes; fatty tissues were then collected from the middle layer after centrifugation for the following studies: trypan blue vital staining for viable fatty cell counts, glycerol-3-phophatase dehydrogenase (G3PDH) assay for functional evaluation of fatty tissues, and routine pathology for histology of fatty tissues. There was no significant difference of viable fatty cell counts in group I compared with group II (2.57 +/- 0.56 versus 2.74 +/- 0.59 x 10/mL, P = 0.56). G3PGH assay showed a marked decrease of the enzyme activity in group I compared with group II (0.34 +/- 0.13 versus 0.76 +/- 0.13 micro/mL, P < 0.0001). Histologically, the normal structure of fatty tissues was found primarily in both groups. Our results indicate that although fatty tissues within adipose aspirates after conventional liposuction maintain normal structure with near the same number of viable fatty cells compared with fresh ones, they have a less-than-optimal level of cellular function and may not survive well after they are transplanted.

Cryopreservation of adipose tissues: the role of trehalose.

BACKGROUND: Several studies have shown that one of the sugars, trehalose, can improve tissue survival after cryopreservation when combined with other cryoprotective agents, and thus may possibly be used in cryopreservation of adipose tissues that have been found more resistant to injury after freezing. OBJECTIVES: The purpose of this study was to test our hypothesis that lipoplasty-derived adipose aspirates could be effectively cryopreserved by adding trehalose as the sole cryoprotective agent (CPA), and to develop a practical technique to effectively preserve adipose tissues for future applications. METHODS: The middle layer of adipose aspirates obtained from conventional lipoplasty was collected after centrifugation and each specimen was randomized into 3 groups: the control group, fresh adipose aspirates without preservation; the simple cryopreservation group (no CPA); and the optimal cryopreservation group (with trehalose as a CPA). Cryopreservation of adipose aspirates was conducted with controlled slow cooling and fast rewarming rates. Fresh or cryopreserved adipose aspirates in each group were evaluated by viable adipocyte counts, glycerol-3-phosphate dehydrogenase (G3PDH) assay, and routine histology. RESULTS: More viable adipocytes and better cellular function of adipose aspirates were found in the optimal cryopreservation group compared to the simple cryopreservation group, but these results were less ideal than results from the control group. CONCLUSIONS: An optimal cryopreservation method using trehalose as a CPA appears to provide better long-term preservation of adipose aspirates than a simple cryopreservation method. Further studies are needed to refine our method for cryopreservation with trehalose as a CPA and confirm our findings in vivo.

Long-term preservation of adipose aspirates after conventional lipoplasty.

BACKGROUND: Optimal cryopreservation permits the long-term storage of living cells or tissues that may have potential clinical applications. Unfortunately, there are no successful studies on the long-term preservation of adipose aspirates for possible autologous fat grafting. OBJECTIVE: The purpose of the current study was (1) to test our hypothesis that adipose aspirates obtained from conventional lipoplasty could be preserved and stored at low temperature (below -85 degrees C) by means of an optimal cryopreservation technique and (2) to develop a novel approach to effectively preserve adipose aspirates for future applications. METHODS: The middle layer of adipose aspirates obtained from conventional lipoplasty was collected after centrifugation and each specimen was then randomized into 3 groups: the control group, fresh adipose aspirates without preservation; experimental group 1, simple cryopreservation with liquid nitrogen only; and experimental group 2, optimal cryopreservation with cryoprotective agents consisting of a combination of dimethyl sulfoxide (DMSO) and trehalose. Cryopreservation of adipose aspirates was conducted with controlled slow cooling and fast rewarming rates. Fresh or cryopreserved adipose aspirates in each group were evaluated by viable adipocyte counts, glycerol-3-phosphate dehydrogenase (G3PDH) assay, and routine histology. RESULTS: Significantly more viable adipocytes and better cellular function of adipose aspirates were found in the experimental group 2 compared to the results in the experimental group 1. CONCLUSIONS: Our results indicated that an optimal cryopreservation approach that utilizes a combination of DMSO and trehalose as cryoprotective agents appears to provide good long-term preservation of adipose aspirates obtained from conventional lipoplasty, albeit not as ideal as fresh specimens. An in vivo study will be conducted to confirm the results from our present in vitro study.

Outcome of reproductive age women with stage IA or IC invasive epithelial ovarian cancer treated with fertility-sparing therapy.

OBJECTIVES: The purpose of this study was to determine the recurrence rate, survival, and pregnancy outcome in patients with Stage IA and Stage IC invasive epithelial ovarian cancer treated with unilateral adnexectomy. METHODS: A multi-institutional retrospective investigation was undertaken to identify patients with Stage IA and IC epithelial ovarian cancer who were treated with fertility-sparing surgery. All patients with ovarian tumors of borderline malignancy were excluded. Long-term follow-up was obtained through tumor registries and telephone interviews. The time and sites of tumor recurrence, patient survival, and pregnancy outcomes were recorded for every patient. RESULTS: Fifty two patients with Stage I epithelial ovarian cancer treated from 1965 to 2000 at 8 participating institutions were identified. Forty-two patients had Stage IA disease, and 10 had Stage IC cancers. Cell type was distributed as follows: mucinous, 25; serous, 10; endometrioid, 10; clear cell, 5; and mixed, 2. Histologic differentiation was as follows: grade 1, 38; grade 2, 9; and grade 3, 5. Twenty patients received adjuvant chemotherapy (mean 6 courses, range 3-12 courses). Patients received the following chemotherapeutic agents: cisplatin/taxol or carboplatin/taxol, 11; melphalan, 5; cisplatin and cyclophosphamide, 3; and single-agent cisplatin, 1. Eight patients had second-look laparotomies and all were negative. Duration of follow-up ranged from 6 to 426 months (median 68 months). Five patients developed tumor recurrence 8-78 months after initial surgery. Sites of recurrence were as follows: contralateral ovary, 3; peritoneum, 1; and lung, 1. Nine patients underwent subsequent hysterectomy and contralateral oophorectomy for benign disease. At present, 50 patients are alive without evidence of disease and 2 have died of disease 13 and 97 months after initial treatment. The estimated survival was 98% at 5 years and 93% at 10 years.Twenty-four patients attempted pregnancy and 17 (71%) conceived. These 17 patients had 26 term deliveries (no congenital anomalies noted) and 5 spontaneous abortions. CONCLUSION: The long-term survival of patients with Stage IA and IC epithelial ovarian cancer treated with unilateral adnexectomy is excellent. Fertility-sparing surgery should be considered as a treatment option in women with Stage I epithelial ovarian cancer who desire further childbearing.