Independent association of angiogenesis index with outcome in prostate cancer.

New molecular factors have been characterized that are associated with the prognosis of prostate carcinoma patients, including p53 status and angiogenesis. We reported recently that mutant p53 (mp53) was associated with decreased expression of an endogenous inhibitor of angiogenesis, thrombospondin-1 (TSP-1), and increased microvessel density in melanoma and breast cancer. In this study, we performed a similar analysis on primary prostate carcinoma to determine whether these factors were associated with each other or patient outcomes. Paraffin-embedded specimens of 98 cases of primary prostate carcinoma were obtained and examined to confirm tissue diagnosis and Gleason scores. Carcinoma-specific levels of p53, TSP-1, and tumor angiogenesis were determined using semiquantitative immunohistochemistry (IHC) methods. Acquisition of mp53 was significantly associated with decreased TSP-1 (P = 0.002) and increased angiogenesis (P < 0.0001). An angiogenesis index integrating mp53, TSP-1, and angiogenesis (CD31) scores was found to be an independent predictor of survival in univariate and multivariate analyses that included Gleason score, clinical stage, and patient age. Further validation of the angiogenesis index in prostate carcinoma may provide a new tool to stratify patient risk.

Levels of multidrug resistance (MDR1) P-glycoprotein expression by human breast cancer correlate with in vitro resistance to taxol and doxorubicin.

To determine whether multidrug resistance (MDR1) P-glycoprotein (Pgp) expression correlated with clinical MDR1-related drug resistance, we established a protocol for quantitative measurement of Pgp expression and in vitro drug resistance in doxorubicin resistant MCF7 breast cancer cell lines and 359 freshly resected specimens of breast carcinoma. Pgp expression was detected with 4E3, UIC2, and JSB-1 monoclonal antibodies using flow cytometry and immunohistochemistry (IHC). Pgp function was determined using PSC833 in a drug resistance-reversal assay and with a three-dimensional agarose-based extreme drug resistance assay. MCF7 calibrator cell lines expressed Pgp, which was functional and in proportion to the degree of drug resistance. Flow cytometry, UIC2 shift assays, IHC scores, and determination of absorbance products by image analysis were all highly correlated (r > 0.9). Overall Pgp expression increased from 11% in untreated patients to 30% in patients who had previously received chemotherapy. Compared with Pgp-negative tumors, a significant increase in doxorubicin and Taxol resistance was seen for breast cancers that expressed Pgp, regardless of prior treatment. A strong correlation between the degree of Pgp expression and in vitro resistance to Taxol and doxorubicin (but not to 5-fluorouracil) was found when either IHC scores or image analysis-based methods were used to quantify Pgp expression (n = 185, P < 0.0001). The degree of Pgp expression strongly correlated with the degree of drug resistance in the clinical specimens studied. These data suggest that (a) Pgp contributes to clinical MDR1-related drug resistance, and (b) both intrinsic and acquired expression of Pgp in breast cancer may contribute in part to therapeutic failure and relapse.

The inferiorly based rectus abdominis island flap for the treatment of complex hip wounds.

Complex wounds in the hip region often result from complications of orthopedic procedures performed in this region such as total hip arthroplasty, ORIF procedures, tumor ablation, and/or radiation therapy. Exposure of bone, joint capsule, prostheses, and other hardware often results with these wounds. Salvage of these exposed and/or infected essential elements and providing soft-tissue coverage are difficult and challenging problems for the orthopedic and plastic surgeon. To provide coverage for such situations, we have developed an aggressive strategy of thorough debridement, systemic antibiotics, and well-vascularized soft-tissue coverage utilizing an inferiorly based rectus abdominis island flap. This technique was utilized in five patients with all wounds and joints remaining stable at follow-up periods ranging from 2 to 7 years.

Anatomical parameters for nipple position and areolar diameter in males.

In this paper we present anatomic parameters for nipple position and areolar diameter in males. Larger forms of gynecomastia with significant ptosis pose a challenge to the plastic surgeon with respect to relocation of the nipples on the chest wall. Selection of the appropriate areolar size is also of concern in gynecomastia correction. There is a paucity of information in the current literature pertaining to this problem. In order to establish guidelines for the placement of the nipple in gynecomastia correction and for the selection of the appropriate areolar size, we set out to determine these anatomic parameters. We believe use of these parameters will enhance the aesthetic results of gynecomastia correction. One hundred males between the ages of 17 to 30 years were chosen for this study. The males selected were of ideal body weight and without evidence of gynecomastia. The distances from the sternal notch to the nipple, the midclavicular line to the nipple, and the nipple-to-nipple distance were recorded. The areolar diameter was also measured in each subject. The average distances were determined for each category. The validity of these values was confirmed with statistical analysis. Equations were then derived, using this analysis, to determine nipple position in males. We have determined the nipple position in males to be approximately 20 cm from the sternal notch and 18 cm from the midclavicular line. The ideal nipple-to-nipple distance is 21 cm. The average areolar diameter is 2.8 cm.

Immunopathology of malignant mesothelioma.

The pathologic diagnosis of malignant mesothelioma is difficult because the disease is rare and because it has many morphologic variants. This chapter emphasizes practical aspects of the pathologic features and of the differential diagnosis of malignant mesothelioma.

Phenotype of bile ducts and infiltrating lymphocytes in graft-versus-host disease.

When graft-versus-host (GVH) disease affects the liver, it is characteristically the bile ducts which are involved, infiltrated by lymphocytes. To characterize this process further, and to determine whether there were any antigenic changes in the bile ducts, we stained 9 liver biopsies involved by GVH disease, 10 non-GVH biopsies that had a prominent portal lymphocytic component, and 8 biopsies taken incidentally at surgery for noninflammatory liver disease with epithelial membrane antigen, AE-3, AE-1, a keratin cocktail, keratin 19, CD45RO (UCHL-1), CD43 (Leu-22), CD20 (L26), vimentin, and LN-3. The infiltrating lymphocytes were T cells (CD45RO+, CD43+, CD20-) which variably expressed LN-3. The bile ducts were positive for the keratin cocktail, AE-1, AE-3, and keratin-19, but only occasionally positive for EMA and LN-3. There was no significant difference in the staining patterns of either the bile duct cells or lymphocytes between the three groups. With the antibodies that we used, there does not appear to be a significant difference in the antigenic phenotype of the bile ducts in GVH as compared to normal or reactive livers.

Antigenic phenotypes of hairy cell leukemia and monocytoid B-cell lymphoma: an immunohistochemical evaluation of 66 cases.

Using a large panel of antibodies on multi-tumor block sections of routinely processed, paraffin-embedded fixed tissue, we compared the antigenic phenotype of 42 clinically, morphologically, and immunologically well-characterized cases of hairy cell leukemia (HCL) with 24 cases of monocytoid B-cell lymphoma (MBCL) selected from the Monocytoid B-Cell Lymphoma Registry at the City of Hope National Medical Center. The predominant antigenic phenotype of hairy cells was CD45 (leukocyte common antigen)+, CD45Ra (4KB5, MB1, MT2)+, L26+, CDw75 (LN1)+, CD74 (LN2)+, LN3+, MB2+, CD45RO (UCHL1)-, MT1-, CD15 (Leu-M1)-, neuron-specific enolase (NSE)-, epithelial membrane antigen-, and CD30 (Ber-H2)-. The immunophenotype of neoplastic monocytoid B lymphocytes was essentially identical to that of the hairy cells, with one exception: the neoplastic monocytoid B lymphocytes were stained by epithelial membrane antigen in seven cases. An interesting observation was the staining by anti-muscle-specific actin of the neoplastic cells of MBCL in 53% of cases, but of none of the cases of HCL. The results of our study (1) indicate that HCL and MBCL can be immunophenotyped reliably on fixed tissue samples, (2) further confirm the proposed lineage relationship between these two lymphoproliferative disorders, and (3) indicate that decalcification of bone marrow biopsies does not adversely affect the immunoreactivity of hematopoietic-associated antigens.

Splenic involvement by aggressive malignant lymphomas of B-cell and T-cell types. A morphologic and immunophenotypic study.

To determine whether there are any consistent morphologic differences between B-cell and T-cell aggressive non-Hodgkin's lymphomas of the spleen, the authors analyzed 16 spleens involved by mixed cell (1 case) or large cell (15 cases) lymphomas. Immunologic data were derived from cell suspensions or frozen tissue in each case. Five cases had a T-cell phenotype, and 11 were B-cell. Morphologic features favoring a T-cell phenotype included epithelioid histiocytic reactions, confinement of the lymphomas to the splenic T-zones (periarteriolar lymphoid sheath and marginal zone), and clear cell or polymorphous cytologic features. Features favoring a B-cell phenotype included multiple discrete nodules in the white pulp, large coalescent tumor nodules in association with small lymphocytic lymphoma, and large non-cleaved or immunoblastic plasmacytoid cytologic characteristics. Four cases were unusual because most neoplastic large cells were distributed diffusely or formed only small aggregates in the red pulp without definite tumor masses or nodules involving the white pulp. Because of this distribution and the frequently encountered erythrophagocytosis by benign-appearing histiocytes, these cases resembled malignant histiocytosis. A T-cell phenotype was predicted for all four cases; however, only one case, a lymphoma with polymorphous cytologic characteristics, was of T-cell lineage. The other three cases were of B-cell lineage. The authors' results indicate that in most instances the B-cell or T-cell nature of aggressive splenic lymphomas is predictable from the distributional and cytologic features. As in lymph nodes, there are cases for which the morphologic characteristics of B-cell and T-cell lymphomas are indistinguishable.

Malignant histiocytosis X. A distinct clinicopathologic entity.

Histiocytosis X (HX) is characterized morphologically by a proliferation of Langerhans' cells (LC), and most often has an indolent, chronic course. To determine whether a distinct clinicopathologic entity of malignant histiocytosis X exists, the authors examined tissues from 31 patients with HX and divided them into four categories. Group A (19 patients) was characterized morphologically by benign-appearing LC and had an indolent course. The male:female (M:F) ratio was 10:9, and the mean age was 21 years (range, 2 months to 60 years). The immunophenotype of this group was S-100+, vimentin+, LN-2+, LN-3+, lysozyme-, LCA-, Leu-M1-. Group B (three patients) had benign-appearing LC, yet had an aggressive clinical course. All patients were male, with a mean age of 47 years (range, 3 years to 72 years). Organs involved included the liver, spleen, heart, thymus, lung, kidney, and pancreas. The immunophenotype was the same as for Group A. Group C (two patients) had atypical and malignant appearing LC, yet a relatively benign clinical course. The ages were four and 65 years, with one female and one male patient. In both patients, the cells were S-100+, vimentin+, LN-2+, LN-3+, and LCA-. Group D (seven patients) was characterized by atypical and malignant-appearing LC and an aggressive clinical course. The mean age was 25 years (range, congenital to 54 years) with one female and six male patients. Organs involved were the thymus, lungs, spleen, liver, kidney, brain, heart, pancreas, stomach, and muscle. Birbeck granules were found in two patients, and the one patient on which fresh tissue was available was CD1+. The typical immunophenotype was S-100+, vimentin+, LN-2+, LN-3+, Leu-M1-, lysozyme-. The results of our study indicate that (1) a distinct clinical entity of malignant HX, characterized morphologically by malignant-appearing LC and clinically by male predominance, atypical organ involvement, and an aggressive clinical course, does exist; and (2) the morphologic appearance of the LC is an imperfect predictor of the clinical severity of HX.

Detection of immunoglobulin light-chain mRNA in lymphoid tissues using a practical in situ hybridization method.

The identification of immunoglobulin protein in routinely fixed and paraffin-embedded sections using antibodies combined with immunoperoxidase or similar techniques of detection is often problematic. We developed an in situ hybridization methodology for the identification of light-chain mRNA that is applicable to formalin-fixed, paraffin-embedded tissues, using either radiolabeled or biotinylated oligonucleotide probes based on the kappa and lambda light-chain gene-constant regions. Reactive plasma cells can be consistently identified in reactive lymphoid tissues, and a monotypic pattern of light-chain mRNA restriction was seen in each of eight cases of multiple myeloma/plasmacytoma. Immunoblasts and germinal center cells also are labeled in reactive lymphoid tissues. Using 355-labeled probes, 29 of 93 cases (30%) of non-Hodgkin's lymphomas had detectable light-chain mRNA, while 19% of non-Hodgkin's lymphomas were positive using biotinylated probes.

Angiotropic (intravascular) large cell lymphoma. A clinicopathologic study of seven cases with unique clinical presentations.

The authors recently reported the antigenic phenotypes of three cases of so-called "malignant angioendotheliomatosis" and suggested that angiotropic large cell lymphoma (ALCL) is a more appropriate designation for this disease. The authors now report an additional seven cases of ALCL with unique clinical presentations. One patient presented with prostate enlargement, the second with lytic bone lesions and thickened nasal sinus mucosa, the third had diffuse myalgia, the fourth had dyspnea and pulmonary infiltrates, the fifth had gangrene of the lower extremities, total-body skin involvement, and pancytopenia, the sixth had a lesion of the foreskin mimicking squamous cell carcinoma, and the seventh had a mediastinal mass. In all cases histologic features were characteristic of ALCL with, in two cases, extravascular spread into soft tissue. Immunohistologic studies showed a B-cell phenotype in five cases and a T-cell phenotype in one case. Two patients received combination chemotherapy using established treatment protocol for large cell lymphoma, and remain in complete clinical remission and two patients are responding clinically to combination chemotherapy. Two patients died shortly after receiving combination chemotherapy. One patient has only recently been diagnosed as having ALCL and no long-term follow-up is available. These data indicate that, although ALCL affects predominantly the central nervous system and skin, unusual clinical presentations may occur, and patients with ALCL may respond to combination chemotherapy for large cell lymphoma.

Surface immunoglobulin-positive lymphoblastic lymphoma. A report of three cases.

Lymphoblastic lymphomas (LBL) are a morphologically homogeneous group of non-Hodgkin's lymphomas which are indistinguishable in tissue sections from acute lymphoblastic leukemia (ALL). Although initial immunologic studies of LBL suggested that these lymphomas are of the T-cell phenotype, investigations have recently described patients with LBL having pre-B-cell, "common" ALL, and natural killer cell phenotypes. The authors recently reported detailed immunophenotypic characteristics in 36 cases of LBL, including a single case of LBL with a surface immunoglobulin-positive B-cell phenotype. Three additional patients with LBL whose cells expressed monoclonal serum immunoglobulins are presented here. In addition, the neoplastic lymphocytes expressed several B-cell-associated antigens. The tumor cells in the single case tested were TdT-negative. Despite the unusual immunologic phenotype, the morphologic features in all three cases were characteristic of LBL. In addition to the previously reported single case, to the authors' knowledge these are the only reported cases of a previously unrecognized variant of LBL: surface immunoglobulin-positive, B-cell LBL.

Relationship between eosinophil density and T-cell activation markers in lymph nodes of patients with Hodgkin's disease.

Hodgkin's disease (HD) is characterized morphologically by a variable infiltration of tissues by eosinophilic granulocytes. The lesions also contain numerous T cells, predominantly of the CD4+ immunophenotype. To investigate whether the presence or absence of tissue eosinophilia is related to the immunophenotype of the T cells, we studied 43 cases of HD (28 nodular sclerosing, ten mixed cellularity, and five unclassifiable) for the relative numbers of lymphocytes positive for CD2, CD3, CD4, CD5, CD8, CD25, CD38, T9, TQ1, HLA-DR, and beta F1, and for the number of eosinophils in tissue sections. By univariate and multivariate analysis, we determined that there was an inverse relationship between the number of eosinophils and the presence of TQ1+ (P less than .0005) and CD25+ (P less than .0005) lymphocytes. In addition, we observed that TQ1 stained the Reed-Sternberg cells in these lesions. We also determined that the T cells expressed HLA-DR more frequently in the nodular sclerosis subtype than in other subtypes of HD (P less than or equal to .0001). We therefore conclude that the degree of tissue eosinophilia in the lymph nodes of patients with HD may be explained, at least in part, by the immunophenotype of the T cells present in the affected lymph nodes.

Antigenic phenotype of Langerhans cell histiocytosis: an immunohistochemical study demonstrating the value of LN-2, LN-3, and vimentin.

In order to determine the antigenic phenotype of the proliferating cells in Langerhans cell histiocytosis (LCH), we studied 15 such examples by using formalin- and B5-fixed, paraffin-embedded tissues. We used a panel of antibodies that are known to react with lymphocyte- and histiocyte-associated antigens. These included LN-1, LN-2, and LN-3 monoclonal antibodies (MoAbs), MoAbs to leukocyte common antigen (LCA), Leu-M1 antigen, vimentin, and epithelial membrane antigen (EMA), as well as polyclonal antibodies to lysozyme and S100 protein. The antigens encountered most frequently in LCH cells were S100 protein (93% of cases), vimentin (86%), and those detected by LN-2 (80%) and LN-3 (82%). Lysozyme was detected focally in two cases and diffusely in one case. The LCH cells were negative for LN-1, LCA, Leu-M1, and EMA. There was only one specimen in which S100 protein was not demonstrated; in this case, LN-3, vimentin, and T6 on frozen section were positive. The phenotype of LCH cells is similar to that of Langerhans' cells and interdigitating histiocytes. Our results demonstrate the value of using a panel of antibodies, including anti-vimentin MoAb, LN-2, and LN-3 for the immunophenotypic diagnosis of LCH in addition to an antibody to S100 protein.

S-100 immunoreactivity in primary and metastatic carcinoma of the breast: a potential source of error in immunodiagnosis.

Immunoreactivity for S-100 protein, typically a marker for malignant melanoma and neural-derived tumors, was observed in neoplastic cells of 57 of 68 cases (84%) of formalin-fixed, paraffin-embedded primary and/or metastatic carcinoma of the breast of various histologic types. The extent of S-100 immunoreactivity varied, with only a minor proportion of positive tumor cells noted in some cases. An awareness of this staining profile for S-100 protein, particularly in metastatic poorly differentiated neoplasms with unknown primaries, is imperative for accurate immunohistochemical interpretation. Using a panel of reagents which includes antibodies to keratin proteins and epithelial membrane antigen, the epithelial nature of S-100-positive carcinomas may be readily defined. Tumor cells in all cases of primary and metastatic carcinoma of the breast evaluated in this study exhibited strong staining for both of these tissue markers. To preclude misinterpretation of tumor type due to anomalous staining patterns for a specific antibody, eg, S-100 protein, a panel of antibodies is recommended for assessment of metastatic poorly differentiated tumors.

Rearrangement of kappa-chain and T-cell receptor beta-chain genes in malignant lymphomas of "T-cell" phenotype.

Detection of immunoglobulin gene rearrangements by molecular hybridization is considered to be a highly sensitive approach to the evaluation of clonality of B-cell-derived neoplasms. Like monoclonal surface immunoglobulin in B cells, which serves as a reliable immunophenotypic marker for clonality, rearrangement of the genes encoding immunoglobulin light chains has been accepted as a reliable genotypic marker for the presence of a clonal expansion of B lymphocytes. The authors now report 3 cases of non-Hodgkin's lymphoma that were immunologically classified as having a T-cell phenotype and in which, in addition to rearrangements of the T-cell receptor beta-chain gene, a rearrangement of an immunoglobulin light-chain gene was clearly identified by Southern blot hybridization. The results demonstrate that the data obtained by molecular hybridization should be interpreted with caution when the immunogenetic findings do not correlate with immunophenotypic expression, and that the results of molecular genetics studies should be interpreted in conjunction with morphologic and immunologic findings.

Angiosarcoma of the bladder: a case report.

We report a case of angiosarcoma of the bladder. Numerous cases of hemangioma of the bladder have been reported previously but only 3 cases of angiosarcoma have been published. In our case immunoperoxidase staining for factor VIII antigen was useful in substantiating the diagnosis of angiosarcoma.

Factors affecting expression of glycolipid tumor antigens: influence of ceramide composition and coexisting glycolipid on the antigenicity of gangliotriaosylceramide in murine lymphoma cells.

Gangliotriaosylceramide (Gg3Cer) was previously described as a tumor-associated antigen in murine L5178Y lymphoma [Young, W. W., Jr., and Hakomori, S., Science (Wash. D.C.), 211: 487-489, 1981]. This paper describes the major factors affecting the expression of Gg3Cer at the surface of various clones of L5178Y lymphoma. Of 26 sublines that were recloned, six cell lines showing different degrees of Gg3Cer expression at the cell surface were used for analysis of the glycolipid composition as related to its cell surface antigenicity. Three remarkable correlations between glycolipid composition and the antigenicity of Gg3Cer have been found: (a) high-expressor sublines were characterized by a large proportion of a unique molecular species of Gg3Cer having alpha-hydroxypalmitic acid in its ceramide moiety in striking contrast to low expressors which did not contain this molecular species; (b) low expressors contained a large quantity of ganglio-N-tetraosylceramide (Gg4Cer) and NeuAc alpha 2 leads to 3Gal beta 1 leads to 3GalNAc beta 1 leads to 4Gal beta 1 leads to 4Glc beta 1 leads to 1 Cer (GM1b) gangliosides, whereas these glycolipids were almost absent in high-expressor clones; and (c) nonexpressors, which were converted from the high expressors in vivo through immunotherapy with the monoclonal antibodies to Gg3Cer, contained a large quantity of ganglio-N-tetraosylceramide and NeuAc alpha 2 leads to 3Gal beta 1 leads to 3GalNAc beta 1 leads to 4Gal beta 1 leads to 4Glc beta 1 leads to 1Cer. The nonexpressors should have an induced enzyme system to metabolize Gg3Cer to ganglio-N-tetraosylceramide and NeuAc alpha 2 leads to 3Gal beta 1 leads to 3GalNAc beta 1 leads to 4Gal beta 1 leads to 4Glc beta 1 leads to 1Cer. Three factors, i.e., ceramide composition, coexisting glycolipids, and an antibody-dependent glycolipid change, are therefore important in determination of glycolipid antigenicity and antigen modulation by antibodies. The ceramide composition may affect glycolipid organization in membranes, and the coexisting glycolipid having a longer carbohydrate chain may mask the accessibility of antibody to the antigenic glycolipid. The antigenic modulation by the action of the antibody in vivo may be based on activation of a new glycosyltransferase.