High resolution microendoscopy for classification of colorectal polyps.

BACKGROUND AND STUDY AIMS: It can be difficult to distinguish adenomas from benign polyps during routine colonoscopy. High resolution microendoscopy (HRME) is a novel method for imaging colorectal mucosa with subcellular detail. HRME criteria for the classification of colorectal neoplasia have not been previously described. Study goals were to develop criteria to characterize HRME images of colorectal mucosa (normal, hyperplastic polyps, adenomas, cancer) and to determine the accuracy and interobserver variability for the discrimination of neoplastic from non-neoplastic polyps when these criteria were applied by novice and expert microendoscopists. METHODS: Two expert pathologists created consensus HRME image criteria using images from 68 patients with polyps who had undergone colonoscopy plus HRME. Using these criteria, HRME expert and novice microendoscopists were shown a set of training images and then tested to determine accuracy and interobserver variability. RESULTS: Expert microendoscopists identified neoplasia with sensitivity, specificity, and accuracy of 67 % (95 % confidence interval [CI] 58 % - 75 %), 97 % (94 % - 100 %), and 87 %, respectively. Nonexperts achieved sensitivity, specificity, and accuracy of 73 % (66 % - 80 %), 91 % (80 % - 100 %), and 85 %, respectively. Overall, neoplasia were identified with sensitivity 70 % (65 % - 76 %), specificity 94 % (87 % - 100 %), and accuracy 85 %. Kappa values were: experts 0.86; nonexperts 0.72; and overall 0.78. CONCLUSIONS: Using the new criteria, observers achieved high specificity and substantial interobserver agreement for distinguishing benign polyps from neoplasia. Increased expertise in HRME imaging improves accuracy. This low-cost microendoscopic platform may be an alternative to confocal microendoscopy in lower-resource or community-based settings.

Adenocarcinoma complicating restorative proctocolectomy for ulcerative colitis with mucosectomy performed by Cavitron Ultrasonic Surgical Aspirator.

This is a report of adenocarcinoma arising in an ileal pouch after restorative proctocolectomy (RPC) with rectal mucosal stripping performed by Cavitron Ultrasonic Surgical Aspirator (CUSA) for ulcerative colitis. The CUSA was introduced to simplify and optimize ileal pouch-anal anastomosis with mucosectomy and has been shown to shorten the operative time and reduce blood loss. Its use however, may increase the number of pathology specimens made uninterpretable on account of tissue ablation. In the present case, even though preoperative colonoscopy had clearly shown dysplasia, the surgical pathology report could not detect any neoplasia in the specimen; hence, the patient was not surveyed for pouch cancer. Six years later, the patient presented with intestinal obstruction caused by cancer. While protocols for universal pouch surveillance remain somewhat controversial, we conclude on the basis of this case and a review of the literature that in RPC with mucosectomy performed by CUSA, pouch cancer surveillance is particularly important because remnants of rectal epithelium may have been left behind and tissue ablation may have made the surgical pathology report uninterpretable.

Organ specific neoantigens reactive in the leukocyte adherence inhibition assay: affinity purification of human colon carcinoma antigen and its cross-reactive protein using monoclonal antibodies.

A monoclonal antibody (mAb) was prepared against a semipurified preparation of an organ specific neoantigen (OSN) reactive in the leukocyte adherence inhibition (LAI) assay. The mAb (LC20.1) induces a positive LAI response when incubated with leukocytes of normal individuals in the presence of OSN derived from either human colon or lung carcinoma cell lines. Absorption of crude OSN preparations from these cell lines on immobilized LC20.1 mAb eliminates all the LAI reactive material suggesting that the mAb recognizes a common determinant on OSN from both colon and lung carcinomas. The LC20 mAb was used to affinity purify the colon cancer OSN as well as a cross-reactive normal protein from the urine of colon cancer patients and healthy donors, respectively. The colon cancer OSN and normal cross-reactive protein display an apparent molecular weight of 29,000, have a similar linear tryptic peptide map, and are indistinguishable by isoelectric focusing analysis. Regardless of the molecular similarity, only the colon cancer OSN preparation could induce a positive LAI when incubated with leukocytes of colon cancer patients. Seven additional anti-colon cancer OSN mAbs were prepared against purified material. These mAbs can be divided into three groups, each of which recognizes a distinct antigenic determinant that is shared by the colon cancer neoantigen and its cross-reactive normal protein.

Loss of heterozygosity affecting the p53, Rb, and mcc/apc tumor suppressor gene loci in dysplastic and cancerous ulcerative colitis.

Allelic deletions of tumor suppressor genes have been observed frequently in a variety of human tumors. These losses are believed to contribute to the development of human cancer. Three of the most frequently deleted chromosomal loci contain the tumor suppressor genes p53, retinoblastoma (Rb), and mcc/apc. In order to detect loss of heterozygosity (LOH) within these genes in dysplastic and cancerous ulcerative colitis, we used an application of the polymerase chain reaction. LOH affecting p53 was observed in 8 of 17 (47%) of heterozygous patients, while LOH of Rb and the mcc/apc locus was observed in 9 of 27 (33%) and 13 of 39 (33%) of heterozygotes, respectively. Among 35 patients heterozygous at 2 or more loci, LOH of p53, Rb, and/or mcc/apc was observed in 18 (51%). LOH was more common in left-sided neoplasms. These data suggest that allelic deletion of p53, Rb, mcc, and/or apc is involved in the pathogenesis and/or progression of at least a subset of colonic dysplasias and carcinomas occurring in the setting of ulcerative colitis.

Adenomatous polyposis coli gene mutations in ulcerative colitis-associated dysplasias and cancers versus sporadic colon neoplasms.

Adenomatous polyposis coli (APC) gene mutations occur in most sporadic colonic adenomas and carcinomas. Precursor lesions of ulcerative colitis (UC)-associated colon carcinomas, although morphologically similar to sporadic adenomas, may be biologically distinct from them and are, in fact, managed differently. Since sporadic adenomas may also occur in UC, a method of discriminating between these forms of neoplasia could have clinical utility. We examined 33 patients with UC-associated dysplasias and cancers and 23 sporadic colon neoplasms in a side-by-side comparison for APC mutations. Codons 686-1693, containing 64% of all reported APC mutations (the mutation cluster region), were screened for truncating mutations using an in vitro synthesized protein assay. Two of thirty-three patients (6%) with UC-associated dysplasias and cancers had a total of three truncating APC mutations, all in frank carcinomas, while 17 of 23 (74%) with sporadic colonic neoplasms had mutations. DNA sequencing confirmed two mutations in codon 1460, replacing arginine with a stop codon, as well as one 2-base pair deletion, resulting in a frameshift and a stop at codon 1477. One specimen contained one each of these APC mutations. This apparent contrast in mutation rates at the mutation cluster region of APC is consistent with other biological characteristics separating sporadic colon neoplasms from UC-associated dysplasias and cancers. These data raise the possibility that nonadenomatous UC dysplasias may arise by a molecular pathway distinct from that prevailing in sporadic colon carcinogenesis, and they suggest a molecular assay to discriminate between sporadic adenomas and dysplasias occurring in UC.

Microsatellite instability in ulcerative colitis-associated colorectal dysplasias and cancers.

Microsatellites are short nucleotide repeat sequences present throughout the human genome. Alterations of microsatellites, comprising extra or missing copies of these sequences, have been termed microsatellite instability. This abnormality occurs in sporadic and hereditary adenocarcinomas of the proximal colon, as well as in many other tumor types. We determined whether microsatellite instability occurred in ulcerative colitis-associated cancers or precancerous dysplasias. Sixty-three patients were evaluated, consisting of 188 samples of genomic DNA (63 normal controls, 68 cancers, 52 dysplasias, and 5 adjacent tissues) at loci D2S119, D2S123, D2S147, D10S197, and D11S904. Multiplex polymerase chain reaction was performed using one radiolabeled nucleotide, and the products were electrophoresed on denaturing polyacrylamide gels. Seventeen of the 63 patients (27%) possessed lesions showing instability at 1 or more loci. Fourteen of 68 tumor samples (21%) and ten of 52 dysplasias (19%) displayed instability. There was no tendency for a greater number of loci to manifest instability in more advanced lesions. Neither anatomic location nor loss of heterozygosity at the p53 locus were associated with microsatellite instability by 2-way table analysis. These data support a role for defective DNA repair in the generation of a subset of both early and advanced ulcerative colitis-associated colorectal neoplastic lesions.

Microsatellite instability in inflammatory bowel disease-associated neoplastic lesions is associated with hypermethylation and diminished expression of the DNA mismatch repair gene, hMLH1.

Twelve to 15% of sporadic colorectal cancers display defective DNA mismatch repair (MMR), manifested as microsatellite instability (MSI). In this group of cancers, promoter hypermethylation of the MMR gene hMLH1 is strongly associated with, and believed to be the cause of, MSI. A subset of colorectal neoplastic lesions arising in inflammatory bowel disease (IBD) is also characterized by MSI. We wished to determine whether hMLH1 hypermethylation was associated with diminished hMLH1 protein expression and MSI in IBD neoplasms. We studied 148 patients with IBD neoplasms, defined as carcinoma or dysplasia occurring in patients with ulcerative colitis or Crohn's disease. MSI was evaluated using multiplex fluorescent PCR to amplify loci D2S123, BAT-25, BAT-26, D5S346, and D17S250 in all cases. Lesions were characterized as high-frequency MSI (MSI-H) if they manifested instability at two or more loci, low-frequency MSI (MSI-L) if unstable at only one locus, or MS-stable (MSS) if showing no instability at any loci. Methylation-specific PCR was performed to determine the methylation status of the hMLH1 promoter region. hMLH1 protein expression was also evaluated by immunohistochemistry. Thirteen (9%) of 148 neoplasms arising in IBD were MSI-H, comprising 11 carcinomas and 2 dysplastic lesions. Sixteen additional lesions (11%) were MSI-L, comprising 11 carcinomas and 5 dysplastic lesions. The remaining 118 neoplasms (80%) were MSS. Six (46%) of 13 MSI-H, 1 (6%) of 16 MSI-L, and 4 (15%) of 27 MSS lesions showed hMLH1 hypermethylation (P = 0.013). Diminished hMLH1 protein expression in neoplastic cell nuclei relative to surrounding normal cell nuclei was demonstrated immunohistochemically in four of four (100%) hypermethylated lesions tested. In IBD neoplasia, hMLH1 promoter hypermethylation occurs frequently in the setting of MSI, particularly MSI-H. Furthermore, hMLH1 hypermethylation and MSI are strongly associated with diminished hMLH1 protein expression in IBD neoplasms. These findings suggest that hMLH1 hypermethylation causes defective DNA MMR in at least a subset of IBD neoplasms.

Frequent mutation of the E2F-4 cell cycle gene in primary human gastrointestinal tumors.

The E2F group of transcription factors transactivates genes that promote progression through the G1-S transition of the cell cycle. Members of the retinoblastoma (Rb) family of proteins bind to E2Fs and inhibit this function. E2F-4, one example of the E2F group, functions as an oncogene when transfected into nontransformed cells in vitro. On the other hand, mice that are homozygously lacking a normal E2F-1 gene develop cancers, consistent with a tumor-suppressive role for this gene. The exact function of E2Fs has thus been unclear; moreover, direct involvement of this gene in primary human tumorigenesis has not been shown. We, therefore, investigated mutation within the E2F-4 coding region in 16 primary gastric adenocarcinomas, 12 ulcerative colitis-associated neoplasms, 46 sporadic colorectal carcinomas, 9 endometrial cancers, and 3 prostatic carcinomas. We limited our investigation to the serine repeat within E2F-4, reasoning that this tract might be altered in genetically unstable tumors (replication error-positive, or RER+). All tumors were RER+, with the exception of a control group of 15 RER- sporadic colorectal carcinomas. PCR with incorporation of [32P]dCTP was performed using primers flanking the serine trinucleotide (AGC) repeat. Twenty-two of 59 gastrointestinal tumors (37%) contained E2F-4 mutations; these comprised 5 of 16 gastric tumors (31%), 4 of 12 ulcerative colitis-associated neoplasms (33%, including 1 dysplastic lesion), and 13 of 31 sporadic colorectal cancers (42%). No mutation was present in any of the endometrial, prostate, or RER- colorectal tumors. Of note, homozygous mutations occurred in three cases, and two of seven informative patients showed loss of one E2F-4 allele in their tumors. Furthermore, the RER+ sporadic colorectal tumors were evaluated at trinucleotide repeats within the genes for N-cadherin and B-catenin; no tumors demonstrated mutation of these genes. These data suggest that E2F-4 is a target of defective DNA repair in these tumors.

Low prevalence of the APC I1307K sequence in Jewish and non-Jewish patients with inflammatory bowel disease.

A germline sequence alteration at codon 1307 of the APC gene (I1307K) has been reported in 6-7% of the Ashkenazi Jewish population in the United States. This alteration is believed to predispose the APC gene to a secondary mutation at the same locus, resulting in an increased risk of colorectal carcinoma. There is an increased risk of colorectal carcinoma in patients with inflammatory bowel disease (IBD), a relatively large proportion of whom are Ashkenazi Jews. We therefore sought to determine whether the I1307K sequence variant occurred in the germline DNA of IBD patients. To our surprise, we found this sequence in only two of 267 patients with IBD (0.7%), occurring in only 1.5% of Jewish IBD patients. The I1307K sequence variant was not found in 67 patients with esophageal cancer, 53 patients with gastric carcinoma (13 MSI-H and 44 MSI-negative), or ten patients with sporadic MSI-H colon cancer. These findings suggest that the I1307K sequence is relatively rare in the germline of Jewish as well as non-Jewish IBD patients. It does not appear to contribute to the increased colorectal cancer risk present in these patients.

Infrequent DPC4 gene mutation in esophageal cancer, gastric cancer and ulcerative colitis-associated neoplasms.

Homozygously Deleted in Pancreatic Cancer 4 (DPC4), a recently identified candidate tumor suppressor gene, was previously shown to be altered in human pancreatic cancers. We examined DPC4 mutation in 30 examples of three other types of gastrointestinal malignancy: 10 esophageal cancers, 10 gastric cancers and 10 colorectal cancers occurring in the preneoplastic condition, ulcerative colitis. The entire coding region of DPC4 (including all 11 exons) was analysed by either direct sequencing of PCR product or the in vitro synthesized protein assay. No coding region mutations of DPC4 were found in any of the samples examined. Our results suggest that inactivation of DPC4 may not be important in the majority of these types of gastrointestinal cancer.

FHIT gene alterations in esophageal cancer and ulcerative colitis (UC).

FHIT (fragile histidine triad gene), a candidate tumor suppressor gene, was recently identified and cloned at chromosome 3p14.2. Alterations of this gene have been reported in a number of primary human tumors, including colorectal, esophageal, gastric and lung carcinomas. However, some reports have found no abnormalities in this gene. We investigated a total of 63 primary esophageal tumors, nine esophageal cancer cell lines and 17 ulcerative colitis-associated neoplasms (UCANs) for alterations of FHIT. In 13 esophageal tumors, we employed overlapping reverse transcriptase-PCRs (RT-PCRs) to amplify and sequence the complete open reading frame of FHIT. One of 13 primary esophageal tumors analysed by RT-PCR expressed no detectable FHIT transcript; the remaining 12 expressed normal-sized transcripts with wild-type open reading frame sequences. In an additional 50 esophageal tumors, the polymorphic microsatellite loci D3S1300 and D3S1313 were used to evaluate loss of heterozygosity (LOH) at 3p14.2. Eleven of these 50 tumors showed LOH at one or both loci. In all these 11 tumors, genomic PCR and direct sequencing of FHIT exons 5-9 was performed. This analysis revealed that none of these 11 primary esophageal tumors contained any alterations in the FHIT open reading frame or adjacent intron sequences. Finally, among 17 UCANs, the in vitro synthesized protein (IVSP) assay detected no truncated protein products, nor were there any abnormalities in size or DNA sequence of FHIT RT-PCR products. However, in six of nine esophageal carcinoma cell lines, no FHIT RT-PCR product was detectable using either of the overlapping primer sets. Genomic PCR and direct sequencing of exons 5-9, also performed in these nine cell lines, revealed wild-type sequence in eight cell lines; however, one cell line contained no exon 5 PCR product. This cell line also lacked detectable FHIT transcript. These data suggest that the open reading frame of FHIT is not important in the development or progression of most primary esophageal carcinomas or UCANs, although lack of expression of the FHIT transcript may be common in esophageal cancer-derived cell lines. The possibility of an additional tumor suppressor gene at chromosome 3p14.2 remains to be evaluated.

Grb7 expression and cellular migration in chronic lymphocytic leukemia: a comparative study of early and advanced stage disease.

Grb7, a noncatalytic intracellular adaptor protein involved in cell migration, is overexpressed in certain invasive and metastatic solid tumors. We found a highly significant difference in the level of expression of Grb7 between chronic lymphocytic leukemia (CLL) cells obtained from stage I and stage IV patients (P<0.001). Using semiquantitative RT-PCR, we detected high levels of Grb7 in 88% of stage IV patients vs only 18% in stage I patients. A corresponding increase was found in the in vitro migration of stage IV CLL cells in comparison to stage I cells. The statistically significant difference in the expression of Grb7 between stage IV and stage I patients was preserved even when tested specifically in the ZAP70-positive group (P<0.01). These findings show that Grb7 levels reflect the severity of the disease, and may be used, in conjunction with ZAP70, to predict disease progression.

Leukocyte adherence inhibition (LAI) for detecting specific tumor immunity in colorectal cancer.

Immunity to colorectal cancer antigen was tested by the tube leukocyte adherence inhibition (LAI) assay, using spent medium of human carcinoma cell lines as a source of antigen. The assay was positive in 18 out of 43 patients (41%) with colorectal tumor in comparison to only 2 out of 34 (5.8%) of colorectal cancer patients clinically free of disease, and to 4 out of 150 (2.6%) healthy subjects. The frequency of positive results correlated negatively with the tumor burden, 16 out of 29 (55.1%) patients with Dukes' A, B and C being positive compared to only 2 out of 14 (14.2%) patients with Dukes' stage D disease. Addition of PGE2 enhanced the sensitivity of the assay without affecting its specificity. The number of positive assays increased from 18 to 32 (41.8% to 74.4%) in the whole group of 43 colorectal cancer patients without altering significantly the frequency of positive results in the control group. The results with all groups of patients were influenced similarly by the addition of prostaglandins, the frequency of positive assays increasing from 55.1% to 82.7% and from 14.1% to 57.1% in early and advanced disease, respectively. These results lend further support to the value of the LAI assay in diagnosis and monitoring of the immune response in human colorectal cancer.

Sialyl-tn antigen expression in Crohn's colitis.

SUMMARY: : Expression of the mucin-associated sialyl-Tn (STn) antigen is correlated with malignant progression in the colon. In patients with longstanding ulcerative colitis (UC) who never exhibited colonic dysplasia, STn was expressed in fewer than 15% of nondysplastic surveillance colonoscopic biopsies, whereas matched patients who developed colon cancer expressed STn in >40% of previous surveillance biopsies, often several years before the first detection of dysplasia. Since no study has systematically examined STn expression in Crohn's colitis, we performed immunohistochemical staining with monoclonal antibody TKH2 on 110 surgical specimens from 59 patients with Crohn's colitis or ileocolitis. Forty percent of specimens expressed STn antigen. STn was preferentially expressed in specimens of the left colon, regardless of whether the patient had segmental left-sided disease or pancolitis. Specimens with active inflammation manifested increased STn expression, regardless of location in the colon or whether the patient had segmental disease or pancolitis. The enhanced expression of STn in Crohn's colitis compared with UC may reflect important differences in local cytokine profiles between the two inflammatory bowel diseases.

p53 protein expression in ulcerative colitis-associated colorectal dysplasia and carcinoma.

The frequency and timing of p53 inactivation in ulcerative colitis (UC)-associated tumorigenesis were investigated using immunohistochemistry (IHC) to detect p53 protein overexpression in 56 carcinomas and 40 dysplastic epithelia derived from 58 patients with UC undergoing colectomy for neoplasia. p53 DNA in 25 of the carcinomas also was evaluated by single-strand conformation polymorphism analysis (SSCP) to detect point mutations in exons 5-8 and by loss of heterozygosity analysis to detect allelic deletions. Point mutations were detected in 20 of the 25 carcinomas (80.0%) undergoing both IHC and DNA analysis. One carcinoma contained an allelic deletion but no mutations of the corresponding allele within the region tested. p53 overexpression occurred in 16 (76.2%) of the 21 carcinomas with point mutations and/or allelic deletions but not in any of those with wild type DNA. Of the 56 carcinomas evaluated by IHC, p53 overexpression occurred in 34 carcinomas (60.7%). The proportion of positive tumors was independent of stage, anatomic location, differentiation, and histological subtype. Overexpression was observed in nine of 20 dysplastic masses devoid of and situated remote from carcinoma (45.0%) and correlated positively with increasing grade of dysplasia (P < .025). In contrast, overexpression occurred in 16 of 20 dysplastic epithelia situated adjacent to carcinoma (80.0%) and correlated with overexpression by the corresponding carcinomas but not with the grade of dysplasia present (P = .013). It is concluded that p53 overexpression can be detected by IHC in most, although not all, UC-associated carcinomas with p53 mutations and/or allelic deletions. Based on this method, p53 overexpression occurs frequently in UC-associated carcinomas regardless of stage and pathological characteristics, in noncancerous dysplastic masses with high grade dysplasia, and in dysplasias of all grades situated adjacent to carcinomas. These findings implicate p53 inactivation in the progression from dysplasia to carcinoma in UC and suggest that its occurrence in dysplastic epithelium may be an independent marker of malignant potential.

Polymorphous low-grade adenocarcinoma of seromucous glands of the nasopharynx. A report of a case and a discussion of the morphologic and immunohistochemical features.

Polymorphous low-grade adenocarcinoma (PLGA) is a minor salivary gland neoplasm that is characterized by morphologic variability, cytologic uniformity, and an infiltrating growth pattern. To date, this entity has been identified either within the confines of the oral cavity or, rarely, in the nasal cavity. The authors report a case of PLGA that arose in the nasopharynx of a 44-year-old female, representing the first documented occurrence of this tumor outside the oral cavity or the sinonasal tract. The histopathologic and immunohistochemical differentiation from pleomorphic adenoma and adenoid cystic carcinoma is discussed.

Inflammatory pseudotumor of the thymus.

A 44-year-old man with inflammatory pseudotumor of the thymus is reported. The patient was seen with fever, myalgia, and dyspnea and was found to have an anterior mediastinal mass and bilateral pleural effusions. The resected lesion consisted of a well-circumscribed mass of chronic inflammatory and fibrous tissue that virtually replaced the thymus. There was no morphological evidence of neoplasia. The patient's symptoms and roentgenographic abnormalities resolved with excision of most of the mass. To our knowledge, this report is the first instance of inflammatory pseudotumor of the thymus.

Anti-tumor immunity in breast cancer evaluated by a computerized tube leukocyte adherence inhibition (LAI) assay.

Seventy-four women admitted for breast biopsy were monitored before surgery for anti-tumor cell-mediated immunity using a computerized tube leukocyte adherence inhibition (LAI) assay. Spent medium from breast, lung and colon adenocarcinoma cell lines was used as the source of organ-specific neoantigens for standardization of the assay. Peripheral blood leukocytes from 25/40 (62.5%) patients diagnosed after surgery as breast cancer responded to spent medium with a positive non-adherence index (NAI). A positive NAI was inversely related to tumor mass because only 7/18 (38.8%) of those with Stage III or IV had a positive NAI; while 18/22 (81.8%) of those with Stage I or II were positive. Cross-reactive antigenicity was not observed when spent medium from breast cancer was incubated with leukocytes from patients with several other solid tumors nor when leukocytes from breast cancer patients were incubated with spent medium from lung or colon carcinoma cell lines. The antigenic material in the spent medium appears to be an organ-specific neoantigen because only 1/34 patients with benign breast disease had a positive NAI and all normal healthy control individuals were negative. The results of this study show that spent medium of a breast carcinoma cell line is more reliable than crude cancer extracts for use in LAI to detect specific anti-tumor cellular immune responses. The improved method presented in this report can be a useful tool in the early diagnosis of breast cancer and for monitoring of patients with this disease.