[Diagnosis and immunohistochemistry of medullary breast cancer]. / Diagnostik und Immunhistochemie des medullären Mammakarzinoms.

Medullary carcinoma of the breast has a relatively favorable prognosis despite its malignant histopathological appearance, providing a challenge for the pathologically based diagnosis of breast cancer. Macroscopic and microscopic findings combined provide diagnostic criteria. The importance of the immunophenotype of medullary carcinoma is not well defined. Because the reproducibility of morphological criteria is limited, we conducted an immunohistochemical study in search of markers that could facilitate histopathological classification. We examined 32 medullary carcinomas in comparison with 30 high grade ductal invasive carcinomas with similar morphology using 23 different immunohistochemical markers. The results showed an overlap with the so called basal like subtype of invasive breast cancer (negativity for steroid hormone receptor, positivity for basal cytokeratins). None of the immunohistochemical markers enabled a specific discrimination between the two groups. Medullary carcinomas overexpress EGF-R more frequently (P<0.004). In combining the characteristic morphological criteria and the immunohistochemical detection of the basal like phenotype and EGFR, a higher diagnostic accuracy can be achieved. The immunophenotype alone does not allow a definite classification of medullary carcinoma.

Severe intestinal bleeding caused by intestinal metastases of a primary angiosarcome of the thyroid gland.

A 75 year old male presented with gastrointestinal bleeding after resection of both upper lobes of the lungs because of metastases. One year ago an angiosarcoma was the reason for a complete removal of the thyroid gland. In esophago-gastro-duodenoscopy we found multiple hemorrhagically stained polyploids lesions in the postbulbar duodenum and jejunum. Colonoscopy showed isolated polyploid lesions of the right flexura. Because of persistent gastrointestinal bleeding a diagnostic laparotomy was done. Intraoperative intestinoscopy demonstrated multiple bleeding metastasis. To remove many of the bleeding lesions two longer intestinal segments of the jejunum and ileum were resected. The histology of the metastases showed arrangements of polygonal cells with prominent nucleoli and atypical mitosis. Immunohistochemistry identified CD 31, vimentin and factor VIII associated antigen. There was an erosion of the superficial intestinal mucosal cells with resulting hemorrhage; same histology had been found in the thyroid gland and the right upper lobe of lung. Eight days after surgery the patient died because of respiratory and circulatory insufficiency.

Genotype and phenotype of a new 2-bp deletion of hMSH2 at codon 233.

Germline mutations within mismatch repair genes, such as hMSH2, hMLH1, and hMSH6, have been shown to be the hallmark of the hereditary nonpolyposis colorectal cancer (HNPCC) syndrome. The spectrum of tumors associated with mismatch repair gene defects and the possible relationship between genotype and phenotype are still unclear. Therefore, the spectrum of tumors and the possible genotype-phenotype relationship are still under discussion. Here, we report on a family with a new germline mutation in the hMSH2 gene with a 2-bp deletion at codons 232 and 233 leading to a frame shift and a stop at codon 254. Accordingly, immunohistochemistry revealed loss of hMSH2 expression in colorectal carcinomas of three affected family members. In this one family, there was a high penetrance. Interestingly, mutational screening of the family revealed a high penetrance of the mutation affecting four of five tested people at risk, with a high mortality rate and a trend toward lower age of onset in subsequent generations. Finally, a metachronous breast cancer in one patient turned out to be a tumor unrelated to microsatellite instability phenocopy, i.e., a sporadic tumor unrelated to HNPCC that expressed the hMSH2 gene and did not show any microsatellite instability.

[Histopathologic breast diagnosis in view of consultant studies of the Mamma-Regisstry Fulda]. / Histopathologische Mammadiagnostik im Spiegel konsiliarischer Untersuchungen des Mamma-Registers Fulda.

The Mamma-Registry Fulda, founded in 1976 by the senior co-author, is a personal service for pathologists having problems with histological diagnosis of breast diseases. From nearly 7000 cases filed up to now we selected 1112 consecutive consultations from 1996 to 1999 for this study. The aims were a critical analysis of a "submission-profile" and for each case a comparison of submitters' diagnoses with that of the register to crystallize special fields of problems in histopathological diagnosis and to make a statement about quality standards which was shown in a raster of results. The submitted cases came from pathologists in university institutes (13.9%), city hospitals (49.0%), group practices (24.2%), and single practices (11.6%). The material consisted of selected paraffin-blocs in about two thirds and of slides only in less than one third. The sendings were accompanied by letters with sufficient information on history, clinical background, and gross findings in 72%, and in an additional rate of 17.1% by copies of the histological reports already given by the submitters to their clinicians. The main reasons for consultations were a primarily uncertain diagnosis (45.8%) or the request to affirm a more or less definite diagnosis (40.7%) in cases of rare lesions or differing judgements in the submitting institution. Each diagnosis of the registry was coded in a special diagnostic key. In a raster of results the diagnosis of each case was listed as identical (55.0%) when there was complete agreement between submitter's and register's result, as included (23.9%) when one of the differential diagnoses named by the submitter fitted the register's diagnosis, and as different (6.7%) when there was only agreement about the dignity of differently classified lesions. False positive (2.3%) and false negative (4.5%) diagnoses of submitters were subclassified as clinically irrelevant (2.6%) and relevant (4.2%). The most often missed diagnostic entity in the latter group was tubular carcinoma. Overall the results of the study justify awarding a high standard of quality to histopathological diagnostics.

Effect of changing the weekly dose intensity of fractionated irradiation on local control of two human squamous cell carcinomas in nude mice.

PURPOSE: To compare the effect of fractionated irradiation with increasing, constant or decreasing weekly dose intensity on local tumour control. MATERIALS AND METHODS: Human squamous cell carcinomas, FaDu and GL, were grown in nude mice. Thirty fractions were applied under ambient conditions with increasing, constant or decreasing weekly dose intensity within a constant overall treatment time of 6 weeks. Dose intensity was changed every 2 weeks. Irradiations were terminated in some groups of animals after 20 fractions in 4 weeks. Endpoint was the tumour control dose 50% (TCD50) at day 120 (FaDu) or day 180 (GL) after end of treatment. RESULTS: In FaDu tumours the TCD50 value of 60 Gy (95% CI 56; 63) for fractionated irradiation with decreasing dose intensity, i.e. high initial doses, was slightly but significantly lower than the TCD50, of 68 (60; 81) after low initial doses (p=0.03). The TCD50 value of 62 Gy (57; 68) after constant doses was intermediate (constant vs increasing p =0.30; constant vs decreasing p=0.15). The higher efficacy of high initial doses in FaDu tumours was explained by local control occurring already during the course of irradiation. In GL tumours the TCD50 values were 52 Gy (43; 62) after high initial dose intensity, 50 Gy (43; 66) after constant doses, and 55 Gy (42; 89) after low initial dose intensity. These values were not statistically different (p-values 0.20-0.75). CONCLUSIONS: The data support the view that initial dose concentration during fractionated irradiation does not enhance radioresistance of FaDu and GL tumours, for instance by an earlier onset of clonogen repopulation.

Epstein-Barr virus DNA, intermediate filaments and epithelial membrane antigen in nasopharyngeal carcinoma.

The aim of this study was to investigate the expression of intermediate filaments (cytokeratin, vimentin), epithelial membrane antigen (EMA) and the presence of Epstein-Barr virus (EBV) DNA in undifferentiated nasopharyngeal carcinoma (NPC). A high incidence of nuclear signals in NPC was found in primaries and regional lymph node metastases (70%), using 35S-labelled probes of EBV plasmids for in-situ hybridization. Keratinizing squamous cell carcinomas were EBV-negative. All carcinomas were immuno-reactive for cytokeratin (KL-1). 45% of the carcinomas were positive for vimentin. The expression of epithelial membrane antigen was restricted to epithelial cells and reduced in NPC as compared to the distribution pattern of cytokeratin. Both EBV DNA and vimentin in NPC were present in 9 cases. However, in 5 cases NPC were harboring EBV but were not immunoreactive for anti-vimentin antibodies. In no case was a vimentin-positive NPC also EBV-negative. The identification of cytokeratin subtypes revealed no specific cytokeratin pattern in NPC. The expression of vimentin in NPC is not specific for EBV, but seems to reflect the loss of inter-epithelial contact in anaplastic carcinomas.

Distribution of collagens in carcinomas of salivary and mammary gland origin in irradiated rats.

OBJECTIVE: While radiation-induced sarcomas or carcinomas following chemical carcinogens are well-documented in rats, radiation-induced carcinomas, especially adenoid-cystic carcinomas (ACC) and adenocarcinomas, originating from the head and neck region, including the major salivary glands (SG) are rarely reported. Because in human ACC of the SG structural changes of the basement membrane (BM) with positive correlation of tumor differentiation loss and BM thinning have been described, this study set out to analyze collagen distribution in malignant rat tumors (TM) developing inside the radiation field (RF) and spontaneously. The TM arose in the course of studies on other questions regarding radiation effects following fractionated radiation (2 Gy/day, 5 times a week; total dose 60 Gy). METHODS: We investigated 22 TM (14 malignant, 8 benign) of 22 female Wistar rats. The RF comprised the left head and neck area. Besides assessment of hematoxylin-eosin (HE)-stained sections collagens (C; types III and IV) were investigated using immunohistochemical methods. RESULTS: Nine malignant TM originated from the SG, a further three from the milk line and two from the maxilla. Two ACC, two cystadenocarcinomas, one microcystic adenocarcinoma and four squamous cell carcinomas (SCC) arising from the SG (one SCC was observed in the maxilla) developed in the RF. One microcystic adenocarcinoma, one ACC and one adenocarcinoma with sebaceous differentiation arising from the milk line and one SCC arising from the maxilla were found in non-irradiated animals. As typical results, in the ACC (glandular subtype), C III was detected in the interstitium with sometimes stronger staining surrounding myoepithelial cells (MC) and excretory duct structures (ECD). Weak C IV staining in a string-like fashion was found in ECD and MC. In larger pseudocysts the lumen contained substances reacting with C IV antibodies. In the cystadenocarcinomas and the microcystic adenocarcinomas reactions at variable levels after anti-C III incubation were found close to modified MC and ECD with transition to the interstitium. C IV was more intensely stained in these entities, in part continuously and with broadening around MC and ECD. However, especially in more anaplastic parts of the tumor, fragments, interruptions or loss of the BM were noted. Focal interstitial immunoreactivity, e.g. conglomerates, was also identified. CONCLUSION: In rat carcinomas collagen detection was partially of a continuous layer, even with BM thickening and more extended deposition. In contrast, BM fragmentation or loss was displayed more often in anaplastic parts of the tumor. Also, the interstitium showed conglomerated collagen formations. Therefore, the increasing loss of BM in rat SG tumors is similar to that in humans and in both species is a sign of dedifferentiation.

Cytokeratin expression in carcinomas of irradiated rats.

OBJECTIVE: Laboratory rats can develop benign or malignant tumors (TM) spontaneously or following various carcinogenic processes, e.g. irradiation. The effects of irradiation vary according to the irradiation field (RF), the dosage and the strain of rat. Radiation-induced malignant TM in rats are predominantly sarcomas. Carcinomas, especially adenoid-cystic carcinomas (ACC) and adenocarcinomas of the head and neck region, are rarely reported in rats. The aim of this study was to add to the knowledge on ACC and adenocarcinomas in rats developing inside the RF and spontaneously. The TM arose in the course of studies on other questions of radiation effects following fractionated irradiation (2 Gy/day, 5 times a week up to a total dose of 60 Gy). METHODS: We investigated 22 TM (14 malignant, 8 benign) of 22 female Wistar rats. Ten malignant TM developed in the RF and 4 outside of the left head and neck area. The RF comprised the left neck, extending from left auricle to left clavicle and included the midline organs of the neck. Besides assessment of hematoxylin-eosin (HE)-stained sections, epithelial differentiation was investigated using cytokeratin (CK) antibodies against CK 5/6, CK 7, CK 8/18, CK 13/15/16, CK 17 and CK 20 and the LSAB-2 detection system. RESULTS: Nine malignant TM originated from the major salivary glands (SG), a further three from the milk line and two from the maxilla. Using HE staining the pattern of rat malignant TM differed from that found in humans and was difficult to interpret. Two ACC, two cystadenocarcinomas, one microcystic adenocarcinoma and four squamous cell carcinomas (SCC) arising from the SG (one SCC was observed in the maxilla) developed in the RF. One microcystic adenocarcinoma, one ACC and one adenocarcinoma with sebaceous differentiation arising from the milk line and one SCC arising from the maxilla were found in non-irradiated animals. As typical results, in the ACC CK 17 was distinctly immunoreactive in excretory duct structures (ECD). CK 5/6 and CK 13/15/16 were marked at variable levels in myoepithelial cells (MC) and in basal cells of ECD. In the cystadenocarcinomas the ECD were clearly identified with CK 17 and CK 8/18 antibodies. MC and basal cells of ECD were positive for CK 5/6 and CK 13/15/16 antibodies. CONCLUSION: The CK expression profile of these rare and aggressive TM in rats differed according to the entity and SG structure. The differentiation markers were predominantly found in ECD and in modified MC. Concerning the growth pattern of the TM, the variation in size of the cysts and pseudocysts was remarkable. The unusual tumor features reduced the comparability with humans. The differentiation pattern did not differ noticeably between TM originating inside or outside the RF. Identification of CK subtypes in rat tumors facilitates their differential diagnosis.

Rat tumors following fractionated irradiation.

BACKGROUND: Rats are susceptible to irradiation and can develop benign and malignant tumors either spontaneously or in the field of irradiation. In the head and neck region, there are no reports available on the type of tumor after fractionated irradiation using a human therapy protocol. MATERIAL AND METHODS: We analyzed 19 tumors, in 19 rats, which developed after external X-irradiation of the left neck area in Wistar rats (2 Gy/day, monofractions, 5 days/week, total dosage 60 Gy) and compared the findings with tumors in untreated rats of the same strain. RESULTS: Tumors in the irradiation field proved to be squamous cell carcinoma or adenoid cystic carcinoma (ACC), not sarcoma. These entities were sporadically found in non-irradiated rats at a higher age. CONCLUSIONS: ACC has rarely been reported in the literature on laboratory rats. The development of this highly aggressive malignant tumor can be expected 3 months to 1 year after completion of irradiation.

[Benign proximal esophageal stenosis--mostly a complication of gastroesophageal reflux disease]. / Die benigne proximale Osophagusstenose--zumeist Komplikation der gastroösophagealen Refluxkrankheit.

BACKGROUND AND OBJECTIVE: Benign stenoses can occur anywhere in the oesophagus, but are most common in its distal part as a result of gastro-oesophageal reflux (GOR). It was the aim of this study to evaluate retrospectively the causes and incidence of benign stenosis of the proximal oesophagus (SPR) as well as its endoscopic and drug treatment. PATIENTS AND METHODS: Between December 1989 and December 1997 a total of 17,413 patients were referred to the authors' hospital for oesophago-gastroduodenoscopy, 1024 of them (6%) for clarification of heartburn, regurgitation and/or dysphagia. 53 of these patients (5%) were found to have benign stenosis of the oesophagus requiring bougie dilatation, located in the lower third in 29 (55%), in the middle third in six (11%) and in the upper third in 18 (34%) patients. Causes of stenosis in the upper third were peptic stricture in nine (50%), heterotopic gastric mucosa in three (17%), caustic corrosion in three (17%), post-radiation in two (11%), and the result of web formation in one (6%). Endoscopic bougie dilatation was performed in all these patients, those with GOR additionally receiving 40 mg omeprazole daily. RESULTS: In those patients with nonpeptic benign stenosis/stricture lasting improvement of symptoms was achieved with one to three dilatation. But those with GOR needed a mean of 13 dilatations during a follow-up period averaging 61 months. Barrett's oesophagus (replacement of squamous by columnar epithelium) was found in five patients. No case of dysplasia was discovered. Laparoscopic fundoplication was performed in one woman in whom bougie dilatation had failed. Remission was maintained, as needed, by bougie and omeprazole in eight patients. CONCLUSION: In benign stenosis of the upper oesophagus endoscopic dilatation is the treatment of choice. In cases of peptic aetiology the administration of proton pump inhibitors is the optimal adjuvant method.

[Is chronic laryngitis associated with Helicobacter pylori? Results of a prospective study]. / Ist die chronische Laryngitis Helicobacter-pylori-assoziiert? Ergebnisse einer prospektiven Studie.

H. pylori is found in the stomach of patients with chronic gastritis. The infection is usually transmitted by the gastro-oral route and bacteria could be identified in saliva and dental plaque. An essential cause of chronic laryngitis is gastroesophageal reflux. The aim of the study was to evaluate if a H.pylori-associated chronic laryngitis exists. 38 patients with chronic laryngitis underwent gastroscopy. Biopsies were taken from the gastric antrum and body, lower, middle and upper esophagus. H. pylori was diagnosed by rapid urease test and histology. 14 of the patients (36.8%) were H.pylori-positive, but the bacteria could not be identified between stomach and larynx. 24 patients were H. pylori-negative. Seven patients (18.4%) suffered from esophagitis, six of these patients were H. pylori-negative. The H. pylori-infected patients received triple therapy for one week, in case of esophogitis Omeprazole 20 mg BID was prescribed. Six weeks later a follow-up endoscopy was performed. The eradication rate was 12/14 (85.7%), in all patients with reflux the esophagitis was cured. The laryngitis was clinically and endoscopically unchanged in ten of the twelve (83.3%) patients after successful treatment for H. pylori; in the remaining two patients as well as in the two H. pylori-positive patients the laryngitis was improved. In six out of the seven patients with esophagitis the laryngitis had healed completely and was improved in the remaining patient. It may be concluded that there is no evidence for the existence of H. pylori-associated laryngitis, suggesting that acid reflux is the underlying etiology.

Linear-quadratic analysis of tumour response to fractionated radiotherapy: a study on human squamous cell carcinoma xenografts.

PURPOSE: To compare values for the alpha/beta ratio in experimental tumours irradiated either under conditions of clamping and short overall time or under more 'clinically realistic' conditions. MATERIALS AND METHODS: Human squamous cell carcinomas, FaDu and GL, were grown in nude mice. Alpha/beta values were determined from local tumour control data after treatment with single doses and 2, 4, and 8 fractions under clamp hypoxia in 3.5 days, using maximum likelihood analysis. Effective alpha/beta values (alpha/beta(eff)) were determined from treatment with 12, 30, and 60 fractions under ambient conditions in a constant overall treatment time of 6 weeks. RESULTS: After correction for an oxygen enhancement ratio of 2.7 the alpha/beta values were 15 Gy (95% CI 9; 24) for FaDu and 49 Gy (26; 122) for GL. In FaDu the TCD50 values after 12 to 60 fractions were not significantly different, the alpha/beta(eff) value was infinite (52; inf.). Unexpected from the high alpha/beta value, the TCD50 values of GL tumours increased from 37 Gy (28; 47) after 12 fractions to 59 Gy (52; 67) after 60 fractions: the alpha/beta(eff) value was 3 Gy (0.6; 12 Gy). CONCLUSIONS: The results support the view that mechanisms other than recovery from sublethal radiation damage and repopulation of clonogenic tumour cells may importantly impact on treatment outcome when the number of fractions is changed in clinical radiotherapy.

[Small-cell sarcoma of the esophagus as a fourth malignancy. Its palliative therapy with argon gas coagulation]. / Kleinzelliges Sarkom des Osophagus als viertes Malignom. Palliative Therapie mit Argongaskoagulation.

HISTORY: A prostatic carcinoma, an early gastric carcinoma and a colon carcinoma had occurred over 15 years in a now 82-year-old patient. He was now admitted because of severe dysphagia. INVESTIGATIONS: Gastroscopy revealed an exophytic tumour of the oesophagus, histologically identified as a small-cell sarcoma. It had caused a 12 cm long severe eccentric stenosis of the oesophagus. Tissue from the previous three tumours were examined immunohistochemically for p-53 gene mutation, but only the oesophageal sarcoma gave positive results. TREATMENT AND COURSE: After part of exophytic tumour had been ablated by argon gas coagulation a prosthetic tube was implanted. Bleeding from erosion of a large metastasis in the gastric fundus was successfully treated by argon gas coagulation 4 months after the previous discharge, but the patient died of the malignancy 1/1 and half months later. CONCLUSIONS: The consecutive occurrence of four different malignant tumours is rare even in advanced age. In this case the malignancies were presumably unrelated and it demonstrates the possibility of removing an eccentric tumour stenosis by argon gas coagulation before implanting a prosthesis.

Long-term results of patients with clinical stage C prostate cancer treated by phototherapy and early orchiectomy. A retrospective analysis of 169 cases.

BACKGROUND: To evaluate the value of radiotherapy and immediate hormonal therapy in the treatment of stage C prostate cancer. PATIENTS AND METHOD: From 1977 to 1986, 169 patients with clinically stage C prostate cancer underwent irradiation with curative intent following early orchiectomy. Sixty-four patients had a transurethral resection, 22 patients a prostatectomy and 83 patients had only a biopsy. In 38 patients a grade Ia/b tumor was found, in 78 patients a grade IIa/b tumor and in 43 patients a grade IIIa/b tumor using the German grade of malignancy. Treatment fields included the prostate, the seminal vesicles and the locoregional lymphatics. Until 1979 the dose was 60 Gy for the tumor encompassing isodose and from then on 65 Gy with a single dose of 2 Gy. RESULTS: With a median follow-up of 98 months, the overall survival rate for 8 and 10 years was 51% and 37% and the cause specific survival rate was 84% and 77%, respectively. Thirty-two patients (19%) developed distant metastases. Patients with local tumor control (n = 148) had a significantly better overall survival rate of 45% for 10 years compared to patients with clinical local progression of disease (n = 21) of 22% (p < 0.05). Multivariate analysis showed the grade of malignancy and local control as independent factors for overall survival and cause-specific survival (p < 0.05). Twenty-three patients (14%) had at least one late side effect for the rectum or the bladder, in almost all cases grade I or II. Five patients (3%) showed severe late side effects RTOG grade III (n = 2) or IV (n = 3). One patient had a colostomy, in 2 patients a severe haemorrhagic cystitis was seen. CONCLUSIONS: Radiotherapy with photons and early orchiectomy for patients with stage C prostate cancer achieves high local control rates and a 30% to 40% 10-year survival rate with a low incidence of late side effects. The value of the radiotherapy of the locoregional lymphatics remains controversial.