Diagnostic Performance of Magnetic Resonance Enterography Disease Activity Indices Compared with a Histological Reference Standard for Adult Terminal Ileal Crohn's Disease: Experience from the METRIC Trial.

BACKGROUND AND AIMS: The simplified magnetic resonance enterography [MRE] index of activity [sMARIA], London, and 'extended' London, scoring systems are widely used in Crohn's disease [CD] to assess disease activity, although validation studies have usually been single-centre, retrospective, and/or used few readers. Here, we evaluated these MRE indices within a prospective, multicentre, multireader, diagnostic accuracy trial. METHODS: A subset of participants [newly diagnosed or suspected of relapse] recruited to the METRIC trial with available terminal ileal [TI] biopsies was included. Using pre-specified thresholds, the sensitivity and specificity of sMARIA, London, and 'extended' London scores for active and severe [sMARIA] TI CD were calculated using different thresholds for the histological activity index [HAI]. RESULTS: We studied 111 patients [median age 29 years, interquartile range 21-41, 75 newly diagnosed, 36 suspected relapse] from seven centres, of whom 22 had no active TI CD [HAI = 0], 39 mild [HAI = 1], 13 moderate [HAI = 2], and 37 severe CD activity [HAI = 3]. In total, 26 radiologists prospectively scored MRE datasets as per their usual clinical practice. Sensitivity and specificity for active disease [HAI >0] were 83% [95% confidence interval 74% to 90%] and 41% [23% to 61%] for sMARIA, 76% [67% to 84%] and 64% [43% to 80%] for the London score, and 81% [72% to 88%] and 41% [23% to 61%] for the 'extended' London score, respectively. The sMARIA had 84% [69-92%] sensitivity and 53% [41-64%] specificity for severe CD. CONCLUSIONS: When tested at their proposed cut-offs in a real-world setting, sMARIA, London, and 'extended' London indices achieve high sensitivity for active TI disease against a histological reference standard, but specificity is low.

A lesson in clinicopathological correlation: Plaque-like myofibroblastic tumour presenting as a pruritic plaque in childhood.

Plaque-like myofibroblastic tumour (PLMT) is a rare skin condition which presents in childhood and infancy as a nodular fibrous plaque. Including our case, there are currently only 14 cases reported in the literature. Although it represents a well-defined clinicopathological diagnosis, there is significant under-reporting of this condition secondary to under-recognition and potential misdiagnosis as dermatofibroma.

Axillary Web Syndrome: Evidence for Lymphatic Origin with Thrombosis.

Background: The axillary web syndrome (AWS) occurs in the axilla and on the frontal side of the upper arm and sometimes along the forearm to the thumb. The cord is painful, particularly on movement, and can therefore be very distressing for the patient. Although the phenomenon has been examined and discussed for decades, no evidence for the origin has been found until now. The aim of this study was to perform a histopathologic analysis of cords taken between 1996 and 1998 in the Surgical Clinic, Skane University Hospital, Lund, Sweden. Methods and Results: In seven patients, biopsies of the AWS cords were obtained 4-5 weeks after axillary node surgery for breast cancer and examined with standard hematoxylin and eosin and D2-40 (lymphatic endothelial cell) staining. In one biopsy, there was a dilated vessel with a thickened wall, which was confirmed by D2-40 immunostaining to represent a lymphatic vessel. The lumen was occluded by organized thrombus, within which new vessels were being formed, indicating recanalization. In two other biopsies, similar lymphatic vessels with thickened walls were present, although the lumen of the vessels was not visualized in the planes of the section. The other four biopsies do not show specific features. Conclusion: Although only one case, this is the first pathological evidence of thrombosis within a confirmed lymphatic vessel from a case of cording. We propose that the axillary cord represents lymphatic vessel thrombosis. Recanalization of the thrombus may eventually restore lymphatic flow consistent with the transient nature of the condition.

Plaque-like Myofibroblastic Tumor: 2 Cases of This Unusual Dermal Tumor Which Occurs in Infancy and Early Childhood.

Plaque-like myofibroblastic tumor (PLMT) is a rare dermal spindle cell tumor which occurs in infancy or childhood within the first 4 years of life. The tumor is often pruritic and mostly presents on the lower back. We describe 2 cases with characteristic clinical and histological features of this entity, thus adding to the 10 cases which have so far been reported. Histologically, the lesion resembles a dermatofibroma. However, diffuse and uniform immunohistochemical staining with smooth muscle actin favors a myofibroblastic lineage. PLMT should be considered in the differential diagnosis of a dermal spindle cell tumor in the pediatric age-group.

ETS1, nucleolar and non-nucleolar TERT expression in nevus to melanoma progression.

TERT (telomerase reverse transcriptase) is the catalytic component of telomerase. TERT shows little expression in normal somatic cells but is commonly re-expressed in cancers, facilitating immortalization. Recently-discovered TERT promoter mutations create binding sites for ETS-family transcription factors to upregulate TERT. ETS1 is reported to be important for TERT upregulation in melanoma. However it is unclear when in melanoma progression TERT and ETS1 proteins are expressed. To elucidate this question, ETS1 and TERT immunohistochemistry were performed on a panel of benign (n=27) and dysplastic nevi (n=34), radial growth phase (n=29), vertical growth phase (n=25) and metastatic melanomas (n=27). Lesions were scored by percentage of positive cells. ETS1 was readily detectable in all lesions, but not in normal melanocytes. TERT was located in either the nucleolus, the nucleoplasm (non-nucleolar) or both. Non-nucleolar TERT increased in prevalence with progression, from 19% of benign nevi to 78% of metastases. It did not however correlate with cell proliferation (Ki-67 immunostaining), nor differ significantly in prevalence between primary melanomas with or without a TERT promoter mutation. These results demonstrate that ETS1 is expressed very early in melanoma progression, and interestingly only non-nucleolar TERT correlates clearly in prevalence with melanoma progression. It can be acquired at various stages and by mechanisms other than promoter mutations.

Ano-genital Granulomatosis and Crohn's Disease: A Case Series of Males Presenting with Genital Lymphoedema.

BACKGROUND AND AIMS: Ano-genital granulomatosis is a rare chronic granulomatous condition of the skin that causes lymphoedema of the external genitalia. There is a reported association with Crohn's disease. Mechanisms of disease and optimal methods of treatment are poorly understood. METHODS: A retrospective casenote review of 25 male patients with ano-genital granulomatosis presenting with genital lymphoedema was performed to determine the clinical and histopathological features of this condition and its relationship to intestinal Crohn's disease. RESULTS: A combination of penile and scrotal oedema was reported at presentation in 80% of patients; 40% of patients had associated intestinal Crohn's disease. The average time from symptom onset to diagnosis was 52.7 months. Half of cutaneous biopsies contained non-caseating granulomas and 14% contained intralymphatic granulomas. In all, 72% of patients responded to oral steroids initially but recurrence was common. Complete or partial response was achieved in 60% of patients treated with azathioprine. Three of six patients responded to anti-tumour necrosis factor [TNF] therapy. A small proportion of patients required circumcision or de-bulking surgery for more debilitating disease. CONCLUSIONS: Ano-genital granulomatosis is a rare condition that presents with genital lymphoedema, and there is frequently a protracted delay in diagnosis. There is a very strong association with intestinal Crohn's disease. Genital lymphoedema associated with gastrointestinal symptoms should prompt careful evaluation to exclude both ano-genital granulomatosis and Crohn's disease.

Quantitative Imaging In Vivo of Functioning Lymphatic Vessels Around Human Melanoma and Benign Nevi.

OBJECTIVES: The density of functioning human lymphatics in vivo and of immunohistochemically defined lymphatics was quantified around melanomas, benign nevi, and matched normal skin, to assess the current lymphangiogenesis paradigm. We investigated whether histological and functioning density increased around melanomas compared with benign nevi or matched skin; whether functioning and histological density increased similarly; and whether larger increases occurred around metastatic melanomas. METHODS: Functioning density was quantified in vivo as the total amount of human dermal microlymphatics taking up fluorescent marker injected at the lesion margin. After tissue excision, perilesion histological density was quantified using podoplanin marker D2-40. RESULTS: Histological density was raised similarly around metastasising and non-metastasising melanomas compared with normal skin (+71%, p < 0.0001, n = 32); but was also raised significantly around benign nevi (+17%, p = 0.03, n = 20). In contrast, functioning lymphatic density was substantially reduced around the margins of melanomas (both metastasising and non-metastasising) compared with benign nevi (by 65%, p = 0.02) or normal skin (by 53%, p = 0.0014). CONCLUSIONS: Raised perilesion histological lymphatic density is not unique to melanoma but occurs also around benign nevi. The findings indicated that the number of functioning lateral lymphatics around human melanomas in vivo but not benign nevi is reduced, despite histologically increased numbers of lymphatics.

Acute exacerbation of dysphagia due to foreign body impaction in an oesophageal stricture due to eosinophilic esophagitis.

A 43-year woman with a 4-year history of swallowing difficulty for solids presented with absolute dysphagia, which was only slightly relieved by intravenous relaxant given in the emergency department. Barium swallow showed a smooth polypoid filling defect in the mid-oesophagus, with a hold-up at this level. Gastroscopy showed a narrowed ringed oesophagus with an impacted foreign body. This was extracted with a basket, with relief of the dysphagia. Oesophageal biopsies confirmed the diagnosis of eosinophilic esophagitis.

A limited form of proteus syndrome with bilateral plantar cerebriform collagenomas and varicose veins secondary to a mosaic AKT1 mutation.

IMPORTANCE: Proteus syndrome is an extremely rare disorder of mosaic postnatal overgrowth affecting multiple tissues including bone, soft tissue, and skin. It typically manifests in early childhood with asymmetric and progressive skeletal overgrowth that leads to severe distortion of the skeleton and disability. The genetic basis has recently been identified as a somatic activating mutation in the AKT1 gene, which encodes an enzyme mediating cell proliferation and apoptosis. OBSERVATIONS: We present a 33-year-old man who developed plantar cerebriform collagenomas on the soles of both feet and varicose veins in early childhood, in the absence of any skeletal or other connective tissue abnormality. Although the patient did not meet the diagnostic criteria for Proteus syndrome, he was found to have the c.49G>A, p.Glu17Lys AKT1 mutation in lesional skin but not in his blood. CONCLUSIONS AND RELEVANCE: To our knowledge, this is the mildest molecularly confirmed case of Proteus syndrome, occurring in the absence of the characteristic skeletal overgrowth. These findings extend the spectrum of Proteus syndrome pathological characteristics and suggest that somatic mutations late in development and restricted in distribution cause subtle clinical presentations that do not meet the published clinical criteria.

Senescence evasion in melanoma progression: uncoupling of DNA-damage signaling from p53 activation and p21 expression.

The best-established function of the melanoma-suppressor p16 is mediation of cell senescence, a permanent arrest following cell proliferation or certain stresses. The importance of p16 in melanoma suggests indolence of the other major senescence pathway through p53. Little or no p53 is expressed in senescent normal human melanocytes, but p16-deficient melanocytes can undergo p53-mediated senescence. As p16 expression occurs in nevi but falls with progression toward melanoma, we here investigated whether p53-dependent senescence occurs at some stage and, if not, what defects were detectable in this pathway, using immunohistochemistry. Phosphorylated checkpoint kinase 2 (CHEK2) can mediate DNA-damage signaling, and under some conditions senescence, by phosphorylating and activating p53. Remarkably, we detected no prevalent p53-mediated senescence in any of six classes of lesions. Two separate defects in p53 signaling appeared common: in nevi, lack of p53 phosphorylation by activated CHEK2, and in melanomas, defective p21 upregulation by p53 even when phosphorylated.

A new long term hepatic complication in survivors of childhood haematological malignancy.

Hepatic abnormalities have been documented in survivors of childhood malignancies and a spectrum of liver diseases has been described in this group The risk factors for liver disease include: hepatic surgery; radiotherapy to field including liver; total body irradiation (TBI); chemotherapy, multiple blood transfusions and use of hematopoietic cell transplantation. We report three cases of hepatic adenomatosis (HA) in young women who had been treated for haematological malignancy as children and had bone marrow transplant. These women were on estrogen and growth hormone replacement. They had mild abnormalities of liver function tests. The diagnosis of HA was made on liver imaging and confirmed by liver biopsy. We also propose a hypothesis for the pathogenesis of hepatic adenomatosis in these patients which vascular damage, estrogen replacement and growth hormone deficiency.

Broad antigenic coverage induced by vaccination with virus-based cDNA libraries cures established tumors.

Effective cancer immunotherapy requires the release of a broad spectrum of tumor antigens in the context of potent immune activation. We show here that a cDNA library of normal tissue, expressed from a highly immunogenic viral platform, cures established tumors of the same histological type from which the cDNA library was derived. Immune escape occurred with suboptimal vaccination, but tumor cells that escaped the immune pressure were readily treated by second-line virus-based immunotherapy. This approach has several major advantages. Use of the cDNA library leads to presentation of a broad repertoire of (undefined) tumor-associated antigens, which reduces emergence of treatment-resistant variants and also permits rational, combined-modality approaches in the clinic. Finally, the viral vectors can be delivered systemically, without the need for tumor targeting, and are amenable to clinical-grade production. Therefore, virus-expressed cDNA libraries represent a novel paradigm for cancer treatment addressing many of the key issues that have undermined the efficacy of immuno- and virotherapy to date.

Antiangiogenic cancer therapy combined with oncolytic virotherapy leads to regression of established tumors in mice.

Clinical trials of oncolytic virotherapy have shown low toxicity and encouraging signs of efficacy. However, it remains critically important to develop methods for systemic viral delivery if such therapies are to be clinically implemented to treat established tumors. In this respect, much effort is being focused on combining oncolytic viruses with standard treatment modalities such as inhibitors of VEGF165 (an alternatively spliced isoform of VEGF-A) signaling, which are widely used to treat several different cancers. Here, we have demonstrated that combining VEGF165 inhibitors with systemic delivery of oncolytic viruses leads to substantial regression and cure of established tumors in immunocompetent mice. We have shown that manipulating VEGF165-mediated signaling by administering VEGF165 to mice harboring mouse melanoma cells that do not express VEGF165 and by administering a VEGF inhibitor and then withdrawing treatment to allow VEGF levels to rebound in mice harboring mouse melanoma cells expressing VEGF165 allows tumor-associated endothelial cells transiently to support viral replication. This approach led to direct tumor cell lysis and triggered innate immune-mediated attack on the tumor vasculature. It also resulted in long-term antitumor effects, even against tumors in which viral replication is poorly supported. Since this combinatorial approach targets the tumor endothelium, we believe these data have direct, wide-ranging, and immediate clinical applicability across a broad range of tumor types.

Antitumor immunity can be uncoupled from autoimmunity following heat shock protein 70-mediated inflammatory killing of normal pancreas.

We have a long-term interest in the connectivity between autoimmunity and tumor rejection. However, outside of the melanocyte/melanoma paradigm, little is known about whether autoimmune responses to normal tissue can induce rejection of tumors of the same histologic type. Here, we induced direct, pathogen-like cytotoxicity to the normal pancreas in association with the immune adjuvant heat shock protein 70. In sharp contrast to our studies with a similar approach for the treatment of prostate cancer, inflammatory killing of the normal pancreas induced a Th1-like, anti-self-response to pancreatic antigens, which was rapidly suppressed by a concomitant suppressive regulatory T cell (Treg) response. Interestingly, even when Treg cells were depleted, the Th1-like response was insufficient to induce significant ongoing autoimmunity. However, the Th1-like response to antigens expressed in the pancreas at the time of damage was sufficient to induce rejection of tumors expressing either a foreign (ova) antigen or fully syngeneic tumor antigens (on Panc02 tumor cells), provided that Treg were depleted before inflammatory killing of the normal pancreas. Taken together, these data indicate that profound differences exist between the immunoprotective mechanisms in place between different tissues (pancreas and prostate) in their response to pathogen-like damage. Moreover, they also show that, although multiple layers of immunologic safeguards are in place to prevent the development of severe autoimmune consequences in the pancreas (in contrast to the prostate), tumor rejection responses can still be decoupled from pathologic autoimmune responses in vivo, which may provide novel insights into the immunotherapeutic treatment of pancreatic cancer.

Induction of hsp70-mediated Th17 autoimmunity can be exploited as immunotherapy for metastatic prostate cancer.

A close connectivity between autoimmune and tumor rejection responses is known to exist in the case of melanoma immunotherapy. However, relatively little is known about self-antigens on other types of normal cells, their relation to the development of autoimmune disease, and their possible coexistence as potential tumor rejection antigens on associated tumors. In the current study, we induced inflammatory killing of normal prostate tissue in situ using a fusogenic membrane glycoprotein along with the immune adjuvant hsp70. We show here that, in the prostate, hsp70 induces interleukin (IL)-6, which triggers a CD4- and CD8-dependent progressive autoimmune reactivity, associated with IL-17 expression. This autoimmune response was also able to induce the rejection of established prostate tumors, but not other histologic types of tumors, growing elsewhere in the animal. These data show that the intimate connectivity between autoimmune and tumor rejection responses extends beyond the classic melanoma paradigm and may be clinically valuable for the treatment of established metastatic disease of the prostate.

Neuroendocrine tumour of the cystic duct: a case report and literature review.

This is a case report of a neuroendocrine tumour of the cystic duct which is extremely rare and was an incidental finding during laparoscopic surgery. A literature review of similar cases is also provided.

Tumor cell surface display of immunoglobulin heavy chain Fc by gene transfer as a means to mimic antibody therapy.

We hypothesized that inducing display of the immunoglobulin Fc (IgFc) molecule on the tumor cell surface by gene transfer would promote tumor cell killing by the same mechanisms as antibody-based approaches but would alleviate some of the problems inherent in the use of antibodies for cancer therapy. We expressed the cDNA of the Fc portion of the murine IgG2a heavy chain on the surface of tumor cells such that its C terminus projected away from the tumor cell surface, mimicking a natural antibody-tagging event. In vitro, Fc receptor-positive natural killer (NK) cells specifically recognized and lysed B16 melanoma cells expressing surface IgFc. Macrophages bound to B16-Fc cells significantly more than to parental B16 cells and surface IgFc expression promoted formation of the terminal complement pore complex leading to cell lysis and death. Expression of IgFc dramatically delayed the ability of B16 cells to form tumors in vivo, attributable largely to the effects of NK cells. Furthermore, fluorescence-activated cell-sorting analysis showed that cells from outgrowth B16 IgFc tumors had lost all IgFc expression. When additional immunostimulatory signals were provided at the time of IgFc-mediated tumor cell killing through expression of heat shock protein 70 (hsp70), significant antitumor immunity was generated. Intratumoral delivery of an adenoviral vector expressing IgFc was effective at treating locally accessible tumors but did not impact metastatic disease. However, delivery of adenoviral vectors expressing both IgFc and hsp70 cured both local and metastatic tumors established for 6 days before viral treatment. These data suggest that it is possible to use gene transfer to mimic the beneficial properties of antibody therapy while alleviating some of the associated problems.

Potent selection of antigen loss variants of B16 melanoma following inflammatory killing of melanocytes in vivo.

We have reported that i.d. injection of plasmids encoding hsp70 and a suicide gene transcriptionally targeted to melanocytes generates specific proinflammatory killing of melanocytes. The resulting CD8+ T cell response eradicates systemically established B16 tumors. Here, we studied the consequences of that CD8+ T cell response on the phenotype of preexisting tumor. In suboptimal protocols, the T cell response selected B16 variants, which grow extremely aggressively, are amelanotic and have lost expression of the tyrosinase and tyrosinase-related protein 2 (TRP-2) antigens. However, expression of other melanoma-associated antigens, such as gp100, was not affected. Antigen loss could be reversed by long-term growth in culture away from immune-selective pressures or within 96 hours by treatment with the demethylating agent 5-azacytidine (5-Aza). When transplanted back into syngeneic animals, variants were very poorly controlled by further vaccination. However, a combination of vaccination with 5-Aza to reactivate antigen expression in tumors in situ generated highly significant improvements in therapy over treatment with vaccine or 5-Aza alone. These data show that inflammatory killing of normal cells activates a potent T cell response targeted against a specific subset of self-antigens but can also lead to the immunoselection of tumor variants. Moreover, our data indicate that emergence of antigen loss variants may often be due to reversible epigenetic mechanisms within the tumor cells. Therefore, combination therapy using vaccination and systemic treatment with 5-Aza or other demethylating agents may have significant therapeutic benefits for antitumor immunotherapy.

A simple method to cure established tumors by inflammatory killing of normal cells.

We describe a simple technology used to cure an established metastatic disease. Intradermal injection of plasmid DNA encoding a transcriptionally targeted cytotoxic gene, along with hsp70, not only promoted tissue-specific, inflammatory killing of normal melanocytes, but also induced a CD8(+) T-cell-dependent, antigen-specific response in mice that eradicated systemically established B16 tumors. This CD8(+) T cell response was subsequently suppressed in vivo within a few days. The data demonstrate that deliberate destruction of normal tissue can be exploited to generate immunity against a malignant disease originating from that tissue. This approach obviates the need to identify tumor antigens and does not require complex isolation of tumor cells or their derivatives. In addition, it provides a model system for studying the mechanisms underlying the etiology and control of autoimmune diseases. Finally, despite targeting normal tissue, therapy could be separated from development of overt autoimmune symptoms, suggesting that the strategy may be valuable against tumors derived from both non-essential and essential tissue types.