Clinical phenotype and mortality in patients with idiopathic small bowel villous atrophy: a dual-centre international study.

OBJECTIVE: Causes of small-bowel villous atrophy (VA) include coeliac disease (CD), its complications and other rare non-coeliac enteropathies. However, forms of VA of unknown aetiology may also exist. We defined them as idiopathic VA (IVA). To retrospectively classify the largest cohort of IVA patients and compare their natural history with CD. METHODS: Notes of 76 IVA patients attending two tertiary centres between January 2000 and March 2019 were retrospectively reviewed. CD, its complications and all the known causes of VA were excluded in all of them. Persistence of VA during follow-up and lymphoproliferative features were used to retrospectively classify IVA, as follows. Group 1: IVA with spontaneous histological recovery (50 patients). Group 2: persistent IVA without lymphoproliferative features (14 patients). Group 3: persistent IVA with lymphoproliferative features (12 patients). Survival was compared between IVA groups and 1114 coeliac patients. HLA was compared between IVA patients, coeliac patients and appropriate controls. RESULTS: Five-year survival was 96% in IVA group 1, 100% in IVA group 2, 27% in IVA group 3 and 97% in CD. On a multivariate analysis hypoalbuminemia (P = 0.002) and age at diagnosis (P = 0.04) predicted mortality in IVA. Group 2 showed association with HLA DQB1*0301 and DQB1*06. CONCLUSION: IVA consists of three groups of enteropathies with distinct clinical phenotypes and prognoses. Mortality in IVA is higher than in CD and mainly due to lymphoproliferative conditions necessitating more aggressive therapies.

Intraoperative prediction of the two axillary lymph node macrometastases threshold in patients with breast cancer using a one-step nucleic acid cytokeratin-19 amplification assay.

The aim of the present study was to assess the sensitivity, specificity and practicality of using a one-step nucleic acid amplification (OSNA) assay during breast cancer staging surgery to predict and discriminate between at least 2 involved nodes and more than 2 involved nodes and facilitate the decision to provide axillary conservation in the presence of a low total axillary node tumour burden. A total of 700 consecutive patients, not treated with neo-adjuvant chemotherapy, received intraoperative sentinel lymph node (SLN) analysis using OSNA for cT1-T3 cN0 invasive breast cancer. Patients with at least one macrometastasis on whole-node SLN analysis underwent axillary lymph node dissection (ALND). The total tumour load (TTL) of the macrometastatic SLN sample was compared with the non-sentinel lymph node (NSLN) status of the ALND specimen using routine histological assessment. In total, 122/683 patients (17.9%) were found to have an OSNA TTL indicative of macrometastasis. In addition, 45/122 (37%) patients had NSLN metastases on ALND with a total positive lymph node burden exceeding the American College of Surgeons Oncology Group Z0011 trial threshold of two macrometastatic nodes. The TTL negative predictive value was 0.975 [95% confidence interval (CI), 0.962-0.988]. The area under the curve for the receiver operating characteristic curve was 0.86 (95% CI, 0.81-0.91), indicating that SLN TTL was associated with the prediction (and partitioning) of total axillary disease burden. OSNA identifies a TTL threshold value where, in the presence of involved SLNs, ALND may be avoided. This technique offers objective confidence in adopting conservative management of the axilla in patients with SLN macrometastases.

The clinical and phenotypical assessment of seronegative villous atrophy; a prospective UK centre experience evaluating 200 adult cases over a 15-year period (2000-2015).

BACKGROUND: Seronegative villous atrophy (SNVA) is commonly attributed to coeliac disease (CD). However, there are other causes of SNVA. More recently angiotensin-2-receptor-blockers (A2RBs) have been reported as an association but data on SNVA have been limited to centres evaluating complex case referrals and not SNVA in general. OBJECTIVES: To provide clinical outcomes and associations in a large prospective study overseeing all newcomers with SNVA. DESIGN: Over a 15-year period (2000-2015) we evaluated 200 adult patients with SNVA at a UK centre. A diagnosis of either seronegative CD (SNCD) or seronegative non-CD (SN-non-CD) was reached. Baseline comparisons were made between the groups, with 343 seropositive CD subjects serving as controls. RESULTS: Of the 200 SNVA cases, SNCD represented 31% (n=62) and SN-non-CD 69% (n=138). The human leucocyte antigen (HLA)-DQ2 and/or DQ8 genotype was present in 61%, with a 51% positive predictive value for SNCD. The breakdown of identifiable causes in the SN-non-CD group comprised infections (27%, n=54), inflammatory/immune-mediated disorders (17.5%, n=35) and drugs (6.5%, n=13; two cases related to A2RBs). However, no cause was found in 18% (n=36) and of these 72% (n=26/36) spontaneously normalised duodenal histology while consuming a gluten-enriched diet. Following multivariable logistic regression analysis an independent factor associated with SN-non-CD was non-white ethnicity (OR 10.8, 95% CI 2.2 to 52.8); in fact, 66% of non-whites had GI infections. On immunohistochemistry all groups stained positive for CD8-T-cytotoxic intraepithelial lymphocytes. However, additional CD4-T helper intraepithelial lymphocytes were occasionally seen in SN-non-CD mimicking the changes associated with refractory CD. CONCLUSIONS: Most patients with SNVA do not have CD, in particular those who are not white. Furthermore, a subgroup with no obvious aetiology will show spontaneous histological resolution while consuming gluten. These findings suggest caution in empirically prescribing a gluten-free diet without investigation.

Clinical and Immunologic Features of Ultra-Short Celiac Disease.

BACKGROUND & AIMS: The clinical effects of gluten-sensitive enteropathy with villous atrophy limited to the duodenal bulb (D1) have not been delineated in adults with celiac disease. We investigated the sensitivity of D1 biopsy analysis in the detection of celiac disease, the number and sites of biopsies required to detect ultra-short celiac disease (USCD, villous atrophy limited to D1), and the clinical phenotype of USCD. METHODS: We performed a prospective study of 1378 patients (mean age, 50.3 y; 62% female) who underwent endoscopy at a tertiary medical center in the United Kingdom from 2008 through 2014; routine duodenal biopsy specimens were collected from D1 and the second part of the duodenum (D2). Quadrantic D1 biopsy specimens were collected from 171 consecutive patients with a high suspicion of celiac disease (mean age, 46.5 y; 64% female). Clinical data from patients diagnosed with USCD, based on biopsy analysis, were compared with those from patients with conventional celiac disease (CCD) (villous atrophy beyond D1) and individuals without celiac disease (controls). The number of intraepithelial lymphocytes (IELs) and immune phenotypes were compared between D1 vs D2 in patients with celiac disease. RESULTS: Of the 1378 patients assessed, 268 (19.4%) were diagnosed with celiac disease; 9.7% of these patients had villous atrophy confined to D1 (USCD; P < .0001). Collection of a single additional biopsy specimen from any D1 site increased the sensitivity of celiac disease detection by 9.3%-10.8% (P < .0001). Patients with USCD were younger (P = .03), had lower titers of tissue transglutaminase antibody (P = .001), and less frequently presented with diarrhea (P = .001) than patients with CCD. Higher proportions of patients with CCD had ferritin deficiency (P = .007) or folate deficiency (P = .003) than patients with USCD or controls. Patients with celiac disease had a median of 50 IELs/100 enterocytes in D1 and a median of 48 IELs/100 enterocytes (P = .7) in D2. The phenotype of IELs from patients with D1 celiac disease was indistinguishable from those of patients with D2 celiac disease. CONCLUSIONS: Collection of a single additional biopsy specimen from any site in the D1 intestine increases the sensitivity of detection for celiac disease. Patients with USCD may have early stage or limited celiac disease, with a mild clinical phenotype and infrequent nutritional deficiencies.

The relationship between semaphorin 3C and microvessel density in the progression of breast and oral neoplasia.

This study aimed to identify the expression of semaphorin 3C (SEMA3C) in the normal-metastatic spectrum of breast and oral cancers, and correlate expression with microvessel density (MVD, CD31), a surrogate marker of angiogenesis. Histological analysis revealed that SEMA3C expression was reduced in the development of oral cancer from normal oral tissue (P<0.0001) and expression was inversely correlated with MVD (r=-0.394, P=0.05). In contrast, SEMA3C expression increased in the transition from normal to invasive breast disease in epithelial/tumour cells (P=0.001) and endothelial cells (P=0.006), with both correlating weakly with MVD (r=0.35, p=0.03 and r=0.243, p=0.041 respectively). Furthermore, histological analysis of a breast cancer tissue microarray revealed a weak positive correlation with tumour grade (r=0.305, P=<0.001) and biological phenotype (r=0.237, p=0.004) with tumour cell expression of SEMA3C highest in triple negative and ER-, PR-, HER2+ subtypes. These data suggest that SEMA3C expression is differentially regulated in the development and progression of breast versus oral neoplasia, and that increased expression of SEMA3C may be modulating breast cancer progression and angiogenesis, and could represent a biomarker of metastatic disease.

Unfolded protein response activation contributes to chemoresistance in hepatocellular carcinoma.

OBJECTIVE: Hepatocellular carcinoma (HCC) has an annual worldwide incidence of 626 000 cases and causes 550 000 deaths per year. Although the mainstay of treatment is surgical resection, for inoperable or metastatic disease, chemotherapy may be offered. The primary agent used is doxorubicin, but response rates are poor (<20%). The unfolded protein response (UPR) is a cytoprotective cellular stress response that enables cells to survive periods of hypoxia and nutrient deprivation. The UPR may confer resistance to anticancer agents and contribute to treatment failure. This study has investigated whether the UPR is activated in HCC and whether this may contribute to doxorubicin resistance. METHODS: Eighty-six human HCCs were immunohistochemically stained for glucose regulated protein 78, the key marker of UPR activation. An in-vitro model of UPR activation in HepG2 HCC cells was developed by glucose deprived culture. UPR activation was confirmed with western blotting and PCR to show overexpression of glucose regulated protein 78. The relative efficacy of doxorubicin chemotherapy on UPR-activated HepG2 cells was compared with normal HepG2 cells by use of an thiazolyl blue tetrazolium bromide colorimetric assay. RESULTS: Expression of glucose regulated protein 78 was shown in 100% of the HCC samples with 66% showing strong staining. In-vitro UPR activation was achieved with glucose deprivation. UPR activation induced significant resistance to doxorubicin: 34% survival under standard culture conditions versus 58% and 63% for UPR-activated cells in 0.5 and 1 mmol glucose respectively (P=0.00928). CONCLUSION: The UPR is activated in HCCs and confers resistance to chemotherapy in vitro. UPR activation may contribute to HCC chemoresistance.

Investigation of genomic instability in paediatric Barrett's oesophagus using laser microdissection on paraffin-embedded endoscopic biopsies.

OBJECTIVES: To investigate the occurrence of microsatellite instability (MSI) in paediatric Barrett's oesophagus (BE) with the aim of identifying a potential marker for patients at risk for developing dysplasia or adenocarcinoma at a later stage. PATIENTS AND METHODS: Endoscopic oesophageal biopsies from 6 pediatric patients harbouring BE and 6 age-matched controls were retrospectively investigated. After all of the samples were made anonymous, a 5-microm section was cut and stained with toluidine blue. A precise cell was selected and captured using a laser microdissection microscope. Microsatellite analysis was performed on the DNA extracted from the captured cells. Genomic DNA was amplified by polymerase chain reaction using primers for 5 mononucleotide repeats and analysed by GeneMapper software on an ABI 3730. DNA extracted from a formalin-fixed colonic adenocarcinoma known to have MSI was used as a positive control. RESULTS: The median age of the patients with BE was 9 years. The relevant complaint was long-standing vomiting in 4 cases and history of dysphagia in 3 cases (1 case had both symptoms). All of the cases had a history of reflux oesophagitis with histological confirmation of oesophagitis. Reflux was associated with a hiatus hernia, obesity, and cerebral palsy in each of 3 cases, and with asthma in 2 patients. Histologically, all of the cases showed the presence of specialized intestinal metaplasia containing goblet cells replacing the squamous oesophageal epithelium. None of the cases tested showed any evidence of MSI. CONCLUSIONS: A single molecular marker that would allow recognition of those patients at risk for Barrett's adenocarcinoma has not yet been identified. The absence of MSI in our cases could be due to the need for a longer period of BE before genomic instability develops, or MSI may only arise in a proportion of patients. This does not exclude other genetic alterations, however rare they may be.

Identificacion del virus Epstein-Barr en carcinomas nasofaringeos en Argentina: su relacion con P53 y determinacion de indices de proliferacion / Identification of Epstein-Barr virus in nasopharyngeal carcinomas in Argentina: its relation with p53 and the determination of proliferation indices

Se estudiaron 37 casos de carcinomas nasofaríngeos (CNF) a partir de biopsias de cavum incluidas en parafina. Los pacientes fueron argentinos, 23 hombres y 14 mujeres cuyo promedio de edad fue de 50 años. Los tumores se clasificaron en carcinoma escamoso queratinizante, 1 caso (2 por ciento), carcinomas escamosos no queratinizantes, 15 casos (41 por ciento) y carcinomas indiferenciados, 21 casos (57 por cento). Se determinó el índice de proliferación (PI) con anticuerpos monoclonales para PCNA y Ki-67 (MIB-1) que fue del 26 por ciento y 17 por ciento respectivamente, no hallándose aparentemente diferencias de acuerdo a las variantes histológicas, estadios clínicos III o IV de presentación. El IP fue del 2 por ciento para estadio II aunque los casos en la serie fueron escasos (n = 3). Se observó positividad para p53 en 30 de los 37 casos, similar para los carcinomas indiferenciados y no queratinizantes, mientras que el carcinoma queratinizante fue negativo. Se estabelecieron dos grupos de pacientes con sobrevida media de 35 y 12 meses a partir de un valor de corte en el porcentaje de positividad por inmunomarcación para p53 (< y > 7 por ciento), si bien la diferencia no fue estadísticamente significativa. Se demostró la presencia del virus Epstein-Barr por PCR en 31 de 37 de los CNF: 19 fueron caracinomas indiferenciados y 12 fueron carcinomas escamosos no queratinizantes, siendo negativo el carcinoma escamoso queratinizante. Estos resultados, obtenidos por primera vez en Argentina, son semejantes a los hallados en países con alta y baja frecuencia de CNF y pueden ser de valor para estabelecer el origen nasofaríngeo de una adenopatía cervical metastásica de origen desconocido.