EWS-FLI1 fusion transcript structure is an independent determinant of prognosis in Ewing's sarcoma.

PURPOSE: More than 90% of Ewing's sarcomas (ES) contain a fusion of the EWS and FLI1 genes, due to the t(11;22)(q24;q12) translocation. At the molecular level, the EWS-FLI1 rearrangements show great diversity. Specifically, many different combinations of exons from EWS and FLI1 encode in-frame fusion transcripts and result in differences in the length and composition of the chimeric protein, which functions as an oncogenic aberrant transcription factor. In the most common fusion type (type 1), EWS exon 7 is linked in frame with exon 6 of FLI1. As the fundamental pathogenetic lesion in ES, the molecular heterogeneity of these fusion transcripts may have functional and clinical significance. PATIENTS AND METHODS: We performed a clinical and pathologic analysis of 112 patients with ES in which EWS-FLI1 fusion transcripts were identified by reverse-transcriptase polymerase chain reaction (RT-PCR). Adequate treatment and follow-up data were available in 99 patients treated with curative intent. Median follow-up in these 99 patients was 26 months (range, 1 to 140 months). Univariate and multivariate survival analyses were performed that included other prognostic factors, such as age, tumor location, size, and stage. RESULTS: Among the 99 patients suitable for survival analysis, the tumors in 64 patients contained the type 1 fusion and in 35 patients contained less common fusion types. Stage at presentation was localized in 74 patients and metastatic in 25. Metastases (relative risk [RR] = 2.6; P = .008), and type 1 EWS-FLI1 fusion (RR = 0.37; P = .014) were, respectively, independent negative and positive prognostic factors for overall survival by multivariate analysis. Among 74 patients with localized tumors, the type 1 EWS-FLI1 fusion was also a significant positive predictor of overall survival (RR = 0.32; P = .034) by multivariate analysis. CONCLUSION: EWS-FLI1 fusion type appears to be prognostically relevant in ES, independent of tumor site, stage, and size. Further studies are needed to clarify the biologic basis of this phenomenon.

Delayed cerebral radionecrosis following treatment of basal cell carcinoma.

Delayed radiation necrosis of the brain was found around the right ear in a patient with basal cell carcinoma of the skin. Five months after excision, the tumor recurred. The patient received 5,575 rads in 24 doses during radiotherapy. Thirteen months later, the patient had cerebral radionecrosis, which was the cause of death. At autopsy, typical radionecrotic lesions of the temporal lobe were found. There were widespread metastases.

Molecular features in a biphenotypic small cell sarcoma with neuroectodermal and muscle differentiation.

We report a case of a 13-year-old girl with soft tissue sarcoma of the hand, which showed muscle and neuroectodermal immunophenotypes. Molecular studies were performed on RNA collected from fine-needle aspiration (FNA) cytology and peripheral blood samples by nested reverse transcriptase-polymerase chain reaction (RT-PCR) and Southern blot analysis. This biphenotypic tumor showed simultaneous expression of EWS-FLI1 and PAX3-FKHR transcripts, specific of Ewing family tumors and alveolar rhabdomyosarcoma, respectively. Although childhood sarcomas with simultaneous muscle and neural differentiation have been described to have EWS-FLI1 transcripts, there are no reports of tumors with both transcripts. Cytological specimens are a good source of RNA for molecular studies.

"Quilty effect" in heart transplantation: is it related to acute rejection?

"Quilty effect" is a lymphocytic infiltrate bulging in the endocardium of cardiac allografts with or without affectation of myocardium. It has been related with cyclosporine treatment. We have reviewed the morphology of 527 endomyocardial biopsy specimens from 46 transplant patients to study the significance and relation of Quilty effect with acute rejection. Paraffin immunoperoxidase studies were performed in 56 cases with Quilty effect or acute rejection. We graded acute myocardial rejection into four degrees according to the Hannover classification. A total of 126 biopsy specimens (24%) showed Quilty effect. Fifty-nine specimens (46.8%) showed different degrees of acute rejection in addition to Quilty effect. If we consider specimens with acute rejection grade greater than or equal to II, which require treatment, the frequency of the association of Quilty effect and acute rejection is statistically significant (p less than 0.01). In cases of acute rejection, the percentage of cases with Quilty effect was higher in cases with the highest degrees of acute rejection. The response of acute rejection to antirejection treatment was similar in all cases with or without Quilty effect. Immunohistochemical study showed a predominance of T lymphocytes in both Quilty effect and in the myocardium of acute rejection. We conclude that Quilty effect is a manifestation of acute rejection, modified by many factors, such as cyclosporine treatment. The finding of isolated Quilty effect may signal the prompt development of an acute rejection episode.

Quinapril inhibits c-Myc expression and normalizes smooth muscle cell proliferation in spontaneously hypertensive rats.

A number of data suggest that angiotensin II-dependent activation of the protooncogene c-myc participates in the proliferative response of smooth muscle cells (SMC) of rats with spontaneous hypertension (SHR). We therefore investigated the effects of chronic treatment with the angiotensin converting enzyme (ACE) inhibitor quinapril on the oncoprotein c-Myc and the proliferating cell nuclear antigen cyclin A in SMC of small intramyocardial arteries from the left ventricle of SHR. The expression of c-Myc and cyclin A was assessed by immunocytochemical analysis. The number of smooth muscle cells was assessed by morphometrical analysis. As compared to normotensive Wistar-Kyoto (WKY) rats, untreated SHR exhibited an increased percentages of cells expressing c-Myc (33% +/- 4% v 19% +/- 2%, mean +/- SEM, P < .005) and cyclin A (25 +/- 2 v 11% +/- 1%, P < .001). In quinapril-treated SHR compared with untreated SHR, we found decreased expression of c-Myc (22% +/- 2%, P < .005) and cyclin A (13% +/- 1%, P < .001). No significant differences were found between WKY rats and quinapril-treated SHR in the above parameters. Cyclin A was directly correlated with the number of SMCs in each group of rats. These results suggest that an enhanced expression of c-Myc may be involved in the increased proliferation seen in SMCs from small arteries of SHR. Quinapril administration normalizes proliferation in the SMCs of SHR, possibly by inhibiting the expression of the oncoprotein c-Myc and its effects on the cell cycle.

Diagnosis of chordoma by cytologic examination of cerebrospinal fluid.

This is a case report of a 44-year-old man with a chordoma of the clivus that caused dysphonia, low back pain, and urinary and fecal incontinence. The diagnosis was made by cytologic study of the CSF, which demonstrated vacuolated malignant cells. The patient was treated with intrathecal methotrexate, dexamethasone, and radiotherapy. At autopsy extensive dissemination of chordoma was found at the base of the brain, in the ventricles, and in the leptomeninges of the spinal cord. This is the sixth reported case of intrathecal dissemination of a chordoma and the first diagnosed by cytology of the cerebrospinal fluid.

Non Hodgkin's lymphomas following chemoradiotherapy for Hodgkin's disease. Two new cases and a review of the literature.

Two patients developed non-Hodgkin's lymphoma (NHL) six and ten years after radiotherapy and chemotherapy for Hodgkin's disease nodular sclerosis type. The histological classification of the developing NHL for the two patients was: IgG (K) secreting lymphoplasmacytoid lymphoma of the stomach, and immunoblastic lymphoma of the cervical lymph nodes. Both patients responded well to conventional chemotherapy for NHL and are alive 22 and 5 months after the diagnosis of the secondary tumor. Forty eight cases of NHL after treatment for HD have been previously reported. We present a review of the literature of these cases, adding to this literature the first reported case of gastric lymphoplasmacytoid lymphoma under such circumstances.

Eosinophilic myocarditis in patients waiting for heart transplantation.

We report three patients waiting for heart transplantation who suddenly worsened clinically. All three explanted hearts showed a myocarditis with a dense eosinophilic infiltrate. Follow-up biopsies and necropsies showed no further evidence of cardiac eosinophilic infiltrates. The possible relationship between drugs administered before transplantation and clinico-pathological findings is discussed.

Utility of immunophenotypic and immunogenotypic analysis in the study of necrotic lymph nodes.

We report a case of complete lymph node necrosis. No specific aetiology could be determined by morphology, but a B lymphoid population and clonal rearrangement of the immunoglobulin heavy chain gene were demonstrated in immunophenotypic and immunogenotypic studies performed using DNA extracted from paraffin embedded necrotic tissue. In the setting of lymph node necrosis, we suggest that immunohistochemical and gene rearrangement studies may provide additional diagnostic information.

Ewing family tumors: potential prognostic value of reverse-transcriptase polymerase chain reaction detection of minimal residual disease in peripheral blood samples.

In more than 95% of patients, the Ewing family of tumors (ET) has chimeric transcripts caused by fusion of the EWS gene to either FLI1 or ERG. The presence of specific EWS-FLI1 or EWS-ERG transcripts in peripheral blood (PB) samples of patients being treated for ET was prospectively evaluated, and these data were correlated to their clinical status. The authors studied 113 PB samples from 28 patients with ET. Treatment included chemotherapy, radiotherapy, and surgical excision of tumor after induction therapy. PB samples were taken prospectively at least 2 weeks after resection of tumor. Nested reverse-transcriptase polymerase chain reaction (RT-PCR) followed by Southern blot was performed in all samples. Resected tumors were reviewed for the degree of response to chemotherapy and volume. Seventy-seven PB samples from 28 patients had EWS-FLI1/ERG transcripts. In 11 patients, PB samples became negative with treatment, and, in 5 of them, the samples remained negative throughout the study. Samples taken during progression were always positive and, in 4 patients, became positive before progression was clinically evident. All patients with transcripts other than EWS-FLI1 type 1 (n = 3) died from tumor progression. This is a sensitive assay to monitor circulating tumor cells in Ewing tumors. The preliminary data suggest that progression is preceded by positive samples and may be related to specific transcript types.

PTEN protein expression correlates with PTEN gene molecular changes but not with VEGF expression in astrocytomas.

PTEN gene (10q23) is a relevant tumor suppressor gene whose protein is a phosphatase involved in the control of angiogenesis of some tumors including astrocytomas. There are no studies correlating molecular changes of PTEN and the immunohistochemical expression of its protein (pPTEN) with the expression of vascular endothelial growth factor (VEGF) in astrocytomas. Fifty-six surgically resected brain gliomas, 10 grade 2, 16 grade 3, and 30 grade 4, were studied by a combined approach, consisting of (1) PCR analysis using four microsatellite markers against the PTEN gene region (10q23), (2) the FISH technique to test chromosome 10 using a pericentromeric probe, and (3) immunohistochemical evaluation of pPTEN and VEGF. Loss of heterozygosity (LOH) of PTEN was observed in 10% of fibrillary grade 2 astrocytomas and all gemistocytic ones. In high-grade tumors, LOH was more frequent in grade 4 than in grade 3 (> or =2 loci deleted, 83% and 56%, respectively). Monosomy for chromosome 10 was observed especially in high-grade tumors (6% of grade 3 and 50% of grade 4) and in 20% of grade 2 tumors, corresponding to gemistocytic astrocytomas. Results with both antibodies against PTEN were concordant: loss of cytoplasmic immunoreactivity was frequently observed according to homogeneous or heterogeneous patterns in 70% and 50% of grades 4 and 3, respectively, but not in grade 2. Immunonegativity of pPTEN was associated with PTEN gene deletion (> or =2 loci deleted) (P = 0.04) but not with monosomy. Cytoplasmic immunoreactivity against VEGF was observed in high-grade and in gemistocytic astrocytomas, but not in conventional grade 2 tumors. Tumor expression of pPTEN was not associated with immunoreactivity against VEGF when the same areas were considered. In conclusion, loss of PTEN expression is frequent in high-grade astrocytomas, but not in grade 2 tumors, and correlates with PTEN deletion and loss of chromosome 10. PTEN immunoreactivity does not correlate with VEGF expression in astrocytomas when similar areas are considered.

Kidney allograft biopsy: a valuable tool in assessing the diagnosis of acute rejection.

In order to determine the value of an isolated renal percutaneous biopsy in renal allografts with acute rejection, we studied 17 allograft nephrectomies, in which the histological degree of acute rejection of each of 30 Tru-cut cylinders, were compared with the histological degree of acute rejection diagnosed in 6 large fragments of each kidney considered as a whole. An accurate histological degree of acute rejection was made in 366 cylinders (71.8%). One hundred twenty-nine kidney cylinders (25.3%) were considered of a minor histological degree of acute rejection and 15 cylinders (2.9%) of a higher histological degree. We conclude that percutaneous renal allograft biopsy provides a representative picture of acute rejection histopathology but must be evaluated with other clinical and biochemical data for a correct clinical management.

Splenic hamartoma, vascular type, with endothelial proliferation.

Vascular tumors of the spleen have shown a wide spectrum of histologic features. We present the case history of a 65-year old woman with weight loss, anemia and thrombocytopenia associated with a vascular tumor of the spleen. Grossly, the tumor appeared like the red pulp of the spleen. On microscopic examination, however, a papillary proliferation of the endothelial cells which caused narrowing of the lumina of newly-formed vessels was seen. The endothelial cells further showed multiple cytoplasmic projections with few junctions under electron microscopy. In spite of the morphology the tumor proved to be benign. This appears to be the first ultrastructural study of such type of vascular tumor.

Pathology of renal transplantation.

Renal transplantation is the most appropriate form of treatment for end-stage renal disease in all age groups. We present the experience of two hospitals in the pathology of kidney allograft. Renal biopsy is the most adequate method for the follow-up of these patients, because it permits the differential diagnosis of acute and chronic rejection, transplant glomerulopathy, recurrent and "de novo" glomerulonephritis and immunosuppression nephrotoxicity, mainly by cyclosporine A. We present the pathology features of all these entities, and study the representativity of the biopsy for diagnosis of rejection. The actuarial survival of the graft is 82% and 71% at 1 and 5 years, respectively.

Pathology of heart transplant through endomyocardial biopsy.

Cardiac transplantation is most effective method for treatment of patients with end-stage heart disease. We present the experience of our institution with 1,564 biopsies and 11 autopsies of 105 orthotopic heart transplants. This report describes the morphological features and the grading systems of acute rejection. Also, we present the morphological characteristics of other complications of heart transplants such as chronic rejection, "Quilty" effect, interstitial fibrosis, heart hypertrophy, previous biopsy sites, calcification, cytomegalovirus infections, toxoplasmosis, and the appearance of malignancies, mainly, lymphomas. Actuarial survival of patients is 91% and 88% at 1 and 5 years' posttransplant, respectively.

FNAC guided by computed tomography in the diagnosis of primary pancreatic adenosquamous carcinoma. A report of three cases.

BACKGROUND: Pancreatic adenosquamous carcinoma (ASqC) is an unusual histologic subtype of nonendocrine neoplasia of the pancreas. Although fine needle aspiration cytology (FNAC) is now accepted as a reliable procedure for the diagnosis of pancreatic malignancies, many of these unusual tumors are still diagnosed after surgery or at necropsy. CASES: Between January 1995 and July 1996, 3 of 35 primary pancreatic malignant tumors were diagnosed as ASqC based on computed tomography-guided FNAC. After cytologic diagnosis, all three patients were treated with neoadjuvant chemotherapy and radiotherapy. Two patients completed the treatment and underwent a surgical pancreatic-duodenectomy with antrectomy. The remaining patient is currently under treatment. That patient had a highly infiltrative pancreatic mass that affected the muscular small bowel wall. An endoscopic biopsy was performed. The cytologic diagnosis was confirmed by histology in all cases. Immunohistochemically both components, squamous and glandular, showed reactivity for several keratins, while only the glandular pattern was reactive with carcinoembryonic antigen (CEA). CONCLUSION: FNAC is an accurate, rapid and sensitive tool in the diagnosis of ASqC of the pancreas. We recommend a careful search for both malignant components. Immunoreactivity for CEA can be of help in the detection of the glandular component of this tumor.

[Lymphoproliferative disease and cancer in the transplant patient]. / Enfermedad linfoproliferativa y cáncer en el enfermo trasplantado.

According to the Spanish Cardiac Transplantation Registry, malignant neoplasm remain the fifth leading cause of death in heart transplant recipients. Skin cancers are the most common malignancies and they are frequently associated to solar keratosis, warts and keratoacanthoma. Geographic areas are high cumulative ultraviolet exposure have a greater incidence of skin cancer. Skin tumors are often located in chronically sun-exposed areas of the body. Lymphoproliferative disorders are the second most frequent malignant neoplasm after heart transplantation. Incidence of lymphoma is 350 times greater in heart transplant recipients than in the general population. B-cell tumors are the most common histologic type and it is associated with infection by the Epstein-Barr virus. T-cell tumors account for a 12% of all lymphoproliferative diseases and are not related to viral infections. Kaposi's sarcoma is the thirth commonest neoplasm in heart transplant recipients. Other malignat tumors are: uterine cervix, vulva, scrotum, colon, stomach, kidney and biliary tract. Prevention of neoplasm in heart transplant recipients include a decrease of immunosuppression and the avoidance of multiple immunosuppressive drug association. Some cases of neoplasm regression have been described when immunosuppressive therapy is decreased.

[Development of a computer-assisted system to teach pathologic anatomy. Preliminary results]. / Implantación de un sistema de enseñanza asistida por ordenador de anatomía patológica. Resultados preliminares.

BACKGROUND: The present study describes the implantation of an interactive teaching system to improve both the active involvement of the student and the learning quality of Pathology. The preliminary results from the evaluation of such system are also reported. METHODS: Two attitude questionnaires (rating scale) were passed to a sample of 36 students of Medicine, randomly elected. These students used for 10 weeks a programme of Pathology (Interpat) assisted by computer. Moreover, the data stored after each session by the control stack of this programme are analyzed. RESULTS: The programme is positively evaluated by the users who consider it as an appropriate mode of learning Pathology. In spite of the scarce experience with computers, students have no difficulty in using this programme. 82% of students consider that they learn more Pathology with Interpat than with the traditional system of magistral classes. 63% of students believe that similar systems must be applied in other curricula. The average time of use of the system by each student has been 11 h 45 min (SD 4 h 55 min). The videodisc is the stack more used. CONCLUSIONS: There is a good acceptance of this methodology by the students, being almost no difficulty in using the programme, despite their low level of computer knowledge. The program is a potent instrument for individualizing the teaching of Pathology. The small size of the sample, accurate for a preliminary study as this is, must be take into account when generalizing the results.

[Changes in autopsies in cancer in Navarra from 1980 to 1988]. / Modificaciones de la autopsia por cáncer en Navarra desde 1980 hasta 1988.

BACKGROUND: Autopsies may be used to know the causes of death in population. In Navarra, the number of patients who died by cancer and were autopsied has increased. A similar pattern appeared in other communities. METHODS: We reviewed 2,643 autopsies performed in the main hospitals of Navarra. In each autopsy, age, sex, existence of primary malignant tumor, and its histologic type and localization were analyzed. The results were compared to the statistics of mortality of the Tumoral Register of Navarra. The modifications from 1980 to 1988 were studied. RESULTS: There is a significant increase of autopsy and mortality by cancer in Navarra. In autopsy cases, there is a high incidence of colon carcinoma and hepato-biliary carcinoma. The incidence in all cancer dead patients is similar being greater in hepato-biliary carcinoma and pancreas carcinoma. The percentage of autopsies in patients over 60 years of age is decreased, but it has increased in all cancer dead patients of the same group of age in the community of Navarra. In the autopsies of patients over 60 years of age there has been a rise in breast carcinoma, while there has been a general increase in all dead patients. In all deaths of people under 60 years of age, there has been a decrease, but in autopsy cases there has been an increase of colon carcinoma. CONCLUSIONS: In autopsy series from 1980 to 1988, cancer deaths increased significantly. There is not relationship between cancer dead patients and autopsy cases in the studied data. In hepato-biliary carcinoma, there is an increase in autopsy cases and cancer dead patients. Discrepancies between the number of deaths of cancer patients and autopsy patients revealed that the performance of autopsy depends of multiple causes.

[Adenoma of Brunner's glands]. / Adenoma de las glándulas de Brunner.

Brunner's glands adenomas represent the 10% of the benign duodenal tumours. The most frequent site is the first portion of the duodenum, and they are extremely rare distally to the ampulla of Vater. We present two cases, one of them associated with an adenocarcinoma of the ampulla. This association has not been previously described in the literature. The transformation of an adenoma into an adenocarcinoma has neither been reported. We believe that the term hyperplasia should be used only for diffuse proliferations.