[Neuroendocrine neoplasms of the breast]. / Neuroendokrine Neoplasien der Mamma.

Neuroendocrine neoplasms (NEN) of the breast are specific tumor entities. According to the literature up to 5% of breast neoplasms are malignant epithelial neoplasms of the breast. They are defined by a neuroendocrine (NE) architecture and cytology combined with an expression of the neuroendocrine vesicle markers chromogranin A and/or synaptophysin. The diagnosis is supplemented by the receptor status and the proliferative activity. According to the World Health Organization (WHO) classification of 2012 the following groups of NEN are distinguished: (1) invasive breast carcinoma with NE differentiation, (2) well-differentiated neuroendocrine tumor (NET) and (3) poorly differentiated small cell carcinoma (NEC). This review article focuses on (1) the definition and basic principles of diagnostics, (2) the history, nomenclature and WHO classification from 2003 and 2012, (3) the frequency of breast NEN, (4) the hereditary background and functional activity, (5) the expression of receptors and (6) the possible clinical implications. In addition, the first results of a retrospective single center study (n = 465 patients with breast cancer over a time period of 4 years) on the frequency of NEN of the breast at the Breast Center of the University Hospital Düsseldorf are presented. In this study a frequency of 4.5% of NEN was found based on a diagnostic cut-off of > 50% Chromogranin A and/or synaptophysin positive tumor cells.

Encapsulation status of papillary thyroid microcarcinomas is associated with the risk of lymph node metastases and tumor multifocality.

The management of papillary microcarcinoma (PMC) of the thyroid is controversial, especially after partial thyroid resection for benign thyroid disease. In order to detect prognostic factors for PMC, we analyzed 116 patients with PMC for encapsulation status and lymph node metastases. Between 10/1992 and 12/2010, 116 patients with PMC have been operated in our department (87 females, 29 males, median age 49 years). Eighty per cent of PMCs were diagnosed postoperatively. Seventy-six patients (66%) received a more extended resection with either thyroidectomy, near total thyroidectomy, or Dunhill operation either primarily or after completion operation, whereas 40 patients (34%) had only partial resection. Fifty patients (43%) received radioiodine (RIA) ablation. Lymph node metastases were found in 21 patients (18%). Univariate analysis showed four risk factors to be significantly associated with the risk of lymph node metastasis (p<0.05): male gender, younger age, age group<50 years and nonencapsulation of the tumor. Multivariate analysis demonstrated statistical significance for gender and tumor capsulation status. The tumor capsulation status also correlated with tumor multifocality. Our data show that the risk of lymph node metastases is significantly higher in partially or nonencapsulated PMC than in encapsulated specimens. We therefore suggest that the WHO classification should be extended to a compulsory notification of the encapsulation status in PMC.

[Neuroendocrine neoplasms of the distal jejunum and ileum]. / Neuroendokrine Neoplasien des distalen Jejunums und Ileums.

Neuroendocrine neoplasms (NEN) of the distal jejunum and ileum derive from serotonin-producing enterochromaffin (EC) cells. Due to their low proliferation rate and their infiltrative growth, they are often discovered at an advanced disease stage when metastasis has already occurred. The biology of these tumours is different from other NEN of the digestive tract. In order to standardise and improve diagnosis and therapy, the guidelines for the diagnosis and clinical management of jejuno-ileal NEN as well as for the management of patients with liver and other distant metastases from NEN were revised by the European Neuroendocrine Tumour Society (ENETS) in 2012. This review focuses on aspects relevant for surgical pathology.

Coincidence of mature cystic teratoma and serotonin-producing neuroendocrine tumor of the ileum.

Mature cystic teratomas are often found in gonadal sites, but are very rarely located extragonadally, for example, in retroperitoneum, mediastinum, central nervous system, lung, or liver. In the literature, only 10 cases of cystic teratoma originating from the diaphragm have been reported. Here, we report for the first time a metachronous occurrence of a benign mature cystic teratoma in the left diaphragm together with a serotonin-producing neuroendocrine tumor of the ileum. The 51-year-old, female patient received a partial resection of the ileum due to a neuroendocrine tumor (pT3N1M0) 4 years ago. Furthermore, she was operated for a benign cystadenoma of the right ovary 3 years ago. In her past medical history, she had an appendectomy in her childhood and a subtotal thyroidectomy 10 years ago. To our knowledge, this is the first report describing the metachronous occurrence of benign mature cystic teratoma in the diaphragm and a highly differentiated neuroendocrine tumor of the ileum. The possible coincidence of both diseases is discussed.

The role of neoadjuvant and adjuvant treatment for adenocarcinoma of the upper gastrointestinal tract.

Both locally advanced adenocarcinoma of the stomach and gastro-esophageal junction are associated with poor prognosis due to the lack of effective treatment. Recently multimodal treatment consisting of neoadjuvant chemotherapy in combination with radiotherapy is reported to improve survival when compared to surgery alone. Neoadjuvant therapy in these locally advanced tumors allows for early tumor responses and the extent of tumor regression that can be achieved is considered a significant prognostic factor. This, in turn, increases the resectability of these tumors. Also due to the high frequency of lymph node metastasis, patients with locally advanced adenocarcinoma should undergo a D2 lymphadenectomy. Postoperative chemo?radiation and perioperative chemotherapy have been studied in gastric adenocarcinomas and showed a survival benefit. However, the surgical techniques used in these trials are no longer considered to be standard by today's surgical practice. In addition, there are no standard recommendations for adjuvant chemotherapy or chemoradiation after R0 resection and adequate lymph node dissection.

Trimodal therapy in squamous cell carcinoma of the esophagus.

Patients with ESCC (squamous cell carcinoma of the esophagus) are most commonly diagnosed with locally advanced tumor stages. Early metastatic disease and late diagnosis are common reasons responsible for this tumor's poor clinical outcome. The prognosis of esophageal cancer is very poor because patients usually do not have symptoms in early disease stages. Squamous cell carcinoma of the esophagus frequently complicates patients with multiple co-morbidities and these patients often require interdisciplinary diagnosis and treatment procedures. At present time, neoadjuvant radiation therapy and chemotherapy followed by surgery are regarded as the international standard of care. Meta-analyses have confirmed that this approach provides the patient with better local tumor control and an increased overall survival rate. It is recommended that patients with positive tumor response to neoadjuvant therapy and who are poor surgical candidates should consider definitive radiochemotherapy without surgery as a treatment option. In future, EGFR antibodies may also be administered to patients during therapy to improve the current treatment effectiveness. Positron-emission tomography proves to be an early response-imaging tool used to evaluate the effect of the neoadjuvant therapy and could be used as a predictive factor for the survival rate in ESCC. The percentage proportions of residual tumor cells in the histopathological analyses represent a gold standard for evaluating the response rate to radiochemotherapy. In the future, early response evaluation and molecular biological tests could be important diagnostic tools in influencing the treatment decisions of ESCC patients.

GNAS1 T393C polymorphism is associated with histopathological response to neoadjuvant radiochemotherapy in esophageal cancer.

Recent studies have shown an association between the GNAS1 T393C polymorphism and clinical outcome for various solid tumors. In this study, we genotyped 51 patients from an observational trial on cisplatin/5-FU-based neoadjuvant radiochemotherapy of locally advanced esophageal cancer (cT2-4, Nx, M0) and genotyping was correlated with histomorphological tumor regression. The C-allele frequency in esophageal cancer patients was 0.49. Pearson's chi(2)-test showed a significant (P<0.05) association between tumor regression grades and T393C genotypes. Overall, 63% of the patients in the T-allele group (TT+CT) were minor responders with more than 10% residual vital tumor cells in resection specimens, whereas T(-) genotypes (CC) showed a major histopathological response with less than 10% residual vital tumor cells in 80%. The results support the role of the T393C polymorphism as a predictive molecular marker for tumor response to cisplatin/5-FU-based radiochemotherapy in esophageal cancer.

HIF-1alpha protein expression is associated with the environmental inflammatory reaction in Barrett's metaplasia.

The oxygen-regulated transcription factor subunit hypoxia inducible factor-1alpha (HIF-1alpha) is involved in angiogenesis, energy metabolism, cell survival, and inflammation. We examined the protein expression of HIF-1alpha within the progression of Barrett's sequence as well as the type and degree of the environmental inflammatory reaction. Squamous epithelium (SE), metaplastic, low- and high-grade dysplastic lesions, and tumor tissue of 57 resection specimens from patients with Barrett's adenocarcinoma were immunohistochemically analyzed. Active and chronic inflammatory reactions were classified according to the Updated Sydney System. HIF-1alpha protein expression increased significantly from SE to Barrett's metaplasia (BM) (P < 0.0001). From metaplasia through low- and high-grade dysplasia to cancer, no further increase could be detected. Active and chronic inflammation were also significantly different between SE and BM (P < 0.0001) but not during further progression in the sequence. HIF-1alpha protein expression did not correlate with histopathologic parameters or survival. HIF-1alpha protein expression pattern resembles the active and chronic environmental inflammatory reaction. All were significantly increased in metaplasia compared to SE without further change in tumor development. HIF-1alpha protein expression appears to be associated with inflammatory processes in the development of BM.

Serosal penetration is an important prognostic factor for gastrointestinal stromal tumors.

Predicting the malignant potential of gastrointestinal stromal tumors (GISTs) remains difficult. We assessed the value of serosal penetration, an established prognostic factor in solid tumors, to determine the clinical outcome in patients with GISTs. From 1996-2002, 25 consecutive patients with GIST underwent surgical resection at our Department. The histopathological presence of serosal penetration was assessed to predict clinical outcome. In addition, the established histopathological classification system by Franquemont (modified by using the Ki-67 proliferation index), was applied to each study patient. A Ki-67 index > or =5% (p<0.001) and a mitotic rate > or =5/50 high-power fields (p<0.047) significantly correlated with a shorter survival, whereas a tumor size >5 cm (p=0.07) tended towards a worse prognosis. The survival of patient groups defined by Franquemont (p=0.03) were of prognostic relevance. The presence of serosal penetration significantly correlated (p<0.01) with a shorter survival. Our data suggest that the presence of serosal penetration is a negative prognostic factor for GISTs. Serosal penetration may become a useful additional parameter for the classification of the malignant potential of GISTs. Since our data are merely hypothesis-generating, serosal penetration should be evaluated in large prospective databases.

Comparative analysis of four histopathological classification systems to discriminate benign and malignant behaviour in gastrointestinal stromal tumors.

UNLABELLED: The prognostic value of the four most common histopathological classification systems in gastrointestinal stromal tumors (GISTs) was evaluated retrospectively. PATIENTS AND METHODS: Twenty-five consecutive patients with resected GIST and a follow-up of five years or more for surviving patients were included in this analysis. All the tumors were c-KIT (CD117) positive and were additionally re-evaluated for the number of mitoses per 50 high-power fields (HPF) and Ki-67 proliferation index. The four most commonly applied histopathological classification systems of the WHO, Franquemont (modified by using the Ki-67 proliferation index), Fletcher and Miettinen were applied to each patient. RESULTS: The survival of patient groups classified by Franquemont (p = 0.03) and the WHO (p = 0.031) were of prognostic relevance, while the grouping of patients by classifications according to both, Fletcher and Miettinen did not show a significant prognostic value. CONCLUSION: The classification systems of Franquemont (modified) or WHO appear to be advantageous for the evaluation of malignant potential and clinical outcome in patients with GISTs. Our data are merely hypothesis generating and should be validated in larger clinical studies.

Is the urokinase-type plasminogen activator system a reliable prognostic factor in gastric cancer?

AIM: The aim of this prospective study was to evaluate the clinical and prognostic impact of immunohistochemically assessed uPA and PAI-1 in patients with gastric cancer. METHODS: This prospective study analyzed specimens obtained from 105 gastric cancer patients who underwent gastrectomy with extended lymphadenectomy. The immunohistochemical expression of uPA and PAI-1 was studied semiquantitatively in the tumor epithelium and was correlated with the clinicopathological features of each patient. RESULTS: Univariate analysis revealed no statistically significant association of uPA levels with pT and pN category (p=0.655 and 0.053, respectively), grading (p=0.374), depth of tumor invasion (p=0.665), UICC classification (p=0.21) and the Laurén classification (p=0.578). PAI-1 expression showed no statistically significant correlation with pT, pN and M category (p=0.589, 0.414, and 0.167, respectively), grading (p=0.273), and the Laurén classification (p=0.368). Only the UICC classification was significantly correlated with PAI-1 (p=0.016). Kaplan-Meier analysis revealed no significant association of uPA and PAI-1 with overall survival (p=0.0929 and 0.0870, respectively). CONCLUSIONS: Our results could not verify any prognostic value of uPA and PAI-1 levels in patients with gastric carcinoma. Therefore, the uPA-system as a biologically defined prognostic marker to identify high-risk gastric cancers should be applied with caution. However, considering the number of patients involved and the borderline level of significance observed in this study, a larger number of events may have resulted in significant differences.

Monoclonal antibody FW6 defines an epitope on alpha 3/4-monofucosylated polylactosaminoglycans expressed by fetal and colon carcinoma-associated mucins.

A mouse IgM monoclonal antibody FW6 was established after immunization of mice with mucins from human amniotic fluid and was characterized with regard to its binding epitope. According to a series of biochemical criteria the epitope is located on O-linked neutral carbohydrates of M(r) 700,000 and M(r) 570,000 mucins in human amniotic fluid. The epitope is presumed to contain alpha 3/4-linked fucose and terminal beta 3/4-linked galactose that are labile to the fucosidase I from almond emulsion or to the galactosidase from bovine testes, respectively. Immunoreactive fractions of glycan alditols from human amniotic fluid mucins were partially characterized by fast atom bombardment-mass spectrometry and methylation analysis to be composed of monofucosylated polylactosamine-type deca- or nonasaccharides. According to antibody competition studies, inhibition assays with defined carbohydrates and binding assays on neoglycolipids monoclonal antibody FW6 are presumed to recognize a novel epitope that is distinct from known carbohydrate markers of the Lex/Ley family associated with colonic carcinomas. The selective reactivity of this monoclonal antibody to the majority of human colonic carcinomas and its nonreactivity to normal colonic mucosa may render this antibody as a valuable tool in cancer diagnosis or cancer treatment.

Feasibility of sentinel node concept in gastric carcinoma: clinicopathological analysis of gastric cancer with solitary lymph node metastases.

BACKGROUND: The feasibility and diagnostic reliability of sentinel lymph node biopsy of gastric carcinoma are still unclear and controversial. PATIENTS AND METHODS: To assess the applicability of the sentinel node concept to gastric carcinoma, we retrospectively analyzed the location of metastatic lymph nodes in patients with only one or two lymph node metastases. RESULTS: A total of 135 patients, who underwent gastrectomy with D2 lymphadenectomy for primary gastric adenocarcinoma between 1997 and 2001, were enrolled in this study. An average of 39 lymph nodes were resected and analyzed for each patient. Of the 135 patients, 88 (65%) were subtyped as pN+ (with lymph node metastasis); of the latter, 15 cases (pT1-3; 17% of N+ cases) showed one or two lymph node metastases. In 14 (93%) of these patients, lymph nodes directly adjacent to the primary tumor were involved. Skip metastases were only seen in one patient with cardia carcinoma and lymph node involvement of compartment II (left gastric artery). CONCLUSION: In patients with gastric carcinoma, especially in early stage carcinoma, the phenomenon of skip metastasis is infrequent. Therefore, the sentinel node concept may be feasible in gastric cancer.

Interactions between endogeneous lectins and fucosylated oligosaccharides in megakaryocyte-dependent fibroblast growth of the normal bone marrow.

In order to elucidate the involvement of adhesion mechanisms in the process of megakaryocyte-dependent fibroblast growth, we applied BSA-coupled polymers of glucose, galactose, fucose, mannose, and several lectins (AAA, LCA, LTA, UEA-I) to cocultures of CD61 -positive (CD61+)/MACS-enriched megakaryocytes and human bone marrow fibroblasts. Fibroblast monocultures served as controls. After 6 days, glucose, as well as galactose-treated cultures showed a significant reduction of fibroblast growth in cocultures and fibroblast monocultures. In contrast, application of mannose caused no reducing effect on fibroblast numbers. Administration of fucose, AAA, LTA or UEA-I revealed a strong impairment of fibroblast growth in the megakaryocyte-fibroblast cocultures. Adhesion experiments using MACS-enriched, fluorescein-labelled megakaryocytes cultured in the presence of carbohydrates and lectins on a near-confluent layer of fibroblasts were additionally performed. Following fucose-BSA, alpha Fuc-1,2Gal beta-HSA or UEA-I treatment a significant reduction of megakaryocyte adhesion to the fibroblast layer could be observed. In the case of AAA a weak impairment of megakaryocyte adhesion could be noticed. Selective pretreatment of either fibroblasts or megakaryocytes with fucose-BSA or alpha Fuc-1,2Gal beta-HSA was consistent with the finding of a prominent involvement of fucosylated residues located on megakaryocytes in this interaction. In conclusion, our studies are in keeping with the assumption that fucosylated and fucose-binding structures are playing a key role in adhesion mechanisms between megakaryocytes and fibroblasts and thus influence significantly the megakaryocyte-dependent growth of bone marrow fibroblasts.

[Submucosal infiltration and local recurrence in pT1 low-risk rectal cancer treated by transanal endoscopic microsurgery]. / Transanale endoskopische Mikrochirurgie beim pT1-Low-risk-Rektumkarzinom. Zusammenhang zwischen Submukosainfiltrationstiefe und Lokalrezidivrate.

BACKGROUND: The association between submucosal infiltration and tumor recurrence was analyzed by long-term follow-up of patients with pT1 "low risk" rectal carcinoma. PATIENTS AND METHODS: Forty patients with pT1 rectal cancer of the upper and middle rectum were treated by transanal endoscopic microsurgery. All carcinomas fulfilled the low-risk criteria, and were completely resected. No further treatment was carried out. Follow-up data were available for all 40 patients, with a median follow-up of 5.4 years. RESULTS: Two patients (5.0%) developed local tumor recurrence after 14 and 18 months, respectively, and had curative rectal resection after neoadjuvant radiochemotherapy. In the histology of the initial specimens, both patients had deep submucosal infiltration (sm3). Another patient, primarily sm2 without local recurrence, developed a metachronous singular liver metastasis which was curatively resected. The risk of developing a recurrent tumor was significant for sm3 carcinomas (sm1+sm2 vs sm3, P=0.046). CONCLUSION: Transanal endoscopic microsurgery is an excellent method of treating low-risk pT1 carcinomas of the rectum. Deep submucosal infiltration (sm3) seems to be an additional high-risk factor for developing local recurrence.

Selectins (CD62L, CD62P) and megakaryocytic glycoproteins (CD41a, CD42b) mediate megakaryocyte-fibroblast interactions in human bone marrow.

Previous in vitro studies are in keeping with the finding that isolated and enriched megakaryocytes attach to bone marrow fibroblasts and generate an increased growth of these cells. This process was assumed to depend on a close spatial relationship between both cell types which supports the paracrine effect of platelet-derived growth factor (PDGF) and transforming growth factor (TGF)-beta1. Moreover, adhesion molecules including beta1 integrin receptors and fucosylated structures were determined to play an important role in these complex interactions. However, up to now the influence of megakaryocyte expressed glycoproteins CD41a and CD42b in these processes was not investigated. In addition, the role of megakaryocytic CD62P and also of CD62L, both adhesion molecules of the selectin group, could also be of interest. Following isolation and enrichment of bone marrow megakaryocytes and fibroblasts, both cell populations were characterized regarding their expression of these factors by applying immunocytochemical techniques. Additionally, their influence on adhesion of megakaryocytes to fibroblasts as well as fibroblast growth was evaluated by comparative megakaryocyte-fibroblast co-cultures and inhibition studies using specific monoclonal antibodies (mabs). Fibroblast monocultures served as controls. In these experiments, selectin-specific antibodies significantly reduced megakaryocyte attachment to fibroblast feeder layers and fibroblast growth in the co-cultures. The effect of CD41a and CD42b specific antibodies was limited to megakaryocyte-dependent fibroblast growth. These results elucidate the involvement of the selectins CD62P and CD62L in the basal activation of megakaryocytes inducing their attachment to bone marrow fibroblasts. In contrast, the megakaryocyte glycoproteins CD41a and CD42b exert their effect on the megakaryocyte dependent fibroblast growth. Altogether, it is tempting to speculate that the various interactions of these mediators reflect certain steps in the complex pathomechanisms causing the evolution of (reactive) myelofibrosis in hematopoietic neoplasias accompanied by megakaryocytic proliferation.

Epitope-dependent differential immunoreactivities of anti-MUC1 monoclonal antibodies in human carcinomas.

According to studies on a variety of malignant tumors from different organs MUC1 mucin antigen presents as a valuable marker of cancer progression and prognosis. During recent years, a great number of monoclonal antibodies (mabs) directed to MUC1 was generated. Their epitopes can be classified according to their position within the tandem repeat domain of the mucin and with respect to effects exerted by site-specific glycosylation. In this study, eight mabs from different clusters were selected to correlate their epitope specificity with their binding pattern in human cancer specimens. By applying an immunohistochemical ABC-peroxidase method, ten carcinomas derived from breast, pancreas, stomach and colon were characterized. A positive reaction of all mabs could be observed in the majority of the carcinomas, however, the extent of the stained tumor area varied significantly. In general, mabs M38, VA1 and BC3 exhibited the strongest staining reaction. Mab BW835 showed a similar binding intensity, especially in pancreatic and gastric carcinomas. It is tempting to speculate that the different binding patterns may reflect differences in epitope specificity. In conclusion, future immunohistochemical, immunoserological and therapeutic studies involving MUC1 antigen should prefer well-characterized and highly reactive mabs detecting defined peptide epitopes.

Soft tissue reactions of different biodegradable polylactide implants.

Soft tissue reactions resulting from biodegradable polylactide implants to bone have not been adequately examined during their 3-year degradation period. An osteotomy was performed on the medial femoral condyle of 36 sheep and secured by either three poly-L-DL-lactide pins (70/30) (Polypin) or three composite pins [10% beta-tricalcium phosphate (beta-TCP) (90/10)]. A histological examination was performed on the synovial membrane and lymph nodes after 3, 18 and 36 months. After 18 months two non-specific, minor reactions of the synovial membrane were observed in the composite pin group. In both groups different reactions of both inguinal lymph nodes were observed. These had no statistical relevance and could not be clearly attributed to the implants. Due to the slow degradation process of biodegradable polylactide implants, there is no clinically relevant inflammation of either joint or lymph nodes. The addition of 10% beta-TCP did not result in any significant enhancement.

The Thomsen-Friedenreich (TF) antigen: a critical review on the structural, biosynthetic and histochemical aspects of a pancarcinoma-associated antigen.

Within the family of blood-group related carbohydrate antigens the Thomsen-Friedenreich (TF) antigen (or T antigen) is an outstanding member by attracting scientific interest for more than 65 years and by having retained its significance as object of current biomedical research; in particular, as a pancarcinoma-associated antigen. In accordance with its constant or even growing attraction scientists have searched for specific reagents which would allow the unambiguous and sensitive detection of the Thomsen-Friedenreich antigen on cells or tissues. While at the beginning, immunohistochemical work on TF antigen expression was restricted by the limited specificity of plant lectins (peanut lectin) a significant progress has been possible since the introduction of the hybridoma technique. The respective monoclonal antibodies display distinct fine specificities and cellular staining patterns in immunohistochemistry and have contributed to controversial discussions on the organ-characteristic and tumor-associated expression of the TF antigen in some organs. It is the aim of this survey to summarize in the context of its structural and biosynthetic aspects the current knowledge on the tissue expression of the TF antigen as based on the use of peanut agglutinin and monoclonal antibodies and to discuss the findings with regard to their biomedical relevance, in particular, with emphasis on their value in tumor diagnosis.