Marijuana use in potential liver transplant candidates.

Concern exists that liver transplant center substance abuse policies may have an inappropriate and disproportionate impact on marijuana users. Our hypothesis is that patients with chronic liver disease who were marijuana users will have inferior survival. This is a retrospective (1999-2007) cohort study. The primary outcome measure is time-dependent, adjusted patient survival from the time of liver transplant evaluation. The primary exposure variable is a positive cannabinoid toxicology screen during the liver transplant evaluation period. Overall, 155 patients qualified as marijuana users while 1334 patients were marijuana non-users. Marijuana users were significantly (p < 0.05) younger (48.3 vs. 52.1), more likely to be male (78.1% vs. 63.0%), have hepatitis C (63.9% vs. 40.6%) and were less likely to receive a transplant (21.8% vs. 14.8%). Marijuana users were more likely to use tobacco, narcotics, benzodiazepines, amphetamines, cocaine or barbiturates (p < 0.05). Unadjusted survival rates were similar between cohorts. Upon multivariate analysis, MELD score, hepatitis C and transplantation were significantly associated with survival, while marijuana use was not (HR 1.09, 95% CI 0.78-1.54). We conclude that patients who did and did not use marijuana had similar survival rates. Current substance abuse policies do not seen to systematically expose marijuana users to additional risk of mortality.

Improving organ procurement practices in Michigan.

Travel to procure deceased donor organs is associated with risk to transplant personnel. In many instances, multiple teams are present for a given operation. We studied our statewide experience to determine how much excess travel this redundancy entails, and generated alternate models for organ recovery. We reviewed our organ procurement organization's experience with deceased donor operations between 2002 and 2008. Travel was expressed as cumulative person-miles between procurement team origin and donor hospital. A model of minimal travel was created, using thoracic and abdominal teams from the closest in-state center. A second model involved transporting donors to a dedicated procurement facility. Travel distance was recalculated using these models, and mode and cost of travel extrapolated from current practices. In 654 thoracic and 1469 abdominal donors studied, the mean travel for thoracic teams was 1066 person-miles and for abdominal teams was 550 person-miles. The mean distance traveled by thoracic and abdominal organs was 223 miles and 142 miles, respectively. Both hypothetical models showed reductions in team travel and reliance on air transport, with favorable costs and organ transport times compared to historical data. In summary, we found significant inefficiency in current practice, which may be alleviated using new paradigms for donor procurement.

Comparison of histidine-tryptophan-ketoglutarate and University of Wisconsin preservation in renal transplantation.

Histidine-tryptophan-ketoglutarate (HTK) is replacing University of Wisconsin (UW) solution as the preservation fluid for renal allografts in many centers, but recent large-scale data to support this transition are lacking. We conducted a retrospective analysis of patient and graft outcomes after renal transplantation at our center, comparing 475 consecutive living donor and 317 deceased donor transplants since the adoption of HTK with equal numbers of grafts preserved using UW solution. Data collected included donor and recipient age, race, sex, comorbidities and graft ischemia time. Graft and patient survival, as well as the incidence of delayed graft function (DGF), were studied by Kaplan-Meier and Cox regression analysis. No significant difference was seen in either patient or graft survival. Deceased donor kidneys in the HTK group had a higher incidence of DGF than the UW cohort, whereas this trend was reversed in the case of living donor organs. In multivariate analysis, HTK was associated with a significant risk reduction on the incidence of DGF. Prolonged preservation with HTK compared to UW was not associated with excess risk to the graft or patient. In summary, HTK demonstrated efficacy similar to UW in terms of patient and graft survival.

Papillary (chromophil) renal cell carcinoma: histomorphologic characteristics and evaluation of conventional pathologic prognostic parameters in 62 cases.

For more than two decades, papillary renal cell carcinoma has been recognized as a possible distinct clinicopathologic subtype of renal cell carcinoma (RCC). However, the histologic criteria for its diagnosis and the clinical outcome are still debated. In an attempt to clarify the diagnostic criteria and resolve issues pertaining to biologic potential, we have evaluated the histologic spectrum of 62 papillary RCCs and assessed significance of conventional pathologic prognostic parameters (Fuhrrman's nuclear grade [NG], pathologic stage [Robson and TNM], tumor size, multifocality, necrosis, and foam cells) and correlated these with outcome. The mean age of patients was 61.8 years (range 22-83), and males were more commonly affected (1.8:1). Grossly, most tumors were well circumscribed, averaged 6.7 cm in size (range 1.8-18), and were predominantly localized to the renal poles (polar vs. mid-renal, 3:1). Multifocality was a prominent feature (24 cases), and in three cases tumors were bilateral. Microscopically, papillary RCCs were predominantly papillary or tubulopapillary, often with a thick fibrous capsule, foam cells, necrosis, hemorrhage, and multifocality. Thirty-five percent of these tumors were low grade (NG I and II) and 65% high grade (NG III and IV). Sixteen of these tumors presented in a higher stage (stages III and IV), and the overall stage correlated with NG (chi 2, p = 0.009). Tumors were further distinguished by cytoplasmic features: eosinophilic (42%), basophilic (34%) and mixed (24%). Eosinophilic tumors were predominantly high grade, and basophilic tumors low grade (chi 2, p = 0.000). A mean follow-up of 57 months showed progression (metastasis, recurrence, or death due to disease) in 21%, whereas 63% were free of disease. Eleven percent died of unrelated causes, and 5% were lost to follow-up. Kaplan-Meier survival analysis showed that both high NG and stage were strongly associated with decreased survival (p = 0.0000 each), as were decreased foam cell (p = 0.0025) and vascular invasion (p = 0.0002). Comparison of 196 reported cases of papillary RCC, including the current series, with reported large series of conventional RCC indicates that papillary RCC usually presents at an early stage, and stage I (Robson) papillary RCC has better 5 year survival rates (87%-100%) than does RCC of the same stage (65-75%). The overall 5 years survival rate for papillary carcinoma (82-90%) was also higher than that of conventional RCC (44-54%). In a Cox proportional hazard regression model, TNM stage appeared to be the only significant variable (p = 0.0000, hazard ratio 10.1) in predicting outcome among papillary RCC. Based on this experience, we conclude that (a) papillary RCC is a malignant tumor, with a tendency to present at a lower stage, but with a distinct potential for progression and aggressive behavior; (b) stratification of these tumors according to cell type, amount of foam cells, presence or absence of vascular invasion, nuclear grade, and pathologic stage provides useful prognostic information; (c) the better 5-year survival rate of papillary RCC (overall and for stage I tumors) compared with that of conventional RCC suggests that it is a tumor with lower malignant potential. Thus, histologic subcategorization of a renal carcinoma as papillary RCC appears to have prognostic implications.

The histologic spectrum of apocrine breast proliferations: a comparative study of morphology and DNA content by image analysis.

Apocrine features occurring in sclerosing adenosis (apocrine adenosis), atypical ductal hyperplasia (ADH), and non-comedo ductal carcinoma in situ (DCIS) often add to diagnostic difficulty. We have evaluated the usefulness of DNA content determined by image analysis in apocrine metaplasia and hyperplasia, apocrine adenosis, ADH, DCIS, lobular carcinoma in situ, invasive ductal carcinoma, and infiltrating lobular carcinoma as a potential diagnostic aid in some of these problematic breast lesions with apocrine features. Infiltrating ductal carcinoma and DCIS were further subdivided into high- or low-grade category based on nuclear features. Microscopic fields containing 63 lesions were identified in slides from breast excisions. From each selected area 100 cells in corresponding fields in paired Feulgen-stained sections were digitized for computerized ploidy analysis with lymphocyte nuclei in the same slides serving as internal diploid controls. Aneuploidy was assessed using combined DNA index and modified Auer histogram criteria for DNA content abnormalities. There was strong association between the assessment of nuclear grade and ploidy (Fisher's exact test, P < .00001). All but one of the benign and low-grade malignant lesions (97%) were in the diploid range (six of seven apocrine metaplasia cases, three of three apocrine adenosis cases, 14 of 14 ADH cases, 10 of 10 low-grade DCIS cases, two of two lobular carcinoma in situ cases, and two of two infiltrating lobular carcinoma cases). In contrast, 24 of 25 (96%) of the high-grade malignant lesions were aneuploid (10 of 10 DCIS cases and 14 of 15 infiltrating ductal carcinoma cases). We conclude that DNA ploidy status does not offer additional diagnostic information to light microscopy in distinguishing among benign apocrine proliferations, ADH, and low-grade DCIS since these proliferations share a diploid range DNA content.

Ki-67 and proliferating cell nuclear antigen tumor proliferative indices in DNA diploid colorectal adenocarcinomas. Correlation with histopathologic characteristics and cell cycle analysis with two-color DNA flow cytometry.

The prognostic significance of tumor proliferative activity (TPA) in colorectal adenocarcinomas (CA) determined by proliferating cell nuclear antigen (PCNA) and Ki-67 staining is not well defined. Previous investigations of TPA using Ki-67 immunohistologic studies and flow cytometric (FCM) analysis have found no correlation with conventional histopathologic parameters. To better define the relationship of these various TPA measurements in CA, the authors selected 46 tumors with diploid DNA content previously analyzed by two-color DNA FCM analysis of fresh specimens to more effectively assess actual S-phase fractions (SPFs) from cytokeratin-gated DNA histograms for comparison with the following: (1) immunohistologic Ki-67 and PCNA tumor proliferation indices (TPIs); and (2) conventional histopathologic observations of prognostic import. These data show no significant correlation coefficient between Ki-67 or PCNA TPIs and SPFs derived from FCM analysis; however, the DNA diploid tumor subset categorized as having a greater than median SPF value had a significantly higher mean Ki-67 but not PCNA proliferation index. There was no correlation of any measure of proliferation with any of the eight histopathologic features of known prognostic significance.

Prognostic value of proliferating cell nuclear antigen index in gastric stromal tumors. Correlation with mitotic count and clinical outcome.

Morphologic studies of gastric stromal tumors (GSTs) indicate that mitotic counts (MCs) and tumor size are major discriminants predictive of biologic behavior. The authors evaluated the tumor proliferation of GSTs with anti-proliferating cell nuclear antigen (PCNA; DAKO clone PC10, DAKO Corporation, Carpinteria, CA) for correlation with MCs, histologic cell type, and clinical outcome. Fifty-eight tumors ranging from 1.5 to 45 cm in size were selected for clinicopathologic assessment. Mitotic activity was counted per 50 high-power fields (MC). For this study, combined parameters of MC and tumor size were used to categorize tumors into three groups: (1) benign: MC less than 5, tumor smaller than 5 cm; (2) borderline: MC less than 5, tumor larger than 5 cm; and (3) malignant: MC greater than 5, tumor any size. The PCNA tumor proliferation index (TPI) was assessed from evaluation of 200 tumor cells per case and expressed as the percentage of cells with positive results. Clinical follow-up was available in 45 cases. None of the 19 benign or 16 borderline tumors recurred or metastasized, whereas 7 of 10 malignant tumors metastasized and 1 of 10 recurred. The mean PCNA TPI values among benign (11.2%), borderline (16%), and malignant (34.5%) tumors were significantly different (P = 0.0002, Kruskal-Wallis test). When the pathologic tumor categories were compared, the mean TPI of benign tumors was significantly different from that of borderline tumors (P = 0.0306, Kruskal-Wallis), and the TPI of borderline tumors was different from that of the malignant tumors (P = 0.0060, Kruskal-Wallis test). The Spearman rank correlation showed a significant relationship between the MC and PCNA TPI (P = 0.0003, r = 0.4543). Logistic regression analysis showed that the TPI, independent of MC and size, contributed significantly (P = 0.00295) to the prediction of outcome. In the malignant group, the mean TPI for malignant tumors with metastases (43.6%) was significantly different (P = 0.0411, Kruskal-Wallis test) from that of malignant tumors without metastases (including the case with probable recurrence) (11.83%). No correlation was found when PCNA TPIs for epithelioid GCTs were compared with those of spindle cell GSTs.(ABSTRACT TRUNCATED AT 400 WORDS)

Small intestinal stromal tumors: a clinicopathologic study of 20 cases with immunohistochemical assessment of cell differentiation and the prognostic role of proliferation antigens.

Small intestinal stromal tumors (SISTs), similar to their gastric counterpart, are complex because of their divergent cellular differentiation and because of the difficulty in accurately predicting their clinical outcome. We studied a series of 22 SISTs from 20 patients to characterize lineage and investigate prognostic morphologic parameters and possible histologic and immunohistochemical differences from gastric stromal tumors (GSTs) and to determine the potential prognostic value of proliferation markers. Cases were categorized into the three following groups based on mitotic count (MC) per 50 high-power fields and tumor size: (1) benign, n = 6 (< 5 MC, < 5 cm); (2) borderline, n = 6 (< 5 MC, > or = 5 cm); and (3) malignant, n = 10 (> or = 5 MC, any size). For the formalin-fixed, paraffin-embedded tissue sections, an immunohistochemical panel was used to characterize differentiation toward myogenic cells (pan-muscle specific actin [HHF-35], alpha-smooth muscle actin, and desmin), Schwann cells (S-100 protein), enteric glial (glial fibrillary acidic protein), and nerve cells (neurofilament). Cellular proliferative activity was assessed immunohistochemically using monoclonal antibodies to proliferating cell nuclear antigen (PCNA) and Ki-67 antigen (MIB-1) and a tumor proliferation index (TPI) was obtained as the percentage of positive-staining tumor nuclei. Clinical follow-up revealed that none of the benign tumors progressed (mean follow-up, 96 months). Half of the patients with borderline tumors were dead of disease (mean, 50.7 months), while 8 of 9 patients with a malignant tumor died of disease (mean, 24.6 months). By Cox Proportional Hazard Regression analysis, mitotic count, tumor size, and cellularity significantly predicted survival. PCNA, MIB-1, tumor necrosis, and atypia were not significant predictors of survival. All tumors stained with vimentin; 17 (77%) and 13 (59%) of the tumors showed immunoreactivity with muscle-specific actin markers (HHF-35) and alpha-smooth muscle actin, respectively. Only 1 tumor stained with desmin, and none stained with S-100 protein, neurofilament, or glial fibrillary acidic protein. Immunophenotypic characteristics did not differ among the 3 groups. The TPI for PCNA and MIB-1 significantly differed between benign and malignant tumors and between borderline and malignant tumors, but it failed to separate the benign and borderline groups. Compared with 52 cases of GST previously reported by us using the same criteria and antibody panel, these tumors were histologically and immunohistochemically indistinguishable. However, none of the 18 borderline GSTs progressed, while 3 of 6 patients with a borderline SIST died of the disease. Based on this series of 22 SISTs, we conclude the following: (1) MC, size, and cellularity are the best predictors of clinical outcome in SIST. (2) The majority of SISTs show smooth muscle differentiation based on their immunoreactivity with HHF-35 and alpha-smooth muscle actin). (3) The TPI for PCNA and MIB-1 correlated with MC but failed to predict survival for individual cases. (4) SISTs and GSTs are morphologically and immunohistochemically similar; however, SISTs seem to have greater malignant potential than GSTs of similar size.

The effect of number of histogram events on reproducibility and variation of flow cytometric proliferation measurement.

Sources of variation in synthesis phase fraction (SPF) calculation were studied, and the number of histogram events was found to be an important quality control consideration. Six cell cycle models (CCMs) for histograms composed of 1,000 to 20,000 events were compared. All CCMs were cytometer based, or available in Multicycle (MC) software. The experiment consisted of five consecutive acquisitions, on the same day, of the same propidium iodide (PI) stained sample of T24 human cell line, at each of nine "landmarks" between 1,000 and 20,000 events. The authors found (1) all CCMs evaluated required > or = 5,000 events for accurate, reproducible SPF; and (2) in the 5,000-20,000 event range the MC models provided the most accurate, reproducible SPF values. Therefore, histogram-dependent curve fitting models may enhance clinical applications of FCM proliferation measurements. The authors conclude that histogram rejection criteria for S-phase analysis should be established, and that two-color multiparametric DNA analysis "live" gating with tissue specific markers may assure acquisition of sufficient events for accurate SPF.

Image cytophotometric DNA analysis of atypical hyperplasias and intraductal carcinomas of the breast.

With the use of image analysis, DNA content was quantified on paraffin-embedded tissue sections of 25 atypical hyperplasias and 35 intraductal carcinomas of the breast by comparison of integrated gray levels of Feulgen-stained control and ductal cell nuclei. The mean full-peak (G0/G1) control cell DNA histogram coefficient of variation was 5.5%. DNA aneuploidy was more common in intraductal carcinomas compared with atypical hyperplasias (71% of intraductal carcinomas vs 36% of atypical hyperplasias) and correlated with a lack of cytologic (nuclear) and architectural differentiation (63% moderate vs 93% poor and 38% cribriform vs 82% solid). In addition, multiple DNA stemlines were observed in 40% of intraductal carcinomas. We conclude that (1) some atypical hyperplasias demonstrate abnormal DNA content consistent with neoplastic transformation, (2) aggressive forms of intraductal carcinoma are more frequently associated with DNA content abnormalities, and (3) frequent DNA stemline heterogeneity in intraductal carcinoma supports the hypothesis that multiple genetic events occur in the development of mammary intraepithelial neoplasia.

Computerized static DNA ploidy analysis of prostatic intraepithelial neoplasia.

The microscopic features of prostatic intraepithelial neoplasia (PIN) are said to identify a precursor of prostatic adenocarcinoma (PC). We investigated this sequence of neoplastic progression by studying the relationship of PIN and PC by static ploidy analysis so that PIN and PC nuclei could be distinguished morphologically from each other and separately analyzed. From 51 archival cases of PC with coexistent high-grade PIN (PIN grades II and III) 50 control nuclei, 100 PIN nuclei, and 100 carcinoma nuclei per case were identified and digitized in corresponding Feulgen-stained slides. Control and PIN ploidy histograms fit a log-normal distribution, whereas malignant nuclei fit a rectangular distribution. When the histogram patterns were classified, the incidence of aneuploidy was 25% in PIN and 41% in PC. By case, the concordance of ploidy between PIN and PC was heterogeneous, yet the DNA ploidy of PIN and the corresponding PC was significantly associated. In four cases, PIN was DNA aneuploid while the associated PC was DNA diploid. These results support the hypothesis that high-grade PIN is a neoplastic precursor of prostatic adenocarcinoma and suggest that further karyotypic instability may result in invasive adenocarcinoma with different DNA content detectable by image analysis.

Prognostic significance of the nuclear DNA content in localized prostatic adenocarcinoma.

The objective of this study was to determine if the nuclear DNA content could predict disease progression in patients with stage A or B prostatic cancer. The nuclear DNA content was determined by image analysis using Feulgen-stained nuclei in tissue sections of prostatic needle biopsies from 44 patients. The patients were followed for a mean of 69.5 months, during which 12 (17%) progressed to stage D2 disease (bone or soft tissue metastases). The average times to progression to stage D2 disease were 68 months for patients who initially had stage A2 disease, 47 months for stage B1 patients and 29 months for stage B2 patients. The DNA pattern was judged diploid or normal-range (Auer type I or II histogram) in 35 tumors (80%) and aneuploid (Auer type III or IV histogram) in 9 tumors (20%). Eight (89%) of 9 tumors with an aneuploid DNA pattern and 4 (11%) of 35 tumors with a normal-range or diploid DNA pattern progressed to stage D2 disease.

Comparison of PCNA/cyclin immunohistochemistry with flow cytometric S-phase fraction in breast cancer.

Kinetic index determined by enumeration of neoplastic cells positive for proliferative cell nuclear antigen (PCNA) in 70 breast carcinomas (avidin-biotin immunoperoxidase technique) was compared to synthesis-phase fraction (S-phase, or SPF) values obtained by flow cytometry (FCM) using a multiparametric, 2 color method (dual-label propidium iodide/cytokeratin-FITC). The percent PCNA positive tumor cells (12.5% mean, range 1-28%) was significantly greater in aneuploid tumors (14.2% mean, N = 35) compared to diploid range tumors (10.7% mean, N = 35) (p less than 0.05), and was correlated with SPF derived from ungated DNA histograms (12.5% mean +/- 5.5%, r = 0.45, p less than 0.001). Marginally stronger statistical correlations were observed between the PCNA index and SPF values calculated from cytokeratin-gated (15.8% mean, r = 0.53, p less than 0.001) DNA histograms or from SPF values obtained following linear baseline debris subtraction (mean = 8.1%, r = 0.48, p less than 0.001). Significant associations were identified between PCNA index and prognostically important clinicopathologic parameters including nuclear grade (p = 0.014), presence of necrosis (p = 0.005), and angiolymphatic invasion (p = 0.003). We conclude: 1) PCNA index is comparable to FCM SPF and correlates with factors of known prognostic importance in carcinoma of the breast; 2) baseline debris and contaminating events derived from non-epithelial cells both represent significant artifacts in proliferative fraction estimates derived from FCM DNA histograms; and 3) multiparametric analysis may represent one means of improving the specificity and clinical value of FCM SPF determinations.

Comparative analysis of the nuclear proliferative index (Ki-67) in benign prostate, prostatic intraepithelial neoplasia, and prostatic carcinoma.

High-grade prostatic intraepithelial neoplasia (HG-PIN) lies in the morphologic continuum between benign and carcinomatous prostate, but its status as a neoplastic precursor remains only putative. We measured nuclear proliferative activity using MIB-1 antibody to further characterize the cell kinetics of HG-PIN and to assess its relationship to prostatic adenocarcinoma. We studied 36 specimens from randomly selected patients who underwent radical prostatectomies for prostatic adenocarcinoma. Sections of formalin-fixed, paraffin-embedded tissue pretreated by a citric acid monohydrate antigen retrieval method were immunostained with the mouse monoclonal antibody MIB-1, which detects the Ki-67 antigen in formalin-fixed tissue. The Ki-67 antigen is expressed by non-G0 proliferating cells and has been used to assess cellular proliferative activity. A maximum of either 20,400 x fields or 100 positively stained nuclei in benign glands, areas of HG-PIN, and adenocarcinoma were counted to obtain an immunohistologic proliferation index for each case. For benign prostate, HG-PIN, and adenocarcinoma, the mean positivity was 0.4 +/- 0.42 cells per field (range, 0-2), 2.5 +/- 3.79 cells per field (range, 0-16.6), and 13.8 +/- 15.05 cells per field (range, 0.25-73.66), respectively. Using a Kruskall-Wallis analysis of variance (chi 2 = 58, P < 0.05) and the t test for dependent samples, we found that the mean Ki-67 antigen expression significantly differs between histologic categories (P < 0.01, all three comparisons). In addition, the proliferative index consistently increased along the continuum from benign to malignant. We conclude that the MIB-1 proliferative index of HG-PIN lies between that of benign and carcinomatous prostate, supporting the assertion that HG-PIN is a biologic intermediate in the multistep process of transformation into carcinoma.

Prognostic significance of DNA ploidy and proliferation in 309 colorectal carcinomas as determined by two-color multiparametric DNA flow cytometry.

BACKGROUND: Although DNA flow cytometry has been shown to be of independent value in determining the prognosis of colorectal carcinoma, a number of well-designed studies with contradictory findings have left unresolved the clinical significance of DNA ploidy and proliferation in biologically meaningful subsets of colorectal carcinoma cases. METHODS: To evaluate the prognostic significance of DNA ploidy and proliferation as determined by flow cytometry in a prospective series of 309 human colorectal carcinomas with 4-6 years of follow-up, fresh tumors were mechanically dissociated into whole cell suspensions and dual fluorescence-labeled to allow gated analysis of subpopulations with phenotypic markers. Software programs with histogram-dependent algorithms employing background, aggregate, and debris correction were used in DNA and cell cycle quantitation. Data were analyzed according to recommendations of the 1992 DNA Flow Cytometry Consensus Conference. RESULTS: None of the clinical, site, or staging parameters, including TNM stage variables, correlated with any flow cytometric DNA ploidy or proliferation measurement. Tumors classified as DNA aneuploid or tetraploid, by any definition, did not differ in prognosis or correlate with stage or any pathologic parameter. Univariate Kaplan-Meier survival analysis showed prognostic significance of the following: Dukes staging, individual components of TNM stage (tumor depth, lymph node status, and metastasis), vascular invasion, histologic pattern of tumor infiltration, and peritumoral lymphocytic inflammation. DNA ploidy status and proliferation measurements were not predictive of survival for the overall group or within any particular stage. Only Dukes Stage D (metastasis), vascular invasion, and depth of invasion (T classification) were significant independent predictors of survival in multivariate Cox regression models. CONCLUSIONS: In this analysis, DNA ploidy and proliferation measurements were not predictive of survival in any stage of colorectal carcinoma. However, clinical and pathologic documentation of staging and select histopathologic observations were significant predictors of survival in univariate and multivariate analyses.