DNA replication regulation protein Mcm7 as a marker of proliferation in prostate cancer.

BACKGROUND: Recent studies have shown that minichromosome maintenance (MCM) proteins (Mcm2-7) may be useful proliferation markers in dysplasia and cancer in various tissues. AIMS: To investigate the use of Mcm7 as a proliferation marker in 79 lymph node negative prostate cancers and compare it with Ki-67, a commonly used cell proliferation marker. METHODS: The percentage of proliferating cells (proliferation index; PI) was calculated for basal and luminal epithelial cells in benign prostate tissue, prostatic intraepithelial neoplasia (PIN), and epithelial cells in adenocarcinoma. The PI for each biomarker was correlated with the preoperative prostate specific antigen concentration, the Gleason score, surgical resection margin status, and the AJCC pT stage for each patient. RESULTS: The mean PIs for Ki-67 and Mcm7 were: benign luminal epithelium 0.7 and 1.2 and benign basal epithelium 0.8 and 8.2; PIN non-basal epithelium 4.9 and 10.6 and PIN basal epithelium 0.7 and 3.1; adenocarcinoma 9.8 and 22.7, respectively. Mcm7 had a significantly higher mean PI (p<0.0001) than Ki-67 for all cell categories except benign luminal epithelial cells. Mcm7 was a better discriminatory marker of proliferation between benign epithelium, PIN, and invasive adenocarcinoma (p<0.0001) than Ki-67. The drop in Mcm7 mean basal cell PI from benign epithelium to PIN epithelium was significantly larger than for Ki-67 (p<0.0001). Mcm7 had a significantly higher PI than Ki-67 at each risk level. CONCLUSION: Mcm7 may be a useful proliferation marker in prostatic neoplasia and warrants further evaluation as a complementary tool in the diagnosis of PIN and prostate carcinoma.

Collagenous gastritis: a long-term follow-up with the development of endocrine cell hyperplasia, intestinal metaplasia, and epithelial changes indeterminate for dysplasia.

This report reviews the literature pertaining to collagenous gastritis and describes the clinicopathologic evolution of this disease in a patient during a 12-year period. We examined 109 biopsy specimens of gastric mucosa from 19 different endoscopic procedures for the severity and distribution of collagenous gastritis in a single patient. Assessments were undertaken for the presence of endocrine and gastrin cell hyperplasias and dysplastic epithelial changes. Relative to biopsy specimens from age- and sex-matched control subjects, the patient's biopsy specimens showed a significantly lower number of antral gastrin cells, along with a significant corpus endocrine cell hyperplasia, suggesting an increased risk of endocrine neoplasia. Gastric corpus biopsy specimens revealed an active, chronic gastritis, subepithelial collagen deposition, smooth muscle hyperplasia, and mild to moderate glandular atrophy. Additional findings of intestinal metaplasia and reactive epithelial changes indeterminate for dysplasia raise concerns about the potential for adenocarcinoma.

The characteristic appearance of non-alcoholic duct destructive chronic pancreatitis: a report of 2 cases.

We report 2 patients with an unusual form of chronic pancreatitis, both of whom were treated for clinical suspicion of pancreatic malignancy. The surgical specimens revealed a dense lymphoplasmacytic infiltration of the main and interlobular branches of the pancreatic duct, causing sclerosis of the duct wall, diffuse irregular lumenal narrowing, extensive parenchymal fibrosis, and organ enlargement. Neither case showed calcifications, fat necrosis, or cyst formation, features usually seen in alcoholic pancreatitis, nor was there any evidence of neoplasia. One patient had an unusual form of acalculous cholecystitis, but without cystic duct inflammation or fibrosis. Both patients recovered well from the surgical procedure and have not had any complications or relapse of their symptoms. To the best of our knowledge, these cases are representative of the recently described non-alcoholic duct destructive chronic pancreatitis, which is thought to be immune-mediated.

Cystic hamartoma of the renal pelvis: a rare pathologic entity.

We report a case of a rare cystic renal tumor previously termed cystic hamartoma of the renal pelvis. A 53-year-old woman presented to her gynecologist with menometorrhagia. She subsequently had a computed tomographic scan that demonstrated an incidental cystic mass in the lower pole of the left kidney. Histologically, the tumor was composed of a mixture of benign mesenchymal and epithelial components. The stroma consisted of spindle cells with monomorphic nuclei and abundant eosinophilic cytoplasm that resembled smooth muscle and that reacted positively with antibodies to alpha-smooth muscle actin, desmin, and vimentin. The epithelial component was composed mostly of cysts lined by cuboidal-to-columnar epithelium. Focal dilated cysts were lined by epithelium with oncocytic features. We think that this entity is distinct from other renal tumors, including mesoblastic nephroma, cystic nephroma, or a cystic, partially differentiated nephroblastoma, and that it is best classified as a cystic hamartoma of the renal pelvis.

Recommended policies for uses of human tissue in research, education, and quality control. Ad Hoc Committee on Stored Tissue, College of American Pathologists.

As recipients of tissue and medical specimens, pathologists and other medical specialists regard themselves as stewards of patient tissues and consider it their duty to protect the best interests of both the individual patient and the public. The stewardship of slides, blocks, and other materials includes providing, under appropriate circumstances, patient materials for research, education, and quality control. The decision to provide human tissue for such purposes should be based on the specific (ie, direct patient care) and general (ie, furthering medical knowledge) interests of the patient and of society. The same standards of responsibility should apply to all medical professionals who receive and use specimens. This document proposes specific recommendations whereby both interests can be fostered safely, ethically, and reasonably.

Utility of hepatic iron index in American patients with hereditary hemochromatosis: a multicenter study.

BACKGROUND & AIMS: A hepatic iron index (hepatic iron concentration divided by age) of more than 1.9 has been proposed as useful to identify patients with homozygous hereditary hemochromatosis (HHC). There are limited data on the diagnostic use of the hepatic iron index in patients with HHC in the United States. This study evaluated the hepatic iron index in the diagnosis of HHC in a multicenter U.S. study. METHODS: Hepatic iron concentration was measured in 509 patients undergoing liver biopsy. The diagnosis of HHC was made using clinical, biochemical, and histopathologic criteria. RESULTS: Fifty-five patients met criteria for HHC; hepatic iron index was > 1.9 in 51 of 55 (93%) patients with HHC but in none of 454 patients with other liver diseases; hepatic iron concentration was > 71 mumol/g dry weight in 54 of 55 patients with HHC but only 1 of the other 454 patients. CONCLUSIONS: A hepatic iron index of > or = 1.9 can identify most U.S. patients with HHC but is < or = 1.9 in 7%. A "threshold" hepatic iron concentration of 71 mumol/g can almost always distinguish patients with HHC from patients with other liver diseases and may be a useful adjunct to the hepatic iron index in the diagnosis of HHC in the diverse U.S. population.

Diagnostic accuracy of a rural live video telepathology system.

Accuracy of diagnoses rendered using a live video telepathology network was assessed for permanent sections of surgical pathology specimens. To determine accuracy, telepathology diagnoses were compared with those obtained by directly viewing the glass slide using a standard microscope. A total of 294 cases were read via both telepathology and glass slide by attending pathologists at a tertiary care medical center. Overall accuracy was defined as exact concordance between diagnoses. Clinically insignificant differences in diagnoses were excluded to determine clinically significant accuracy. For the 285 cases with complete data, the overall accuracy for telepathology was 0.912 (95% confidence interval [CI], 0.872-0.941), whereas the overall accuracy for glass slide readings was 0.968 (95% CI, 0.939-0.985). This difference is statistically significant (p = 0.009). When focusing on clinically significant discrepancies, where the difference in diagnosis might affect therapeutic decisions, the video accuracy was only slightly less than the glass slide accuracy (0.965 [95% CI, 0.934-0.982] vs. 0.982 [95% CI, 0.957-0.994], respectively), but this difference is not statistically significant (p = 0.302). Most of the cases with clinically significant differences involved lesions with inherently high interobserver variation. Certainty of diagnosis did not differ between video and glass slide readings (p = 0.911), but there was an association between certainty of diagnosis and diagnostic accuracy for video (p = 0.003 for clinically significant accuracies). Based on these findings, we recommend when using this telepathology system that only preliminary diagnoses should be given in the following situations: for diagnostic areas with known high interobserver variability; when the consultant has any degree of uncertainty about the presence or absence of the lesion in question; and when there is insufficient experience using telepathology as a diagnostic medium.

Controlled trial of 4-ASA in ulcerative colitis.

A six-week placebo-controlled trial of the efficacy and safety of 6 g per day of 4-aminosalicylic acid (4-ASA) was conducted in 30 subjects with mild to moderately severe ulcerative colitis. Subjects were stratified into groups having distal (< 60 cm) or more extensive (> 60 cm) disease. Diarrhea, bleeding, sigmoidoscopic and biopsy appearance, and physician global assessment were scored to judge efficacy. Safety was evaluated by monitoring untoward symptoms and laboratory values. Median percent improvement was significantly greater (P < 0.05) in the 4-ASA > 60-cm group (42.7%) than in the placebo > 60-cm group (21.2%), but 4-ASA was not better than placebo for the < 60-cm group or the total study group. Severe dyspepsia (one subject), abnormal AST (transient in five, persistent in one) and elevated lipase without pancreatitis (six subjects) were noted. Thus 6 g 4-ASA for six weeks was more effective than placebo in mild to moderate ulcerative colitis extending more than 60 cm above the anus, but not in distal disease, and the drug was generally well tolerated.

The pathologist's role in the use of human tissues in research--legal, ethical, and other issues.

Because of their central role in examining and storing samples of human tissues obtained for diagnosis or therapy of diseases, pathologists frequently are involved in providing human tissues for a wide range of research. This is an important role for the pathologist that leads to increased understanding of disease, to potential methods of prevention, and to improved therapy. Recent conferences concerning uses of human tissues in research have indicated that there is confusion with respect to legal issues and requirements of pathologists who are involved in research with human tissues. This paper discusses current federal regulations concerning the use of human tissues and medical information in research as specified in Title 45, Part 46 of the Code of Federal Regulations (45 CFR 46) "Protection of Human Subjects." The authors also recommend approaches that pathologists can utilize to ensure that they are meeting all federal regulations with respect to the use of human tissues in research.

Development of the human fetal testis.

We describe the histological features of the fetal testis, utilizing 68 fetuses ranging in gestational age from 10 to 41 weeks. During fetal life, the tunica albuginea progressively increases in thickness, and between 29 and 32 weeks it develops two layers. Beyond 25 to 28 weeks, septa are invariably present. Tubules begin as straight structures and become maximally coiled by 30 weeks. Tubular diameter reaches its maximum by 16 weeks and remains constant throughout the rest of gestation. Germ cell and Sertoli cell numbers per tubular diameter have a wide range, but the median number for each cell type remains constant after 13 to 16 weeks. Leydig cells are most numerous between 17 and 19 weeks and decline thereafter. They are infrequent but still present at term. Interstitial lipochrome pigment accumulates during the latter half of gestation and may represent breakdown products from Leydig cell degeneration.

Intratubular germ cell neoplasia (ITGCN) with p53 and PCNA expression and adjacent mature teratoma in an infant testis. An immunohistochemical and morphologic study with a review of the literature.

Intratubular germ cell neoplasia (ITGCN) and mature teratoma of the testis are uncommon findings in children. We report a case of a 3-year-old boy with both ITGCN and mature teratoma--a unique finding in our experience. Immunohistochemical markers, including placental alkaline phosphatase (PLAP), 43-9F, p53, and proliferating cell nuclear antigen (PCNA), as well as the periodic acid-Schiff (PAS) stain, were applied to the ITGCN. PLAP and 43-9F were not detected, whereas p53 and PCNA nuclear expression was detected in approximately 5% of atypical germ cells. Abundant clumped intracytoplasmic glycogen deposits were identified within atypical germ cells. Our findings indicate that both PCNA and p53, in addition to a PAS stain, may be useful markers in detecting malignant intratubular germ cells.

Localization of anti-Leu-M1 (CD15) binding sites in Hodgkin's disease by immunoelectron microscopic examination.

Anti-Leu-M1 (CD15) is a monoclonal antibody used in surgical pathology to diagnoses Hodgkin's disease. By light microscopic immunohistochemistry, anti-Leu-M1 reacts with Reed-Sternberg cells and their variants, notably lacunar cells in nodular sclerosing Hodgkin's disease, as well as granulocytes in Hodgkin's disease. The immunostaining of Reed-Sternberg cells has been characteristically described as a diffuse cytoplasmic pattern with a prominent perinuclear globular component. In addition, irregular plasma membrane reactivity has been observed. To define the intracellular localization of Leu-M1 precisely, the authors performed postembedding immunoelectron microscopy with the protein A-gold technique on sections embedded in Lowicryl K4M from a patient with nodular-sclerosing-type Hodgkin's disease. At the electron microscopic level, gold particle staining indicative of Leu-M1 binding was found within cytoplasmic granules and the Golgi apparatus, as well as focally at the plasma membrane. The cytoplasmic granules were located in a perinuclear region and in the cell periphery. Although the morphology of the granules was suggested of lysosomal structures, immunolabel was not detected on serial sections of these granules with three different antibodies directed against lysosomal antigens.

Ultrastructural study of a pituitary adenoma (prolactinoma) within the clivus bone using immunoelectron microscopy.

In a case of a pituitary adenoma in the clivus bone in a 71-year-old man, ultrastructural investigation using conventional aldehyde-fixed, epoxy-embedded tissue revealed the tumor to be composed of cells with euchromatic nuclei, dense nucleoli, abundant rough endoplasmic reticulum, spherical secretory granules, and granule extrusion at the lateral cell surface, all of which suggest a prolactin-producing adenoma. Using a protein A-gold immunolabeling technique on snap-frozen tissue subsequently fixed in a mild fixative and embedded in a hydrophilic resin, the presence of prolactin immunoreactivity within secretory granules at the ultrastructural level was demonstrated. This case represented the first use of protein A-gold immunolabeling at the electron microscopic level for diagnostic purposes at our institution and exemplifies the value of this technique when the need for diagnostic immunoelectron microscopy is not anticipated. Because this tumor arose in an unusual location, ultrastructural study, including immunoelectron microscopy, not only confirmed the light microscopic diagnosis of pituitary adenoma, but further allowed subclassification of the tumor.

Diagnostic immunoelectron microscopy in surgical pathology: assessment of various tissue fixation and processing protocols.

We have investigated various tissue fixation and embedding protocols in an effort to allow expanded use of immunoelectron microscopy in diagnostic surgical pathology. A sample of normal human small bowel mucosa was processed using seven different methods for subsequent postembedding localization of chromogranin A. In addition, several archival cases of neuroendocrine tumors previously fixed and routinely embedded for electron microscopy, stored in formalin, or snap-frozen were retrieved and variously processed for chromogranin A localization at the ultrastructural level. Precise localization of chromogranin A in dense core granules was achieved with protein A-gold on sections from all of the processing methods. The methods included retrieval into mild fixative of previously formalin-fixed or snap-frozen tissues followed by embedding in Lowicryl K4M (Polysciences Ltd., Eppelheim, Germany). Thus, tissue processed without foresight of the need for immunoelectron microscopic localization can be successfully used. Since embedding of tissues in Lowicryl K4M has been shown to preserve a variety of antigens, it may prove to be a superior resin for use in diagnostic immunoelectron microscopy.

HMB-45 antibody demonstrates melanosome specificity by immunoelectron microscopy.

The intracellular localization of antigenic sites recognized by the monoclonal antibody HMB-45 was investigated in melanomas of the choroid and skin by postembedding immunoelectron microscopy. Antigenic sites were detected by a three-step procedure, consisting of incubating sections with the monoclonal HMB-45 antibody (protein G affinity-purified ascites from Enzo Diagnostics Inc or tissue culture supernatant from Dako Corp), followed by incubation with an affinity-purified rabbit anti-mouse IgG and finally with protein A-gold complex. Gold particles, indicative of HMB-45 immunoreactivity, were restricted to melanosomes in the malignant melanocytes. Early stages in melanosome formation (stages I through III) were most intensely stained, while late-stage melanosomes (stage IV) were only sparsely labeled or not stained at all. Melanophages adjacent to a cutaneous melanoma showed intense immunoreactivity in the cytoplasm and especially over electron-dense portions of lysosomes with the HMB-45 antibody from Enzo. In marked contrast, only very sparse labeling was detected over melanophages using a similar concentration of the HMB-45 antibody from Dako. Subsequently, when the Enzo antibody was diluted 40 times above the recommended working dilution, most of the melanophage staining disappeared, while melanocyte-specific staining was maintained. Immunolabeling of melanosomes with HMB-45 was drastically reduced or absent following section pretreatment with neuraminidase, confirming an earlier report that the HMB-45 antigen is partially composed of sialic acid. Our immunoelectron microscopic results show that HMB-45 antibody specifically stains melanosomes, rather than diffuse cytoplasmic antigen, as described by light microscopic immunohistochemical analysis, thus explaining its specificity for melanocytes. In addition, the elimination of HMB-45 immunoreactivity by neuraminidase pretreatment supports the idea that sialylation of antigen is crucial to HMB-45 binding, and suggests that the absence of staining in normal adult melanocytes, dermal nevi, and other melanocytic lesions may be a result of differential sialylation.

Orbital paraganglioma: case report and review of the literature.

Paragangliomas of the orbit are extremely rare. A case of an orbital paraganglioma, including the first magnetic resonance imaging description of this tumour is described here. The patient underwent surgery with gross total removal of the tumour and relief of his initial chief complaint of visual blurring. The differential diagnosis and therapeutic options for the management of this tumour are discussed.

Error in histologic dating of secretory endometrium: variance component analysis.

OBJECTIVE: To characterize the extent and sources of imprecision in histologic dating of the endometrial biopsy. DESIGN: Duplicate endometrial biopsies from 25 women were dated by five evaluators on two separate occasions to evaluate the overall precision of the measure. Using variance component analysis, estimates of intrauterine, intraevaluator, and interevaluator variability were determined. SETTING: Samples were obtained during outpatient fertility testing. Evaluators were colleagues at the same institution. PATIENTS, PARTICIPANTS: Women presenting with infertility undergoing routine evaluation. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Variability in histologic dating of the endometrium. RESULTS: Inconsistencies between evaluators accounted for 65% of the observed variability, whereas 27% was because of inconsistencies in duplicate readings by the same evaluator. Regional differences in the uterus accounted for only 8% of the total variability. CONCLUSIONS: The overall error from these sources have the potential to result in a substantial false-positive rate for diagnosis of luteal phase defect.

Adenocarcinoma of the uterine cervix of small intestinal type containing numerous Paneth cells.

A case of invasive adenocarcinoma of the uterine cervix with small intestinal differentiation to include numerous Paneth cells is presented. The light microscopic findings are confirmed by immunohistochemical and electron microscopic study. To our knowledge, this is only the second reported case of small intestinal cervical adenocarcinoma that contained Paneth cells and the first with ultrastructural and immunohistochemical confirmation. A small focus of in situ adenocarcinoma with similar features is seen adjacent to the invasive area.

Collagenous gastritis.

Subepithelial fibrosis has previously been reported in the small intestine (collagenous sprue) and colon (collagenous colitis). We report a 15-yr-old girl with chronic gastritis and subepithelial fibrosis of the gastric corpus who presented with recurrent abdominal pain and acute upper gastrointestinal bleeding. Nodularity and erythema of the gastric corpus were persistent endoscopic findings. Biopsies revealed patchy chronic active gastritis with a striking focal thick band of collagen immediately beneath the surface epithelial cells that did not extend to deeper portions of the lamina propria. Contrast radiography demonstrated an abnormal mucosa of the gastric corpus with a mosaiclike surface pattern. Numerous studies have failed to elucidate the etiology. Despite treatment with ranitidine, sucralfate, and furazolidone, there has been no clinical or pathologic improvement. The pathogenesis and prognosis of collagenous gastritis, and its relationship to collagenous sprue and collagenous colitis, remain to be defined.