Comparison of HER2 status in primary and paired metastatic sites of gastric carcinoma.

BACKGROUND: Trastuzumab has recently shown efficacy in the treatment of HER2-positive advanced gastric adenocarcinoma. Although antibody-based therapies target the metastatic disease, HER2 status is usually evaluated in the primary tumour because metastatic sites are rarely biopsied. The aim of this study was to compare HER2 status in primary and paired metastatic sites of gastric adenocarcinoma. METHODS: The HER2 status was assessed by fluorescence in situ hybridisation (FISH) and immunohistochemistry (IHC) in 72 secondary lesions of gastric adenocarcinoma and in the corresponding primary tumours. RESULTS: Concordance of FISH results, evaluable in 68 primary and matched metastatic sites, was 98.5%. Concordance of IHC results, available in 39 of the 72 paired cases, was 94.9%. Only one case showed discordance between primary tumour and metastasis, being negative by both IHC and FISH in the primary and showing HER2 overexpression and amplification in the corresponding pancreatic lymph node metastasis. CONCLUSION: The high concordance observed between HER2 results obtained by both IHC and FISH on primary tumours and corresponding metastases suggests that in gastric cancer HER2 status is maintained in most cases unchanged during the metastatic process.

A randomized clinical trial comparing 22G and 25G needles in endoscopic ultrasound-guided fine-needle aspiration of solid lesions.

BACKGROUND AND STUDY AIMS: The study aimed to investigate whether the 25G needle is superior to the 22G needle when used in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of solid lesions. PATIENTS AND METHODS: The study was a single-center randomized clinical trial. The setting was a tertiary referral hospital, where EUS-FNA of solid lesions was assisted by an on-site cytopathologist, who was blinded to the needle size. The main end point was the number of passes performed to obtain adequate samples. Crossover to the other type of needle was allowed after five passes, or when the gastroenterologist experienced difficulties in puncturing the lesions. RESULTS: A total of 129 solid lesions were randomized and data regarding 127 lesions were analyzed. The mean number of passes was 3.7 (± 1.9) in the 22G needle group and 3.8 (± 2) in the 25G needle groups (difference of means: 0.1; 95% CI: -0.59 to 0.79). Fifty-eight of 63 (92.1%) and 60/64 samples (93.7%) in the 22G and 25G needle groups respectively were adequate (difference: -1.6%; 95%CI: -12.1% to 8.9%). Crossover to the other type of needle was performed in 11/63 (17.5%) and in 12/64 (18.7%) lesions in the two groups respectively (difference: -1.2%; 95%CI: -16.2% to 13.8%). A crossover to the 25G needle was successfully performed in four masses in the uncinate process; these lesions were difficult to puncture using the 22G needle. CONCLUSIONS: Our study failed to demonstrate that the 25G is more effective than the 22G needle in EUS-FNA of solid lesions. However, targeting of lesions in the distal duodenum may be simplified by using the 25G needle.

Is a five-category reporting scheme for thyroid fine needle aspiration cytology accurate? Experience of over 18,000 FNAs reported at the same institution during 1998-2007.

OBJECTIVE: Fine needle aspiration (FNA) has long been recognized as an essential technique for the evaluation of thyroid nodules. Although specific cytological patterns have been recognized, a wide variety of reporting schemes for thyroid FNA results have been adopted. This study reports our experience with a five-category reporting scheme developed in-house based on a numeric score and applied to a large series of consecutive thyroid FNAs. It focuses mainly on the accuracy of thyroid FNA as a preoperative test in a large subset of histologically distinct thyroid lesions. METHODS: During the 1998-2007 period, 18,359 thyroid ultrasound-guided FNAs were performed on 15,269 patients; FNA reports were classified according to a C1-C5 reporting scheme: non-diagnostic (C1), benign (C2), indeterminate (C3), suspicious (C4), and malignant (C5). RESULTS: Non-diagnostic (C1) and indeterminate (C3) FNA results totalled 2,230 (12.1%) and 1,461 (7.9%), respectively, while suspicious (C4) and malignant (C5) results totalled 238 (1.3%) and 531 (2.9%), respectively. Histological results were available in 2,047 patients, with thyroid malignancy detected in 840. Positive predictive value of FNA was 98.1% with a 49.0 likelihood ratio (LR) of malignancy in patients with a C4/C5 FNA report. CONCLUSIONS: This five-category scheme for thyroid FNA is accurate in discriminating between the virtual certainty of malignancy associated with C5, a high rate (92%) of malignancy associated with C4, and a 98% probability of a histological benign diagnosis associated with C2. Further sub-classifications of C3 may improve the accuracy of the diagnostic scheme and may help in recognizing patients eligible for a 'wait and see' management.

Characterization of xenobiotic metabolizing enzymes in bovine small intestinal mucosa.

The intestinal mucosa plays a capital role in dictating the bioavailability of a large array of orally ingested drugs and toxicants. The activity and the expression of several xenobiotic metabolizing enzymes were measured in subcellular fractions from the duodenal mucosa of male veal calves and beef cattle displaying a functional rumen but differing in both age (about 8 months vs. 18 to 24 months) and dietary regimens (i.e., milk replacer plus hay and straw vs. corn and concentrated meal). Intestinal microsomes showed cytochrome P450 (CYP) 2B, 2C- and 3A-mediated activities and the presence of the corresponding immunorelated proteins, but no proof of CYP1A expression and/or functions could be provided. Intestinal microsomes were also active in performing reactions typically mediated by carboxylesterases (indophenylacetate hydrolysis), flavin-containing monooxygenases (methimazole S-oxidation), and uridindiphosphoglucuronyltransferases (1-naphthol glucuronidation), respectively. Cytosolic fractions displayed the glutathione S-transferase (GST)-dependent conjugation of 1-chloro-2,4-dinitrobenzene; besides, the GST-mediated conjugation of ethacrinic acid (GSTpi) or cumene hydroperoxide (GSTalpha) was matched by the presence of the corresponding immunorelated proteins. Conversely, despite the lack of measurable activity with 3,4-dichloronitrobenzene, a protein cross reacting with anti-rat GSTmu antibodies could be clearly detected. Although, as detected by densitometry, CYPs and GST isoenzymes tended to be more expressed in beef cattle than in veal calf preparations, there was a general poor correlation with the rate of the in vitro metabolism of the selected diagnostic probes.

Pathologist's assistant (PathA) and his/her role in the surgical pathology department: a systematic review and a narrative synthesis.

In recent decades, various highly qualified individuals have increasingly performed tasks that have historically been handled by physicians with the aim of reducing their workload. Over time, however, these "physician assistants" or "physician extenders" have gained more and more responsibilities, showing that specific tasks can be performed equally skilfully by specialised health care professionals. The pathologist's assistant (PathA) is a highly qualified technician who works alongside the pathologist and is responsible for the grossing and autopsies. This profession was developed in the USA, with formal training programmes starting in 1970 when Dr. Kinney, director of the Department of Pathology of Duke University, Durham, NC, started the first dedicated course. Most institutes in the USA and Canada currently employ these technical personnel for grossing, and numerous papers published over the years demonstrate the quality of the assistance provided by the PathA, which is equal to or sometimes even better than the performance of pathologists. The PathA can be employed to carry out a wide range of tasks to assist the pathologist, such as grossing (the description and reduction of surgical specimens), judicial autopsies and administrative and supervisory practices within the laboratory or assistance in research, although the diagnosis is always the pathologist's responsibility. Since this role has already been consolidated in North America, part of the relevant literature is altogether out of date. However, the situation is different in Europe, where there is an increasing interest in PathA, mainly because of the benefits of their inclusion in anatomic pathology laboratories. In the UK, biomedical scientists (BMS, the British equivalent of PathA) are involved in many tasks both in surgical pathology and in cytopathology, which are generally performed by medically trained staff. Several papers have been recently published to highlight the role of BMS with the broader public. This report aimed to conduct a systematic review of all the articles published about the PathA/BMS and to perform a narrative synthesis. The results may contribute to the evidence for including the PAthA/BMS within a surgical pathology laboratory organisation.

Impact of 2013 ASCO/CAP guidelines on HER2 determination of invasive breast cancer: A single institution experience using frontline dual-color FISH.

PURPOSE: The new ASCO/CAP guidelines published in 2013 (AC2013) significantly modified the scoring criteria for HER2-FISH, introducing the most controversial change to the HER2-equivocal category. We retrospectively evaluated the impact of AC2013 in a cohort of consecutive invasive breast cancers (IBCs) analyzed with frontline dual-color FISH. METHODS: 2788 consecutive IBCs were reclassified based on the AC2013 guidelines. Clinico-pathological features of equivocal IBCs were compared with HER2-negative and HER2-positive IBCs. FISH HER2-equivocal cases underwent reflex tests: HER2-IHC, RARA-FISH, and SMS-FISH. Overall and disease-free survivals were evaluated in AC2007 HER2-positive patients treated with trastuzumab and in patients that became eligible for target-therapy according to AC2013. RESULTS: Two-hundred HER2-negative cases (7.2%) were classified differently, following AC2013: 0.3% (8/2788) became HER2-positive and 6.9% (192/2788) HER2-equivocal. AC2013, compared with AC2007, significantly increased initial HER2-equivocal cases (6.9%vs1.6%, p < 0.001). AC2013 equivocal-IBCs affected older patients and showed pathological features between HER2-negative and HER2-positive IBCs. After reflex tests, 102 of the 190 equivocal cases (53.7%) were reclassified as HER2-positive, 51 (26.8%) as negative and 37 (19.5%) as equivocal. IHC tested negative in 44.7% of cases, whereas SMS-FISH showed the highest percentage of positive results (45.8%). Clinical outcomes showed no statistically significant differences. CONCLUSION: Overall, 80.5% of FISH-equivocal cases were solved with at least one reflex test and 3.6% of patients became AC2013 HER2-positive, therefore eligible for target-therapy, but showed clinical outcomes similar to HER2-positive patients treated with trastuzumab. Our data belittle the clinical impact of AC2013 HER2-equivocal reclassification; further prospective randomized clinical studies are necessary to support these findings.

Juvenile Leigh syndrome with protracted course presenting as chronic sensory motor neuropathy, ataxia, deafness and retinitis pigmentosa: a clinicopathological report.

We herein describe a male patient who died at 37 years of age, after having suffered from a slowly progressive syndrome of chronic sensory motor neuropathy, deafness, retinitis pigmentosa and ataxia. The neuropathological study showed symmetric areas of necrosis and demyelination affecting the cerebellum and brainstem. The type of lesion was consistent with the characteristics of Leigh Syndrome. On the basis of the histology of the lesions, we believe that they appeared only a few months before the death of the patient. We underline the atypical clinical picture and suggest that, in certain cases, brain MRI may not be a reliable diagnostic tool.

Comparison between western blotting, immunohistochemical and ELISA assay for p185neu quantitation in breast cancer specimens.

The protein encoded by erbB2 oncogene was evaluated by three different methodological approaches (Western blotting, ELISA and immunohistochemistry) in 147 breast cancer specimens. A highly significant correlation was found between Western blotting and ELISA results (p < 0.001). The data from ELISA and Western blotting were categorized as negatives (-), low-overexpressing (+) and high-overexpressing (++). Immunohistochemical results were classified as (-) or (+) according to the absence or the presence of specific staining. Overall positive cases (+ and ++) were 42.2% by Western blotting and 51% by ELISA, while (++) cases were 23.8% and 25.2% respectively. Histochemical staining was found in 29.8% of cases. The two by two evaluation of the assays showed a close association (chi2, p < 0.0001). In particular, the comparison between both ELISA and Western blotting with immunohistochemistry showed concordance rates of 78.9% for ELISA and 83.1% for Western blotting considering the + and ++ cases as a single group. When only the ++ cases were considered as positive, the overall agreement rises to 93.3% and 89.1% respectively. From these preliminary data we conclude that p185 values obtained with the three evaluated methods are possibly superimposable. Nevertheless, the biochemical methods seem to identify an intermediate p185 expression group, whose clinical meaning should be investigated.

Ancient schwannoma arising in a lymph node: report of a case and review of the literature.

We report a case of an intranodal schwannoma in a 79-year-old woman. The patient underwent a left colectomy for a colonic adenocarcinoma, with regional lymph node dissection. Macroscopic examination of the specimen revealed a well-circumscribed 4 cm nodule located in the pericolic fat. Macroscopically, it was interpreted as a metastatic lymph node. Microscopically, the nodule was composed of a proliferation of bland spindle cells, was immunohistochemically positive for S100 protein, and negative for smooth muscle actin, desmin, and cytokeratin. The pathological findings led to the diagnosis of a very rare case of primary schwannoma of the lymph node.

Well-differentiated angiosarcoma of the skin following radiotherapy. Report of two cases.

Two cases of well-differentiated angiosarcoma following radiotherapy together with an immunocytochemical and electron-microscopical study are reported. Both cases occurred in young females (16- and 22-yr-old respectively) who had been irradiated after birth for an "angiomatous" lesion. These cases have to be added to 34 similar cases reported in the literature.

Stromal osseous metaplasia in metastatic adenocarcinoma of the gallbladder.

A case of stromal osseous metaplasia in the abdominal scar metastasis of a gallbladder adenocarcinoma is described. The occurrence of stromal osseous metaplasia in carcinomas probably does not affect prognosis; however, it must be recognized to avoid a misdiagnosis of carcinosarcoma.

Metastasizing meningeal melanocytoma.

The first case in the literature of a metastasizing meningeal melanocytoma is described. The tumor, which arose at the D9-D11 spinal cord level of a 46-year-old woman, metastasized 7 years later to the latero-suprasellar region.

[The correlation of bacteriobilia/wound infections in elective biliary surgery]. / Correlazione bactobilia/infezioni della ferita in chirurgia biliare d'elezione.

The authors report their experience concerning the cultural study of bile samples taken during elective biliary surgery. All the operations were carried out after a randomized preoperative antibiotic prophylaxis. Among the 138 cases examined the presence of surgical infections (wound infection) was taken into account. A lack of correlation between the germs present in the bile and those isolated from samples of complicated cases, was registered. However, the Authors emphasize that, although antibiotic prophylaxis gives a reduced percentage of postoperative infections, it is unable to sterilize the bile.

[Aztreonam and clindamycin in short-term antibiotic prophylaxis in colorectal surgery: results of a multicenter studies]. / Aztreonam e clindamicina nella profilassi antibiotica a breve termine in chirurgia colorettale: risultati di uno studio policentrico.

The Authors studied the effects of a short-term prophylaxis (Aztreonam + Clindamycin) administered to 259 patients operated on for colo-rectal diseases. Thirteen wound sepsis (5.15%) and 49 different infections (19.44%) occurred in this group of patients. The study confirms the link between P.N.I. greater than 50 and the incidence of wound infections. The incidence of urogenital sepsis was correlated with the catheterization period (greater than 6 days), operative time (greater than 200 min.), hospitalization (greater than 12 days) and age (greater than 70 years). General tolerance to the antibiotics was good.

Lymphomatoid granulomatosis: a practical review for pathologists dealing with this rare pulmonary lymphoproliferative process.

Lymphomatoid granulomatosis (LYG) is a rare B-cell lymphoproliferative disorder predominantly involving the lungs, but poorly-recognized among clinicians and pathologists. It is an Epstein-Barr virus (EBV)-driven disease mimicking several other diseases on clinical and radiological grounds, generally showing multiple, bilateral nodular, ill-defined infiltrates of the lungs tending to coalescence and/or cavitation. LYG often affects middle-aged males with an underlying immunodeficiency and commonly involves skin and central nervous system during disease progression. Diagnosis requires a generous biopsy and careful histologic examination with immunohistochemical staining and molecular demonstration of EBV genome in large atypical B-cells. LYG is graded as I to III based on the number of large EBV-positive B-cells; grades II/III are now considered as a peculiar variant of T-cell rich diffuse large B-cell lymphoma. In this brief review, clinical, radiologic and pathologic features of LYG will be analyzed with focus on differential diagnosis, the most appropriate treatment and prognosis.

Synergistic antitumor activity of lapatinib and retinoids on a novel subtype of breast cancer with coamplification of ERBB2 and RARA.

All-trans retinoic acid (ATRA), the only clinically available cyto-differentiating agent, has potential for the therapy/chemoprevention of breast carcinoma. Given the heterogeneous nature of this tumor, a rational use of ATRA and derivatives (retinoids) in the clinic requires the identification of patients that would benefit from retinoid-based protocols. Here, we demonstrate that 23-32% of the human ERBB2(+) breast cancers show coamplification of retinoic acid receptor alpha (RARA), encoding the retinoic acid receptor, RARα. This represents a novel subtype of breast cancer characterized by remarkable sensitivity to ATRA and RARα agonists, regardless of positivity to the estrogen receptor, a known modulator of retinoid sensitivity. In estrogen-receptor-negative cellular models showing coamplification of ERBB2 and RARA, simultaneous targeting of the corresponding gene products with combinations of lapatinib and ATRA causes synergistic growth inhibition, cyto-differentiation and apoptosis. This provides proof-of-principle that coamplification of ERBB2 and RARA can be exploited for the stratified and targeted therapy of a novel subtype of breast cancer patients, with an approach characterized by tumor cell selectivity and low predicted toxicity. The available cellular models were exploited to define the molecular mechanisms underlying the antitumor activity of combinations between lapatinib and ATRA. Global gene expression and functional approaches provide evidence for three components of the antiproliferative/apoptotic responses triggered by lapatinib+ATRA. Induction of the retinoid-dependent RARRES3 protein by ATRA stabilizes the effect of lapatinib inhibiting ERBB2 phosphorylation. Upregulation and activation of the transcription factor FOXO3A integrates ATRA-dependent transcriptional and lapatinib-dependent posttranscriptional signals, controlling the levels of effector proteins like the antiapoptotic factor, BIRC5. Stimulation of the TGFß pathway by ATRA mediates other components of the apoptotic process set in motion by simultaneous targeting of ERBB2 and RARα.

Novel strategies for tracing the exposure of meat cattle to illegal growth-promoters.

Official monitoring of residues in cattle throughout the European Union in 2007 found <0.2% non-compliance for the use of illegal growth-promoters (GPs), including sex steroids, corticosteroids and ß-agonists. There is evidence, however, that these figures may underestimate the real incidence of GP abuse in meat cattle breeding. One source of evidence arises from the introduction of new detection strategies in response to the demand for safe and wholesome food. These strategies are based on the biological effects of the different GP classes in target species, with a focus on identifying reliable and cost effective biomarkers to improve detection methods. This review summarises the published data relating to experimental and field studies performed in meat cattle, emphasising the impact of the 'omic' technologies and bioinformatics to discover suitable biomarkers for residue surveillance. Further research is required before any potential biomarkers can be utilised for large scale high throughput screening tests.