Mast cells and exosomes in hyperoxia-induced neonatal lung disease.

Chronic lung disease of prematurity (CLD) is a frequent sequela of premature birth and oxygen toxicity is a major associated risk factor. Impaired alveolarization, scarring, and inflammation are hallmarks of CLD. Mast cell hyperplasia is a feature of CLD but the role of mast cells in its pathogenesis is unknown. We hypothesized that mast cell hyperplasia is a consequence of neonatal hyperoxia and contributes to CLD. Additionally, mast cell products may have diagnostic and prognostic value in preterm infants predisposed to CLD. To model CLD, neonatal wild-type and mast cell-deficient mice were placed in an O2 chamber delivering hyperoxic gas mixture [inspired O2 fraction (FiO2 ) of 0.8] (HO) for 2 wk and then returned to room air (RA) for an additional 3 wk. Age-matched controls were kept in RA (FiO2 of 0.21). Lungs from HO mice had increased numbers of mast cells, alveolar simplification and enlargement, and increased lung compliance. Mast cell deficiency proved protective by preserving air space integrity and lung compliance. The mast cell mediators ß-hexosaminidase (ß-hex), histamine, and elastase increased in the bronchoalveolar lavage fluid of HO wild-type mice. Tracheal aspirate fluids (TAs) from oxygenated and mechanically ventilated preterm infants were analyzed for mast cell products. In TAs from infants with confirmed cases of CLD, ß-hex was elevated over time and correlated with FiO2 Mast cell exosomes were also present in the TAs. Collectively, these data show that mast cells play a significant role in hyperoxia-induced lung injury and their products could serve as potential biomarkers in evolving CLD.

Prognostic significance of peritumoral lymphatic and blood vessel invasion in node-negative carcinoma of the breast.

The prognostic significance of intramammary lymphatic and blood vessel invasion was evaluated in a retrospective series of 221 patients with node-negative carcinoma of the breast treated with modified radical mastectomy. To facilitate identification of lymphatic and blood vessel invasion, the tumors were studied with an immunohistochemical technique using antibodies to endothelial markers. Peritumoral lymphatic and blood vessel invasion (PLBI) (encompassing both lymphatic and blood vessel invasion) was an adverse prognostic indicator independent of menopausal status, tumor size, and other histologic variables. Recurrence of disease and death resulting from carcinoma were significantly higher for patients with PLBI-present (+) tumors compared with patients with PLBI-absent (-) tumors (P less than .0001). The risk of recurrence for patients with PLBI+ tumors was 4.7 times that for their PLBI- counterparts. The presence of intratumoral lymphatic and blood vessel invasion (ILBI) is less important because few examples were found without concomitant PLBI. When PLBI was separated into lymphatic invasion and blood vessel invasion individually, the prognostic significance was retained in both groups. The immunohistochemical approach reduced both false-negative and false-positive observations and identified about 40% of PLBI that would have been missed by routine histologic examination alone. The presence of PLBI appears to be a potentially useful discriminant in predicting the outcome of patients with node-negative carcinoma of the breast.

Somatic mutation of PTEN in vulvar cancer.

PTEN, a candidate tumor suppressor gene located at chromosome 10q23.3, has been shown to be mutated in approximately 40% of endometrial cancers. Such mutations have also been identified in endometrial hyperplasia, indicating that inactivation of the PTEN tumor suppressor gene is an early event in the genesis of some endometrial cancers. In this study, we have extended the analysis of PTEN in gynecological cancer to include adenocarcinoma of the cervix and vulvar carcinomas. Microdissected tissue (including normal tissues), preneoplastic, and neoplastic lesions were analyzed from 9 patients with cervical cancer and 10 patients with vulvar cancer. Only 1 cervical adenocarcinoma displayed a PTEN mutation. In contrast, five of eight vulvar carcinomas studied harbored PTEN mutations. Alterations were identified in carcinoma in situ as well as squamous cell carcinoma of the vulva. In two patients, PTEN mutations were identified in mucosal regions with mild or focal dysplasia. These results suggest that PTEN is frequently altered in vulvar carcinomas and can be found associated with early dysplastic changes in vulvar mucosa.

S-100 protein positivity in breast carcinomas: a potential pitfall in diagnostic immunohistochemistry.

S-100 protein, originally isolated from neural tissues, has also been identified in various normal and neoplastic cells, including malignant melanomas. A systematic immunohistochemical investigation of this antigen was performed on formalin-fixed paraffin-embedded samples of benign and malignant breast tissues with use of the avidin-biotin-peroxidase complex immunoperoxidase technique and a polyclonal antiserum that recognizes both the alpha and beta subunits of S-100 protein. In benign breast tissue, S-100 protein was present in both epithelial and myoepithelial cells of terminal ducts and lobules; the staining was cytoplasmic and sometimes nuclear. Of 100 randomly selected invasive breast carcinomas, 48 per cent contained S-100 protein-positive tumor cells. Lobular and medullary carcinomas (60 per cent and 80 per cent, respectively) were more frequently positive than ductal carcinomas (45 per cent). Dendritic cells, most likely Langerhans' cells, were present in some carcinomas and were also positive for S-100. There was no relationship of S-100 positivity to histologic differentiation, recurrence interval, or the expression of various tumor markers. The presence of S-100 protein positivity in metastatic breast carcinomas may lead to the erroneous diagnosis of malignant melanoma. Our observations underscore the importance of testing for a broad panel of tumor markers rather than relying on single antigens in evaluating metastatic malignancies of undetermined origin.

Lymphatic and blood vessel invasion in breast carcinoma: a useful prognostic indicator?

Recent studies have presented compelling evidence to support the prognostic importance of peritumoral lymphatic and blood vessel invasion in breast cancer. This parameter appears to be particularly valuable in the hands of pathologists who are experienced in diseases of the breast and who have developed standardized criteria and expertise in their recognition. However, its application is seriously hampered by various factors, especially interobserver and intraobserver differences in interpretation. A more uniform and objective approach, such as the use of immunohistochemical techniques, may be helpful in overcoming these obstacles. This may render lymphatic and blood vessel invasion a reliably reproducible indicator that a practicing pathologist can utilize to recognize high-risk patients and recommend appropriate therapy. The extension of this approach to evaluate neoplasms of other organs--such as malignant melanomas and thyroid, uterine, and cervical carcinomas--should also be explored.

Occult axillary lymph node metastases in "node-negative" breast carcinoma.

The presence of occult axillary nodal metastases was evaluated in 159 patients with "node-negative" invasive breast carcinoma. Multiple additional levels of the lymph nodes were examined with hematoxylin-eosin staining and keratin immunostaining. Occult nodal metastases were detected in 50 (31%) patients; of these, 28 (17%) were detectable by hematoxylin-eosin stain alone, while the other 22 (14%) consisted of mostly single cells or very small clusters and required immunostaining for detection. The size of the metastatic deposit was < or = 0.2 mn in 31 (19%) patients and greater than 0.2 mm in 19 (12%) patients. Occult nodal metastasis correlated with the presence of peritumoral lymphatic invasion (P = .02) and was seen more frequently with larger tumor size, increased microvasculature, and aneuploidy. As a group occult metastases had no significant prognostic impact. However, patients with metastases measuring greater than 0.2 mm had significantly worse recurrence (P = .02), disease-free survival (P = .04), and overall survival (P = .07) rates; those with metastases detectable by hematoxylin-eosin stain alone also had a less favorable, although not significant, outcome. In contrast, patients with occult metastases that were < or = 0.2 mm or that were detected only by immunostaining had a survival rate comparable to and in fact slightly higher than that of the group without occult metastasis; 23 of these patients were without recurrence after a median follow-up of 11 years. Extension into perinodal soft tissue was an unfavorable feature. In a multivariate analysis peritumoral lymphovascular invasion and increased microvasculature were the most important prognostic parameters, and the presence of occult metastases greater than 0.2 mm was no longer significant. Our data suggest that occult metastases < or = 0.2 mm, especially those consisting of single cells, do not add useful prognostic information, and immunohistochemical studies to detect them are probably unnecessary. Larger metastases and extranodal involvement may have important prognostic value, but in this study they accounted for only 20% of patients who had recurrences or 6% of the total population. This underscores the importance of using more than one prognostic parameter in evaluating breast carcinoma.

Splenic hamartoma and capillary hemangioma are distinct entities: immunohistochemical analysis of CD8 expression by endothelial cells.

The histologic and immunohistologic features of two morphologically similar splenic tumors, a capillary hemangioma and a splenic hamartoma, are reported. The hemangioma was composed predominantly of small vascular channels lined by endothelium expressing factor VIII-related antigen and lacking T-subset antigen (CD8). In contrast, the splenic hamartoma was predominantly a spindle cell lesion with numerous vascular channels coursing through the tumor; these contained splenic-type endothelium expressing both CD8 and factor VIII-related antigen. Our results justify the concept that the splenic hamartoma is a tumor of splenic origin or a true hamartoma and is distinct from the splenic capillary hemangioma.

Expression of classic cadherins type I in urothelial neoplastic progression.

Loss or reduced expression of E-cadherin has been shown to be associated with poor survival in patients with bladder cancer. In numerous cases, loss of E-cadherin expression in bladder tumors has been accompanied by continued association of catenins with the membrane, suggestive of the expression of an alternative cadherin member. In this study we examined 75 bladder tumors using immunohistochemistry for the expression of E-, P-cadherin, and alpha-, beta-, and gamma-catenins. As reported previously, loss or reduced E-cadherin expression is a frequent event in late stage bladder cancer, accompanied by less frequent alterations associated with different catenin family members. Analysis of 51 tumors for expression of E-, P-, and N-cadherin showed P-cadherin localized to the basal cell layers of normal urothelium, with retention of expression in the majority of tumors. In low-grade tumors P-cadherin was found localized to an expanded basal cell compartment, contrasting with the more extensive staining observed in late stage tumors. Membranous P-cadherin staining was often found in the absence of E-cadherin staining. N-cadherin is not expressed in normal bladder mucosa, but detection of this cadherin member was recorded in 39% (20/51) of bladder tumors. Unlike P-cadherin, membranous N-cadherin was detected in focal regions within tumors, representing novel expression in urothelial neoplastic progression. Although focal N-cadherin staining was observed in 3 noninvasive lesions, the majority of tumors expressing N-cadherin were invasive (17/20). Coexpression of E-, P-, and N-cadherin was recorded in 5 grade 2 bladder tumors. Expression of P-cadherin is maintained throughout bladder tumorigenesis, accompanied by aberrant expression of N-cadherin. Clearly, neither P- nor N-cadherin act in an invasive-suppressor mode in bladder cancer, but whether they have a primary role to play in urothelial neoplastic progression has yet to be established.

Sucrase-isomaltase expression in chronic ulcerative colitis and dysplasia.

Sucrase-isomaltase (SI) is a mucosal disaccharidase that is present in normal small intestine and fetal colon. It also has been noted in colonic adenomas and adenocarcinomas. We used a polyclonal antibody to human SI to investigate enzyme presence and utility in detecting dysplastic changes in chronic ulcerative colitis. Sections from 32 cases were reviewed for the presence or absence of active colitis and dysplasia. Immunostaining of these cases for SI was performed and the results were reported based on location of immunoreactivity (ie, membrane and cytoplasmic staining in superficial and crypt epithelial cells) and percentage of positivity. Of 81 sections examined, 48 were rated negative for dysplasia (23 inactive colitis, 20 active, and five probably negative) and 28 were rated positive (eight low grade and 20 high grade). Surface membrane staining of epithelial cells was noted in all 28 dysplastic slides and positive cases (sensitivity, 100%) but also in 29 of 48 negative sections (P less than .001). In contrast, cytoplasmic positivity was present in 25 of 28 dysplastic and in only two of 48 negative slides (P less than .0001). The presence of cytoplasmic staining of SI in the superficial or crypt cells revealed a sensitivity of 92% and a specificity of 94%. There were five additional sections rated as indefinite for dysplasia (probably positive or unknown); two showed staining patterns typical of negative slides and three showed positive staining patterns. Of the 18 samples of transitional mucosa next to areas of dysplasia, surface membrane staining of SI was seen in all samples and cytoplasmic staining was seen in 15. We conclude that membrane staining of SI can be detected in inflammatory, regenerative, and dysplastic mucosa in ulcerative colitis. Cytoplasmic staining, however, correlates strongly with the presence of dysplastic change and may help in its detection.

Microvessel quantitation and prognosis in invasive breast carcinoma.

The prognostic significance of microvessel quantitation in invasive breast carcinoma was analyzed in a study group that comprised 88 patients with axillary node-negative carcinoma and 32 patients with axillary node-positive carcinoma who had a minimum follow-up period of 9 years. Microvessels were identified by immunohistochemistry using antibodies to endothelial markers, including factor VIII-related antigen and blood group isoantigens (ABH). Factor VIII-related antigen staining provided more consistent results for microvessel quantitation than did staining for ABH isoantigens. The three most vascular areas within a tumor were selected, and the microvessels within a x200 microscopic field of each area were counted by two investigators simultaneously. Node-positive carcinomas demonstrated significantly higher microvessel counts than did node-negative carcinomas (mean +/- SD, 99 +/- 42 and 73 +/- 22, respectively; P less than .001). In node-negative carcinomas, tumors from patients who experienced distant recurrence had higher microvessel counts than did tumors from patients who were disease-free (84 +/- 19 and 70 +/- 22; P = .01). Similarly, in patients with node-positive carcinoma, microvessel counts were considerably higher in tumors from patients who experienced distant recurrence than in patients who did not, although the difference did not reach statistical significance (113 +/- 44 and 93 +/- 34, respectively). Among patients with node-negative carcinoma, those with a microvessel count of less than 84 had a recurrence rate of 20% compared with 57% in patients with counts greater than 84 (P = .003). Microvessel counts were independent of histologic parameters, ploidy status, and S-phase fraction but correlated with peritumoral vascular invasion. Both microvessel counts and vascular invasion were independent prognostic parameters by multivariate analysis. High vessel counts may represent increased tumor angiogenesis and are correlated with tumor aggressiveness. Microvessel quantitation may be an additional prognostic factor that, when used in conjunction with more established parameters, can help in appropriate patient management.

Splenic hamartoma.

This paper describes five cases of splenic hamartoma, a benign lesion, usually found incidentally in the spleen at autopsy. The current practice of laparotomy for staging of malignant lymphomas, especially Hodgkin's disease, has increased the numbers of surgically removed spleens. Because splenic hamartomas may be confused histologically with Hodgkin's disease involving the spleen, the authors have reviewed this entity, stressing the importance of recognizing and distinguishing it from a malignant process.

Flow cytometric and image analyses of colorectal adenocarcinomas. A comparative study with clinical correlations.

Quantitative DNA measurements were performed in 183 colorectal carcinomas by image and flow cytometric analyses of paraffin-embedded tissue. Flow cytometric analysis yielded more diploid tumors compared with image analysis, which identified more tetraploid tumors. Histogram patterns were concordant in 115 tumors (66%); the discordant cases were primarily tumors interpreted as diploid by flow cytometric analysis but were aneuploid or tetraploid by image analysis. Linear regression analysis of DNA indices of concordant samples showed good correlation but only moderate correlation for the entire group. Both techniques revealed more aneuploid tumors in the distal colon and rectum than in the proximal colon. Diploid tumors were associated with a better prognosis; however, tetraploid tumors behaved like aneuploid tumors by flow cytometric analysis but like diploid tumors by image analysis. When stratified by stage, the prognostic value of diploid tumors was seen in stages A and B disease by image analysis only and in stage C disease by flow cytometric analysis only, possibly because of the small cohort size. The S-phase fraction (mean value, 16.8% +/- 9.9%) was higher in aneuploid than in diploid tumors, but no relationship to prognosis was seen. Flow cytometric and image analyses are useful to study ploidy of colorectal carcinoma from archival material. However, important discordant observations reflecting differences in characteristics of the two techniques should be considered, depending on which technique is used.

Hürthle cell carcinoma of the thyroid gland: prognostic factors and results of surgical treatment.

BACKGROUND: Hürthle cell carcinomas of the thyroid are unusual variants of well-differentiated thyroid cancers. Considered more aggressive tumors, their optimal treatment is controversial. Our institution's half century of experience, the largest series to date, includes 40 patients with Hürthle cell carcinomas of 1000 well-differentiated thyroid cancers. METHODS: A retrospective study was carried out on 40 patients. RESULTS: Seventy-two percent were female, with a median age of 53 years. Median follow-up was 9 years. With the AMES risk stratification (age, distant metastasis, capsular extent, tumor size), among the 21 high-risk patients, 10 (48%) had a recurrence or died, with median time to recurrence 3 years (range, 0.5 to 14 years). Of these 10, 5 died of disease, one died of unrelated causes with disease, and 4 are alive with disease. Five recurrences presented as distant metastases. Extent at operation was the strongest predictor of recurrence, occurring in 66% of those with gross extraglandular involvement. CONCLUSIONS: The AMES criteria are useful in predicting recurrence and death. Although more aggressive surgery is appropriate for high-risk patients, in general their outlook remains grim.

Adenocarcinoma arising in an ileostomy. Report of two cases and review of the literature.

Adenocarcinoma arising in an ileostomy is rare. Two cases are reported, one of a 58-year-old woman and the other of a 54-year-old man who had each undergone a colectomy for chronic ulcerative colitis. Seven other cases previously reported in the literature are reviewed. Though the exact pathogenesis is uncertain, several possibilities, particularly with regard to antecedent dysplasia and backwash ileitis, are discussed. Routine yearly follow-up and examination of the stoma by a physician or enterostomal therapist may lead to earlier detection of this rare complication.

Management of bile duct cysts in adults.

In 31 adult patients with bile duct cysts seen at the Lahey Clinic (Burlington, Mass) during a 20-year period, the median age at time of initial therapy at Lahey Clinic was 34 years. Abdominal pain was the most common presenting symptom, followed by jaundice and fever. The 31 patients underwent a total of 86 biliary tract procedures, of which 37 were performed at Lahey Clinic. Internal drainage was the most common operation, but it frequently resulted in recurrent symptoms requiring reoperation. Cyst excision was associated with a significantly lower incidence of recurrent cholangitis and need for reoperation and was not associated with increased operative mortality. Cystic disease was frequently associated with other hepatobiliary diseases. Biliary carcinoma occurred in five (16%) of our patients, and late deaths from biliary-related disease occurred in seven patients (22%). When technically possible, cyst excision is the treatment of choice.

Gastric adenocarcinoma. A disease in transition.

Two hundred eleven gastric adenocarcinomas diagnosed from 1967 to 1982 were analyzed. Thirty-four percent had a proximal location, a proportionate increase from previous decades that suggested a distinctive epidemiology. Diffuse histology occurred in 49% of cases overall and in 55% of unresectable cases, which were also increases from previous decades. No deaths followed curative resections, two (4%) of 50 patients with palliative resections died, and three (6%) of 54 patients who underwent exploration without resection died, indicating improved operative management. Superficial gastric cancer constituted 6% of cases; 91% were cured. Seventeen percent of cases were linitis plastica and required total gastrectomy in 77% of resections; only 13% of patients had curative operations; none were cured. Seventy-nine percent of cases were polypoid or ulcerated focal cancers. Of operable focal cancers, 72% were resected; 27 (47%) of 57 patients who underwent resection for cure survived five years, a distinct improvement from previous reports, as was the overall survival of 21%.

Early somatostatinoma of the papilla of the duct of Santorini.

We studied a patient with a very small somatostatinoma that arose from the prominence of the orifice of the duct of Santorini. The patient presented clinically with epigastric discomfort, marked loss of weight, diarrhea, exertional dyspnea, and chest pain. He flushed intermittently and had occasional tachycardia and hypertension. Levels of serum serotonin and urinary 5-hydroxyindoleacetic acid were normal. A small ampullary tumor was resected and identified by immunohistochemical staining to be a somatostatinoma. The patient had gained 6.75 kg and was essentially free of symptoms 16 months after surgery.

Clinical and pathologic correlations in patients with periampullary tumors.

Perioperative data on 87 patients undergoing pancreatoduodenectomy for periampullary tumors were correlated with pathologic study of operative specimens to identify the accuracy of diagnosis and the factors affecting survival. Accuracy of endoscopic retrograde cholangiopancreatography and computed tomography in locating lesions was 75% and 44%, respectively. Histologic diagnosis before or at the time of resection was available in only 61% of the patients. Carcinoma was correctly diagnosed clinically by the pathologist or the surgeon in 95% (83/87) of patients with 4 patients found to have benign disease on final pathologic examination. Intraoperative diagnosis of site of origin was incorrect in 18% (16/87) of patients. In 28% (23/83) of patients, pathologists identified nodal metastatic disease missed by the surgeon. Survival correlated with nodal and margin status and tumor grade. Tumor size demonstrated no predictive capacity. Although preoperative diagnostic accuracy is less than optimal, surgeons can usually diagnose malignant lesions but more often fail to identify tumor origin and nodal disease. We continue to advocate resection for patients with periampullary lesions thought to be malignant and resectable without a positive histologic diagnosis.

Surgically incurable well-differentiated thyroid carcinoma. Prognostic factors and results of therapy.

A series of 97 consecutive patients with well-differentiated thyroid carcinoma treated between 1941 and 1970 presented with distant metastatic disease or extensive nonresectable local neck disease or had residual carcinoma after thyroid resection. Men 40 years of age or younger and women 50 years of age or younger were considered at low risk for dying of disease; older patients were considered at high risk for dying of disease. Of 17 patients with distant metastatic carcinoma, 40% of younger patients in the low-risk group and 92% of older patients in the high-risk group died. Of 80 patients with unresectable or residual local neck cancer, only 13% of younger patients but 71% of older patients died. Survival related better to risk group classification as defined by age and sex than to any details of disease presentation or management. Treatment was far more successful in patients in the low-risk group.

Primary skeletal metastasis of a nonseminomatous germ cell tumor.

Bony metastasis is common in patients with germ cell tumor of the testicle; however, it is usually seen late in the disease process and is associated with lymph node or other visceral involvement. We present a case of isolated bony metastasis in a patient with a nonseminomatous germ cell tumor of the testis and normal retroperitoneal lymph nodes as determined by surgical resection.