Current diagnostic modalities and clinical pitfalls in malignant secondary breast tumours.

Breast cancer is the most common malignancy in women with increasing incidence. The occurrence of metastatic disease to the breast in both females and males is relatively rare, constituting 0.5-6% of all breast malignancies. The therapy of secondary breast cancer is usually completely different from that of primary malignant lesions. Thus, early confirmation of secondary involvement is crucial to direct appropriate and to avoid potentially harmful treatment. The main focus remains to include secondary breast involvement in the differential diagnosis of breast tumours. In recent years, a number of new or improved imaging modalities have been introduced in the diagnosis of breast neoplasm. Current diagnostic concepts of metastatic neoplasm to the breast, including latest imaging modalities and their possible future applications, are presented in this review with special emphasis on possible pitfalls.

Heterogeneous distribution of angiotensin I-converting enzyme (CD143) in the human and rat vascular systems: vessel, organ and species specificity.

Angiotensin I-converting enzyme (kininase II, ACE, CD143) availability is a determinant of local angiotensin and kinin concentrations and physiological actions. Limited information is available on ACE synthesis in peripheral vascular beds. We studied the distribution of ACE along the human and rat vascular tree, and determined whether the enzyme was uniformly distributed in all endothelial cells (EC) or if differences occurred among vessels and organs. The distribution of ACE was assessed by using a panel of anti-human ACE monoclonal antibodies and serial sections of the entire vascular tree of humans. Comparison was made with other EC markers. EC of small muscular arteries and arterioles displayed high ACE immunoreactivity in all organs studied except the kidney, while EC of large arteries and of veins were poorly reactive or completely negative. Only 20% on average of capillary EC in each organ, including the heart, stained for ACE, with the remarkable exception of the lung and kidney. In the lung all capillary EC were labeled intensively for ACE, whereas in the kidney the entire vasculature was devoid of detectable enzyme. In contrast to the man, the rat showed homogeneous endothelial expression of ACE in all large and middle-sized arteries, and in veins, but in renal vessels ACE expression was reduced. This study documents a vessel, organ and species specific pattern of distribution of endothelial ACE. The markedly reduced ACE content of the renal vasculature may protect the renal circulation against excess angiotensin II formation and kinin depletion, and maintain high renal blood flow.

Conformational fingerprinting of the angiotensin I-converting enzyme (ACE). 1. Application in sarcoidosis.

Fine epitope mapping of monoclonal antibodies (mAbs) to 16 epitopes on human angiotensin I-converting enzyme (ACE) revealed that the epitopes of all mAbs contained putative glycosylation sites. ACE glycosylation is both cell- and tissue-specific and, therefore, the local conformation of ACE produced by different cells could be also unique. The pattern of ACE binding by a set of mAbs to 16 epitopes of human ACE - "conformational fingerprint of ACE" - is the most sensitive marker of ACE conformation and could be cell- and tissue-specific. The recognition of ACEs by mAbs to ACE was estimated using an immune-capture enzymatic plate precipitation assay. Precipitation patterns of soluble recombinant ACE released from Chinese hamster ovary (CHO)-ACE cells was influenced by conditions that alter ACE glycosylation. This pattern was also strongly cell type specific. Patients with sarcoidosis exhibited conformational fingerprints of tissue ACE (lungs and lymph nodes), as well as blood ACE, which were distinct from controls. Conformational fingerprinting of ACE may detect ACE originated from the cells other than endothelial cells in the blood and when combined with elevated blood ACE levels in patients with sarcoidosis may potentially reflect extrapulmonary sarcoidosis involvement (bone marrow, spleen, liver). If proven true, this would serve as a biomarker of enormous potential clinical significance.

Prognostic relevance of granulocyte colony-stimulating factor in ovarian carcinomas.

PURPOSE: Granulocyte colony-stimulating factor (G-CSF) producing tumours were found associated with poor prognosis. Unfortunately, this finding is based on several case reports only. Thus, we investigated the expression of G-CSF in the tumour cells and the tumour stroma in a large collective of patients with ovarian cancer with long-term follow-up. METHODS: Tissue and clinical records of 175 patients with histologically confirmed ovarian carcinoma were analysed for G-CSF expression in tumour cells and the surrounding stroma. The results were compared with peripheral blood counts and other prognostic factors in ovarian cancer. RESULTS: No correlations were found between both G-CSF expression in tumour cells and the surrounding stroma and prognosis as well as peripheral blood counts. We only found a positive influence of granulocytes in the tumour stroma on prognosis, which however, was not significant in multifactorial analyses. CONCLUSIONS: In contrast to the many case reports from other entities, G-CSF expression in tumour cells and the surrounding stroma is not an adverse prognostic factor. To find out the safety of G-CSF administration for the prevention or treatment of febrile neutropenia, it is suggested for clinical trials to include long-term follow-up and immunohistochemical characterisation of the tumour.

Squamous-cell carcinoma in mature cystic teratoma of the ovary: systematic review and analysis of published data.

Up to a quarter of ovarian masses originate from germ cells, and many of these are mature cystic teratomas. The secondary development of malignancy is a rare but well-known phenomenon in patients with ovarian teratomas. Squamous-cell carcinoma accounts for 80% of secondary malignant transformations of ovarian teratomas. We aimed to do an up-to-date systematic review of this rare malignant transformation. 64 suitable studies provided information on 277 patients. Squamous-cell carcinoma in mature cystic teratoma was mainly found in women aged more than 50 years, with high concentrations of squamous-cell-carcinoma antigen and cancer antigen CA125, and with ovarian tumours more than 100 mm in size. Patients with FIGO stage Ia tumours had better survival than those with more advanced disease. Complete resection together with hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy for patients with advanced disease, followed by adjuvant chemotherapy with an alkylating drug was associated with higher survival, radiotherapy was not. We make proposals for investigation and treatment of this rare disorder.

Influence of body mass index on prognosis in gynecological malignancies.

OBJECTIVE: To evaluate the effect of obesity on the presentation and course of disease in patients with gynecological cancers. STUDY DESIGN: Records of patients with endometrial (n = 1180), cervical (n = 738), and ovarian cancer (n = 824) treated between 1986 and 2005 were reviewed. Body mass index (BMI) was analyzed in relation to tumor stage, tumor grading, and prognosis. Steroid hormone receptor status and growth fraction (MIB1; Ki-67-antigen) of tumors in relation to BMI were analyzed in subgroups with endometrial (n = 183) and advanced ovarian (n = 221) cancers. In the latter subgroup, tumor vascularization (CD31) and expression of bcl-2, c-erb-B2, fibronectin, and tumor markers (CA-125, CA15-3, CEA) were also evaluated. Statistical analyses included bivariate correlation, cross-tabulation, Kaplan-Meier-survival analyses, and multifactorial residual survival analyses. RESULTS: Obese patients with endometrial carcinoma were significantly younger (p < 0.001) and their tumors were less advanced at diagnosis (p = 0.001) and were better differentiated (p = 0.010). In the subgroups, neither steroid hormone receptor status nor MIB1-determined growth fraction correlated with BMI. For both endometrial and cervical carcinomas, a high BMI influenced overall survival favorably (p (endometrial )= 0.004 and p (cervical )= 0.026). In ovarian cancer, there was a trend toward improved survival in more obese patients (p = 0.053). Immunohistochemistry revealed that c-erb-B2 expression was slightly lower in tumors of obese patients (r = -0.142; p = 0.039), but BMI did not influence any other factor. CONCLUSIONS: Although obesity increases the incidence of cancer, a high BMI does not seem to adversely influence the prognosis in patients with the mentioned gynecological malignancies.

C-kit receptor in the human vas deferens: distinction of mast cells, interstitial cells and interepithelial cells.

The molecular mechanisms underlying the regulation of vas deferens (VD) motility and semen emission are still poorly understood. Interstitial cells of Cajal (ICC), which harbour the c-kit receptor (CD117), provide the basis of coordinated gut motility. We investigated whether c-kit receptor-positive cells also exist in the normal human VD. Enzyme and fluorescence immunohistochemical techniques were applied on serial sections of human proximal, middle, and distal VD segments (n=49) employing 13 different monoclonal and polyclonal antibodies recognizing the c-kit receptor. The c-kit receptor was detected in either round- or spindle-shaped cells. On account of their antigenic profile, the round- and oval-shaped c-kit receptor-positive cells were identified as mast cells (MC) occurring in all layers of the VD except the epithelium. In contrast, two distinct populations of exclusively c-kit receptor-positive spindle-shaped cells were found within the lamina propria and, rarely, in the inner and outer smooth muscle layers, as well as within the epithelium. Different shaped c-kit receptor-positive MC and IC were present in all layers of the human VD. Our findings demonstrate the presence of different c-kit receptor-positive cells also in the human VD. Their rather ubiquitous distribution within the lamina propria and muscle layers suggests that IC and MC may modulate the neuromuscular transmission and the propagation of electrical signals in multiple systems involved in the draining of fluids. The importance of the c-kit receptor-positive interepithelial cells remains unclear.

Percutaneous left atrial cardiac biopsy with CT fluoroscopy guidance.

Percutaneous computed tomographic (CT) fluoroscopy-guided biopsy was performed to evaluate an intracardiac tumor located within the left atrium of a 72-year-old woman. Postinterventional follow-up was unproblematic and free of complications. Histopathologic examination revealed a high-grade cardiac sarcoma, and the patient underwent consecutive resection and radiation therapy. In general, percutaneous puncture of the heart must be considered hazardous. Under certain conditions (eg, broad-based tumor, advanced luminal mass, myocardial and/or pericardial infiltration), however, percutaneous CT-guided biopsy may be an appropriate alternative to transluminal catheter biopsy for the minimally invasive investigation of cardiac tumors.

High-resolution MRI of basal cell carcinomas of the face using a microscopy coil.

OBJECTIVE: The objective of this article is to evaluate the diagnostic accuracy of high-resolution MRI using a microscopy surface coil to stage basal cell carcinomas of the face. CONCLUSION: High-resolution MRI using a microscopy surface coil is a promising method to determine the extension of basaliomas of the facial region and to exclude infiltration of bone by the tumor.

Prognostic value of PIK3CA and phosphorylated AKT expression in ovarian cancer.

Disrupted phosphatidylinositol 3-kinase (PI3K) activity and its effect on the downstream target AKT plays an important role in malignant diseases. Gain and/or amplification of PIK3CA gene, encoding the catalytic subunit of phosphatidylinositol 3-kinase (p110 alpha) and its increased expression are associated with enhanced PI3K activity in ovarian cancer cell lines. In this study, ovarian carcinomas with documented clinical outcome were assessed for genetic aberrations at the 3q26.3 locus, including PIK3CA, by fluorescence in situ hybridization. PIK3CA amplification was evaluated by quantitative real-time PCR with respect to a control gene situated at 3q13. The expression of p110 alpha, phosphorylated AKT (pAKT) and the proliferation marker Ki-67 were immunohistochemically investigated. PIK3CA amplification and Ki-67 index were strong predictors for an early tumour-associated death. p110 alpha expression correlated with 3q26.3 gain and Ki-67 index but not with the patient outcome. No relationship could be observed between p110 alpha and pAKT or between pAKT and disease outcome. It is interesting to note that cases with a nuclear pAKT immunoreactivity showed a trend of improved overall survival. Our results underline the prognostic significance of PIK3CA in ovarian carcinoma and argue against a simple linear model of PIK3CA gain/amplification followed by PI3K activation and consecutive AKT phosphorylation in ovarian carcinoma.

D2-40: a reliable marker in the diagnosis of pleural mesothelioma.

OBJECTIVE: Malignant mesotheliomas of the pleura, peritoneum and pericardium can easily be confused with either metastatic adenocarcinomas or reactive pleural lesions. D2-40, a monoclonal antibody used as a marker for seminomatous germ cell tumours and lymphatic endothelial cells, was recently described in mesothelial cells and type I but not type II pneumocytes. METHOD: The immunoreactivities of D2-40 in 76 lung carcinomas of different histological types (adenocarcinomas, squamous cell, small cell, and bronchioloalveolar carcinomas) were compared with those of 36 pleural epithelioid and sarcomatoid mesotheliomas and 5 specimens of chronic pleuritis. RESULTS: While all 18 analysed epithelioid mesotheliomas displayed a strong membranous immunostaining, 18 sarcomatoid mesotheliomas showed no, or a merely faint, cytoplasmic signal, comparable with fibroblasts in chronic pleuritis. Out of all analysed lung carcinomas, 49 showed no immunoreactivity for D2-40 (64%), while the other 27 (36%) showed a focal weak to moderate and only cytoplasmic signal. CONCLUSIONS: We regard D2-40 as a valid marker in the differential diagnosis of epithelioid mesotheliomas versus pulmonary adenocarcinomas. However, this marker may not properly label sarcomatoid mesotheliomas or distinguish them from reactive pleural lesions.

Glucocorticosteroid receptors in ovarian carcinomas.

The use of glucocorticoids (GCs) in oncology, including in the treatment of ovarian carcinomas, is controversial. In vitro experiments suggest that GCs negatively influence the response to chemotherapy, but the few available clinical data show only benefits. Glucocorticoid action is mediated via glucocorticoid receptors (GRs). This study aims to define any clinical implications of GR expression in ovarian cancer to further the debate. Archived tissue samples from patients with histologically confirmed ovarian cancer were analyzed for GR expression and evaluated by immunohistochemistry and immunoreactive score. The results were related to the patients' overall survival. Kaplan-Meier survival and residual survival analyses gave no evidence that GR expression had any prognostic value in the 85 cases studied. No evidence of poorer survival was found in a small subset of GR-positive patients who received GC treatment. Glucocorticoid receptor expression had no prognostic impact in our study. However, GC (cortisol) is being produced continuously by the body, which may have stimulated GR-positive ovarian cancer cells. Our finding does not exclude the possibility that long-term GC treatment has adverse effects, and it should also be emphasized that treatment duration, dosage and dosing regimens, as well as the choice of an appropriate GC and the mode of application, determine the risks and benefits. Our study showed no evidence against using GC for antiemetic prophylaxis in ovarian carcinomas.

Testicular isoform of angiotensin I-converting enzyme (ACE, CD143) on the surface of human spermatozoa: revelation and quantification using monoclonal antibodies.

PROBLEM: The elucidation of the role of angiotensin-converting enzyme (ACE, CD143) in the male fertility has been hampered by the absence of highly specific antibodies to the native testicular isoform (tACE). The quantification of tACE expression on human-ejaculated spermatozoa was performed using a novel panel of monoclonal antibodies (mAbs). METHOD OF STUDY: The expression of tACE on the surface of live and fixed human spermatozoa was analyzed by flow cytometry and immunocytochemistry using new mAbs to human tACE. RESULTS: Monoclonal antibodies 1E10 and 4E3 similarly revealed tACE on the surface of live and fixed spermatozoa. The high percentage of tACE-positive spermatozoa (median 81%) was revealed in the swim-up fraction of sperm. Antibody-induced tACE shedding occurs preferentially from live sperm with defective function and/or morphology. Testicular ACE is located on the plasma membrane of the post-acrosomal region, the neck and midpiece of normal spermatozoa, but showed a variable distribution on the defective cells. CONCLUSIONS: The new mAbs recognizing the C-terminal domain of human ACE are useful tools for quantification of tACE expression on human live and fixed spermatozoa and further adequate analysis of the tACE role in reproduction.

Gonadoblastoma: evidence for a stepwise progression to dysgerminoma in a dysgenetic ovary.

Gonadoblastomas are neoplasms of dysgenetic gonads which may undergo regression or become overgrown by malignant germ cell tumors (mGCTs). Since little is known about their relationship to normal gonadal development and mGCTs, we studied the phenotype and antigenic profile of gonadoblastomas in comparison with adjacent dysgerminomas and fetal gonads. Three cases of gonadoblastomas and fetal gonads of both sexes were analyzed using oncofetal markers to M2A-antigen (M2A), germ cell alkaline phosphatase (PLAP/GCAP), receptor tyrosine kinase c-kit (c-kit), and somatic angiotensin converting enzyme (sACE) as well as the proliferation marker MIB-1. Morphologically, microfollicular pattern of gonadoblastomas showed a fetal germ cell organization reminiscent of oocytic clusters of fetal ovaries. They contained both cell types, similar to oocytes (M2A-, GCAP-, c-kit+/-, sACE-) and oogonia (M2A+, GCAP+, c-kit+, sACE+). The percentage of germ cells immunoreactive for oncofetal markers and the proliferation index increased from microfollicular over coronary patterns to adjacent dysgerminomas. Supportive cells of gonadoblastomas showed a uniform phenotype (CK18+, vimentin+, sACE+, alpha-inhibin+, M2A-) but in contrast to fetal germ cells lacked a clear equivalence to fetal tissues. Our results show that gonadoblastomas mimic female fetal ovary and exhibit a stepwise progression from follicular pattern to coronary pattern and finally to dysgerminomas.

Monoclonal antibodies 1B3 and 5C8 as probes for monitoring the integrity of the C-terminal end of soluble angiotensin-converting enzyme.

Angiotensin-converting enzyme (ACE) is a membrane-anchored ectoprotein that is proteolytically cleaved, yielding an enzymatically active soluble ACE. Two mouse monoclonal antibodies, MAbs 1B3 and 5C8, were generated to the C-terminal part of human soluble ACE. MAb 1B3 recognized the catalytically active ACE, as revealed by ELISA and precipitation assays, whereas Western blotting and immunohistochemisty on paraffin- embedded sections using MAb 5C8 detected denatured ACE. MAb 1B3 showed extensive cross-reactivity, recognizing 15 species out of the 16 tested. The binding of this MAb to ACE was greatly affected by conformational changes induced by adsorption on plastic, formalin fixation, and underglycosylation. Furthermore, MAb 1B3 binding to the mutated ACE (Pro1199Leu substitution in the juxtamembrane region, leading to a fivefold increase in serum ACE level) was markedly decreased. MAb 5C8 detected all the known expression sites of full-size ACE using formalin-fixed and paraffin-embedded human tissues. The sequential epitope for MAb 5C8 is formed by the last 11 amino acid residues of soluble ACE (Pro1193-Arg1203), whereas the conformational epitope for 1B3 is formed by a motif within these 11 amino acid residues and, in addition, by at least one stretch that includes Ala837-His839 located distal to the sequential epitope. Our findings demonstrated that MAbs 1B3 and 5C8 are very useful for the study of ACE shedding, for identification of mutations in stalk regions, and for studying alternatively spliced variants of ACE. In addition, binding of MAb 1B3 is a sensitive determinant of the integrity of soluble ACE.

Differentiation markers of Sertoli cells and germ cells in fetal and early postnatal human testis.

The definition of the temporal sequence of appearance of fetal markers during prenatal and early postnatal development in Sertoli and germ cells may be important for understanding the mechanisms underlying their reexpression in disorders of the adult testis. For this reason, we studied the expression of Sertoli and germ cell markers in 25 human testes spanning a period from 8 gestational weeks to 4 years. Well-characterized antibodies were employed to anti-Müllerian hormone (AMH), cytokeratin 18 (CK18), vimentin (VIM), M2A-antigen (M2A), germ cell alkaline phosphatase (GCAP), and somatic angiotensin-converting enzyme (sACE) on formalin-fixed and microwave-pretreated paraffin sections. In Sertoli cells, AMH and VIM were consistently present. While VIM and CK18 were coexpressed in embryonic testes, CK18 was progressively downregulated and completely absent from the 20th gestational week. M2A was absent or moderately expressed in fetal Sertoli cells but increased during further development. In germ cells, M2A was consistently found in primordial germ cells (PGCs) as well as in M- and T1-prespermatogonia. In contrast, sACE and GCAP were absent from PGCs but were a distinct feature of late M- and early T1-prespermatogonia and appeared predominantly between the 18th and the 22nd gestational weeks. Both T2-prespermatogonia and postnatal prespermatogonia were devoid of any marker. While CK18 represents a differentiation marker for fetal Sertoli cells, M2A, GCAP, and sACE can be used as differentiation markers for the discrimination of different germ cell types during human prespermatogenesis. Because various immunophenotypes reflect distinct differentiation stages, this knowledge may be important for understanding adult testicular pathology.

Role of primary surgery in advanced ovarian cancer.

BACKGROUND: Major issues in surgery for advanced ovarian cancer remain unresolved. Existing treatment guidelines are supported by a few published reports and fewer prospective randomized clinical trials. METHODS: We reviewed published reports on primary surgical treatment, surgical expertise, inadequate primary surgery/quality assurance, neoadjuvant chemotherapy, interval debulking, and surgical prognostic factors in advanced ovarian cancer to help resolve outstanding issues. RESULTS: The aim of primary surgery is a well-planned and complete intervention with optimal staging and surgery. Surgical debulking is worthwhile as there are further effective treatments available to control unresectable residual disease. Patients of gynecologic oncology specialist surgeons have better survival rates. This may reflect a working 'culture' rather than better technical skills. One major problem though, is that despite pleas to restrict surgery to experienced surgeons, specialist centers are often left to cope with the results of inadequate primary surgical resections. Patients with primary chemotherapy or those who have had suboptimal debulking may benefit from interval debulking. A proposal for a better classification of residual tumor is given. CONCLUSIONS: Optimal surgical interventions have definite role to play in advanced ovarian cancers. Improvements in surgical treatment in the general population will probably improve patients' survival when coupled with improvements in current chemotherapeutic approaches.