"Ask The Pathologist": An Internet Forum Facilitating Communication Between Cancer Registrars and Pathologists.

CONTEXT.­: Cancer registrars should work closely with pathologists to ensure compliance with reporting standards. Many registrars, however, have little contact with pathologists, resulting in a lack of "real-time" interaction that is essential for their professional activities and development. OBJECTIVE.­: To facilitate registrars' case management, as cancer biology becomes more complex, we developed the ATP (Ask the Pathologist) forum as a place to ask pathology-related questions about neoplasms, such as terminology, biology, histologic classification, extent of disease, molecular markers, and prognostic factors. DESIGN.­: Questions posted are reviewed by the ATP multidisciplinary oversight committee, which consists of 3 pathologists, 4 cancer registrars, 1 internal medicine physician, the pathology resident member of the College of American Pathologists Cancer Committee, and 2 medical technologists. The oversight committee may answer the question. Alternatively, the committee may forward the question to a content expert pathologist, determine that the question is better suited for another reference Web site, or both. RESULTS.­: Since September 2013, when the ATP forum became available, users have posted 284 questions, of which 48 (17%) related to gastrointestinal tumors, 43 (15%) to breast tumors, and 37 (13%) to general pathology. The average turnaround time, from question posted to response, is 11.1 days. CONCLUSIONS.­: The ATP forum has had a positive impact in the daily activities of cancer registrars. Of 440 registrars surveyed, more than 90% considered that questions were answered satisfactorily, and one-third reported that ATP answers affected how they managed a given case.

College of American Pathologists Cancer Protocols: Optimizing Format for Accuracy and Efficiency.

CONTEXT: -The data in College of American Pathologists cancer protocols have to be presented effectively to health care providers. There is no consensus on the format of those protocols, resulting in various designs among pathologists. Cancer protocols are independently created by site-specific experts, so there is inconsistent wording and repetition of data. This lack of standardization can be confusing and may lead to interpretation errors. OBJECTIVE: -To define a synopsis format that is effective in delivering essential pathologic information and to evaluate the aesthetic appeal and the impact of varying format styles on the speed and accuracy of data extraction. DESIGN: -We queried individuals from several health care backgrounds using varying formats of the fallopian tube protocol of the College of American Pathologists without content modification to investigate their aesthetic appeal, accuracy, efficiency, and readability/complexity. Descriptive statistics, an item difficulty index, and 3 tests of readability were used. RESULTS: -Columned formats were aesthetically more appealing than justified formats (P < .001) and were associated with greater accuracy and efficiency. Incorrect assumptions were made about items not included in the protocol. Uniform wording and short sentences were associated with better performance by participants. CONCLUSIONS: -Based on these data, we propose standardized protocol formats for cancer resections of the fallopian tube and the more-familiar colon, employing headers, short phrases, and uniform terminology. This template can be easily and minimally modified for other sites, standardizing format and verbiage and increasing user accuracy and efficiency. Principles of human factors engineering should be considered in the display of patient data.

Hepatoprotective effects of select water-soluble PARP inhibitors in a carbon tetrachloride model.

BACKGROUND: Inhibitors of the nuclear enzyme poly (ADP-ribose) polymerase (PARP-1) have been demonstrated to attenuate pathophysiologic conditions associated with oxidative stress, specifically with carbon tetrachloride (CT)-induced hepatotoxicity. SETTINGS AND DESIGN: In this investigation, we evaluated 3 previously untested water-soluble PARP-1 inhibitors, namely, 3-aminobenzamide (ABA), 5-aminoisoquinolinone (AIQ), and N-(6-oxo-5,6-dihydro-phenanthridin-2-yl)-N,N-dimethylacetamide HCl (PJ-34) to determine their efficacy in blocking or attenuating CT-induced hepatotoxicity in male imprinting control region (ICR) mice. STATISTICAL ANALYSIS: Indicators of hepatotoxicity were compared with F-tests among groups to determine statistically significant effects. Pearson's correlation coefficients were used to evaluate the correlation between PARP inhibition and the attenuation of hepatotoxicity. RESULTS AND CONCLUSIONS: CT treatment resulted in hepatic cytotoxicity, increased serum transaminase (ALT), lipid peroxidation (MDA), intracellular glutathione (GSH) depletion, increased carbonyl content, and substantially increased PARP-1 activity. CT treatment also produced profound observable hemorrhagic necrosis in the hepatic centrilobular region of ICR mice. Pretreatment with PJ-34, ABA, and AIQ before CT treatment significantly decreased PARP-1 activity in hepatocytes after CT treatment by 3.4, 2.0, and 1.9 times, respectively. Corresponding to this reduction in PARP-1 activity, a significant reduction in the ALT levels and MDA and a reduction in the GSH depletion were observed. Also, there were no visible tissue defects in the liver samples from animals pretreated with individual PARP-1 inhibitors before CT administration. These results demonstrate the efficacy of the 3 previously untested water-soluble PARP-1 inhibitors in attenuating CT-induced hepatocellular toxicity and further characterize the role of PARP-1 activation and oxidative stress among the cascade of events in hepatocellular necrosis induced by CT treatment.

Extraskeletal para-articular osteochondroma of the posterior knee.

Extraskeletal para-articular osteochondromas are unusual osteocartilaginous lesions that arise in the soft tissues adjacent to the joint with no bone or joint continuity. This diagnosis should be considered in patients with a well-circumscribed, extraskeletal, mineralized mass without any direct continuity with adjacent bone or joint. Although the knee is a common location for extraskeletal para-articular osteochondroma, it has not been described arising in the posterior aspect of the knee. This article presents a case of extraskeletal paraarticular osteochondroma posterior to the knee joint. Differentiation from other extraskeletal mineralized lesions, particularly extraskeletal sarcomas and synovial osteochondromatosis, is essential to avoid unnecessary aggressive surgical procedures as marginal excision is adequate for these lesions. Correlation of clinical and radiographic features with pathology is essential for diagnosis. The lesion in our patient was marginally excised, and the postoperative course was uneventful with no recurrence at 2-year follow-up.

Aberrant methylation inactivates transforming growth factor Beta receptor I in head and neck squamous cell carcinoma.

Background. Alterations in TGF-beta signaling are common in head and neck cancer (HNSCC). Mutations in TGF-beta type II receptor (TbetaR-II) occur frequently in HNSCC while TGF-beta type I receptor (TbetaR-I) mutations are rare, suggesting that other molecular alterations in the TGF-beta pathway are likely. To identify abnormalities in TbetaR-I expression we analyzed 50 HNSCCs and correlated the results with clinical-pathologic features. Methods. Hypermethylation of TbetaR-I was evaluated via methylation-specific PCR (MSP) and restriction enzyme-mediated PCR (MSRE). Mutations in exons 1 and 7, mRNA and protein expression were analyzed by direct sequencing, semiquantitative RT-PCR and immunohistochemistry, respectively. Results. TbetaR-I expression was lost in 83% HNSCCs and was linked to DNA hypermethylation of the CpG-rich promoter region in 62% of the tumors. The variants 9A/6A and Int7G24A were found in two patients. Conclusions. This study shows that suppression of TbetaR-I expression in HNSCC is associated with DNA hypermethylation.

Soft-tissue amyloidoma of the extremities: a case report and review of literature.

Amyloidosis is a heterogeneous group of disorders characterized by extracellular deposition of unique protein fibrils. Amyloidosis may be hereditary or acquired, and the deposits may be focal, localized, or systemic in distribution. The least common presentation of an amyloid deposition is as a discrete mass called amyloidoma or amyloid tumor. Although described at various body sites, soft-tissue amyloidoma in an extremity is exceedingly rare. We report such a case of a large amyloidoma in the thigh, which simulated a soft-tissue sarcoma. In spite of attaining a very large size over a course of more than 20 years, the clinical course and the histology of this lesion were benign. Awareness of this entity will allow this rare diagnosis to be considered, prevent confusion with malignant disease, and allow appropriate management and patient reassurance. A review of literature on soft-tissue amyloidomas of extremities is also being presented.

Aggressive proximal tibio-fibular joint ganglion cyst after a total knee arthroplasty--a case report.

Although the knee is a common location, a ganglion cyst arising from the proximal tibio-fibular joint (PTFJ) is relatively rarer. Unique diagnostic and management difficulties are encountered as these can extend into subcutaneous tissue, or spread along peroneal muscles and nerve, or erode adjacent bone. We report here a PTFJ ganglion cyst which was indolent for at least 12 years and then caused destructive and expansile changes in the fibula over a period of 6 years after a total knee arthroplasty (TKA), simulating a malignancy. Although no wear or foreign body reaction could be shown, this alarming progression of a PTFJ ganglion cyst in the fibula after the TKA is a noteworthy association, and has not been recognized and reported before. Awareness of such a lesion can aid in the diagnosis and prevent unnecessary aggressive management.

Signal transduction proteins in tumors from Puerto Rican and Caucasian gastric adenocarcinoma patients: expression differences with potential for specific targeted therapies.

Overexpression of the HER2/NEU gene is associated with aggressive behavior and poor prognosis in breast cancer, making the Her2/neu protein a directed-therapy target. Tumors of two Puerto Rican (PR) patients overexpressed Her2/neu and resulting partial clinical responses motivated us to compare Her2/neu expression in PR (n = 101) and Caucasian non-Hispanic (n = 95) patients. Immunohistochemistry of tumors showed overexpression of p-Stat3, Cyclin D1, and Her2/neu, compared to non-neoplastic mucosa. Her2/neu and EGF-R protein levels were statistically significantly different with higher levels of both proteins in the PR group. Importantly, Her2/neu expression was strong and diffuse in tumors with signet-ring morphology, while other histo-pathological subtypes showed higher intra-tumoral Her2/neu heterogeneity than typically observed in breast cancer. Targeted therapies in gastric cancer directed at EGF-R and Hers-2/neu pathways warrant further investigation. These therapies may be especially effective in PR patients and in patients with signet-ring cell morphologies with a dismal prognosis.

Pigmented villonodular bursitis/diffuse giant cell tumor of the pes anserine bursa: a report of two cases and review of literature.

Pigmented villonodular synovitis (PVNS) is a benign but potentially aggressive lesion, characterized by synovial villonodular proliferation with hemosiderin pigmentation and stromal infiltration of histiocytes and giant cells. This consists of a common family of lesions, including localized and diffuse forms of pigmented villonodular synovitis, giant cell tumor of the tendon sheath (nodular tenosynovitis) and the very rare cases of extra-articular pigmented villonodular synovitis arising from the bursa (pigmented villonodular bursitis or diffuse giant cell tumor of the tendon sheath). The purpose of this paper is to present two rare cases of pigmented villonodular bursitis arising from the pes anserinus bursa. The various differentials along with a review of literature of similar lesions are also being discussed. However, as with other lesions, clinicoradiographic features along with close histological correlation is essential for diagnosis.

Fibrinogen gamma overexpression in pancreatic cancer identified by large-scale proteomic analysis of serum samples.

Detection of serum markers for pancreatic cancer has been elusive. Although CA 19-9 is most commonly used, its sensitivity and specificity are modest. We used large-scale proteomics to identify potential serum markers for pancreatic cancer. Samples were analyzed using high-resolution two-dimensional gel electrophoresis to identify differentially expressed proteins in 32 normal and 30 pancreatic cancer patients. Up to 1,744 protein spots were resolved for each serum sample. Candidate proteins were identified using mass spectrometry. ANOVA was used to identify proteins that could discriminate cancer from normal sera. Serum fibrinogen level was also measured using enzymatic assay. Immunohistochemistry was used to detect fibrinogen in resected pancreatic cancers. One hundred fifty-four proteins were commonly overexpressed in all pancreatic cancers. Nine protein spots (four with identifications by mass spectrometry) could effectively separate cancer from normal controls using cross-validation. These proteins successfully discriminated all pancreatic cancer samples (30 of 30) and 94% of normal (30 of 32) samples. Prominent among these candidates was fibrinogen gamma, which was subsequently confirmed to be overexpressed in pancreatic cancer sera by enzymatic analysis (54.1 +/- 64.1 versus 0.0 +/- 0.0 mg/dL, P < 0.05) and tissue by immunohistochemistry (67% versus 29%, P < 0.05) relative to normal pancreas. Proteomic analysis combining two-dimensional gel electrophoresis and mass spectrometry successfully identified 154 potential serum markers for pancreatic cancer. Of these, fibrinogen gamma, a protein associated with the hypercoagulable state of pancreatic cancer, discriminated cancer from normal sera. Fibrinogen is a potential tumor marker in pancreatic cancer.

Activation of stat3 in primary tumors from high-risk breast cancer patients is associated with elevated levels of activated SRC and survivin expression.

PURPOSE: Constitutive activation of signal transducer and activator of transcription 3 (Stat3) protein has been observed in a wide variety of tumors, including breast cancer, and contributes to oncogenesis at least in part by prevention of apoptosis. In a study of 45 patients with high-risk breast cancer enrolled in a phase II neoadjuvant chemotherapy trial with docetaxel and doxorubicin, we evaluated the levels of Stat3 activation and potentially associated molecular biomarkers in invasive breast carcinoma compared with matched nonneoplastic tissues. EXPERIMENTAL DESIGN: Using immunohistochemistry and image analysis, we quantified the levels of phospho-Stat3 (pY-Stat3), phospho-Src (pY-Src), epidermal growth factor receptor, HER2/neu, Ki-67, estrogen receptor, Bcl-2, Bcl-xL, Survivin, and apoptosis in formalin-fixed, paraffin-embedded sections from invasive carcinomas and their paired nonneoplastic parenchyma. The levels of molecular biomarkers in nonneoplastic and tumor tissues were analyzed as continuous variables for statistically significant correlations. RESULTS: Levels of activated pY-Stat3 and pY-Src measured by immunohistochemistry were significantly higher in invasive carcinoma than in nonneoplastic tissue (P < 0.001). In tumors, elevated levels of pY-Stat3 correlated with those of pY-Src and Survivin. Levels of pY-Stat3 were higher in partial pathologic responders than in complete pathologic responders. In partial pathologic responders, pY-Stat3 levels correlated with Survivin expression. CONCLUSIONS: Our findings suggest important roles for elevated activities of Stat3 and Src, as well as Survivin expression, in malignant progression of breast cancer. Furthermore, elevated Stat3 activity correlates inversely with complete pathologic response. These findings suggest that specific Stat3 or Src inhibitors could offer clinical benefits to patients with breast cancer.

Persistent activation of stat3 signaling induces survivin gene expression and confers resistance to apoptosis in human breast cancer cells.

PURPOSE: Signal transducer and activator of transcription 3 (Stat3) protein is persistently activated in breast cancer and promotes tumor cell survival. To gain a better understanding of the role of constitutive Stat3 signaling in breast cancer progression, we evaluated the expression profile of potential Stat3-regulated genes that may confer resistance to apoptosis. EXPERIMENTAL DESIGN: Stat3 signaling was blocked with antisense oligonucleotides in human MDA-MB-435s breast cancer cells and Affymetrix GeneChip microarray analysis was done. The candidate Stat3 target gene Survivin was further evaluated in molecular assays using cultured breast cancer cells and immunohistochemistry of breast tumor specimens. RESULTS: Survivin, a member of the inhibitor of apoptosis protein family, was identified as a potential Stat3-regulated gene by microarray analysis. This was confirmed in Survivin gene promoter studies and chromatin immunoprecipitation assays showing that Stat3 directly binds to and regulates the Survivin promoter. Furthermore, direct inhibition of Stat3 signaling blocked the expression of Survivin protein and induced apoptosis in breast cancer cells. Direct inhibition of Survivin expression also induced apoptosis. Increased Survivin protein expression correlates significantly (P = 0.001) with elevated Stat3 activity in primary breast tumor specimens from high-risk patients who were resistant to chemotherapy treatment. CONCLUSIONS: We identify Survivin as a direct downstream target gene of Stat3 in human breast cancer cells that is critical for their survival in culture. Our findings suggest that activated Stat3 signaling contributes to breast cancer progression and resistance to chemotherapy by, at least in part, inducing expression of the antiapoptotic protein, Survivin.

Differences in Smad4 expression in human papillomavirus type 16-positive and human papillomavirus type 16-negative head and neck squamous cell carcinoma.

The SMADs are a group of interrelated proteins that mediate transforming growth factor beta (TGF-beta) signaling. Upon TGF-beta binding the TGF-beta type I receptor phosphorylates Smad2 and Smad3, which then complex with Smad4 and translocate to the nucleus, with subsequent activation of target genes. Disruption of TGF-beta signaling is thought to contribute to the development of head and neck squamous cell carcinomas (HNSCC). Alterations in the function of the DPC4/Smad4 tumor suppressor gene have been found to inactivate TGF-beta signaling in several tumor types. For example, DPC4/Smad4 is lost or mutated in colorectal, pancreatic, and esophageal cancers. In addition, DPC4/Smad4 transcriptional activity and TGF-beta ability to inhibit DNA synthesis is blocked by the E7 protein of the human papillomavirus type 16 (HPV16) in cervical carcinoma cell lines. HPV16 infection is a risk factor for the development of a subset of HNSCC. This study was undertaken to investigate a potential correlation between expression of components of the TGF-beta signaling pathway and HPV16 status in HNSCC tumors. We examined the expression of TGF-beta signaling proteins Smad2, Smad2-P, and Smad4 by immunohistochemistry in 27 HPV16-negative and 16 HPV16-positive HNSCCs. We compared the expression patterns and assessed their relationship to HPV16 status. No significant differences were detected between HPV16-positive and HPV16-negative tumors in the expression of Smad2 and Smad2-P. Smad4 expression, however, was decreased in 56% of the HPV16-positive tumors and in 39% of HPV16-negative tumors. This difference was statistically significant (P = 0.01) suggesting that loss of Smad4 expression may be involved in HPV16-induced carcinogenesis of HNSCC.