A Gene Expression Panel is Accurate for Diagnosis and Monitoring Treatment of Eosinophilic Esophagitis in Adults.

OBJECTIVE: Eosinophilic esophagitis (EoE) can be difficult to diagnose. We aimed to evaluate whether a gene expression score could differentiate adult EoE cases from non-EoE controls and to determine whether scores normalized after treatment for EoE. METHODS: We analyzed prospectively collected esophageal biopsies from EoE patients (diagnosed as per consensus guidelines and after a proton pump inhibitor trial) and non-EoE controls. Gene expression for a previously constructed 94 gene panel was quantified for a single RNA-later preserved biopsy. For diagnosis, a summary expression score and the area under the receiver operating characteristic curve (AUC) were calculated. For treatment response (defined as <15 eosinophils per high-power field), pretreatment and posttreatment EoE samples were compared. RESULTS: For 91 EoE cases and 174 controls, gene scores for EoE cases were lower than non-EoE controls (mean 198 vs. 420; P<0.001), with an AUC of 0.927. A score ≤263 yielded a positive predictive value=91%; a score ≥349 yielded a negative predictive value=90%; only 12% of subjects had an indeterminate score (264-348) by this classification scheme. For the 89 EoE cases with paired pretreatment and posttreatment samples, overall gene scores improved after treatment from 199 to 343 (P<0.001). This normalization was seen only in cases with histological response (202 vs. 425; P<0.001); scores were unchanged in non-responders (189 vs. 226; P=0.25). CONCLUSIONS: A gene expression score has high diagnostic utility for distinguishing EoE patients from non-EoE controls in adults and can be used in clinical algorithms. Because it is highly responsive to treatment, the test could be used to monitor disease status.

Hydroxyurea, azacitidine and gemtuzumab ozogamicin therapy in patients with previously untreated non-M3 acute myeloid leukemia and high-risk myelodysplastic syndromes in the elderly: results from a pilot trial.

Elderly patients with acute myeloid leukemia (AML) and high-risk myelodysplastic syndromes (MDS) have a poor prognosis due to low response rates (26-46%) to standard chemotherapy and high treatment-related mortality (11-31%). In this Phase II study, we used a combination of hydroxyurea (HU), azacitidine and low dose gemtuzumab ozogamicin (GO) to assess its efficacy and toxicity in this group of patients. Twenty patients with non-M3 AML and MDS were treated with this regimen. The treatment was begun with HU 1500 mg orally twice daily to lower white blood cell count below 10,000/microL, followed by azacitidine 75 mg/m(2) subcutaneously for 7 days and GO 3 mg/m(2) on day 8. Patients who achieved complete remission (CR) received a consolidation course. The median age of patients was 76 years. Eleven patients (55%) were treated in the outpatient setting. Fourteen (70%) achieved a CR, three of which were incomplete (CRi). The median duration of remission was 8 months and median survival was 10 months. Performance status of 0-1 was associated with high complete response rate. Overall toxicity was acceptable with only one (5%) early death due to disease progression. The combination of HU, azacitdine and GO appears to be a safe and effective regimen in the treatment of AML and high risk MDS in the elderly. These results need to be confirmed in a larger cohort of patients.

Podoplanin is a highly sensitive and specific marker to distinguish primary skin adnexal carcinomas from adenocarcinomas metastatic to skin.

Distinction of primary skin adnexal carcinomas from cutaneous metastasis of adenocarcinomas is challenging. In this study, we evaluated podoplanin immunoreactivity in a series of primary skin adnexal tumors and adenocarcinomas metastatic to skin using a D2-40 antibody. The initial test series were composed of a total of 93 cases including 32 primary skin adnexal carcinomas, 46 benign primary adnexal tumors, and 15 cutaneous metastatic adenocarcinomas. We found that variable D2-40 reactivity was seen in all of the primary cutaneous carcinomas including sebaceous carcinomas (10/10), squamous cell carcinomas (10/10), porocarcinomas (4/4), trichilemmal carcinomas (4/4), skin adnexal carcinomas not otherwise specified (4/4), and in the majority of benign skin adnexal tumors. In contrast, no podoplanin immunoreactivity was seen in any of the 15 (0/15) cutaneous metastases. To confirm the initial findings and to further explore the utility of podoplanin reactivity in the distinction of these tumors, we also examined a test set of 35 unknown cases, including 21 adenocarcinomas metastatic to skin and 14 primary adnexal tumors, in a blinded fashion. In this test set of cases, podoplanin was negative in 22 cases and positive in 13 cases. Of the 22 podoplanin negative cases, 20 were proven to be metastatic adenocarcinoma. Of the 13 D2-40 positive cases, 12 were proven to be primary adnexal tumors. Our results suggest that podoplanin can be a useful tool to distinguish primary skin adnexal carcinomas form adenocarcinomas metastatic to skin with high sensitivity (94.5%) and specificity (97.2%).

Narrow-spectrum staining pattern of Pityrosporum.

BACKGROUND: Broad-spectrum fungal stains are used to detect fungal organisms, but narrow-spectrum stains can assist in fungal differential diagnosis. These stains include mucicarmine and Fontana-Masson (FM) for Cryptococcus, Alcian Blue for Cryptococcus and Blastomyces, Congo Red for Blastomyces and Coccidioides, and Ziehl-Neelsen for some examples of Blastomyces and Histoplasma. Pityrosporum is increasingly being recognized as a pathogen capable of significant cutaneous and systemic infections, but the narrow-spectrum staining pattern of Pityrosporum has not yet been systematically studied and reported. METHODS: Paraffin-embedded archival tissue from 10 skin biopsies containing Pityrosporum was stained with Alcian Blue, Congo Red, Ziehl-Neelsen acid-fast stain, and FM stain. In addition to the 60-min staining time, a modified FM stain with 15-, 30-, and 45-min staining times was also performed. RESULTS: All cases stained positive with Alcian Blue, Congo Red, and FM stains and negative with the Ziehl-Neelsen stain. The modified FM stain with the 15-min staining time showed significant staining in more than 50% of the cases. DISCUSSION: The narrow-spectrum staining pattern of Pityrosporum distinguishes it from Cryptococcus, Blastomyces, Candida, Histoplasma, and Coccidioides.

Mast cell ultrastructure and staining in tissue.

Mast cells are bone marrow-derived cells that are widely distributed in the tissue. They are found predominantly in the subepithelial tissue near blood vessels and nerves and usually are sprinkled diffusely without forming clusters. In tissue sections stained with hematoxylin and eosin, normal mast cells usually display a round-to-oval nucleus with clumped chromatin and indistinct or no nucleoli. They have moderately abundant cytoplasm and are oval, spindle, or polygonal in shape. The cytoplasm is amphophilic, and sometimes small slightly eosinophilic granules may be visible. Hematoxylin and eosin staining is not a specific or reliable method for detecting mast cells in tissue sections because of variable cellular morphology. For confirmation of mast cells, special stains, such as mast cell tryptase or CD117, are required.