Histologic features and cytologic techniques that aid pathologic stage assessment of colonic adenocarcinoma.

Cancer involvement of the colonic serosa is designated pT4a by the American Joint Committee on Cancer Staging Manual, 7th edition. The manual defines criteria for pT4a as either tumor penetration of the serosa or comingling of cancer cells and mesothelial cells in histologic sections. Unfortunately, the pT4a grouping is inconsistently applied, because these guidelines are overly limited: fibroinflammatory changes near the serosa may be associated with peritoneal metastases even in the absence of overt peritoneal penetration. Thus, reliable ancillary techniques for detecting serosal penetration by the tumor and accurate criteria for stage assessment are needed. We evaluated the utility of cytologic preparations in determining tumor stage by comparing results of serosal scrape cytology with histologic stage assessment of 120 colon cancer resection specimens. We correlated our findings with the presence and type of inflammatory changes near the serosa to determine which, if any, are reliable indicators of peritoneal penetration. Cytologic smears from all pT1 and pT2 tumors were negative for carcinoma. However, 13 (19%) pT3 tumors showed cancer in cytologic smears, all of which were deeply invasive. In fact, 46% of pT3 cancers present ≤1 mm from a serosal tissue reaction were associated with cancer in cytologic preparations from the serosa, which was comparable to pT4a tumors (55%). We conclude that cytologic smears improve detection of peritoneal penetration among pT3 tumors compared with histology alone. Tumors close (≤1 mm) to a fibroinflammatory tissue reaction on the serosa are likely associated with peritoneal involvement by cancer. Peritumoral abscesses that communicate with the serosa and hemorrhage or fibrin on the serosa also predict cancer involvement of the peritoneum. The presence of these findings among deeply invasive cancers should prompt their classification as pT4a lesions.

ALK+ large B-cell lymphoma: a rare variant of aggressive large B-cell lymphoma mimicking carcinoma on cytology specimens.

Anaplastic lymphoma kinase positive large B-cell lymphoma (ALK+ LBCL) was recognized as a distinct entity by the 2008 WHO classification of lymphomas. Histologically, the tumor cells exhibit either plasmablastic or immunoblastic morphology, with characteristic granular staining for ALK. The purpose of this study is to evaluate the cytologic findings of ALK+ LBCL. The cytologic material obtained by needle biopsy from three cases of ALK+ LBCL was evaluated. All lesions were nodal and the cytologic material analyzed included air-dried and alcohol-fixed slides stained with modified Giemsa and/or HE stains. The following morphologic criteria were assessed: cellularity, cluster characteristics, cell size, cytoplasmic and nuclear characteristics, and background composition. The cytology specimens obtained from the needle biopsies were moderately to highly cellular and composed of a population of large cells with immunoblastic or plasmablastic morphology. Single cells were present in all three cases, but two cases also showed the presence of clusters with acinar and papillary architecture. Multinucleation was noted in all three cases. Amorphous metachromatic background material was noted focally in the modified Giemsa stained slides in all three cases. Immunostains performed on cytology specimens showed cytoplasmic immunoreactivity for ALK, with characteristic granular features. ALK+ LBCL is a rare recently recognized type of lymphoma with unique morphologic and immunophenotypic findings that can mimic epithelial tumors. Recognition of this potential diagnostic pitfall is critical to prevent unnecessary additional work-up and mistreatment.

Suitability of thoracic cytology for new therapeutic paradigms in non-small cell lung carcinoma: high accuracy of tumor subtyping and feasibility of EGFR and KRAS molecular testing.

INTRODUCTION: The two essential requirements for pathologic specimens in the era of personalized therapies for non-small cell lung carcinoma (NSCLC) are accurate subtyping as adenocarcinoma (ADC) versus squamous cell carcinoma (SqCC) and suitability for EGFR and KRAS molecular testing. The aim of this study was to comprehensively review the performance of cytologic specimens for the above two goals in a high-volume clinical practice. METHODS: Subtyping of primary lung carcinomas by preoperative cytology was correlated with subsequent resection diagnoses during a 1-year period (n = 192). The contribution of various clinicopathologic parameters to subtyping accuracy and utilization of immunohistochemistry (IHC) for NSCLC subtyping were analyzed. In addition, the performance of cytologic specimens submitted for EGFR/KRAS molecular testing during a 1-year period (n = 128) was reviewed. RESULTS: Of the 192 preoperative cytology diagnoses, tumor subtype was definitive versus favored versus unclassified in 169 (88%) versus 15 (8%) versus 8 (4%) cases, respectively. Overall accuracy of cytologic tumor subtyping (concordance with histology) was 93% and accuracy of definitive diagnoses 96%. For a group of patients with ADC and SqCC (n = 165), the rate of unclassified cytologic diagnoses was 3% and overall accuracy 96%. IHC was used for subtyping of 9% of those cases, yielding 100% accuracy. The strongest predictors of difficulty in subtyping of ADC and SqCC were poor differentiation (p = 0.0004), low specimen cellularity (p = 0.019), and squamous histology (p = 0.003). Of 128 cytologic specimens submitted for molecular testing, 126 (98%) were suitable for analysis, revealing EGFR and KRAS mutations in 31 (25%) and 25 (20%) cases, respectively. CONCLUSIONS: Cytologic subtyping of NSCLC is feasible and accurate, particularly when morphologic assessment is combined with IHC. Furthermore, routine cytologic specimens can be successfully used for EGFR/KRAS mutation analysis. Our data strongly support the suitability of cytologic specimens for the new therapeutic paradigms in NSCLC.

Nomogram for predicting malignancy in thyroid nodules using clinical, biochemical, ultrasonographic, and cytologic features.

BACKGROUND: Thyroid nodules often discovered incidentally and present a management problem particularly when investigations suggest atypical or suspicious cells. Prediction of the risk of malignancy within such a thyroid nodule is based on clinical, biochemical, ultrasonographic, and cytologic features. Our aim was to create a nomogram to predict accurately the chance of malignancy within a thyroid nodule. METHODS: All patients with thyroid nodules who underwent ultrasonographic-guided fine needle aspiration and operative resection at our institution during 2007-2008 were identified. Clinical records, biochemical profiles, pathology reports, ultrasonographic images, and cytology slides were reviewed. A multivariate logistic regression was used to quantify the value of the variables in estimating the risk of malignancy. RESULTS: The records of 158 patients with 190 nodules were reviewed. Eighteen nodules were excluded. The 8 variables with the greatest predictive value selected for the nomogram were biochemical (thyroid-stimulating hormone), ultrasonography (shape, echo texture, and vascularity), and cytology (nuclear grooves, pseudoinclusions, cellularity, and presence of colloid). The nomogram had an excellent predictive accuracy with a concordance index of 91%. CONCLUSION: We produced a nomogram that can quantify accurately the risk of malignancy in a thyroid nodule based on biochemical, ultrasonographic, and cytologic features.

Secretory carcinoma in the axilla: probable origin from axillary skin appendage glands in a young girl.

Invasive carcinoma in the axilla may arise from skin appendage glands or ectopic breast tissue or it may be a metastasis. Carcinomas of the skin adnexal glands and breast can be difficult to distinguish from each other as they often display the same patterns of growth. Tubular, cribriform, papillary, apocrine, mucinous, and adenoid cystic are histologic types of carcinoma seen in the breast and skin appendage glands. To our knowledge, secretory carcinoma, the most common form of mammary carcinoma in children, has not yet been described as a morphologic pattern of skin adnexal carcinoma, although we cannot exclude the possibility that such a case was reported with a different diagnosis. We report a case of a young girl with secretory carcinoma that seems to have arisen from skin appendage glands in the skin of the axilla in the absence of demonstrable ectopic breast tissue.

The "Rosen Triad": tubular carcinoma, lobular carcinoma in situ, and columnar cell lesions.

The histologic triad of tubular carcinoma (TC), columnar cell lesion (CCL), and lobular carcinoma in situ (LCIS) has been recognized, but has not yet been fully characterized. The "Rosen Triad"-named in tribute to its first categorical description by the eponymous pathologist-is a morphologic observation that may have important clinical and pathologic implications. To study these implications, the literature on the topic was reviewed. Our own institution's experience with this triad was also reviewed via a study of clinicopathologic material from all TCs diagnosed at excision during a 5-year period (2001 to 2006). The diagnosis of TC was confirmed in 86 of our cases, and relevant patient data were analyzed. TC was associated with some degree of CCL in all (100%, 86/86) cases and with LCIS in 53% (46/86) of cases. Although cases of TC that were associated with LCIS (vs. those not associated with LCIS) seemed to be slightly more likely to have multifocal TC, have another synchronous higher-grade invasive carcinoma and show nodal positivity, these differences were not found to be statistically significant (P<0.05). All 3 lesions (TC, CCL, and LCIS), whenever tested, were estrogen receptor positive, progesterone receptor-positive, and Her-2/neu negative. On the basis of our review of the literature and our own experience, until such time as the biologic explanation and clinical implication of this triad is further elucidated, we recommend that pathologists be aware of this triad and should proactively seek the other 2 lesions if any one of these elements of this triad is identified in any diagnostic breast tissue.

Stimulation of enhanced CD8 T cell responses following immunization with a hyper-antigen secreting intracytosolic bacterial pathogen.

The intracytosolic niche for replication of Listeria monocytogenes (Lm) facilitates delivery of bacteria-derived Ags into the MHC class I pathway for subsequent stimulation of CD8 effector T cells. Using Lm strains that are equivalent for in vivo virulence yet express marked differences in the level of secretion of a protective target Ag, we have evaluated how these specific differences in secretion levels influences the magnitude and effector function of Ag-specific CD8 T cell responses following Lm injection. Immunization with low doses of a hyperantigen-secreting Lm strain stimulated enhanced target-Ag specific CD8 T cell responses compared with the magnitude stimulated following immunization with the same dose of wild-type Lm. The enhanced determinant-specific response was also evident by in vivo CTL activity, increased numbers of memory cells 4 wk following immunization, and enhanced antilisterial protection following a challenge infection. Initiation of antibiotic treatment 24 h following infection with wild-type Lm markedly reduced the magnitude of the effector CD8 T cell response. In contrast, antibiotic treatment initiated 24 h following immunization with the hyperantigen secreting strain of Lm did not impact the frequency of the target-Ag specific CD8 T cells. Thus, immunization with a low dose of a hyperantigen secreting Lm strain, followed by antibiotic treatment to limit the extent of the infection, may represent a safe strategy for the stimulation of enhanced effector CD8 T cell responses to specific Ag by a rLm vaccine.

Protective and immunochemical activities of monoclonal antibodies reactive with the Bacillus anthracis polypeptide capsule.

Bacillus anthracis is surrounded by a polypeptide capsule composed of poly-gamma-d-glutamic acid (gammaDPGA). In a previous study, we reported that a monoclonal antibody (MAb F26G3) reactive with the capsular polypeptide is protective in a murine model of pulmonary anthrax. The present study examined a library of six MAbs generated from mice immunized with gammaDPGA. Evaluation of MAb binding to the capsule by a capsular "quellung" type reaction showed a striking diversity in capsular effects. Most MAbs produced a rim type reaction that was characterized by a sharp increase followed directly by a decrease in refractive index at the capsular edge. Some MAbs produced a second capsular reaction well beneath the capsular edge, suggesting complexity in capsular architecture. Binding of MAbs to soluble gammaDPGA was assessed by a fluorescence perturbation assay in which a change in the MAb intrinsic fluorescence produced by ligand binding was used as a reporter for antigen-antibody interaction. The MAbs differed considerably in the complexity of the binding curves. MAbs producing rim type capsule reactions typically produced the more complex binding isotherms. Finally, the protective activity of the MAbs was compared in a murine model of pulmonary anthrax. One MAb was markedly less protective than the remaining five MAbs. Characteristics of the more protective MAbs included a relatively high affinity, an immunoglobulin G3 isotype, and a complex binding isotherm in the fluorescence perturbation assay. Given the relatively monotonous structure of gammaDPGA, the results demonstrate a striking diversity in the antigen binding behavior of gammaDPGA antibodies.

Identification of a monoclonal antibody from Peromyscus maniculatus (deer mouse) cytomegalovirus (PCMV) which binds to a protein with homology to the human CMV matrix protein HCMV pp71.

In this study we identified and characterized a monoclonal antibody against the matrix protein of a cytomegalovirus isolated from the common deer mouse (Peromyscus maniculatus) (PCMV). The monoclonal antibody was isolated using previously described technology which could be applied to the production of monoclonal antibodies against zoonotic disease. The antibody was found to react with a protein homologous to the human cytomegalovirus (HCMV) matrix protein (pp71), the product of the UL82 open reading frame (ORF). mAbs were generated from heterologous fusion of spleen cells from PCMV-positive mice and Balb/C P3X63-Ag8.653 myeloma cells. Using this approach, four monoclonal antibodies: B8C4, C12E8, G6A2 and P4E5 were generated. Antibody G6A2 reacted strongly with PCMV-infected cells as well as purified virions on ELISA and immunofluorescence. Western blot analysis, using sucrose gradient-purified virions, demonstrated that this mAb reacted specifically to a single protein with an apparent molecular weight of 71 kDa. The protein band was excised from the gel, purified and subjected to trypsin digestion followed by mass spectrometry. The protein sequences obtained were found to have identity to HCMV UL82 gene product. Sequence analysis indicated that it is the putative HCMV pp71 protein homolog of PCMV. G6A2 mAb did not cross-react with either human or murine recombinant pp71 proteins expressed in mammalian cells.

Economic burden of acute myeloid leukemia: a literature review.

OBJECTIVE: The primary objective was to examine the economic burden associated with acute myeloid leukemia (AML), a deadly hematological malignancy. AML is the most common form of acute leukemia in adults, particularly in individuals over 60 years of age; AML also accounts for 15-20% of childhood leukemia. MATERIALS AND METHODS: A systematic review was conducted of relevant studies published in the English language. Economic analyses of AML published between 1990 and 2002 were identified from electronic data sources using broad search criteria. Additional studies were obtained by manual searches of bibliographies of articles identified in the electronic searches. Articles were screened for relevance and included if the main theme included some element of AML cost of treatment, cost drivers, or cost-effectiveness. Studies reporting only drug prices without a formal comparison or analysis were not included. RESULTS: Twenty-nine studies were included in the review. Although information was limited on the comprehensive economic burden of AML from a societal perspective, the costs appear to be split equally between direct and indirect costs. Direct costs of AML from a public payer perspective were available for a few countries such as the Netherlands, Sweden, US (Medicare), and Italy. These studies found that the key cost drivers appear to be hospitalization length of stay related to initial chemotherapy, relapse of disease, and bone marrow transplant (BMT) and peripheral blood stem cell transplant (PBSCT). Several cost analyses have been published comparing the different treatment strategies; however, most of them were published in the early 1990s, and their analysis revolved around cost-comparison rather than comprehensive cost-effectiveness. The published studies investigated pharmacological agents (e.g., idarubicin, daunorubicin, mitoxantrone, fludarabine and combination therapies), as well as BMT, PBSCT, and the treatment of complications. CONCLUSION: Studies addressing the economic costs and burden of AML are relatively sparse in the international literature. Possible reasons for such a lack of information appear to include the low incidence rate of AML (e.g., about 260,000 new cases were reported in 2002 in the world) and the fact that it primarily afflicts older adults >60 years of age, making broad, well-designed economic analyses a challenge for most researchers. However, due to the high cost associated with the medical procedures (e.g., BMT, PBSCT) and the aging of the world population, further research is warranted.

mAbs to Bacillus anthracis capsular antigen for immunoprotection in anthrax and detection of antigenemia.

Bacillus anthracis is surrounded by an antiphagocytic polypeptide capsule composed of poly gamma-D-glutamic acid (gammaDPGA). gammaDPGA has been identified recently as a potential target for vaccine development. Studies of the role of gammaDPGA in disease have been hampered by the poor Ab response to this antigen and the lack of immunochemical reagents. As a consequence, neither the extent of gammaDPGA production during anthrax nor the protective activity of gammaDPGA Abs in inhalation anthrax are known. Here we report production of IgG Abs to gammaDPGA in mice following an immunization regimen using gammaDPGA in combination with agonist mAbs to CD40. mAbs were produced that are specific for gammaDPGA. Passive immunization with gammaDPGA mAbs protected >90% of mice in a pulmonary model of anthrax that was lethal in control mice (P < 0.0001). Use of gammaDPGA mAb in an antigen detection immunoassay found that the appearance of gammaDPGA in serum coincided with the emergence of bacteremia. These studies identify CD40 stimulation as a means for production of Ab and generation of mAbs against a weakly immunogenic antigen and demonstrate that the capsule is an effective target for immunoprotection and for antigen detection in the diagnosis of anthrax.

Short- and long-term effects of acute myeloid leukemia on patient health-related quality of life.

OBJECTIVES: Patients with acute myeloid leukemia (AML) may receive aggressive therapies (e.g., chemotherapy and bone marrow transplantation (BMT)) that are thought to significantly affect HRQL. Therefore, the goal of this study was to assess the HRQL impact on patients of AML and its treatments. MATERIALS AND METHODS: An electronically assisted literature survey and synthesis was conducted of English-language literature published worldwide between 1990 and 2002. The review was enhanced by inclusion of articles, including those published before 1990, which were manually identified from the bibliographies of the electronically identified publications. Articles were analyzed with respect to HRQL instruments used, HRQL domains assessed, aspects of disease and treatment evaluated, and outcomes observed. RESULTS: The survey identified 21 articles that warranted review. AML and associated treatments have a substantial negative impact on patient HRQL as has been measured by several different leukemia-specific, cancer-specific and generic instruments. The most negative HRQL burden is apparent soon after the diagnosis of the disease and during the course of therapy. Long-term survivors appear to recover HRQL almost completely with respect to physical, psychological and emotional well being, but incur continued sexual dysfunction. CONCLUSION: Clinicians responsible for the care of patients with AML should be aware of the HRQL impact of the disease and its treatment, in the long-term as well as the short-term. Researchers should evaluate the HRQL impact of new and investigational therapies.

Monoclonal antibodies reactive with immunorecessive epitopes of glucuronoxylomannan, the major capsular polysaccharide of Cryptococcus neoformans.

Cryptococcus neoformans is surrounded by an antiphagocytic capsule whose primary constituent is glucuronoxylomannan (GXM). An epitope shared by GXM serotypes A, B, C, and D is immunodominant when mice are immunized with serotype A GXM. In contrast, an epitope shared only by serotypes A and D is immunodominant when mice are immunized with serotype D. Hybridomas secreting antibodies reactive with subdominant epitopes were identified through a positive-negative screening procedure in which antibody-secreting colonies were characterized by reactivity with both the immunizing polysaccharide and GXMs from each of the four major serotypes. In this manner, a monoclonal antibody (MAb) that was reactive with an epitope shared only by serotypes A and B was identified and designated F10F5. Such an epitope has not been described previously. Immunization of mice with de-O-acetylated serotype A GXM generated a hybridoma that secreted an antibody, designated F12D2, that was reactive with all four serotypes. Unlike previously described monoclonal and polyclonal panspecific antibodies, the reactivity of MAb F12D2 was not altered by de-O-acetylation of GXM. These results indicate that there are at least two panspecific GXM epitopes; one epitope is dependent on O acetylation for antibody reactivity, and the other is independent of O acetylation. This study identifies strategies for production of MAbs that are reactive with subdominant or cryptic GXM epitopes and provides new information regarding the antigenic makeup and the humoral immune response to GXM, an essential virulence factor that is a target for active and passive immunization.

Economic burden of long-term complications of deep vein thrombosis after total hip replacement surgery in the United States.

BACKGROUND: Estimates of the cost of long-term complications of a primary deep vein thrombosis (DVT), including the post-thrombotic syndrome (PTS) and recurrent venous thromboembolism (VTE), may be relevant for resource allocation decisions. OBJECTIVE: The objective of this study was to provide US cost estimates of the long-term complications of a primary DVT, which occurs in approximately 5% to 20% (with adequate thromboprophylaxis) and 50% (in the absence of thromboprophylaxis) of total hip replacement surgeries (THRS). METHODS: A literature-based model was used to project the excess long-term complication costs of DVT following THRS. The model simulated the natural history of DVT complications using published estimates of the incidence and prognosis of PTS and recurrent VTE. Each complication was assigned a cost obtained by multiplying the amount of resources used in its management by the unit price of these resources. RESULTS: The annual per-patient cost of each complication was as follows: mild-to-moderate PTS, 839 dollars in the first year and 341 dollars in subsequent years; severe PTS, 3817 dollars in the first year and 1677 dollars in subsequent years; DVT, 3798 dollars; and pulmonary embolism, 6604 dollars. The average discounted lifetime cost of DVT complications was estimated to be 3069 dollars (95% interval 2091 dollars-4279 dollars). CONCLUSIONS: The long-term complications of a primary DVT represent a significant economic burden. Preventing a DVT could arguably lead to substantial savings in long-term DVT complications.