Significance of H3K27M mutation with specific histomorphological features and associated molecular alterations in pediatric high-grade glial tumors.

PURPOSE: Pediatric high-grade gliomas (pHGGs) constitute almost 15% of all childhood brain tumors. Recurrent mutations such as H3K27M mutation in H3F3A and HIST1H3B genes encoding histone H3 and its variants were identified in approximately 30% of pediatric glioblastomas. This study aimed to ascertain the morphological and molecular characteristics of pHGGs with H3K27M mutation. METHODS: In total, 61 cases of pHGGs (anaplastic astrocytoma, 12; glioblastomas, 49) from four university hospitals were studied. The histomorphological features were examined and immunohistochemistry was performed to evaluate the mutation status of H3K27M, ATRX, IDH1, BRAF V600E, and p53 genes. RESULTS: The study comprised 25 females and 36 males (age range, 1-18 years) with a clinical follow-up of up to 108 months. From the total, 31 patients were positive for H3K27M mutation located in the midline, mostly in the pons and thalamus. H3K27M mutation was commonly associated with ATRX loss (32.3%) and p53 (74.2%) immunoreactivity with a co-expression rate of 25.8%. While IDH1 mutation was not detected in pHGGs with H3K27M mutation, BRAFV600E mutation was rarely observed. Among the various histomorphological features, increased number of mitosis, increased Ki-67 proliferation index, and palisading and geographical necrosis along with small cell patterns were significantly associated with the H3K27M wild-type tumors. Focal infarct-like necrosis and pilomyxoid morphology was significantly associated with these tumors. CONCLUSION: H3K27M mutation occurs exclusively in pHGGs arising from the midline and presents with varied histomorphological features ranging from low-grade pilomyxoid astrocytoma to highly pleomorphic glioblastoma along with ATRX loss and p53 mutations.

Proximal muscle weakness as a result of osteomalacia associated with celiac disease: a case report.

UNLABELLED: A 24-year-old woman suffering from back and hip pain with difficulty in walking was reported. She had proximal muscle weakness. Laboratory findings led to the diagnosis of osteomalacia. Positivity of antibodies strengthened suspicion of celiac disease. In patients with proximal muscle weakness, osteomalacia should be considered in differential diagnosis even in a young woman. INTRODUCTION: A 24-year-old woman suffering from back pain, bilateral hip pain, and difficulty in walking was reported. Her symptoms had started in the first trimester of pregnancy. METHODS: In her physical examination, proximal muscle weakness and waddling gait pattern were determined. Her lumbar spine and hip MRI revealed no obvious pathological findings. Electromyography showed a myophatic pattern. RESULTS: Physical examination, normal values of creatine kinase, and muscle biopsy were supplied to exclude the diagnosis of primer muscle diseases. Laboratory findings led to the diagnosis of osteomalacia with normal renal function. Gastrointestinal symptoms and positivity of anti-gliadin and anti-endomysium antibodies strengthened the suspicion of celiac disease as a cause of the osteomalacia. The diagnosis of celiac disease was confirmed with duodenal mucosal biopsy. CONCLUSION: In patients with proximal muscle weakness and waddling gait pattern, osteomalacia should be considered in differential diagnosis even in a young woman and underlying disease should be investigated.

New radiological clues in the diagnosis of spindle cell oncocytoma of the adenohypophysis.

AIM: To present three new cases of spindle cell oncocytoma (SCO) from a single centre and to identify new radiological clues in the diagnosis of SCO according to the information obtained from the cases presented. MATERIALS AND METHODS: Three adults with SCO confirmed at histopathology were retrospectively reviewed. The medical records, imaging findings, operative notes, and histopathology findings for each patient were recorded. Magnetic resonance imaging (MRI) findings were evaluated, including tumour localisation, tumour size, signal intensity, imaging features on T1-weighted and T2-weighted images, and contrast enhancement characteristics. The study protocol was approved by the institutional review board. Informed consent was obtained from each patient. RESULTS: T1-weighted imaging (WI) and T2WI demonstrated millimetric hypointense foci and linear signal void areas in all lesions. Consistent with the hypervascular features of the tumour, intense contrast enhancement was observed during the early stages of dynamic contrast enhanced (DCE) MRI. Linear signal void areas showed contrast enhancement, but some of the hypointense millimetric foci remained without contrast enhancement. CONCLUSIONS: Although the radiological findings and preoperative diagnosis of SCO have been reported to be non-specific and impossible, respectively, in the literature, the characteristics of MRI and different patterns of contrast enhancement can help in recognising this rare entity. This article represents a single institution case series of SCOs and also includes the first description of a correlation of the histopathological findings with radiological findings and new clues in the differential diagnosis of SCOs. We described these new radiological clues as "Hasiloglu's Signs".

[Molecular diagnostics of lung cancer]. / A tüdorák molekuláris diagnosztikája.

Development of the target therapies of lung cancer was a rapid process which fundamentally changed the pathological diagnosis as well. Furthermore, molecular pathology became essential part of the routine diagnostics of lung cancer. These changes generated several practical problems and in underdeveloped countries or in those with reimbursement problems have been combined with further challenges. The central and eastern region of Europe are characterized by similar problems in this respect which promoted the foundation of NSCLC Working Group to provide up to date protocols or guidelines. This present paper is a summary of the molecular pathology and target therapy guidelines written with the notion that it has to be upgraded continuously according to the development of the field.

Using a safe taxi service to transport newborn babies home from hospital.

AIM: To evaluate an intervention to enhance parents' use of car safety seats (CSSs) for their newborn baby's first journey home from the hospital in a population not usually exposed to television, internet and mainstream printed media. METHODS: Parents of newborn babies who did not bring a CSS to the hospital before their baby was discharged were lent a CSS to use in a 'safe taxi' service. All taxi drivers were trained to install the CSS safely. The intervention was evaluated using preprogramme questionnaires and follow-up interviews 4-8 weeks after discharge. RESULTS: Twelve parents participated in the intervention during the study period (January to April 2011) and in the evaluation process. Eleven couples were Jewish and one was Muslim. Most (75%) reported that they had not previously used CSS routinely and the reason was not financial. Following the 'safe taxi' intervention, 83% reported the use of CSS when travelling in all vehicles (excluding buses). On follow-up, most participants reported that the intervention increased their awareness and the use of CSS. CONCLUSION: The intervention, targeted at this specific population, was well received by the parents, increased awareness, changed practices and assured that more newborns travelled home safely in a CSS.

Déjà vu: Ralstonia mannitolilytica infection associated with a humidifying respiratory therapy device, Israel, June to July 2011.

Following a bloodstream infection in June 2011 with Ralstonia mannitolilytica in a premature infant treated with a humidifying respiratory therapy device, an investigation was initiated at the Hadassah Medical Centres in Jerusalem. The device delivers a warmed and humidified mixture of air and oxygen to patients by nasal cannula. The investigation revealed colonisation with R. mannitolilytica of two of 15 patients and contamination of components of five of six devices deployed in the premature units of the Hadassah hospitals. Ten isolates from the investigation were highly related and indistinguishable from isolates described in an outbreak in 2005 in the United States (US). Measures successful in containing the US outbreak were not included in user instructions provided to our hospitals by the distributor of the device.

Gastrointestinal colonization with ESBL-producing Klebsiella in preterm babies--is vancomycin to blame?

In this study, we examine the possible association between treatment with vancomycin and colonization with extended-spectrum beta-lactamase (ESBL)-producing Klebsiella in our neonatal intensive care unit (NICU). Variables compared between newborns which developed rectal colonization and those who did not include: gestational age, birth weight, gender, and total length of hospital stay until positive stool culture or discharge, treatment with vancomycin, and positive blood culture for coagulase-negative Staphylococcus. We found that lower birth weight, younger gestational age, and treatment with vancomycin were statistically significant risk factors for gastrointestinal colonization with ESBL-producing Klebsiella. When applying a multivariate model, treatment with vancomycin, both for a full 10-day course and for a short 3-day empirical treatment, remained statistically significant. Treatment with vancomycin is a risk factor for gastrointestinal colonization with ESBL-producing Klebsiella in premature babies.

Congenital fetal and neonatal visceral chylous effusions: neonatal chylothorax and chylous ascites revisited. A multicenter retrospective study.

This retrospective study was carried out at eight Neonatal Intensive Care Units (NICU) Centers worldwide on 33 newborns presenting at birth with pleural, pericardial, or abdominal chylous effusions. Diagnosis of chylous effusion is based on findings of fluid with a milk-like appearance, a concentration of triglycerides in pleural effusion >1.1 mmol/l, and a total cell count >1,000 cells/ml with a predominance of >80% lymphocytes. Thirty-three newborns met the inclusion criteria and were studied. Six subjects who presented at birth with fetal effusion were treated by in-utero pleuro-amniotic shunt. Five of these patients are alive at follow-up. At birth, pleural drainage was performed in 29/33 patients and abdominal drainage was carried out in 3/33. Total parenteral nutrition (TPN) was given to 32/33 patients; 19/23 patients were fed a medium-chain triglycerides (MCT). No adverse effects were observed. Eight patients were treated with Octreotide at dosages ranging from 1 to 7 mcg/kg/hour for 8 to 35 days. All patients showed decreased chylous production. Two patients were treated by pleurodesis. Twenty-two babies are alive after at least 6 months follow-up, 9/33 are deceased, and 2 were lost to follow-up. Clinical conditions of survivors are basically good except for lung involvement [chronic lung disease (CLD) or lung lymphangiectasia] and lymphedema. All patients were using a MCT diet at follow-up with good control of chylous effusion. Visceral chylous effusions of the fetus and neonate are rare disorders, and there currently is only partial agreement on decision-making strategies. We suggest the need for an international prospective trial in an effort to establish the efficacy and effectiveness of diagnostic and therapeutic options described in this article.

Sudden death due to a rare brain tumor: an autopsy case.

UNLABELLED: Sudden death in persons with intracranial neoplasms is a rare mechanism of death detected in the forensic autopsies. 10 years-old girl was brought to a local clinic death shortly after analgesic therapy for headache. Autopsy findings showed a large, solid cerebellar mass. Histological diagnosis was pilomyxoid astrocytoma, low-grade tumor with features alike to pilocytic astrocytomas. In this case report we present and discuss rare autopsy case of pilomyxoid astrocytoma from medicolegal point of view. KEYWORDS: sudden death - brain - pilomyxoid astrocytoma - autopsy.

Intracranial inflammatory pseudotumor: case report and review of the literature.

OBJECTIVE: Inflammatory pseudotumor is an uncommon lesion of unknown etiology most frequently involving the lungs and orbits. Primary intracranial inflammatory pseudotumors are exceptionally rare. Herein, we report a case of inflammatory pseudotumor that arises from the central nervous system in a 25-year-old man. MATERIAL AND METHOD: The patient presented with numbness in his right arm and right leg. Computed Tomography and Magnetic Resonance Imaging demonstrated a left fronto-parietal lobulated mass with intense contrast enhancement and perilesional edema mimicking a high grade glioma or metastasis. The lesion was removed by complete surgical resection. RESULTS: Pathologic examination showed spindle cell proliferation in a collagenous background with dense infiltrates of mononuclear inflammatory cells.The spindle cells were diffusely immunopositive for vimentin and focally positive smooth muscle actin but the cells did not show glial fibrillary acidic protein, epithelial membrane antigen, synaptophysin, S-100 protein, anaplastic lymphoma kinase-1 protein and CD1a immunoreactivity. Based on the morphologic and immunohistochemical findings, the diagnosis of inflammatory pseudotumor was made. After surgery, the symptoms had disappeared. No recurrence was observed at the eleven-month follow-up. CONCLUSION: Although rare, inflammatory pseudotumor of central nervous system is important in the differential diagnosis of the tumor-like intracranial lesions. We discuss the etiopathogenetic, diagnostic and therapeutic issues related to this entity, and review the literature.

The diagnostic utility of maspin in the distinction between malignant mesothelioma and pulmonary adenocarcinoma.

Immunohistochemistry is frequently employed to differentiate between malignant mesothelioma (MM) and pulmonary adenocarcinoma (AC) infiltrating the pleura, but there is uncertainty as to which antibodies are most useful. The present study investigated the presence of the serine protease, maspin, in epithelioid MMs and evaluated the diagnostic utility of maspin for the differential diagnosis between epithelioid MM and pulmonary AC with pleural involvement. The results showed more frequent maspin immunostaining among AC cases compared with MM cases. Maspin positivity was significantly higher among AC cases with respect to both the extent and intensity of staining. A significant difference also existed between the two tumour types with respect to the overall maspin score. Despite these findings, the sensitivity and specificity of maspin positivity to detect AC were only 59% and 73%, respectively, indicating that detection of maspin is of no value for the differential diagnosis of AC and MM.

The relationship between histomorphological characteristics and Ki-67 proliferation index in meningiomas.

OBJECTIVES: This study had two aims. The first was to use the Ki 67 proliferation index (Ki-67 PI) to study the relationship between the proliferation potential and histopathological features such as mitosis, necrosis, loss of architecture, small cell change, hypercellularity, pleomorphism, brain invasion, dura invasion, bone invasion, and histological grade. The second aim was to compare primary and recurrent meningioma with respect to morphological characteristics and Ki-67 PI values. BACKGROUND: Meningiomas are tumors whose histological features do not predict their biological behavior. Despite their slow growth and even after total resection, recurrence may occur METHODS: A total of 245 meningioma cases in whom Ki-67 PI was studied were included in the study. The cases were assessed with respect to 10 morphological characteristics, and a possible significant relationship between these and Ki 67 PI was statistically tested. RESULTS: We found a statistically significant relationship between Ki-67 PI and mitotic activity, necrosis, loss of architecture, small cell change, brain invasion. In contrast to brain invasion, no significant relationship was present between dura or bone invasion and Ki-67 PI. We identified asignificant increase in the histological grade, mitotic activity and Ki-67 PI value of recurrent tumors, as compared to primary ones CONCLUSION: Ki-67 PI values overlap in different grades. This overlapping might be due to the heterogeneity of biological activity within the tumor tissue (Tab. 2, Fig. 7, Ref. 21).

Non small cell lung cancer within the small cell lung cancer radiotherapy field after 11 years.

A 71-year-old male was diagnosed with a non-small cell lung cancer (NSCLC) within the radiotherapy field that was used for the treatment of a small cell lung cancer (SCLC) 11 years ago. At the initial diagnosis in 1996 the patient had limited-stage SCLC located in the right upper lobe of the lung with mediastinal involvement. He received 4 cycles of chemotherapy and then mediastinal radiotherapy. With a complete response after chemoradiotherapy he was given prophylactic cranial radiotherapy. After 11 years of disease-free period a new mass in left lower lobe of the lung was detected. Bronchoscopic biopsy showed second lung cancer with epidermoid histology. Although the incidence of a second lung cancer is higher in SCLC survivors, this is a unique case in the literature with second NSCLC developing in the previously irradiated side of limited-stage SCLC.

ALK immunohistochemistry positive, FISH negative NSCLC is infrequent, but associated with impaired survival following treatment with crizotinib.

OBJECTIVE: Metastasized non-small cell lung cancer (NSCLC) with an anaplastic lymphoma kinase (ALK) rearrangement is usually sensitive to a range of ALK-tyrosine kinase inhibitors. ALK-positive NSCLC have been identified in pivotal phase III trials with fluorescence in situ hybridization (ALK FISH+). These tumors are also expressing the fusion product (ALK immunohistochemistry (IHC)+). However, discrepant cases occur, including ALK IHC + FISH-. The aim of this study was to collect ALK IHC + cases and compare within this group response to crizotinib treatment of ALK FISH + cases with ALK FISH- cases. MATERIALS AND METHODS: In this European prospective multicenter research study patients with Stage IV ALK IHC + NSCLC treated with crizotinib were enrolled. Tumor slides were validated centrally for ALK IHC and ALK FISH. RESULTS: Registration of 3523 ALK IHC tests revealed a prevalence of 2.7% (n = 94) ALK IHC + cases. Local ALK FISH analysis resulted in 48 concordant (ALK IHC+/FISH+) and 16 discordant (ALK IHC+/FISH-) cases. Central validation revealed 37 concordant and 7 discordant cases, 5 of which had follow-up. Validation was hampered by limited amount of tissue in biopsy samples. The PFS at 1 year for ALK concordant and discordant was 58% and 20%, respectively (HR = 2.4; 95% CI: 0.78-7.3; p = 0.11). Overall survival was significantly better for concordant cases than discordant cases after central validation (HR=4.5; 95% CI= 1.2-15.9; p=0.010. CONCLUSION: ALK IHC + FISH- NSCLC is infrequent and associated with a worse outcome on personalized treatment. A suitable predictive testing strategy may be to screen first with IHC and then confirm with FISH instead of considering ALK IHC equivalent to ALK FISH according to the current guidelines.

Preoperative Somatostatin Analogue Treatment Might Trigger Apoptosis and Autophagy in Tumor Tissues of Patients with Acromegaly: A Pilot Study.

OBJECTIVE: To evaluate the effect of preoperative somatostatin analog (SRL) treatment on proteins associated with apoptosis and autophagy in patients with acromegaly and to determine factors correlating with these parameters. METHODS: Ex-vivo tumor samples of 11 SRL-treated and 9 SRL-untreated patients were retrospectively included in the study. Apoptotic and autophagic proteins were determined via immunohistochemical staining and apoptosis was evaluated via in situ DNA end labeling (TUNEL). RESULTS: TUNEL, caspase-3, and ATG-5 immunopositivity was significantly increased (p<0.01, p=0.01, p=0.01, respectively), survivin and beclin-1 immunopositivity was significantly decreased (p=0.03, p=0.02, respectively) in SRL-treated patients as compared with SRL-untreated controls. Ki-67 index was decreased significantly in the SRL-treated group (p=0.01). Significant positive correlations were detected between TUNEL and caspase-3 immunopositivity (r=0.577, p<0.01), and between survivin and beclin-1 immunopositivity (r=0.503, p=0.03). Age at diagnosis, preoperative GH, IGF-1 levels, tumor size, and invasion status were not found to affect TUNEL positivity nor did they correlate with caspase-3, survivin, beclin-1, ATG-5 immunopositivity (p>0.05 for all). Preoperative SRL treatment was the only factor that had a significant effect on TUNEL positivity (adjusted R2=0.39, p=0.02). Preoperative treatment duration was positively correlated with TUNEL and caspase-3 immunopositivity (r=0.526, p=0.02; r=0.475, p=0.04, respectively) and negatively correlated with survivin immunopositivity (r=-0.533, p=0.01). CONCLUSIONS: Somatostatin analog treatment might induce apoptosis, increase autophagy, and decrease cell proliferation in GH-secreting adenomas. Also, proteins related to cross-talk between autophagy and apoptosis are upregulated after SRL treatment.

The R110C mutation in Notch3 causes variable clinical features in two Turkish families with CADASIL syndrome.

Mutations in Notch3 gene are responsible for the cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). It is a late onset neurological disorder recognized by recurrent strokes and dementia. We describe here the clinical and molecular findings of three unrelated Turkish families with CADASIL syndrome. Two of the families were identified to have the same mutation, p.R110C (c.C328T), located in exon 3 of the Notch3 gene. Interestingly, the phenotypic expression of the disease in these two families was markedly different in severity and age of onset implicating additional genetic and/or non-genetic modulating factors involved in the pathogenesis. In addition, we identified the novel p.C201R (c.T601C) mutation in exon 4 of the Notch3 gene in a proband of the third family with two consecutive stroke-like episodes and typical MRI findings. Mutations described here cause an odd number of cysteines in the N-terminal of the EGF domain of Notch3 protein, which seems to have an important functional effect in the pathophysiology of CADASIL. The phenotypic variability in families carrying the same molecular defect as presented here makes the prediction of prognosis inconceivable. Although DNA analysis is effective and valuable in diagnosing approximately 90% of the CADASIL patients, lack of genotype-phenotype correlation and prognostic parameters makes the presymptomatic genetic counseling very difficult.

Correlation of endothelial nitric oxide synthase and vascular endothelial growth factor expression with malignancy in patients with astrocytic tumors.

PURPOSE: Many characteristics of malignant brain tumors (increased vascular permeability, vasodilatation, neovascularisation and free radical injury to the tumor and adjacent normal tissues) are believed to be mediated by nitric oxide (NO) synthetized by endothelial NO synthase (eNOS). Overexpression of vascular endothelial growth factor (VEGF) is associated with several central nervous system (CNS) diseases and tumors. Our aim was to study immunohistochemically the coexpression of eNOS and VEGF in astrocytic tumors and to analyse their possible correlation with tumor grade, angiogenesis and proliferation index. MATERIALS AND METHODS: Sections from 120 randomly selected patients with supratentorial astrocytic tumors [38 glioblastomas (GB), 22 anaplastic astrocytomas (AA) and 20 low-grade astrocytomas (LA)], also including oligodendrogliomas (n=20) and mixed oligoastrocytomas (n=20), were immunostained with monoclonal antibodies for eNOS and VEGF using the avidin-biotin method. The proliferative potential was assessed as the MIB-1 staining index for tumor cells. RESULTS: There was positive correlation between eNOS and VEGF expressions and histological grade (p<0.05) in terms of intensity and extent of immunoreactivity distribution. Oligodendrogliomas showed significantly less VEGF and eNOS immunoreactivity compared to pure astrocytomas (p<0.05). CONCLUSION: Overexpressions of eNOS and VEGF in astrocytic tumors were significantly correlated with histological grade, proliferative potential and malignant transformation. The expression of VEGF in a necrotic and ischemic tumor such as GB is more intense and diffuse than low-grade astrocytomas. These findings suggest that eNOS overexpression in tumor vasculature would be precipitated by transformation into an angiogenic phenotype in the process of neovascularisation in astrocytic tumors.

Somatostatin impairs clearance of exogenous insulin in humans.

Somatostatin has been widely used to suppress endogenous pancreatic hormone secretion in research studies. Many of these studies required the simultaneous infusion of a hormone together with somatostatin. A critical assumption for its use in metabolic investigation is that somatostatin has no effect on the action or clearance of a concomitantly infused hormone. To test whether clearance of an exogenously infused hormone is affected, we infused insulin with or without somatostatin in two sets of studies. Insulin (40 mU X kg-1 X h-1) was infused for 100 min (n = 6). Plasma glucose levels fell to 55 +/- 4.1 mg/dl with insulin alone and significantly lower, to 44 +/- 1.9 mg/dl, when somatostatin (250 micrograms/h) was also infused (P less than .01). Plasma immunoreactive insulin (IRI) rose to 57 +/- 12.5 microU/ml with insulin alone, which was significantly different from 88 +/- 15 microU/ml when insulin was infused together with somatostatin (P less than .01). When a smaller dose of insulin (30 mU X kg-1 X h-1) was infused for 100 min (n = 4), similar results were observed. When somatostatin was infused together with insulin, plasma glucose fell to lower levels (41 +/- 4.2 vs. 62 +/- 9.5 mg/dl; P less than .01) and plasma IRI rose higher (39 +/- 8.5 vs. 27 +/- 5.9 microU/ml; P less than .01) than when insulin was infused alone. C-peptide was equally suppressed by hypoglycemia regardless of whether somatostatin was administered, indicating suppression of endogenous insulin during these studies. We conclude that somatostatin infusion impairs the clearance of exogenous insulin.(ABSTRACT TRUNCATED AT 250 WORDS)

Autocrine motility factor receptor expression implies an unfavourable prognosis in resected stage I pulmonary adenocarcinomas.

BACKGROUND: Pulmonary adenocarcinomas constitute a different histological subtype among the histological subtypes of non small cell lung carcinomas by showing comparably unfavourable rates of prognosis and different immunobiological features. Autonomous motility of tumour cells plays an important role in the regulation of local invasion and distant metastasis of tumour lesions which have great impact on overall survival. AMF (Autocrine motility factor) is a tumour secreted cytokine that stimulates motility during invasion and metastasis via its receptor, AMFR. We conducted an immunohistochemical study to investigate AMFR expression in pulmonary adenocarcinomas and its effect on survival. MATERIAL AND METHODS: We assessed AMFR expression using a monoclonal antibody (3F3A) in a total of 32 surgical specimens with stage I pulmonary adenocarcinomas that underwent curative resection. We analyzed AMFR expression as a possible prognostic factor on survival and its correlations with clinicopathological features. RESULTS: A total of 19 (59.3%) specimens showed AMFR expression. The 3-year survival rates of AMFR positive and AMFR negative patients were 47.3% and 84.6%, respectively, which was a significant difference (P = 0.0197). The univariate predictors of surgical outcome were AMFR expression (P = 0.032) and perineural invasion (P = 0.038). However, multivariate analysis revealed AMFR expression (P = 0.045) as the only independent prognostic factor. CONCLUSIONS: AMFR expression predicts an unfavourable surgical outcome in patients with stage I pulmonary adenocarcinomas.