Persistent clonal areas and clonal expansion in Barrett's esophagus.

Three patients with Barrett's esophagus who had cytogenetic abnormalities detected in their metaplastic epithelium developed high-grade dysplasia or adenocarcinoma during prospective surveillance over a period of 1.5 to 6 years. In the 3 cases, cytogenetic abnormalities that were associated with the most advanced histological lesions were present in samples obtained 11, 25, and 48 months prior to the diagnosis of high-grade dysplasia or carcinoma. In a fourth patient, marker chromosomes found in a Barrett's adenocarcinoma were also present in an esophageal region spatially removed from the tumor. In all four patients, clonal cytogenetic abnormalities were present in samples obtained at widespread locations in the Barrett's segment. These observations suggest that in some patients with Barrett's esophagus clonal proliferations arise in regions of benign histology and spread to involve large areas of Barrett's mucosa. These clones persisted when the disease progressed to high-grade dysplasia or adenocarcinoma.

Microsatellite instability and K-ras mutations associated with pancreatic adenocarcinoma and pancreatitis.

ras oncogene mutations and microsatellite instability (MIN) have been described in pancreatic cancer studies from paraffin blocks and fresh frozen tissue. We sought to determine whether they could be detected in endoscopic retrograde cholangiopancreatography-derived pancreatic juice. ras mutations were detected in the pancreatic juice of 40% (2 of 5) of patients with pancreatic cancer and 2 of 5 patients with pancreatitis. MIN was detected at a single locus in the pancreatic juice of 40% of pancreatic cancer patients and at > or = 2 loci of 100% of pancreatitis patients. The finding of MIN in pancreatitis specimens was verified in studies performed on paraffin blocks. MIN was not detected in normal pancreas controls. All of the cancer patients who had ras mutations in their pancreatic juice also had evidence of MIN at one or more loci (P < or = 0.05), suggesting that MIN is associated with the development of a ras mutation. More importantly, the finding of MIN in pancreatitis specimens suggests that MIN can occur in nonneoplastic conditions of the pancreas and may represent the saturation of an intact mismatch repair system.

17p allelic deletions and p53 protein overexpression in Barrett's adenocarcinoma.

Barrett's esophagus is a condition in which the stratified squamous epithelium of the esophagus is replaced by metaplastic columnar epithelium that predisposes to the development of esophageal adenocarcinoma. Allelic deletions of 17p and alterations of p53 including elevated p53 protein levels have been observed in many different tumors. To investigate the presence of 17p allelic deletions and p53 protein overexpression in Barrett's adenocarcinomas, we have combined the use of restriction fragment length polymorphism analysis, multiparameter flow cytometry, and DNA content cell sorting. The combined use of these methodologies permits the purification of aneuploid tumor cells for restriction fragment length polymorphism analysis of 17p allelic deletions and the evaluation of p53 protein expression by multiparameter flow cytometry in the same aneuploid tumor cell populations. We analyzed 15 aneuploid populations and one tetraploid populations from 13 Barrett's adenocarcinomas for 17p allelic deletions and p53 protein overexpression to determine whether both of these alterations are involved in carcinogenesis in Barrett's esophagus. Twelve of 13 tumors (92%) had 17p allelic deletions, and 8 of 13 tumors (62%) had p53 protein overexpression. Eight of the 12 tumors (67%) with 17p allelic deletions also had p53 protein overexpression. These data indicate that both 17p allelic deletions and p53 protein overexpression are frequently involved in carcinogenesis in Barrett's esophagus.

Microsatellite instability in nonneoplastic mucosa from patients with chronic ulcerative colitis.

Microsatellite instability (MIN) has been detected in many cancer types; however, recently we also observed it in the nonneoplastic but inflammatory setting of pancreatitis. Consequently, we sought to examine whether MIN was present in another inflammatory condition, ulcerative colitis (UC). MIN was found in 50% of UC patients whose colonic mucosa was negative for dysplasia, 46% of those with high-grade dysplasia, and 40% of those with cancer but in none of the ischemic or infectious colitis controls (P<0.03). Thus, UC patients may have MIN within mucosa that has no histological evidence of neoplastic change. MIN in this setting may reflect the inability of DNA repair mechanisms to compensate for the stress of chronic inflammation, and may be one mechanism for the heightened neoplastic risk in UC.

Pancolonic chromosomal instability precedes dysplasia and cancer in ulcerative colitis.

Patients with long-standing ulcerative colitis (UC) are at increased risk for colon cancer. These cancers are thought to arise from preexisting dysplasia in a field of abnormal cells that often exhibits aneuploidy and p53 abnormalities. Using dual color fluorescence in situ hybridization with centromere probes and locus-specific arm probes for chromosomes 8, 11, 17, and 18, we demonstrate that chromosomal instability (CIN) is present throughout the colon of UC patients with high-grade dysplasia or cancer. In rectal biopsies that were negative for dysplasia, abnormalities in chromosomal arms, especially losses, were most common, whereas centromere gains were most common in dysplasia and cancer. The frequency and type of abnormalities varied between the chromosomes examined; chromosome 8 was the least affected, and 17p loss was found to be an early and frequent event. Chromosomal arm instability showed 100% sensitivity and specificity for distinguishing control biopsies from histologically negative rectal biopsies from these UC patients, raising the possibility that a screen for CIN might detect the subset of UC patients who are at greatest risk for development of dysplasia and cancer. These results suggest that dysplasia and cancer in UC arise from a process of CIN that affects the entire colon; this may provide the mutator phenotype that predisposes to loss of tumor suppressor genes and evolution of cancer.

Frequent loss of heterozygosity at the retinoblastoma locus in human esophageal cancers.

Abnormalities in the retinoblastoma tumor suppressor gene (Rb) have been observed in a large number of human cancers. Loss of heterozygosity is a common mode of allelic inactivation of Rb and other tumor suppressor genes. We investigated DNA from 61 primary human esophageal tumors for loss of heterozygosity at the Rb locus using a polymerase chain reaction-based restriction fragment length polymorphism assay. Of informative cases, we found loss of heterozygosity in 14 of 26 (54%) squamous cell carcinomas and 5 of 14 (36%) adenocarcinomas. These data support the hypothesis that Rb inactivation is involved in the pathogenesis and/or progression of esophageal cancer.

Histopathology of reflux-induced esophageal and supraesophageal injuries.

As many as half of patients who have symptoms and objective evidence of gastroesophageal reflux disease (GERD) will have normal mucosa or only hyperemia at endoscopy. Because inflamed esophageal mucosa may appear normal endoscopically, and because hyperemia may or may not reflect histologic espophagitis, biopsy to document tissue injury in symptomatic patients with these minimal endoscopic findings may be helpful. Reflux may induce inflammation in the squamous mucosa of the esophagus, but in many patients only hyperplasia of the epithelium is seen. This hyperplasia is defined by a basal zone that exceeds 15% of the thickness of the mucosa and subepithelial papillae that exceed 67% of the thickness of the mucosa. Because these changes may be present normally in the distal 2.5 cm of the esophagus, and because they may be distributed over the distal 8 cm in a patchy fashion, multiple biopsies taken more than 2.5 cm above the esophagogastric junction are necessary to detect them reliably. Supraesophageal complications of GERD include posterior laryngitis, inflammatory polyp of the larynx (contact ulcer or laryngeal granuloma), subglottic stenosis and laryngeal squamous cell carcinoma.

A comparative study of generic stains for carcinoid secretory granules.

Generic stains for secretory granules in carcinoid tumors often yield inconsistent and unpredictable results. Consequently, these techniques have been modified and new ones devised; however, very few studies comparing the efficacy of the various methods have been published. To determine which method would most consistently demonstrate carcinoid granules, we applied a battery of six stains to 73 tumors, all morphologically identified as carcinoids, from various sites (17 pulmonary, 13 small intestinal, 20 appendiceal, 18 rectal, five miscellaneous). Stains employed included four argyrophil (Sevier-Munger, Grimelius, Pascual, Churukian-Schenk), one argentaffin (Fontana-Masson), and one non-silver technique (lead hematoxylin). Of the 73 carcinoids, 97% stained positively with the Churukian-Schenk, 82% with the Pascual, 79% with the Grimelius, 74% with the Sevier-Munger, 67% with lead hematoxylin, and 51% with the Fontana-Masson technique. The two cases negative by the Churukian-Schenk technique were also negative with all other stains; thus, this technique most consistently demonstrated secretory granules in carcinoids, including all 18 rectal tumors. The Churukian-Schenk method achieves its superior results by reducing background staining and nonspecific precipitation to a level that permits sparse, small granules to be readily identified. In control sections of normal mucosa and in some tumors, this stain revealed more than one population of argyrophil cells as identified by the size, color, and staining intensity of the granules.

Hereditary gastrointestinal polyposis syndromes.

Hereditary gastrointestinal polyposis syndromes can be divided into adenomatous and hamartomatous types. Familial adenomatous polyposis coli (FAPC) is the prototype adenomatous polyposis syndrome and is defined by the autosomal dominant transmission of multiple (more than 100) colorectal adenomas. Virtually all affected patients develop colorectal carcinoma if untreated. Adenomas may develop also in the stomach and small bowel in FAPC patients, but the incidence of carcinoma in these sites is low. A variety of extracolonic manifestations has been reported in FAPC, with the name Gardner's syndrome applied to kindreds with osteomas of the skull and mandible, multiple epidermal cysts, and other skin and soft-tissue lesions. In Turcot's syndrome, brain tumors are present. The distinction between Gardner's and Turcot's syndromes and classical FAPC has become blurred because of marked overlap between them; some authorities consider them to be varying manifestations of a single genetic defect. The hamartomatous polyposes include Peutz-Jeghers syndrome, familial juvenile polyposis, Cowden's disease, intestinal ganglioneuromatosis, and the Ruvalcaba-Myrhe-Smith syndrome. The incidence of gastrointestinal cancer in patients with Peutz-Jeghers syndrome and familial juvenile polyposis exceeds that in the normal population, but is relatively low. In Cowden's disease, the gastrointestinal tract may be the site of multiple hamartomas, but there is no associated increase in the incidence of gastrointestinal cancers; instead, there is an increased incidence of carcinoma of the breast and thyroid. Intestinal ganglioneuromatosis occurs in von Recklinghausen's disease, in association with multiple endocrine neoplasia, type 2b, or as an isolated abnormality. Patients with ganglioneuromatosis do not appear to have an increased risk of developing gastrointestinal cancer. Ruvalcaba-Myrhe-Smith syndrome comprises macrocephaly, mental deficiency, an unusual craniofacial appearance, hamartomatous intestinal polyposis, and pigmented macules on the penis. No increased risk of developing cancer has been identified in the few reported cases.

The prevalence and prognostic significance of argyrophil cells in colorectal carcinomas.

The presence of argyrophil cells in the proliferative compartment of noncarcinoid carcinomas of the GI tract is well-documented; however, their prevalence and prognostic significance in colorectal carcinomas have never been systematically investigated and reported in the English literature. We applied the Churukian-Schenk argyrophil stain, a histochemical technique previously shown to be the most effective for demonstrating argyrophil cells, to 94 carcinomas of the colon and rectum from patients in whom a minimum 5-year follow-up was available. The 94 cases included 25 nonmucinous colonic and 25 nonmucinous rectal adenocarcinomas; 25 mucinous adenocarcinomas from all sites; and 19 undifferentiated carcinomas from all sites. Twenty control colorectal carcinoids all gave a positive argyrophil stain. Nineteen (20%) of the 94 carcinomas contained argyrophil cells as follows: adenocarcinoma of the colon, 52%; adenocarcinoma of the rectum, 16%; mucinous adenocarcinoma, 4%; and undifferentiated carcinoma, 5%. Crude 5-year survival rates were: carcinoids 80%; all carcinomas containing argyrophil cells, 37%; all without argyrophil cells, 27%. Chi-square between the later two groups was 0.723 (p less than 0.5). Because of the intrinsically poorer prognosis of mucinous and undifferentiated carcinomas, a comparison of survival rates was made excluding these tumors; chi-square was 0.095 (p less than 0.8). We conclude that argyrophil cells are commonly present in nonmucinous adenocarcinoma of the colon, but are less common in nonmucinous adenocarcinomas of the rectum and rare in mucinous and undifferentiated carcinomas. The presence of argyrophil cells did not influence prognosis in this series of cases.

Normal histology of the colon.

We describe the normal gross anatomy and histology of the colon, with emphasis on the appearance of the mucosa as seen in the endoscopic biopsies. Various artifacts that may be encountered as a result of trauma from the biopsy forceps, incorrect orientation of the tissue, fixation, and the effects of laxatives and enemas are described and illustrated. Recommendations for optimum handling of biopsies are made.

Malignant epithelioid hemangioendothelioma of the liver in young women. Relationship to oral contraceptive use.

Epithelioid hemangioendothelioma (EH) is a vascular neoplasm that occurs predominantly in soft tissue and is not infrequently misdiagnosed as an epithelial neoplasm or angiosarcoma. Only a few cases of hepatic EH have been described, and a relationship to oral contraceptive (OC) use in patients with the hepatic lesions has not generally been recognized. We present a series of five patients with malignant epithelioid hemangioendothelioma of the liver. Confirmation of the endothelial origin of these tumors was provided by positive immunoperoxidase staining for Factor-VIII-related antigen in the four cases studied by that technique, and by the demonstration of Weibel-Palade bodies in two tumors examined by electron microscopy. All five patients were young women (mean age 33 years) and all five gave a history of OC use of 4-7 years' duration. The clinical course varied from indolent but progressive to rapid death. One patient who underwent resection of the primary tumor has survived 3 years without evidence of disease, and one patient with metastatic disease who was treated with radiation and chemotherapy has survived for 8 years with disease. Three patients with extrahepatic spread have died of the tumor. Early diagnosis of this distinctive tumor might offer the hope of salvage by resection or liver transplantation.

Mesenteric inflammatory veno-occlusive disease. A seldom recognized cause of intestinal ischemia.

We describe seven patients (three men, four women; ages 27-78) who presented with signs of intestinal ischemia requiring surgical intervention. In each case, the resected colon, small bowel, or both showed striking phlebitis and venulitis affecting veins of the bowel and mesentery and resulting in ischemic injury of the bowel. In each case, this vasculopathy was the only demonstrable cause of ischemia. Arteritis involving the bowel or the mesentery was not found in any patient, and none had clinical evidence or a history of extraintestinal vasculitis. The composition of the inflammatory infiltrate was variable; in four patients, it was predominantly lymphocytic, in two necrotizing and in one lymphocytic/granulomatous. In addition, three patients also had myointimal hyperplasia of the affected mesenteric veins. Six of seven patients recovered uneventfully after surgery, suggesting a self-limited or indolent process, and the seventh died of an unknown cause. We propose the name mesenteric inflammatory veno-occlusive disease (MIVOD) to describe this unusual and previously unrecognized cause of intestinal ischemia. Its etiology is unknown, and MIVOD may represent a precursor of the recently described idiopathic myointimal hyperplasia of mesenteric veins.

Familial fibrocystic pancreatic atrophy with endocrine cell hyperplasia and pancreatic carcinoma.

Understanding the pathology of familial pancreatic carcinoma may provide important insights into pancreatic tumorigenesis. We now describe in detail the pancreatic pathology of an autosomal dominant pancreatic carcinoma kindred with distinct clinical, genetic, and pathologic manifestations differing from all other reported forms of sporadic or familial pancreatic neoplasia. Affected individuals develop a prodrome of diabetes mellitus, pancreatic exocrine insufficiency, and characteristic pancreatic imaging abnormalities. Eleven family members have undergone total pancreatectomy, revealing a unique and characteristic fibrocystic, lobulocentric pancreatic atrophy. This was patchy to diffuse in distribution and was invariably associated with a nesidioblastosis-like endocrine cell hyperplasia. All but one resected pancreas demonstrated glandular epithelial dysplasia: 10 had low-grade dysplasia (pancreatic intraductal neoplasia grade II of III or PanIN II) and seven also had high-grade dysplasia (pancreatic intraductal neoplasia grade III of III or PanIN III). Dysplasia was multifocal in small-to medium-sized duct-like structures within areas of acinar atrophy, microcystic change, and mucinous hyperplasia. Two pancreata had carcinomas of multiple and unusual histologic subtypes, including small cell undifferentiated carcinoma and giant cell anaplastic carcinoma. The findings in this kindred yield important information on a distinctive and previously unrecognized pancreatic cancer precursor. Recognition of this entity may help identify additional kindreds and perhaps the underlying genetic defect. As is the case for other familial cancers, the as yet unknown specific genetic defect may have wider implications for pancreatic cancer in general.

Biopsy-directed immunosuppression following hepatic transplantation in man.

Patients undergoing orthotopic hepatic transplantation were studied with routinely available liver function studies and serial hepatic biopsies. Rejection was diagnosed only if confirmed histologically. Cyclosporine and a rapidly decreasing dose of corticosteroids were used for immunosuppression. Hepatic dysfunction suggesting rejection was seen in 22 instances, but acute rejection was diagnosed histologically in only 6 patients. The liver function studies used in these patients did not accurately distinguish rejection from other causes of hepatic dysfunction. We conclude that liver biopsy as performed in these patients is an accurate and safe means of assessing the adequacy of immunosuppression and minimizing the use of high dose corticosteroids.

Enzymes of salvage and de novo pathways of synthesis of pyrimidine nucleotides in human colorectal adenocarcinomas.

The activity of uridine-cytidine kinase (Urd-Cyd kinase). a key enzyme in the salvage of pyrimidine nucleosides, averaged 0.86 +/- 0.16 (S.E.M.) nmole uridine phosphates . min-1 . (mg protein)-1 in fifty-three specimens of human colorectal adenocarcinomas. The activity of fluorouracil phosphoribosyltransferase (FUPRTase) in thirty-five carcinoma specimens averaged only 0.19 +/- 0.07 nmole fluorouridine phosphates . min-1 . (mg protein)-1. The activity of the last enzyme in the de novo pathway of biosynthesis of UMP, i.e. orotidine 5'-monophosphate (OMP) decarboxylase, averaged 0.21 +/- 0.04 nmole CO2 . min-1 . (mg protein)-1. The activity of Urd-Cyd kinase was increased approximately 2.3-fold, and that of OMP decarboxylase by about 91%, while that of FUPRTase was increased by only 27%, as compared to that of normal human colonic mucosa. Of the colorectal carcinomas studied, 72% were moderately differentiated, 21% poorly differentiated, and 7% well differentiated. The mean diameter of the fifty-three carcinomas was 5.5 cm, and pathologic staging led to classification of 15% as Dukes' A, 36% as Dukes' B, 47% as Dukes' C, and 2% as carcinoma in situ. No correlations between the level of the enzyme activities studied and any pathologic characteristics of the carcinomas could be discerned.

Barrett's esophagus, dysplasia, and adenocarcinoma.

In Barrett's esophagus the normal stratified squamous epithelium lining the esophagus becomes replaced by metaplastic columnar epithelium containing goblet cells; it develops as a complication of chronic gastroesophageal reflux disease and predisposes the patient to adenocarcinoma. The frequency with which it leads to adenocarcinoma is not established with certainty, but the reported prevalence averages approximately 10% when the diagnosis of Barrett's esophagus is first made. The estimated incidence of adenocarcinoma varies from one in 152 to one in 441 cases per patient year, or a 30- to 125-fold excess risk. Esophageal adenocarcinoma arises only in patients with metaplastic columnar epithelium. Dysplasia precedes adenocarcinoma in Barrett's esophagus and arises from the metaplastic epithelium; it has been proposed as a marker for detecting patients at high risk for developing carcinoma. Problems with the use of dysplasia as a marker for cancer risk include difficulty in differentiating it from reactive change, variability in diagnosis and grading between observers and when the same observer interprets the sections on different occasions, and lack of understanding of its natural history. Methods other than dysplasia for detecting patients at highest risk for developing carcinoma have been sought, but flow cytometric analysis of DNA content is the only one proven to be valuable to date. Flow cytometric abnormalities correlate well with histological progression in Barrett's esophagus. The prevalence of elevated S phase and G2/tetraploid fractions and of aneuploid cell populations increases with histological progression from metaplasia to indefinite/low grade dysplasia to high grade dysplasia and cancer. Flow cytometric abnormalities in endoscopic biopsy specimens identify those patients with a higher risk of progression to high grade dysplasia or adenocarcinoma.

Observer variation in the diagnosis of dysplasia in Barrett's esophagus.

The potential value of biopsy surveillance of patients with Barrett's esophagus for dysplasia is diminished by a lack of agreement on the diagnostic criteria for dysplasia. In a preliminary consensus conference, experienced gastrointestinal pathologists from four medical centers agreed on criteria for a five-tiered histologic classification of dysplasia in Barrett's esophagus--negative for dysplasia, indefinite for dysplasia, low-grade dysplasia, high-grade dysplasia, and intramucosal carcinoma. Eight morphologists in the four centers tested the criteria for interobserver agreement by examining a set of coded slides that had been chosen to include some especially difficult interpretative problems in all five histologic classifications. Interobserver agreement of 85 and 87% was achieved in successive reviews when the combined group of high-grade dysplasia and intramucosal carcinoma was compared with the combined group of low-grade dysplasia, indefinite for dysplasia, and negative for dysplasia. Comparison of other groups yielded less agreement. For example, negative for dysplasia could be distinguished from all other diagnoses with an interobserver agreement of 72%. We conclude that experienced gastrointestinal morphologists can diagnose high-grade dysplasia and intramucosal carcinoma with a high degree of agreement and thus can detect those patients who may need immediate rebiopsy or esophageal resection. Either further refinement of histologic criteria or alternate diagnostic methods will be needed to achieve the reproducible diagnosis of indefinite changes and low-grade dysplasia. This is important because patients with such changes theoretically merit closer endoscopic surveillance.

Dysplasia in inflammatory bowel disease: standardized classification with provisional clinical applications.

Assessment of epithelial dysplasia in ulcerative colitis has been hindered by inconsistencies in and disagreements about nomenclature and interpretation. To resolve these issues, pathologists from ten institutions participated in three exchanges of multiple slides and, following each exchange, in discussions of the results. A classification system for the epithelial changes that occur in ulcerative colitis was developed, which should be applicable to other forms of inflammatory bowel disease as well. The classification makes use of standardized terminology, addresses specific problem areas, and offers practical solutions. The reproducibility of the system was studied by means of examinations of both inter- and intra-observer variations. The clinical implications of the findings were incorporated into suggestions for patient management. The basis of the classification is that the term "dysplasia" is reserved for epithelial changes that are unequivocally neoplastic and may therefore give rise directly to invasive carcinoma. Specimens are categorized as negative, indefinite, or positive for dysplasia. The negative category includes all inflammatory and regenerative lesions and indicates that only continued regular surveillance is required. The indefinite category is applied to epithelial changes that appear to exceed the limits of ordinary regeneration but are insufficient for an unequivocal diagnosis of dysplasia or are associated with other features that prevent such unequivocal diagnosis. Clinically, it indicates that early repeat biopsy is often required to assess the changes more accurately. The positive category is divided into two subcategories: 1) high-grade dysplasia, for which colectomy should be strongly considered after confirmation of the diagnosis, and 2) low-grade dysplasia, which also requires confirmation and early repeat biopsy or colectomy, depending on other findings.

Mucoepidermoid and adenoid cystic carcinomas of the esophagus.

Four case reports of patients with tumors of the esophagus resembling those of salivary gland origin are presented with a review of the cases published to date. These tumors arise in the submucosal glands in the esophagus and are histologically similar to adenoid cystic and mucoepidermoid carcinomas of the salivary glands. The mucoepidermoid variety occurs more frequently in men than in women, and the adenoid cystic carcinomas are equally distributed between the sexes. In most of the cases reported the tumors were resectable but the overall survival rate is poor and is similar to the rates found with the more frequent squamous cell cancer of the esophagus.