A pilot study to explore circulating tumour cells in pancreatic cancer as a novel biomarker.

BACKGROUND: Obtaining tissue for pancreatic carcinoma diagnosis and biomarker assessment to aid drug development is challenging. Circulating tumour cells (CTCs) may represent a potential biomarker to address these unmet needs. We compared prospectively the utility of two platforms for CTC enumeration and characterisation in pancreatic cancer patients in a pilot exploratory study. PATIENTS AND METHODS: Blood samples were obtained prospectively from 54 consenting patients and analysed by CellSearch and isolation by size of epithelial tumour cells (ISET). CellSearch exploits immunomagnetic capture of CTCs-expressing epithelial markers, whereas ISET is a marker independent, blood filtration device. Circulating tumour cell expression of epithelial and mesenchymal markers was assessed to explore any discrepancy in CTC number between the two platforms. RESULTS: ISET detected CTCs in more patients than CellSearch (93% vs 40%) and in higher numbers (median CTCs/7.5 ml, 9 (range 0-240) vs 0 (range 0-144)). Heterogeneity observed for epithelial cell adhesion molecule, pan-cytokeratin (CK), E-Cadherin, Vimentin and CK 7 expression in CTCs may account for discrepancy in CTC number between platforms. CONCLUSION: ISET detects more CTCs than CellSearch and offers flexible CTC characterisation with potential to investigate CTC biology and develop biomarkers for pancreatic cancer patient management.

Active CMV disease does not always correlate with viral load detection.

The use of quantitative cytomegalovirus (CMV) real-time polymerase chain reaction (RT-PCR) and preemptive ganciclovir therapy is replacing prophylaxis as the management of choice in high-risk patients undergoing stem cell transplantation (SCT). However, there are limited data defining its role in this setting. In the current retrospective single-centre study, quantitative RT-PCR was used to determine CMV in 577 consecutive patients undergoing SCT (172 allogeneic and 405 autologous) over a 5-year period. CMV RT-PCR was performed weekly until cessation of immunosuppression (allogeneic) or for 30 days post-SCT (autologous). Treatment was commenced after two consecutive positive results or a high copy on the first occasion (> 1000 copies/ml, > 3 log). The overall CMV reactivation rate in patients undergoing allogeneic SCT was 30%, with reactivation observed in 72% of high-risk patients (recipient positive patients). CMV end-organ disease was observed in eight patients (1%); of these, four were CMV RT-PCR negative at the time of diagnosis of end-organ CMV disease, with three remaining negative throughout the course of the disease. CMV-related mortality was recorded in three patients. The current data support a preemptive treatment strategy-based CMV RT-PCR, but indicate that in symptomatic patients, a negative CMV PCR result does not exclude CMV end-organ disease.

Follicular dendritic cell sarcoma: a rare tumor presenting as an abdominal mass.

Follicular dendritic cell (FDC) sarcoma is a rare and probably even underreported entity. Only approximately some 50 cases have been described in the literature, the majority of which had a lymph node origin. The authors report a case of FDC sarcoma arising within the soft tissues of the abdominal cavity. As FDC markers are often not routinely included in antibody panels, awareness of this sarcoma is important, as it can be confused with other tumors, especially when occurring extranodally.

Comparative genomic hybridisation of ductal carcinoma in situ of the breast: identification of regions of DNA amplification and deletion in common with invasive breast carcinoma.

Comparative genomic hybridisation has been used to map copy number changes in nine cases of ductal carcinoma in situ of the breast obtained from wax-embedded archive material. A wide variety of abnormalities were detected including gain of regions of 1q, 17q, 19q, 20p and 20q and loss on 13q, 14q, 17p, 16q and 22q. Amplification of areas on 10p, 8q and 20q were also observed. Chromosomal alterations were more frequent in higher grade DCIS and closely resemble those previously detected in invasive breast cancer using the same technique. These data provide strong molecular support for the view that DCIS is a precursor lesion of invasive breast carcinoma.

Pseudomyxoma peritonei: unusual origin from an ovarian mature cystic teratoma.

Pseudomyxoma peritonei (PMP) is classified into pathologically and prognostically distinct categories, such as disseminated peritoneal adenomucinosis (DPAM) and peritoneal mucinous carcinomatosis. There is overwhelming evidence that DPAM arises from a mucinous adenoma of the appendix. The one exception to this is the presentation of a mature ovarian cystic teratoma as PMP where the appendix is normal. This report describes such a case and discusses the presentation, histopathology, and treatment options.

Structural abnormalities of the X chromosome in non-Hodgkin's lymphoma.

It has recently been reported that additional X chromosomes occur in over 30% of B-cell non-Hodgkin's lymphomas (NHL), and that monosomy of the X chromosome occurs in 38% of female patients with T-cell leukaemia or lymphoma. These observations have suggested a possible role for the X chromosome in the evolution of NHL. We have now examined 280 cases of NHL, and have identified 19 examples of structurally altered X chromosomes in the malignant cells from 17 of these cases. These abnormalities were mainly characterized by either a translocation involving Xp22, or a translocation/deletion involving Xq28. The relevance of these observations is discussed with respect to other published reports, and together they suggest that lymphoma-associated oncogenes may exist on the X chromosome at bands p22 or q28.

Regressed cutaneous malignant melanoma mimicking lymphoma: a potential diagnostic pitfall.

We report 2 cases of partially regressed malignant melanoma in which the brisk lymphocytic response closely resembled mycosis fungoides in 1 case and nodular sclerosing Hodgkin lymphoma in the other. Striking epidermotropism was present in both cases. The lymphocytes were predominantly of T8 cytotoxic subtype, and oligoclonal T-cell expansion was detected in 1 of the cases. The scanty residual melanoma cells were highlighted with HMB45 and S100 protein. We highlight the features of regression in melanoma that may lead to an erroneous diagnosis of lymphoma and discuss the finding of oligoclonal T-cell expansion in regressed melanocytic lesions.

Malignant melanoma showing ganglioneuroblastic differentiation: report of a unique case.

We report a case of metastatic malignant melanoma in an inguinal lymph node, expressing ganglioneuroblastic differentiation. This was characterized by the presence of discrete nests and islands of large ganglion cells with abundant cytoplasm and eccentric nuclei with prominent nucleoli admixed with smaller primitive neuroblasts. The cells were separated by pale pink fibrillar material representing neuritic cell processes. These foci of ganglioneuroblastoma were seen over a background of an otherwise typical metastatic epithelioid, focally melanotic, malignant melanoma. Immunohistochemistry showed positivity for neurofilament, synaptophysin, chromogranin, vasoactive intestinal peptide, and glial fibrillary acidic protein in the areas with ganglioneuroblastic differentiation, but not in the melanocytic component. Conversely, HMB45 positivity was expressed by the melanocytic cells only. S-100 protein and Melan-A, a putative melanocytic marker, showed positivity in both melanocytic and ganglioneuroblastic components. Ultrastructurally, neuritic cell processes and dense core neurosecretory granules were identified in the ganglionic and neuroblastic cells. A subsequent nodal metastasis in the same region showed focal neuroblastic differentiation without the ganglionic element. No evidence of neuronal or ganglionic differentiation was seen in the primary skin melanoma.

Adenocarcinoma of the rete testis.

Adenocarcinoma of the rete testis is a rare testicular tumour, which often presents late, with metastatic disease present in a significant proportion of patients. We record the clinicopathological findings in a man who presented with an apparently localized testicular tumour. He however went on to develop a rapidly progressive local recurrence and metastatic disease, despite primary radiotherapy. Detailed immunohistochemical examination was performed and we record positivity of this tumour for the recently developed markers HBME1 and thrombomodulin.

Basement-membrane-related peri-vascular matrices not organised as a basal lamina: distribution in malignant tumours and benign lesions.

Peri-vascular matrices having a finely textured granular substructure have been identified in 27 human lesions: these were mostly malignancies but included benign tumours and reactive processes. The matrices were defined as stromal components surrounding endothelium and pericytes, and lying between vessels and adjacent lesional cells. They were identified as having a finely textured, uniform and moderately dense substructure, and differed from a conventional basal lamina expected at these sites by the absence of the typical lamina densa/lamina lucida configuration. By light microscope immunohistochemistry, vessels stained positively for laminin and collagen IV, two of the main proteins characterising a conventional basal lamina. The present observations emphasise the following. 1) The proteins laminin and collagen IV can be found in peri-vascular locations which have a finely textured granular substructure, and which have clearly defined ultrastructural differences from a conventional basal lamina. 2) While conventional light microscope immunohistochemistry demonstrates the presence and cellular location of proteins, electron microscopy is helpful for giving information on their physical organisation. 3) Peri-vascular granular matrices have a widespread distribution in malignant tumours but also exist in benign tumours and reactive lesions. This paper briefly discusses the possible functions of these matrices as modulators of cell biological processes.

Detection of viral infection by immunofluorescence in formalin-fixed tissues, pretreated with trypsin.

The presence of viral antigen in sections from formalin-fixed and paraffin-embedded human tissues was demonstrated by trypsin digestion followed by direct or indirect immunofluorescence. The specimens may be used for retrospective diagnosis. The immunofluorescence technique has to be adapted to the suspected virus infection on the basis of previous histopathologic study. Variations of trypsin concentration time and temperature of incubation, expose different viral antigens and have to be previously tested for each unknown system. For measles virus detection in lung a stronger digestion has to be applied as compared to adenovirus or respiratory disease viruses in the same tissue. Flavivirus in liver tissue needs a weaker digestion. The reproducibility of the method makes it useful as a routine technique in diagnosis of virus infection.

Metastatic carcinoma of uncertain primary site: a retrospective review of 57 patients treated with vincristine, doxorubicin, cyclophosphamide (VAC) or VAC alternating with cisplatin and etoposide (VAC/PE).

BACKGROUND: Metastatic carcinoma of uncertain primary site (CUPS) is a common problem and has a poor prognosis. The intention of this study was to determine whether the addition of cisplatin and etoposide (PE) to vincristine, doxorubicin and cyclophosphamide (VAC) chemotherapy improves outcome. METHODS: Fifty-seven consecutive patients with an initial diagnosis of CUPS were studied. The first 40 patients had received six or 10 cycles of VAC and 17 patients VAC alternating with PE for six cycles. Review of histology using immunohistochemical techniques where appropriate was performed in all cases. RESULTS: Histologic review resulted in six tumors reclassified as non-Hodgkin's lymphoma (NHL), one as hepatocarcinoma, and one as adenocarcinoma. Six of the 11 responses occurred in patients with a review diagnosis of NHL. If the six cases of NHL and the case of hepatocarcinoma were excluded, there was no difference in survival between VAC and VAC/PE treated patients. Five patients with true CUPS who responded to VAC or VAC/PE had poorly differentiated histology, and this group (n = 24) also had a significantly longer survival. CONCLUSIONS: Some patients thought to have CUPS actually have NHL, and it is this group which responds well to chemotherapy. True CUPS patients respond to chemotherapy only if the tumor is poorly differentiated; survival is significantly longer for this group of patients. An advantage for VAC/PE over VAC chemotherapy was not identified.

Follicular lymphoid hyperplasia of the hard palate and oral mucosa: report of three cases and a review of the literature.

AIMS: To bring to wider attention this uncommon, poorly understood entity which may closely resemble, clinically and morphologically, follicular lymphoma. METHODS AND RESULTS: We report three cases of follicular lymphoid hyperplasia of the hard palate and oral mucosa which caused diagnostic difficulties for the referring pathologists. The clinicopathological features are described and integrated into a review of the 16 previously recorded cases. The condition most commonly presents as a slowly growing mass situated in the posterior hard palate but may present with multicentric oral lesions and lymphadenopathy. Morphologically, it is characterized by a dense follicular lymphoid infiltrate within the lamina propria which may show the classical features of benign reactive hyperplasia, but not uncommonly, indistinct germinal centres, ill-defined mantles and a lack of tingible-body macrophages are features which may lead to an erroneous diagnosis of follicular lymphoma. CONCLUSIONS: Follicular lymphoid hyperplasia of the palate is a poorly recognized entity which is frequently confused with follicular lymphoma. Awareness of the entity combined with the use of immunohistochemistry for immunoglobulin light chains and bcl-2 protein allows a correct diagnosis to be made avoiding extensive investigation and aggressive treatment to the patient.

Histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease): continuing diagnostic difficulties.

AIMS: To describe the clinicopathological and immunophenotypic features of 25 cases of Kikuchi-Fujimoto disease (K-F), which remains a poorly recognized entity and is still frequently confused with malignant lymphoma, and to discuss the main diagnostic problems experienced by the referring pathologist. METHODS AND RESULTS: Haematoxylin and eosin sections of 27 lymph node biopsies were re-examined. Immunostains for B-lymphocytes, T-lymphocytes and macrophages were performed. Clinical and follow-up data were obtained through a questionnaire to the referring pathologist or from the patients' notes where available. The suggested initial diagnoses are discussed. The lymph nodes showed a necrotizing process characterized by patchy or confluent areas of necrosis associated with karyorrhexis and absence or paucity of granulocytes. This was associated with a proliferation of large blastic cells consisting of a mixture of T-lymphocytes and histiocytes. Fragmentation of the biopsy was a frequent feature. The diagnosis of K-F was suggested by the referring pathologist in three cases only. The most common suggested diagnosis was that of a non-Hodgkin's lymphoma. CONCLUSION: This series documents continuing difficulties in the diagnosis of Kikuchi-Fujimoto disease in the UK and emphasizes that cases are still being mistakenly diagnosed as malignant lymphomas. The diagnosis of Kikuchi-Fujimoto disease merits active consideration in any nodal biopsy showing fragmentation, necrosis and karyorrhexis, especially in young women presenting with cervical lymphadenopathy.

Mutation of the TP53 gene and allelic imbalance at chromosome 17p13 in ductal carcinoma in situ.

A panel of 36 cases of preinvasive breast lesions, including 35 cases of ductal carcinoma in situ (DCIS), has been examined for mutation of TP53, allelic imbalance (AI) on 17p13, and expression of TP53, in a number of cases, has been studied using immunohistochemistry. Areas of DCIS, with or without adjacent invasive or benign cells, have been separately microdissected from paraffin-embedded sections and analysed by PCR for genetic changes to chromosome 17p13. TP53 mutations and AI on 17p have been identified in cases of 'pure' DCIS as well as those with associated invasive carcinoma and, furthermore, have been identified in well-differentiated lesions as well as poorly differentiated ones.

Allelic imbalance in the region of the BRCA1 gene in ductal carcinoma in situ of the breast.

Thirty-four cases of ductal carcinoma in situ (DCIS) of the breast, with or without associated benign or invasive disease, were analysed for allelic imbalance (AI) in the region of the BRCA1 gene. AI on 17q12-23 in DCIS was demonstrated in 74% of cases, and in the majority of cases the region of AI included the BRCA1 gene. However, two cases showed AI distal to BRCA1, supporting the presence of a second tumour-suppressor gene on 17q.

Deletion of a common region on the long arm of chromosome 6 in acute lymphoblastic leukaemia.

We have characterised a region of deletion on the long arm of chromosome 6 (6q) in six cases of acute lymphoblastic leukaemia, by fluorescence in situ hybridisation, using a series of YAC clones which map to 6q. Conventional cytogenetic analysis of four of these cases had been interpreted as showing terminal deletions of 6q. We demonstrated by FISH that in all cases the deletions were interstitial. D6S246 (6q16.3) was the only marker which was missing in all six cases, indicating a common region of deletion between the markers M6P1 at 6q14-15 and FYN at 6q21. Our results suggest the presence of a tumour suppressor gene within this interval.

Common region of deletion on the long arm of chromosome 6 in non-Hodgkin's lymphoma and acute lymphoblastic leukaemia.

We have used fluorescence in situ hybridisation (FISH) with a series of yeast artificial chromosome (YAC) clones that map to the long arm of chromosome 6 (6q) to define the region(s) of deletion in seven cases of non-Hodgkin's lymphoma (NHL), in which a deletion of 6q had been detected by conventional cytogenetics. The FISH analysis detected two regions of deletion: (i) A proximal region flanked by M6P1 (6q14-15) and FYN (6q21), containing D6S246, which was missing in all seven cases. This locus was also found to be deleted in all six cases of acute lymphoblastic leukaemia (ALL) studied previously. (ii) A second region of 6q, which was distal to 6q23.1 (D6S238) and included ESR (6q25.1) and D6S281 (6q27), which was shown to be present in all our cases of ALL, was found to be deleted in 4 of the 7 cases of NHL. Our results support the suggestion that tumour suppressor genes, involved in the pathogenesis of lymphoid malignancies, may be present within these regions.