Clinical relevance of DNA ploidy and proliferative activity in childhood rhabdomyosarcoma: a retrospective analysis of patients enrolled onto the Italian Cooperative Rhabdomyosarcoma Study RMS88.

PURPOSE: Evaluation of the possible clinical relevance of DNA ploidy and proliferative activity assessed as S-phase fraction (SPF) in childhood rhabdomyosarcoma (RMS). PATIENTS AND METHODS: We conducted a retrospective study on 59 RMS patients enrolled onto the ICS-RMS88 protocol (seven botryoid, 35 embryonal, and 17 alveolar RMS), for which formalin-fixed paraffin-embedded (FFPE) tissue was available. Nuclear suspensions for cytometric investigation were obtained using a mechanical disaggregation. Tumors were distinguished according to their DNA index (DI) value as follows: diploid (0.9 < DI < 1.1), hyperdiploid (1.1 < or = DI < 1.8 or DI > or = 2.2), and tetraploid (1.8 < or = DI < 2.2); for analysis of SPF, a cutoff value of 14% was used. RESULTS: DNA histograms were diploid in 19 (33%) cases, hyperdiploid in 29 (49%), and tetraploid in 10 (32%). One patient showed both a hyperdiploid and a tetraploid peak. The 5-year overall survival (OS) rate by ploidy status was 73% in hyperdiploid patients as compared with 33% and 25% in diploid and tetraploid patients, respectively (P = .0012). A striking difference emerged when the 5-year OS for the combined diploid and tetraploid RMS groups was compared with survival of the hyperdiploid RMS group: 30% versus 73%, respectively (P = .0006). In addition, the SPF was prognostically relevant: 5-year OS by SPF less than or greater than 14% was 70% and 36%, respectively (P = .009). Multivariate analysis confirmed the importance of DNA content (P = .0006) and SPF (P = .034) in predicting survival. CONCLUSION: These findings confirm that ploidy and SPF are important new prognostic factors that are able to identify selected groups of patients at high risk of treatment failure, even if the tumor's presentation is favorable according to standard criteria.

Plexiform fibromyxoma of the gallbladder.

We report the unusual case of a plexiform fibromyxoma, occasionally assessed in a lithiasic gallbladder. The full thickness assessment of the gallbladder wall revealed an intra-mural, well demarked multi-nodular tumor (1 cm), consisting of a plexiform growth of spindle cells, included within a fibromyxoid stroma with a rich micro-vascular network. The tumor cells featured no nuclear atypia, nor mitotic activity. At the immunohistochemical profiling, the spindle shaped cells unequivocally featured vimentin, SMA, HHF35, collagen IV, and CD34; no cells expressed CD117, PDGFRA, CD10, desmin, GFAP, EMA, and S-100. Faint STAT6 nuclear expression was observed in isolated tumor cells. The molecular profiling did not revealed any CKIT and PDGFRA genes mutations. The uncommon site of the tumor presentation and its aberrant CD34 expression both confer to the reported case a unique place among the myxoid tumors of the gastrointestinal tract.

p53 alterations but no human papillomavirus infection in preinvasive and advanced squamous esophageal cancer in Italy.

Geographic differences in exposure to suspected carcinogens have been identified in esophageal carcinogenesis, and both p53 alterations and human papillomavirus (HPV) infection have been reported in esophageal squamous carcinoma (ESC) from high-risk areas, including China and South Africa. The status of p53 alterations and HPV infection in ESC has not been determined in northern Italy, where the incidence of ESC is low. Formalin-fixed paraffin-embedded esophageal samples containing normal, dysplastic, and carcinomatous tissue from 18 patients were examined for p53 protein accumulation with immunohistochemistry, p53 mutation (exons 5-8) with PCR-single-strand conformation polymorphism analysis and DNA sequencing, and HPV infection with PCR using general primers to amplify the L1 gene. Accumulation of p53 protein was observed in both precancerous and carcinomatous lesions. p53 mutations were rare in dysplastic lesions but were detected in 9 of 18 carcinomas, a finding consistent with reports from other geographic areas. Examination of the p53 mutation spectrum revealed no hot spot mutation. In contrast, HPV was not found in any of these 18 cases. This is consistent with the findings from other low ESC risk areas in which HPV infection may not play a crucial role in esophageal oncogenesis, whereas the high risk of ESC in China and South Africa may be attributed to frequent HPV infection.

Nuclear p53 protein expression in resected hepatic metastases from colorectal cancer: an independent prognostic factor of survival.

An association has been reported between nuclear p53 protein expression in tumour cells and a poor outcome in patients with colorectal cancer (CRC). In this study we investigated the prognostic significance of nuclear p53 protein expression in CRC liver metastases after curative hepatic resection. The study population consisted of 69 consecutive patients who underwent curative hepatic resection for metastases from CRC at our Institution between February 1987 and October 1993. Immunohistochemical expression of p53 protein was evaluated in formalin-fixed paraffin-embedded sections of CRC liver metastases using the monoclonal antibodies (MAbs) D01 and Pab 1801. The Cox proportional hazards model was used in forward stepwise regression to assess the relative influence of different prognostic factors. Forty-four (63.8%) CRC liver metastases were p53-positive. Kaplan-Meier survival curves demonstrated that patients with p53-positive metastases had a median survival of 27 months versus 93 months for patients with p53-negative metastases (P < 0.01). The 3 and 5 years survival rates were 31.5 and 21.0% in patients with p53-positive metastases and 71.8 and 53.1% in patients with p53-negative metastases. At multivariate analysis p53 protein status was the single best predictor of survival (P = 0.0079); the odds ratio of death among patients with p53-positive tumours was 2.53. Nuclear p53 protein expression in hepatic metastases from CRC is an independent prognostic factor of survival following liver resection. These findings may be of clinical importance in the selection of patients more likely to benefit from liver resection and could be used as criteria for stratification in trials on adjuvant therapy.

Primary carcinoid tumor of the cystic and common bile ducts.

We report a case of primary carcinoid tumor arising at the confluence of the cystic and common bile ducts. The patient was a 64-year-old woman who developed a sudden onset of biliary colic and jaundice. Computerized tomography and nuclear magnetic resonance showed a mass lesion close to the head of the pancreas. At laparotomy a nodular lesion was found at the confluence of the cystic and common bile ducts. Microscopic observation revealed a type B-C carcinoid (Soga's classification) with positive immunoreactivity to chromogranin and cytokeratin. The presence of neurosecretory intracytoplasmic granules was demonstrated by electron microscopy. Flow cytometry showed diploid DNA content of the neoplastic cells with less than 5% of the nuclei in the S-phase region.

p53 overexpression in the multistep process of esophageal carcinogenesis.

The timing of p53 mutation in the multistep process of esophageal carcinogenesis is still under debate. We tested p53 expression in 16 samples of low-grade and 29 samples of high-grade esophageal dysplasia (ED) coexisting with esophageal squamous cancer (ESC) in 31 patients who underwent total esophagectomy. In normal mucosa, a positive immunoreaction was detected in 10 of 31 cases, always restricted to the lower half of the epithelial thickness. We detected p53-positive nuclei in 11 of 16, 23 of 29, and 23 of 31 samples of low-grade ED, high-grade ED, and ESC, respectively. Cases exhibiting positive staining in dysplastic samples also demonstrated positive immunoreaction in the carcinomatous tissue. Immunoreactivity in cancer cells was never found in the absence of positive dysplastic nuclei. A significantly higher score of immunoreactive nuclei was detected in high-grade versus low-grade and in low-grade compared with normal mucosa. These data suggest that p53 mutation may represent an early event in esophageal oncogenesis.

Spindle cell rhabdomyosarcoma. A prognostically favorable variant of rhabdomyosarcoma.

Twenty-one cases of embryonal rhabdomyosarcoma, composed mainly of elongated spindle cells arranged in a fasciculated or storiform pattern, were retrieved from the files of the German-Italian Cooperative Soft Tissue Sarcoma Study. The term spindle cell rhabdomyosarcoma is proposed to designate this histotype. Spindle cell rhabdomyosarcoma predilected male patients (18 males, three females) and involved mostly the paratesticular area (12 cases) and the head and neck region (six cases). Histologically, all cases were characterized by a uniform proliferation of elongated spindle cells with eosinophilic and fibrillar cytoplasm mimicking smooth muscle fibers; immunocytochemical studies disclosed high expression of the muscle markers titin, desmin, and myoglobin. Clinical information was available in 17 cases; according to the Intergroup Rhabdomyosarcoma Study (IRS) grouping system, 13 were classified in group I, two in group II, and two in group III. Sixteen patients were well and alive 24 to 100 months after diagnosis; one patient died from disease progression 24 months after diagnosis. Analysis of our results determined that spindle cell rhabdomyosarcoma constitutes a rare variant of the embryonal form, showing a high degree of skeletal muscle differentiation and a low malignant potential; it should therefore be distinguished from classical forms of embryonal rhabdomyosarcoma.

Hepatitis B virus antigens in primary hepatic carcinoma: immunofluorescent techniques on fixed liver tissue.

The presence of hepatitis B surface (HBsAg) and core (HBcAg) antigens was investigated by immunofluorescence in specimens of liver tissue obtained at necrospy in 107 patients with primary hepatic carcinoma. HBsAg was detected in the cytoplasm of liver cells in 16 cases, and in eight of them the antigen was also found in malignant cells. HBcAg, which was present in the nuclei of liver cells in eight cases, was detected in the nuclei of tumour cells in six of these and also in two other cases showing HBsAg, but not HBcAg, in the nonneoplastic tissue. Although most of the primary hepatic carcinomas studied were associated with cirrhotic changes in the non-neoplastic tissue, HBsAg and HBcAg were also detected in the absence of underlying cirrhosis. Hepatitis B virus markers were demonstrated in non-neoplastic tissue, mainly in patients with a well-differentiated carcinoma, and only in these cases were they found also in the neoplastic tissue. These results show that hepatitis B virus antigens, including HBcAg, can be detected in the neoplastic cells of well-differentiated carcinoma of the liver. Although these cells could have been infected after the malignant transformation, a direct oncogenic role of the virus cannot be excluded.

A mesenchymal chondrosarcoma of a child with the reciprocal translocation (11;22)(q24;q12).

The reciprocal translocation (11;22)(q24;q12) was observed in a seven day culture from a mesenchymal chondrosarcoma of the bone, a tumor not characterized cytogenetically so far. We suggest that because of the presence of a similar cytogenetic abnormality, mesenchymal chondrosarcoma may belong to the wide group of "t(11;22)-small round cell tumors".

Management of primary sarcomas of the retroperitoneum.

We here report on our 10-year experience of surgery in 25 patients with primary retroperitoneal sarcoma and make an appraisal of the more effective available clinical approach. Ten patients had leiomyosarcoma, eight liposarcoma, and seven had other tumor types. Histological grading was G1 in seven patients, G2 in six patients and G3 in 12. Ten patients (40%) underwent wide tumor excision, five (20%) marginal excision, four (16%) partial excision and six (24%) wedge biopsy at laparotomy. Adjacent organ resection was required in 10 of the 15 patients who underwent wide or marginal resection, seven of whom had adjuvant chemoradiotherapy. After wide resection, local recurrences were observed in 2/10 patients; the 10-year survival rate was 33%. Three out of five patients who underwent marginal resection had local recurrences; one is alive 10 years after surgery and chemo-radiotherapy. Histological grading was the most important prognostic factor. Radical resection is the only effective available treatment for retroperitoneal sarcomas, and patients with low-grade tumors benefit most from it with respect to survival and local recurrence rate. The efficacy of adjuvant treatment has yet to be clarified.

Proliferating cell nuclear antigen (PCNA) and recurrence in patients with cutaneous melanoma.

A positive correlation between PCNA and the most important histoprognostic factors of cutaneous melanoma has been demonstrated. The aim of our work was to evaluate the efficacy of PCNA in predicting melanoma recurrence and to compare it with that of Breslow thickness. One-hundred and fifteen patients (75 women, 40 men; mean age 50 years) with primary cutaneous melanoma were retrieved. pTNM stages were as follows: stage I, 54 patients; stage II, 31 patients; stage III, 26 patients; and stage IV, four patients. The mean follow-up period was 55 months (range 2-260). Six patients developed lymph node metastases and 28 developed distant metastases; 27 patients died within 2-202 months from diagnosis. Tumour thickness was re-evaluated for each case. PCNA immunostaining was performed using the avidin-biotin complex method and the percentage of PCNA-positive tumour cells was indicated as the PCNA index. In order to evaluate and compare the PCNA index and Breslow thickness as predictors of recurrence, the receiver-operating characteristic (ROC) curve method, based on true-positive and false-positive rates was used. The PCNA index showed the highest true-positive rates and the lowest false-positive rates in the 5-30 interval. The PCNA index optimal cut-off is 20, characterized by 70% sensitivity and 80% specificity; Breslow thickness optimal cut-off is 3.5 mm, with 40% sensitivity and 90% specificity. Our results indicate that the PCNA index has a higher efficacy in predicting locoregional and distant recurrences in patients presenting primary cutaneous melanoma.

Small-cell carcinoma of gallbladder. An immunocytochemical and ultrastructural study.

An unusual carcinoma of the gallbladder in a seventy-one-year-old woman displayed features of a well-differentiated adenocarcinoma, atypical carcinoid and small cell undifferentiated carcinoma. The patient died from progressive hepatic failure four months after surgery. Autopsy showed bulky liver masses and several peritoneal nodules exclusively composed of small, hyperchromatic cells. The neuroendocrine nature of the small cell component of the tumor was documented by the presence of neurosecretory granules at the ultrastructural level and by immunocytochemical positivity to NSE and Synaptophysin. The epithelial markers, cytokeratin and CEA, were also positive in the carcinoid and in the undifferentiated portions of the tumor. A common endodermal origin is suggested for carcinoid and small cell carcinoma of the gallbladder.

Telomerase activity, Ki-67, cyclin D1 and A expression, and apoptosis in solitary fibrous tumors: additional features of a predictable course?

Solitary fibrous tumors (SFTs) are infrequent soft tissue neoplasms which are usually benign and surgically curable. However, their behavior is not always predictable, although several clinical and pathological criteria of malignancy have been established. In many cancers, including some soft tissue tumors, telomerase activity (TA) has been shown to be a new reliable pathological marker of malignancy. Overexpression of some cyclins is associated with higher degrees of malignancy and predictive of the clinical course. In this study, we evaluated TA, mitotic and apoptotic indices (MI, AI), and the expression of Ki-67, cyclins D1 and A in five typical and two clinicopathologically atypical SFTs, the latter two of which had also recurred. High TA was demonstrated in the two atypical cases, which also showed a higher labeling index to Ki-67, as well as higher cyclin D1 and A expression, and either none or very few apoptoses. We suggest that TA, Ki-67, cyclin expression, and AI be evaluated in SFTs as possible adjunctive pathological criteria of behavior.

Clear cell tumors of the somatic soft tissues.

The prototypic soft tissue tumor showing "clear" cytoplasmic features is the so-called clear cell sarcoma or malignant melanoma of soft parts, a tumor characterized by immunophenotypic and ultrastructural melanogenic differentiation and specific cytogenetic and molecular abnormalities, ie, t(12;22)(q13;q12) translocation and Ewing's sarcoma oncogene/activating transcription factor 1 rearrangement. A number of other malignant soft tissue tumors occasionally show cytoplasmic clarity, including epithelioid leiomyosarcomas, malignant peripheral nerve sheath tumors, and sclerosing fibrosarcomas, as well as metastatic carcinomas and malignant melanomas. These tumors are discussed in relation to their differential diagnosis with clear cell sarcomas.

Soft tissue small round cell tumors: morphological parameters.

Soft tissue small round cell tumors (SRCTs) comprise a heterogeneous group of neoplasms that predominate in childhood and adolescence and share similar morphological features, consisting of dense cellular proliferation of small round cells with a primitive appearance. Rhabdomyosarcomas, peripheral neuroepitheliomas, Ewing's sarcomas, and lymphomas/leukemias are the prototypic SRCT; other recently described tumors that should be added to the list are the desmoplastic SRCT and the rhabdoid tumor of soft tissues. In addition, several other primary soft tissue neoplasms and metastatic tumors have occasionally been considered in the differential diagnosis of SRCT. The precise identification of a given SRCT is important because of its clinical relevance. However, it may be difficult because the diagnostic criteria are sometimes subtle and several histologic and immunohistochemical features are not specific and/or may be simulated by different tumor types. We discuss the morphological clues that in our opinion are most useful for their diagnosis, the criteria for distinguishing between peripheral neuroepithelioma and Ewing's sarcoma, and the main diagnostic pitfalls.

Tumors of the soft tissues composed of large eosinophilic cells.

Soft tissue neoplasms composed of large eosinophilic cells include benign and malignant tumors with different degrees of biological aggressiveness. The main histotypes discussed in this review are the heterogeneous group of benign and malignant granular cell tumors with neural and non-neural differentiation, alveolar soft part sarcomas, rhabdomyomas, and rhabdomyosarcomas. The salient anatomic, clinical, morphological, and immunophenotypic features in differential diagnosis with metastatic melanomas, carcinomas, and paragangliomas are discussed separately for each histotype.

Parafollicular C-cell hyperplasia. Report of three cases in primary thyroid lymphomas.

Three cases of C-cell hyperplasia were observed in a series of 21 cases of primary thyroid lymphoma (PTL). The association is not well understood, since PTL is not included in the group of thyroid diseases which are known to cause C-cell hyperplasia. It may be interpreted as a compensatory reaction to diffuse and rapid destruction of most of the gland, or a "stimulation" related to the production of "bio-humoral" factors by neoplastic cells.

Histological evaluation of thyroid carcinomas: reproducibility of the "WHO" classification.

AIMS AND BACKGROUND: Thyroid carcinomas display several pathologic features, show different behavior and necessitate different treatment; thus correct classification is mandatory. METHODS: The kappa statistic was used as a measure of agreement in a panel of seven pathologists who reviewed 200 cases of thyroid tumors. RESULTS: Overall agreement was 83% (k = 68). Good agreement was found for anaplastic (k = 0.85) and papillary carcinomas (k = 0.81); agreement for medullary carcinoma was acceptable (k = 0.80), suboptimal for other (k = 0.67), and poor for follicular carcinoma (k = 0.54). CONCLUSIONS: Central pathology review of thyroid carcinomas is recommended when clinical and epidemiologic trials are planned.

Plasma cell granuloma of the lung (inflammatory pseudotumor).

A case of plasma cell granuloma (PCG) of the lung in a 54-year old man is reported. PCG is a rare benign lesion that usually presents as a solitary nodule in the lung (coin lesion) at routine X-ray examination. Microscopically it consists of a granulomatous tissue where the major components are mature plasma cells. The immunohistochemical demonstration of polyclonality of plasma cells, excluding the diagnosis of plasmacytoma, confirms the inflammatory pseudotumoral nature of this lesion, although the etiology remains obscure. The presence of lymphocytes, histiocytes, macrophages, blood vessels with prominent endothelial cells and peripheral sclero-hyalinized connective tissue may pose problems in the differential diagnosis with sclerosing hemangioma, pseudolymphoma, nodular amyloidosis, pulmonary hyalinizing granuloma, chronic abscess and neoplasms of true histiocytic origin. The term inflammatory pseudotumor is preferable in describing this type of lesion.