Variable presence of KITD816V in clonal haematological non-mast cell lineage diseases associated with systemic mastocytosis (SM-AHNMD).

In a substantial number of patients with systemic mastocytosis (SM), an associated clonal haematological non-mast cell lineage disease (AHNMD) is detectable. Although most of these patients display KIT mutations, especially KIT(D816V), little is known about their exact frequency and their distribution in AHNMD subtypes. We examined 48 patients with SM-AHNMD for the presence of mutant KIT in the SM and AHNMD components of the disease. Mast cells and AHNMD cells were obtained from immunostained bone marrow sections by laser microdissection and examined by melting point analysis of nested-PCR products. KIT(D816V) was found in AHNMD cells in the vast majority of patients with SM-chronic myelomonocytic leukaemia (CMML, 89%). Unexpectedly, KIT(D816V) was far less frequently detectable in AHNMD cells in patients with SM-myeloproliferative neoplasm (MPN, 20%) and SM-acute myeloid leukaemia (AML, 30%). None of the patients with lymphoproliferative AHNMDs displayed KIT codon 816 mutations in AHNMD cells (0/8). In FIP1L1/PDGFRA-positive chronic eosinophilic leukaemia (CEL), neither the SM nor the CEL component of the disease exhibited the KIT mutation. Our findings demonstrate that KIT codon 816 mutations are variably present in AHNMD cells in patients with SM-AHNMD, depending on the subtype of AHNMD. The high frequency of KIT(D816V) in neoplastic mast cells and leukaemic myelomonocytic cells in SM-CMML may point to a common precursor in these patients, and may have implications for the biology of the disease and the development of KIT-targeting therapies.

Predictors of outcome in patients with suspected myocarditis.

BACKGROUND: The objective of this study was to identify the prognostic indicators in patients with suspected myocarditis who underwent endomyocardial biopsy. METHODS AND RESULTS: Between 1994 and 2007, 181 consecutive patients (age, 42+/-15 years) with clinically suspected viral myocarditis were enrolled and followed up for a mean of 59+/-42 months. Endomyocardial biopsies were studied for inflammation with histological (Dallas) and immunohistological criteria. Virus genome was detected by polymerase chain reaction. The primary end point was time to cardiac death or heart transplantation. In 38% of the patients (n=69), the Dallas criteria were positive. Immunohistological signs of inflammation were shown in 50% (n=91). Genomes of cardiotropic virus species were detected in 79 patients (44%). During follow-up, 22% of the patients (n=40) reached the primary end point. Three independent predictors were identified for the primary end point, namely New York Heart Association class III or IV at entry (hazard ratio, 3.20; 95% confidence interval, 1.36 to 7.57; P=0.008), immunohistological evidence of inflammatory infiltrates in the myocardium (hazard ratio, 3.46; 95% confidence interval, 1.39 to 8.62; P=0.008), and beta-blocker therapy (hazard ratio, 0.43; 95% confidence interval, 0.21 to 0.91; P=0.027). Ejection fraction, left ventricular end-diastolic pressure, and left ventricular end-diastolic dimension index were predictive only in univariate, not in multivariate, analysis. Neither the Dallas criteria nor the detection of viral genome was a predictor of outcome. CONCLUSIONS: For patients with suspected myocarditis, advanced New York Heart Association functional class, immunohistological signs of inflammation, and lack of beta-blocker therapy, but not histology (positive Dallas criteria) or viral genome detection, are related to poor outcome.

Systemic mastocytosis associated with chronic idiopathic myelofibrosis: a distinct subtype of systemic mastocytosis associated with a [corrected] clonal hematological non-mast [corrected] cell lineage disorder carrying the activating point mutations KITD816V and JAK2V617F.

In approximately 20 to 30% of patients with systemic mastocytosis (SM), an associated clonal hematological nonmast cell lineage disorder (AHNMD) is diagnosed. Although SM may be considered to be closely related to the myeloproliferative disorders (MPDs), it is unknown whether JAK2(V617F+) MPD may occur as AHNMD in patients with SM. We here describe five patients with SM and co-existing chronic idiopathic myelofibrosis (SM-CIMF). In five of five patients, we detected the SM-related KIT mutation D816V, and in four of five patients, the MPD-related JAK2 mutation V617F. Surprisingly, JAK2(V617F) was found not only in the AHNMD component of the disease but also in microdissected mast cells in all four JAK2(V617F)-positive cases. Conversely, in two of the five patients, KIT(D816V) was found not only in neoplastic mast cells but also in microdissected CD15(+) neoplastic myeloid cells. Control experiments showed that 10 indolent SM patients without associated MPD did not carry the JAK2 mutation V617F and that 15 CIMF patients without SM did not carry the KIT mutation D816V. Altogether, these data suggest that KIT(D816V+) SM can co-exist with JAK2(V617F+) CIMF and that, in some of these SM-CIMF cases, the two mutations are present in the neoplastic cells of both disease components.

Inter-laboratory validation of PCR-based HPV detection in pathology specimens.

The detection and typing of human papilloma virus (HPV) in pathology specimens is gaining increasingly in importance. In the context of the initiative for quality assurance in pathology (QuIP) of the German Society of Pathology and the Professional Association of German Pathologists, four panel laboratories with experience and expertise in polymerase chain reaction (PCR)-based HPV detection were selected to establish an inter-laboratory trial. In a first step, these laboratories performed an internal testing of their own methodologies, which comprised DNA sequencing, multiplex nested PCR and hybridization techniques. Material from 39 samples including paraffin sections and DNA preparations of tissues and plasmids were evaluated by each panel institute according to their own protocols. Despite the different methodologies, a high degree of inter-laboratory reliability was achieved. In this report, we summarise the results. Pretested specimens are available for the external trail and can be ordered from the steering institute via provitro GmbH Berlin ( http://www.provitro.de ). Supplementary data are online available at http://pathologie-ccm.charite.de (rubric "Forschung"), which includes a web-based photo gallery of HPV-associated lesions and their potential association with specific virus types. The initiative is intended to foster the quality assurance of molecular HPV analysis in pathology and its correlation with morphological changes.

Sudden death after pancreatic head resection: rupture of hepatic artery caused by clostridial infection.

BACKGROUND: Rupture of the hepatic artery caused by clostridial infection has not been reported before. METHODS: Case report and literature review. RESULTS: A 75 year-old man was admitted to the hospital for resection of a cystic tumor of the head of the pancreas. A pylorus-preserving radical pancreaticoduodenectomy was performed. On the fifth postoperative day, he developed fever (38.2 degrees C), and computed tomography scanning revealed free air in the subhepatic area near the pancreaticojejunal anastomosis. On the ninth postoperative day, the patient died suddenly. Autopsy revealed a ruptured hepatic artery secondary to clostridial infection. CONCLUSIONS: Close monitoring and early recourse to invasive diagnostic and therapeutic procedures may be advisable in the presence of suspect findings after pancreatic surgery to prevent this fatal complication.

Detection of c-kit point mutation Asp-816 --> Val in microdissected pooled single mast cells and leukemic cells in a patient with systemic mastocytosis and concomitant chronic myelomonocytic leukemia.

The c-kit mutation Asp-816-->Val is detectable not only in neoplastic mast cells (MCs) in patients with systemic mastocytosis (SM) but also in most associated hematologic non-MC lineage disease (AHNMD). In order to prove a monoclonal disease evolution we investigated DNA of pooled microdissected single cells for the presence of the mutation in a patient with SM and concomitant chronic myelomonocytic leukemia (CMML). LightCycler melting curve analysis and direct sequencing of nested polymerase chain reaction (PCR) products revealed the c-kit mutation in tryptase-positive MC and in leukemic CD15-positive cells in bone marrow infiltrates, but not in colonic epithelial cells, thus, suggesting a monoclonal evolution of SM and concurrent CMML on the basis of a somatic mutation in a common hematologic progenitor.

Fatal parvovirus B19-associated myocarditis clinically mimicking ischemic heart disease: an endothelial cell-mediated disease.

We report the case of a 34-year-old female patient who died 4 days after hospital admission of acute heart failure clinically mimicking ischemic heart disease. Microscopic examination of the heart showed severe myocarditis. Polymerase chain reaction (PCR), including quantitative real-time PCR, disclosed exclusively parvovirus B19 (PVB19), with a high viral load of 4.3x10(5) PVB19 viral genome equivalents per microg myocardial nucleic acid. Radioactive in situ hybridization detected viral genomes in endothelial cells (ECs) predominantly in the venular compartment and (to a lesser degree) in small arteries and arterioles of the heart, but not in cardiac myocytes or other tissue components. Concomitant with EC infection, marked expression of the adhesion molecule E-selectin was noted, accompanied by margination, adherence, penetration, and perivascular infiltration of T lymphocytes. We speculate that, due to the high viral load in cardiac ECs, PVB19 infection of endothelial cells was sufficient to induce impaired coronary microcirculation with secondary cardiac myocyte necrosis.

Parvovirus B19: a pathogen responsible for more than hematologic disorders.

The clinical and pathomorphological patterns of parvovirus B19 (PVB19)-associated diseases is the result of a balance between virus, host target cells and immune response. It is a characteristic feature of PVB19 that in patients with various other preexisting diseases, e.g., many hemolytic anemias, immune complex-mediated vasculitic disorders, and primary or secondary immunodeficiencies, the underlying diseases can be triggered, aggravated or complicated by severe organ manifestations. Identification of PVB19 by means of routine histology and immunohistology is only given in lytic infections occurring in transient aplastic anemia or nonimmune hydrops fetalis by the detection of viral inclusion bodies in erythroid precursor cells. In all other PVB19-associated diseases, molecular pathological methods must be applied. In this report, quantitative real-time polymerase chain reaction was used to determine the viral load in formalin-fixed and paraffin-embedded tissues derived from various organs. Using in situ hybridization it was demonstrated that endothelial cells of the microcirculatory periphery of the heart and hepatobiliar system in lytic infections are PVB19-specific target cells in children and adults. Because treatment of lytic PVB19 infection has been successfully applied, the pathologist should be alerted to include PVB19 into the diagnostic spectrum of viral disease, especially in immunocompromised patients.

Resolved hypersensitivity myocarditis after ventricular circulatory assist.

Hypersensitivity myocarditis is known to be a cardiac manifestation of a delayed-type hypersensitivity response caused by drug treatment. In heart transplantation candidates the incidence is elevated. We report the case of a patient with end-stage heart failure who underwent implantation of a left ventricular assist device as a bridge to transplantation. The histologic investigation of the left ventricular specimen obtained during device implantation revealed the diagnosis of a hypersensitivity myocarditis. Ten months later this lesion showed complete reversibility within specimens of the explanted heart, maybe as a result of the termination of inotropic therapy after implantation of the left ventricular assist device.

Application of a novel and low cost technique to construct paraffin tissue microarrays out of paraffinised needle biopsy specimens from patients with breast cancer.

BACKGROUND: Paraffin tissue microarrays (TMAs) are a well accepted tool in pathology for high throughput molecular profiling, quality control and clinicopathological trials. No reports on TMAs constructed from paraffinised needle biopsy specimens (PNBSs) derived from patients with breast cancer can be found in the literature. PNBSs are sometimes the only source for tumour characterisation important for treatment. AIM: To develop a novel and low cost technique to construct TMAs from PNBSs (PNBSs-TMAs) in order to close this gap in TMA technology. METHODS: Using a skin biopsy punch, tumour-bearing parts of 84 PNBSs were punched out of the donor blocks, freed from the surrounding paraffin by melting and manually transferred into the preformed holes in the recipient block. After filling the holes, the PNBSs-TMA was fixed to a double sided adhesive tape and completely melted. Quality assessment of this new technique was performed comparing the HER2 status (synonym: cerbB2) of the PNBSs-TMA with the results of the original PNBSs and a TMA harbouring the tumour in corresponding resection and mastectomy specimens (RM-TMA). RESULTS: A 187-hole PNBSs-TMA with 84 PNBSs was successfully constructed. About 1% of the included PNBSs displayed signs of rolling and folding or of floating off the slide during the staining procedure. The results of immunohistochemistry, fluorescence in situ hybridisation and automated brightfield double in situ hybridisation showed high quality standard of the PNBSs-TMA, suitable for precise tumour profiling. CONCLUSIONS: PNBSs-TMAs are suitable for clinicopathological trials, especially those in which PNBSs are the only tumour source.

Reversed pulmonary artery flow in isolated noncompaction of the ventricular myocardium.

OBJECTIVE: To investigate the morphology and genetics of a fetus at 22 weeks. This fetus demonstrated progressive fetal hydrops and cardiomegaly with retrograde flow in the pulmonary artery and progressive myocardial deterioration and heart failure. METHODS: Postmortem examination, light and electron microscopy of the myocardium, karyotyping, fetal DNA analysis, screening for mutations in the G4.5 gene, alpha-dystrobrevin gene, FKBP 12 gene, Desmin, Syntrophin and Cypher/ZASP genes, which have been described as being associated with noncompaction ventricular myocardium, using single-strand DNA conformation polymorphism analysis and DNA sequencing. RESULTS: The morphological diagnosis was compatible with noncompaction ventricular myocardium or spongyforme myopathy. The karyotype was normal. Mutation analysis in exons and introns of all six genes did not show any known mutation. CONCLUSION: Noncompaction ventricular myocardium or spongyforme myopathy may be associated with mutations in genes which have previously not been thought to be associated with this phenotype. Alternatively, this disease could be the result of abnormal cardiac hemodynamics.

High prevalence of viral genomes and inflammation in peripartum cardiomyopathy.

Molecular pathologic investigation of endomyocardial biopsy specimens from 26 patients with peripartum cardiomyopathy revealed viral genomes (parvovirus B19, human herpes virus 6, Epstein-Barr virus, and human cytomegalovirus) in 8 patients (30.7%) that were associated immunohistologically with interstitial inflammation. These findings indicate a high prevalence of virus-associated inflammatory changes in peripartum cardiomyopathy.

Oral anticoagulant treatment: friend or foe in cardiovascular disease?

Calcification is a common complication in cardiovascular disease and may affect both arteries and heart valves. Matrix gamma-carboxyglutamic acid (Gla) protein (MGP) is a potent inhibitor of vascular calcification, the activity of which is regulated by vitamin K. In animal models, vitamin K antagonists (oral anticoagulants [OACs]) were shown to induce arterial calcification. To investigate whether long-term OAC treatment may induce calcification in humans also, we have measured the grade of aortic valve calcification in patients with and without preoperative OAC treatment. OAC-treated subjects were matched with nontreated ones for age, sex, and disease. Calcifications in patients receiving preoperative OAC treatment were significantly (2-fold) larger than in nontreated patients. These observations suggest that OACs, which are widely used for antithrombotic therapy, may induce cardiovascular calcifications as an adverse side effect.

NCAM(CD56) and RUNX1(AML1) are up-regulated in human ischemic cardiomyopathy and a rat model of chronic cardiac ischemia.

Chronic myocardial ischemia is the leading cause of impaired myocardial contractility and heart failure. To identify differentially expressed genes in human ischemic cardiomyopathy (ICM), we constructed a subtracted cDNA library using specimens of ICM compared to normal human heart. Among 100 randomly sequenced clones, seven sequences represented recently identified candidate genes for differential expression in cardiac hypertrophy. A further clone without a known hypertrophy-association coded for the adhesion molecule NCAM(CD56). RNase protection assay, immunohistochemistry, and Western blotting revealed strong overexpression of NCAM(CD56) in all hearts with ICM (n = 14) compared to normal hearts (n = 8), whereas in congestive cardiomyopathy (CCM) (n = 8), hypertrophic obstructive cardiomyopathy (n = 2), myocarditis (n = 4), and sarcoidosis (n = 2), at most slight overexpression of NCAM(CD56) was observed. NCAM(CD56) overexpression abnormally involved the whole cell membrane and the cytoplasma of cardiomyocytes only inside and adjacent to ischemia-induced cardiac scars. Normal or hypertrophic fibers at a distance from ischemic scars were devoid of NCAM overexpression. Identical alterations were observed in an experimental rat ICM model, but not in normal nor in spontaneously hypertensive rat hearts. In search of NCAM(CD56)-related transcription factors we found RUNX1(AML1) up-regulation in ICM and detected RUNX1(AML1) binding within the NCAM(CD56) promoter by electromobility shift assay. We concluded that strong overexpression of NCAM(CD56) and RUNX1(AML1) is a constant and characteristic feature of cardiomyocytes within or adjacent to scars in ICM.

Detection of high-risk human papillomavirus E6 and E7 oncogene transcripts in cervical scrapes by nested RT-polymerase chain reaction.

The oncogenic potential of the high-risk human papillomavirus (HPV) genotypes (types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68) depends on the expression of the two viral oncogenes E6 and E7. Thus, the detection of HPV E6/E7 oncogene transcripts could serve as a factor in the evaluation of a risk of development of cervical intraepithelial neoplasia (CIN) and its progression to cervical cancer. A nested RT-PCR assay for the detection of E6/E7 oncogene transcripts of all known high-risk HPV genotypes was established. In the study described, 779 high-risk HPV-DNA-positive cervical scrapes exhibiting all grades of CIN, including non-dysplastic cervical mucosa (CIN 0), were examined. Spliced E6/E7 oncogene transcripts of all the high-risk HPVs were detected in numerous samples, with an overall detection rate of 47%. In 227 cases with agreement between the cytologic and histologic findings, the prevalence increased with lesion severity: CIN 0, 18%; CIN I, 58%; CIN II, 77%; CIN III, 84%. Multiple transcriptionally active high-risk HPVs were detected in 12% (33/279) of patients with multiple high-risk HPV infections. This work sets the stage for a prospective follow-up study currently being undertaken to evaluate the prognostic relevance of the detection of high-risk HPV E6/E7 oncogene transcripts for the persistence of a high risk HPV infection, and the possible evolution and further development of a CIN. Future applications of the assay described may include the monitoring of women in studies investigating antiviral treatment or vaccination.

One-step detection of c-kit point mutations using peptide nucleic acid-mediated polymerase chain reaction clamping and hybridization probes.

The prognostic significance of somatic activating codon 816 c-kit mutations in pediatric urticaria pigmentosa has not yet been established in detail. Detection of such mutations in archival paraffin-embedded biopsies is usually hampered by an abundance of surrounding normal cells. Here we describe a method for the selective amplification and specific detection of c-kit mutation Asp816-->Val in complete tissue sections cut from up to 24-year-old paraffin blocks. Peptide nucleic acid-mediated polymerase chain reaction clamping of the wild-type allele was combined with on-line mutation detection using oligonucleotide hybridization probes. In DNA extracted from HMC-1 cells heterozygously carrying the c-kit mutation Asp816-->Val, the one-tube assay allowed specific detection of this mutation in a more than 1000-fold excess of normal background DNA within 1 hour and without the need for additional analytical steps. In a series of 38 cases with pediatric urticaria pigmentosa we detected c-kit codons 815 and 816 mutations in 16 cases. Mutation detection did not correlate with clinical outcome after a mean follow-up of 11.2 years. In conclusion, the procedure described may represent an ideal screening tool for all kinds of clinical applications, using point mutations as markers of, for example, early events in carcinogenesis, circulating metastatic tumor cells, and minimal residual disease.