Ovarian Granulocytic Sarcoma with Central Nervous System Involvement

The authors describe 2 cases of acute myeloid leukemia (AML) with ovarian granulocytic sarcoma (GS) and central nervous system (CNS) involvement. The patients had an unfavorable clinical course in a short period of time. It has been reported that GS or CNS involvement does not have a bad prognostic significance. We suggest that the association of these two complications worsens the prognosis of AML.

Human equilibrative nucleoside transporter 1 and carcinoma of the ampulla of Vater: expression differences in tumour histotypes

The human equilibrative nucleoside transporter 1 (hENT1) is the major means by which gemcitabine enters human cells; recent evidence exists that hENT1 is expressed in carcinoma of the ampulla of Vater and that it should be considered as a molecular prognostic marker for patients with resected ampullary cancer. Aim of the present study is to evaluate the variations of hENT1 expression in ampullary carcinomas and to correlate such variations with histological subtypes and clinicopathological parameters. Forty-one ampullary carcinomas were histologically classified into intestinal, pancreaticobiliary and unusual types. hENT1 and Ki67 expression were evaluated by immunohistochemistry, and apoptotic cells were identified by the terminal deoxynucleotidyl transferase mediated deoxyuridine triphosphate biotin nick end labelling (TUNEL) method. hENT1 overexpression was detected in 63.4% ampullary carcinomas. A significant difference in terms of hENT1 and Ki67 expression was found between intestinal vs. pancreaticobiliary types (P=0.03 and P=0.009 respectively). Moreover, a significant statistical positive correlation was found between apoptotic and proliferative Index (P=0.036), while no significant correlation was found between hENT1 and apoptosis. Our results on hENT1 expression suggest that classification of ampullary carcinoma by morphological subtypes may represent an additional tool in prospective clinical trials aimed at examining treatment efficacy; in addition, data obtained from Ki67 and TUNEL suggest a key role of hENT1 in tumour growth of ampullary carcinoma.

Effect of ursodeoxycholic acid on inflammatory infiltrate in gallbladder muscle of cholesterol gallstone patients

BACKGROUND

Reduced gallbladder (GB) contractility and chronic inflammatory changes in the mucosa have been reported in patients with cholesterol gallstones (GS). Ursodeoxycholic acid (UDCA) restores GB contractility and antagonises liver macrophage activation. In the colon, hydrophobic bile acid, not hydrophilic UDCA, induces mast cell degranulation. We studied the presence of monocyte/macrophage infiltrate, cyclooxygenase (COX)-2, inducible nitric oxide synthase (iNOS) expression, the number of total and degranulated mast cells in the GB muscle layer of cholesterol GS patients, and the effect of UDCA administration.

METHODS

Gallbladder tissue was obtained from cholesterol GS patients, either treated or untreated with UDCA (10 mg kg(-1) day(-1)) for 30 days prior to surgery. Gallbladders removed for neoplastic diseases, not involving GB, were evaluated for control purposes. The presence of monocytes/macrophages (CD68 positive), granulocytes, and mast cells, and the COX-2 and iNOS expression, was determined immunohistochemically.

KEY RESULTS

The number of CD68, granulocytes, mast cells, COX-2 and iNOS positive cells was significantly higher in the muscle layer of GS patients than in controls. Compared to untreated patients, those treated with UDCA showed significantly lower levels of CD68, COX-2 positive cells and degranulated mast cells and a lesser number of iNOS positive cells and granulocytes.

CONCLUSIONS & INFERENCES

An inflammatory monocyte/macrophage, mast cell and granulocyte infiltrate is present in the GB muscle layer of GS patients. Ursodeoxycholic acid decreases macrophages, degranulated mast cells and COX-2 expression. These results suggest that monocytes/macrophages and degranulating mast cells contribute to muscle cell dysfunction in cholesterol GS patients and support the anti-inflammatory effect of UDCA.

Human equilibrative nucleoside transporter 1 (hENT1) protein is associated with short survival in resected ampullary cancer

BACKGROUND

Gemcitabine is an acceptable alternative to best supportive care in the treatment of advanced biliary tract cancers. The human equilibrative nucleoside transporter 1 (hENT1) is a ubiquitous protein and is the major means by which gemcitabine enters human cells. Moreover, recent reports indicate a significant correlation between immunohistochemical variations of hENT1 in tumor samples and survival after gemcitabine therapy in patients with solid tumors.

MATERIALS AND METHODS

We used immunohistochemistry to assess the abundance and distribution of hENT1 in tumor samples from radically resected cancer of the ampulla, and sought correlations between immunohistochemical results and clinical parameters including disease outcomes.

RESULTS

In the 41 individual tumors studied, 12 (29.3%) had uniformly high hENT1 immunostaining. Statistical analysis showed a significant correlation between hENT1 and Ki-67 (P = 0.04). No statistical significant differences were found between immunohistochemical findings and patient characteristics (sex, age, and tumor-node-metastasis). On univariate analysis, hENT1 and Ki-67 expression were associated with overall survival (OS). Specifically, those patients with overexpression of hENT1 showed a shorter OS (P = 0.022) and those with high Ki-67 staining showed a shorter survival (P = 0.05).

CONCLUSIONS

hENT1 expression is a molecular prognostic marker for patients with resected ampullary cancer and holds promise as a predictive factor to assist in chemotherapy decisions.

Characteristics at haematoxylin and eosin staining of ruptures of the long head of the biceps tendon

OBJECTIVE

To examine the relative prevalence of histological changes that have been found to be associated with the process of tendinopathy in lesions of the tendon of the long head of the biceps brachii and to evaluate the reliability of histopathological evaluation of tendon tissue in lesions of the tendon of the long head of the biceps.

DESIGN

Tendon samples were taken from 51 patients (31 men, 20 women; mean age 63.2 years) who underwent arthroscopic release of the long head of the biceps tendon because of refractory biceps tendinopathy and from 5 male patients who died of cardiovascular events (mean age 69.6 years). Histological examination was performed using haematoxylin and eosin staining of sections, which were interpreted using a semiquantitative grading scale assessing fibre structure and arrangement, rounding of the nuclei, regional variations in cellularity, increased vascularity, decreased collagen staining and hyalinisation.

RESULTS

The mean (SD) pathological sum score of ruptured tendons was greater than that of control tendons (15.76 (3.11) vs 3.4 (1.9), p<0.001). Within each specific category of tendon abnormalities, the chi(2) test showed significant differences between the control and ruptured tendons; all the variables were significantly different (Mann-Whitney U test 0.05, p<0.001). Using the kappa statistic, the agreement between the two readings ranged from 0.53 to 0.85.

CONCLUSIONS

Unruptured tendons of the long head of the biceps, even at an advanced age and ruptured tendons of the long head of the biceps are clearly part of two distinct populations.

COX-2 expression in lobular in situ neoplasia of the breast: correlation with histopathological grading system according to the Tavassoli classification

AIMS

There is considerable evidence to link cyclooxygenase (COX)-2 to the development of cancer. The aim of this study was to assess COX-2 expression and its subcellular localization in lobular in situ neoplasia (LIN) of the breast and to verify differences in COX-2 expression between different grades of lesions according to the Tavassoli classification.

METHODS AND RESULTS

We analysed the expression of COX-2 protein by immunohistochemistry in tissue samples of 51 LIN lesions classified into three grades according to the Tavassoli classification. COX-2 immunostaining was observed in 78.4% of LIN samples and showed a prevalent membranous rather than cytoplasmic pattern. COX-2 was expressed in 16/17 (94.1%) LIN1, 22/25 (88%) LIN2 and 2/9 (22.2%) LIN3. As regards COX-2 expression, a statistically significant difference was found between LIN1 and LIN3 (P = 0.001) and between LIN2 and LIN3 (P =0.001). No difference was found between LIN1 and LIN2. Moreover, a significant negative correlation was found between LIN grade and COX-2 expression (P < 0.0001).

CONCLUSIONS

COX-2 is highly expressed in LIN, supporting a role for this protein in the early stage of breast carcinogenesis, representing the rationale for using COX-2 selective inhibitors in the earliest stages of breast cancer.

Dilated intercellular spaces and acid reflux at the distal and proximal oesophagus in patients with non-erosive gastro-oesophageal reflux disease

BACKGROUND

Acid exposure of proximal oesophagus and dilated intercellular space diameters of oesophageal epithelium are relevant in the perception of gastro-oesophageal reflux.

AIM

To explain the relationship between gastro-oesophageal reflux disease symptoms, acid exposure and intercellular space diameter along the oesophageal epithelium and to assess time-related variability of intercellular space diameter.

METHODS

Thirty-three non-erosive reflux disease (NERD), six erosive oesophagitis patients and 12 asymptomatic controls underwent oesophageal manometry and 24-h dual-channel oesophageal pH-monitoring following endoscopy. Biopsies were taken 5 cm above the LES and 10 cm below the UES, at comparable levels, as pH sensors. A total of 100 intercellular space diameters per patient/control were measured blindly at transmission electron microscopy. In 15 patients, the investigation was repeated after 1 year.

RESULTS

In all NERD patients, acid exposure was higher at mid-proximal oesophagus (P < 0.01) and mean intercellular space diameters, at distal and mid-proximal oesophagus, was three- and twofold higher (1.5 and 0.82 micro m, respectively) compared with controls. Intra-patient intercellular space diameter values were stable over time, not overlapping with those of controls.

CONCLUSIONS

Dilation of intercellular space diameter occurs along the distal and proximal oesophageal epithelium in NERD patients and could be responsible for the enhanced perception of proximal acid reflux. This finding appears to be time-reproducible and to represent a sensitive, histopathological marker of NERD.

Tumor regression in mesorectal lymphnodes after neoadjuvant chemoradiation for rectal cancer

AIMS

The histological modification produced by neoadjuvant chemoradiation on primary rectal cancer has been investigated by many authors, and a prognostic value of tumor regression grade (TRG) has been identified. Tumor regression grade on metastatic mesorectal lymphnodes has been never evaluated. The purpose of this study is to analyse the TRG on mesorectal lymphnodes (lymphnode regression grade, LRG) after preoperative chemoradiation in rectal cancer patients and to determine the correlation with TRG of primary tumor.

METHODS

Surgical specimens from 35 patients who underwent chemoradiation were included. LRG on mesorectal lymphnodes was assessed by immunohistochemistry. Response to treatment was evaluated by a 5-point LRG based on the ratio of residual tumor to fibrosis.

RESULTS

Complete pathologic response (LRG 1) was observed in 18 patients (51%). In 4 patients (11%) no regression was observed (LRG 5). In 4 cases only reactive lymphnodes were found. LRG on lymphnodes significantly correlated with TRG on primary tumor (p<0.05).

CONCLUSIONS

Neoadjuvant chemoradiation determines a tumor regression on mesorectal lymphnodes as on primary tumor; further studies are needed to evaluate the prognostic value of LRG.

Subcellular shift of the hepatic growth hormone receptor with progression of hepatitis C virus-related chronic liver disease

AIMS

To evaluate the cytoplasmic and nuclear expression of hepatic growth hormone receptor (GHR) in different stages (S0, S1, S3 and S4, according to Knodell's classification) of chronic liver disease (CLD) and in hepatocellular carcinoma (HCC).

METHODS AND RESULTS

Liver specimens from 31 patients with hepatitis C virus-related CLD, five patients with HCC and nine controls were examined for expression of hepatic GHR by immunohistochemistry with MAb 263. Cytoplasmic and nuclear staining were evaluated as a percentage of positively stained cells. The cytoplasmic expression of GHR was comparable between normal liver and S0 hepatitis, while it progressively decreased in S1, S3 and S4 CLD (P < 0.01). Conversely, nuclear GHR showed increased expression in S3 and S4 CLD (P < 0.05). No differences were observed between HCC and normal liver in terms of GHR immunoreactivity.

CONCLUSIONS

This is the first study to show that the subcellular expression of hepatic GHR changes with the progression of CLD. The increase in nuclear expression of GHR with advanced stages of CLD suggests that GH may act directly at the nuclear level to promote hepatocyte proliferation/regeneration.

Complementary use of local excision and transanal endoscopic microsurgery for rectal cancer after neoadjuvant chemoradiation

BACKGROUND

Neoadjuvant therapies have significantly improved local control and survival of patients with rectal cancer. Nevertheless, although a complete pathologic response can be achieved in 30% of cases, a transabdominal surgical resection is always required. This study aimed, for the first time, to test in the literature the feasibility of local excision combined with transanal endoscopic microsurgery (TEM) as a surgical option for patients treated with neoadjuvant chemoradiation.

METHODS

Between July 1997 and December 2002, 30 patients with rectal cancer affected by an extraperitoneal tumor entered a protocol consisting of neoadjuvant chemoradiation followed by surgery. The surgical treatment, consisting of open surgery, local excision, or TEM, was planned according to the patient's clinical response after chemoradiation and distance from the anal verge.

RESULTS

A significant clinical downstaging was observed in eight patients. Five of these patients underwent TEM, and three had local excision. Consequently, open surgery was performed for 22 patients. Histology showed six cases of complete pathologic response: three in the open surgery group and three in the transanal excision group. After a mean follow-up period of 47 months, the disease-free survival rate was 77% in the open surgery group and 100% in TEM or local excision group.

CONCLUSIONS

The findings suggest the complementary feasibility of TEM and local excision after neoadjuvant chemoradiation. However, randomized trials are needed to confirm the oncologic safety of this approach.

Cetuximab and irinotecan as third-line therapy in advanced colorectal cancer patients: a single centre phase II trial

The epidermal growth factor receptor (EGFR), which participates in signalling pathways that are deregulated in cancer cells, is frequently mutated in colorectal-cancer cells. Cetuximab is a monoclonal antibody that specifically blocks the EGFR. We evaluated the efficacy of cetuximab in weekly combination with irinotecan in metastatic colorectal cancer patients refractory to previous treatments based on oxaliplatin or irinotecan. We included 55 heavily pretreated patients (colon/rectum: 34/11, M/F: 16/29, median age 63 years, range: 27–79) whose disease had progressed during or within an oxaliplatin-based first-line chemotherapy and a irinotecan-based second-line regimen. Patients were followed for tumour response and were also evaluated for the time to tumour progression, and safety of treatment. Cetuximab was given at an initial dose of 400 mg m⁻², followed by weekly infusions of 250 mg m⁻². Irinotecan was administered weekly at the dose of 90 mg m⁻². All patients were assessable for treatment efficacy and safety response rate was 25.4% (95% CI: 21.7–39.6%); 38.2% (95 CI: 18.6–39.8%) of patients showed a disease stability as the best response. As a consequence, the overall tumour control rate was 63.6% (95% CI: 46.4–70.6%). The median time to progression was 4.7 months (95% CI: 2.5–7.1 months) and the median survival time was 9.8 months (95% CI: 3.9–10.1 months). The most common G3-4 noncutaneous side toxicities were: diarrhoea (16.4%), fatigue (12.7%) and stomatitis (7.3%). 89.1% of patients developed skin toxicity and 32.6% of cases was of grade 3–4. No allergic reactions were identified at any courses in any patients. Fever was documented in 27.3% of patients and was most commonly recorded after the first administration. Cetuximab has clinically significant activity even in heavily pretreated colorectal cancer patients progressed after both oxaliplatin and irinotecan-based chemotherapy regimens.

Expression and heterodimer-binding activity of Ku70 and Ku80 in human non-melanoma skin cancer

BACKGROUND

Experimental data suggest that exposure to ultraviolet radiation may indirectly induce DNA double-strand breaks.

AIM

To investigate the contribution of the non-homologous end-joining repair pathway in basal and squamous cell carcinomas.

METHODS

Levels of Ku70 and Ku80 proteins were determined by immunohistochemical analysis and Ku70-Ku80 heterodimer-binding activity by electrophoretic mobility shift assay. Matched pathological normal margins and skin from healthy people were used as controls.

RESULTS

A significant increase in Ku70 and Ku80 protein levels was found for both tumour types as compared with normal skin (p<0.001). Squamous cell carcinoma showed increased immunostaining as compared with basal cell tumours (p<0.02). A direct correlation was found between Ku70 and Ku80 protein levels and expression of the proliferation markers Ki-67/MIB-1 (p<0.02 and p<0.002, respectively) in basal cell carcinoma. DNA binding activity was increased in basal cell carcinoma samples as compared with matched skin histopathologically negative for cancer (p<0.006). In squamous cell carcinomas, however, the difference was significant only with normal skin (p<0.02) and not with matched pathologically normal margins.

CONCLUSIONS

Overall, an up regulation of the Ku70 and Ku80 protein levels seems to correlate only with tumour proliferation rate. As non-homologous end joining is an error-prone mechanism, its up regulation may ultimately increase genomic instability, contributing to tumour progression.

COX-2 expression in ampullary carcinoma: correlation with angiogenesis process and clinicopathological variables

BACKGROUND

There is evidence that the anti-neoplastic effect of non-steroidal anti-inflammatory drugs is attributable to cyclooxygenase-2 (COX-2) inhibition, but the exact mechanisms whereby COX-2 can promote tumour cell growth remain unclear. One hypothesis is the stimulation of tumour angiogenesis by the products of COX-2 activity. To data, there have been few clinicopathological studies on COX-2 expression in human ampullary carcinoma and no data have been reported about its relation with tumour angiogenesis.

OBJECTIVE

To investigate by immunohistochemistry the expression of COX-2 and the angiogenesis process in a series of primary untreated ampullary carcinomas.

METHODS

Tissue samples from 40 archival ampullary carcinomas were analysed for COX-2, vascular endothelial growth factor (VEGF), and an endothelial cell marker von Willebrand factor (vWF) by immunohistochemistry, using specific antibodies.

RESULTS

COX-2 expression was detected in 39 tissue samples (97.5%), of which two (5%) were graded as weak, 26 (65%) as moderate, and 11 (27.5%) as strong. Only one lesion (2.5%) was negative for COX-2 expression. VEGF expression was detected in 36 tissue samples (90%). A significant positive correlation was found between COX-2 and VEGF expression. No statistic correlation was found between COX-2 expression and microvessel density.

CONCLUSIONS

COX-2 is highly expressed in ampullary carcinomas. This suggests an involvement of the COX-2 pathway in ampullary tumour associated angiogenesis, providing a rationale for targeting COX-2 in the treatment of ampullary cancer.

Tumour proliferation, angiogenesis, and ploidy status in human colon cancer

AIMS

Tumour angiogenesis is essential for carcinogenesis and facilitates the process of tumour development and metastasis. Vascular endothelial growth factor (VEGF) is a well characterised angiogenetic factor and is known to play a crucial role in new vessel development. To gain further insight into the effects of microvessel density and VEGF expression in colon cancer, their relation with tumour proliferation, ploidy status, and p53 expression was investigated in colon cancer.

METHODS

Tissue samples of 50 archived colon cancers were analysed by immunohistochemistry for VEGF, p53, and the endothelial cell marker, von Willebrand factor (VWF), using specific antibodies. The same samples were re-cut for flow cytometric studies to obtain S phase fraction (SPF) and ploidy status.

RESULTS

A positive significant correlation was found between SPF and angiogenesis. The median microvessel count in high SPF tumours was significantly higher than in low SPF ones. No association was found between VEGF expression and SPF. A positive correlation was found between ploidy status and p53 expression and microvessel count. Furthermore, a positive correlation was established between DNA ploidy, VEGF expression, and microvessel count.

CONCLUSION

This study provides evidence that in colon cancer, tumour growth may be stimulated by vascular supply, and the lack of a correlation between tumour cell proliferation and VEGF expression indicates that these two parameters may be regulated by separate mechanisms. Furthermore, the positive correlation between microvessel density, VEGF expression, and ploidy status provides more evidence that genetic alterations are involved in tumour angiogenesis.

Cutaneous lymphoadenoma: a rare clinicopathological entity

Cutaneous Lymphadenoma (Benign Lymphoepithelial tumour of the skin) is a rare tumour, with distinctive clinical and histological features. To date, very few cases of this entity have been reported. We present a case of cutaneous lymphoadenoma in a 52-year-old man and a short review of the literature, summarizing the principal clinical and morphological characteristics of this rare tumour.

A rare case of solitary fibrous tumour of the pre-sacral space: morphological and immunohistochemical features

A 28-year-old woman presented with abdominal pain. Ultrasonograhic examination showed a pre-sacral mass, with complex structure and well delimitated cystss with thick walls. The resected specimen was 7.5 x 6 x 4 cm in size, well circumscribed and yellow in colour, with cysstic change containing mucoid-like material. Histologically, the lesion was composed of spindle cells with high cellularity and rich vascularization with a haemangiopericytoma-like pattern. The diagnosis of solitary fibrous tumour (SFT) was made. The differential diagnosis for SFT of the pre-sacral spaace involves haemangiopericytoma, GIST, malignant mesothelioma, synovial sarcoma, leiomyomatous tumours and granulosa cell tumour. Immunohistochemical studies revealed reactivity for CD34, CD99 and Bcl-2, but no staining for desmin, inhibin, c-kit, EMA, CK, SMA, S-100 and CD31, confirming a diagnosis of SFT. Although SFT is usually associated with a favourable prognosis, close follow-up is recommended because of the limited information on its long-term behaviour.

COX-2 expression in DCIS: correlation with VEGF, HER-2/neu, prognostic molecular markers and clinicopathological features

AIMS

There is considerable evidence that links COX-2 to the development of cancer. The aim of our study was to assess, by immunohistochemistry, COX-2 expression in ductal carcinoma in situ (DCIS) and its possible correlation with HER-2/neu, vascular endothelial growth factor (VEGF) expression and other common immunohistochemical parameters (p53, ER, PGR, Ki67).

METHODS AND RESULTS

Tissue samples of 49 archival cases of DCIS without any invasive component were analysed for COX-2, HER-2/neu, VEGF, oestrogen and progesterone receptors, Ki67 and p53 by immunohistochemistry using specific antibodies. COX-2 expression was detected in 43 (87.8%) tissue samples, of which 12 (24.5%) were graded as weak, 22 (44.9%) as moderate and nine (8.4%) as high expression. Only six (12.2%) lesions were negative for COX-2 expression. VEGF expression was detected in 93.8% of samples; 66.7% of lesions were found to be positive for HER-2/neu expression. Furthermore, COX-2 expression was significantly correlated with VEGF expression (P = 0.003). A significant positive correlation was also observed between COX-2 and HER-2/neu expression (P < 0.0001).

CONCLUSIONS

Our results suggest that COX-2 is highly expressed in DCIS and takes part in the molecular pathway implicated in progression of breast cancer and may provide a rationale for targeting COX-2 in preinvasive breast cancer therapy.

[Xanthogranulomatous pyelonephritis and renal carcinoma. Report of a clinical case and review of the literature]

Xanthogranulomatous pyelonephritis is a rare disease of the kidney; renal parenchyma is replaced by lesions radiologically simulating clear cell carcinoma. We present a case of a 62-year-old diabetic woman observed at our institution for the appearance of back pain and dysuria. A CT scan revealed a large lesion of left kidney with psoas muscle infiltration and the patient undrwent a nephrectomy. Histology surprisingly showed a xanthogranulomatous pyelonephritis. Though recent reports demonstrated the feasibility of conservative management of XGP with antibiotics, the use of pre-operative biopsy is still limited by the risk of seeding and the high false-negative results. How to distinguish xanthogranulomatous pyelonephritis from renal cancer?

[Pancreatic tumor: unusual onset of Von-Hippel Lindau syndrome]

The Von-Hippel Lindau (VHL) disease is a rare genetically determined syndrome. Clinical course depends on the occurrence of multiple tumors as central nervous system tumors, phaeochromocytoma and renal cell carcinoma. We describe the second case in the literature reporting about a patient affected by a pancreatic neuroendocrine tumor as the first clinical sign of VHL disease. It has been showed that only a strict follow-up can effectively improve survival. Based on the present case, the follow-up of patients affected by VHL syndrome should routinely include functional tests and imaging exams of the pancreas.

Correlation of p53 and bcl-2 expression with vascular endothelial growth factor (VEGF), microvessel density (MVD) and clinico-pathological features in colon cancer

This study was designed to elucidate the possible relationship between tumour related genes and angiogenesis in colon cancer. The protein expression of p53, bcl-2, Von Willebrand factor and vascular endothelial growth factor (VEGF) were analysed by immunohistochemistry in 57 paraffin-embedded colon cancer. The results showed that microvessel density (MVD) was lower in VEGF negative tumours than in VEGF positive ones (P<0.0001). MVD and VEGF in p53 negative tumours were significantly lower than in p53 positive tumours (respectively, P=0.003 and P<0.0001). Moreover, positive correlations were recorded between VEGF expression and MVD, and bcl-2 expression (respectively, P<0.0001 and P=0.009). Our data confirm the central role of VEGF in angiogenesis and suggest direct correlations among p53, bcl-2 and VEGF expression in colon cancer.

Prognostic impact of VEGF, CD31, CD34, and CD105 expression and tumour vessel invasion after radical surgery for IB-IIA non-small cell lung cancer

AIMS

To evaluate the prognostic impact of tumour angiogenesis assessed by vascular endothelial growth factor (VEGF), microvessel density (MVD), and tumour vessel invasion in patients who had undergone radical resection for stage IB-IIA non-small cell lung cancer (NSCLC).

METHODS

Fifty one patients (42 men, nine women; mean age, 62.3 years; SD, 6.9) undergoing complete surgical resection (35 lobectomy, 16 pneumonectomy) of pathological stage IB (n = 43) and IIA (n = 8) NSCLC were evaluated retrospectively. No patient underwent postoperative chemotherapy or neoadjuvant treatment. Tumour specimens were stained for VEGF and specific MVD markers: CD31, CD34, and CD105.

RESULTS

VEGF expression significantly correlated with high CD105 expression (p < 0.0001) and tumour vessel invasion (p = 0.04). Univariate analysis showed that those patients with VEGF overexpression (p = 0.0029), high MVD by CD34 (p = 0.0081), high MVD by CD105 (p = 0.0261), and tumour vessel invasion (p = 0.0245) have a shorter overall survival. Furthermore, multivariate Cox regression analysis showed that MVD by CD34 (p = 0.007), tumour vessel invasion (p = 0.024), and VEGF expression (p = 0.042) were significant predictive factors for overall survival. Finally, the presence of both risk factors, tumour vessel invasion and MVD by CD34, was highly predictive of poor outcome (odds ratio, 3.4; 95% confidence interval, 1.7 to 6.5; p = 0.0002).

CONCLUSIONS

High MVD by CD34 and tumour vessel invasion are more closely related to poor survival than the other neoangiogenetic factors in stage IB-IIA NSCLC. This may be because these factors are more closely related to the metastatic process.

Detection of mitochondrial DNA mutations in primary breast cancer and fine-needle aspirates

To determine the frequency and distribution of mitochondrial DNA mutations in breast cancer, 18 primary breast tumors were analyzed by direct sequencing. Twelve somatic mutations not present in matched lymphocytes and normal breast tissues were detected in 11 of the tumors screened (61%). Of these mutations, five (42%) were deletions or insertions in a homopolymeric C-stretch between nucleotides 303-315 (D310) within the D-loop. The remaining seven mutations (58%) were single-base substitutions in the coding (ND1, ND4, ND5, and cytochrome b genes) or noncoding regions (D-loop) of the mitochondrial genome. In three cases (25%), the mutations detected in coding regions led to amino acid substitutions in the protein sequence. We then screened an additional 46 primary breast tumors with a rapid PCR-based assay to identify poly-C alterations in D310, and we found seven more cancers with alterations. Using D310 mutations as clonal marker, we detected identical changes in five of five matched fine-needle aspirates and in four of four metastases-positive lymph nodes. The high frequency of D310 alterations in primary breast cancer combined with the high sensitivity of the PCR-based assays provides a new molecular tool for cancer detection.

Huge response to letrozole in inoperable T4 breast cancer: a case report

A 73 years-old woman presented with locally advanced breast cancer (cT4b cN1 M0, stage IIIB) and atrial flutter. Because of the arrhythmia, chemotherapy or tamoxifen, although malignancy was hormone-sensitive, were discarded. Letrozole was started. Two months later, the breast nodule and skin ulceration cleared up. Surgery was performed. Nowadays, 24 months later, patient does fine, continuing letrozole as adjuvant treatment.

Biovularity and "coalescence of primary follicles" in ovaries with mature teratomas

Several theories have been postulated regarding the origin of ovarian teratomas, including incomplete twinning, neoplastic proliferation of sequestered totipotent blastomeres or primordial cells, derepression of totipotent genetic information in the nuclei of somatic cells, and parthenogenetic development of germ cells. At present parthenogenetic development of ova is the most widely accepted theory, primarily because of the presence of a 46 XX karyotype in almost all mature teratomas. However, some authors have raised the possibility of fusion of ova in the mechanism of formation of ovarian teratomas. We report the results of a study on ovarian tissue adjacent to 31 teratomas to assess the frequency of biovularity, which could provide evidence favoring the last theory. On the whole we found biovularity in 26 ovaries of young patients (mean age, 27 years) with variable numbers of biovular follicles ranging from 1 in 4 cases to more than 10 in 2 cases; the number of biovular follicles depended on the quantity of ovarian tissue examined as well as on the total number of ova in the tissue. In multiple occasions 2 ova were included within a single follicle; in 24 ovaries the biovularity was correlated with coalescence of primary follicles characterized morphologically by an ovoid or hourglass-like shape that resulted from cohesion of 2 follicles. As control cases, 30 ovaries of patients with an average age of 28 years were examined (12 removed for endometriosis, 8 for serous cystadenoma, 7 for tubal pregnancy, and 3 for acute salpingo-oophoritis). Only 1 ovary with endometriosis contained a single biovular follicle. The results suggest that ovarian teratoma development may result from fusion of ova in ovaries containing biovularity and phenomena of coalescence of primary follicles.

Tumor specific modulation of KU70/80 DNA binding activity in breast and bladder human tumor biopsies

The Ku70/80 heterodimer is the regulatory subunit of the DNA-dependent protein kinase (DNA-PK) and its DNA-binding activity mediates DNA double-strand breaks repair. Although Ku80 was recently proposed as a caretaker gene involved in the control of genome integrity, no data are available on Ku70/80 DNA-binding activity in human tumors. Heterodimer DNA-binding activity and protein expression were assayed by electrophoretic-mobility-shift-assay (EMSA) and Western blot analysis, in nuclear and cytoplasmic extracts from eight breast, seven bladder primary tumors and three metastatic nodes from breast cancers. Corresponding normal tissues of the same patients were used as controls. Ten out of 15 tumors showed nuclear Ku-binding activity 3-10 times higher than in the normal tissues, irrespective of bladder or breast origin. Conversely, in 5/15 primary tumors and in all the metastatic nodes analysed, nuclear Ku-activity was 1.5-4.5-fold lower than in the corresponding normal tissues. Cytoplasmic heterodimer activity significantly differed between tumor and normal tissues, displaying a 2-10-fold increase in neoplastic tissues. Three different patterns combining both Ku expression and activity with tumor characteristics were identified. In low aggressive breast tumors p70/p80 proteins were expressed in tumor but not in normal tissues. The heterodimer binding-activity matched the protein levels. In non-invasive bladder carcinomas no significant differences in protein expression between tumor and the corresponding normal tissues were found, however heterodimer binding-activity was increased in tumor samples. In breast and bladder tumors, at the advanced stage and in node metastases, the binding activity was strongly reduced in tumor biopsies, however no differences were demonstrated between normal and tumor protein levels. Our results suggest a different modulation of Ku70/80 DNA-binding activity in human neoplastic tissues, possibly related to tumor progression. Findings provide further data on tissue-specific protein expression and post-translational regulation of heterodimer activity.

Atypical case of metastatic undifferentiated prostate carcinoma in a 36 years old man: clinical report and literature review

Prostate carcinoma occurs infrequently in patient less than 50 years old with an incidence of 0.8% to 1.1%. In literature are described less than 20 cases occurred in younger men (< 40 years old). A 36 year-old man with a two-months history of lower back pain, anorexia and loss of weight, showed at clinical examination a mild enlargement of inguinal lymph nodes and right inferior leg and scrotus edema. CT scan demonstrated marked enlargement and fusion of pelvic, inguinal, sacral and periaortic nodes with a pelvic mass that caused local ureterohydronephrosis and obstruction of the urinary flow. X-rays showed osteoblastic metastases. At total body scintigram were observed fixation areas corresponding to lumbar metamers, pelvis, thigh bones, left humeral head, left acromioclavicular articulation and multiple ribs. Tumor markers resulted negative except prostate specific antigen (PSA: 500 mgr/ml) and prostatic acid phosphatase (PAP: 208 U/l); prostate biopsy showed an undifferentiated carcinoma. The patient was submitted to right percutaneous nephrostomy, chemotherapy (PEB, cisplatinum, etoposide and bleomycin for 6 cycles) and ormonotherapy (LHRH analogues) reporting a clinical partial response. After 6 months the disease progressed and was started a second line chemotherapy. After 18 months from diagnosis patient is still alive with progressing disease. Our patient represents, with respect to many features, an original clinical case of prostate carcinoma occurring in young age, for the atypical association of an undifferentiated carcinoma with high levels of PSA and PAP and with osteoblastic-pattern of bone metastases. Further studies would be useful to identify new risk factors for development of prostate cancer in young men in order to achieve early diagnosis.

Early cervical carcinoma: the natural history of lymph node involvement redefined on the basis of thorough parametrectomy and giant section study

BACKGROUND

Although parametrectomy is the most difficult step in the surgical treatment of cervical carcinoma and is the main cause of postoperative complications, little attention has been given to the patterns of parametrial spread.

METHODS

Sixty-nine patients with previously untreated cervical carcinoma (Fédération Internationale de Gynécologie et d'Obstétrique [FIGO] Stage IB1, 49 patients [71%]; Stage IB2, 8 patients [12%]; and Stage IIA, 12 patients [17%]; squamous, 59 patients [86%]; and adenocarcinoma, 10 patients [14%]) underwent radical hysterectomy and pelvic +/- aortic lymphadenectomy. Hysterectomy specimens were processed with the giant section technique. To obtain a thorough three-dimensional assessment of the paracervical tissue, both the superficial and deep layers of the cervicovesical ligament (anterior parametrium) and the uterosacral ligament (posterior parametrium) were separated from the uterus and submitted for pathologic evaluation. After resection of the lateral parametrium with hemoclips, the lympho-fatty tissue remaining around the pudendal vessels was removed carefully and referred to as "the distal part of the lateral parametrium."

RESULTS

When analyzing all the parametria, lymph nodes were present in 64 patients (93%). Clinically undetected parametrial involvement was found by pathologic examination in 15 Stage IB1 patients (31%), 5 Stage IB2 patients (63%), and 7 Stage IIA patients (58%). Metastases were found in the cardinal, cervicovesical, and sacrouterine ligaments and principally were comprised of lymph node and vascular space invasion. Twenty-five patients (36%) had pelvic lymph node metastases whereas concomitant parametrial involvement was observed in all patients. The overall 5-year survival was 91%, being higher for parametria and lymph node negative patients (100%) than for those with lymph node and/or parametrial metastases (78%).

CONCLUSIONS

A three-dimensional pathologic assessment showed that subclinical parametrial spreading of the so-called "early" tumors (Stage IB-IIA) occurred in approximately 30-60% of these patients, and metastasis to the pelvic lymph nodes always was associated with parametrial disease. A better understanding of the patterns of parametrial diffusion will improve knowledge of the natural history of cervical carcinoma and in the future may influence the treatment of these patients. Furthermore, pathologic assessment of cervical carcinoma should be modified to evaluate correctly the parametrial status of each patient. The current routine pathologic evaluation of the parametria makes it very difficult to detect lymph node metastases and tumor emboli.

Clinical experience with recombinant human thyrotrophin (rhTSH) in the management of patients with differentiated thyroid cancer

The purpose of this work was to gain clinical experience with and to identify the optimal conditions for the use of recombinant human TSH (rhTSH, commercially available as Thyrogen) in the management of patients with differentiated thyroid cancer (DTC). The study involved 22 patients for a total of 27 administration cycles of rhTSH, for either diagnostic (in 19 instances) and/or therapeutic purposes (in 8 instances). There were 19 patients with papillary cancer (follicular variant in 4, columnar variant in 1) and 3 patients with follicular cancer (1 Hurtle cell variant). All patients had previously undergone total thyroidectomy and 1-5 cycles of 131I-therapy. Thyrogen was administered i.m. according to the suggested protocol: 0.9 mg i.m. on days 1 and 2, radioiodine on day 3. Peak serum TSH levels between 68-237 microIU/mL were observed after rhTSH administration; these were on average 65% higher, on a patient-by-patient basis, than peak serum TSH observed after conventional withdrawal of thyroxine treatment in 19 patients, while in 3 patients they were 28% lower, but still in the potent stimulation range (86-94 microIU/mL). There was general agreement between imaging results obtained under rhTSH stimulation and those obtained on prior occasions during thyroxine withdrawal, although radioiodine uptake was interpreted as less intense following Thyrogen administration. Of 18 patients undergoing rhTSH administration for diagnostic purposes, 11 patients had a negative radioiodine whole-body scan (WBS) and 7 had a positive WBS. Three of the WBS-negative patients were shown to be actually affected by tumor recurrence, respectively by PET with [18F]FDG (in 2 cases) and by post-131I therapy scan. Serum thyroglobulin (hTg) increased to abnormal levels following rhTSH stimulation in 3/7 of the WBS-positive patients as well as in 1/11 WBS-negative patients. In 3/7 WBS-positive as well as in 3/11 WBS-negative patients, serum hTg progressively rose under rhTSH stimulation, yet still remaining below 3 ng/mL. Post-131I therapy scans following Thyrogen administration showed good radioiodine uptake in 7/8 patients, the single unsuccessful case being most likely due to expansion of the iodine pool because of recent use of an iodinated contrast medium. The overall results show the feasibility and practical advantages of employing rhTSH stimulation in the general clinical setting rather than thyroxine withdrawal in the management of DTC patients. Caution should be raised on the interpretation of the serum hTg response to such potent but short-lived TSH stimulation.

Cervical cancer response to neoadjuvant therapy: MR imaging assessment

PURPOSE

To determine the accuracy of magnetic resonance (MR) imaging in evaluating the invasive cervical carcinoma response to concurrent chemotherapy and radiation therapy.

MATERIALS AND METHODS

MR imaging was performed before and after concurrent chemotherapy and radiation therapy in 18 patients with locally invasive cervical carcinoma. Surgery followed neoadjuvant therapy in all patients. The presence of a lesion, signal intensity, zonal anatomy integrity, vaginal and parametrial invasion, and lymph node enlargement was determined. Posttreatment MR and histopathologic findings were correlated.

RESULTS

Fourteen patients had histopathologic confirmation of MR findings: Twelve had true-negative and two had true-positive findings. (Two had microscopic neoplastic foci beyond the spatial resolution of MR images; these foci do not change surgical treatment planning and probably do not influence prognosis. Therefore, these two patients were considered to have complete response). Four patients had false-positive findings; the hyperintense lesion on posttreatment MR images was due to a tunnel cluster pattern (focal hyperplasia of the endocervical glands with inflammation) in three patients and necrosis in one patient, without any evidence of neoplastic tissue. Thirty-three of 36 parametrial halves and 67 of 72 vaginal fornices were correctly interpreted on posttreatment images. Involvement of three parametrial halves and five fornices was overestimated at MR, because edema or inflammation was not distinguishable from tumor.

CONCLUSION

MR imaging is 78% accurate in evaluation of tumor response; in 22% of patients, however, benign conditions were not distinguishable from tumor.

Management of cervical intraepithelial neoplasia of the uterine cervix: 110 cases treated by cold-knife conization

PURPOSE OF INVESTIGATION

The purpose of this study was to evaluate treatment by cold-knife-conization in women carriers of cervical intraepithelial neoplasia (CIN).

METHODS

The histologic findings of pre-clinical neoplasia of the cervix after conization were compared to the previous findings of cytology, colposcopy and punch-biopsy in 110 women examined between 1985 and 1995. The chi square test (chi2) was used for the statistical analysis.

RESULTS AND CONCLUSIONS

A close correlation is clinically important where complementary roles of these three methods are used to identify lesions suitable for local ablative therapy. The Pap test alone is no longer sufficient for the screening of the pre-cancerous lesion of the cervix and colposcopy is compulsory each time the smear is inadequate or altered. Conization permitted us to single out 13 (11.8%) cases of carcinoma. After cold-knife conization we had six (5.4%) recurrences within two years and two (1.8%) within three years. Our data show that conservative therapy by conization in women with CIN reduces the risk of invasive cancer of the cervix but careful follow-up of these patients is essential.

Role of planimetric analysis in diagnosing thyroid follicular lesions on fine needle aspiration biopsies: a study with histologic correlation

BACKGROUND

Follicular lesions represent a gray area of interpretation in fine needle aspiration biopsy (FNAB) of the thyroid, with as much as 25% inconclusive reports. We identified "predominantly follicular lesions" (PFLs) as the cytologic category most apt to take advantage of planimetric analysis to reach a more definitive diagnosis.

STUDY DESIGN

Sixty-eight cases of FNAB were diagnosed as PFL among the 1,296 FNABs submitted to our institution between January 1994 and June 1995. These cases underwent planimetric analysis with a Leica semiautomatic image analyzer. A smear from a colloid nodule was used as a reference slide. Nuclear areas, perimeters, form factors and maximum diameters were evaluated. Cases in which nuclear areas and maximum nuclear diameters values were found to be > or = 30% higher than the corresponding values found in the reference slide were reported to the clinician as suspicious for malignancy ("flagged" by the computer). These cases required closer follow-up with repeat FNAB within a month, ultrasound and nuclear imaging studies. Nineteen of these cases underwent surgical resection.

RESULTS

Histologic reports diagnosed 9 cases of follicular carcinomas, 4 cases of follicular adenomas and 6 cases of nodular hyperplasia. When nuclear areas, perimeters and maximum diameters were all utilized, all the malignant lesions were reported correctly by the computer analysis as flagged, and all the benign lesions were reported as "not flagged." The sensitivity and specificity were 100%, and statistically significant correlations were proven.

CONCLUSION

Although the above data provide strong evidence for the value of planimetric analysis in differentiating between follicular lesions, we cannot reach definitive conclusions on the basis of such a limited number of cases. However, the results stimulated our current efforts in applying planimetry along with the evaluation of other biologic markers to a larger set of cases.

[Hyperthyroidism and carcinoma of the thyroid gland]

The incidence of thyroid carcinoma in hyperthyroidism varies considerably from as low as 0.3% to as high as 16.6% with a higher rate in toxic nodular goiters. Occult thyroid carcinoma (< 1.5 cm or microscopic foci) is the rule and only a few tumors are suspected preoperatively with ultrasonography or fine needle aspiration or 131 I scan. In 408 patients who underwent surgery for hyperthyroidism in our Surgery Department from January 1967 through December 1994 the incidence of thyroid carcinoma was 5.6% (23 cases). In detail, a neoplasm occurred in 5 cases of Graves' disease (specific incidence: 3.8%), in 13 cases of toxic nodular goiter (12.5%) and in 5 cases of hyperfunctioning adenomas (2.8%). 19 cancers were papillary (12 in toxic nodular goiter, 3 in Graves' disease, 4 in hyperfunctioning adenomas), three were follicular (1 in Graves' disease, 1 in toxic nodular goiter, 1 in hyperfunctioning adenomas) and 1 medullary in Graves' disease. A papillary carcinoma was diagnosed preoperatively on fine needle aspiration with ultrasonography in only two patients with Graves' disease and confirmed by postoperative histological examination on permanent section. We do not believe in the frozen-section examination intraoperatively because it's not diagnostical for follicular lesions and evaluates rarely capsular invasion. Twenty patients received total thyroidectomy and four of them also lymphoadenectomy. Three patients received emithyroidectomy: in two cases for occult papillary carcinoma and in the last case for local cancer invasion (T4N0M0). Twenty patients are alive and with no evidence of cancer recurrence. Mean follow-up is 59.6 months. Our retrospective study shows a progressive increase of the incidence of coexisting thyroid malignancy and hyperthyroidism especially in toxic nodular goiter, probably related to extended surgical indications. Our findings do confirm that, even in the presence of hyperthyroidism, all thyroid nodules require careful diagnostics for exclusion of malignancy.

Cytology, histology, and colposcopy in the diagnosis of neoplastic non-invasive epithelial lesions of the cervix

The purpose of our study was to examine the concordance among colposcopy, cytology, and histology in the diagnoses of intraepithelial lesions of the uterine cervix. We compared the results of Pap tests, biopsies, and colposcopy in 190 patients, who had histologically proven CIN and/or HPV infection, using histology as "the gold standard". The chi 2 (chi square) test was used for the statistics analysis. The sensitivity of cytology for the detection of CIN was 70%, and was lower for LGL (low grade lesions) than for HGL (high grade lesions): 61.2% versus 88.5%, respectively (p < 0.0001). We obtained a high rate of false negative smears (30%), with a relatively high rate of inadequate samples (59.6%). The sensitivity of colposcopy was 92%. Our results suggest that the Pap test alone is no longer sufficient for the screening of precancerous lesions of the cervix, and colposcopy is compulsory each time the smear is inadequate or altered.

Lymphatic spread of cervical cancer: an anatomical and pathological study based on 225 radical hysterectomies with systematic pelvic and aortic lymphadenectomy

To assess the patterns of lymphatic spread in cervical carcinoma, radical hysterectomy with systematic lymphadenectomy was performed in 66 patients FIGO stage IB-IIA <4 cm, and 159 patients stage IB-IIA >4 cm to stage IV. The latter patients were treated with neoadjuvant chemotherapy (NACT). Parametria were evaluated by the giant section technique in 109 patients. In 40 of these, the superficial and deep layers of the vesicouterine ligament, the sacrouterine ligament, and the distal part of the cardinal ligament were separately evaluated. The median number of nodes removed was 48 pelvic (range 20-107) and 22 aortic (range 7-64). Positive nodes were found in 14 (21%) stage IB-IIA <4 cm and in 38 (23%) NACT-treated patients, all having pelvic node metastasis. Aortic nodes were involved in 2 (3%) and 5 (3%) patients, respectively. Solitary metastases were found in the superficial obturator (21% of stage IB-IIA <4 cm and 31% of NACT-treated positive node patients, respectively), external iliac (7 and 3%, respectively), and common iliac nodes (7 and 3%, respectively). Parametrial nodes were found in 59% of giant sections (8% metastatic). The superficial and deep layers of the vesicouterine ligament, the uterosacral ligament, and the distal part of the lateral parametrium revealed the presence of nodes in 33% (no metastatic nodes), 26% (3% metastatic), 5% (no metastatic nodes), and 70% (5% metastatic) of patients, respectively. Overall, parametrial nodes were positive in 12% of stage IB-IIA <4 cm and 7% of NACT-treated patients. The diameter of node metastasis was <10 mm in more than 80% of positive nodes. In conclusion, parametrial nodes were mainly located in the cardinal and vesicouterine ligaments, both being a potential site of metastasis. The superficial obturator, external iliac, common iliac, paracaval, intercavoaortic, and paraaortic nodes were the groups more frequently involved. These data may be useful for tailoring radical hysterectomy and lymphadenectomy according to the primary tumor and the surgeon's intent.

Verrucous squamous cell carcinoma of the larynx: diagnostic and therapeutic considerations

The clinical findings, histopathology, management and outcome of 31 patients with verrucous squamous cell carcinoma of the larynx (VSCC) are discussed. Laryngeal VSCC is a rare, highly differentiated variant of SCC and has specific morphological features and clinical behavior. A close liaison between the laryngologist and pathologist is needed to formulate a correct diagnosis, because this tumor appears to be malignant clinically and histologically benign. A low-power magnification of multiple large specimens, including the deep margins of the lesion, is required in order to differentiate VSCC from keratosis, verruca vulgaris or SCC with verrucous appearance, and to detect underlying microscopic foci of invasive SCC within or adjacent to a verrucous carcinoma. Long-lasting hoarseness was the most common symptom as the glottic region was the most common site of VSCC. Presumed clinically positive N1 lymph nodes were observed in the necks of 7 patients, but none had metastatic disease on histopathological study. Surgery alone was the most effective form of treatment, as it allowed a good outcome of all treated patients. Surgery plus radiotherapy was associated with an early recurrence and a poor outcome in 2 of 7 patients treated. The generally "benign" behavior of VSCC allows for conservative surgery, with complete endoscopic resection using the carbon dioxide laser representing a more conservative surgical approach. Neck dissection is not indicated due to the non-metastatic behavior of this tumor.

Morphologic and planimetric diagnosis of follicular thyroid lesions on fine needle aspiration cytology

During 1989-1992, 2,729 fine needle aspiration biopsies were performed; 585 with histologic controls were reviewed. The aim of the study was to demonstrate the incidence of carcinoma in follicular-structured smears without nuclear enlargement, evaluated with planimetric techniques, and to suggest a new cytodiagnostic classification. Of 398 follicular-structured smears, 188 were colloid nodules, 38 were thyreocytic hyperplasias without nuclear atypia, 146 were predominantly follicular lesions (PFL) and 26 were follicular lesions with nuclear pleomorphism. The last showed a high incidence of neoplasia (69.2%) and carcinoma (46.1%) and the largest planimetric values for nuclear area, perimeter and maximum diameter. The second and third categories showed only a difference in the incidence of benign neoplasms (32.9 vs. 15.8%). These results suggest that six months of expectant management might be useful in simple follicular lesions, whereas a follicular pattern with nuclear enlargement requires surgical treatment for the strong possibility of carcinoma.

[Preoperative cytodiagnosis by needle aspiration of follicular thyroid lesions]

In the period 1989-92, 2729 F.N.A.B. were performed: 585 with an histological control were reviewed. The aim of the study was to evaluate the risk of carcinomatous occurrence in the follicular-structured smears and to suggest a new cytodiagnostic classification. Out of 398 follicular-structured smears, 188 were colloid nodules (CN), 38 thyreocytic hyperplasias without nuclear atypia (THWNA), 146 predominantly follicular lesions (PFL), 26 follicular lesions with nuclear pleomorphism (FLWNP). The last one showed a high incidence of neoplasia (69.2%) and carcinoma (46.1%); the second and the third only a difference in the incidence of benign neoplasms (32.9 vs. 15.8%), with almost the same percentage of occurrence of malignancies (2.6 vs. 2.1%). Such results suggest that a six-months dilatory strategy might be useful in simple follicular lesions (THWNA and PFL) whereas a cytological follicular pattern with nuclear pleomorphism requires a surgical treatment for the high risk of carcinomatous occurrence.

[Lymphocytic infiltration in thyroid neoplasms. Preliminary prognostic assessments]

INTRODUCTION

It is known that the immune system is involved in several thyroid diseases and in the reaction against cancer progression. We have therefore evaluated lymphocytic infiltration in the slices of surgically removed thyroids in patients affected by thyroid carcinomas, to further clarify the anatomic and clinical characteristics of this pathology and the possible prognostic correlations.

MATERIALS AND METHODS

Thirty-eight patients, 7 men and 31 women, aged 23-73 years, were studied. They underwent total or subtotal thyroidectomy for thyroid carcinoma. The histopathological findings were: papillary carcinomas (P): 22 cases; follicular carcinomas (F): 10 cases; undifferentiated carcinomas (U): 3 cases; other types (e.g., medullary carcinoma, M): 3 cases.

RESULTS

The lymphocytic infiltration was evaluated in 4 different grades. The following results, regarding the different histological types, were found: grade 0 (no lymphocytic infiltration) in 10 cases (6 P, 2 F, 1 U, 1 mixed); grade 1 (poor lymphocytic infiltration, equivalent to a non specific inflammatory reaction) in 21 cases (11 P, 6 F, 2 U, 1 M); grade 2 (moderate lymphocytic infiltration) in 4 cases (2 P, 2 F); grade 3 (plentiful lymphocytic infiltration) in 3 cases (2 P, 1 trabecular carcinoma). In 3 patients a lymphocytic (Hashimoto's) thyroiditis was also present. The follow-up, 2 years after surgery, showed, among 17 patients examined, local recurrence and/or lymph node localization in 8 cases (the lymphocytic infiltrations was: grade 1: n = 6; grade 0: n = 2; no one exhibited a higher grade) and apparent remission in 9 (grade 3: n = 2; grade 2: n = 1; grade 1: n = 6; no one exhibited a grade 0 lymphocytic infiltration).

DISCUSSION

In most patients a poor or absent infiltration was found. In 7 cases, however, the infiltration was moderate or high. In our experience, no correlation between the histologic type and the infiltration grade was observed. However, in no patient with recurrence of neoplasia a relevant (grade 2-3) infiltration could be observed; patients without recurrence often showed a grade 2-3 infiltration, and no one of them showed a grade 0. The significance of lymphocytic infiltration in thyroid carcinoma is not well clarified. In fact, a few studies underline a possible unfavourable role, since a relevant infiltration seems to be associated with a weak cell-mediated immunity, mostly in follicular and anaplastic carcinomas. However, most data support the hypothesis that the lymphocytic infiltration is a good prognostic feature: in fact, it can be often found in papillary carcinomas and in juvenile thyroid carcinomas, both characterized by a good long-term prognosis.

CONCLUSIONS

Our preliminary data underline the opportunity of comparing the clinical course of the disease, the histologic grading and the tumour staging with the lymphocytic infiltration grade, an easily available pathologic datum, for a better prognostic evaluation of patients.

[Gastroenterologic pathology and replacement organotherapy in thyroidectomized patients]

Thyroid replacement therapy in patients treated by near-total or total thyroidectomy, as well as spontaneous hypothyroidism , can be difficult in patients with alterations in absorption functions or specific gastroenteric diseases. We have studied 25 patients, 22 women and 3 men, 18-72 years old (mean 47 years), affected by spontaneous or post-surgical hypothyroidism, who presented, during the usual replacement therapy, persistently elevated or high-normal TSH levels, and therefore required repeated variations in the prescribed dose of thyroxine. In these patients we evaluated hormone pattern, the presence of autoantibodies (anti-tyroglobulin, anti-Sm, anti-DNA, anti-microsomal antigens, anti-gliadin and anti-parietal cell), and performed an esophagogastroduodenoscopy (EGD) with histological examination. In all patients, plasma TSH ranged from 2.5 to 20 microU/ml. Only 17% of patients exhibited the presence of antibodies against thyroglobulin, 17% of patients had antibodies against microsomal antigens, 6% of patients presented antibodies against nuclear antigens; 4% had against gliadin. Histological examination revealed chronic gastritis (98%) with atrophic aspects (20%) and intestinal metaplasia (28%); and chronic duodenitis (86%) with villus abnormalities (23%) and total villus atrophy (4%). We underline the case of a patient, treated by total thyroidectomy for papillary carcinoma, who presented, two months after starting L-thyroxine therapy, a recurrence of celiac disease, that had been silent after childhood. The EGD showed, at the level of the second duodenal segment, a reduction of number and thickness of mucosal folds; the histological examination showed total villus atrophy, elongated crypts and a dense infiltration of chronic inflammatory cells in the lamina propria. Our experience underlines the frequent association of gastroenteric disease and hypothyroidism.(ABSTRACT TRUNCATED AT 250 WORDS)

Anatomical and pathological study of retroperitoneal nodes in epithelial ovarian cancer

The pattern of lymphatic spread was evaluated in 81 previously untreated ovarian cancer patients (Stage I, 35; Stage II, 2; Stage III, 44) undergoing systematic aortic and pelvic lymphadenectomy. Positive nodes were found in 14% Stage I and 68% Stage III patients. Either pre- and paraaortic, or pre- and paracaval nodes were the only aortic node metastasis in 14% of patients. Common iliac nodes were the sole metastasis in pelvic area in 11%, external iliac in 14%, and obturator in 6% of patients. Therefore, the above node groups, which overall were the most frequently involved, may be considered those primarily invaded by the tumor. When data were analyzed according to stage, aortic nodes were the site of metastasis in 6% Stage I and 14% Stage III patients and pelvic nodes in 8% Stage I and 11% Stage III patients. Both aortic and pelvic areas were positive in 43% Stage III patients. The median number of positive nodes/patient was 2 (range, 1-3) and 4 (range 2-46) in Stages I and III, respectively. Lymphatic spread was ipsilateral to the tumor in all Stage I and in 40% Stage III patients. In Stage III metastases were also observed in intercavoaortic, retrocaval, retroaortic, internal iliac, and presacral nodes. In apparent Stage I, lymphatic metastasis seemed to be limited to one ipsilateral group, and the removal of the primary nodes ipsilateral to the tumor may be considered an adequate procedure. In Stage III, the presence of metastasis beyond the primary nodes and the frequent bilateral involvement suggest that all lymphatic tissue surround the aorta, the cava, and the pelvic vessels should be removed if a cytoreductive intent is pursued.

Collection of 'normal' blood repopulating cells during early hemopoietic recovery after intensive conventional chemotherapy in chronic myelogenous leukemia

Twenty-five patients with CML (chronic phase (CP): 15 patients; accelerated phase (AP): 10 patients) at a median of 40 months after diagnosis and ineligible for allogeneic BMT, received an intensive chemotherapy regimen consisting of idarubicin, intermediate-dose ara-C and etoposide (ICE protocol). All patients had previously received alpha-interferon and only two patients had had partial cytogenetic response. During recovery from chemotherapy-induced aplasia, blood progenitors cells (BPC) were harvested by leukapheresis. All metaphases were found to be Ph-negative in the collection of 12 of 25 (48%) patients (CP: 9 of 15 (60%), AP: 3 of 10 (30%)) and a decrease of < 50% Ph-positive metaphases was seen in an additional five (CP: 4 patients; AP: 1 patient). The percentage of complete Ph-disappearance was 66% in patients receiving this procedure within the first 2 years of diagnosis and 30% in those treated after the second year of diagnosis. So far, the Ph-negative collections have been used in 9 patients (CP: 8 patients; AP: 1 patient) as autograft after conditioning with total body irradiation/etoposide/CY. Seven of 9 patients engrafted and 5 are alive and well, Ph-negative at 2+, 3+, 6+, 10+ and 18+ months.

[Hemangiopericytoma of parapharyngeal space]

The parapharyngeal space is a rare site of parapharyngeal neoplasms: their diagnosis and therapeutic treatment offer peculiar challenges. Parapharyngeal tumours may be primary, metastatic or diffused with regaed continuity. They are mostly benign (mixed, neurogenic, vascular tumours, etc.) rather than malignant neoplasms (adenocystic carcinoma, adenocarcinoma, lymphoma, etc.). In order to diagnosis parapharyngeal tumours differentially it is important to consider very rare type of neoplasms such as hemangiopericytomas. In this paper the Authors describe a case of hemangiopericytoma of the parapharyngeal space indicating the main diagnosis procedures, especially CT scan, Magnetic resonance and angiography. They discuss pathological aspects with particular regard to the differential diagnosis between benign and malignant tumour of this kind as well as prognoses. The Authors also describe surgical treatment in relation to particular parapharyngeal localization.