Inter-observer and intra-observer variability in the diagnosis of dysplasia in patients with inflammatory bowel disease: correlation of pathological and endoscopic findings

AIM

Colonic epithelial dysplasia is deemed the precursor lesion of cancer arising in inflammatory bowel disease (IBD). It has been suggested that many dysplastic lesions could be endoscopically detected to obtain target biopsies, leading to better yield. However, the clinical impact of a diagnosis of dysplasia may be hampered by a significant degree of histological and endoscopic intra-observer and inter-observer variability. This study aimed to evaluate intra-observer and inter-observer variability in the microscopic diagnosis of dysplasia in IBD and correlate endoscopic and histological findings.

METHOD

In total, 158 cases of ulcerative colitis and 14 of Crohn's disease with dysplasia were selected from a pathology database. Slides were blindly reviewed twice by two expert gastrointestinal pathologists. Results of endoscopic examinations were extracted from the reports. The degree of intra-observer and inter-observer variability was determined by kappa statistics.

RESULTS

Overall, there was an excellent degree of histopathological inter-observer agreement (κ = 0.786). The lowest level of agreement in the dysplasia group was for indefinite dysplasia (κ = 0.251). Negative and high grade dysplasia diagnosis reached the highest level of agreement with κ values of 0.822 [95% confidence interval (CI) 0.673-0.971] and 1.00 (95% CI 0.850-1.149), respectively. Intra-observer agreement was good and increased during the latter period of the study (κ = 0.734, 95% CI 0.642-0.826). Endoscopic-histological correlation was poor among the negative endoscopies, as up to 43% of cases were diagnosed with at least focal high grade dysplasia. The endoscopic-histological correlation improved when evaluating suspicious endoscopic lesions.

CONCLUSION

Dysplasia is reliably diagnosed by expert gastrointestinal pathologists but has poor correlation with an endoscopic diagnosis of dysplasia.

Local excision of T1 and T2 rectal cancer: proceed with caution

AIM

This study aimed to compare the clinical outcome between local excision (LE) and total mesorectal excision (TME) for early rectal cancer.

METHOD

After Institutional Review Board approval, charts of patients with T1 or T2 N0M0 rectal adenocarcinoma treated by curative LE or TME without preoperative radiotherapy from 2004 to 2012 were reviewed. Categorical and continuous variables were compared using chi-square analysis and the ANOVA test. Kaplan-Meier analysis compared survival rates.

RESULTS

The study included 153 patients: 79 underwent TME and 74 LE. Postoperative infection was more common after TME (P = 0.009). There was tumour involvement of the margins in 13.5% after LE compared with 0% after TME (P = 0.001). Of the patients treated initially by LE, 13.5% had additional surgery for unfavourable histological findings and 4.1% had residual tumour. Median follow up was 35 (17-96) months. No deaths were recorded in 56 patients with a pT1 lesion. There was no significant difference in local recurrence (P = 0.332) or 3-year disease-free survival (DFS; P = 0.232) between patients having LE or TME. The 68 patients with a T2 lesion had higher local recurrence (P = 0.025) and lower DFS following LE compared with TME (P = 0.044). There was no difference in overall survival (P = 0.351).

CONCLUSION

LE of early rectal cancer is associated with higher local recurrence and decreased DFS. These disadvantages are significant for T2 lesions.

P2-12-32: Association between Progranulin (GP88) Expression and Recurrence Risk for Breast Cancer Patients with Estrogen Receptor Positive Invasive Ductal Carcinoma

Purpose: GP88 (progranulin) is a critical player of breast tumorigenesis for estrogen receptor positive (ER+) breast cancer. Pathological studies showed that GP88 was expressed in invasive ductal carcinoma (IDC), but not in normal mammary tissue, benign lesions or lobular carcinoma. The present study examines GP88 prognostic significance in association with recurrence risk for patients with ER+ IDC.

Patients and Methods: Two retrospective multi-site clinical studies examined GP88 expression by immunohistochemistry (IHC) analysis in paraffin-embedded tumor tissues in correlation with patients’ survival outcomes. The training study established a GP88 cut-off value associated with decreased disease-free (DFS) and overall (OS) survivals. The validation study verified the GP88 cut-off value and compared GP88 prognostic information with other prognostic factors in multivariate analysis.

Results: GP88 expression is associated with a statistically significant increase in recurrence risk for ER+ IDC patients. The training study established that GP88 3+ score by IHC analysis was associated with decreased DFS (p=0.0004) and OS (p=0.0036). The independent validation study verified that GP88 3+ score for the high risk group and demonstrated that GP88 3+ score was associated with a 5.9-fold higher hazard of disease recurrence and a 2.5-fold higher mortality hazard compared to patients with tumor GP88<3+. GP88 remained an independent risk predictor after considering age, nodal status, tumor size, tumor grade, progesterone receptor expression, treatment and disease stage.

Conclusion: Our training and validation studies demonstrate that the survival factor GP88 is a prognostic biomarker, predictive of recurrence risk and increased mortality for ER+ IDC patients, independent from other prognostic factors. These results provide support for measuring GP88 tissue expression for newly diagnosed early stage breast cancer patients.

This work was supported by grants R43CA124179, and U01CA113916 from the National Cancer Institute, grants 07-2007-064 and 02-2010-010 from the Avon Foundation for Women.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-32.

Tissue expression of the growth factor GP88 is a predictor of recurrence in patients with estrogen receptor positive breast tumors

Abstract #1088

Background
 Our laboratory is working on the characterization of novel breast cancer targets that have therapeutic an/or diagnostic applications. We have previously identified the growth factor GP88 as a significant player of breast tumorigenesis. GP88 is expressed in human breast cancer cells in a positive correlation with tumorigenesis. In estrogen receptor positive breast cancer cells, GP88 mediates estrogen proliferation effect and its increase is associated with resistance to anti-estrogen therapy. Inhibition of GP88 expression in human breast adenocarcinoma lead to inhibition of tumor incidence and tumor growth in nude mice. Pathological studies showed that ductal carcinoma expressed GP88 whereas benign lesions and normal mammary tissue were negative. Based on this evidence, the present study was carried out to investigate whether high GP88 expression in estrogen receptor positive invasive ductal carcinoma is associated with increased recurrence and decreased overall survival.
 Methods
 Under an IRB approved study, 239 archival formalin-fixed, paraffin-embedded estrogen receptor positive invasive ductal carcinoma with a minimum of 4 years follow-up were obtained from three United States tumor banks The clinical data included patients demographics such as age and race, tumor characteristics including tumor size, tumor grade, nodal status, disease stage and receptor status, time and type of first recurrence, time and status of last follow-up. GP88 expression was determined by immunohistochemistry using Oncostain 88TM IHC kit on five-micrometer sections. GP88 expression was scored as: <10% of cells staining – negative, >10% of cells staining – positive with positive staining graded from weak/focal (1+) to moderate/focal or diffuse (2+) to strong/diffuse (3+). The statistical analysis of GP88 expression in all cases was carried out. The Oncostain 88TM test performance was evaluated for its ability to predict disease-free (DFS) and/or overall survivals (OS) using Kaplan Meier curves and the Cox proportional hazards models for quantification of risk.
 Results
 The data show that ER+ cases with high GP88 expression (3+) had a hazard ratio for OS of 2.29 (95% CI, 1.38-3.78; p< 0.0013) and a HR for DFS of 2.88 (95% CI 1.59-5.24; p<0.0005). GP88 3+ remained highly significant for OS and DFS even when the data were adjusted for covariates such as nodal status, disease stage, tumor grade, tumor size, supporting the findings that GP88 brings independent information on the recurrence risk and overall survival of ER+ invasive ductal carcinoma.
 Conclusion
 This study demonstrates for the first time that high GP88 expression (3+) is a predictor of higher recurrence and increased mortality in ER+ IDC. These data provide a novel biomarker tissue assay (Oncostain 88TM) with prognostic significance in breast cancer.
 This study was supported by grant 1R43 CA 124179-01A1 from the National Institutes of Health.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1088.

Very late recurrence of hepatocellular carcinoma after liver transplantation: case report and literature review

Hepatocellular carcinoma (HCC) recurs in 10% to 60% of the patients after liver transplantation (OLT) and is associated with increased mortality. The average time to recurrence ranges from 1 to 2 years following OLT, and the median survival from the time of diagnosis is about 1 year. We report a case of a 69-year-old man who underwent OLT for hepatitis C virus-related cirrhosis with HCC, and was diagnosed with recurrent HCC 6.5 years after OLT. Biopsies from the initial and recurrent tumors showed a well-differentiated HCC with foci of clear cell pattern. The patient was still alive and asymptomatic 32 months after the diagnosis despite extensive tumor burden. He expired 9 years, 9 months after OLT and 3 years, 2 months after the detection of recurrence. In conclusion, HCC may recur more than 6 years after OLT and may exhibit an indolent course. This case illustrates the highly variable rate of tumor growth and progression post-OLT. The impact of this information on the need for long-term surveillance for recurrent HCC post-OLT remains to be determined.

International grading scheme for acute rejection in small bowel transplantation: implementation and experience at the University of Miami

In 2003, an international collection of pathologists and clinicians proposed a unified grading system for acute cellular rejection in endoscopically derived small intestine allograft biopsies. This grading system was implemented at the University of Miami over the past 2 years and the results are presented herein. A total of 1136 small bowel allograft biopsies with sufficient tissue for analysis were obtained from 123 hospitalized, clinic, and referral patients. The overall most common diagnosis assessing all time periods was grade IND (40%), and grade 1 rejection or greater was present in 19% percent of biopsies. A suspected vascular component to the acute rejection as identified by specific mucosal vascular changes was present in 6% of cases. Clinical decision making was very consistent with different grades. Our experience has confirmed that this new grading system is reliable and identifies clinical subsets of patients that can receive different therapy. We recommend that this international grading system be implemented for acute cellular rejection in bowel allografts as a means to standardize pathological assessment of alloimmune-induced graft injury, which will allow comparisons between different centers and clinical trials.

The Impact of Campath 1H Induction in Adult Liver Allotransplantation

BACKGROUND

We report our experience with Campath 1H in adult liver allotransplantation.

METHODS

Between December 2001 and February 2004, 77 patients underwent liver transplantation using Campath 1H induction and low-dose maintenance tacrolimus immunosuppression. The control group consisted of 50 patients with similar baseline characteristics and the same eligibility criteria, transplanted under our standard Tacrolimus/steroids regimen. Hepatitis C patients were excluded from the study.

RESULTS

Patient and graft survival were similar for both groups. The incidence of rejection was significantly lower in the Campath vs the control group (51% vs 65% at 12 months, P = .009). Tacrolimus trough levels and conversion from Tacrolimus or the addition of other immunosuppressive drugs due to nephrotoxicity were also significantly lower in the Campath 1H group.

CONCLUSION

Campath 1H induction with low-dose Tacrolimus maintenance immunosuppression is an effective regimen in reducing acute rejection in adult liver transplantation, while maintaining lower tacrolimus levels and less nephrotoxicity than our conventional immunosuppressive regimen.

Sclerosing mesenteritis in small bowel transplantation: possible manifestation of acute vascular rejection

BACKGROUND

Acute rejection of human small bowel allografts is characterized by clinical symptoms combined with characteristic morphologic alterations. The typical geographic distribution of acute rejection in the bowel is involvement of the intestinal parenchyma, which can be transmural, particularly when the rejection is more severe. However, little is known concerning the potential for donor-derived soft tissue adjacent to the bowel to become involved by the host alloimmune response.

METHODS

We describe a male patient who, several weeks after combined small bowel and liver transplantation, demonstrated sclerosing mesenteritis with vasculitis and acute rejection of the bowel.

RESULTS

The vascular lesions in the mesentery demonstrated increased IgG deposition and the patient developed an alloantibody to the donor.

CONCLUSIONS

The changes described herein may represent a novel presentation of acute vascular rejection.

Malignant thymoma with metastases to the gastrointestinal tract and ovary: a case report and literature review

This is the first clinical case report of a thoracic invasive thymoma metastatic to the ovary with disease noted in the entire abdomen including the pelvis 5 1/2 years after initial diagnosis. The involved areas of metastases include the distal ileum, peritoneal and serosal surfaces (including the surface of the distal colon, bladder, and pelvis), and the surface of the right ovary. The patient survived 13 years after her initial diagnosis and 7 1/2 years after discovery of her metastases. Thymomas are rare tumors but comprise the most common primary tumor of the anterior mediastinum. Extrathoracic metastases of malignant thymomas are also rare, and the literature reports that the most common sites for metastases are the liver, lung, lymph nodes, and bone. Extrathoracic disease is associated with a poor prognosis. The average time of survival after the diagnosis of metastases is 1.5 years.

PRK, a cell cycle gene localized to 8p21, is downregulated in head and neck cancer

The human PRK gene encodes a protein serine/threonine kinase of the polo family and plays an essential role in regulating meiosis and mitosis. We have previously shown that PRK expression is downregulated in a significant fraction of lung carcinomas. Our current studies reveal that PRK mRNA expression is downregulated in a majority (26 out of 35 patients) of primary head and neck squamous-cell carcinomas (HNSCC) compared with adjacent uninvolved tissues from the same patients, regardless of stage. In addition, PRK transcripts were undetectable in one of the two HNSCC cell lines analyzed. Ectopic expression of PRK, but not a PRK deletion construct, in transformed A549 fibroblast cells suppresses their proliferation. Furthermore, fluorescence in situ hybridization analyses show that the PRK gene localizes to chromosome band 8p21, a region that exhibits a high frequency of loss of heterozygosity in a variety of human cancers, including head and neck cancers, and that is proposed to contain two putative tumor suppressor genes. Considering that PRK plays an important role in the regulation of the G2/M transition and cell cycle progression, our current studies suggest that deregulated expression of PRK may contribute to tumor development. Genes Chromosomes Cancer 27:332-336, 2000.

Microsatellite instability is absent in liver and biliary mucosa of patients with primary sclerosing cholangitis

Microsatellite instability occurs in the colonic mucosa of patients with inflammatory bowel disease and may predispose the mucosa to neoplastic transformation. It is unknown whether microsatellite instability also plays a role in the neoplastic risk associated with primary sclerosing cholangitis. We examined 134 tissue samples from 21 patients with sclerosing cholangitis for microsatellite instability at eight loci. All tissues were also stained immunohistochemically using an antibody to the proliferation marker Ki-67. Microsatellite instability did not occur in any samples from the intrahepatic or extrahepatic biliary system, although one patient demonstrated instability in the colon. Ki-67 indices ranged from 0 to 2.5 in nondysplastic biliary epithelium and from 1.5 to 29.4 in areas of dysplasia. The absence of microsatellite instability in sclerosing cholangitis suggests that the genetic basis of neoplastic progression in chronic inflammatory disease of the bile ducts differs from that of intestinal cancers arising in the setting of chronic inflammatory bowel disease and may relate to differences in the microenvironment in these two sites.

Primary hepatic pheochromocytoma?

We report a case of a single intrahepatic pheochromocytoma in the absence of an adrenal lesion and no evidence of metastatic disease. The patient had strong clinical and biochemical evidence of a pheochromocytoma. A CT scan was abnormal but nondiagnostic for pheochromocytoma. An 123I-metaiodobenzyl guanidine (MIBG) scan was falsely negative, but an MRI scan showed a definitive hepatic abnormality. After confirmation of endocrine activity by venous sampling, the tumor was surgically removed. The patient's symptoms have resolved and her plasma catecholamine levels as well as her 24-h urine catecholamine excretion have normalized. The case shows an unusual location of an isolated pheochromocytoma and provides an example of a false negative I-123 MIBG scan.

Influence of beta 2-adrenergic receptor genotypes on signal transduction in human airway smooth muscle cells

The phenotypic relevance of allelic variation in the structure of the beta 2-adrenergic receptor (beta 2AR) expressed in lung cells is unknown. In particular, altered responsiveness of the beta 2AR expressed on airway smooth muscle, which are responsible for bronchodilation in the treatment of asthma, may be an important factor in the ultimate physiologic response to agonist. To approach this, we established primary cultures of human airway smooth muscle cells obtained at autopsy and developed a method to determine the beta 2AR genotype at the polymorphic loci of codons 16 and 27, using allele-specific polymerase chain reactions. Radioligand binding studies revealed that these cells expressed approximately 70 fmol/mg of receptor which was exclusively of the beta 2AR subtype. All cell lines obtained (n = 10) exhibited normal agonist binding and receptor-mediated activation of the adenylyl cyclase second messenger pathway. However, distinct differences were found in the response to long-term agonist exposure between the different beta 2AR genotypes. Cells expressing Arg at codon 16 (Arg16) traditionally referred to as wild-type, underwent 77.8 +/- 8.1% downregulations of beta 2AR following prolonged (24-h) exposure to the beta 2AR agonist isoproterenol (10 microM). In contrast, cells expressing Gly16 beta 2AR underwent enhanced agonist-promoted downregulation (95.6 +/- 1.7%, P < 0.05 versus Arg16), whereas cells expressing Glu27 beta 2AR were relatively resistant to such downregulation (29.5 +/- 12.7%, P < 0.01 versus Arg16). For cells expressing Glu27 beta 2AR, this difference resulted in a significant attenuation of agonist-promoted functional desensitization (33 +/- 7 versus 90 +/- 5% desensitization for Arg16, P < 0.001) following preincubation with 1 microM isoproterenol.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of the p53 gene in the malignant transformation of pleomorphic adenomas of the parotid gland

Pleomorphic adenoma (PA), the most common neoplasm of the parotid gland in adults, undergoes malignant transformation in only two to six percent of cases. In order to determine whether or not the p53 gene is involved in the malignant transformation of PA of the parotid gland, we have analyzed archival specimens from four patients with carcinoma ex-pleomorphic adenoma (CEPA) by immunohistochemistry and sequencing of the amplified DNA. Tissue specimens from each patient contained both the CEPA and the precursor PA. Immunostaining revealed that while all CEPA were p53 positive, only one of the four precursor PA was positive for p53. In this case, DNA was isolated from both the PA and CEPA and exons five through eight were amplified using the polymerase chain reaction. The same p53 mutation (single base substitution) was found in both the PA and the CEPA at codon 248. Adjacent normal tissue contained the wild-type p53 sequence. To our knowledge, this is the first report of the same p53 point mutation in both a PA and the associated CEPA of the parotid. These results strongly suggest a role for p53 gene mutation in the malignant transformation of some PA of the parotid gland.