Histologic Correlation of Breast Biopsies Presenting as Non-Mass Enhancing Lesions on Magnetic Resonance Imaging: A Contemporary Single Institutional Series

Introduction/Objective

Non-mass enhancement (NME) in breast tissue is an area of enhancement on MRI that appears distinct from background breast parenchyma, but lacks definitive features of a mass. NME is characterized by its internal enhancement pattern and distribution, and can represent benign, high risk, or malignant pathology. Given this considerable overlap, a core biopsy is often necessary for diagnosis and management. We aimed to elucidate the most frequent histologic findings found on breast biopsies for MRI NME.

Methods

Using our institutional database we identified 70 female patients with high risk status for breast cancer with MRI screen detected NME (BIRADS-4-suspicious for malignancy) that underwent subsequent biopsy procedure during the period of 01/2016-12/2017. Primary pathologic diagnoses were subcategorized as follows: malignant, atypical, benign mass-like lesions, fibrocystic changes (proliferative, nonproliferative), or “other” primary diagnoses.

Results

The median age of patients was 48 years (range: 22-76 years). Of the 70 patients, 66 underwent MRI-guided core biopsy, 3 underwent ultrasound-guided core biopsy and 1 underwent excisional biopsy. The primary diagnosis was analyzed. Of these 70 cases, 8 (11.4%) were malignant (7 with ductal carcinoma in situ and 1 with invasive ductal carcinoma), 1 (1.4%) had atypical lobular hyperplasia, and the remaining 61 (87.1%) showed benign findings (36 with fibrocystic changes (FCC), 22 benign mass-like lesions, 3 with other non-specific findings). The FCC were subcategorized as proliferative (usual ductal hyperplasia, columnar cell change, incidental radial scar, incidental intraductal papilloma, sclerosing adenosis, focal pseudoangiomatous stromal hyperplasia (PASH)) or nonprolifeative (stromal fibrosis, duct ectasia, apocrine metaplasia). Majority (61.1%) of FCC were both proliferative and nonproliferative, 22.2% proliferative only and 16.7% nonproliferative only. Benign mass-like lesions included PASH (45.4%), fibroadenomatoid nodule (22.7%), fat necrosis (18.2 %) and remaining had the diagnosis of clustered apocrine cysts, papillomatosis, and radial sclerosing lesion.

Conclusion

Less than a third of cases showed malignant findings and more than two-third of cases showed benign findings with a high rate of detection of proliferative lesions and PASH.

Skin barrier lipid enzyme activity in Netherton patients is associated with protease activity and ceramide abnormalities

Individuals with Netherton syndrome (NTS) have increased serine protease activity, which strongly impacts the barrier function of the skin epidermis and leads to skin inflammation. Here, we investigated how serine protease activity in NTS correlates with changes in the stratum corneum (SC) ceramides, which are crucial components of the skin barrier. We examined two key enzymes involved in epidermal ceramide biosynthesis, β-glucocerebrosidase (GBA) and acid-sphingomyelinase (ASM). We compared in situ expression levels and activities of GBA and ASM between NTS patients and controls and correlated the expression and activities with i) SC ceramide profiles, ii) in situ serine protease activity, and iii) clinical presentation of patients. Using activity-based probe labeling, we visualized and localized active epidermal GBA, and a newly developed in situ zymography method enabled us to visualize and localize active ASM. Reduction in active GBA in NTS patients coincided with increased ASM activity, particularly in areas with increased serine protease activity. NTS patients with scaly erythroderma exhibited more pronounced anomalies in GBA and ASM activities than patients with ichthyosis linearis circumflexa. They also displayed a stronger increase in SC ceramides processed via ASM. We conclude that changes in the localization of active GBA and ASM correlate with i) altered SC ceramide composition in NTS patients, ii) local serine protease activity, and iii) the clinical manifestation of NTS.

WAKMAR2, a Long Noncoding RNA Downregulated in Human Chronic Wounds, Modulates Keratinocyte Motility and Production of Inflammatory Chemokines

Chronic wounds represent a major and growing health and economic burden worldwide. A better understanding of molecular mechanisms of normal as well as impaired wound healing is needed to develop effective treatment. Herein we studied the potential role of long noncoding RNA LOC100130476 in skin wound repair. LOC100130476 is an RNA polymerase II-encoded polyadenylated transcript present in both cytoplasm and nucleus. We found that its expression was lower in wound-edge keratinocytes of human chronic wounds compared to normal wounds of healthy donors and intact skin. In cultured keratinocytes, LOC100130476 expression was induced by TGF-β signaling. By reducing LOC100130476 expression with antisense oligos or activating its transcription with CRISPR/Cas9 Synergistic Activation Mediator system, we showed that LOC100130476 restricted the production of inflammatory chemokines by keratinocytes, while enhancing cell migration. In line with this, knockdown of LOC100130476 impaired re-epithelization of human ex vivo wounds. Based on these results, we named LOC100130476 wound and keratinocyte migration-associated long noncoding RNA 2 (WAKMAR2). Moreover, we identified a molecular network that may mediate the biological function of WAKMAR2 in keratinocytes using microarray. In summary, our data suggest that WAKMAR2 is an important regulator of skin wound healing and its deficiency may contribute to the pathogenesis of chronic wounds.

Degree of Skin Barrier Disruption Affects Lipid Organization in Regenerated Stratum Corneum

Previously, a skin barrier repair model was developed to examine the effect of formulations on the lipid properties of compromised skin. In this model, the lipid organization mimics that of several skin diseases with impaired skin barrier and less dense lateral lipid organization. In addition, parakeratosis was occasionally observed. The present study investigated whether the extent of initial barrier disruption affects lipid organization and parakeratosis in regenerated stratum corneum. After barrier disruption and stratum corneum regeneration the fraction of lipids adopting a less dense lateral organization gradually increased with increasing degree of barrier disruption. Only when 75% of the stratum corneum was removed, were parakeratosis and a change in lamellar organization observed. This demonstrates the possibility of using the skin barrier repair model to study the effects of formulations on compromised skin in which the presence of parakeratosis and lipid organization can be modified by the extent of barrier disruption.

Topically Applied Ceramides Interact with the Stratum Corneum Lipid Matrix in Compromised Ex Vivo Skin

PURPOSE

To determine whether formulations containing ceramides (including a ceramide with a long hydroxyl acyl chain linked to a linoleate, CER EOS) and fatty acids are able to repair the skin barrier by normalizing the lipid organization in stratum corneum (SC).

METHODS

The formulations were applied on a skin barrier repair model consisting of ex vivo human skin from which SC was removed by stripping. The effect of formulations on the lipid organization and conformational ordering in the regenerated SC were analyzed using Fourier transform infrared spectroscopy and small angle X-ray diffraction.

RESULTS

Application of the formulation containing only one ceramide on regenerating SC resulted in a higher fraction of lipids adopting an orthorhombic organization. A similar fraction of lipids forming an orthorhombic organization was observed after application of a formulation containing two ceramides and a fatty acid on regenerating SC. No effects on the lamellar lipid organization were observed.

CONCLUSIONS

Application of a formulation containing either a single ceramide or two ceramides and a fatty acid on regenerating SC, resulted in a denser lateral lipid packing of the SC lipids in compromised skin. The strongest effect was observed after application of a formulation containing a single ceramide.

Ki67: A Time-Varying Biomarker of Risk of Breast Cancer in Atypical Hyperplasia

Background: Uncontrolled proliferation is a defining feature of the malignant phenotype. Ki67 is a marker for proliferating cells and is overexpressed in many breast cancers. Atypical hyperplasia is a premalignant lesion of the breast (relative risk ∼ 4.0). Here we asked if Ki67 expression could stratify risk in women with atypia.Methods: Ki67 expression was assessed immunohistochemically by digital image analysis in archival sections from 192 women with atypia diagnosed at the Mayo Clinic 1/1/67-12/31/91. Risk factor and follow-up data were obtained via study questionnaire and medical records. Observed breast cancer events were compared to population expected rates (Iowa SEER) using standarized incidence ratios (SIRs). We examined both short-term (within 10 years) and long-term (after 10 years) risk of breast cancer (BC) following atypia biopsy.Results: The median value for percent positive cells for Ki67 was 1.0%; the 75th percentile value was 2.3%. Based on the empirical distribution of staining values in our cohort, we selected a cutoff of 2% cells positive to separate high from low staining. There were no differences in Ki67 levels by age at biopsy, type of atypia (ADH, ALH, or both), number of foci of atypia, or family history. 32 women developed BC over a median of 14.6 years. Among them, those with ≥2% Ki67 expression had a shorter time to breast cancer (median 5.5 years, IQR=3.2-7.2) than those with <2% cells positive (median=13.8 years, IQR=11.6-20.3). There was a positive association between Ki67 overexpression (≥2% of cells positive) and risk of BC in the first 10 years of follow-up (SIR=4.42 [95% CI 2.21-8.84]). This excess risk resulted in a 10-year cumulative incidence of 14.1%. In contrast, in the women with low Ki67 expression, we found no increased risk of BC in the first 10 years, with SIR 1.01 (95% CI 0.38-2.70), which was significantly lower than the women with high expression (p=0.01). The 10-year cumulative incidence of BC was 3% for the low Ki67group, in line with population averages. After 10 years, risk increased significantly in the low Ki67 group [SIR 5.69 (3.63-8.92)] vs. no increased risk in the high Ki67 group [SIR 0.78 (0.11-5.55)]. We formally examined this apparent time-dependent difference in incidence patterns by Ki67 staining levels via Poisson regression analysis, and found a statistically significant interaction between pre- vs. post-10 years incidence and high vs. low staining levels (p<0.001).Conclusions: Ki67 appears to be a time-varying biomarker of risk of breast cancer in women with atypical hyperplasia. Women whose atypias show higher proliferation rates have an increased risk for an earlier BC (within 10 years). Those with lower proliferation rates tend to develop BCs later, after 10 years. Ki67 levels may help to define the time period of greatest risk for women with atypia.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 909.

Lobular Involution and Mammographic Density: Independent Contributors to Breast Cancer Risk

Background: Women with benign breast disease are at elevated breast cancer risk. In order to accurately predict a woman's individual risk of breast cancer, a breast cancer risk-prediction model is needed that incorporates significant breast cancer risk factors. This report describes two factors: tissue based assessment of lobular involution, and radiological marker- mammographic density (MD). Lobular involution, or physiologic atrophy of the breast glandular epithelium, is inversely associated with breast cancer risk. MD is a strong positive risk factor for breast cancer. With increasing age, the extent of lobular involution increases while MD decreases. However, it is unclear whether involution and MD represent independent breast cancer risk factors. We examined breast cancer risk associated with lobular involution and MD in women with benign breast disease (BBD) to determine whether these features are independently associated with breast cancer risk.Methods: Using the Mayo Clinic Surgical and Pathology Indices, 9376 women ages 18 to 85 with benign excisional breast biopsy between January 1, 1967 and December 31, 1991 were identified and formed the Mayo BBD cohort. We studied a sub-cohort of women diagnosed with BBD between 1985 and 1991 (when MD was clinically assessed and recorded) who had a mammogram within 6 months of the BBD diagnosis. Breast cancer outcomes were determined through the Mayo medical records and a study-specific questionnaire. Lobular involution extent was assessed in background tissue as 'none' (0% lobules involuted), 'partial' (1-74% lobules involuted) or 'complete' (≥75% lobules involuted). MD was classified as Wolfe's parenchymal pattern (PP) as N1/ fatty; P1; P2; and DY/ homogenously dense. Hazard ratios and confidence intervals were calculated using Cox regression analyses, adjusting for confounders: age, parity, BMI, BBD histology, menopausal status, family history, PP and involution extent.Results: A total of 2666 women in the Mayo BBD cohort, with biopsies between 1985 and 1991, had a mammogram within 6 months of the breast biopsy. The mean age at biopsy was 54.6 years. After a mean follow-up of 13.3 years, 172 (6.5%) women developed breast cancer. After adjustment for PP and other confounders, women with no or partial involution had elevated risk compared to women with complete involution (HR 2.62 [95% CI 1.39, 4.94] for no involution and 1.61 [95% CI 1.03, 2.53] for partial involution; complete involution as reference group; p for trend 0.003). Moreover, women with dense breasts were at greater risk compared to women with nondense breasts (HR 1.67 [95% CI 1.0, 2.73] for DY pattern, 1.96 [95% CI 1.2 – 3.21] for P2, 1.23 [95% CI 0.67, 2.26] for P1; N1 category as reference group; p for trend 0.02). Multivariate analyses also showed that women with the combination of no involution and dense breasts had greater risk compared to those with complete involution and nondense breasts (HR 4.08 [95% CI 1.72, 9.68]).Conclusion: Lobular involution and MD are both risk factors for breast cancer; this report is the first to demonstrate that each provides unique information about breast cancer risk. These findings emphasize the potential for inclusion of both these factors in future breast cancer risk-prediction models.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6064.

Handling, storage, and preparation of human tissues

Human tissue for flow cytometry must be prepared as an adequate single-cell suspension. The appropriate methods for tissue collection, transport, storage, and dissociation depend on the cell parameters being measured and the localization of the markers. This unit includes a general method for collecting and transporting human tissue and preparing a tissue imprint. Protocols are supplied for tissue disaggregation by either mechanical or enzymatic means and for preparation of single-cell suspensions of whole cells from fine-needle aspirates, pleural effusions, abdominal fluids, or other body fluids. Other protocols detail preparation of intact nuclei from fresh, frozen, or paraffin-embedded tissue. Support protocols cover fixation, cryospin preparation, cryopreservation, and removal of debris.

Maspin expression inversely correlates with breast tumor progression in MMTV/TGF-alpha transgenic mouse model

Maspin is a novel serine protease inhibitor (serpin) with tumor suppressive activity. To date, despite the mounting evidence implicating the potential diagnostic/prognostic and therapeutic value of maspin in breast and prostate carcinoma, the lack of a suitable animal model hampers the in vivo investigation on the role of maspin at different stages of tumor progression. In this study, we used MMTV/TGF-alpha transgenic mouse model to study the expression profile of maspin in mammary tumor progression. Histopathological examinations of MMTV/TGF-alpha transgenic mice revealed TGF-alpha expression leading to hyperproliferation, hyperplasia, and occasional carcinoma in mammary gland. Interestingly, when MMTV/TGF-alpha transgenic mice were breed to homozygocity, they also developed characteristic skin papillomas. Immunohistochemistry analysis of maspin expression in the breast tissues of TGF-alpha transgenic mice showed a direct correlation between down-regulation of maspin expression and tumor progression. The loss of maspin expression was concomitant with the critical transition from carcinoma in situ to invasive carcinoma. Subsequent in-situ hybridization analyses suggest that the down-regulation of maspin expression is primarily a transcriptional event. This data is consistent with the tumor suppressive role of maspin. Furthermore, our data suggests that MMTV/TGF-alpha transgenic mouse model is advantageous for in vivo evaluation of both the expression and the biological function of maspin during the slow multi-stage carcinogenesis of mammary gland.

Clinicopathologic analysis of invasive micropapillary differentiation in breast carcinoma

Invasive micropapillary carcinoma (IMPCa) of breast is histologically characterized by growth of cohesive tumor cell clusters within prominent clear spaces resembling dilated angiolymphatic vessels. In this study, eighty three breast carcinomas with IMPCa differentiation were identified by review of the invasive carcinoma cases in our institution and correlated retrospectively with standard clinicopathologic parameters and survival status relative to a control series of cases (mean follow up 7 years). IMPCa growth pattern was present in 6% of all breast carcinomas; it was generally a focal component in otherwise typical invasive ductal carcinoma. It comprised more than 80% of the total neoplasm in only 10 cases (12%), 50-80% of the neoplasm in 7 cases (8%), 20-50% of the neoplasm in 22 cases (26%) and less than 20% in 44 cases (53%). The mean tumor size was 4 cm, 22% invaded skin, and 58% were poorly differentiated, but 71% were ER positive. Axillary node metastases were present in 77% of cases, were typically multiple (51% had three or more positive), and usually contained an IMPCa component (81% of the cases). There was no significant difference in node status, ER status, size, tumor grade, or peritumoral angiolymphatic invasion between tumors with predominant (more than 50%) v/s focal IMPCa components. In both groups 46% of the patients died from their disease (mean interval to death = 36m). Skin involvement and nodal status were the only parameters which predicted poor survival (P =.01). The outcome of patients with IMPCa did not differ significantly from infiltrating ductal carcinomas of similar node status. In conclusion, our results suggest that IMPCa growth pattern may be a manifestation of aggressive behavior, as shown by frequent skin invasion and extensive nodal involvement. However, clinicopathologic features and outcome of IMPCa are not strongly dependent on the relative amount of micropapillary component.

Impact of breast carcinoma on African-American women: the Detroit experience

BACKGROUND

National and regional population-based data have demonstrated substantially worse outcome in African-American patients with breast carcinoma when compared with white patients, as well as a younger age distribution among African-American patients with breast carcinoma. The extent to which various socioeconomic, environmental, lifestyle, and genetic factors interact to account for this ethnicity-related disparity in survival is poorly understood. Greater than one-half of the inner-city population of Detroit, Michigan is African American, and greater metropolitan Detroit has been one of the contributing registries for the Surveillance, Epidemiology, and End Results (SEER) program since its inception in 1973. The impact of breast carcinoma on African Americans in the Detroit area is therefore well documented and provides significant insight into the history, epidemiology, and biology of this major public health care problem.

METHODS

A review of the medical literature published over the past 20 years regarding African-American patients with breast carcinoma was performed. The pertinent findings were summarized in the context of advances made in breast carcinoma screening, treatment, and risk reduction during that period.

RESULTS

The large African-American population of Detroit is a major factor contributing to the excessive breast carcinoma mortality rate reported for this city, which is one of the highest in the United States. Improvements in early detection of breast carcinoma by using screening mammography have been apparent in the earlier stage distributions of breast carcinoma observed in both white and African-American patients; however, progress has lagged substantially for the latter group. Detroit SEER registry data also have shown a younger age distribution of African-American patients with breast carcinoma and higher rates of estrogen receptor negative tumors. Finally, preliminary data from health maintenance organizations have suggested improved breast carcinoma outcome for African Americans who possess greater socioeconomic benefits, but disparities in disease stage at presentation persist.

CONCLUSIONS

The diverse Detroit community is ideally suited for breast carcinoma screening programs and clinical investigations that seek to address and overcome ethnicity-related survival disparities and barriers to health care. Findings from these studies can be correlated with results from similar projects in other geographic areas.

Histopathologic analysis of chromosome aneuploidy in ductal carcinoma in situ

Formalin-fixed, paraffin-embedded sections from 28 cases of ductal carcinoma in situ (DCIS; 12 with coexisting invasive neoplasm) were analyzed for numerical alterations of chromosomes 7, 8, 16, and 17 by performing fluorescence in situ hybridization (FISH) using centromeric (alpha-satellite) probes. Based on signal counts in 200 to 300 nuclei, each hybridization was classified as disomic (copy loss in <40%, copy gain in < 10%), monosomic (copy loss in at least 50% of nuclei, partial if 40% to 49%) or trisomic/polysomic (copy gain in at least 20% of nuclei, partial if 10% to 19%). Grade I lesions were characterized by complete lack of significant chromosome gain, but 29% showed partial (focal) monosomy. Grade III lesions, in contrast, showed partial or complete trisomy/polysomy in 88% of hybridizations versus monosomy in only 4%. Grade II DCIS exhibited a mixed pattern of chromosome aneuploidy: 38% hybridizations were disomic, 36% trisomic/polysomic, and 26% monosomic (8 of 10 hybridizations showing complete monosomy occurred in grade II lesions). Disomic hybridizations exhibiting rare cells (5% to 10%) with copy gain were more frequent in tumors with coexisting invasive neoplasm (5 of 17 v 2 of 33, P = .02). In morphologically heterogeneous lesions, higher-grade foci were characterized by chromosome copy gain relative to corresponding lower-grade areas in 17 of 22 (77%) hybridizations. These results show the presence of multiple (at least 3) distinct chromosome aneuploidy patterns in DCIS, in keeping with divergent mechanisms of genetic alteration. Degree of chromosomal instability, moreover, may correlate with progression of DCIS to invasive growth, implying that genetic instability is a parameter that impacts the likelihood of early breast carcinoma progression.

Inhibition of murine renal carcinoma pulmonary metastases by systemic administration of interferon gamma: mechanism of action and potential for combination with interleukin 4

We have previously demonstrated that IFN-gamma causes cell growth inhibition and up-regulation of MHC antigens in human renal cell carcinoma cell lines. In this study, we have investigated the therapeutic potential of IFN-gamma for the treatment of 5-day established pulmonary metastases induced by i.v. injection of Renca cells, a murine renal adenocarcinoma. We found that systemic injections of IFN-gamma significantly reduced the number of lung metastases in a dose-dependent manner and increased mouse survival. Histological evaluation of IFN-gamma-treated lungs showed residual small tumor nodules containing extensive necrosis and mononuclear infiltrates. Immunohistochemistry studies on lung sections showed macrophage infiltration into tumor nodules, and in vivo depletion of macrophages partially inhibited IFN-gamma antitumor effect, suggesting a role for the macrophages in tumor destruction. Lymphocyte depletion of either natural killer (NK) cells or CD4+ or CD8+ T-cell subsets or both T-cell subsets did not affect the IFN-gamma effect, whereas depletion of both NK and T cells decreased the antitumor activity of IFN-gamma. These data indicate that neither T cells nor NK cells are essential for this activity but that either lymphocyte population can contribute to the IFN-gamma effect. An optimal dose of IFN-gamma inhibited by 60% the growth of Renca cells treated for 3 days in vitro, but this effect was transient and less pronounced in a long-term colony assay, suggesting that IFN-gamma direct growth inhibition may play a role but may not be sufficient to mediate its antitumor effect in vivo. In vitro, IFN-gamma caused up-regulation of class I MHC antigens and induction of class II antigen expression in Renca cells, an effect that may enhance Renca immunogenicity but may be relevant only when a T-cell response is elicited. A sequential administration of IFN-gamma followed by interleukin 4 was therapeutically better than IFN-gamma alone for the treatment of advanced pulmonary metastases, probably due to different antitumor mechanisms induced by these two cytokines.

Antiintegrin alpha v beta 3 blocks human breast cancer growth and angiogenesis in human skin

Angiogenesis plays a fundamental role in human breast tumor progression. In fact, recent findings indicate that vascular density is a prognostic indicator of breast cancer disease status. Evidence is presented that the integrin alpha v beta 3 is not only a marker of human breast tumor-associated blood vessels, but that it plays a significant role in human angiogenesis and breast tumor growth. To assess the role of alpha v beta 3-dependent angiogenesis in the progression of human breast cancer, we examined a SCID mouse/human chimeric model with transplanted full thickness human skin containing alpha v beta 3-negative human breast tumor cells. This tumor induced a human angiogenic response as measured by vascular cell immunoreactivity with monoclonal antibodies LM609 and P2B1 directed to human alpha v beta 3 and CD31, respectively. Intravenous administration of LM609 either prevented tumor growth or markedly reduced tumor cell proliferation within the microenvironment of the human skin. These LM609-treated tumors not only contained significantly fewer human blood vessels but also appeared considerably less invasive than tumors in control animals. These findings demonstrate that alpha v beta 3 antagonists may provide an effective antiangiogenic approach for the treatment of human breast cancer.

Geographic distribution of co-dominant DNA stemlines in breast carcinoma

Breast carcinomas often contain multiple DNA stemlines in flow cytometric DNA histograms. However, due to mixing during tissue disaggregation the microanatomical relationship between the cells which comprise distinct stemlines is unclear. We performed image cytophotometric DNA analysis (IA) on two separate areas of intact tissue sections of 19 breast carcinomas which were selected on the basis of flow cytometric (FCM) DNA content heterogeneity (i.e., multiple stemlines). For comparison, similar analyses were performed on seven tumors with unimodal FCM DNA histograms. Six of the 7 tumors (86%) with unimodal FCM histograms were also unimodal in both IA DNA histograms. Among tumors with heterogeneous FCM DNA histograms, the presence of multiple stemlines was confirmed in IA DNA histograms in 16/19. In nine of these 16 cases, multiple DNA stemlines having similar DNA indices were present in both areas of neoplasm examined with IA. The remaining seven cases displayed unimodal IA histograms in both areas, however DNA indices differed between the two histograms. These findings imply that cell populations corresponding to flow cytometrically detected DNA stemlines are often intimately admixed, even within geographically separated portions of breast tumors. This pattern suggests that productive interactions between genetically distinct tumor populations may lead to stable co-dominance of ancestral clones during progression of some breast carcinomas.

Intralesional treatment of established murine primary renal tumor with interleukin-4: localized effect on primary tumor with no impact on metastases

In an effort to develop new strategies for immunotherapy of metastatic renal cell carcinoma, we investigated the therapeutic potential of interleukin-4 in a visceral renal tumor using the murine Renca renal adenocarcinoma model. Renca cells were implanted underneath the renal capsule of Balb/c mice to induce a primary tumor that spontaneously metastasized to several organs. Established primary renal tumors 4 to 6 mm. in diameter were treated by intralesional administration of recombinant murine interleukin-4 (IL-4). This treatment caused a marked inhibition of the primary tumor growth but had little effect on the progression of metastases in the liver, mesentery and lungs. Immunohistochemistry studies performed on renal tumor sections showed a macrophage infiltration that became predominant 7 days after IL-4 treatment. CD8+ T cells were also observed at the periphery and within the tumor. These data suggest that IL-4 mediated a potent antitumor effect when administered intralesionally although its effects remained localized with no impact on metastases at distant sites. Interleukin-4 antitumor activity seems to be mediated by recruitment of macrophages and T cells in the tumor.

Systemic treatment with interleukin-4 induces regression of pulmonary metastases in a murine renal cell carcinoma model

Advanced metastatic renal cell carcinoma has been shown to be responsive to immunotherapy but the response rate is still limited. We have investigated the therapeutic potential of systemic interleukin-4 (IL-4) administration for the treatment of pulmonary metastases in the murine Renca renal adenocarcinoma model. Renca cells were injected iv in Balb/c mice to induce multiple pulmonary tumor nodules. From Day 5, Renca-bearing mice were treated with two daily injections of recombinant murine IL-4 for 5 consecutive days. IL-4 treatment induced a significant reduction in the number of lung metastases in a dose-dependent manner and significantly augmented the survival of treated animals. Immunohistochemistry studies, performed on lung sections, showed macrophage and CD8+ T cell infiltration in the tumor nodules 1 day after the end of IL-4 treatment. The CD8 infiltration increased by Day 7 after IL-4 treatment. Granulocyte infiltration was not detectable. To clarify further the role of the immune system in IL-4 anti-tumor effect, mice were depleted of lymphocyte subpopulations by in vivo injections of specific antibodies prior to treatment with IL-4. Depletion of CD8+ T cells or AsGM1+ cells abrogated the effect of IL-4 on lung metastases, whereas depletion of CD4+ T cells had no impact. These data indicate that CD8+ T cells and AsGM1+ cells are involved in IL-4-induced regression of established renal cell carcinoma.

Flow cytometric DNA analysis of fresh prostatic resections. Correlation with conventional prognostic parameters in patients with prostate cancer

BACKGROUND

DNA ploidy analysis has been investigated as a prognostic indicator in prostate cancer. Most of the data is derived from retrospective studies using paraffin-embedded tissue. This method has drawbacks related to the quality of DNA histograms and uncontrolled data collection.

METHODS

DNA ploidy analysis of freshly resected prostatic tissue was prospectively compared with conventional prognostic variables in 97 men treated with radical prostatectomy for localized prostate cancer.

RESULTS

Regarding the patients, 31.9% were African American and 66% had pathologic Stages C or D1 disease. Only 9.6% of patients with Stages A2 and B had a prostate-specific antigen (PSA) value greater than 10 ng/ml, whereas 97% of patients with PSA values greater than 20 ng/ml had pathologic Stages C and D1. PSA levels correlated with Gleason score (P = < 0.05); 51% and 100% of patients with Gleason score 5-7 and 8-10, respectively, had PSA values greater than 10 ng/ml. Twenty-two patients (23%) had DNA aneuploid tumors. Comparisons of mechanical to enzymatic cell suspensions indicated that DNA aneuploidy was better preserved in mechanical cell preparations. DNA ploidy correlated with pathologic stage (P = < 0.05) and Gleason score (P = < 0.05). Fifteen of 79 patients (18.9%) with Gleason score 5-7 had DNA aneuploid tumors versus 71.4% of patients with Gleason score 8-10. PSA groups correlated with ploidy status (P = 0.01). Although the majority of patients (19 of 22) with DNA aneuploid tumors had elevated preoperative PSA levels, none had a PSA value greater than 50 ng/ml.

CONCLUSIONS

DNA ploidy analysis correlated with established prognostic indicators in prostate cancer; however, its independent correlation with natural history and treatment outcome must be established for it to have an effect on therapeutic decisions.

Gastrocolic fistula with pyloric stenosis and benign gastric ulcer

We have reported a case of gastrocolic fistula with gastric outlet obstruction as a complication of benign gastric ulcer. The single-stage surgical procedure described resulted in a successful outcome. Benign gastric ulcer currently appears to be the most prevalent cause of gastrocolic fistula.

Histologic and immunophenotypic evaluation of pretreatment renal biopsies in OKT3-treated allograft rejections

The histologic features immunophenotype of intragraft mononuclear populations, and HLA-Dr expression in pretreatment formalin-fixed renal allograft biopsies were correlated with outcome of OKT3 therapy in 35 steroid resistant renal transplant rejections. Therapeutic response (63% overall) was better in pure acute cellular rejections (ACR) (13/15, 87%) than ACR with interstitial fibrosis (4/12, 33%) or with vascular injury (5/8, 62%). Intragraft T lymphocytes were more numerous in vascular rejection (mean 566/mm2) compared with pure ACR (mean 265/mm2, P = .049), and macrophages were greater in pure ACR (203/mm2) compared with ACR with interstitial fibrosis (83/mm2, P = .051). Distribution of T cells, B cells, plasma cells, and macrophages among various histologic categories was otherwise statistically similar. There was no correlation between therapeutic response to OKT3 and intragraft concentrations of individual mononuclear cell subsets. Vascular and/or epithelial HLA-Dr expression was present in 17/25 (68%) cases and was not associated with histologic features or treatment response. Follow-up graft function (median 7 months) correlated significantly with therapeutic response to OKT3 (P = .0004) and histologic presence of interstitial fibrosis (P = .031), but was not related to concentration of individual mononuclear subsets or HLA-Dr expression. We conclude that intragraft concentrations of major mononuclear cell types may relate to histology, but that these do not predict treatment response or graft outcome, and thus poorly reflect intensity or possible heterogeneity of host immunologic rejection mechanisms.

Photodynamic therapy for treatment of AIDS-related oral Kaposi's sarcoma

Since 1975, Phase I and II studies have demonstrated the successfulness of hematoporphyrin derivative photodynamic therapy in the treatment of various malignancies of the skin, eye, bladder, lung, and head and neck. Moreover, two cases of traditional Western cutaneous Kaposi's sarcoma (TKS) have been treated with photodynamic therapy with both early and late complete response. To date, attempts at cure and palliation of the more aggressive AIDS-related oral Kaposi's sarcoma with conventional radiation, chemotherapy or immunotherapy, or surgical excision have been limited and often associated with debilitating mucositis and further immunosuppression. Certain aspects of photodynamic therapy may be efficacious for treatment of Kaposi's sarcoma: (1) the selective retention of hematoporphyrin derivative by neoplastic lesions; (2) a tumor-specific cytotoxic agent (i.e., free oxygen radical); (3) absence of systemic toxicity from immunosuppression; and (4) the potential for retreatment without increasing side effects. Herein we present five cases of AIDS-related KS (EKS) with diffuse, superficial, and nodular oral lesions treated with dihematoporphyrin derivative and photodynamic therapy with subsequent dramatic early partial and complete responses.

Cutaneous neuroendocrine (Merkel cell) carcinoma: an immunophenotypic, clinicopathologic, and flow cytometric study

Twenty-one cases of cutaneous neuroendocrine (Merkel cell) carcinoma (CNEC) were examined by the ABC-immunoperoxidase method with a panel of antibodies to 5 intermediate filaments, 6 neuroendocrine-associated antigens, 6 peptide hormones, as well as melanoma-associated cytoplasmic antigen (HMB-45) and leukocyte common antigen. All tumors showed strong cytokeratin staining in characteristic dense, inclusion-like, cytoplasmic globules and in a reticular peripheral cytoplasmic pattern. Cytoplasmic coexpression of inclusions of neurofilament antigen was observed in 9/21 cases. Staining for one or more neuroendocrine markers in formalin-fixed tissue (bombesin, 7/20; chromogranin, 11/21; synaptophysin, 6/21) was weak and focal but present in 17/21 cases. In 3 cases, sections of unfixed, snap-frozen tumor were compared with formalin-fixed tissue, and these showed strong, diffuse staining for multiple neuroendocrine antigens. Immunostaining for peptide hormones was not observed, with the exception of weak, focal staining for insulin (1 case), calcitonin (1 case) and somatostatin (2 cases). In 13 cases DNA indices and S-phase fractions (SPF) were determined by flow cytometry on nuclear suspensions from paraffin blocks. DNA histograms in 12 of 13 cases had normal range DNA content (diploid) and elevated S-phase fractions (mean 15%, range 8 to 22%). Mean SPF was not significantly different in the group of patients who developed recurrent and/or metastatic disease (15.6%, N = 10) compared with patients without recurrence (15.8%, N = 10).(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of crystalline inclusions in lung granulomas

We describe six examples of nonnecrotizing lung granulomatosis in which there were numerous polarizable crystalline inclusions. The crystals were easily visible in routine H&E-stained slides and were so prominent that the question of a pneumoconiosis or other exogenous source was raised. There was no clinical history to suggest an inhalational source, however, and no patient used intravenous drugs. In one case, an atypical mycobacterial infection was proven to be etiologic, while sarcoidosis was documented in three. A review of 63 additional consecutive lung biopsies and 24 extrapulmonary biopsies showing nonnecrotizing granulomatous inflammation demonstrated crystals in almost two-thirds of cases. X-ray spectroscopy and histochemistry demonstrated that the crystals contained mainly calcium oxalate and calcium carbonate and thus represented products of cellular metabolism. These findings emphasize that crystalline inclusions are common in lung granulomas of varying etiology. They may be numerous, and their presence does not necessarily indicate a pneumoconiosis or other exogenous source.

Relationship between rat renal accumulation of gentamicin, tobramycin, and netilmicin and their nephrotoxicities

Gentamicin, tobramycin, and netilmicin were given to rats in daily doses of either 5 or 20 mg/kg for 30 days to determine the renal accumulation kinetics of the compounds and to correlate steady-state renal parenchymal concentrations with nephrotoxicity. Four rats from each group were sacrificed daily and renal parenchymal tissue concentrations were determined microbiologically. Nephrotoxicity was assessed by changes in creatinine values in serum, renal creatinine clearances, and pathological scores. There was no indication of aminoglycoside-induced nephrotoxicity in any tests performed. The following steady-state levels resulted: 36, 148, and 176 micrograms/g after 5 mg/kg per day and 148, 260, and 510 micrograms/g after 20 mg/kg per day for tobramycin, gentamicin, and netilmicin, respectively. We conclude that aminoglycoside parenchymal accumulation in rats follows this order: tobramycin less than gentamicin less than netilmicin. Therefore, differences in the relative toxicities of gentamicin, tobramycin, and netilmicin do not correlate with the renal parenchymal accumulation of these agents and may be more dependent on intrinsic toxicity to the renal proximal tubule than to the concentration of the aminoglycoside in the kidney.