Curative effect of second curettage for treatment of gestational trophoblastic disease - Results of the Belgian registry for gestational trophoblastic disease

OBJECTIVE

We assessed the curative effect of a second curettage in patients with persistent hCG serum levels after first curettage for a gestational trophoblastic disease (GTD).

STUDY DESIGN

This prospective observational study used the data of the Belgian register for GTD between July 2012 and January 2017. We analysed the data of patients who underwent a second curettage. We included 313 patients in the database. Primary endpoints were need for second curettage and chemotherapy.

RESULTS

Thirty-seven patients of the study population (12 %) underwent a second curettage. 20 had persistent human chorionic gonadotropin hormone (hCG) elevation before second curettage. Of them, 9 patients (45 %) needed no further treatment afterwards. Eleven patients (55 %) needed further chemotherapy. Nine (82 %) were cured with single-agent chemotherapy and 2 patients (18 %) needed multi-agent chemotherapy. Of the 37 patients, patients with hCG levels below 5000 IU/L undergoing a second curettage were cured without chemotherapy in 65 % versus 45 % of patients with hCG level more than 5000 IU/L. Of the ten patients with a hCG level below 1000 IU/L, eight were cured without chemotherapy.

CONCLUSIONS

Patients with post-mole gestational trophoblastic neoplasia can benefit from a second curettage to avoid chemotherapy, especially when the hCG level is lower than 5000 IU/L.

[Belgian register and reference centers for gestational trophoblastic diseases]

Gestational trophoblastic diseases include placental pathologies comprising fertilization abnormalities (hydatidiform moles) and malignant lesions (choriocarcinoma, placental site trophoblastic tumor and epithelioid trophoblastic tumor). Due to their low incidence and heterogeneity, their diagnosis, management and treatment are not always optimal. Following the example of other European countries, a national registration system with two reference centers has been set up to guide physicians and patients and to propose individualized management. The centers offer their expertise through a systematic centralised pathology review by a panel of experts. HCG values are plotted in regression curves. In case of gestational trophoblastic neoplasia, an imaging work-up is proposed, from which the FIGO score and stage are derived and will guide the choice of treatment. Belgian centers offer a multidisciplinary approach, in partnership with the referent physician. More information for practitioners and patients is available on a web site: www.mole-chorio-bgog.eu, which also harbours a forum of discussion.

Assessment of proliferating activity in Paget's disease of the nipple by double stain immunohistochemistry

Paget disease of the nipple is a rare disease characterized by the presence of malignant glandular cells within the squamous epithelium of the nipple. The most common hypothesis to explain the development of Paget's disease is an intraepithelial epidermotropic migration of malignant epithelial cells originating from an underlying intraductal carcinoma. Although the immunohistochemical properties of Paget cells in the nipple have been extensively studied, their proliferating characteristics remain paradoxically poorly studied. In the present study we have investigated the proliferating activity of Paget cells in the nipple by using double stain immunohistochemistry with both Ki-67 (a protein which is expressed in all active parts of the cell cycle) and cytokeratin 7 (a highly sensitive marker of Paget cells). Ten cases of Paget's disease and the associated intraductal carcinomas (n = 10) and/or invasive carcinomas (n = 4) were tested. The mean Ki-67 index was in Paget's disease (26% +/- 10), in intraductal carcinomas (23% +/- 8) and/or in invasive carcinomas (20% +/- 8) (p > 0.05). This is the first report to convincingly demonstrate by specific double stain immunohistochemistry that Paget's disease and underlying intraductal carcinomas share a close proliferating activity.

An immunohistochemical study of abnormal keratinocyte proliferation in molluscum contagiosum

BACKGROUND

Molluscum contagiosum is a common cutaneous tumour that is characterized by usually spontaneous involution and self-limited spreading in immunocompetent individuals.

OBJECTIVE

We aimed to investigate the apoptosis and the expression of cell-cycle proteins in molluscum contagiosum lesions.

METHODS

The terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labelling (TUNEL)-based apoptotic index and the expression of the cell-cycle proteins Ki-67, p53, p21WAF and Bcl-2 were investigated in molluscum contagiosum lesions obtained from the trunk of 20 immunocompetent patients and in normal skin samples from the trunk of six healthy volunteers.

RESULTS

Whereas molluscum contagiosum lesions displayed a TUNEL-based apoptotic index similar to that of normal skin, they exhibited an increased Ki-67 index, which was confined to the basal and first suprabasal layers (P < 0.001). Compared with normal non-sun-exposed skin, molluscum contagiosum lesions also exhibited increased p53 staining in basal cells (P < 0.01), increased p21WAF in suprabasal cells (P < 0.001) and loss of Bcl-2 expression.

CONCLUSIONS

These results indicate that molluscum contagiosum lesions exhibit an increased proliferation rate of keratinocytes, which is likely to be partially counteracted by accumulation of p53.

Persisting active and proliferative intrinsic ureteral endometriosis under GNRH agonists therapy: a case with immunohistological study

We report the case of a 30-year-old patient who underwent a segmental ureteral resection with ureteroureterostomy because of the presence of a left ureterohydronephrosis caused by an intrinsic ureteral endometriotic lesion. Preoperatively, the patient received a 3 months course of GNRH agonists. The serum estradiol level was at 12 pg/ml at the moment of surgery. Histology and immunohistochemistry performed on the resected specimen showed the presence of numerous large haemorrhagic endometriotic foci containing very high levels of alpha-estrogen and progesterone nuclear receptors, a high Ki-67 labeling index and a strong positivity for EGF-receptor. This is the first report of immunohistochemical study performed on ureteral endometriosis preoperatively treated with GNRH agonists. Because hormonal treatments are often prescribed in the treatment of ureteral endometriosis, clinicians should be aware of the possibility of persisting very active and proliferative ureteral endometriotic lesions even under treatment with GNRH agonists and very low levels of circulating estradiol.

Early- and late-stage Kaposi's sarcoma-derived cells but not activated endothelial cells can invade de-epidermized dermis

Whether Kaposi's sarcoma is a true neoplasm or a reactive endothelial cell outgrowth triggered by inflammatory cytokines remains unclear. In this study, we investigated the differential invasive properties of activated endothelial cells and Kaposi's sarcoma cells in a model of de-epidermized dermis, supplying the cells with matrix barriers similar to those found in vivo. Cells derived from early "patch-stage" and from late "nodular-stage" Kaposi's sarcoma lesions exhibited similar invasive properties, which indicates that cells with an invasive potential are present in the early stages of tumor development. Slow accumulation of the cells into the extracellular matrix, together with a low proliferation index and with expression of anti-apoptotic proteins, suggest that the progression of Kaposi's sarcoma may be related to escape from cell death rather than to increased proliferation. The Kaposi's sarcoma-Y1 cell line, which is tumorigenic in nude mice, also exhibited invasive properties. By contrast to the Kaposi's sarcoma-derived spindle cells, however, which were scattered between the collagen bundles, the Kaposi's sarcoma-Y1 cell population had a higher proliferation index and displayed a multilayer arrangement. Inflammatory cytokines and Kaposi's sarcoma cell supernatant could activate and stimulate the growth of human dermal microvascular endothelial cell, but could not induce their invasion in this model, showing that activated endothelial cells do not fit all the requirements to traverse the various barriers found in the dermal extracellular matrix. These results confer to Kaposi's sarcoma cells a tumor phenotype and suggest that the in vivo dominant endothelial cell population represents a reactive hyperplasia rather than the true tumor process.

Iron induces Bcl-2 expression in human dermal microvascular endothelial cells

Iron is suspected to be involved in the induction and/or progression of various human tumors. The present study was designed to investigate the effects of iron on endothelial cells, keeping in mind that the homeostasis of microvessels plays a critical role in neo-angiogenesis. Applying a model of human dermal microvascular endothelial cell terminal differentiation and death induced by serum deprivation, we found that iron salts (iron chloride and ferric nitrilotriacetate) provided a survival advantage to endothelial cells. Using immunohistochemistry and Western Blot analysis, we found that the extended cellular life span induced by iron was paralleled by an increase of Bcl-2 protein expression. Taken together, these observations suggest that iron may give a survival advantage to endothelial cells and represent a novel mechanism through which iron may contribute to tumorigenesis.

Iron chelators inhibit the growth and induce the apoptosis of Kaposi's sarcoma cells and of their putative endothelial precursors

Iron is suspected to be involved in the induction and/or progression of various human tumors. More particularly, iron may be involved in the pathogenesis of Kaposi's sarcoma, a tumor of probable vascular origin. This study was designed to investigate the effect of iron deprivation on Kaposi's sarcoma. The effects of iron chelators and iron deprivation associated with serum withdrawal were investigated on Kaposi's sarcoma-derived spindle cells, on a transformed Kaposi's sarcoma cell line (Kaposi's sarcoma Y-1) and on endothelial cells, which are the probable progenitors of Kaposi's sarcoma cells. Desferrioxamine and deferiprone, two chemically unrelated iron chelators, induced a time- and concentration-dependent inhibition of endothelial and Kaposi's sarcoma cell growth. The inhibition of cell growth was associated with a decrease in Ki-67 and in both stable and total proliferating cell nuclear antigen expression. Inhibition of the progression through the G1-phase of the cell cycle was further evidenced by decreased expression of cyclin D1 and of p34 cyclin-dependent kinase 4. Terminal deoxynucleotidyl transferase-mediated desoxyuridinetriphosphate nick end labeling assay, flow cytometry with annexin-V-fluorescein and morphologic analysis indicated that iron chelation also induced a time- and concentration-dependent apoptosis. This apoptotic effect was prevented by the addition of exogenous iron. Induction of iron deprivation in the culture medium by serum withdrawal led to similar cell cycle effects, which, however, could only be partly reverted by the addition of exogenous iron. In conclusion, these results show that iron deprivation inhibits the growth and induces the apoptosis of Kaposi's sarcoma cells and of their putative endothelial precursors. This suggests that iron chelators may represent a potential therapeutic approach for the treatment of Kaposi's sarcoma.

Carcinoma of the glans penis arising 20 years after lichen sclerosus

Lichen sclerosis (LS) is an inflammatory disease of incompletely characterized pathogenesis. The relation between LS and carcinoma is well known in women, but in men it is still a matter of debate whether LS is a premalignant lesion or not. We describe a case of LS of the glans penis which occurred in 1976. Within the next 20 years, the patient developed carcinoma at this site.

Role of viral agents in the pathogenesis of Kaposi's sarcoma

Several viruses have been detected, at various frequencies, in Kaposi's sarcoma (KS) tissues. The detection of human herpesvirus 8 (HHV-8) in all the epidemiological and histological forms of KS makes it the most attractive candidate causative agent to date. In this report, we discuss the possible explanations for the detection of genomic sequences of various viral agents in KS and the putative role of those viruses in the pathogenesis of the disease.

Relationship between endometriotic foci and nerves in rectovaginal endometriotic nodules

The histological relationships between fibrotic tissue, endometriotic foci and nerves in the rectovaginal septum endometriotic or adenomyotic nodule were studied. This is considered to be one of the most severe forms of deep endometriosis. Masson's trichrome staining for fibrosis detection and immunohistochemistry with the S100 monoclonal antibody for nerve detection were performed in 28 rectovaginal endometriotic nodules from patients presenting with severe dysmenorrhoea and deep dyspareunia (23 patients with no other endometriotic location or potential cause of pain at laparoscopy and ultrasonography; five patients with multiple pelvic endometriotic localizations and other potential causes of pain at laparoscopy). Patients were allocated to two groups on the basis of their preoperative pain scores for pelvic pain, dysmenorrhoea and deep dyspareunia (group 1, score >7; group 2, score < or =7). For each symptom, the mean number of nerves and endometriotic lesions per high-power field and the mean largest diameter of the lesions were not statistically different in groups 1 and 2. The mean percentages of nerves located within the fibrosis of the nodule and within endometriotic lesions were significantly higher in group 1 than in group 2. Among nerves located within endometriotic lesions, there was a significantly higher proportion showing intraneurial and perineurial invasion by endometriosis in group 1 than in group 2. In rectovaginal endometriotic nodules, there was a close histological relationship between nerves and endometriotic foci, and between nerves and the fibrotic component of the nodule. We postulate that such topographical relationships could at least partially explain the strong association between this lesion and pain.

Multinucleate cell angiohistiocytoma: report of two cases with no evidence of human herpesvirus-8 infection

Multinucleate cell angiohistiocytoma (MCA) is a vascular tumor of unknown pathogenesis. Possible misinterpretation of this disorder with Kaposi's sarcoma (KS), a human herpesvirus-8 (HHV-8)-associated tumor, prompted us to look for this virus in two women with MCA. None of the multiple skin specimens obtained from both our patients produced amplified HHV-8 DNA. Using a cell culture methodology similar to that used for KS, we established cell cultures from MCA lesions. While KS spindle cells are known to exhibit in vitro invasive properties and can be grown up to more than 20 passages, the MCA-derived cells were short-lived and were not able to traverse basement membranes. Taken together, our data support the hypothesis that MCA is not a neoplasm but a benign vascular proliferation which is clearly distinguishable from KS.

Sigmoid endometriosis and ovarian stimulation

In-vitro fertilization (IVF) and ovarian stimulation are frequently performed in patients with endometriosis. Although endometriosis is a hormone-dependent disease, the rate of IVF complications related to endometriosis is low. We report four cases of severe digestive complications due to the rapid growth of sigmoid endometriosis under ovarian stimulation. In three patients, sigmoid endometriosis was diagnosed at laparoscopy for sterility. Because of the absence of digestive symptoms or repercussion on the bowel, no bowel resection was performed before ovarian stimulation. All patients experienced severe digestive symptoms during ovarian stimulation, and a segmental sigmoid resection had to be performed. Analysis of endoscopic and radiological data demonstrated that bowel lesions of small size may rapidly enlarge and become highly symptomatic under ovarian stimulation. At immunohistochemistry, these infiltrating lesions displayed high populations of steroid receptors and a high proliferative index (Ki-67 activity), suggesting a strong dependence on circulating ovarian hormones and a potential for rapid growth under supraphysiological oestrogen concentrations. Clinicians should be aware of this rare but severe digestive complication of ovarian stimulation. The early diagnosis of such lesions may help the patients to avoid months of morbidity falsely attributed to ovarian stimulation side effects. Further experience is necessary to determine the optimal attitude when diagnosing a small and asymptomatic endometriotic bowel lesion before ovarian stimulation.

Cidofovir, a new approach for the treatment of cervix intraepithelial neoplasia grade III (CIN III)

Cervix intraepithelial neoplasia grade III (CIN III) is an intraepithelial proliferative process with different levels of severity depending on both the extension of the proliferation in the epithelium and the presence of cellular atypia. Human papillomavirus (HPV) has been clearly associated with such lesions. The results of a preliminary study are described on the local application of cidofovir, an acyclic nucleoside phosphonate derivative with broad-spectrum anti-DNA virus activity for the treatment of CIN III. Cidofovir 1% in gel was applied three times, every other day, on the cervix of each of 15 women with biopsy proven CIN III. Within 1 month after the start of treatment, the cervix was removed surgically. Histology and human papillomavirus polymerase chain reaction (HPV-PCR) were carried out. In 7 of the 15 patients the histology showed a complete response, whereas 5 patients had a partial response characterized by the persistence of CIN II-III lesions, 1 patient had a dysplasia of lower grade (CIN I), and 2 patients did not show differences in the histology. Complete response was confirmed by PCR in 4 of the 7 patients, with complete response histologically. Cidofovir was not toxic to the normal epithelium. Cidofovir 1% gel was able to inhibit partially or completely cervical dysplasia lesions after only three applications (every other day). This effect was specific and tissue other than the dysplastic epithelium was not affected by the treatment.

Classic Kaposi's sarcoma after multiple-partner heterosexual behavior in Central Africa

We present a case of a possible sexual transmission of classic Kaposi's sarcoma. To our knowledge, this is the first report of such a case. We noted a long delay between the probable contaminant contact and onset of lesions, suggesting that human herpesvirus 8 has longer incubation periods in healthy individuals than in immunocompromised patients.

Penile intraepithelial neoplasia overlying Kaposi's sarcoma lesions: role of viral synergy?

Several viral agents have been detected in the lesional tissue of Kaposi's sarcoma (KS). Their precise oncogenic role remains to be determined. A 32-year-old heterosexual man with acquired immunodeficiency syndrome (AIDS) who had penile lesions of KS with overlying epithelial changes characteristic of intraepithelial neoplasia associated with concurrent infection by human papillomavirus (HPV) and human herpesvirus 8 (HHV-8) is reported. The absence of viral DNA from uninvolved skin suggests that this coinfection is more than coincidental and may involve synergy between these viruses, as has already been suggested for HPV and herpes simplex 2 virus.

Dual phase helical CT of a primary malignant fibrous histiocytoma of the right renal vein

A case is reported of primary malignant fibrous histiocytoma of the right renal vein involving the ipsilateral kidney which showed early enhancement on dual phase helical CT. The correct diagnosis of a primary tumour of the renal vein involving the kidney was not made but in retrospect could have been achieved pre-operatively by considering several CT features.

Adenoid cystic carcinoma of Bartholin's gland: what is the optimal approach?

AIMS AND METHODS

We report the case of a locally advanced adenoid cystic carcinoma of Bartholin's gland which required posterior pelvic exenteration, radical vulvectomy and ablation of the ischiorectal fossa in order to obtain tumour clearance with negative margins. Including this case, only three pelvectomies have been performed for this disease. This is the first reported case in which a controlateral unsuspected intravulvar metastasis was found on histology.

RESULTS AND CONCLUSIONS

No consensus exists on the adequate surgical management of this particular disease. Nevertheless, a review of the literature and this reported case suggest that radical vulvectomy with negative margins should be preferred to wide local excision as the primary surgical procedure. It also suggests that inguinofemoral lymph-node dissection should only be performed when suspect lymph nodes are found at clinical examination.

Sporadic carcinoid of the stomach: a highly proliferative disease with a probable role for p53 protein dysregulation

We describe here one case of sporadic carcinoid of the stomach, occurring in a 65-year-old man. It is a rare, recently recognized entity, with only few cases reported in the literature. We were able to detect strong MIB-1 and p53 expression in this tumour, with 86 and 80% of tumoral cells positive, respectively. These data suggest that gastric sporadic carcinoids are a highly proliferative entity probably induced by dysregulation of p53 function.

Correlation and prognostic significance of p53, p21WAF1/CIP1 and Ki-67 expression in patients with superficial bladder tumors treated with bacillus Calmette-Guerin intravesical therapy

PURPOSE

We determine if, before intravesical bacillus-Calmette Guerin (BCG) therapy, p53, p21WAF-1-CIP1 (a critical downstream effector of p53 pathway of cell growth control, inhibiting cyclin dependent kinases) and the cell proliferation marker Ki-67 (MIB-1) could be used as prognostic markers of response to BCG in patients with superficial bladder tumors.

MATERIALS AND METHODS

The study included 47 patients with superficial bladder tumors at high risk for recurrence or progression treated with 6 weekly intravesical BCG instillations. We analyzed p53, p21 and Ki-67 on paraffin embedded samples by immunohistochemistry and the percentage of positive cells was determined in a blinded fashion. Quantitative immunostaining was analyzed in relation to time to recurrence and progression using univariate or multivariate analysis and the Kaplan-Meier method.

RESULTS

During a mean followup of 24.6 months 23 of the 47 patients (48.9%) presented with tumor recurrence and 10 (21.2%) had later progression to invasive disease. A p21 over expression (greater than 10%) was observed in 23 tumors (48.9%) and positively correlated with p53 (p = 0.0097) but not with Ki-67 (p = 0.327). Of the tumors 18 (38.2%) were p53 and p21 negative. Among p21 positive tumors 15 (65.2%) were p53 and p21 positive, suggesting that p21 may also be regulated by p53 independent pathways. However, p53 did not act as a predictor of recurrence or progression. In contrast, using Kaplan-Meier curves p21 over expression (greater than 10%) and Ki-67 at a 25% cutoff were associated with shorter recurrence-free survival (both p = 0.02 log rank test) but they did not predict additional information about risk of progression. However, multivariate analysis failed to demonstrate any independent prognostic value for p21 or Ki-67 in contrast to tumor stage.

CONCLUSIONS

Our results indicate that p21WAF-1-CIP1 seems to be regulated by p53 independent pathways in superficial bladder cancer. The present study did not indicate an independent prognostic significance in patients treated with BCG for p53, p21WAF-1-CIP1 or Ki-67 markers. Larger prospective studies are needed to evaluate further the independent value of these biological markers in superficial bladder cancer management.

Early- and late-stage Kaposi's sarcoma lesions exhibit similar proliferation fraction

There are few studies on the proliferative activity of cells in Kaposi's sarcoma. It remains unclear whether the different progressive histologic stages of Kaposi's sarcoma correlate with the proliferative activity of the tumor. To clarify this issue, we studied the Ki-67 proliferation index in 40 specimens of acquired immune deficiency syndrome-related Kaposi's sarcoma in correlation with the histologic stage of the lesions. The mean proliferation index in our combined material was rather low (8%, range 1-20%) and there was no significant difference among the different stages of the disease. Contrary to a common and probably misleading concept, our results suggest that the histologic progression of the Kaposi's sarcoma is not related to an increase of the proliferative compartment.

Iron as a potential co-factor in the pathogenesis of Kaposi's sarcoma?

The role of iron in the pathogenesis of several tumours is being increasingly investigated. In particular, its involvement in the pathogenesis of Kaposi's sarcoma (KS) is suggested by the distribution of the endemic form of KS corresponding to continental rifts and associated iron-oxide-rich volcanic clays. We investigated in vitro to what extent iron supplementation or withdrawal could affect the growth of KS-derived cells, by analysing the effects of adding iron salts (iron chloride and ferric nitrilotriacetate) and/or reducing iron by iron chelators (desferrioxamine) on KS-derived cell cultures. The addition of iron salts strongly stimulated the growth of KS cells, as reflected by increase in thymidine incorporation and cell number. Conversely, desferrioxamine and deferiprone inhibited cell growth. The inhibitory effect of iron chelation was more pronounced on rapidly dividing basic fibroblast-growth-factor-stimulated cells. These results may point to a novel therapeutic approach to KS.

Overexpression of Bcl-2 in Kaposi's sarcoma-derived cells

The pathogenesis of Kaposi's sarcoma (KS), a tumor of probable vascular origin, remains an enigma. It is still unclear whether KS is a true malignancy or whether it represents a reactive polyclonal process. Using both an immunohistochemical and an immunoblot approach, we found that cells derived from KS lesions express significant levels of Bcl-2, a protein known to prolong cellular viability and to antagonize apoptosis. Bcl-2 expression was found in AIDS-related KS-derived cells, as well as in cells derived from iatrogenic and sporadic KS, indicating that Bcl-2 upregulation may be important in the pathogenesis of KS regardless of its epidemiologic form. By contrast, fibroblasts and dermal microvascular endothelial, cells which are the probable vascular progenitors of KS cells, expressed low levels of Bcl-2. The expression of Bcl-2 in KS-derived cells was associated with a long-term survival in serum-deprived conditions, a situation that has been shown to induce apoptosis in various cell types. Incubation of fibroblasts or of dermal microvascular endothelial cells with KS cell-free supernatants did not enhance Bcl-2 expression, suggesting that Bcl-2 expression is not mediated by an agent released by KS cells. Analogously, KS supernatants failed to promote the viability of fibroblasts and of dermal microvascular endothelial cells cultured in serum-free conditions. Our findings suggest that the spindle cells derived from KS have a survival advantage and may adequately represent the tumor cells of KS.

Treatment of classical Kaposi's sarcoma with intralesional injections of cidofovir: report of a case

The effect of intralesional injections of cidofovir, a nucleotide analog with potent in vitro activity against human herpesvirus 8 (HHV-8), was studied in vivo in an HIV-negative patient with classical Kaposi's sarcoma (KS). After five weekly injections of the drug, no clinical, histological, immunohistological, or virological changes could be detected in comparison with saline-injected lesions. These findings suggest that, once the KS tumor has developed, active viral replication is no longer involved in the pathogenesis of the disease. Alternative hypotheses are that HHV-8 replication in blood-borne cells may foster growth of spindle cells in the skin, or that blocking HHV-8 may not affect existing lesions but may prevent new lesions from developing.

Methotrexate induces apoptotic cell death in human keratinocytes

The mechanism by which low doses of methotrexate act in psoriasis to restore a clinically normal skin is poorly understood. Apoptosis is a programmed cell death activated when cell removal is needed. The purpose of the present work was to examine using an organotypical model of keratinocyte culture, the possibility that low doses of methotrexate can induce apoptosis of keratinocytes. Epidermal explants were cultivated on dead deepidermized dermis under air-exposed conditions. After 10 days, methotrexate (10(-7) M) was added. After a further 5 days, one part of each culture was fixed and submitted to routine histology, DNA nick end labelling (TUNEL) to detect DNA fragmentation (a molecular marker of apoptotic cell death) and immunohistochemical detection of p53 (a protein involved in apoptosis induced by DNA-damaging agents). The other part of each culture was processed for electron microscopy. A significant proportion of keratinocytes (1%) were damaged and exhibited the morphological features of apoptotic cell death. Immunohistochemical overexpression of p53 was detected in the basal layer of the cultures treated with methotrexate. Low doses of methotrexate induce apoptosis. This mode of action could explain the reduction in epidermal hyperplasia during treatment of psoriasis with methotrexate.

[Cap polyposis: a rare syndrome]

We report a case of inflammatory cap polyposis of the colon, a rare syndrome, affecting the rectosigmoid. It was observed in a context of mucous diarrhea. Endoscopic and radiological features consisted of elevated and umbilicated nodular lesions. Histology revealed polypoid lesions containing elongated crypts with superficial abrasions, covered by inflammatory and fibrinoid material. Etiopathogenesis of this new syndrome is unknown.

Percutaneous transperineal radiofrequency ablation of prostate tumour: safety, feasibility and pathological effects on human prostate cancer

OBJECTIVE

To evaluate the safety of radiofrequency (RF) energy delivered interstitially in patients with prostate cancer scheduled for radical prostatectomy and to correlate the proposed theoretical lesion size with the pathological findings.

PATIENTS AND METHODS

Radiofrequency interstitial tumour ablation (RITA) was performed in 15 patients with localized prostate cancer before radical surgery. RF energy was delivered to the prostate by active needle electrodes (monopolar or bipolar) placed transperineally under transrectal ultrasonography guidance. Needle electrodes were used with different configurations and in some cases were covered by retractable shields to vary the length and circumference of the thermal lesions created. In eight patients, the procedure was performed immediately before radical prostatectomy, in six RITA was performed under spinal anaesthesia 1 week before surgery and in one patient, no surgery was performed but the patient was followed by serial determinations of prostate specific antigen (PSA). At least two lesions were created in each prostate, including both capsule and peripheral zones. NADPH and haematoxylin & eosin (H&E) staining were used to assess the extent of the necrotic lesion in the radical prostatectomy specimen.

RESULTS

The mean energy delivered was 10.5 kJ, with central temperatures reaching up to 105 degrees C during 12 min of ablation; rectal temperature remained at < 38 degrees C. There were no complications. Macroscopic examination showed well-demarcated lesions including the prostatic capsule, up to 2.2 x 1.5 x 4.5 cm. With monopolar energy, the observed lesion size was comparable to the predicted 2 x 2 x 2 cm lesion, while with bipolar energy, lesion size was related to interneedle distance and uncovered needle length. Microscopic examination showed clearly delineated lesions both with NADPH (in prostates immediately removed after surgery) and H&E (at 1 week after RITA) staining. The lesion size observed on pathological analysis correlated with the predicted lesion size. In one patient, no residual cancer was found in the specimen. In the patient whose entire prostate was targeted and followed by serial PSA measurements, the latter were undetectable at 3 months of follow-up.

CONCLUSION

Transperineally delivered RF energy is capable of safely creating extensive coagulative necrotic lesions in prostate cancer tissue, in a reproducible and controlled manner. The results presented here provide basic information for the potential future application of this form of energy for localized prostate cancer.

Radiofrequency interstitial tumor ablation (RITA) is a possible new modality for treatment of renal cancer: ex vivo and in vivo experience

Small renal tumors are increasingly diagnosed and are frequently treated by nephron-sparing surgery. Tumors can be ablated by radiofrequency (RF) energy, which allows the operator to create very localized necrotic lesions. Radiofrequency interstitial tumor ablation (RITA) has been used in human kidneys in an ex vivo experiment to assess the necrotic lesions produced in a model close to physiologic conditions and then in three patients with localized renal cancer prior to radical nephrectomy. In the ex vivo model, four freshly removed kidneys were treated. Bipolar RF energy was delivered by a generator connected to two needles introduced parallel to each other into the renal parenchyma. A thermocouple was inserted between the two active electrodes. The renal artery at physiologic conditions was maintained at a constant temperature of perfusion of 37 degrees C by a computer-assisted Hot-line monitor. Two lesions were produced in each pole of each kidney including the cortex and the medulla. In an initial human study focusing on safety, feasibility, and pathology, three patients were treated by RITA with bipolar and monopolar energy. One patient with a peripheral 2-cm upper-pole tumor was treated percutaneously under ultrasound guidance with local anesthesia only 1 week prior to surgery. The other patients, with 3- and 5-cm tumors, were treated during surgery under general anesthesia just before nephrectomy. Ex vivo, the maximum temperature at the active needles ranged from 84 degrees C to 130 degrees C with 10 to 14 W applied during 10 to 14 minutes. Lesions were on average 2.2 x 3 x 2.5 cm.3 Microscopic examination showed stromal edema with intensive pyknosis. No damage was seen to adjacent untreated tissue. In the in vivo procedure, tolerance of RTA as an anesthesia-free procedure was excellent. The size of the observed lesions was comparable to the forecast size depending on the needle deployment. No side effects were noted, and no adjacent structures were affected by the RF ablation. These preliminary studies demonstrate the ability of RITA to produce localized extensive necrosis in kidney parenchyma and tumors safely under local anesthesia. Further studies could evaluate this new minimally invasive treatment in small kidney tumors considered for nephron-sparing surgery.

Possible mechanisms of action of transurethral needle ablation of the prostate on benign prostatic hyperplasia symptoms: a neurohistochemical study

PURPOSE

Transurethral needle ablation of benign prostatic hypertrophy (BPH) is a rapid, anesthesia-free outpatient procedure using low level radiofrequency energy that produces coagulative necrosis lesions at temperatures of approximately 100C. Clinically, significant improvement in objective and subjective parameters has been observed in BPH patients. Transurethral needle ablation has also been shown to be effective in relieving urinary retention. However, the precise mechanism of action of this procedure remains to be clarified. Ablation could produce its action on the dynamic component of the infravesical outlet obstruction. We analyzed the possible effects of transurethral needle ablation on the intraprostatic innervation.

MATERIALS AND METHODS

Histological sections from 10 open prostatectomy specimens (BPH) recovered 1 to 46 days after transurethral needle ablation were stained with hematoxylin and eosin and an immunohistochemical technique, using antibodies against S100 proteins and nonspecific enolase as specific nerve markers, and against anti-prostate specific antigen and anti-desmin for glandular and muscle cells, respectively. We used 5 BPH specimens as controls.

RESULTS

Microscopic examination of the treated areas showed necrotic lesions affecting epithelial and smooth muscle cells in the transition zone at a depth of 0.3 to 1.0 cm, from the preserved urethra. Nerve fibers in the control specimens and untreated prostatic areas were predominant in the urethral submucosal layer and in the stroma surrounding the epithelial nodules. No staining of any axon or isolated nerve cell was observed in any specimen treated by transurethral needle ablation, and there was a sharp and clear delineation between treated and untreated areas.

CONCLUSIONS

Our study demonstrated severe thermal damage to intraprostatic nerve fibers caused by transurethral needle ablation. A long-term denervation of alpha-receptors and/or sensory nerves could explain the clinical effects of transurethral needle ablation of the prostate. Theoretically, the best location to produce necrotic lesions should include submucosal and subcapsular nerve endings. Differences in the distribution of the adrenoreceptors and morphometry of the prostate transition zone could partly explain differences in clinical outcome observed after transurethral needle ablation of the prostate.

Herpesvirus-like DNA sequences and Kaposi's sarcoma: relationship with epidemiology, clinical spectrum, and histologic features

BACKGROUND

The evidence of an infectious agent other than human immunodeficiency virus (HIV) acting as a possible etiologic cause of Kaposi's sarcoma (KS) has received considerable attention in the last years. Recently, DNA sequences from a new herpesvirus (HHV-8) have been observed in several cases of KS. The discovery suggests that this virus may play a role in the pathogenesis of KS. To evaluate these results, we determined the frequency of HHV-8 DNA sequences in 78 specimens of KS according to different epidemiologic origins (sporadic KS: 6, immunosuppressive drug-associated: 11, and AIDS-associated: 61), clinical forms (cutaneous: 69, mucocutaneous: 4 and visceral; 5) and histologic variants (early-patch: 40, late-plaque or nodular: 38).

METHODS

We used the hot start polymerase chain reaction amplification method with KS330 primers specific for HHV-8 DNA. Tumoral or nontumoral skins and visceral specimens free of KS, originating from patients with KS positive for HHV-8 DNA sequences or from immunosuppressed patients without KS, served as controls. Normal skin from healthy HIV seronegative patients was also included.

RESULTS

HHV-8 DNA sequences were found in 3 of the 6 sporadic KS (50%), in 5 of the 11 immunosuppressive drug-associated KS (45%), in 41 of the 61 AIDS-associated KS (67%), in 32 of the 69 cutaneous KS (46%), in 3 of the 4 mucocutaneous KS (75%) in 2 of the 5 systemic KS (40%), in 23 of the 40 early or patchstage KS (58%), in 30 of the 38 late plaque or nodular stages KS (79%). These sequences were also demonstrated in one sample of skin with scabies and in a glomerulonephritis lesion from two immunosuppressed patients with KS who were also positive for herpesvirus-like in their KS lesions. None of the other skin or visceral specimens, originating from healthy, AIDS, or transplanted patients without KS, were positive.

CONCLUSIONS

Our results reinforce the hypothesis that HHV-8 is incriminated in different epidemiologic, clinical and histologic stages of KS and could contribute to the pathogenesis of this tumor. However, the presence of HHV-8 DNA sequences in skin and visceral samples free of KS from KS indicates that the virus is not restricted to the tumor tissue, and thus is able to disseminate in many organs of the target individual. Absence of the virus from healthy, AIDS, or transplanted patients without KS suggests that the viral Sequences either do not spread easily or do not easily maintain themselves in the human population.

Is one single prostate biopsy helpful for choosing a medical treatment of benign prostatic hyperplasia? A quantitative computerized morphometric study

OBJECTIVES

Individual differences in proportion of stroma, epithelium, and luminal space components prostatic hyperplasia (BPH) may explain the differences in clinical outcome of the patients treated with alpha-reductase inhibitors or alpha-blocking agents and other alternative treatments. Knowledge of the individual proportions of these elements may orient the clinician toward different therapeutic approaches. To determine whether a single prostate biopsy is representative of the whole adenoma, using quantitative morphometry, we have compared the percentage of smooth muscle cells and glandular cells in one prostate needle biopsy and in the corresponding prostate adenoma removed by open surgery.

METHODS

Quantification was made using a computerized image analysis system and immunohistochemical staining (actin antiactin for the smooth muscle cells and anti-prostate-specific antigen (PSA) for the epithelial cells) in 14 patients who underwent retropubic prostatectomy.

RESULTS

Mean percentage of smooth muscle fibers, glandular epithelium, and glandular lumina in the prostate biopsy were, respectively, 34% (range, 20% to 42%, SD 5.9), 29% (range, 13% to 42%, SD 7.2), and 20% (range, 13% to 30%, SD 4.8). In the corresponding prostate adenoma, they were, respectively, 38% (range, 28% to 45%, SD 4.7), 32% (range, 25% to 40%, SD 4.5), and 19% (range, 13% to 34%, SD 6.1). The mean percentages of epithelial or glandular cells in the prostate biopsy and the corresponding adenoma were not statistically different (P > 0.05), whereas those for the smooth muscle cell percentage were different (P = 0.02). However, a statistically significant correlation between the whole adenoma and the needle biopsy sample was found in the percentage of smooth muscle cells (P = 0.028). Analyzing the morphometric data in conjunction with the serum PSA level and the volume of the adenoma, we found a statistically significant positive correlation between the volume of the adenoma and the ratio (percentage of epithelial cells/serum PSA level) (P = 0.009, r = 0.67).

CONCLUSIONS

Major differences are found in the primary tissue composition of different hyperplastic prostates. Computerized histologic quantification of the different components of BPH in the entire adenoma and a needle biopsy demonstrate that a single prostate biopsy is representative of the entire prostate adenoma. Morphometric data from a single biopsy of the prostate adenoma in combination with the serum PSA level and the volume of the prostate adenoma could therefore help to orient medical treatment of BPH by patient selection based on the knowledge of the distribution of the various components of BPH.

p53 Protein overexpression in verrucous carcinoma of the skin

BACKGROUND

Verrucous carcinoma is a rare variant of well-differentiated squamous cell carcinoma which is characterized by a marked local aggressivity and a poor metastatic potential. Until now, little has been known about the oncogenic mechanisms of this tumor. Recently, extensive investigations have shown that p53 protein, a nuclear protein with oncogene-suppressing activity, may play a crucial role in cell transformation and immunoreactivity for this protein is found in a wide variety of cancers.

OBJECTIVE AND METHODS

The aim of the present study is to examine the frequency of immunohistochemically detectable p53 protein by using two monoclonal antibodies (D07 and BP53-12) in 8 cases of formalin-fixed and paraffin-embedded specimens of verrucous skin carcinoma.

RESULTS

Overexpression of p53 protein was detected in 6 (75%) of the cases examined with the D07 antibody and in 5 (62.5%) cases with BP53-12. The p53 positivity was shown in a peripheral distribution affecting mainly the basal cell layers of tumoral islands.

CONCLUSION

In a high percentage of verrucous carcinoma, p53 immunoreactivity has not been previously described in the literature and our findings suggest that abnormal expression of p53 tumor suppressor protein is a common event in the pathogenesis of this tumor.

Proliferating cell nuclear antigen distribution in verrucous carcinoma of the skin

Verrucous carcinoma (VC) of the skin is a rare variety of well-differentiated squamous cell carcinoma (SCC) characterized by aggressive local growth and a low metastatic potential. These tumours are known to have histological and virological features similar to classic warts or condylomata. The aim of the present study was to map the proliferative compartment in VC (n = 7) in comparison with warts (n = 10) and typical well-differentiated SCC (n = 10). The proliferating cells were detected by immunostaining of proliferating cell nuclear antigen (PCNA) in formalin-fixed, paraffin-embedded tissue sections, using the commercially available anti-PCNA monoclonal antibody PC10. Normal epidermis served as a positive control and reference. In VC and warts, the PCNA-positive cells were principally located at the periphery of lesions, in the basal layer of the tumour islands. In some warts, however, stronger PCNA expressed was noted in the superficial layers, of the lesions corresponding to virus-infected keratinocytes (koilocytotic cells). In contrast, in SCC, PCNA-positive cells were randomly scattered throughout the tumours. Our findings suggest that, on the basis of mapping of PCNA distribution, VC resembles large warts or condylomata rather than typical SCC. Thus, VC appears to be a distinct clinical entity, intermediate between these two types of lesions, not only because of its clinical entity, intermediate between these two types of lesions, not only because of its clinical and virological features, but also with regard to its proliferative organization.