Network module analysis and molecular docking-based study on the mechanism of astragali radix against non-small cell lung cancer

BACKGROUND

Most lung cancer patients worldwide (stage IV non-small cell lung cancer, NSCLC) have a poor survival: 25%-30% patients die < 3 months. Yet, of those surviving > 3 months, 10%-15% patients survive (very) long. Astragali radix (AR) is an effective traditional Chinese medicine widely used for non-small cell lung cancer (NSCLC). However, the pharmacological mechanisms of AR on NSCLC remain to be elucidated.

METHODS

Ultra Performance Liquid Chromatography system coupled with Q-Orbitrap HRMS (UPLC-Q-Orbitrap HRMS) was performed for the qualitative analysis of AR components. Then, network module analysis and molecular docking-based approach was conducted to explore underlying mechanisms of AR on NSCLC. The target genes of AR were obtained from four databases including TCMSP (Traditional Chinese Medicine Systems Pharmacology) database, ETCM (The Encyclopedia of TCM) database, HERB (A high-throughput experiment- and reference-guided database of TCM) database and BATMAN-TCM (a Bioinformatics Analysis Tool for Molecular mechanism of TCM) database. NSCLC related genes were screened by GEO (Gene Expression Omnibus) database. The STRING database was used for protein interaction network construction (PIN) of AR-NSCLC shared target genes. The critical PIN were further constructed based on the topological properties of network nodes. Afterwards the hub genes and network modules were analyzed, and enrichment analysis were employed by the R package clusterProfiler. The Autodock Vina was utilized for molecular docking, and the Gromacs was utilized for molecular dynamics simulations Furthermore, the survival analysis was performed based on TCGA (The Cancer Genome Atlas) database.

RESULTS

Seventy-seven AR components absorbed in blood were obtained. The critical network was constructed with 1447 nodes and 28,890 edges. Based on topological analysis, 6 hub target genes and 7 functional modules were gained. were obtained including TP53, SRC, UBC, CTNNB1, EP300, and RELA. After module analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis showed that AR may exert therapeutic effects on NSCLC by regulating JAK-STAT signaling pathway, PI3K-AKT signaling pathway, ErbB signaling pathway, as well as NFkB signaling pathway. After the intersection calculation of the hub targets and the proteins participated in the above pathways, TP53, SRC, EP300, and RELA were obtained. These proteins had good docking affinity with astragaloside IV. Furthermore, RELA was associated with poor prognosis of NSCLC patients.

CONCLUSIONS

This study could provide chemical component information references for further researches. The potential pharmacological mechanisms of AR on NSCLC were elucidated, promoting the clinical application of AR in treating NSCLC. RELA was selected as a promising candidate biomarker affecting the prognosis of NSCLC patients.

Network pharmacology analysis of the therapeutic mechanisms of the traditional Chinese herbal formula Lian Hua Qing Wen in Corona virus disease 2019 (COVID-19), gives fundamental support to the clinical use of LHQW

BACKGROUND

The traditional Chinese Medicine (TCM) herbal formula Lian Hua Qing Wen (LHQW) improves the results of COVID-19 treatment. Three very recent studies analyzed with network pharmacology some working mechanisms of LHQW. However, we used more techniques and also included Angiotensin converting enzyme 2 (ACE2) (a SARS-CoV receptor, possibly the viral entry point in alveolar lung cells) and the immune system, as cytokine storm is essential in the late phase.

PURPOSE

Extensive detailed Network Pharmacology analysis of the LHQW- treatment mechanism in COVID-19.

METHODS

TCM-herb-meridian and protein interaction network (PIN) of LHQW, based on LHQW herbs meridian information and the protein-protein interaction (PPI) information of the LHQW-component targets. Hub and topological property analyses to obtain crucial targets and construct the crucial LHQW-PIN. Functional modules determination using MCODE, GO and KEGG pathway analysis of biological processes and pathway enrichment. Intersection calculations between the LHQW-proteins and ACE2 co-expression-proteins.

RESULTS

LHQW herbs have relationships to Stomach-, Heart-, Liver- and Spleen-systems, but most (10 of the 13 herbs) to the Lung system, indicating specific effects in lung diseases. The crucial LHQW PIN has the scale-free property, contains 2,480 targets, 160,266 PPIs and thirty functional modules. Six modules are enriched in leukocyte-mediated immunity, the interferon-gamma-mediated signaling pathway, immune response regulating signaling pathway, interleukin 23 mediated signaling pathway and Fc gamma receptor-mediated phagocytosis (GO analysis). These 6 are also enriched in cancer, immune system-, and viral infection diseases (KEGG). LHQW shared 189 proteins with ACE2 co-expression proteins.

CONCLUSIONS

Detailed network analysis shows, that LHQW herbal TCM treatment modulates the inflammatory process, exerts antiviral effects and repairs lung injury. Moreover, it also relieves the "cytokine storm" and improves ACE2-expression-disorder-caused symptoms. These innovative findings give a rational pharmacological basis and support for treating COVID-19 and possibly other diseases with LHQW.

Evaluating supersaturation in vitro and predicting its performance in vivo with Biphasic gastrointestinal Simulator: A case study of a BCS IIB drug

This study aimed to develop an evaluation approach for supersaturation by employing an in vitro bio-mimicking apparatus designed to predict in vivo performance. The Biphasic Gastrointestinal Simulator (BGIS) is composed of three chambers with absorption phases that represent the stomach, duodenum, and jejunum, respectively. The concentration of apatinib in each chamber was detected by fiber optical probes in situ. The dissolution data and the pharmacokinetic data were correlated by Gastroplus^TM. The precipitates were characterized by polarizing microscope, Scanning Electron Microscopy, Powder X-ray diffraction and Differential scanning calorimetry. According to the results, Vinylpyrrolidone-vinyl acetate copolymer (CoPVP) prolonged supersaturation by improving solubility and inhibiting crystallization, while Hydroxypropyl methylcellulose (HPMC) prolonged supersaturation by inhibiting crystallization alone. Furthermore, a predictive in vitro-in vivo correlation was established, which confirmed the anti-precipitation effect of CoPVP and HPMC on in vitro performance and in vivo behavior. In conclusion, CoPVP and HPMC increased and prolonged the supersaturation of apatinib, and then improved its bioavailability. Moreover, BGIS was demonstrated to be a significant approach for simulating in vivo conditions for in vitro-in vivo correlation in a supersaturation study. This study presents a promising approach for evaluating supersaturation, screening precipitation inhibitors in vitro, and predicting their performances in vivo.

Assessing the prognostic value of PAX2 and PTEN in endometrial carcinogenesis

In order to avoid the consequences of over- and under-treatment of endometrial hyperplasia, diagnostic accuracy and progression risk assessment must be improved. The aim of this study was to assess whether PAX2 or PTEN expression could predict progression-free survival in endometrial intraepithelial neoplasia (EIN) and endometrial endometrioid carcinoma (EEC). Immunohistochemistry for detection of PAX2 and PTEN was performed on 348 endometrial samples; 75 proliferative endometrium (PE), 36 EIN and 237 EEC. Cases classified as PTEN null (1 or more glands negatively stained) were more prevalent in EEC than in PE and EIN (64% EEC vs 11% PE/EIN). A progressive decrease in PAX2 expression was observed from PE to EIN to EEC. Long-term clinical follow-up (6-310 months, median: 126) was available for 62 PE cases, all 36 EIN cases and 178 EEC cases. No patients with PE demonstrated progression to EIN or EEC. Progression of disease was observed in 10 (28%) EIN patients. These patients had significantly lower PAX2 expression than those that regressed (P = 0.005). Progression-free survival analysis revealed that EIN patients with a high-risk PAX2 expression score (H-score ≤75) had a higher probability of progression of disease in comparison to those with a low-risk score (H-score >75). PAX2 expression was not prognostic in EEC nor was PTEN status of prognostic value in either EIN or EEC. PAX2 expression analysis by means of H-score has prognostic potential for the identification of high-risk progression cases in EIN but needs to be validated in a larger cohort.

Abstract 4768: Paired box 2 (PAX2) is involved in carcinogenesis and regulated by DNA methylation in endometrial cancer

Objective: PAX2 is recognized as a significant factor in the development of urogenital system. It is expressed in multiple tumors and is essential in tumor cell survival. This study aimed to investigate the effect, expression, methylation of PAX2 in endometrial cancer, and the possible regulative mechanism of DNA methylation related PAX2 expression.

Methods: PAX2 expression in endometrial cancer, hyperplasia and normal tissues was detected by immunohistochemistry, and its expression in cell lines was measured by real-time PCR, western blot and immunocytochemistry. The role of PAX2 on cell viability and mobility was measured by CCK-8, invasion and migration assays. Bisulfite sequencing and MassARRAY were used to quantify the DNA methylation level of PAX2 promoter in endometrial cells and tissues. Deletion analysis of PAX2 promoter was performed by luciferase reporter gene to analyze its promoter activity. Transcription factors (TFs) combined with PAX2 promoter were forecasted by TF search database and the regulatory function of these TFs were measured by detecting the expression of PAX2 mRNA and protein following the knock down of these TFs.

Results: PAX2 was over-expressed in endometrial cancer tissues compared to hyperplasia and normal endometrium. Compare to normal endometrial epithelial cells, endometrial cancer cell lines exhibited moderate to high PAX2 expression. Knocking down PAX2 by siRNA reduced cell viability, invasion and migration, while PAX2 over-expression exhibited opposite role. The methylation level of PAX2 promoter was higher than normal counterparts in both cancer tissues and cells, which was positively related to PAX2 expression. After 5-Aza-CdR treatment, the PAX2 mRNA and protein was down-regulated along with the methylation level of PAX2 promoter. Deletion analysis confirmed that a repressive transcriptional regulatory region of PAX2 promoter coincided with the hypermethylated region found in MassARRAY analysis. The binding sites of myeloid zinc finger 1 (MZF1) and the early growth responsive gene 1(EGR-1) were found in the repressive transcriptional regulatory region of PAX2 promoter. Knocking down MZF1 or EGR-1 upregulated both the mRNA and protein level of PAX2 after 5-Aza-CdR treatment, which indicated that MZF1 and EGR-1 may act as repressive transcription factors in the DNA methylation related PAX2 transcription.

Conclusion: PAX2 is involved in carcinogenesis of endometrial cancer by stimulating cell growth and promoting cell motility. Overexpression of PAX2 in endometrial cancer may be regulated by promoter hypermethylation via repressive transcription factors such as MZF1 or EGR-1.

Citation Format: Nan Jia, Jieyu Wang, Qing Li, Xiang Tao, Keqin Hua, Yinhua Yu, Jan P. Baak, Kwong Kwok Wong, Weiwei Feng. Paired box 2 (PAX2) is involved in carcinogenesis and regulated by DNA methylation in endometrial cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4768. doi:10.1158/1538-7445.AM2015-4768

Vascular proliferation is a prognostic factor in breast cancer

Angiogenesis is important for the growth and spread of malignant tumors, and anti-angiogenesis treatment is currently being evaluated for breast cancer and other tumors. Although microvessel density is the most commonly used tissue-based marker of tumor associated angiogenesis, it has significant limitations and has not proven effective as a predictive factor in selecting patients for treatment. We here wanted to explore the significance of vascular endothelial cell proliferation in breast carcinoma. We examined microvessel proliferation in breast cancer by dual immunohistochemical staining, using the pan-endothelial marker Factor-VIII combined with proliferation of endothelial cells by Ki-67 expression, in three independent series of breast cancer, including a total of 499 patients and 141 events during follow-up. Common statistical tests of associations as well as univariate and multivariate regression analysis of patient survival were used. By counting vessels with actively proliferating endothelium, we show that microvascular proliferation is a significant predictor of disease progression in breast cancer, especially among high-grade and ER-negative tumors. Our findings indicate that this novel marker of active tumor angiogenesis might be of value in patient management and should be further studied in the context of patient selection for anti-angiogenesis treatment.

Biomarkers and microsatellite instability analysis of curettings can predict the behavior of FIGO stage I endometrial endometrioid adenocarcinoma

The prognostic value of molecular biomarkers, microsatellite instability, DNA ploidy and morphometric mean shortest nuclear axis in endometrial cancer is conflicting, possibly due to the fact that different studies have used mixtures of histotypes, FIGO stages and different non-standardized non-automated methods. We have evaluated the prognostic value of classical prognostic factors, molecular biomarkers, microsatellite instability, DNA ploidy and morphometric mean shortest nuclear axis in a population-based cohort of FIGO stage I endometrial endometrioid adenocarcinomas. Curettings of 224 FIGO stage I endometrial endometrioid adenocarcinoma patients were reviewed. Clinical information, including follow-up, was obtained from the patients' charts. Microsatellite instability and morphometric mean shortest nuclear axis were obtained in whole tissue sections and molecular biomarkers using tissue microarrays. DNA ploidy was analyzed by image cytometry. Univariate (Kaplan-Meier method) and multivariate (Cox model) survival analysis was performed. With median follow-up of 66 months (1-209), 14 (6%) patients developed metastases. Age, microsatellite instability, molecular biomarkers (p16, p21, p27, p53 and survivin) and morphometric mean shortest nuclear axis had prognostic value. With multivariate analysis, combined survivin, p21 and microsatellite instability overshadowed all other variables. Patients in which any of these features had favorable values had an excellent prognosis, in contrast to those with either high survivin or low p21 (97 vs 78% survival, P<0.0001, hazard ratio=7.8). Combined high survivin and low p21 values and microsatellite instability high identified a small subgroup with an especially poor prognosis (survival rate 57%, P=0.01, hazard ratio=5.6). We conclude that low p21 and high survivin expression are poor prognosis indicators in FIGO stage I endometrial endometrioid adenocarcinoma, especially when high microsatellite instability occurs.

High frequency microsatellite instability has a prognostic value in endometrial endometrioid adenocarcinoma, but only in FIGO stage 1 cases

OBJECTIVES

To analyze the prognostic value of microsatellite instability (MSI) in a population-based study of FIGO stage 1-4 endometrial endometrioid adenocarcinomas.

STUDY DESIGN

Survival analysis in 273 patients of MSI status and clinico-pathologic features. Using a highly sensitive pentaplex polymerase chain reaction to establish MSI status, cases were divided into microsatellite stable (MSS), MSI-low (MSI-L, 1 marker positive) and MSI-high (MSI-H, 2-5 markers positive).

RESULTS

After 61 months median follow-up (1-209), 34 (12.5%) of the patients developed metastases but only 6.4% of the FIGO-1. MSI (especially as MSI-H versus MSS/MSI-Lcombined) was prognostic in FIGO-1 but not in FIGO2-4. The 5 and 10 year recurrence-free survival rates were 98% and 95% in the MSS/MSI-L versus 85% and 73% in the MSI-H patients (P = 0.005).

CONCLUSIONS

MSI-H status assessed by pentaplex polymerase chain reaction is an indicator of poor prognosis in FIGO 1, but not in FIGO 2-4 endometrial endometrioid adenocarcinomas.

Abstract 3145: Comparing the reproducibility and prognostic value of proliferation markers Ki67, MAI, PPH3 in node negative breast cancer

Background. The proliferation factor Ki67 is prognostic but determination methods differ. Their reproducibility and independent prognostic value is largely unknown.

Aim. To evaluate the reproducibility of different Ki67 assessment methods and compare their prognostic value with Mitotic Activity Index (MAI), Phosphohistone-3 (PPH3) and other prognosticators.

Methods. In 240 T1,2N0M0 breast cancers without systemic adjuvant treatment, standardized automated quantitative immunohistochemistry was used for Ki7 and PPH3 and a strictly formalized protocol for MAI assessment. The percentages of Ki67 positive nuclei were assessed by two pathologists, computerized interactive morphometry (CIM) and fully automated digital image analysis (DIA). Reproducibility was studied by duplicate blind assessments. Continuous variables were discretized. We analyzed the prognostic value of widely used Ki67 thresholds (15%, 20%), others). We also tested at which places within the tumour (periphery, center), Ki67 was prognostically strongest. Univariate and multivariate survival analyses were performed.

Results. The Ki67 results of the two pathologists differed and their optimal prognostic thresholds greatly varied (4% and 14%). Moreover, Ki67% by one pathologist was well reproducible but not strongly prognostic, the other was strongly prognostic but not well reproducible. On the other hand, subjective Ki67% assessments were strongly prognostic (&lt;0.0001) over a wide range of Ki67% thresholds (between 5% and 20%) (with an optimum Hazard Ratio for thresholds between 10%-14%). DIA-Ki67 and CIM-Ki67 were very well reproducible (r&gt;0.99 and 0.94) and also strongly prognostic (P&lt;0.0001 for both methods). Ki67 determinations are prognostically strongest in the periphery of the tumor. DIA-Ki67-6.5 is the strongest prognosticator, overshadowing subjective Ki67 assessments, Ki67-15% and 20% thresholds, tumor diameter, grade, ER, PR, Her2, CK5-6. CIM-Ki67 is a cheap well reproducible strongly prognostic alternative. MAI (&lt;3 versus ≥3) or PPH3 (&lt;13 versus ≥13) were slightly prognostically stronger than Ki67-DIA and considerably stronger than Ki-67-CIM.

Conclusions. In node negative breast cancer without adjuvant systemic treatment, Ki67 by digital image analysis or computerized morphometry but not by subjective counts is well reproducible and prognostically strong. MAI or PPH3 were prognostically slightly stronger.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3145. doi:10.1158/1538-7445.AM2011-3145

Molecular biomarkers in endometrial hyperplasias predict cancer progression

OBJECTIVE

The purpose of this study was to assess the value of the 2003 World Health Organization (WHO) and endometrial intraepithelial neoplasia (EIN) classifications, D-score, and molecular biomarkers in endometrial hyperplasia (EH) for cancer progression.

STUDY DESIGN

We conducted a review of 307 endometrial hyperplasias for WHO and EIN classifications and an analysis of biomarkers, D-score, and cancer progression-free survival.

RESULTS

The WHO, EIN, D-score, and many biomarkers were prognostic; 7.2% of the samples progressed to cancer. The WHO and EIN classifications correlated weakly with CK5/6 and p16. The D-score was strongest prognostically. When >1, it had the lowest false-negative progression rate of all features analyzed. COX2 negativity was the only other independent multivariate cancer progression predictor in endometrial hyperplasia, but only in cases with D-score <1. Eight of 13 cases (61%), with a combined D-score of <1 and negative COX2 progressed, which contrasted with 3 of 139 of all other cases (2.8%) (P < .0001; hazard ratio, 53.0). The biomarkers did not strengthen the prognostic value of the WHO or EIN classification.

CONCLUSION

Combined D-score <1 and COX2 negativity strongly predict cancer progression in endometrial hyperplasias.

The impact of epithelial biomarkers, local immune response and human papillomavirus genotype in the regression of cervical intraepithelial neoplasia grades 2–3

Background and aims

15–30% of cases of cervical intraepithelial neoplasia grades 2–3 (CIN2–3) detected in punch biopsies regress spontaneously (ie, show CIN1 or less in the follow-up cone). Epithelial retinoblastoma protein (pRb), tumour suppressor protein (p53), HPV genotype and immunoreactive cells have been reported to be helpful in predicting regression but their interaction in regression prediction is unknown.

Material and methods

55 cases of CIN2–3 in cervical biopsies with subsequent cervical cones were studied retrospectively to assess how epithelial biomarkers, immunoreactive cells (with immunohistochemistry) and high-risk (hr) HPV genotypes (by the AMPLICOR and linear array tests) prognostically interact with epithelial pRb and p53.

Results

18% of CIN2–3s regressed (median biopsy–cone interval of 12.0 weeks, range 5.0–34.1 weeks). CIN2–3s that regressed had higher epithelial pRb and p53, lower stromal CD25+ and CD138+, and higher CD8 cells than persistent lesions. They also had higher ratios of CD4+/CD25+ and CD8+/CD25 in stroma and epithelium. HPV16 correlated with low pRb and low CD8+. With multivariate analysis a combined high ratio of CD8+/CD25+ in the stroma, high epithelial pRb and p53 expression had independent value to predict the regression.

Conclusions

CIN2–3 lesions with a non-hrHPV16 infection, high ratios of stromal CD8+/CD25+ and high epithelial expression of pRb or p53 are associated with spontaneous regression.

Counting of apoptotic cells: a methodological study in invasive breast cancer

Aims-To arrive at a reproducible sampling technique for counting apoptotic cells in tissue sections of invasive breast cancer that can serve as a protocol for further clinical studies.Methods-In 4 mum thick haematoxylin and eosin stained tissue sections of 12 breast cancers, apoptotic cells, recognised by strict morphological criteria, were counted in consecutive fields of vision at x1000 magnification in a marked area in the most poorly differentiated region of tumour. These counts were regarded as the gold standard. Subsequently, in a systematic sampling experiment, the number of fields that had to be counted to derive an acceptable coefficient of variation (CV) was determined. To compare counts at different magnifications, all fields of vision were also counted at x630 and x400. The intra- and inter-observer reproducibility was tested by repeated measurements at these magnifications in 10 systematically selected fields of vision.Results-Apoptosis seemed to be a rare event, affecting, on average, about 1% of tumour cells. Noticeable clustering of apoptotic cells was observed. The systematic sampling experiment showed that at x1000 magnification, the CV was improved by counting up to 20 fields. When comparing x400 and x630 magnifications with the x1000 magnification, the correlation coefficients were 0.88 and 0.87, respectively. However, the lower magnifications yielded lower counts. With regard to reproducibility, the intra-observer correlation coefficient was 0.91 at x630 and 0.76 at x400. The inter-observer correlation coefficient was 0.77 at x630 and 0.68 at x400.Conclusions-Apoptotic cells can be counted readily in haematoxylin and eosin stained tissue sections. However, a systematic sampling protocol must be followed and cells should be counted at a relatively high magnification to obtain acceptable reproducibility. The suggested protocol will permit further correlative and prognostic studies and the monitoring of the effects of treatment.

High frequency microsatellite instability has a prognostic value in endometrial endometrioid adenocarcinoma, but only in FIGO stage 1 cases

OBJECTIVES

to analyze the prognostic value of microsatellite instability (MSI) in a population-based study of FIGO stage 1-4 endometrial endometrioid adenocarcinomas.

STUDY DESIGN

survival analysis in 273 patients of MSI status and clinico-pathologic features. Using a highly sensitive pentaplex polymerase chain reaction to establish MSI status, cases were divided into microsatellite stable (MSS), MSI-low (MSI-L, 1 marker positive) and MSI-high (MSI-H, 2-5 markers positive).

RESULTS

after 61 months median follow-up (1-209), 34 (12.5%) of the patients developed metastases but only 6.4% of the FIGO 1. MSI (especially as MSI-H vs. MSS/MSI-Lcombined) was prognostic in FIGO 1 but not in FIGO 2-4. The 5 and 10 year recurrence-free survival rates were 98% and 95% in the MSS/MSI-L vs. 85% and 73% in the MSI-H patients (p=0.005).

CONCLUSIONS

MSI-H status assessed by pentaplex polymerase chain reaction is an indicator of poor prognosis in FIGO 1, but not in FIGO 2-4 endometrial endometrioid adenocarcinomas.

Patients with clinical/radiological hyperplasia of mammary glands show pathological persistence of temperature of skin points

BACKGROUND

Hyperplasia of mammary glands (HMG) is a frequent disease, with increased cancer risk for women aged 20-55 years. The aim of this study was to explore a non-invasive method to identify which patients with breast complaints need additional mammography for HMG diagnosis.

PATIENTS AND METHODS

Skin digital infrared thermal imaging (DITI) in 74 patients with HMG and 63 controls was carried out.

RESULTS

In the controls, the temperature of points close to the breasts and ovaries decreased with age. In women older than 39 years, HMG patients showed persistently high temperatures but in the lower extremities there were no differences. With a threshold for thoracic skin point KI21 of 33.2 degrees C, sensitivity and specificity in distinguishing controls from HMGs were 96% and 52% (p=0.0001) respectively, as validated in a test set, similar to recent DITI results for breast cancer detection.

CONCLUSION

Infrared temperature imaging of specific skin points is a rapid, non-invasive method to identify patients requiring mammography to confirm HMG.

Adenomyoepitheliomatous lesions of the mammary glands in transgenic mice with targeted PLAG1 overexpression

PLAG1 proto-oncogene overexpression has been causally linked to multiple tumors, highlighting its broad tumorigenic relevance. Here, the oncogenic potential of PLAG1 in mammary gland tumorigenesis was investigated in PLAG1 transgenic mice. To target mammary glands, mice of 2 independent PLAG1 transgenic strains, PTMS1 and PTMS2, in which PLAG1 expression can be modulated by Cre-mediation, were crossed with MMTV-Cre transgenic mice, resulting in P1-MCre and P2-MCre offspring, respectively. Hundred percentage of P1-MCre female mice showed mammary gland hyperplasia, caused by adenomyoepithelial adenosis, at 8 weeks. The tumorigenic process could not be studied further in P1-MCre mice, because concomitant fast-growing salivary gland tumors required euthanasia. Sixteen percentage of P2-MCre females developed mammary gland adenomyoepitheliomas within 30-45 weeks, and none displayed concomitant salivary gland tumors. To further study mammary gland tumorigenesis in PTMS1-derived mice, intercrossing with WAP-Cre transgenic mice, resulting in P1-WAPCre mice, was performed to target PLAG1 expression more specifically to mammary glands. Eighty percentage of such mice developed adenomyoepitheliomas within 53-88 weeks. All PLAG1-induced adenomyoepitheliomas revealed expression upregulation of Igf2/H19, Dlk1/Gtl2, Igfbps and Wnt signaling genes (Wnt6, Cyclin D1). Collectively, these results establish the oncogenic potential of PLAG1 in mammary glands of mice and point towards contributing roles of Igf and Wnt signaling.

The molecular genetics and morphometry-based endometrial intraepithelial neoplasia classification system predicts disease progression in endometrial hyperplasia more accurately than the 1994 World Health Organization classification system

BACKGROUND

The objective of this study was to compare the accuracy of disease progression prediction of the molecular genetics and morphometry-based Endometrial Intraepithelial Neoplasia (EIN) and World Health Organization 1994 (WHO94) classification systems in patients with endometrial hyperplasias.

METHODS

A multicenter, multivariate analysis was conducted on 477 patients with endometrial hyperplasia who were required to have a 1-year minimum disease-free interval from the time of the index biopsy (1-18 years of follow-up). The results from that analysis were compared with the results from 197 patients who had < 1 year of follow-up.

RESULTS

Twenty-four of 477 hyperplasias (5.0%) progressed to malignant disease over an average of 4 years (maximum, 10 years). According to the WHO94 classification, 16 of 123 atypical hyperplasias (13%) and 8 of 354 nonatypical hyperplasias (2.3%) progressed (hazard ratio [HR] = 7). Twenty-two of 118 EINs (19%) and 2 of 359 non-EINs (0.6%) progressed (HR = 45). EIN was prognostic within each WHO94 subcategory. Progression rates were 3% in simple hyperplasias, 22% in complex hyperplasias, 17% in simple atypical hyperplasias, and 38% in complex atypical hyperplasias with EIN, compared with progression rates of 0.0-2.0% in all hyperplasias if EIN was absent. EIN detected precancerous lesions (sensitivity, 92%) better than WHO94 atypical hyperplasias collectively (67%) or complex atypical hyperplasias alone (46%). In a Cox regression analysis, EIN was the strongest prognostic index of future endometrial carcinoma. The same was true for patients with < 1 year of follow-up (HR for EIN, atypical hyperplasia, and complex atypical hyperplasia: 58, 7, and 8, respectively).

CONCLUSIONS

The EIN classification system predicted disease progression more accurately than the WHO94 classification and identified many women with benign changes that would have been regarded as high risk according to the WHO94 classification system.

Evaluation of prospective, routine application of Ki-67 immunoquantitation in early CIN for assessment of short-term progression risk

OBJECTIVE

To prospectively validate, in early cervical intraepithelial neoplasia (CIN), routine assessment of a previously developed prognostic Ki-67 immunoquantitative progression-risk model.

STUDY DESIGN

Two hundred sixty-six consecutive cervical biopsies taken for an abnormal cytologic smear were routinely diagnosed by experienced pathologists as CIN. Ki-67 immunoquantitation was performed routinely by 3 technicians blinded to clinical and pathologic information. Progression of CIN 1-2 to CIN 3 in histologic follow-up biopsies was used as the intermediate end point.

RESULTS

In 58 (22%) biopsies, technical shortcomings prevented Ki-67 immunoquantitation, and in 22 biopsies no follow-up was available. The routine diagnosis in the 186 remaining biopsies was CIN 1 = 24, CIN 2 = 56 and CIN 3 = 106. In 52 marker biopsies with expert review diagnosis of CIN 1-2 and adequate follow-up, histologic biopsies revealed CIN 3 in 9 (17%) cases: 9 of 34 (26%) of Ki-67 high-risk and 0 of 18 (0%) of Ki-67 low-risk lesions (log rank = 5.0, P = .03). Routine CIN grade (1 or 2) was not prognostic (P = .65). Eleven (55%) of 20 CIN 1 and 7 of 32 (22%) CIN 2 cases were Ki-67 low risk and none progressed, contrasting with 4 of 9 (44%) progressions of Ki-67 high risk CIN 1s and 5 of 25 (20%) high risk CIN 2s. Expert CIN grades were stronger prognostically than routine CIN grade, but Ki-67 was still stronger.

CONCLUSION

Routine Ki-67 immunoquantitative progression prediction in CIN 1-2 is more predictive of CIN 3 in follow-up than are routine and review CIN grades.

Cytogenetic characteristics of oral squamous cell carcinomas in Fanconi anemia

Fanconi anemia (FA) is an autosomal recessive syndrome with a marked predisposition to malignancies, in particular acute myeloid leukemia and squamous cell carcinoma of the oral cavity. We examined oral squamous cell carcinoma tissue from two FA patients (FA-A and FA-C) by comparative genomic hybridization. Both tumors, which were negative for human papilloma as well as Epstein-Barr viral sequences, showed multiple alterations with a high proportion of whole-arm chromosomal gains and losses. This combination of features as well as the sites involved in chromosomal breakage are very similar to what is typically observed in non-FA oral tumors. These results suggest that the process leading to early occurrence of oral cancer in FA patients follows a similar pathway as in non-FA cancer patients, which would support a caretaker function for FA genes in the protection against oral carcinogenesis. Since FA patients are uniquely hypersensitive to DNA cross-linking agents, while oral cancer in the general population is thought to be environmentally induced, these results also suggest that environmental DNA cross-linkers may be causally involved in oral carcinogenesis.

Reproducibility and prognostic variability of grade and lamina propria invasion in stages Ta, T1 urothelial carcinoma of the bladder

PURPOSE

We assessed the reproducibility and prognostic variability of grade and lamina propria invasion in stages Ta, T1 urothelial carcinoma of the bladder.

MATERIALS AND METHODS

A total of 130 consecutive stages Ta, T1 urothelial carcinomas routinely diagnosed by 15 pathologists (original diagnosis) were reviewed by 3 independent experienced pathologists using 1999 WHO criteria (diagnoses 1 to 3 and reviewer consensus diagnosis). Interreviewer disagreement cases were blindly reviewed again. Each remaining disagreement case was discussed in a multihead microscope session to attempt to solve remaining disagreements. In cases of continuing disagreement the majority diagnosis on stage and grade was considered the consensus diagnosis. Stage progression at followup was the dependent variable. Stage progression-free Kaplan-Meier survival curves and hazard ratios of each stage and grade diagnosis were calculated and prognostic variability was determined.

RESULTS

There was complete interobserver agreement on stage and grade among reviewers in 80% and 59% of cases, while it was 87.7% and 75.4%, respectively, after the second review. More than 1 grade difference occurred in 1.5% of cases (0% after the second review). The consensus and original diagnoses agreed on stage and grade in 68.5% and 62.3% of cases, respectively. Assignment of individual cases to 1 category of the 1999 WHO classification per reviewer varied considerably. The incidence of cases classified as stage T1 grade 3 by the reviewers was between 12.3% and 18.9% (average 14.1%). Consensus diagnosis grade had the strongest prognostic value (HR 68.8, range 8.9 to 528.0). Of the 63 original diagnoses of stage T1 tumors the consensus diagnosis down staged 35 (55.6%) to Ta and up staged 8 (12.7%) to T2-3. Progression was more common in the 20 consensus diagnosis stage T1 cases (5 or 25%) than in the 55 original diagnosis stage T1 cases (11 or 20%). Original diagnosis stage T1 tumors that were down staged by the consensus diagnosis showed less progression than consensus diagnosis confirmed stage T1 tumors (17% versus 25%). The prognostically worst subgroup (T1 grade 3) also showed considerable prognostic variation among reviewers (28% to 76% at 5 years of followup), in that the consensus diagnosis again had the highest prognostic significance (HR 3.5, range 1.2 to 10.2). At the end of the study all pathologists expressed that they were regularly uncertain about stage and grade assessment in an individual case in a considerable percent of all cases.

CONCLUSIONS

Observer prognostic variability in staging and grading is considerable with potentially strong implications for patients. Interobserver variation did not decrease using the new 1999 WHO grading classification.

Relationship between the presence of oncogenic HPV DNA assessed by polymerase chain reaction and Ki-67 immunoquantitative features in cervical intraepithelial neoplasia

The aims of this study were firstly to determine which Ki-67 immunoquantitative parameters correlate with the presence of oncogenic human papillomavirus (HPV) in cervical intraepithelial neoplasia (CIN) lesions; and secondly to compare prospectively the routinely assessed CIN grades with the Ki-67 quantitative pathological CIN grade, the expert revised grade, and the presence of oncogenic HPV DNA. HPV polymerase chain reaction (PCR) and Ki-67 immunoquantitation were performed on 90 consecutive biopsies (16 CIN 1, 35 CIN 2, and 39 CIN 3). CIN grade was assessed routinely by six different pathologists. The presence of the lesion was confirmed in a histological section following the material used for PCR and Ki-67 analysis. In a second prospective routine test set analysis, 66 more CIN lesions (14 CIN 1, 15 CIN 2, and 37 CIN 3) were routinely graded (also by six different pathologists, routine CIN grade=CIN(ROUT)), studied for oncogenic HPV DNA, and graded by quantitative Ki-67 features (quantitative pathological CIN grade=CIN(QP)). These latter cases were blindly revised by one of the authors (reference CIN grade=CIN(REF)). Eight of the nine Ki-67 immunoquantitative features showed a significant difference between the oncogenic HPV-positive and -negative cases. The best single discriminator was the 90th percentile of the stratification index (SI90). All 61 cases with Ki-67 SI90>0.60 were HPV-positive (68% of the total group studied). Of the 29 cases with SI90< or =0.60, 16 were negative and 13 positive for oncogenic HPV and none of the Ki-67 features (either single or combined) could distinguish them. Using stepwise multivariate analysis, the best discriminating combination of features was SI90 and the percentage of Ki-67-positive nuclei in the deep third layer of the epithelium (PERC DL). The combination of SI90 and the percentage of Ki-67-positive nuclei per 100 microm basal membrane was nearly as strong as that of SI90 and PERC DL. With these two features, 86% of the cases were correctly classified. The subjective estimate of SI90 (>0.60 or < or =0.60) by two independent observers was not accurate and not reproducible. In the prospective routine test set analysis of 66 cases, the 37 CIN(ROUT)=3 all had CIN(QP) and CIN(REF)=3 and all these cases were oncogenic HPV-positive. Eight of the 14 original CIN(ROUT)=1 grades were oncogenic HPV (=HPV)-positive and five of these eight were upgraded by CIN(QP) to CIN 2 and CIN 3. These upgrades were in agreement with the blind reference revisions. The six HPV-negative CIN(ROUT)=1 cases were CIN 1 both by CIN(QP) and by CIN(REF). Thirteen of the 15 original CIN(ROUT)=2 grades were HPV-positive and seven of these were CIN(QP)=3. All six HPV-positive CIN(ROUT)=2 cases that were CIN(QP)=2 were also CIN(REF)=2 at blind revision. In conclusion, this study has shown firstly, that in CIN lesions, Ki-67 immunoquantitative features and the presence of oncogenic HPV are highly correlated, and also within one subjective CIN grade; secondly, that subjective impressions of SI90 are not as accurate or reproducible as quantitative image analysis results; and thirdly, that the routine application of QP CIN-grading gives results that are in very good agreement with CIN grades assessed by an expert. Thus, routine QP-grading may be used to correct the subjective grade assessed by non-expert pathologists.

Improved objectivity of grading of T(A,1) transitional cell carcinomas of the urinary bladder by quantitative nuclear and proliferation related features

AIM

To analyse whether the mean nuclear area of the 10 largest nuclei (MNA-10), the mitotic activity index (MAI), and Ki-67 immunoquantitative features have additional value to discriminate different grades of T(A,1) transitional cell carcinoma (TCC) of the urinary bladder.

MATERIALS/METHODS

One hundred and fifty of 200 consecutive cases (75%) showing interobserver agreement on duplicate blind grade assessment by independent pathologists were studied. Using random numbers, the 150 cases were divided into sets for learning (n = 75) and testing (n = 75). Single and multivariate analyses were applied to discriminate the different grades in the learning set. The multivariate classifier developed in this way was evaluated in the test set (n = 75).

RESULTS

With the MNA-10 alone, using the classification MNA-10 < 80 microm(2) = grade 1, 80 microm(2) < MNA-10 < 130 microm(2) = grade 2, MNA-10 > 130 microm(2) = grade 3, 71% of all 150 cases were correctly classified (69% of grade 1 v grade 2 and 76% of grade 2 v grade 3). With multivariate analysis, the best discriminating features in the learning set (17 grade 1, 30 grade 2, and 28 grade 3) between grades 1 and 2 were MNA-10 and MAI, and between grades 2 and 3 MAI and Ki-67. With these features, 94% of grade 1 v grade 2 and 97% of grade 2 v grade 3 were correctly classified in the learning set (overall, 95% correct, none of the grade 3 cases misclassified). In the test set the classification results were similar. When the three grades were entered at the same time for discrimination, Ki-67 area % and MAI was the best discriminating combination, both in the sets for learning and testing. Overall correct classification results in the sets for learning and testing were slightly lower, but still 94% and 92%. Most importantly, none of the grade 3 cases was misclassified; the classification shifts all occurred between grades 1 and 2.

CONCLUSIONS

The combination of MNA-10, MAI, and Ki-67 gives much better discrimination between grades 1, 2, and 3 in T(A,1) TCC of the urinary bladder than MNA-10 alone. The similarity of the classification results of the learning set and test set are encouraging and this quantitative pathological grading model should be applied in a prospective study.

Global expression changes of constitutive and hormonally regulated genes during endometrial neoplastic transformation

OBJECTIVE

Endometrioid endometrial carcinoma is caused by a combination of mutational events and hormonal factors. We used large-scale messenger RNA expression analysis to discover genes that distinguish neoplastic transformation and examine the patterns of tumor expression of those genes which are normally regulated during the menstrual cycle.

METHODS

Expression of approximately 6000 unique genes was quantified in 4 normal (2 proliferative, 2 secretory) and 10 malignant endometria using Affymetrix Hu6800 GeneChip probe arrays. Expression differences between normal and malignant tissue groups were measured by a test of statistical significance comparing the individual t statistic for each gene to the distribution of maximum t statistics among all genes following 1001 permutations of the tissue group assignments (Permax test). Hormonally responsive genes, selected by comparison of proliferative and secretory subsets of normal endometria using a combination of filters applied to the group means and t test rankings, were then examined in the tumors.

RESULTS

Fifty genes with a Permax <0.50 provided excellent discrimination between normal and malignant groups and were predominantly characterized by diminished expression levels in the cancers. We found that 100 genes which are hormonally regulated in normal tissues are expressed in a disordered and heterogeneous fashion in cancers, with tumors resembling proliferative more than secretory endometrium.

CONCLUSION

Neoplastic transformation is accompanied by predominant loss of activity of many genes constitutively expressed in normal source tissues and absence of expression profiles which characterize the antitumorigenic progestin response.

Quantitative assessment of gastric corpus atrophy in subjects using omeprazole: a randomized follow-up study

OBJECTIVES

Atrophy of the gastric mucosa most frequently results from chronic Helicobacter pylori infection and is a risk factor for the development of gastric cancer. Profound acid suppression has been suggested to accelerate the onset of gastric mucosal atrophy. The aim of the present study was to evaluate the effects of H. pylori eradication and acid inhibition by omeprazole on gastric atrophy by means of quantitative analysis of tissue morphology.

METHODS

Corpus biopsy specimens were obtained during endoscopy in 71 gastroesophageal reflux disease (GERD) patients at baseline and after 3 and 12 months. A total of 48 subjects were H. pylori positive and 23 were H. pylori negative. All subjects received omeprazole 40 mg once daily after the first endoscopy for 12 months. After randomization, 27 of the 48 H. pylori-positive patients also received eradication therapy. In hematoxylin and eosin-stained slides the volume percentages of glands (VPGL), volume percentages of stroma (VPS), and volume percentages of infiltrate (VPI) were measured in the glandular zone of the mucosa. The results were evaluated by computerized morphometric analysis.

RESULTS

In the eradication group, the mean VPGL increased from 63.0% to 67.7% and 71.5% after 3 and 12 months (p < 0.001), respectively. The mean VPS and VPI decreased from 33.1% and 4.0% to 29.3% and 3.0% and to 26.4% and 2.1% (p < 0.001 and p = 0.04), respectively. Patients with the lowest VPGL at baseline showed the largest increases of VPGL after eradication treatment as compared to patients with high a VPGL at baseline. In the H. pylori-persistent group the VPI showed a significant increase (p = 0.01), and in the H. pylori-negative group VPGL increased significantly from 71.9% to 75.2% (p = 0.03) after 12 months.

CONCLUSIONS

Eradication of H. pylori leads to restitution of the volume percentage of glandular epithelium to normal levels, even during treatment with proton pump inhibitors. Whether this effect can also be seen in patients with marked atrophy needs further investigation.

Comparative genomic hybridization of microdissected familial ovarian carcinoma: two deleted regions on chromosome 15q not previously identified in sporadic ovarian carcinoma

The vast majority of familial ovarian cancers harbor a germline mutation in either the breast cancer gene BRCA1 or BRCA2 tumor suppressor genes. However, mutations of these genes in sporadic ovarian cancer are rare. This suggests that in contrast to hereditary disease, BRCA1 and BRCA2 are not commonly involved in sporadic ovarian cancer and may indicate that there are two distinct pathways for the development of ovarian cancer. To characterize further differences between hereditary and sporadic cancers, the comparative genomic hybridization technique was employed to analyze changes in copy number of genetic material in a panel of 36 microdissected hereditary ovarian cancers. Gains at 8q23-qter (18 of 36, 5 cases with high-level amplifications), 3q26.3-qter (18 of 36, 2 cases with high-level amplifications), 11q22 (11 of 36) and 2q31-32 (8 of 36) were most frequent. Losses most frequently occurred (in decreasing order of frequency) on 8p21-pter (23 of 36), 16q22-pter (19 of 36), 22q13 (19 of 36), 9q31-33 (16 of 36), 12q24 (16 of 36), 15q11-15 (16 of 36), 17p12-13 (14 of 36), Xp21-22 (14 of 36), 20q13 (13 of 36), 15q24-25 (12 of 36), and 18q21 (12 of 36). Comparison with the literature revealed that the majority of these genetic alterations are also common in sporadic ovarian cancer. Deletions of 15q11-15, 15q24-25, 8p21-ter, 22q13, 12q24 and gains at 11q22, 13q22, and 17q23-25, however, appear to be specific to hereditary ovarian cancer. Aberrations at 15q11-15 and 15q24-25 have not yet been described in familial ovarian cancer. In these regions, important tumor suppressor genes, including the hRAD51 gene, are located. These and other yet unknown suppressor genes may be involved in a specific carcinogenic pathway for familial ovarian cancer and may explain the distinct clinical presentation and behavior of familial ovarian cancer.

Quantitative assessment of gastric corpus atrophy in subjects using omeprazole: a randomized follow-up study

OBJECTIVES

Atrophy of the gastric mucosa most frequently results from chronic Helicobacter pylori infection and is a risk factor for the development of gastric cancer. Profound acid suppression has been suggested to accelerate the onset of gastric mucosal atrophy. The aim of the present study was to evaluate the effects of H. pylori eradication and acid inhibition by omeprazole on gastric atrophy by means of quantitative analysis of tissue morphology.

METHODS

Corpus biopsy specimens were obtained during endoscopy in 71 gastroesophageal reflux disease (GERD) patients at baseline and after 3 and 12 months. A total of 48 subjects were H. pylori positive and 23 were H. pylori negative. All subjects received omeprazole 40 mg once daily after the first endoscopy for 12 months. After randomization, 27 of the 48 H. pylori-positive patients also received eradication therapy. In hematoxylin and eosin-stained slides the volume percentages of glands (VPGL), volume percentages of stroma (VPS), and volume percentages of infiltrate (VPI) were measured in the glandular zone of the mucosa. The results were evaluated by computerized morphometric analysis.

RESULTS

In the eradication group, the mean VPGL increased from 63.0% to 67.7% and 71.5% after 3 and 12 months (p < 0.001), respectively. The mean VPS and VPI decreased from 33.1% and 4.0% to 29.3% and 3.0% and to 26.4% and 2.1% (p < 0.001 and p = 0.04), respectively. Patients with the lowest VPGL at baseline showed the largest increases of VPGL after eradication treatment as compared to patients with high a VPGL at baseline. In the H. pylori-persistent group the VPI showed a significant increase (p = 0.01), and in the H. pylori-negative group VPGL increased significantly from 71.9% to 75.2% (p = 0.03) after 12 months.

CONCLUSIONS

Eradication of H. pylori leads to restitution of the volume percentage of glandular epithelium to normal levels, even during treatment with proton pump inhibitors. Whether this effect can also be seen in patients with marked atrophy needs further investigation.

Prognostic value of morphometry in patients with normal breast tissue or usual ductal hyperplasia of the breast

Women with usual ductal hyperplasia have a relative risk of 1.6-1.9 of subsequent breast cancer development. This slightly increased risk is generally not considered sufficiently high to justify (chemo)preventive therapy. It is therefore important to identify high-risk ductal hyperplastic lesions that would benefit from such a treatment. Nuclear morphometric features have been shown in previous work to be useful for objectively describing morphologic features associated with high risk in (pre)invasive breast lesions. The aim of this study was to evaluate whether such morphometric features can also predict subsequent invasive cancer development in patients with the common pattern of usual ductal hyperplasia or a normal breast biopsy. The present case-control study included 423 women with normal breast biopsies (n = 89) or biopsies containing usual ductal hyperplasia (n = 334). Of these 423 women, 132 developed invasive breast cancer during follow-up (mean 16.7 +/- 7.0 years). On the original hematoxylin and eosin-stained sections, nuclear morphometry was performed with a digitizing video overlay system, and mitotic and apoptotic indices were assessed. Patients with mean nuclear feature values for area, perimeter, diameter or longest axis above the 75th percentile had 1.6-1.7 times the breast cancer risk of women with mean nuclear feature values below this value. Pairwise combinations of these features yielded slightly higher cancer risks for the fourth quartile patients, with the highest risk (1.9) for patients with SD of nuclear area and perimeter values above the 75th percentile. The number of apoptotic or mitotic cells had no prognostic value for patients with apparently normal tissue or usual ductal hyperplasia. Our results give a first indication that normal breast tissue or usual ductal hyperplasia harbor nuclear morphologic changes that, when assessed by morphometry, may be used to predict breast cancer development. It is worthwhile studying this further in independent groups of patients with long-term follow-up.

Distinct chromosomal aberrations in Epstein-Barr virus-carrying gastric carcinomas tested by comparative genomic hybridization

BACKGROUND & AIMS

Approximately 10% of gastric adenocarcinomas carry the human pathogenic Epstein-Barr virus (EBV). The role of EBV in the pathogenesis of these carcinomas remains to be established.

METHODS

To obtain a comprehensive overview of chromosomal aberrations in EBV-carrying and EBV-negative gastric carcinomas we performed comparative genomic hybridization (CGH) on 44 gastric carcinomas, 10 EBV-positive, and 34 EBV-negative. Additionally, DNA flow cytometry was done.

RESULTS

Loss of chromosome 4p (P < 0.001) and of 11p (P < 0.02) was exclusively restricted to EBV-carrying gastric carcinomas. In addition, loss of 18q (P < 0.02) was significantly more frequent in EBV-carrying gastric carcinomas. The latter involves loci, which have already been linked to gastric carcinogenesis such as the DCC and SMAD4 gene. In contrast, the losses on chromosome 4 and 11 do not yet harbor a gene related to gastric carcinogenesis. No significant correlation was found between DNA-ploidy and the EBV-status. A number of chromosomal aberrations were found at comparable frequencies in both groups, i.e., losses of chromosome 17, 12q, and loss of 1p. Interestingly, gains of 13q (10/34) and 3q (5/34) and loss of 1q (5/34) were solely observed in EBV-negative gastric carcinomas.

CONCLUSIONS

These data indicate that EBV-carrying and EBV-negative gastric carcinomas have different pathogenetic pathways in which EBV might play a crucial role.

Prospective multicenter evaluation of the morphometric D-score for prediction of the outcome of endometrial hyperplasias

Prospective multicenter evaluation of the WHO classification and the morphometric D-score to predict endometrial hyperplasia cancer progression. In 132 endometrial hyperplasias WHO classification was performed by two experienced gynecologic pathologists. The D-score was assessed blindly by technicians in a routine diagnostic setting. Development of endometrial carcinoma during a 1-10-year follow-up was used as the end point. Eleven of 132 patients (8%), 10 of 61 (16%) atypical hyperplasias, and 1 of 71 (1%) nonatypical hyperplasias developed cancer. Twenty-six curettings had a D-score < or = 0 ("unfavorable" or endometrial intraepithelial neoplasia) of which 10 (38%) developed cancer. None of the 86 cases with a D-score > 1 ("favorable") and one of the 20 (5%) cases with 0 < D-score < or = 1 ("uncertain") developed cancer. Sensitivity of the D-score was 100%, specificity 82%, the positive and negative predictive values were 38% and 100%, respectively. These values are similar to those in three prior retrospective D-score studies but higher than the WHO values (which are 91%, 58%, 16%, and 99%, respectively). The D-score in endometrial hyperplasias is a more sensitive and specific marker for cancer prediction than the WHO classification, can be assessed in a routine clinical setting on standard hematoxylin and eosin sections (15-30 minutes per case), and is highly reproducible and cost-effective (U.S. $50 per case).

Similarity in expression of cell cycle proteins between in situ and invasive ductal breast lesions of same differentiation grade

There is increasing evidence that there are different progression routes leading to invasive breast cancer, depending on histology and differentiation grade. The aim of this study was to determine alterations in the expression of proteins involved in proliferation and apoptosis in non-invasive and invasive ductal breast lesions. Immunohistochemistry was performed on 106 usual ductal hyperplasias (UDH), 61 DCIS lesions and 53 invasive ductal breast carcinomas. Increased proliferation (Ki67), overexpression of cyclin D1, HER-2/neu, p21 and p53, and decreased expression of bcl-2 and p27 could already be found in UDH. Significant differences between UDH and DCIS lesions were found for only one protein when UDH was compared with well-differentiated DCIS (p27), for three proteins when compared with intermediately differentiated DCIS (p21, cyclin D1, Ki-67), and for all proteins when compared with poorly-differentiated DCIS. Comparing DCIS with invasive lesions of same differentiation grade, proliferation was elevated in the invasive lesions. Altered expression of the other proteins was in general only slightly increased in the invasive lesion compared with DCIS. The number of proteins with altered expression per lesion was highest in poorly-differentiated lesions and was comparable between DCIS and invasive cancer of the same differentiation grade. In conclusion, the biggest changes in expression of these proliferation and apoptosis related proteins appear to occur during the transition from hyperplasia to DCIS; they probably play a minor role in the transition from DCIS to invasive breast lesion of same differentiation grade. Well-differentiated in situ and invasive breast lesions share many of the aberrations in expression of these proteins, as do poorly-differentiated in situ and invasive lesions. However, there are many differences between the well and poorly-differentiated lesions. This further supports the existence of different progression routes leading to breast cancer.

Molecular identification of latent precancers in histologically normal endometrium

Discovery of somatically mutated cells in human tissues has been less frequent than would be predicted by in vitro mutational rates. We analyzed the PTEN tumor suppressor gene as an early marker for endometrial carcinogenesis, and we show that 43% of histologically normal premenopausal endometria contain rare glands that fail to express PTEN protein because of mutation and/or deletion. These persist between menstrual cycles. Histopathology of PTEN-null glands is initially unremarkable, but with progression, they form distinctive high-density clusters. These data are consistent with a progression model in which initial mutation is not rate limiting.

Expression of growth factors, growth factor receptors and apoptosis related proteins in invasive breast cancer: relation to apoptotic rate

PURPOSE

To assess the relation between growth factors, growth-factor receptors, p53, bcl-2 and bax expression, and the rate of apoptosis in invasive breast cancer patients.

MATERIALS AND METHODS

Tumors from 45 patients were assessed by immunohistochemistry for expression patterns of five growth factors and their receptors; platelet-derived growth factor A chain (PDGF-AA) and PDGF-receptor alpha (PDGFalphaR), PDGF-BB and PDGFbetaR, transforming growth-factor alpha (TGFalpha) and its receptor-epidermal growth factor receptor (EGFR) and vascular-endothelial growth factor (VEGF) and its receptors vascular-endothelial growth factor receptor I (FLT-1) and vascular-endothelial growth factor receptor II (FLK-1/KDR), two growth-inhibiting factors; transforming-growth factor beta I (TGFbeta1) and TGFbeta2 and their receptor couple TGFbeta receptor I (TGFbetaR-I) and TGFbetaR-II, and basic-fibroblast growth factor (bFGF). Besides, the expression patterns of the bcl-2, bax and p53 gene products were investigated. Expression patterns were correlated to the number of apoptotic cells assessed by light microscopy.

RESULTS

PDGF-BB and bFGF showed a positive correlation with the AI (p = 0.006 and p = 0.030, respectively). EGFR expression was associated with a high number of apoptotic cells but did not reach significance (p = 0.10). None of the other individual growth factors, growth-inhibiting factors or receptors showed a significant relation with the AI. The presence of a possible auto- or paracrine loop of the TGFalpha/EGFR combination was associated with a high number of apoptotic cells but did not reach significance (p = 0.20). PDGF-AA, bFGF and EGFR expression showed a significant relation to p53 overexpression. TGFbeta2 expression showed an inverse correlation with p53 overexpression.

CONCLUSION

We found an association between several growth factors and growth-factor receptors with number of apoptotic cells. This underlines the importance of growth factors and their receptors not just in proliferation, but also, directly and/or indirectly, in regulating the rate of apoptosis in invasive breast cancer. Growth factors and their receptors may therefore be useful as targets of anti-cancer therapy by inducing apoptosis or increasing the sensitivity of cells for chemo- or hormonal therapy induced apoptosis.

Hemostatic imbalance in active and quiescent ulcerative colitis

OBJECTIVE

In healthy conditions, factors inducing or inhibiting coagulation and factors inducing or inhibiting fibrinolysis are in balance. In ulcerative colitis, hypercoagulation is presumed, which may explain part of the clinical features of this disease. Therapy strategies affecting hemostasis may improve the course of ulcerative colitis. This study was conducted to evaluate the balance of coagulation and fibrinolysis in the course of treatment of active ulcerative colitis.

METHODS

Patients with active ulcerative colitis were studied by serial determination of markers of the coagulation cascade (thrombin-antithrombin complexes and fibrin degradation products [FbDP]) and the fibrinolytic cascade (fibrinogen degradation products [FgDP]). Parameters of inflammation were also measured (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], albumin, platelet count, and fibrinogen). Disease activity was assessed by endoscopic and histopathological scores. Follow-up measurement was performed in the course of treatment at the third or fourth month after baseline. Measurements were compared with healthy controls.

RESULTS

Thirty-three patients and 22 healthy controls were included. During active ulcerative colitis, inflammatory parameters (CRP, ESR, platelet count) and hemostatic parameters (thrombin-antithrombin complexes, fibrinogen, FgDP, and FbDP) were elevated in comparison with healthy controls. Albumin was decreased and antithrombin-III remained unchanged. During treatment, disease activity decreased significantly endoscopically and histopathologically (p < 0.001). CRP, ESR, platelet count, and fibrinogen also decreased significantly. The hemostatic balance, expressed as the ratio between the plasmin-dependent generation of FgDP and coagulation-dependent generation of FbDP, increased from 0.69 to 1.12 during treatment, mainly because of a decrease of FbDP. In healthy controls, this ratio was

CONCLUSIONS

The coagulation and fibrinolytic cascades were activated in active ulcerative colitis, with a hemostatic imbalance in favor of coagulation. This hypercoagulability persisted in 20% (7/33) of patients with ulcerative colitis in remission. The decrease of FbDP and the increase in the FgDP/FbDP ratio during reconvalescence of ulcerative colitis showed that the coagulation cascade was more activated than the fibrinolytic cascade in active disease.

Hemostatic imbalance in active and quiescent ulcerative colitis

OBJECTIVE

In healthy conditions, factors inducing or inhibiting coagulation and factors inducing or inhibiting fibrinolysis are in balance. In ulcerative colitis, hypercoagulation is presumed, which may explain part of the clinical features of this disease. Therapy strategies affecting hemostasis may improve the course of ulcerative colitis. This study was conducted to evaluate the balance of coagulation and fibrinolysis in the course of treatment of active ulcerative colitis.

METHODS

Patients with active ulcerative colitis were studied by serial determination of markers of the coagulation cascade (thrombin-antithrombin complexes and fibrin degradation products [FbDP]) and the fibrinolytic cascade (fibrinogen degradation products [FgDP]). Parameters of inflammation were also measured (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], albumin, platelet count, and fibrinogen). Disease activity was assessed by endoscopic and histopathological scores. Follow-up measurement was performed in the course of treatment at the third or fourth month after baseline. Measurements were compared with healthy controls.

RESULTS

Thirty-three patients and 22 healthy controls were included. During active ulcerative colitis, inflammatory parameters (CRP, ESR, platelet count) and hemostatic parameters (thrombin-antithrombin complexes, fibrinogen, FgDP, and FbDP) were elevated in comparison with healthy controls. Albumin was decreased and antithrombin-III remained unchanged. During treatment, disease activity decreased significantly endoscopically and histopathologically (p < 0.001). CRP, ESR, platelet count, and fibrinogen also decreased significantly. The hemostatic balance, expressed as the ratio between the plasmin-dependent generation of FgDP and coagulation-dependent generation of FbDP, increased from 0.69 to 1.12 during treatment, mainly because of a decrease of FbDP. In healthy controls, this ratio was

CONCLUSIONS

The coagulation and fibrinolytic cascades were activated in active ulcerative colitis, with a hemostatic imbalance in favor of coagulation. This hypercoagulability persisted in 20% (7/33) of patients with ulcerative colitis in remission. The decrease of FbDP and the increase in the FgDP/FbDP ratio during reconvalescence of ulcerative colitis showed that the coagulation cascade was more activated than the fibrinolytic cascade in active disease.

Quantitative immunohistochemistry of estrogen and progesterone receptor positivity in ovarian tumors : a rapid and reliable stereological approach

Several assays exist to determine receptor status in ovarian cancers, like radio ligand binding assays, biochemical analysis, and even Northern blotting. However, patholo- gists generally prefer to judge the presence of biological markers in the context of tissue architecture, using immunohistochemistry (IHC). This allows for a better appreciation of exactly what in a tumor is positive for staining, and what is not.

Nuclear cytometric changes in breast carcinogenesis

Breast cancer is thought to originate through progressively aberrant precursor lesions, paralleled by increasing morphological changes. The aim of this study was to quantify nuclear features by image cytometry in invasive breast cancer and its early (hyperplasia) and late (ductal carcinoma in situ) precursor lesions, in order to objectively describe nuclear changes in the spectrum of proliferative intraductal and invasive breast lesions. Image cytometry was performed on tissue sections of 20 samples of normal breast tissue, 71 of usual ductal hyperplasia (UDH), nine of atypical ductal hyperplasia (ADH), and 11 of well-differentiated and 13 of poorly differentiated ductal carcinoma in situ (DCIS) lesions. The invasive breast carcinomas consisted of 19 well-differentiated and 24 poorly differentiated lesions. Through the spectrum from normal breast tissue to invasive carcinoma, progressive changes in many nuclear features were measured. Significant differences were found between nuclei of florid ductal hyperplasia compared with mild and moderate ductal hyperplastic lesions, suggesting that florid ductal hyperplasia may be a more advanced lesion than assumed and may contain cancer precursor cells. No differences were found between ADH and well-differentiated DCIS, suggesting that these lesions are closely related. Feature values of well-differentiated DCIS were comparable to values found in well-differentiated invasive carcinoma and the same applied to poorly differentiated DCIS and invasive lesions. These results support the hypothesis that breast cancer develops through different routes of progression, one leading to well-differentiated invasive cancer through well-differentiated DCIS, and one leading to poorly differentiated invasive cancer through poorly differentiated DCIS. In conclusion, image cytometry reveals progressive changes in nuclear morphological and subvisual chromatin distribution features in the spectrum from intraductal proliferations to invasive breast cancer. This provides evidence for a progression from usual to atypical ductal hyperplasia and then to invasive cancer, through different routes for well-differentiated and poorly differentiated lesions.

Ki-67 immunoquantitation in cervical intraepithelial neoplasia (CIN): a sensitive marker for grading

The aim of this study was to assess the value of Ki-67 immunoquantitation with a computerized image analysis system for grading support in cervical intraepithelial neoplasia (CIN). Sixty-five 'blind' consensus biopsies (23 CIN 1, 22 CIN 2, and 20 CIN 3) were used as a learning set. Measurements were done in the carefully selected most severely dysplastic part of the epithelium of each CIN case. The resulting discriminating combination of quantitative features was then prospectively applied on 121 new biopsies (test set) and compared with the classical CIN grade assessed routinely by six different pathologists and with the blind review grades assessed by two experienced pathologists. In the learning set of 65 cases, a jack-knifed stepwise discriminant analysis showed that the 90th percentile of the stratification index and the number of positive nuclei per 100 microm basal membrane are the best discriminating set of features to distinguish the three CIN grades at the same time. With these features, two CIN 1 cases were 'misclassified' as CIN 2 and nine CIN 2 cases as CIN 3. Overall agreement, therefore, was only 83%. However, recut of the paraffin blocks in the two 'misclassified' CIN 1 cases revealed CIN 2 in the first and CIN 3 in the other, while the other CIN 1 cases that were correctly classified with Ki-67 quantitation remained CIN 1. Likewise, nine CIN 2 cases were misclassified as CIN 3, but in two of these nine cases histological follow-up clearly indicated CIN 3. Agreement may thus be higher than the 83% in the learning set suggests. In the subsequent prospective evaluation on 121 routine CIN cases (test set), agreement between routine CIN grades (by six independent different pathologists) and quantitative Ki-67 classification was 78%. However, when compared with the blind review CIN grades of two expert pathologists, agreement was 97% and sensitivity, specificity, and positive and negative predictive value were very high. It is concluded that Ki-67 immunoquantitation is a useful diagnostic adjunct to distinguish different CIN grades and may also be a sensitive biological indicator of progression of seemingly low-grade CIN.

Comprehensive Cancer Centre Amsterdam Barrett Advisory Committee: first results

BACKGROUND

Treatment and follow-up policy for Barrett's oesophagus are dependent on the grade of dysplasia. However, sampling error of random biopsy protocols and subjectivity of pathological grading may hamper endoscopic surveillance.

METHODS

The Amsterdam Comprehensive Cancer Center Barrett Advisory Committee (BAC) is a regional multidisciplinary consultative working-group, offering revision of pathology, revision of pathology plus additional endoscopic diagnostics, or referral for treatment.

RESULTS

Between July 1998 and July 1999 30 patients were referred to the B.A.C for advice; eighteen patients were referred because of suspicion of high grade dysplasia. Reassessment of biopsies, including additional quantitative pathology, with or without additional endoscopic diagnostics, led to adjustment of the grading of dysplasia in 15 patients (50%). A suspicion of low grade dysplasia was rejected in nine out of ten cases. Adjustment of the original diagnosis often influenced further therapy or follow-up.

CONCLUSIONS

reassessment of conventional pathology, quantitative pathology, and additional diagnostic procedures might improve the accuracy of diagnosis and staging of malignant degeneration of Barrett's oesophagus, although experience is still limited. The complexity of the management of these patients demands a specialised multidisciplinary approach. A Barrett Advisory Committee can offer valuable contributions to the treatment of patients with Barrett's oesophagus.

Fourth updated ESACP consensus report on diagnostic DNA image cytometry

A task force of experts in the field of diagnostic DNA image cytometry, invited by the ESACP, and further scientists or physicians revealing experience in that diagnostic procedure (names are given in Addendum A), agreed upon the following 4th updated Consensus Report on Standardised Diagnostic DNA Image Cytometry during the 7th International Congress of that society in Caen, 2001. This report is based on the three preceding ones [6,14,17]. It deals with the following items:- Critical review and update of the definitions given in the 1997 Consensus Update;- Review and detailed description of basic terms, principles and algorithms for diagnostic interpretation;- Recommendations concerning diagnostic or prognostic applications in specific fields of tumour pathology. This update is not aimed to substitute the 1997 consensus, but to make necessary addenda and give more detailed descriptions of those items not unequivocally to interpret by potential users of the methodology.

Rapid quantitative assessment of gastric corpus atrophy in tissue sections

BACKGROUND/AIMS

Grading of Helicobacter pylori induced atrophic gastritis using the updated Sydney system is severely limited by high interobserver variability. The aim of this study was to set up a quantitative test of gastric corpus mucosal atrophy in tissue sections and test its reproducibility and correlation with the Sydney scores of atrophy.

METHOD

Mucosal atrophy was assessed in 124 haematoxylin and eosin stained corpus biopsy specimens by two experienced gastrointestinal pathologists (EB, JL) according to the updated Sydney system as none (n = 33), mild (n = 33), moderate (n = 33), or pronounced (n = 25). In each specimen, the proportions of glands, stroma, infiltrate, and intestinal metaplasia in the glandular zone were measured as volume percentages using a point counting method. The optimal point sample size, intra-observer and interobserver reproducibility, discriminative power for degrees of atrophy, and correlations with H pylori status were evaluated.

RESULTS

Counting 400 points in 200 fields of vision provided the smallest sample size that still had excellent intra-observer and interobserver reproducibility (r > or = 0.96). Overall, the volume percentage of glands (VPGL), infiltrate (VPI), and stroma (VPS) correlated well with the Sydney scores for atrophy (p < or = 0.003). However, no differences were found between non-atrophic mucosa and mild atrophy. No correlation was found between age and either the Sydney grade of atrophy or the VPGL or VPS. In non-atrophic mucosa and mild atrophy, H pylori positive cases showed a significantly higher VPI than did H pylori negative cases. A lower VPGL was seen in H pylori positive cases than in H pylori negative cases in the mild atrophy group. VPS did not correlate with H pylori status within each grade of atrophy.

CONCLUSION

Point counting is a powerful and reproducible tool for the quantitative analysis of mucosal corpus atrophy in tissue sections. These data favour the combination of "none" and "mild" atrophy into one category, resulting in a three class grading system for corpus atrophy, when using the updated Sydney system.

Helicobacter pylori-related and -non-related gastric cancers do not differ with respect to chromosomal aberrations

Gastric carcinogenesis is strongly associated with Helicobacter pylori infection, but the underlying genetic mechanisms are largely unknown. The aim of this study was to correlate chromosomal aberrations in gastric cancer to H. pylori status and its different strains, as well as to histological type and other clinico-pathological variables. DNA from 46 gastric cancers (male/female 35/11, age 27-85 years) was extracted from formaldehyde-fixed, paraffin-embedded material and tested for chromosomal gains and losses by comparative genomic hybridization (CGH). Chromosomal aberrations with frequencies of 20% or higher were considered to be non-random changes associated with gastric cancer. The mean number of chromosomal events per tumour was 9.7 (range 0-27), with a mean of 3.2 gains (range 0-16) and 6.5 losses (range 0-15). Gains were most frequently found at chromosomes 8q and 13q (24% and 26%, respectively). Losses were predominantly found on chromosome arms 2q, 9p, 12q, 14q, 15q, 16p, 16q, 17p, 17q, 19p, 19q, and 22q (22%, 30%, 43%, 22%, 33%, 50%, 28%, 50%, 39%, 33%, 39%, and 37%, respectively). Common regions of overlap narrowed down to 2q11-14, 8q23, 9p21, 12q24, 13q21-22, 14q24 and 15q11-15. The mean number of gains was higher in tumours with metastases than in localized tumours (4.1 vs. 1.9, p=0.04). Tumours with a loss at 17p showed a higher number of losses than tumours without a 17p loss (9. 5 vs. 4.7 on average, p<0.001). Neither H. pylori status (+, n=25; -, n=21) nor H. pylori strain was correlated to the total number of events or to any specific chromosomal aberration, nor were there differences between intestinal (n=30) and diffuse (n=15) cancers or any other clinico-pathological variable tested. In conclusion, a complex of chromosomal aberrations is involved in gastric cancer, but their pattern does not depend on H. pylori status or strain, nor on the histological type of the tumour. The exact biological meaning of these aberrations in carcinogenesis needs further clarification.

Computerised morphometrical analysis in endometrial hyperplasia for the prediction of cancer development. A long-term retrospective study from northern Norway

AIMS

To evaluate and compare the long term prognostic value of the WHO classification and the computerised multivariate morphometrical D score in endometrial hyperplasia. To test the reproducibility of the D score in two different centres.

METHODS

Histopathological WHO classification and computerised morphometrical analysis using the D score (< 0, high risk; > 1, low risk; 0-1, uncertain) in a population based study from northern Norway of archival dilatation and curettage material from 68 women with 10-20 years of follow up.

RESULTS

Of the 68 patients included in the study, 18 developed cancer. The sensitivity and specificity of the D score (< 0 v > 1) were 100% and 78%, respectively, which was better than the WHO classification (89% and 60%, respectively). The negative and positive predictive values for the D score were 100% and 58% and of the WHO classification 94% and 44%, respectively. This study found a slightly higher specificity for the D score than former retrospective studies, but otherwise the results were comparable. The D score results were reproducible between the two centres (R = 0.91; slope = 0.98; intercept = 0.3).

CONCLUSIONS

D score assessment is a reproducible and more accurate predictor of outcome of endometrial hyperplasia than the WHO classification assessed by an experienced gynaecological pathologist. Routine application of the D score might reduce over and undertreatment of endometrial hyperplasia.

Altered PTEN expression as a diagnostic marker for the earliest endometrial precancers

BACKGROUND

PTEN tumor suppressor gene mutations are the most frequent genetic lesions in endometrial adenocarcinomas of the endometrioid subtype. Testing the hypothesis that altered PTEN function precedes the appearance of endometrial adenocarcinoma has been difficult, however, partly because of uncertainties in precancer diagnosis.

METHODS

Two series of endometrial cancer and precancer (endometrial intraepithelial neoplasia, as diagnosed by computerized morphometric analysis) tissue samples were studied, one for PTEN mutations by the use of denaturing gradient gel electrophoresis and another for PTEN protein expression by immunohistochemistry. Endometria altered by high estrogen levels that are unopposed by progestins-conditions known to increase cancer risk-were also studied by immunohistochemistry. Fisher's exact test was used for statistical analysis.

RESULTS

The PTEN mutation rate was 83% (25 of 30) in endometrioid endometrial adenocarcinomas and 55% (16 of 29) in precancers, and the difference in number of mutations was statistically significant (two-sided P =.025). No normal endometria showed PTEN mutations. Although most precancers and cancers had a mutation in only one PTEN allele, endometrioid endometrial adenocarcinomas showed complete loss of PTEN protein expression in 61% (20 of 33) of cases, and 97% (32 of 33) showed at least some diminution in expression. Cancers and most precancers exhibited contiguous groups of PTEN-negative glands, while endometria altered by unopposed estrogens showed isolated PTEN-negative glands.

CONCLUSIONS

Loss of PTEN function by mutational or other mechanisms is an early event in endometrial tumorigenesis that may occur in response to known endocrine risk factors and offers an informative immunohistochemical biomarker for premalignant disease. Individual PTEN-negative glands in estrogen-exposed endometria are the earliest recognizable stage of endometrial carcinogenesis. Proliferation into dense clusters that form discrete premalignant lesions follows.

Hot spot microvessel density and the mitotic activity index are strong additional prognostic indicators in invasive breast cancer

AIMS

Recent studies have drawn attention to intratumoral microvessel density (MVD) as a prognostic factor in invasive breast cancer. Various methods have been applied to assess MVD and the prognostic value of MVD in different studies varies considerably. Counting of microvessels in the most highly vascularized area (hot spot) of a tumour is the method most widely used. In this study we compared three counting methods.

METHODS AND RESULTS

To assess MVD in 112 cases of invasive breast cancer with long-term follow-up we performed microvessel counting in the hot spot of the tumour in four and 10 fields of vision (HS-MVD4 and HS-MVD10) and microvessel counting in 10 fields of vision distributed systematically over the whole tumour area (global MVD). The HS-MVD4, HS-MVD10 and global MVD showed good correlations with each other. HS-MVD4 provided the highest number of microvessels (median value 71) followed by HS-MVD10 and global MVD, with median values of 58 and 39, respectively. HS-MVD4 showed the best prognostic value for overall survival (P = 0.0001) whereas HS-MVD10 showed less (P = 0.01) and the global MVD showed no (P = 0.75) prognostic value. In univariate analysis, the HS-MVD4 was the second strongest prognostic factor after tumour size. In multivariate survival analysis, the HS-MVD4, mitotic activity index (MAI), lymph node status and tumour size were found to be independent prognostic factors. When combining MVD4 and MAI in lymph node negative patients, none of the patients with low MVD (< 71/mm2) and a low MAI (< 10 per 10 HPF) died, in contrast to patients with a high MVD or high MAI who have a 10-year survival of 57%.

CONCLUSIONS

These data suggest that the hot spot MVD in four fields of vision is a major independent prognostic factor for overall survival in invasive breast cancer. For the first time, it is shown that hot spot MVD provides additional prognostic information to well established factors like lymph node status and the MAI, and may therefore be useful for designing treatment strategies in invasive breast cancer.

Computerized quantitative pathology for the grading of dysplasia in surveillance biopsies of Barrett's oesophagus

Decision models for surveillance of Barrett's oesophagus (BO) are governed by the grade of dysplasia on endoscopic biopsy, but subjective grading is prone to observer variation. Computerized morphometry and immunoquantitation can objectively discriminate between different grades of dysplasia in oesophagectomy specimens with BO. The present study evaluated the feasibility of such quantitative analysis on surveillance biopsies of BO. Biopsy criteria for quantitative analysis were defined, excluding 101 (21%) of 472 archival BO surveillance biopsies. In the remaining haematoxylin and eosin (H&E) sections, 105 areas that distinctively displayed no dysplasia (ND), low-grade dysplasia (LGD) or high-grade dysplasia (HGD) were demarcated. Agreement on double-blind examination by two experienced pathologists was reached in 66 areas (63%; kappa: 0.44). For 21 ND/LGD and 11 LGD/HGD disagreement areas, corresponding sections for p53 and Ki67 immunohistochemistry were available. The best combination of two discriminating features was stratification index (SI) with p53 area % for ND versus LGD (89% correct classification), and SI with Ki67 area % for LGD versus HGD (91% correct classification). Fifteen of the 21 ND/LGD disagreement areas could be classified uniquely as either ND or LGD by SI and p53, and eight of the 11 LGD/HGD disagreement areas as either LGD or HGD by SI and Ki67. Correlation coefficients for repeated measurements of SI, Ki67, and p53 by the same observer were 0.94, 0.92, and 0.86, and by two independent observers 0.86, 0.93, and 0.92, respectively. Computerized quantitative pathology on BO surveillance biopsies is feasible provided that well-defined biopsy criteria are used. Using a combination of features associated with cellular differentiation and proliferation, such as SI, p53, and Ki67, quantitative pathological analysis assists in reducing diagnostic variability in the grading of dysplasia during surveillance of BO.

Computerized quantitative pathology for the grading of dysplasia in surveillance biopsies of Barrett's oesophagus

Decision models for surveillance of Barrett's oesophagus (BO) are governed by the grade of dysplasia on endoscopic biopsy, but subjective grading is prone to observer variation. Computerized morphometry and immunoquantitation can objectively discriminate between different grades of dysplasia in oesophagectomy specimens with BO. The present study evaluated the feasibility of such quantitative analysis on surveillance biopsies of BO. Biopsy criteria for quantitative analysis were defined, excluding 101 (21%) of 472 archival BO surveillance biopsies. In the remaining haematoxylin and eosin (H&E) sections, 105 areas that distinctively displayed no dysplasia (ND), low-grade dysplasia (LGD) or high-grade dysplasia (HGD) were demarcated. Agreement on double-blind examination by two experienced pathologists was reached in 66 areas (63%; kappa: 0.44). For 21 ND/LGD and 11 LGD/HGD disagreement areas, corresponding sections for p53 and Ki67 immunohistochemistry were available. The best combination of two discriminating features was stratification index (SI) with p53 area % for ND versus LGD (89% correct classification), and SI with Ki67 area % for LGD versus HGD (91% correct classification). Fifteen of the 21 ND/LGD disagreement areas could be classified uniquely as either ND or LGD by SI and p53, and eight of the 11 LGD/HGD disagreement areas as either LGD or HGD by SI and Ki67. Correlation coefficients for repeated measurements of SI, Ki67, and p53 by the same observer were 0.94, 0.92, and 0.86, and by two independent observers 0.86, 0.93, and 0.92, respectively. Computerized quantitative pathology on BO surveillance biopsies is feasible provided that well-defined biopsy criteria are used. Using a combination of features associated with cellular differentiation and proliferation, such as SI, p53, and Ki67, quantitative pathological analysis assists in reducing diagnostic variability in the grading of dysplasia during surveillance of BO.

Endometrial precancer diagnosis by histopathology, clonal analysis, and computerized morphometry

Management of endometrial precancers is compromised by longstanding debate over the natural history of endometrial hyperplasias and inconsistencies in their diagnosis. The recent demonstration that some hyperplasias, like cancers, are phenotypically monoclonal is useful in recognizing biological precancers. A clonal analysis has been undertaken of a series of 93 endometrial tissues and their morphology has been evaluated by subjective diagnostic classification and computerized morphometric analysis. A pathologist's diagnosis of atypical endometrial hyperplasia was highly associated with monoclonal growth. Both microsatellite-stable and microsatellite-unstable precancers were classified as atypical hyperplasias, indicating overlapping morphologies for these two groups. Diagnosis of non-atypical endometrial hyperplasias was not reproducible and identified a group of lesions equally likely to be monoclonal as polyclonal. Computerized morphometry resolved these lesions into monoclonal and polyclonal subgroups with a high degree of accuracy and reproducibility. The predictive value of morphometry was dominated by that fraction of the sample which consisted of stroma (volume percentage stroma). This can be measured manually and used to predict monoclonality when below the threshold value of 55%. This study shows that morphometric analysis reproducibly and precisely identifies monoclonal endometrial precancers from histological sections. It may serve, furthermore, to classify accurately lesions judged by pathologists as indeterminate (non-atypical hyperplasias). The material from this study (available at www.endometrium.org from March 1, 2000) and precisely defined architectural diagnostic criteria provide new tools for diagnostic standardization of endometrial precancers.

[Computer-based morphometric image analysis of endometrial hyperplasia]

Former studies have shown that only 20% of endometrial hyperplasias progress to carcinoma. Objective criteria for predicting the outcome of hyperplasias have been lacking. Because hysterectomy has been the therapy of choice to avoid malignant development, overtreatment of these patients is still a clinical problem. A computer-based morphometric image analysis system has proved to be a considerable improvement for the pathologist in assessing which patients will develop cancer. The system is based on ten nuclear and twelve glandular architectural features. The three parameters with the best statistical power of discriminating between patients developing malignancy and those remaining healthy were combined into a morphometric classification rule (D-score or discriminating score). We give a brief description of this method and its background.

Computerized quantitative pathology for the grading of dysplasia in surveillance biopsies of Barrett's oesophagus

Decision models for surveillance of Barrett's oesophagus (BO) are governed by the grade of dysplasia on endoscopic biopsy, but subjective grading is prone to observer variation. Computerized morphometry and immunoquantitation can objectively discriminate between different grades of dysplasia in oesophagectomy specimens with BO. The present study evaluated the feasibility of such quantitative analysis on surveillance biopsies of BO. Biopsy criteria for quantitative analysis were defined, excluding 101 (21%) of 472 archival BO surveillance biopsies. In the remaining haematoxylin and eosin (H&E) sections, 105 areas that distinctively displayed no dysplasia (ND), low-grade dysplasia (LGD) or high-grade dysplasia (HGD) were demarcated. Agreement on double-blind examination by two experienced pathologists was reached in 66 areas (63%; kappa: 0.44). For 21 ND/LGD and 11 LGD/HGD disagreement areas, corresponding sections for p53 and Ki67 immunohistochemistry were available. The best combination of two discriminating features was stratification index (SI) with p53 area % for ND versus LGD (89% correct classification), and SI with Ki67 area % for LGD versus HGD (91% correct classification). Fifteen of the 21 ND/LGD disagreement areas could be classified uniquely as either ND or LGD by SI and p53, and eight of the 11 LGD/HGD disagreement areas as either LGD or HGD by SI and Ki67. Correlation coefficients for repeated measurements of SI, Ki67, and p53 by the same observer were 0.94, 0.92, and 0.86, and by two independent observers 0.86, 0.93, and 0.92, respectively. Computerized quantitative pathology on BO surveillance biopsies is feasible provided that well-defined biopsy criteria are used. Using a combination of features associated with cellular differentiation and proliferation, such as SI, p53, and Ki67, quantitative pathological analysis assists in reducing diagnostic variability in the grading of dysplasia during surveillance of BO.

Experience with a dynamic inexpensive video-conferencing system for frozen section telepathology

AIM

To evaluate the feasibility of an inexpensive, generally applicable video-conferencing system for frozen section telepathology (TP).

METHODS

A commercially widely available PC-based dynamic video-conferencing system (Picture-Tel LIVE, model PCS 100) has been evaluated, using two, four and six ISDN channels (128-384 kilobits per second (kbs)) bandwidths. 129 frozen sections have been analyzed which were classified by TP as benign, uncertain (the remark probably benign, or probably malignant was allowed), malignant, or not acceptable image quality. The TP results were compared with the original frozen section diagnosis and final paraffin diagnosis.

RESULTS

Only 384 kbs (3 ISDN-2 lines) resulted in acceptable speed and quality of microscope images, and synchronous image/speech transfer. In one of the frozen section cases (0.7%), TP image quality was classified as not acceptable, leaving 128 frozen sections for the analysis. Five of these cases were uncertain by TP, and also deferred by frozen section procedure (FS). One more benign and three malignant FS cases were classified as uncertain by TP. Three additional cases were uncertain by FS, but benign according to TP (in agreement with the final diagnosis). In one case, FS diagnosis was uncertain but TP was malignant (in agreement with the final diagnosis). Thus, test efficiency (i.e., cases with complete agreement) was 120/128 (93.8%, Kappa = 0.88) between FS and TP. Sensitivity was 93.5%, specificity 98.6%, positive and negative predictive values were 97.7% and 96.0%. Between TP and final diagnosis agreement was even higher. More importantly, there was not a single discrepancy as to benign-malignant. Moreover, there was a clear learning effect: 5 of the 8 FS/TP discrepancies occurred in the first 42 cases (5/42 = 11.9%), the remaining 3 in the following 86 cases (3/86 = 3.5%).

DISCUSSION

The results are encouraging. However, TP evaluation is time-consuming (5-15 min for one case instead of 2-4 min although speed went up with more experience) and is more tiring. The system has the following technical drawbacks: no possibility to point at objects or areas of interest in the life image at the other end, resolution (rarely) may become suboptimal (blocky), storage of images evaluated (which is essential for legal reasons) is not easy and no direct control of a remote motorized microscope. Yet, all users were positive about the system both for telepathology and personal contact by video-conferencing.

CONCLUSION

With a relatively simple videoconferencing system, accurate dynamic telepathology frozen section diagnosis can be obtained without false positive or negative results, although a limited number of uncertain cases will have to be accepted.