Enhancing upper tract urothelial carcinoma diagnosis: Utility of cytokeratin 17 and CK20/CD44/p53 immunohistochemical panel

Upper tract urothelial carcinoma (UTUC) presents diagnostic challenges due to small biopsy specimen size, poor orientation, and technical obstacles that can yield equivocal diagnoses. This uncertainty often mandates repeated biopsies to evaluate the necessity of nephroureterectomy. Prior studies have suggested cytokeratin 17 (CK17) immunostain as an adjunctive tool for diagnosing bladder urothelial neoplasia in both urine cytology and tissue biopsy specimens. We evaluated the utility of CK17 in differentiating UTUC from benign urothelium and its ability to stratify low-grade from high-grade neoplasia. Our study involved a cohort of previously diagnosed cytology (n = 29) and tissue specimens from biopsies and resections (n = 85). We evaluated CK17 staining percentage in cytology and tissue samples and localization patterns in biopsy/resection samples. Our findings showed a statistically significant distinction (p < 0.05) between UTUC and benign tissue specimens based on full thickness localization pattern (odds ratio 8.8 [95% CI 1.53-67.4]). The percentage of CK17 staining failed to significantly differentiate neoplastic from non-neoplastic cases in cytology or tissue samples. Additionally, based on prior research showing the efficacy of CK20/CD44/p53 triple panel in bladder urothelial neoplasia, we utilized tissue microarrays to evaluate if these markers could distinguish UTUC from benign urothelium. We found that CK20/CD44/p53, individually or in combination, could not distinguish urothelial neoplasia from non-neoplasia. Full thickness CK17 urothelial localization by immunohistochemistry was highly reproducible with excellent interobserver agreement and may play a supplementary role in distinguishing upper tract urothelial neoplasia from benign urothelium.

SATB2, CKAE1/AE3, and synaptophysin as a sensitive immunohistochemical panel for the detection of lymph node metastases of Merkel cell carcinoma

Histopathological evaluation of lymph nodes in Merkel cell carcinoma has become crucial in progression estimation and treatment modification. This study was undertaken to determine the most sensitive immunohistochemical panel for detecting MCC nodal metastases. We included 56 patients with 102 metastatic MCC lymph nodes, which were tested with seven antibodies: cytokeratin (CKAE1/AE3), CK20, chromogranin A, synaptophysin, INSM1, SATB2, and neurofilament (NF). Tissue microarrays (TMA) composed of 2-mm tissue cores from each nodal metastasis were constructed. A semiquantitative 5-tier scoring system (0%, < 25%, 25-74%, 75-99%, 100% positive MCC cells with moderate to strong reactivity) was implemented. In the statistical assessment, we included Merkel cell polyomavirus (MCPyV) status and expression heterogeneity between lymph nodes from one patient. A cumulative percentage of moderate to strong expression ≥ 75% of tumoral cells was observed for single cell markers as follows: 91/102 (89.2%) SATB2, 85/102 (83%) CKAE1/AE3, 80/102 (78.4%) synaptophysin, 75/102 (75.5%) INSM1, 68/102 (66.7%) chromogranin A, 60/102 cases (58.8%) CK20, and 0/102 (0%) NF. Three markers presented a complete lack of immunoreactivity: 8/102 (7.8%) CK20, 7/102 (6.9%) chromogranin A, and 6/102 (5.9%) NF. All markers showed expression heterogeneity in lymph nodes from one patient; however, the most homogenous was INSM1. The probability of detecting nodal MCC metastases was the highest while using SATB2 as a first-line marker (89.2%) with subsequential adding CKAE1/AE3 (99%); these results were independent of MCPyV status. Synaptophysin showed a superior significance in confirming the neuroendocrine origin of metastatic cells. This comprehensive analysis allows us to recommend simultaneous evaluation of SATB2, CKAE1/AE3, and synaptophysin in the routine pathologic MCC lymph node protocol.

Intestinal-type mucinous adenocarcinoma of the Bartholin gland in a perimenopausal woman. A case report and review of the literature

We report the case of a 46-year-old woman who presented with a tumor on the left labium majus in the region of the Bartholin gland. Surgical excision revealed a mucinous adenocarcinoma of intestinal-type (CK20⁺, CDX-2⁺). Magnetic resonance imaging, computed tomography of the chest and abdomen and colonoscopy ruled out the presence of other tumors. A second immunohistochemical study showed negative results for GATA-3, mammaglobin and GCDFP-15. Molecular analysis revealed a mutation in exon 2 of the KRAS gene. We discuss its differential diagnosis and the importance of being aware of this unusual variant of a mucinous adenocarcinoma the Bartholin gland.

Comprehensive Gene Expression Analyses of Immunohistochemically Defined Subgroups of Muscle-Invasive Urinary Bladder Urothelial Carcinoma

A number of urinary bladder urothelial carcinoma (UB UC) mRNA-based classification systems have been reported. It also has been observed that treatment response and prognosis are different for each molecular subtype. In this study, cytokeratin (CK)5/6 and CK20 immunohistochemistry (IHC) were performed, and IHC-based subgroup classification was applied. UB UC was classified into CK5/6 single-positive (SP), CK20 SP, double-positive (DP) and double-negative (DN) subgroups, and transcriptional analysis was performed. The results of gene ontology (GO) terms and functional analysis using differentially expressed genes indicate that, CK5/6 SP and DP subgroups were enriched in cell migration, immune activation, interleukin 6-Janus kinase-signal transducer and activator of transcription 3 (IL6-JAK-STAT3) signaling pathway and tumor necrosis factor-α signaling via the nuclear factor-κB (NF-κB) signaling pathway signature gene. In addition, compared with the other subgroups, the DN subgroup showed inhibited cell movement, cell migration, and cell activation. Furthermore, in survival analysis, the CK5/6 SP subgroup was significantly associated with poor progression-free survival (p = 0.008). The results of our study indicate that the CK5/6 positive subgroup exhibited high gene expression signature related to aggressive behavior and exhibited worse clinical outcome.

Curious Residents of the Thyroid Gland: Two Case Reports of Colorectal Carcinoma Metastasis by Fine-Needle Aspiration Diagnosis

BACKGROUND

The most frequent metastases to the thyroid originate in the kidney, lung or breast. Colorectal adenocarcinoma represents less than 4% of metastases to the thyroid gland. Solitary metastases of colorectal cancer with no other manifestation of disseminated cancer disease are exceedingly rare. Within the Bethesda Classification for Reporting -Thyroid Cytopathology, metastases are included in Diagnostic Categories "Suspicious for Malignancy" and "Malignant."

CASES

We present 2 cases of colorectal adenocarcinoma metastatic to the thyroid gland, diagnosed by fine-needle aspiration (FNA). One metastasis occurred in normal thyroid parenchyma; the other was a tumour-to-tumour metastasis into a follicular carcinoma of the thyroid. The latter is the first published tumour-to-tumour metastasis of a colorectal carcinoma in the thyroid from which both components were diagnosed by FNA.

CONCLUSION

Diagnosing a metastasis to the thyroid is challenging. On FNA, a dual cell population should raise suspicion. Immunocytochemical and molecular analysis may be helpful. Clinical information is essential in guiding specific ancillary technique panels in scant cellular material.

Dual Immunostain With SATB2 and CK20 Differentiates Appendiceal Mucinous Neoplasms From Ovarian Mucinous Neoplasms

OBJECTIVES

Determination of the primary site of origin for mucinous neoplasms identified in the peritoneal and/or pelvic cavities may be challenging, with major differential diagnoses including appendiceal mucinous neoplasm (AMN) and ovarian mucinous neoplasm (OMN). Special AT-rich sequence binding protein 2 (SATB2) has been shown to be highly selectively expressed in the lower gastrointestinal tract, including the appendix.

METHODS

We investigated the utility of a dual stain (DS) with SATB2 or caudal type homeobox 2 (CDX2) and cytokeratin 20 (CK20) or villin in distinguishing AMNs from OMNs. Tissue microarrays with 40 AMNs and 18 OMNs were stained with SATB2 or CDX2 paired with either CK20 or villin.

RESULTS

SATB2 single stain showed a good sensitivity of 83% and the highest specificity of 78% for AMNs over OMNs among all four stains. DS with SATB2 and villin showed an identical sensitivity of 78% but specificity increased to 94%, while DS with SATB2 and CK20 showed a sensitivity of 80% and a specificity of 100%. In contrast, DS with CDX2 and CK20/villin showed slightly higher sensitivity but much lower specificity.

CONCLUSIONS

DS with SATB2/CK20 shows the greatest potential clinical utility in distinguishing AMNs from OMNs and is superior to DS with CDX2/CK20. Importantly, DS could be helpful for specimens with limited tissues.

Immunohistochemistry of Cytokeratin 7, Cytokeratin 20 and Thyroid Transcription Factor-1 in Metastatic Carcinoma of Cervical Lymph Node Biopsy for Identification of Pulmonary Origin in Rajavithi Hospital

BACKGROUND

One of the most powerful tools used in “the team approach in modern medicine” is immunohistochemistry, a minimally invasive investigative technique which is helpful in many respects, such as in suggesting or defining the primary site of metastatic malignant neoplasms. The panel of Cytokeratin7 (CK7), Cytokeratin20 (CK20) and Thyroid Transcription Factor-1 (TTF-1) is one of the most frequently used, and this study examined expressions of this panel in Rajavithi Hospital in order to assess their significance.

OBJECTIVE

To study the expression of CK7, CK20 and TTF-1 in metastatic carcinoma in neck node biopsy found in the Rajavithi Hospital database, and to assess their effectiveness in identifying pulmonary origin.

MATERIAL AND METHOD

The Rajavithi Hospital database was searched for all cases of lymph node biopsy in the neck and supraclavicular area for which the pathological diagnosis was metastatic carcinoma. Expressions of CK7, CK20 and TTF-1 were analyzed to measure their sensitivity, specificity, positive predictive values, and negative predictive values.

RESULTS

Average age of the subjects, of whom 56.9% were male, was 61.35±12.9 years. Lung (51.2%), breast (7.3%) and gastrointestinal tract (6.5%) were the three most common organ site origins, and the most common cell type was adenocarcinoma. Expressions are shown in terms of sensitivity (98.4%), specificity (95.0%), positive predictive value (95.4%), negative predictive value (98.3%) and others. The most reliable antibody for identification of pulmonary origin was TTF-1.

CONCLUSION

The immunohistochemistry panel of CK7, CK20 and TTF-1 in the Rajavithi Hospital database is useful as a guide in locating the origin of clinically unknown primary cases of metastatic cervical lymph nodes.

Clinical Use of Tumor Markers for the Detection and Prognosis of Bladder Carcinoma: A Comparison of CD44, Cytokeratin 20 and Survivin

PURPOSE

To investigate the role of CD44, cytokeratin 20 (CK20) and survivin for the detection and prognosis of patients with urothelial carcinoma of the bladder.

MATERIALS AND METHODS

The study included 82 patients who underwent transurethral resection of bladder tumors between 2009 and 2014. The patient and tumor characteristics with relevance to age, tumor size and focality, grade and stage, recurrence and progression were noted. Patients with carcinoma in situ, those who had at more than 3 sites of lesions and greater than 3 cm tumors were excluded. All cases were ex-smokers. All histological samples stained with hematoxylin and eosin were re-evaluated according to the 2004 World Health Organization/International Society of Urological Pathology (WHO/ISUP) classification system and immunohistochemically stained for CD44, CK20 and survivin.

RESULTS

The study group comprised 57 (69.5%) males and 25 (30.5%) females with a mean age of 60 years (range, 26-87 years). All were newly-diagnosed patients with bladder tumors. Immunohistochemical evaluation revealed that there was a statistically significant correlation between the grade and stage of the tumor with CK20 and survivin positivity (P &lt; .05). As the grade and stage increased CD44 immunoreactivity significantly decreased (P = .002, P = .0001, respectively). However, relationship of protein expressions with recurrence and progression remained insignificant (P &gt; .05).

CONCLUSION

In cases of bladder urothelial carcinoma positivity for CD44, CK20, and survivin has significant relation with the tumor grade and stage while no significant relationship was determined in terms of recurrence and progression&nbsp.

Comparison of the Diagnostic Value Between Real-Time Reverse Transcription-Polymerase Chain Reaction Assay and Histopathologic Examination in Sentinel Lymph Nodes for Patients With Gastric Carcinoma

OBJECTIVES

Sentinel lymph node (SLN)-based diagnosis in gastric cancers has shown varied sensitivities and false-negative rates in several studies. Application of the reverse transcription-polymerase chain reaction (RT-PCR) in SLN diagnosis has recently been proposed.

METHODS

A total of 155 SLNs from 65 patients with cT1-2, N0 gastric cancer were examined. The histopathologic results were compared with results obtained by real-time RT-PCR for detecting molecular RNA (mRNA) of cytokeratin (CK)19, carcinoembryonic antigen (CEA), and CK20.

RESULTS

The sensitivity and specificity of the multiple marker RT-PCR assay standardized against the results of the postoperative histological examination were 0.778 (95% confidence interval [CI], 0.577-0.914) and 0.781 (95% CI, 0.700-0.850), respectively. In comparison, the sensitivity and specificity of intraoperative diagnosis were 0.819 (95% CI, 0.619-0.937) and 1.000 (95% CI, 0.972-1.000), respectively. The positive predictive value of the multiple-marker RT-PCR assay was 0.355 (95% CI, 0.192-0.546) for predicting non-SLN metastasis, which was lower than that of intraoperative diagnosis (0.813, 95% CI, 0.544-0.960).

CONCLUSIONS

The real-time RT-PCR assay could detect SLN metastasis in gastric cancer. However, the predictive value of the real-time RT-PCR assay was lower than that of precise histopathologic examination and did not outweigh that of our intraoperative SLN diagnosis.

Krukenberg tumor in a 18-year-old-female: a rare case

BACKGROUND

Krukenberg tumors mostly occur after 40 years. Metastatic ovarian tumors in young age are very rare.

CASE

A 18-year-old female presented with colon cancer which was accompanied by Krukenberg tumor. The present case was a very rare case of metastatic ovarian tumor in very young age. The present patient presented with abdominal pain. On examination, colon tumor was detected and bilateral ovary were almost normal with only slight swelling. During the operation for colon tumor, biopsy of bilateral ovary was performed for histopathological evaluation. Although there were no specific findings in bilateral ovary, microscopic examination revealed poorly differentiated adenocarcinoma, diffusely invading the ovarian parenchyma. Diagnosis of colon cancer was made postoperatively and ovarian Krukenberg tumor was confirmed.

CONCLUSION

In case of suspecting colon cancer even in very young patient with normal ovary, biopsy of ovary should be considered for the diagnosis of Krukenberg tumor.

Differential expression of GSK3β and pS9GSK3β in normal human tissues: can pS9GSK3β be an epithelial marker?

Glycogen synthase kinase 3β (GSK3β) and phosphorylated GSK3β at Ser9 (pS9GSK3β) are crucial in cellular proliferation and metabolism. GSK3β and pS9GSK3β are deregulated in many diseases including tumors. Data on altered expression of GSK3β and pS9GSK3β are mainly limited to tumor tissues, thus the expression of GSK3β and pS9GSK3β in normal human tissue has been largely unknown. Thus, we examined the immunohistochemical localization of GSK3β and pS9GSK3β in human fetal and adult tissues, and also compared the expression pattern of GSK3β and pS9GSK3β with that of the CK7 and CK20. We found GSK3β expression in neurons of brain, myenteric plexus in gastrointestinal tract, squamous epithelium of skin, and mammary gland. The expression of pS9GSK3β was restricted to the epithelial cells of breast and pancreaticobiliary duct, distal nephron of kidney, gastrointestinal tract, fallopian tube, epididymis, secretory cell of prostatic gland, and umbrella cell of urinary tract. The staining pattern of pS9GSK3β and CK7 was overlapped in most organs except for gastrointestinal tract where CK7 was negative and CK20 was positive. Our results show that the expression of GSK3β may be associated with differentiation of ectodermal derived tissues and pS9GSK3β with that of epithelial cells of endodermal derived tissues in human. In addition, the expression of pS9GSK3β in the selective epithelial cells may indicate its association with secretory or barrier function of specific cells and may serve as another immunohistochemical marker for epithelial cells.

Vaginal metastasis of pancreatic cancer

Vaginal metastasis from pancreatic cancer is an extreme case and often indicates a poor prognosis. We present a case of pancreatic carcinoma with metastasis to the vagina that was discovered by vaginal bleeding. To our knowledge, this is the third case in the world of a primary pancreatic adenocarcinoma discovered of symptoms from a vaginal metastasis.

Coexistence of mature cystic teratoma and adenocarcinoma in situ within atypical proliferative mucinous tumour of ovary--a case report of 35-year-old woman

Combined ovarian tumors are found in common pathologic practice due to amazing potential of ovarian tissue to copy almost every tissue of human body and imitate many neoplasms of various other organs in a very flexible way. A multicystic tumor is presented in this case report of 35-year-old woman. It consisted of a cyst with sebum and hair and cavities with papillomatous projections and mucus. The ovarian tumor was diagnosed a mature cystic teratoma presenting mainly as dermoid cyst and mucinous adenocarcinoma in situ, arising within atypical proliferative mucinous tumor. This report demonstrates how histoformative properties are reflected in ovarian tumorigenesis. Such a stunning histoformativity makes ovaries the possible site of primary origin for malignant tumors that mimic extra ovarian differentiation. In the authors' point of view, the diagnosis of primary ovarian mucinous tumor within cystic teratoma is firm, whenever simultaneous extraovarian involvement by mucinous neoplasm is excluded.

Synchronous triple cancers of the pancreas, stomach, and cecum treated with S-1 followed by pancrelipase treatment of pancreatic exocrine insufficiency

CONTEXT

Pancreatic cancer is frequently complicated by malignancies in other organs. However, synchronous triple cancers including pancreatic cancer have been seldom reported in the English language literature.

CASE REPORT

We describe the rare case of a 77-year-old man with triple cancers of the pancreas, stomach, and cecum. Biopsies revealed that all three tumors were adenocarcinomas. The pancreatic and gastric tumors were positive for cytokeratin 7 and negative for cytokeratin 20, whereas the cecal tumor was negative for cytokeratin 7 and positive for cytokeratin 20. K-ras mutations were present at codon 12 in the pancreatic tumor and at codon 13 in the cecal tumor, but were absent from the gastric tumor. Since the three tumors had different characteristics, the patient was diagnosed with synchronous triple cancers. Because invasive surgery was required to remove all three tumors and the patient had risk factors for surgery, we elected to treat him with chemotherapy. All three cancers were markedly reduced in size by treatment with cycles of 100 mg/day S-1 for 2 weeks, followed by a 1-week rest. The patient later developed hypoproteinemia and anasarca, which was diagnosed as pancreatic exocrine insufficiency due to pancreatic head cancer. Treatment with pancrelipase resulted in dramatic improvements in hypoproteinemia and anasarca.

CONCLUSIONS

This is the first case report in which S-1 was effective in triple cancers of the pancreas, stomach, and cecum. Patients with pancreatic head cancer should be monitored for pancreatic exocrine insufficiency.

Local immune response in bladder pain syndrome/interstitial cystitis ESSIC type 3C

INTRODUCTION AND HYPOTHESIS

Bladder pain syndrome/interstitial cystitis (BPS/IC) is identified based on subjective symptoms which lead to heterogeneous patient populations. Previous studies using gene expression arrays for BPS/IC with Hunner's lesions [European Society for the Study of Interstitial Cystitis (ESSIC) type 3C], a subtype of the condition discernible by cystoscopy, have revealed characteristic immune responses and urothelial abnormalities. This current study aimed to further characterize this subtype using a gene expression panel. We hypothesized that B-cell activation with high levels of urinary antibody concentration would be found.

METHODS

Cold-cup bladder biopsies, catheterized urine and blood were collected from 15 BPS/IC ESSIC type 3C patients, 11 non-inflammatory overactive bladder (OAB) patients and eight healthy controls. Gene expression in biopsies was quantified by real-time quantitative polymerase chain reaction (RT-qPCR), immunohistochemistry was performed on bladder tissue and urinary immunoglobulins G and A were quantified by enzyme-linked immunosorbent assay. Statistical analyses included the Kruskal-Wallis test for non-parametric data and post hoc tests identified differences between groups.

RESULTS

High expression of T- and B-cell markers (CTLA4, CD20, CD79A, IGH@), low expression of urothelial markers (KRT20, UPK1B, UPK3A), focal lymphoid aggregates in the submucosa and high immunoglobulin concentration in urine were found exclusively in BPS/IC ESSIC type 3C patients. Results for OAB were in intermediate ranges between the other two groups and UPK1B even reached significantly lower expression when compared to healthy controls.

CONCLUSIONS

BPS/IC ESSIC type 3C is characterized by a local adaptive immune response with elevated urinary antibody concentrations. Quantification of urinary immunoglobulin levels could be used for a non-invasive diagnosis of BPS/IC ESSIC type 3C.

Adjuvant therapy for intrahepatic cholangiocarcinoma: the debate continues

Presentation of the Case A 37-year-old woman presented at 35 weeks of gestation with her third child with failure to adequately gain weight and was noted by her obstetrician to have delay in the growth of her baby. Ultrasound of the abdomen incidentally revealed the presence of a liver lesion. After additional evaluation, she ultimately delivered her daughter at 36 weeks uneventfully. She subsequently underwent additional evaluation. Liver magnetic resonance imaging (MRI) revealed a 5-cm solitary solid mass in segment 4A of the liver, concerning for malignancy. Serum α-fetoprotein, carcinoembryonic antigen, cancer antigen (CA)19-9, CA15-3, and CA125 were all normal. Liver biopsy was positive for adenocarcinoma. The tumor cells demonstrated a phenotype suggesting a possible breast primary, although the immunohistochemistry did not support that diagnosis and the tumor was negative for mammaglobin, gross cystic disease fluid protein (GCDFP)-15, estrogen receptor (ER), and progesterone receptor (PR) (Table 1). The tumor was also CDX2 and cardiotrophin-1 negative, but cytokeratin (CK) 19 positive. Her endoscopic retrograde cholangiopancreatography, upper endoscopy, colonoscopy, breast mammogram, and breast MRI were completely normal. A positron emission tomography-computed tomography scan showed a fluorodeoxyglucose-avid 5.8-cm × 6.0-cm hypoattenuating lesion with peripheral enhancement involving segment 4 and segment 8 at the dome. In addition, central necrosis within the lesion was noted. The left main portal vein was mildly attenuated by the mass. She eventually underwent a left hepatectomy en bloc with caudate resection, portal lymphadenectomy, cholecystectomy, and omental pedicle flap. On exploration of the abdomen, no additional disease was noted. The final pathology revealed a 9.4-cm moderately to poorly differentiated adenocarcinoma of the intrahepatic bile ducts. Venous invasion was present. Perineural invasion was absent. The margins were negative. Thirteen lymph nodes were obtained, all of which were negative, consistent with a stage T2, N0, MX intrahepatic cholangiocarcinoma. The tumor was positive for CK7, CK19, and CA19-9 and negative for CK20, CDX2, CA125, ER, PR, GCDFP-15, synaptophysin, and chromogranin (Table 1). The uninvolved liver was unremarkable and a trichrome stain showed no fibrosis. Following an uneventful postoperative recovery, she was referred for consideration of adjuvant therapy.

[Primary adenocarcinoma of the male urethra]

We present a case of a 43-year-old man treated for urethral stricture. Cystoscopy showed unusual tissue in the posterior urethra. Biopsies showed adenocarcinoma which was positive for cytokeratins 7 and 20 and negative for prostate specific antigen. Immunohistochemistry in this case was important for the diagnosis, primary urethral adenocarcinoma.

Radical distal gastrectomy in laparoscopic and open surgery: is it necessary for pancreatic capsule resection?

BACKGROUND/AIMS

To explore the involvement of the pancreatic capsule during radical gastrectomy in gastric cancer.

METHODOLOGY

Pancreatic capsule samples were collected from the 83 cases (56 men and 27 women) during open radical gastrectomy and laparoscopic resection between January 2007 and July 2008. RT-PCR and immunohistochemistry were applied for tumor detection. There was a 2-year follow-up; the relationship of the pancreatic capsule involvement, tumor stage and survival rate were evaluated. Results from radical distal gastrectomy were combined with those of gastric cancer pancreatic capsule cleaning; clinical data, pathology, immunohistochemistry and RT-PCR were used to confirm the necessity of pancreatic capsule resection in laparoscopic radical gastrectomy.

RESULTS

H&E staining of the pancreatic capsule showed no tumor existence in any of the 83 patients but immunohistochemistry showed CK20 positive cells in 20 patients (33.7%), while RT-PCR detected CK20 mRNA positive cells in 42 patients (50.6%). Cases with stage T1 and T2 were negative for CK20 in both RT-PCR and immunohistochemistry and the few cases with T3 and T4 were also negative in both RT-PCR and immunohistochemistry. The metastasis in the pancreatic capsule correlated mainly with the invasive serous membrane, lymph node metastasis and tumor stage (p<0.05) but not with gender and age (p>0.05).

CONCLUSIONS

For T1 and T2 stage, there was no evidence of pancreatic capsule metastasis, which may facilitate the decision making of the pancreatic capsule resection during radical distal gastrectomy.

Malignant potential of Barrett's esophagus: special reference to HDAC-1 and MTA-1 expression

BACKGROUND/AIMS

Barrett's esophagus is a major risk factor for esophageal adenocarcinoma. It is important to decide when and how to treat the patients with Barrett's esophagus (BE). It was reported that HDAC-1 (Histone Deacetylase-1) and MTA-1 (Metastasis-Associated Protein-1) were associated with initiation and progression of cancer. The aim of this study is to assess malignant potential of BE using the expression of HDAC-1 and MTA-1.

METHODOLOGY

Seven BE cases with pathological specialized columnar epithelium and CK7/20 in an immunohistochemically positive state were selected from resected specimens of 23 patients with gastro-esophageal junction cancer. The expression of HDAC-1 and MTA-1 protein was evaluated using an immunohistochemical method.

RESULTS

All seven cases with Barrett's esophagus were diagnosed as low grade dysplasia. Positive expression of HDAC-1 and MTA-1 was found in 0 out of 7 cases (0%) with normal esophageal epithelium, and 0 out of 7 cases (0%) with normal gastric epithelium. On the other hand, positive expression of both HDAC-1 and MTA-1 was found in 6 out of 7 (85.7%) cases with Barrett's epithelium and 7 out of 7 (100%) cases with gastro-esophageal-junction-cancer, respectively.

CONCLUSION

Positive expression of HDAC-1 and MTA-1 was found even in low grade dysplasia. Therefore, BE with HDAC-1 and MTA-1 expression is considered to be a precancerous lesion re quiring curative treatment.

Intraepithelial ductal spread in colorectal carcinoma liver metastasis

BACKGROUND/AIMS

This study aimed to evaluate the usefulness of immunohistochemical combinations for discrimination between intraepithelial ductal spread of colorectal carcinoma liver metastasis (CRLM) and that of intrahepatic cholangiocarcinoma (ICC).

METHODOLOGY

A retrospective analysis of resected specimens from 151 patients with CRLM and 28 patients with ICC was conducted. Intraepithelial ductal spread along the bile ducts was judged positive when tumor cells spreading along the intact basement membranes of intrahepatic bile ducts. We evaluated immunoreactivity of cytokeratin (CK) 7, CK20, CDX2, MUC2, MUC5AC and human gastric mucin (HGM).

RESULTS

Of the 151 patients with CRLM, 21 had intrahepatic bile duct involvement verified histologically. Intraepithelial ductal spread was detected in 17 of 21 (81%) patients with CRLM with bile duct involvement, whereas it was detected in 22 of 28 (79%) patients with ICC. CK20-positive/ CK7-negative immunophenotype demonstrated a high accuracy of 95% for evaluation of intraepithelial ductal spread from CRLM. CK7-positive/ CK20-negative immunophenotype demonstrated the highest accuracy of 85% for evaluation of intraepithelial ductal spread from ICC.

CONCLUSION

Intraepithelial ductal spread is a common feature of CRLM with bile duct involvement. Immunohistochemical combination of CK7 and CK20 is useful for discrimination between intraepithelial ductal spread of CRLM and that of ICC.

Isolated sigmoid colon metastasis from a primary fallopian tube carcinoma: a case report

Isolated metastasis of primary fallopian tube carcinoma (PFTC) is extremely rare. We describe a case of a 41-year-old asymptomatic woman who was referred three years after the initial treatment for PFTC due to elevated sertum CA-125 levels. The abdominal and pelvic CT scans revealed a pelvic mass near the top of the vaginal vault. On surgery, a sigmoid colon tumour was found and a sigmoidectomy was performed. On histopathology the tumour involved the bowel wall from serosa to submucosa, without involvement of the underlying mucosa. Immunohistochemical staining was positive for cytokeratin 7 and negative for cytokeratin 20, and the tumour was determined to be a metastatic müllerian neoplasm, consistent with the initial PFTC. Although this is the first reported case of colon metastasis of PFTC, the possibility of such an unusual site of metastasis should be kept in mind, as PFTC may recur as isolated bowel lesions even in the absence of peritoneal disease.

Safety distance in the resection of colorectal lung metastases: a prospective evaluation of satellite tumor cells with immunohistochemistry

OBJECTIVE

After complete pulmonary metastasectomy of colorectal lung metastases, tumor recurrence at the site of former resection develops in some patients. Well-described risk factors for local recurrence in the lung include incomplete resection and aerogenous spread of floating cancer cell clusters. The aim of this study was to describe the distribution and frequency of satellite cancer cells or clusters in resected tissue to deduce recommendations for safety margins in the future.

METHODS

Seventeen colorectal metastases from 10 patients were processed. Evaluation for pattern of growth, satellite cancer cells, and inflammatory reaction at the surface of the metastases was performed on 102 sections with CDX2 and cytokeratin 20 stains. The distance between the surface of the nodule and the satellite cancer cell was measured for each satellite and statistically evaluated.

RESULTS

As a pattern of growth, interstitial spread, inflammatory reaction, and lymphangitic spread were observed in 41.2%, 35.3%, and 23.5%, respectively. A total of 205 satellite cancer cells were identified in 16 of 17 metastases with a mean distance to the nodule of 0.99 ± 0.85 mm (range, 0.06-6.43 mm). The percentages of satellite tumor cells that are likely to be found within 1.59 mm, 3.43 mm, and 7.4 mm around the nodule are 68.27%, 95.5%, and 99.73%, respectively.

CONCLUSIONS

Satellite tumor cells, a potential source for local recurrence, are found in a high number around colorectal lung metastases. As a standard of care, a safety distance of 3 mm for small metastases and 8 to 10 mm for larger metastases must be maintained around the lesion to prevent local recurrence.

[The prognosis and immunohistochemical evaluation of five perianal Paget's disease cases]

Perianal Paget's disease is categorized as Paget's disease, which is epidermotropic neoplasm arising from the apocrine glands of perianal region, or Pagetoid spread invaded from rectal or anal canal cancer. It has been reported that the immunohistochemical staining of GCDFP15, the marker of the apocrine epithelium, and CK20 is used to be distinguished between Paget's disease and Pagetoid spread. Five patients with perianal Paget's disease who underwent a surgical operation had been treated in our department between 1997 and 2006. We analyzed the clinical findings and the treatment of these patients and investigated the expression of GCDFP15 and CK20 by immunohistochemical staining. All cases presented the redness around perianal regions, and 2 cases were recognized a tumor at the anal canal. We preoperatively diagnosed these cases as Pagetoid spread and others without tumor regions as Paget's disease. Surgical treatment was performed for all patients. As a result of immunohistochemical staining, 2 cases of Pagetoid spread were negative for GCDFP15, and positive for CK20. It was compatible with the preoperative diagnosis. Only one of 3 Paget's disease cases was positive for GCDFP15 and negative for CK20 resulting in the diagnosis of perianal Paget's disease. Based on the expression of negative for GCDFP15 and positive for CK20, others were seemed to be Pagetoid spread. A treatment strategy including surgical operation and chemotherapy is different between patients with Paget's disease and those with Pagetoid spread. Therefore, it is essential to investigate the expression pattern of GCDFP15 and CK20 using the tissue from the biopsy to identify the disease for appropriate treatment.

Exploiting the residual of cervical thin layer brush samples through cytohistology in cases with invasive carcinoma with application of antibodies

OBJECTIVE

To exploit cervical thin layer brush samples through cytohistology in cases with invasive carcinoma with application of antibodies.

STUDY DESIGN

Fourteen cases from women with carcinoma diagnosed in 2006 were selected out of 29 invasive carcinomas. From these 14 cases liquid-based cervical cytology material was available to prepare cytohistology. Eight women had squamous cell carcinoma, 4 endocervical adenocarcinoma, 1 endometrial adenocarcinoma and 1 ovarian adenocarcinoma. The residual material from the thin layer sample, collected by brushes by general practitioners, was used to prepare paraffin sections. These were stained with the Papanicolaou method and for the biomarkers Ki-67 and p16 and, if desired, for differentiation markers, including carcinoembryonic antigen, vimentin, cytokeratin 7 and cytokeratin 20 to establish the immunoprofile of the carcinoma.

RESULTS

The morphologic details in the cancer nuclei in the paraffin sections were excellent, while in all cases the thin layer cytology slide contained thick epithelial fragments with blurred nuclei. In 5 of the 6 adenocarcinomas, the glandular architecture diagnostic of adenocarcinoma was visible in the cytohistology, which was highlighted in the biomarker stainings, particularly so in the Ki-67 sections. With the exception of endometrial adenocarcinoma, all p16(INK4a) stainings were positive, as they were in the ovarian adenocarcinoma case.

CONCLUSION

Cytohistology is an adjunct to routine cervical cytologic examination of thin layer samples, allowing an unequivocal and refined diagnosis.

The diagnostic value of cytokeratins expression in the renal parenchyma tumors

Renal carcinomas are a heterogeneous group of tumors, difficult to classify and identify precisely. Since their prognosis depends very much upon their type, precise diagnosis might mean the difference between therapeutic success and patient death. Cytokeratins are particularly useful for the identification of the epithelial nature of the tumors, because their expression is maintained even in poorly differentiated tumors. Monoclonal cytokeratins such as CK7 and CK20 stain different components of the renal tubular system and are a useful duo for the identification of the origin of the different tumors that might arise in the kidney. Along with polyclonal cytokeratins such as AE1/AE3 and high molecular weight cytokeratin antibodies (34betaE12, Cam 5.2), epithelial membrane antigen (EMA) and vimentin, they are included in every diagnostic panel for renal tumors. We have selected 138 renal parenchyma tumor specimens, performed morphological diagnosis and then stained them with polyclonal cytokeratin antibody AE1/AE3, and monoclonal antibodies to CK7 and CK20. AE1/AE3 was expressed in 61.7% of the renal parenchyma tumors, with high intensity and percentage of positive cases in the papillary carcinomas (100%), and with rare and weakly positive cells in chromophobic cells carcinomas, clear cells carcinomas and sarcomatous carcinomas. CK7 was positive in 68% of the renal parenchyma tumors, with positive reaction in 100% of the cases of chromophobic cells and sarcomatous carcinomas. Clear cells carcinomas had the less percentage of positive cells, whereas papillary carcinomas were positive in seven out of eight cases. No difference in the staining pattern was noticed between type I and type II papillary carcinomas. CK20 was negative in all cases studied.

Skin metastases from lung cancer

Cutaneous metastases from the lung are rare but must be ruled out in patients with suspicious skin lesions and history of smoking or lung cancer. All histological types of lung cancer may metastasize to the skin and clinical lesions are variable. The percentage of patients with lung cancer that develop cutaneous metastases ranges from 1 to 12 percent. In 20-60 percent of cases the skin lesions present before or synchronously with the diagnosis of the primary tumor. Skin lesions are often described as nodular, mobile or fixed, hard or flexible, single or multiple, and painless. Histologically, cutaneous metastases from the lung are frequently moderately or poorly differentiated. IHC markers that may be useful in these cases are anti-thyroid transcription factor (TTF) and CK7/20. Treatment of solitary cutaneous metastases usually includes surgery alone or combined with chemotherapy, and/or radiation. If multiple cutaneous lesions or internal metastases exist, chemotherapy is the primary option. Cutaneous metastases and their primaries in the lung are usually incurable and suggest an unfortunate prognosis. Poor prognostic indicators include non-resectable or small-cell primary tumors, multiple cutaneous metastases, or other distant metastases. Mean survival is usually about 5-6 months.

[Immunohistochemical profile of colorectal and ovarian carcinomas--examination with cytokeratin 7, cytokeratin 20, beta catenin and cDX 2]

INTRODUCTION

Metastases from colorectal adenocarcinomas can be histologically similar to serous, mucinous and endometrioid ovarian adenocarcinomas. The differentiation between primary and metastatic ovarian tumours is of great importance for the patients because of the different treatment and prognosis.

AIM

The aim of the study was to determine whether the differences in the expression of Cytokeratin 7, Cytokeratin 20, Beta catenin and CDX2 can be used to distinguish the different types of carcinomas and their metastases.

MATERIALS AND METHODS

The immunohistochemical expression of the listed above antibodies was examined retrospectively and prospectively in 38 colorectal adenocarcinomas (primary and metastatic) and 32 ovarian adenocarcinomas (primary and metastatic). The metastases in both types of adenocarcinomas are located in the peritoneum.

RESULTS

The immunohistochemical expression was evaluated using a semi-quantitative method. The ovarian adenocarcinomas are mostly positive for Cytokeratin 7 (in 63%), while colorectal carcinomas are mostly positive for Cytokeratin 20 (in 73%). Regarding Beta catenin, in colorectal carcinomas the expression is mostly nuclear (in 65%) and in ovarian carcinomas mostly membrane (in 68%). In cases of uncertain expression of the markers mentioned above, CDX2 was used. Positive nuclear expression was observed only in intestinal tumours (in 86%).

CONCLUSION

For differential diagnosis between ovarian and colorectal adenocarcinomas, the use of antibodies, determining the intestinal differentiation of the tumours like Cytokeratin 20, Beta catenin and CDX2 is recommended.

Primary invasive micropapillary carcinoma of the colon: case report and review of the literature

Invasive micropapillary carcinoma is associated with frequent lymph node metastases and adverse clinical outcome. It has been reported in breast, urinary bladder, lung and the parotid gland, but very rarely in the colon. We report a new case in a 63-year-old man involving the colon, and discuss the clinicopathologic features of this rare and particularly aggressive tumour.

Comparison of core and fine needle aspiration biopsies for diagnosis of liver masses

BACKGROUND/AIMS

Core biopsy of liver mass comprises an alternative to fine needle aspiration biopsy. We decided to compare diagnoses established with the use of both methods and assess whether the use of both methods together is warranted.

METHODOLOGY

Each of the 116 patients enrolled in study underwent a guided fine needle and core biopsy of liver tumor. The results were compared. Histopathologic diagnoses of carcinomas were supported by immunohistochemistry (anti-CK7, anti-CK19, anti-CK20 and Hepatocyte antibodies).

RESULTS

In 83 out of 116 cases (71.5%), major cytological and histopathological diagnoses (malignancy vs. benign lesion vs. diagnosis impossible) were univocal. In one case, establishing diagnoses was not possible due to 'non-diagnostic' material harvested during both biopsies. In 15 cases, diagnoses were established solely on the basis of one examination In 13 cases, histopathologic diagnosis was contrary (malignant vs. benign) to cytologic diagnosis. In 27 cases histopathologic examination enabled us to reach more precise diagnosis than cytological examination. Despite the simultaneous use of both methods, we were able to establish definite diagnoses only in 29.3% of malignant cases.

CONCLUSIONS

Although core biopsy provided more information and more precise information than fine needle biopsy, most complete results were achieved with the use of both methods together.

Use of GI tumor markers in clinical practice: a practical interpretation

During the past two decades, there has been a remarkable increase in the availability and utility of tumor markers and tumor genetics in the diagnosis, and management of the various GI malignancies. Still, there is considerable variability among physicians in the use of followup studies following potentially curative resection of any of the GI cancers. Multiple surveillance strategies have been published at cost ranging from a few hundred to several thousand dollars per patient. Therefore, the literature on the currently available GI tumor markers, will be reviewed. Those tumor markers can be tested and detected basically in one of two clinical settings: (a) serum-based; in serum specimens, and (b) tissue-based; in endoscopic and surgical specimens.

Immunohistochemical biomarkers of value in distinguishing primary ovarian carcinoma from gastric carcinoma: a systematic review with statistical meta-analysis

AIMS

To compare the relative risk of antigen expression being detected immunohistochemically in ovarian and gastric carcinoma aggregated from studies performed for diagnostic purposes, with the relative risks of their expression in all patients in the English literature.

METHODS AND RESULTS

Both types of series indicated that cytokeratin (CK) 7 expression was greater and that of CK20 and carcinoembryonic antigen less in ovarian than in gastric carcinoma (P < 0.05). Synthesis of all data available for MUC-2 suggested it was more commonly expressed in ovarian carcinoma, whereas the relative risk in papers that directly compared its expression suggested that it was more common in the gastric carcinoma (P = 0.2, NS). Aggregating all possible data suggested villin was more likely to be expressed in ovarian cancers, whereas studies in which its expression was compared directly in both tumours suggested the opposite. Although statistically significant, patient numbers were small.

CONCLUSION

Provided sufficient numbers of cases are studied, analysis of studies comparing antigen expression for diagnostic purposes in tumours from two body sites is likely to be supported in the wider literature. The design of such comparative studies is informed by aggregating data from single tumour studies.

Primary mucin-producing urothelial-type adenocarcinoma of prostate: report of 15 cases

Prostatic urothelial-type adenocarcinoma arises through a process of glandular metaplasia of the prostatic urethral urothelium and subsequent in situ adenocarcinoma sometimes associated with villous adenoma. These prostatic adenocarcinomas are analogous to nonurachal adenocarcinomas arising in the bladder from cystitis glandularis. Only 2 cases of urothelial-type adenocarcinoma from an institution other than our own have been previously described. The distinction between adenocarcinoma from another organ secondarily involving the prostate, usual adenocarcinoma of the prostate, and prostatic urothelial-type adenocarcinoma can present a significant diagnostic challenge and has significant therapeutic implications. Fifteen cases of prostatic urothelial-type adenocarcinoma were retrieved from the consult files of one of the authors. Mean patient age at diagnosis was 72 years (range 58 to 93 y). All men had negative colonoscopies, clinically excluding a colonic primary. Bladder primaries were ruled out clinically or pathologically in radical resection specimens. Follow-up was available on all men with a mean of 50.3 months (range 2 to 161 mo). All men presented with urinary obstruction symptoms with 3 (20%) also having mucusuria and 2 (13.3%) also having hematuria. Four men (26.7%) developed metastatic disease and 8 (53.3%) died of disease. In 8/15 (53%) cases, glandular metaplasia of the prostatic urethra and contiguous transition to adenocarcinoma were identified. Multiple histologic patterns were observed including dissection of the stroma by mucin pools 15/15 (100%), villous features 7/15 (47%), necrosis 2/15 (13.3%), signet ring cells 3/15 (20%), perineural invasion 1/15 (6.7%), focal squamous differentiation 1/15 (6.7%), and a granulomatous inflammatory response 1/15 (6.7%). Immunohistochemical stains were negative for prostate specific antigen, prostate specific acid phosphatase, CDX2, and beta-catenin in all cases. Stains were positive for high molecular weight cytokeratin in 12/12 cases (100%), and CK7 and CK20 in 10/12 cases (83.3%). Prostatic urothelial-type adenocarcinoma is a rare aggressive cancer arising in the prostate. The differential diagnosis includes conventional prostatic mucinous adenocarcinoma and secondary infiltration from a colonic or bladder adenocarcinoma. Immunohistochemistry for prostate specific antigen, prostate specific acid phosphatase, and high molecular weight cytokeratin along with morphology can help rule out conventional prostate carcinoma. beta-catenin, CDX2, and clinical studies are needed to rule out colonic adenocarcinoma. As prostatic urothelial-type adenocarcinoma is entirely analogous to bladder adenocarcinoma in both, its morphology and immunophenotype, only clinical studies or in some cases pathologic examination of the cystoprostatectomy specimen can exclude infiltration from a primary bladder adenocarcinoma.

Primary mucinous adenocarcinoma of the bladder with signet-ring cells: case report

CONTEXT

Primary adenocarcinomas of the bladder are uncommon and usually occur by contiguity with or hematogenic dissemination of other adenocarcinomas such as colorectal, prostate and gynecological tract carcinomas. Mucinous and signet-ring cell histological patterns are even rarer and it is often difficult to morphologically distinguish them from metastatic colorectal adenocarcinoma.

CASE REPORT

We present and discuss a rare case of primary mucinous adenocarcinoma of the bladder with signet-ring cells in a 57-year-old male patient. Other primary sites for the tumor had been excluded and, in the absence of digestive tract tumor and for confirmation that it was a primary bladder tumor, an immunohistochemistry study was performed.

Effect of lymph node micrometastases on prognosis of gastric carcinoma

AIM: To evaluate the relationship between lymph node micrometastases and prognosis of patients with gastric carcinoma and to evaluate the significance of the new assessment of nodal status in determining the pN categories in the 5th edition of the UICC TNM classification.

METHODS: A total of 850 lymph nodes from 30 patients with gastric carcinoma who underwent gastrectomy with lymphadenectomy were assessed by reverse transcription polymerase chain reaction assay in addition to histologic examination. Cytokeratin-20 gene marker was used in this assay.

RESULTS: Routine examination by HE staining confirmed metastasis in 233 lymph nodes from 20 patients. All these 233 lymph nodes were cytokeratin-20 positive. Moreover, lymph node micrometastases were detected in an additional 67 lymph nodes in 12 of these 20 patients. Lymph node micrometastases were also detected in 10 lymph nodes from 2 of 10 patients who had no obvious metastases identified by HE staining. Totally, lymph node micrometastases were identified by the reverse transcription polymerase chain reaction assay in 77 (12.5%) lymph nodes from 14 (46.7%) patients with gastric carcinoma. Of 27 patients who underwent curative resection, 7 (25.9%) were up-staged (fromIB stage to II stage in 1 patient, from IB stage to IIIA stage in 1 patient, from II stage to IIIA stage in 1 patient, from IIIA stage to IIIB stage in 1 patient, from IIIA stage to IV stage in 1 patient, from IIIB stage to IV stage in 2 patients). In a median follow-up of 32 (range 8-36) mo, Kaplan-Meier survival analysis showed significant improvements in median survival (22.86 ± 3.17 mo, 95% CI: 16.64-29.08 mo vs 18.00 ± 7.4 mo, 95% CI: 3.33-32.67 mo) of patients with negative lymph node micrometastases over patients with positive lymph node micrometastases (log-rank, P < 0.05).

CONCLUSION: Lymph node micrometastases have a significant impact on the current staging system of gastric carcinoma, and are significant risk factors for prognosis of patients with gastric carcinoma.

Adenocarcinoma originating from a mature teratoma of the testis

Malignant transformation in testicular teratomas has been reported very rarely in the literature. Although testicular teratomas in childhood are regarded as benign neoplasms, these tumors, if left untreated until advanced ages, may present the risk of malignant transformation. We report a case of differentiated adenocarcinoma originating from colonic glands in primary testicular teratoma.

Use of Caveolin-1, Thyroid Transcription Factor-1, and Cytokeratins 7 and 20 in Discriminating Between Primary and Secondary Pulmonary Adenocarcinoma from Breast or Colonic Origin

The objectives of this study were firstly to compare the immunostaining patterns of antibodies against caveolin-1, thyroid transcription factor-1 (TTF-1), cytokeratin 7 (CK7) and cytokeratin 20 (CK20) in primary and secondary pulmonary adenocarcinomas of breast or colonic origin, and secondly, to investigate their use alone and in combination, in distinguishing between primary and secondary lung adenocarcinomas from breast or colonic origin. Of the 49 lung adenocarcinoma specimens that were enrolled in this study, 30 were primary pulmonary adenocarcinomas, and 19 (9, breast origin; 10, colonic origin) were metastatic pulmonary carcinomas. Immunohistochemical staining was used to detect the expression of caveolin-1, TTF-1, CK7, and CK20. Primary pulmonary adenocarcinoma most often had the CK7-positive/CK20-negative immunohistochemical phenotype and was either TTF-1 positive or caveolin-1 negative. Secondary pulmonary adenocarcinoma of breast origin most often had the CK7-positive/CK20-negative immunohistochemical phenotype and was either TTF-1 negative or caveolin-1 positive, while secondary pulmonary adenocarcinoma of colonic origin most often had the CK20-positive/CK7-negative immunohistochemical phenotype and was either TTF-1 negative or caveolin-1 positive. The results suggest that caveolin-1, TTF-1, or CK7/CK20 alone did not distinguish reliably between primary and secondary pulmonary adenocarcinomas originating from breast or colon. The use of a panel of antibodies that includes TTF-1, caveolin-1, and CK7/CK20 may have higher sensitivity in discriminating between primary adenocarcinomas and metastatic lung adenocarcinomas from breast or colonic origin.

Merkel cell carcinoma and chronic lymphocytic leukemia (collision tumor) of the arm: a diagnosis by fine-needle aspiration biopsy

Simultaneous involvement of the same anatomical site by two different primary malignant tumors is rare. Cases of hematopoietic malignancies associated with breast and skin neoplasms have been described. The association of chronic lymphocytic leukemia (CLL) and Merkel cell carcinoma (MCC) has been established, although the cause for this association is still unclear. There are reports of MCC metastatic to lymph nodes involved by CLL. We report the case of a 57-year-old man with history of CLL with concurrent involvement of the arm by CLL and MCC diagnosed on fine-needle aspiration biopsy (FNA). To our knowledge, this is the first reported case of such tumors colliding in a nonlymphoid site, diagnosed by FNA in the English literature.

Clinical applications of immunohistochemistry in gynecological malignancies

Over the past two decades, immunohistochemical techniques have improved to such a degree that it is now a common adjuvant test to the traditional hematoxylin and eosin-stained histologic sections. It is used in most realms of surgical pathology and can often aid in final diagnosis and, in some cases, prognosis. However, immunohistochemistry (IHC) is not always helpful and many pitfalls to its use exist. Understanding the basics of IHC, its utility and difficulties will aid clinicians in better understanding how diagnoses are rendered. This study reviews the general principles of IHC and demonstrates its utility with several commonly encountered problematic areas in gynecological pathology.

The use of cytokeratin stain to distinguish Barrett's esophagus from contiguous tissues: a systematic review

Our objective was to systematically review the existing literature regarding the use of cytokeratin (CK) stain in differentiating Barrett's esophagus (BE) from tissues of the gastric cardia, corpus, or antrum, with or without intestinal metaplasia (IM). Pubmed was searched for full publications in English (1983-2005) addressing the use of CK for differentiation of BE from contiguous tissues. Information was collected on the study sample, blinding, the methods used for CK staining, and for defining and applying the gold standard tests. Test characteristics were obtained or calculated. Sixteen studies (containing 46 comparisons) met the inclusion and exclusion criteria. Immunostaining for CK 7 and 20 was generally highly specific in distinguishing long-segment BE from antrum IM, fundus IM, or noncardiac gastric IM; 27 comparisons showed statistically significant differences. However, only 8 of 15 comparisons (6 of 12 studies) reported significant differences in CK staining patterns between BE and gastric cardia IM with a high sensitivity (89%-100%) and specificity (83%-100%) for long-segment BE and lower estimates for short-segment BE, while the other seven comparisons showed no significant differences and a very low sensitivity. Examination by a blinded pathologist was reported in five of six positive studies and in only one of six of the negative studies. In addition, variation in the patient populations, use of surgical resection versus endoscopic biopsies, and biopsy sampling technique in endoscopic studies may have accounted for these differences. Finally, two studies did not find significant differences in CK staining patterns between BE and normal cardiac mucosa. In conclusions, CK immunostaining has not performed well in differentiating BE, especially short-segment BE, from cardia IM. There seems to be a spectrum bias where the accuracy varies with different tested populations. CK immunostaining distinguished well between BE and IM in noncardiac segments of the stomach; however, these comparisons are not clinically relevant.

Immunopathological Patterns of the Stomach in Adenocarcinoma of the Esophagus, Cardia, and Gastric Antrum: Gastric Profiles in Siewert Type I and II Tumors

BACKGROUND

The morphologic and immunohistochemical profiles of gastric mucosa and of the tumor were assessed in Siewert type I, type II, and gastric antrum adenocarcinomas.

METHODS

Sixty-two patients, prospectively operated upon, were included in the study: 37 type II, 15 type I, and 10 antrum adenocarcinoma. Samples of the tumor, the surrounding area, and the gastric corpus and antrum were analyzed histologically, and immunostained for cytokeratins (CK)7/20 (staining positive for cells labeled > or = 50%).

RESULTS

Among the 37 type II adenocarcinomas were the following: (1) 13 of 37 (35%) had intestinal metaplasia (IM) in the stomach; (2) 24 of 37 (65%) did not show IM at any level; (3) 34 of 37 (92%) had Helicobacter pylori (HP) infection; (4) 13 of 37(35%) had CK7/20 expression of "Barrett's type" (CK7+/20-); 24 of 37 (65%) had a "no Barrett's type" profile (10 of 37 with CK7-/CK20+ and 14 of 37 with CK7+/CK20+); (5) 100% showed the same CK immunoprofile, both in IM and adenocarcinoma (measure of agreement k = 1, p = 0.000). Type I adenocarcinomas showed the following: (1) 87.5% CK Barrett's type, both in the tumor, and in the surrounding IM; (2) 100% gastric samples devoid of both IM and HP infection. Comparison between CK immunoprofiles in type I and type II tumors showed a difference within the two groups (p = 0.002). One hundred percent of antrum adenocarcinomas showed a no Barrett's type CK profile, both in the tumor and in the IM of the entire stomach.

CONCLUSIONS

Data suggest that type II adenocarcinoma cannot be always considered a gastroesophageal reflux disease-related tumor; other pathogenetic pathways should be taken into consideration.