Biopsy surveillance is still necessary in patients with Barrett's oesophagus despite new endoscopic imaging techniques

BACKGROUND AND AIMS

Endoscopic surveillance including stepwise four quadrant biopsies (4QB) is still regarded as the standard approach in patients with Barrett's oesophagus (BO). Several methods such as dye staining with methylene blue (MB) and tissue autofluorescence (AF) have been advocated to reduce the number of biopsies. We assessed their sensitivity and specificity compared with the standard approach-that is, endoscopy with 4QB-in the surveillance of a mixed BO population.

PATIENTS AND METHODS

Thirty five consecutive BO patients (mean age 64.9 years; 30 men, five women) were included in the study. AF endoscopy was followed by high resolution video endoscopy (VE) plus tissue staining with 0.5% MB. Biopsies were taken from any suspicious area found on any of the above tests, in addition to 4QB every 2 cm. The results were classified as either positive or negative for the various tests used. Histopathological results were used as the reference standard.

RESULTS

In the 35 study patients, a total of 345 biopsies showed low grade dysplasia (LGD) in 88 biopsies, high grade dysplasia (HGD) in 19 biopsies, and carcinoma in 12 biopsies. The sensitivity and specificity rates for AF and MB for the diagnosis of cancer or dysplasia versus BO mucosa without dysplasia were 21%/91% and 37%/91%, respectively. 4QB revealed five cancer/HGD areas and 76 LGD areas not detected by AF, MB, or VE. The additional yield of MB and AF over VE with 4QB concerned only one HGD area (in the vicinity of a cancer) and seven LGD areas.

CONCLUSIONS

Due to their low sensitivity, AF and MB are not suitable techniques for reducing the high numbers of routine biopsies needed for finding additional foci of HGD or cancer. Careful endoscopic observation and stepwise four quadrant biopsy therefore still represent the gold standard for surveillance of Barrett's oesophagus.

[Risk estimation in Barrett's esophagus: biomolecular marker and histopathologic classification]

The diagnosis of Barrett's esophagus and the different degrees of intraepithelial neoplasia appear to be demanding in several aspects. Current data on genetic alterations involved in the carcinogenesis of Barrett's esophagus are discussed. Several new biomarkers are being tested to help better to determine the risk of cancer development. However, a few immunohistochemical markers have emerged which could be helpful for the differential diagnosis of low- and high-grade intraepithelial neoplasia. Markers which could predict the progression of premalignant Barrett's epithelium to carcinoma are still to be established. At present, the "gold standard" for classifying the malignant potential in Barrett's esophagus is the degree of intraepithelial neoplasia found on standard biopsy protocols.

Which factors influence therapeutic decisions in Parkinson's disease?

Development of dyskinesia is a common phenomenon during the long-term course of Parkinson's disease. During the last few years, some but not all pathogenetic mechanisms causing dyskinesias in PD have become better understood. Severity of Parkinson's disease and levodopa dosing are the main clinical risk factors. Most concepts underline the significance of pulsatile D1-receptor stimulation for the development of dyskinesias. The interactions between D1- and D2-mediated STR-Gpi pathways and colocalized neuropeptides are important but not fully understood. Glutamatergic overactivity might also be a significant pathogenetic factor. According to these pathophysiological concepts, therapeutic strategies focus mainly on continuous postsynaptic DA-receptor stimulation by long-acting DA-agonists or highly selective D2-agonists. Another strategy is the use of NMDA antagonists.

[Comparative DNA cytometric investigations on aneurysmal bone cysts and giant cell tumors]

Giant cell-rich bone lesions consist of tumor-like lesions and true neoplastic giant cell tumors. In this study it was investigated whether DNA cytometry may contribute to the differential diagnosis between aneurysmal bone cysts and giant cell tumors. Statistically significant differences in the frequency of tetraploid stemlines were detected. Nevertheless, the knowledge of age, localization and radiological signs in addition to morphological findings are essential to distinguish between these lesions.

[Fibrous dysplasia]

The observations in 222 cases of fibrous dysplasia of the Hamburg Bone Tumor Registry will be presented. This benign lesion is based on the appearance of postzygotic point mutations in a gene encoding the Gsa protein. It occurs as a mono- and a polyostotic variant and may affect every bone of the skeleton. Most often affected are the proximal femur, the skull and the ribs. Polyostotic lesions tend to occur on one side of the body. The monostotic form is 7.6 times more frequent, but both variants show no predilection for gender. Most cases are diagnosed during adulthood. On x-rays the lesion has a ground-glass appearance and is located intramedullary with a sharply defined edge. The cortical bone is arroded and the bone is expanded. Histologically typical signs are slender curved fibrous trabeculae with a C and Y shape embedded in a morphologically bland and moderately cellular fibrous stroma. Diagnostically important are collagen fibres emerging perpendicular from the surface of the trabeculae. Cartilage is present in 8% of the cases. Therapeutically, thorough clinical controls are indicated and operative procedures are rarely needed to prevent progressive deformities and fractures. The formerly applied radiotherapy is now obsolete because of the increased occurrence of malignant transformations.

[Telecommunication and telepathology. New diagnostic routes for orthopaedics and orthopaedic pathology]

In a pilot project of the Department of Bone Pathology of the University of Hamburg and the Orthopaedic Department of the University of Heidelberg, the cases of 121 patients with suspicion of a primary bone tumour have been discussed at weekly interdisciplinary conferences during the period from July 2001 to May 2002., The consequent differential diagnoses were made prior to the biopsy, the optimal location of the biopsy and the further strategy was determined according to the guidelines of the international bone tumour centres. The latter includes the decision if a conventional biopsy or a intraoperative pathology examination on frozen sections should be performed. In 27 cases an intraoperative pathology examination was performed and then assessed in Hamburg. In 24 cases this diagnosis was identical with the final diagnosis. In three cases no definitive diagnosis could be made from the frozen sections. Additionally the pathohistological diagnoses of the cases of the previous week have been discussed in the video-conferences. Through this a unusually close interdisciplinary cooperation over a large distance has evolved, that is highly appreciated especially by the young and less experienced colleagues at the department of bone pathology and the orthopaedic department in Heidelberg. The awareness of the potential and limitations of a medical subject leads to an improved safety in the diagnostic process for bone tumours. The interdisciplinary discussion of all aspects of the diseases may also optimise the therapy of bone tumours.

[Histogenesis of giant cell tumors]

The giant cell tumor of bone (GCT) is a local osteolytic tumor with variable degrees of aggressiveness. In rare cases pulmonary metastases can be observed. The lesion most frequently occurs in the epiphysis of long tubular bones of the knee region, predominantly affecting young adults after closure of the growth plate. The characteristic histological appearance of GCT displays a high number of osteoclast-like multinucleated giant cells, which resulted in the classification "osteoclastoma" or "giant cell tumor". Apart from the multinucleated giant cells, there are two mononuclear cell types in the GCT. The first one has a round morphology and resembles a monocyte. The second cell type is the spindle-shaped, fibroblast-like stromal cell. Cell culture experiments with GCT cells revealed the stromal cell to be the proliferating component of the GCT. The other two cell types, the monocyte and the multinucleated giant cell, were lost after a few cell culture passages. Furthermore, latest results from GCT reveal that the stromal cells secrete a variety of cytokines and differentiation factors, including MCP1, ODF and M-CSF. These molecules are monocyte chemoattractants and are essential for osteoclast differentiation, suggesting that the stromal cell stimulates blood monocyte immigration into tumor tissue and enhances their fusion into osteoclast-like, multinucleated giant cells. The multinucleated giant cell itself demonstrates properties of a normal osteoclast that is able to resorb bone leading to extended osteolysis. This new model of GCT genesis supports the hypothesis that the stromal cell is the neoplastic component whilst the monocytes and the multinucleated giant cells are just a reactive component of this tumor. Taking this into consideration, the nomenclature of the "giant cell tumor" needs to be reconsidered.

[Clinical pathological aspects of Mazabraud's syndrome]

Mazabraud's syndrome is a rare, sporadic disorder characterised by the association of mainly polyostotic fibrous dysplasia and intramuscular myxoma. Fibrous dysplasia is mostly diagnosed at a younger age, while myxomas only occur during adulthood. We report a case of a 42-year-old female with Mazabraud's syndrome where a polyostotic fibrous dysplasia was already diagnosed and at presentation two newly formed intramuscular myxomas were found in the gluteal muscle.

Urogenital abnormalities in male children with cystic fibrosis

BACKGROUND

Congenital bilateral absence of the vas deferens (CBAVD) is presumed to occur prenatally and is present in over 99% of adult males with cystic fibrosis (CF).

AIMS

To describe ultrasonic features in male children with CF. We aimed to describe urogenital anomalies, comparing pancreatic sufficient and insufficient CF patients.

METHODS

Pelvic and scrotal ultrasonography were performed in 12 boys with CF aged 2-12 years and 16 age matched healthy controls.

RESULTS

Nine patients had pancreatic insufficiency (PI): seven had two severe mutations and two had unknown mutations. Three boys were pancreatic sufficient (PS), two with splicing mutations (5T and 3849+10kb C-T respectively) and borderline sweat tests. Seminal vesicles were visualised in 5/12 patients and 8/16 controls, compared to non-visualisation reported in all adults with CBAVD. Testicular microlithiasis was found in 4/18 PI, 0/6 PS, and 0/32 control testes, compared to 0.6-1.4% in healthy males and 15% in CF adults; 7/18 PI, 4/6 PS, and 0/32 control testes were smaller than predicted for age. The epididymal head was non-homogeneous with cysts, hypo-, or hyper-echogenicity in 5/18 PI, 1/6 PS, and 0/32 control testes.

CONCLUSIONS

Genital abnormalities may occur early in CF, but are less common than described in adults. They are found more often in pancreatic insufficient than in pancreatic sufficient CF patients. However, a positive finding, if present, may aid in the diagnosis of the latter. A larger longitudinal study is recommended to better define the onset and progression of urogenital abnormalities.

[Oncogene amplification and genetic heterogeneity in the metaplasia-dysplasia-adenocarcinoma sequence of Barrett esophagus]

AIMS

Information about numerical genomic alterations in the tumorigenesis of Barrett's adenocarcinoma (BCA) is still limited. In order to search for gene amplification and ploidy status, a series of locus-specific DNA probes and associated centromere probes was analysed in the metaplasia-dysplasia-adenocarcinoma-sequence.

METHODS

Fluorescence in situ hybridisation (FISH) was performed on paraffin sections with locus-specific DNA probes for D7S486, c-myc, cyclin D1, Her-2/neu, 20q13.2 and associated chromosomes 7, 8, 11, 17 and 20. Corresponding areas of intestinal metaplasia (IM, n = 5), low grade dysplasia (LGD, n = 9), high grade dysplasia (HGD, n = 15) and BCA (n = 16) were analysed.

RESULTS

Gene amplification of c-myc, Cyclin D1, Her-2/neu and 20q13.2 was observed in 15-35% of BCA. Coincident amplification of genes was also present. Polysomies for all investigated centromere probes were highly prevalent (up to 85%). Gene amplification was also demonstrated in HGD lesions. Polysomies were observed in HGD in high frequency (up to 80%). Extensive genetic heterogeneity was observed in both, BCA and HGD displaying different levels of amplification. None of the samples with LGD showed a locus-specific amplification, but polysomies for all investigated chromosomes were present in 18-48% of LGD. No changes were detected in BCA associated IM and squamous epithelium.

CONCLUSIONS

Our data indicate that oncogene amplification of c-myc, cyclin D1, Her-2/neu, and 20q13.2 occurring in BCA and less frequently in HGD is a late event in the tumorigenesis. Polysomies of chromosomes 7, 8, 11, 17 and 20, which were highly prevalent in BCA and HGD occur already at the stage of LGD. This may be a result of an early polyploidization, preceding the later genetic events, such as gene amplification in HGD and BCA. The detection of shared numerical genomic changes and the detected extensive genetic heterogeneity in the metaplasia-dysplasia-carcinoma-sequence in Barrett's esophagus supports the hypothesis of a process of multiclonal expansion underlying this progression.

[Molecular pathologic diagnosis in solid tumors. What is clinically relevant?]

There are only a few clinically relevant applications of molecular pathology assays in solid tumors. Among the findings which may influence therapy decisions are the amplification of Her-2/new in breast cancer and specific translocations in sarcomas. Mutation analyses of p53 may be helpful for only a very few cases, e.g. for confirming high grade dysplasia in the upper gastrointestinal tract or for diagnosing malignant soft tissue tumors in isolated cases. Microsatellite analyses are important for HNPCC screening or distinguishing tissue specimens of questionable identity. Other applications of molecular pathology assays such as detection of minimal residual disease or tumor cell dissemination and FISH analysis of urine and effusion specimens, may be increasingly applied in the future.

[Morphological diagnosis of spinal diseases. Current technical possibilities and challenges for the histological preparation of transpedicular biopsies]

The spine is the central component for the mobility of the human body. Both locally limited and diffuse pathologies of the spine are a challenge for the treating physician due to the difficult anatomy. The biopsy of a pathologically altered vertebral body is a fast and reliable basis for further therapy but until now this has not regularly been made use of as a diagnostic standard for spinal diseases, since the tissue gained was often microfractured because of the difficult anatomical position. Our own experience with transpedicular vertebral biopsies of 70 patients with different diseases is reported because of the considerable improvement in the biopsy technique and the methodical possibilities for processing the bony tissue. Methods which have proven particularly valuable are contact radiographs, embedding in plastic, careful decalcifying with EDTA and immunohistological procedures. In this way a definite diagnosis can be made in 97% of the cases. A close cooperation with the clinician carrying out the biopsy and a greater use of methods other than just fast decalcification is recommended.

In vivo-induction of antibodies to mistletoe lectin-1 and viscotoxin by exposure to aqueous mistletoe extracts: a randomised double-blinded placebo controlled phase I study in healthy individuals

BACKGROUND

Several studies have been performed in tumour patients to analyse the immunological response to mistletoe extracts. Considering the fact that these extracts are given subcutaneously in most instances, the kind of application resembles a typical immunization schedule. We therefore wanted to see how those extracts act on immunocompetent cells of healthy individuals hoping that this kind of provocation test may give new informations about a more specific application of these extracts in certain diseases.

SUBJECTS/METHODS

47 healthy individuals were exposed for twelve weeks either to Iscador Quercus special (IQ) known to be rich in mistletoe lectin (ML)-1 (n = 16), to Iscador Pini (IP) being poor in ML-1 but enriched in viscotoxins (n = 15), or to placebo (physiological saline) (n = 16) in a randomised, double-blinded placebo-controlled study. Humoral immunoreactivity was analysed by measuring antibodies towards the two compounds ML-1 and viscotoxin VA2 (VA2). Sera were collected in intervals of four weeks up to week 12 and again three months after last exposure.

RESULTS

None of the subjects had antibodies to ML-1 or VA2 before exposure. In week 12, anti-ML-1 antibodies of the IgG-type were found in all 16 IQ-treated individuals but only 6 of the 15 probands exposed to IP. In contrast, anti-VA2 IgG-antibodies could be detected in all individuals of both groups. The antibodies were preferentially of the IgG1 and IgG3 type while antibodies of the IgA and IgM type were produced only in a few probands. Antibodies of the IgE-type occurred only in the IQ-exposed individuals and were directed against ML-1 but not VA2. None of the probands receiving placebo developed antibodies to ML-1 or VA2. Severe side effects were not observed in any of the probands.

CONCLUSIONS

These data obtained in healthy individuals clearly indicate that IQ and IP-extracts can induce antigen-specific humoral responses. They may, therefore, provide, a solid basic for the evaluation of the humoral immune response in disease states.

Preoperative chemotherapy unmasks underlying Barrett's mucosa in patients with adenocarcinoma of the distal esophagus

BACKGROUND

Intestinal metaplasia of the distal esophagus frequently cannot be detected in patients with esophageal adenocarcinoma. It has therefore been questioned whether Barrett's esophagus is the primary precursor lesion of such lesions. We hypothesized that the underlying Barrett's mucosa may be masked by tumor overgrowth in the majority of these patients.

METHODS

The pretherapeutic endoscopy and biopsy records of 79 patients with locally advanced esophageal adenocarcinoma who had undergone preoperative chemotherapy were reviewed and compared to findings on restaging endoscopy/biopsy and subsequent resection and histopathologic analysis of the resected specimen.

RESULTS

Pretherapeutic endoscopy and biopsy showed associated Barrett's esophagus in 59/79 patients, whereas there was no evidence of associated intestinal metaplasia in 20/79 patients on extensive biopsies. Following neoadjuvant chemotherapy, Barrett's mucosa was unmasked and later documented by biopsy or histopathologic assessment of the resected specimen in 18 of the latter 20 patients. This resulted in an overall association of Barrett's mucosa with adenocarcinoma in the distal esophagus of 97.4%

CONCLUSION

Underlying Barrett's mucosa is frequently masked by tumor overgrowth in patients with locally advanced adenocarcinoma of the distal esophagus.

[Low-grade central osteosarcoma . 3 case reports]

Low-grade central osteosarcoma is a well-differentiated subtype of osteosarcoma, which is often confused with benign lesions. Males and females were affected about equally in our study. The tibia and femur were most commonly involved. Three case reports demonstrate the distinct features of the tumor. Excision of the tumor almost invariably led to recurrences. Wide resection was almost never followed by recurrence and seems to be the treatment of choice for this very rare variant of osteosarcoma.

Lymphatic vessel invasion is an independent prognostic factor in patients with a primary resected tumor with esophageal squamous cell carcinoma

BACKGROUND

Little data exist about the prognostic role of a lymphatic vessel invasion (LVI) in patients with esophageal carcinoma. The objective of this study was to clarify the presence and prognostic impact of LVI in a large group of patients resected for esophageal squamous cell carcinoma (SCC) at one surgical center.

METHODS

Three hundred sixty-six patients, who had a primary resection for SCC, were analyzed by univariate and multivariate analysis. Follow-up was complete for 93.7% patients with a median follow-up of 8.3 years.

RESULTS

The total rate of LVI was 39.1% (n = 143). Univariate analysis revealed a significant relation between LVI and different T classifications (P = 0.001), N classifications (P < 0.0001), M classifications (P < 0.0001), International Union Against Cancer (UICC) stages (P < 0.0001), and residual tumor (P < 0.0001). Multivariate analysis of the patients with R0-resected tumors proved LVI as an independent prognostic factor. The 2-, 5- and 10-year survival rates in patients with LVI were 28.5%, 11.1%, and 9.2% compared with 63.4%, 46.6%, and 27%, respectively, without LVI (P < 0.0001). Patients with LVI had a median survival time of 11.4 months compared with 28.6 months without LVI (P < 0.0001). Patients with R0-resected tumors without LVI had a median survival time of 54.1 months compared with 12.1 months in patients with LVI (P < 0.0001) and compared with 11.3 months in patients with R1-resected tumors P < 0.0001).

CONCLUSIONS

These data clearly show that LVI is an independent prognostic factor in patients with SCC and confirm the importance of a systematic pathohistologic workup. The prognosis of patients with R0-resected tumors with LVI is equal to patients with an incomplete tumor resection. This supports the inclusion of LVI in the UICC classification system for esophageal carcinoma.

Lymphatic vessel invasion is an independent prognostic factor in patients with a primary resected tumor with esophageal squamous cell carcinoma

BACKGROUND

Little data exist about the prognostic role of a lymphatic vessel invasion (LVI) in patients with esophageal carcinoma. The objective of this study was to clarify the presence and prognostic impact of LVI in a large group of patients resected for esophageal squamous cell carcinoma (SCC) at one surgical center.

METHODS

Three hundred sixty-six patients, who had a primary resection for SCC, were analyzed by univariate and multivariate analysis. Follow-up was complete for 93.7% patients with a median follow-up of 8.3 years.

RESULTS

The total rate of LVI was 39.1% (n = 143). Univariate analysis revealed a significant relation between LVI and different T classifications (P = 0.001), N classifications (P < 0.0001), M classifications (P < 0.0001), International Union Against Cancer (UICC) stages (P < 0.0001), and residual tumor (P < 0.0001). Multivariate analysis of the patients with R0-resected tumors proved LVI as an independent prognostic factor. The 2-, 5- and 10-year survival rates in patients with LVI were 28.5%, 11.1%, and 9.2% compared with 63.4%, 46.6%, and 27%, respectively, without LVI (P < 0.0001). Patients with LVI had a median survival time of 11.4 months compared with 28.6 months without LVI (P < 0.0001). Patients with R0-resected tumors without LVI had a median survival time of 54.1 months compared with 12.1 months in patients with LVI (P < 0.0001) and compared with 11.3 months in patients with R1-resected tumors P < 0.0001).

CONCLUSIONS

These data clearly show that LVI is an independent prognostic factor in patients with SCC and confirm the importance of a systematic pathohistologic workup. The prognosis of patients with R0-resected tumors with LVI is equal to patients with an incomplete tumor resection. This supports the inclusion of LVI in the UICC classification system for esophageal carcinoma.

Fluoroscopy-guided transpedicular trocar biopsy of the spine--results, review, and technical notes

The purpose of this study was to evaluate the technique and value of fluoroscopy-guided percutaneous transpedicular trocar biopsy in obtaining diagnostic tissue from vertebral body lesions and to review the current literature. The bone cores from 32 patients who underwent 34 transpedicular Jamshidi trocar biopsies for lesions in the thoracic, lumbar and sacral spine were examined. All samples were examined macroscopically for length and breakage and microscopically for trabeculae, marrow, and artifacts. Each sample was graded for its value for histologic examination. The diagnostic accuracy was assessed by the patient's clinical course and follow-up examinations. In 30 (93.8%) of the 32 patients a confirmed diagnosis or exclusion of pathology could be made. In 31 (91.2%) of 34 biopsies the quality of the specimen was assessed as "excellent". Two (5.9%) specimens were "good" and one (2.9%) was "poor". There were two minor complications (5.9%). Transpedicular biopsy of the spine using a Jamshidi trocar with an internal diameter of 3.1 mm under fluoroscopic guidance can be performed safely and efficiently and provides suitable bone cores for histologic examination. A combined clinical, radiological and pathological approach to the lesions leads to an excellent diagnostic yield.