Endoscopic findings in patients with Schatzki rings: Evidence for an association with eosinophilic esophagitis

AIM: To investigate endoscopic findings in patients with Schatzki rings (SRs) with a focus on evidence for eosinophilic esophagitis (EoE).

METHODS: We consecutively approached all adult patients scheduled for elective outpatient upper endoscopy for a variety of indications at the German Diagnostic Clinic, Wiesbaden, Germany between July 2007 and July 2010. All patients with endoscopically diagnosed SRs, defined as thin, symmetrical, mucosal structures located at the esophagogastric junction, were prospectively registered. Additional endoscopic findings, clinical information and histopathological findings with a focus on esophageal eosinophilia (≥ 20 eosinophils/high power field) were recorded. The criteria for active EoE were defined as: (1) eosinophilic tissue infiltration ≥ 20 eosinophils/hpf; (2) symptoms of esophageal dysfunction; and (3) exclusion of other causes of esophageal eosinophilia. Gastroesophageal reflux disease was excluded by proton pump inhibitor treatment prior to endoscopy. The presence of ≥ 20 eosinophils/hpf in esophageal biopsies in patients that did not fulfil the criteria of EoE was defined as esophageal hypereosinophilia.

RESULTS: A SR was diagnosed in 171 (3.3%; 128 males, 43 females, mean age 66 ± 12.9 years) of the 5163 patients that underwent upper gastrointestinal-endoscopy. Twenty of the 116 patients (17%) from whom esophageal biopsies were obtained showed histological hypereosinophilia (≥ 20 eosinophils/hpf). Nine of these patients (8 males, 1 female, mean age 49 ± 10 years) did not fulfill all diagnostic criteria of EoE, whereas in 11 (9%) patients with ≥ 20 eosinophils/hpf, a definite diagnosis of EoE was made. Three of the 11 patients (27%) with definite EoE had no suspicious endoscopic features of EoE. In contrast, in the 25 patients in whom EoE was suspected by endoscopic features, EoE was only confirmed in 7 (28%) patients. Patients with EoE were younger (mean age 41.5 ± 6.5 vs 50.5 ± 11.5 years, P = 0.012), were more likely to have a history of allergies (73% vs 29%, P = 0.007) and complained more often of dysphagia (91% vs 34%, P = 0.004) and food impaction (36% vs 6%, P = 0.007) than patients without EoE. Endoscopically, additional webs were found significantly more often in patients with EoE than in patients without EoE (36% vs 11%, P = 0.04). Furthermore, the SR had a tendency to be narrower in patients with EoE than in those without EoE (36% vs 18%, P = 0.22). The percentage of males (73% vs 72%, P = 1.0) and frequency of heartburn (27% vs 27%, P = 1.0) were not significantly different in both groups. The 9 patients with esophageal hypereosinophilia that did not fulfil the diagnostic criteria of EoE were younger (mean age 49 ± 10 years vs 58 ± 6 years, P = 0.0008) and were more likely to have a history of allergies (78% vs 24%, P = 0.003) than patients with < 20 eosinophils/hpf. Predictors of EoE were younger age, presence of dysphagia or food impaction and a history of allergies.

CONCLUSION: A significant proportion of patients with SRs also have EoE, which may not always be suspected according to other endoscopic features.

[Tumor infiltrates suspicious of carcinoma in mediastinal lymph nodes]

Myelosarcomas are, due to their rarity, a difficult differential diagnosis. Not infrequently, extensive immunohistochemical staining for characterization of the tumor is performed, if one does not directly think of myelosarcoma. In the present case, there was a positivity of the myeloid blasts for cytokeratin. This may complicate the discrimination of myelosarcoma from carcinoma, in particular small cell carcinoma, not only in the mediastinum, but also in the skin, e.g., Merkel cell carcinoma.

[A rare cause of recurrent small bowel intussusception. Case report and review of the literature]

Small bowel intussusception is a rare cause of abdominal pain in adult patients. Due to varying symptoms and different underlying causes its diagnosis and treatment is challenging for physicians. This case report describes recurrent intussusception in an adult female patient and celiac disease could only be diagnosed as the cause of these symptoms after surgery. In addition a review of the literature regarding adult intussusception is presented.

Requirements to assess feasibility of phase 0 trials during major abdominal surgery: variability of PARP activity

PURPOSE

The aim of this study was to evaluate the feasibility of phase 0 trials in the setting of a routine surgical procedure. Logistic considerations, tissue sampling and tissue handling, and variability of a biomarker during surgery, in here PARP, were evaluated.

EXPERIMENTAL DESIGN

Patients with highly suspicious or proven diagnosis of advanced ovarian cancer, planned for debulking surgery were asked to allow sequential tumor biopsies during surgery. Biopsies were frozen immediately and PARP activity was measured subsequently.

RESULTS

Baseline biopsies were obtained from eight patients after a median time of 88 minutes (minimum of 50 to maximum of 123 minutes). Second and third biopsies were obtained after a median of 60 (32-96) and 101 (79-130) minutes, respectively. Mean tumor load was 44% (5%-100%), with a cellular viability of 98% (85%-100%). Median baseline PARP activity was 1035 pg/mL (range, 429-2663 pg/mL). The observed interpatient variability at baseline was large: SD was 0.59 after natural logarithm transformation.

CONCLUSIONS

Conducting phase 0 trials during surgery seems to be feasible in terms of logistic considerations. In preparation of a phase 0 trial during surgery, a feasibility study like this should be conducted to rule out major interactions of the surgical intervention with respect to the targeted biomarker.

Borderline tumors of the ovary: clinical course and prognostic factors

BACKGROUND

The prognosis in borderline tumors of the ovary (BOT) is generally favorable. However, some patients experience recurrence, and mortalities occur. There is a need to better characterize prognostic factors to be considered for individualized treatment planning.

PATIENTS AND METHODS

The data of 158 consecutive patients who underwent surgery for BOT at a tertiary referral center for gynecologic oncology between 1997 and 2008 were retrospectively analyzed.

RESULTS

Most patients had early stage disease, and advanced stages FIGO II/III only occurred in 23.4%. Serous histology was most frequent (68%), followed by mucinous histology (22%). All patients received surgery as initial treatment with no adjuvant systemic therapy. 37 patients (40.7% of the patients under the age of 50) had fertility-sparing surgery (FSS). Recurrent disease occurred in 18 (11.4%) patients, and 4 (2.5%) patients died. Independent risk factors for recurrence were FIGO stages > I (hazard ratio (HR) 37.1; 95% confidence interval (CI) 4.5-155.5), tumor rupture (HR 12.4; 95% CI 1.5-61.5), incomplete staging (HR 5.9; 95% CI 1.6-21.3), and FSS in patients < 50 years (HR 8.0; 95% CI 2.0-31.6).

CONCLUSION

Intraoperative tumor rupture, incomplete staging, and FSS - all influenced by the surgeon - may impose a substantial recurrence risk. Therefore, careful counseling and balancing of risk and benefit are mandatory before therapy is applied, especially if FSS is planned.

The influence of the primary tumor on the long-term results of pulmonary metastasectomy for metastatic renal cell carcinoma

OBJECTIVE

To investigate one of the primary tumor (PT) on pulmonary metastasectomy (PM) for metastatic renal cell carcinoma (RCC) and to define prognostic factors.

METHODS

Retrospective review of patients with pulmonary metastases from RCC from January 1999 through December 2008 was performed. All patients underwent PM with curative intend. TNM-classification, tumor stage and PT grade, disease-free-interval (DFI) from nephrectomy to the diagnosis of metastasis, systemic chemotherapy before surgical intervention, surgical procedures, morbidity, mortality, and survival were investigated.

RESULTS

One-hundred seven consecutive patients (age 61.5 ± 9.6 years) underwent PM. Morbidity and mortality rates were 15.0 and 0.9%, respectively. Thirty-six patients (33.6%) had systematic therapy before PM. Complete resections could be achieved in 104 patients (97.2%). Mean survival was 63.4 ± 5.1 months. The overall 5- and 10-year survival rates were 47 and 9%, respectively. Advanced N-Status (p < 0.001), grade (p < 0.001) and stage group (stage I/II vs. III/IV, p = 0.022) of the PT were associated with inferior survival in the univariate analysis. T-Status (p = 0.89) and M-Status (p = 0.96) of the PT had no significant impact on survival. In a multivariable Cox proportional hazards model, N-Status and tumor grade were the only significant prognostic factors.

CONCLUSIONS

PM can be performed safely. Long-term survival is achievable in selected patients. Nodal disease and high tumor grade of the PT at the time of the initial nephrectomy were associated with worse survival after PM. These results might help to identify a high-risk group of patients who might benefit from enrollment in adjuvant therapy protocols after primary treatment of RCC.

[Histopathological evaluation of the meniscus]

Menisci fulfill many functions within the complex biomechanics of the knee joint. In the case of meniscus lesions, sparing arthroscopic resection and surgical refixation are the treatments of choice. In terms of diagnosis, this means in general that histopathologic diagnostics are carried out on detached meniscus fragments of between 5 mm and 2 cm in size. A good knowledge of physiologically possible cellular and fibrous histological meniscus damage, as opposed to nonphysiological change regarded as normal with respect to age, is essential for diagnostic meniscus evaluation. The clinician expects clear statements from the pathologist regarding the severity of previous or secondary degenerative meniscus damage, the age and type of traumatic tears, and an appraisal of the relationship between trauma and meniscus damage from an insurance point of view. Close cooperation between the clinician and the pathologist allows for a fast and unambiguous correlation of anamnesis, the clinical picture, and morphological reporting such that problematic insurance cases can be clarified quickly.

Cerebral metastases in metastatic breast cancer: disease-specific risk factors and survival

BACKGROUND

Survival of patients suffering from cerebral metastases (CM) is limited. Identification of patients with a high risk for CM is warranted to adjust follow-up care and to evaluate preventive strategies.

PATIENTS AND METHODS

Exploratory analysis of disease-specific parameter in patients with metastatic breast cancer (MBC) treated between 1998 and 2008 using cumulative incidences and Fine and Grays' multivariable regression analyses.

RESULTS

After a median follow-up of 4.0 years, 66 patients (10.5%) developed CM. The estimated probability for CM was 5%, 12% and 15% at 1, 5 and 10 years; in contrast, the probability of death without CM was 21%, 61% and 76%, respectively. A small tumor size, ER status, ductal histology, lung and lymph node metastases, human epidermal growth factor receptor 2 positive (HER2+) tumors, younger age and M0 were associated with CM in univariate analyses, the latter three being risk factors in the multivariable model. Survival was shortened in patient developing CM (24.0 months) compared with patients with no CM (33.6 months) in the course of MBC.

CONCLUSION

Young patients, primary with non-metastatic disease and HER2+ tumors, have a high risk to develop CM in MBC. Survival of patients developing CM in the course of MBC is impaired compared with patients without CM.

[Acetone compression. A fast, standardized method to investigate gastrointestinal lymph nodes]

Lymph node staging is the most important prognostic parameter in malignant gastrointestinal tumors. Manual dissection of adipose tissue is time-consuming and also depends on the experience of the individual examiner. By combining elution with acetone and mechanical compression using simple equipment it was possible to completely embed adipose tissue from 404 surgical specimens (colon 348, stomach 28, greater omentum 14, other location 14) without manual dissection. As a result of the procedure, the weight of the adipose tissue could be reduced by 90%-95%, making full histological examination possible. The colon specimens included an average of 43.8 lymph nodes (14-109) in 14 embedding cassettes (1-38) with a native fat weight of 234.7 g (42.8-820 g). The quality of histological staining, including immunohistochemical and molecular investigations, is of comparable quality to routine work-up. Elution with acetone enables the prompt, standardized and full histological work-up of adipose tissue without manual dissection. Moreover, additional costs are low. The number of lymph nodes required by medical associations was attained in all cases and often exceeded. This method was successfully used in other organs (greater omentum, breast).

[New TNM classification of malignant lung tumors 2009 from a pathology perspective]

Based on the IASLC multicenter data collected worldwide on 81495 patients diagnosed or registered with lung cancer between 1990 and 2000, the T, N, and M descriptors were analyzed and recommendations for changes in the seventh edition of the TNM classification were proposed on the basis of differences in survival. This new TNM classification replaces the old UICC classification and the staging system according to C. Mountain 1997. The changes principally affect the T and M classifications. For the T component, tumor size was found to have prognostic relevance and its analysis led to recommendations to subclassify T1 into T1a and T1b, and T2 tumors into T2a and T2b and to reclassify T2 tumor>7 cm into T3 tumors. In the M category, M1 was recommended to be subclassified into M1a (contralateral lung nodules and pleural dissemination) and M1b (distant metastasis). There is no change in the N category. The proposed changes for the new stage grouping are to upstage T2b N0 M0 from stage IB to stage IIA and to downstage T2a N1 M0 from stage IIB to stage IIA and T4 N0-N1 M0 from stage IIIB to stage IIIA. The particulars of the new classification are discussed in the context of practice-relevant aspects from a pathology perspective view.

Expression of extracellular matrix-proteins in perisellar connective tissue and dura mater

PURPOSE

To describe the pattern of expression of extracellular matrix (ECM) proteins in perisellar connective tissue.

METHODS

Dural and perisellar specimens from ten individuals were investigated immunohistochemically for collagens I to IV, tenascin, fibronectin, elastin, laminin, and vitronectin.

FINDINGS

Collagen I and III and fibronectin were strongly expressed and collagen IV, tenascin, and vitronectin were moderately expressed in the boundaries of the sella and around the CS. In six of nine specimens from the anterior boundary of the sella, and in 11 of 19 samples from the lateral boundary of the sella (medial wall of CS), two different layers could be detected by the expression of different ECM proteins. None of the antigens generally allowed differentiation between two layers of the pituitary envelope.

CONCLUSIONS

The pituitary boundary may consist of a single or a double layer, infrequently differentiated from each other by the expression of different ECM proteins.

Assessment of the sentinel lymph node in patients with invasive squamous carcinoma of the vulva

OBJECTIVE

This study aims to evaluate the feasibility and diagnostic validity of the sentinel lymph node technique in detecting inguinal lymph node metastases in patients with invasive squamous cancer of the vulva.

DESIGN

Retrospective analysis of the in-house tumor registry.

SETTING

Dr. Horst Schmidt Klinik, a tertiary gynecologic oncology unit in Wiesbaden, Germany, June 2000-May 2008.

POPULATION

All consecutive operated patients with primary envisaged diagnosis were included.

METHODS

The sentinel node identification technique was performed and patients were informed accordingly. Patients who consented and were found eligible underwent preoperative lymphscintigraphy on the day before surgery.

MAIN OUTCOME MEASURES

Sentinel node detection in specimen from sentinel lymph node biopsy and from full lymphadenectomy (LNE); sentinel lymph node biopsy as a sole surgical groin procedure in patients with histological negative sentinel node; benefit with respect to side effects for sentinel lymph node biopsy compared to full LNE; complication rates; and recurrences of vulvar cancer.

RESULTS

In all, 46 of 59 patients with vulvar malignancy underwent inguinofemoral LNE, sentinel lymph node biopsy (SLB) of the groin followed by LNE, or SLB alone. Most patients had been diagnosed in the early stages of the disease. Since no false positive or false negative results were recorded, the sensitivity, specificity, positive predictive value and negative predictive value of the sentinel lymph node were 100%. However, in 6%, a sentinel lymph node could not be detected intraoperatively indicating a feasibility of 94%.

CONCLUSION

The implementation of sentinel lymph node technique for groin staging in squamous cell vulvar cancer seems to provide a feasible and safe technique in tertiary gynecologic oncology.

Hypersensitivity pneumonitis associated with the use of temozolomide

The aim of the present study was to investigate a case of hypersensitivity pneumonitis associated with the use of temozolomide in the treatment of gliosarcoma. A 54-yr-old female developed dyspnoea, cough and hypoxia after surgical resection for gliosarcoma and adjuvant radio- and chemotherapy with temozolomide. A high-resolution computed tomography scan of the thorax showed a bilateral ground-glass pattern. Bronchoscopy with bronchoalveolar lavage and lung biopsies was performed. Bronchoalveolar lavage demonstrated significant lymphocytic alveolitis and transbronchial lung biopsies revealed lymphocytic infiltration with foamy macrophages, consistent with hypersensitivity pneumonitis. There was no evidence of other causes, including infections. After withdrawing temozolomide and initiating prednisolone therapy, the patient had no further pulmonary symptoms. To the present authors' knowledge, this is the first definitively described case of temozolomide-associated hypersensitivity pneumonitis.

[Molecular diagnostics and imaging]

Molecular diagnostic methods and biological imaging techniques can make a major contribution to tailoring patients' treatment needs with regard to medical, ethical and pharmaco-economic aspects. Modern diagnostic methods are already being used to help identify different sub-groups of patients with thoracic tumours who are most likely to benefit significantly from a particular type of treatment. This contribution looks at the most recent developments that have been made in the field of thoracic tumour diagnosis and analyses the pros and cons of new molecular and other imaging techniques in day-to-day clinical practice.

Thymidylate synthase polymorphisms and immunohistochemistry in non-small cell lung cancer

11101

Background: Recently, pemetrexed has been introduced into the treatment of non-small cell lung cancer (NSCLC). There's evidence that pemetrexed appears to be more efficient in non squamous NSCLC including adenocarcinoma (AC) and large cell carcinoma (LCC). TS represents a major target enzyme of pemetrexed. We evaluated the expression of TS among different histological types of NSCLC and its association with functional genetic polymorphisms of the TS gene. Methods: Archived tumor samples from 312 individuals with NSCLC were analyzed. Immunohistochemistry (IHC) was performed using a mouse monoclonal antibody to TS. TS stained sections were scored for cytoplasmic and nuclear localization. For each compartment, the tumor was evaluated for the estimated percentage of positive cells with the greatest intensity within the tumor. Intensity was scored on a scale of 0–4. A score of 3–4 was classified as high expression. Genotyping of TS-VNTR including the G/C SNP and TS1394del6 was performed by PCR based RFLP techniques. Genotypes supposed to be associated with low expression were grouped (group A: 2R/2R or 2R/3RC or 3RC/3RC + -6/-6) and compared to genotype groups associated with high expression (group B: 2R/3RG or 3RC/3RG or 3RG/3RG + -6/+6 or +6/+6). Results: IHC and polymorphisms could be performed successfully in 312 (100%) and 287 (92%), respectively. Distribution of histology was as follows: 50% AC, 42% squamous cell carcinoma (SCC), 3% LCC and 5% mixed or other histological subtypes. Group B genotypes were significantly more present in SCC than in AC (49% vs 23%, p=.002). Tumors with group B genotypes were more likely to display high nuclear staining intensity than group A tumors (30% vs. 17%, p=.077). A similar but not significant trend was seen for cytoplasmic staining intensity. There was no significant difference between histological subtypes of NSCLC with respect to TS protein expression. AC were more common than SCC to show a G1 differentiated tumors (8% vs 1%, p<.001). No difference between genotype groups were observed with respect to grading. Conclusions: TS polymorphisms are significantly associated with histology subtypes in NSCLC. These results represent a potential explanation for efficacy differences of pemetrexed in NSCLC and warrants further investigations.

[Table: see text]

[Sickle cell anemia in perinatal placental diagnostics]

Hereditary hemoglobinopathies should be considered as differential diagnosis when examining placental specimens for fetal growth retardation and spontaneous abortion. They can cause various macroscopic and microscopic changes in the placenta that are relevant for routine pathology examination. The importance of interdisciplinary co-operation between obstetrics and pathology to achieve optimum diagnostics and therapy planning is demonstrated using the case of a pregnant woman with heterozygous genotype and her child with homozygous genotype. Within this context, the influence of hemoglobinopathies on placental pathology and fetal development are summarized and exemplified.