Superficial gastric carcinoma developed on localized hypertrophic lymphocytic gastritis: a variant of localized Ménétrier's disease?

Ménétrier's disease is a rare premalignant condition that usually involves the entire stomach. Only few cases of localized disease have been reported, rarely with cancer. Lymphocytic gastritis is a newly described entity that may share a common pathogenesis with Ménétrier's disease. The authors report the case of a 62 year old woman with known liver cirrhosis in whom endoscopic examination of the stomach showed an antral tumor. Examination of the surgical specimen showed a superficial gastric adenocarcinoma developed on an hypertrophic gastropathy with both Ménétrier's disease and lymphocytic gastritis features. This observation strengthens the hypothesis of a common mechanism between Ménétrier's disease and lymphocytic gastritis, which may be part of the same disease spectrum. This disease could also correspond to the "hypertrophic lymphocytic gastritis" recently described.

[Pancreatic neuroendocrine tumors and von Hippel-Lindau disease]

Pancreatic neuroendocrine tumors are rare in von Hippel-Lindau disease, most often asymptomatic, nonfunctioning, non secreting, and benign. We report a case of low grade malignant pancreatic, secreting and asymptomatic neuroendocrine tumors, occurring in a 27 year old woman in the setting von Hippel-Lindau disease with recurrent pheochromocytoma, retinal and medullary hemangioblastomas, paraganglioma of the carotid body and ovarian cystadenoma. Neuroendocrine pancreatic tumors of von Hippel-Lindau disease are often constituted by clear cells, in the contrary of other neuroendocrine tumors of the pancreas. Occurrence of a pancreatic neuroendocrine tumor, especially in association with pheochromocytoma, may be misdiagnosed with a type 2 multiple endocrine neoplasia syndrom instead of von Hippel-Lindau disease.

[Symptomatic renal metastases of bronchial carcinoma]

Renal metastasis from carcinoma of the lung is rarely a clinical problem. Autopsic series however prove that the kidney is a frequent metastatic organ (20%). We report the case of a 43-years-old male patient affected with a squamous cell carcinoma of the lung, with bilateral renal extension. These secondary localizations were detected through a left flank pain prior to a systemic inflammatory response syndrome. The absence of hematuria (even microscopic) contrasted with the importance of the lesions. The age, along with the poor general state of our patient and the absence of any CT specificity justified an exploratory lobotomy. The pathologic analysis of the renal biopsies confirmed the metastatic nature of the lesion.

Cytokeratins expression in paragangliomas of the cauda equina

BACKGROUND

Paragangliomas rarely involve the cauda equina region. In this location, these tumors can show misleading morphological features such as trabecular or papillary growth patterns and variable expression of cytokeratins.

METHODS

We comparatively studied the immunohistochemical and ultrastructural patterns of 3 paragangliomas of the cauda equina (PCE) and of 8 paragangliomas from other sites.

RESULTS

All the paragangliomas expressed neuroendocrine markers (neuron-specific enolase, chromogranin A, synaptophysin and neurofilament protein). In PCE, chief cells exhibited a strong positivity with a broad spectrum anti-cytokeratin antibody. The staining was diffuse in the cytoplasm or had a paranuclear dot-like disposition. In other sites, only one paraganglioma showed a focal expression of cytokeratins. At ultrastructural level, chief cells of PCE contained characteristic dense core granules and intermediate-sized filaments sometimes grouped in paranuclear whorls.

CONCLUSION

The dual immunophenotype of PCE, paraganglionic and epithelial, must be recognized in order to distinguish these tumors from, for example, a metastasis of a neuroendocrine carcinoma. PCE are slow-growing tumors and have mostly a favorable prognosis after complete surgical excision.

Deletion mapping of the tumor suppressor locus involved in colorectal cancer on chromosome band 8p21

Several somatic genetic alterations have been described in colorectal carcinoma (CRC). Recurrent chromosomal deletions have suggested the presence of tumor suppressor genes (TSG) specifically involved in colorectal carcinogenesis. For one of them, two non-overlapping regions have been proposed on the short arm of chromosome 8, encompassing the LPL and NEFL genes. The short arm of chromosome 8 has been extensively studied in colorectal cancer and in other cancer types. Both regions have been reported as candidate loci for a TSG. In order to delineate a reliable region of deletional overlap on chromosome arm 8p in CRC, a series of 365 CRC samples was selected for the absence of microsatellite instability (RER, replication error); tumor and normal matched DNAs were studied for 54 microsatellite polymorphisms distributed on 8p using multiplex-PCR amplification. After purification of tumor nuclei by flow cytometry based on either the abnormal DNA index or the presence of a high expression of cytokeratin, complete allelic losses on 8p were observed in 48% of cases. Measurement of the DNA index showed that 88% of RER tumors were hyperploid. Complete allelic losses of only part of the short arm were observed on 26 occasions. These data allowed us to define a 1 cM interval of common deletion, flanked by the loci D8S1771 and NEFL, where a putative TSG may be localized.

[Mitral papillary fibroelastoma in a HIV infected patient]

BACKGROUND

Papillary fibroelastoma of the endocardium is a benign cardiac tumor which may cause embolic events.

CASE REPORT

We report the first case, to our knowledge, of cardiac papillary fibroelastoma which was revealed by cerebral ischemic events in a patient infected by the human immunodeficiency virus. The initial diagnosis was mitral endocarditis complicated by cerebral embolic events.

DISCUSSION

This case demonstrates that fibroelastomas should be added to other valvular diseases described in HIV infected patients. We recall the embolic potential of cardiac papillary fibroelastomas which warrant surgical treatment.

[Ischemic cholecystitis from cholesterol crystal embolism]

Cholesterol crystal embolism is a serious complication of atherosclerosis resulting in renal, cutaneous and rarely digestive manifestations. We report two cases of systemic cholesterol crystal embolization with gallbladder involvement in two patients with gallstones, severe atherosclerosis with an abdominal aortic aneurysm as well as predisposing factors for cholesterol crystal migration. These two cases show that, like vasculitis, cholesterol crystal embolization may result in ischemic cholecystitis, and that diagnosis of cholesterol crystal embolization on routine cholecystectomy suggests severe systemic involvement and a poor prognosis.

[Cholesterol crystal embolisms in adenomatous polyposis coli]

Cholesterol crystal embolism is a serious complication of atherosclerosis responsible for renal, cutaneous and less often digestive manifestations. We report a case of cholesterol crystal embolization in an adenomatous colonic polyp with foci of adenocarcinoma in a patient with an abdominal aortic aneurysm taking anticoagulant therapy. This case shows that cholesterol crystal embolization may be diagnosed by microscopic examination of a colonic polyp.

[Cystic tumors of the kidney in adults: radio-histopathologic correlations]

The purpose of this study is to provide an updated pathologic-radiologic classification of cystic renal tumors and to assess imaging diagnostic capabilities. Eighty seven cases of cystic renal tumors explored with multimodality imaging (ultrasonography, CT, MRI, arteriography) and with histopathologic correlation are reported. The most common cystic carcinomas were multilocular cystic renal cell carcinoma (33%) and the pseudocystic necrotic carcinoma (31%), which usually belong to category IV. Less common cystic carcinomas were unilocular cystic renal cell carcinoma (6%) and renal cyst wall carcinoma (6%). The association of thin septa and large locules are suggestive findings for multilocular cystic nephroma, but such criteria are not specific enough to recognize benign multilocular cystic nephroma and to exclude multilocular cystic renal cell carcinoma. Since carcinomatous degeneration may occur within the wall of such tumors, especially in von Hippel Lindau disease, surgery is still required. The results of our study corroborate the Bosniak classification of cystic renal masses: no tumors belonged to the category I or II, all cystic masses which belonged to the category IV were malignant tumors, category III included benign and malignant tumors.

[Practice of microscopic diagnosis of Helicobacter pylori infection on gastric biopsy in the laboratories of French Pathology. Hepatic and Digestive Histopathology Club]

The histological study of gastric biopsies is very much used for the diagnosis of Helicobacter pylori infection. A survey was performed among the members of the "Club d'Histopathologie Digestive et Hépatique" on the conditions of this diagnosis. The diagnosis is performed systematically by 91% of the pathologists. A special stain is used in 72% of cases (most often Giemsa), and immunohistochemistry is very rarely used. The classifications of gastritis that are frequently used are the Sydney system and the Whitehead's classification. In conclusion, it appears that the methods in use in France for the histological diagnosis of Helicobacter pylori infection are relatively homogeneous.

Expression of CD44 in premalignant and malignant Barrett's oesophagus

AIMS

To establish the prevalence of CD44 protein expression in a large surgical series of Barrett's adenocarcinoma and associated preneoplastic lesions and to correlate this expression with clinicopathological data and prognosis.

METHODS AND RESULTS

CD44H and variants (V4/V5, V6) expression was detected by immunohistochemistry in formalin-fixed, paraffin wax tissue samples of Barrett's mucosa (50) and Barrett's adenocarcinoma (73) obtained from surgical resections from 73 patients. This expression was correlated with pathological features of the tumour and prognosis. CD44H and V6 expression was found in 62% and 55% of Barrett's specialized mucosa negative for dysplasia and in 70% and 63% of Barrett's adenocarcinoma, respectively. CD44H and V6 expression was restricted to the lower part of the crypts in Barrett's specialized mucosa negative for dysplasia and reached the upper part of the crypts in high-grade dysplasia. A significant relation was found between CD44V6 expression and depth of tumour invasion in the oesophageal wall (P = 0.05), neoplastic vascular invasion (P = 0.0001), neoplastic perineural invasion (P = 0.0004) and stage in Rosenberg's classification (P = 0.02). Cancers with CD44V6 expression had a significantly poorer prognosis (5-year survival: 17%) than those without (5-year survival: 44%) (P = 0.02) in univariate analysis. However, multivariate analysis showed that CD44V6 expression had no independent prognostic value when tumour invasion and lymph node involvement were taken as explanatory variables.

CONCLUSION

CD44H and V6 are frequently expressed in Barrett's oesophagus. The pattern of expression that we observed from mucosa negative for dysplasia to adenocarcinoma suggests that CD44H and V6 may be involved in the carcinogenesis of Barrett's mucosa. CD44V6 expression in adenocarcinoma is correlated to aggressive pathological features.

Intraoperative localization of neuroblastoma in children with 123I- or 125I-radiolabeled metaiodobenzylguanidine

BACKGROUND

This study describes a novel method of intraoperative localization of neuroblastoma with a gamma-detecting probe, to detect in situ tumor binding of radiolabeled 123I- or 125I-metaiodobenzylguanidine (MIBG) and improve the quality of tumor resection.

METHODS

Fifty-eight children underwent 66 surgical procedures with intraoperative detection of radiolabeled MIBG. All patients with positive MIBG scintiscans at diagnosis were included in the study. A tumor/background ratio exceeding 2:1 at the time of operation was considered positive, indicating a significant uptake of MIBG, compatible with the presence of malignant cells. The surgeons were requested to evaluate the contribution of the method to the surgical procedure. Sensitivity and specificity of the method with either 123I-labeled MIBG or 125I-labeled MIBG, on the basis of correlations between probe findings and pathologic analysis of 288 resected specimens, were determined.

RESULTS

Intraoperative detection was helpful in 65% of surgical procedures, allowing a better definition of tumor limits and extension to locoregional nodes or detection of small and nonpalpable tumors in sites with difficult surgical access, especially during operation for relapse. The detection was not contributory in 35% of the procedures (well-localized tumors, thoracic neuroblastoma for technical reasons, highly differentiated tumors as ganglioneuroma, and tumors with mainly necrosis or fibrosis). The sensitivity of 123I and 125I was the same (91% and 92%), but the specificity of 125I (85%) was significantly higher than that of 123I (55%) (p < 0.005).

CONCLUSIONS

First, this study demonstrates the feasibility of intraoperative detection, with radiolabeled MIBG, of neuroblastoma in children. We advocate the use of 125I rather than 123I. Second, the method is useful to improve the quality of macroscopic resection in widespread neuroblastoma with nodal involvement, in sites with difficult access, and in operations for relapse.

Brain tumor-polyposis syndrome: two genetic diseases?

PURPOSE AND DESIGN

This report presents a comprehensive and statistical analysis of the brain tumor-polyposis (BTP) cases referred to as Turcot's syndrome in the literature.

RESULTS

BTP patients encompass a heterogeneous group that can be classified into two statistically distinct clinical entities based on phenotype of the polyps (P = .0001), presence of colorectal cancer (P = .0001), type of brain neoplasm, ie, glioma or medulloblastoma (P = .0001), presence of skin lesions (P = .0004) and cafe-au-lait spots (P = .0008), as well as consanguinity (P = .0135).

CONCLUSION

The first entity (BTP syndrome type 1) consists of patients who have glioma and colorectal adenomas without polyposis (non-FAP cases), and their siblings with glioma and/or colorectal adenomas. For these patients, we show that the patient's age at malignant glioma occurrence is less than 20 years (50 to 80 years in the general population), which strongly supports the existence of an underlying genetic cause. The neoplasms of these patients show DNA replication errors, which suggests a relationship with hereditary nonpolyposis colorectal cancer (HNPCC), a disease characterized by germline alterations in DNA mismatch repair genes. The second entity (BTP syndrome type 2) consists of patients with a CNS tumor that occurs in a familial adenomatous polyposis kindred (FAP cases). These patients carry germline mutations in the APC gene, which suggests that mutations in this gene might predispose to brain tumors. Risk analysis shows increased incidence of medulloblastoma in FAP patients, but APC mutations are not found in sporadic glioma or medulloblastoma. Therefore, further investigations should establish whether the occurrence of medulloblastoma in an FAP family represents a variant of FAP.

[Subadventitial cyst of the popliteal artery. Non-invasive explorations. Anatomo-pathologic data]

Subadventitial cyst of the popliteal artery is a well known entity. We report a new case and the diagnostic and therapeutic advantages of noninvasive explorations. Transcutaneous duplex-scan provided diagnosis and showed cystic formations in contact with a segmentary occlusion of the popliteal artery. Magnetic resonance imaging (MRI) evidenced communication between the cysts and the articular capsule of the knee joint. Surgical exeresis confirmed the communication with the synovial fluid. This observation demonstrated: i) the contribution of duplex-scan for the diagnosis of adventitial cysts and arterial consequences; ii) the contribution of MRI in identifying communication with the synovial fluid; iii) the presence of arterial wall lesions (necrosis of the media) would favor no conservative treatment.

Unusual fat-containing tumors of the kidney: a diagnostic dilemma

Unusual fat-containing renal tumors in a series of 27 cases comprised five categories: atypical and complicated angiomyolipomas (AMLs) (n = 15), including AMLs with extrarenal growth (n = 5), AMLs with undetectable fat (n = 4), and hemorrhagic AMLs (n = 6); fat-containing renal cell carcinomas (RCCs) (n = 9); lipoma (n = 1); liposarcoma (n = 1); and fat-containing renal oncocytoma (n = 1). Fat was present within RCCs by the following mechanisms; lipid-producing necrosis within a large RCC (n = 2), intratumoral bone metaplasia with fatty marrow elements and calcification within a small RCC (n = 2), and entrapment of perirenal (n = 4) or sinus (n = 1) fat by large irregular RCCs. Fat-containing RCC must be considered in cases of fat-containing renal tumors, even though the presence of intratumoral fat is characteristic of AML. A dedicated computed tomography scanning protocol and strict diagnostic criteria are mandatory for accurate diagnosis. Malignancy should be suspected on the basis of the following criteria: presence of intratumoral calcifications; large, irregular tumor invading the perirenal or sinus fat; large necrotic tumor with small foci of fat; and association with nonfatty lymph nodes or venous invasion.

[Localization of a tumor suppressor gene distal to D22S270 in colorectal cancers]

Recurrent allelic losses on chromosome 22q have been reported in colorectal cancer, distal to the NF2 gene, suggesting that another tumor suppressor gene might be involved. We report here the typing of 256 sporadic colorectal tumors and 18 colonic cancer cell lines using a set of chromosome 22 polymorphisms, ranging from 20 to 45. A panel of somatic cell hybrids, that allows to distinguish 11 bins in the 22q13 region, was used to localize 19 of the 45 selected markers and the putative tumor suppressor gene BZRP. Allelic-loss was observed in 43% of tumors. The minimal region of deletion that could be determined, telomeric to locus D22S270, refines significantly the position of the gene. The localization of the BZRP gene in this region led to a systematic screening for somatic point mutation. Direct sequencing of its coding sequence in 36 tumors hemizygous for chromosome 22 allowed the identification of three polymorphisms but failed to detect somatic mutation.