Distinction between dysplasia-associated lesion or mass (DALM) and adenoma in patients with ulcerative colitis

Polyps with epithelial dysplasia in ulcerative colitis (UC) represent either dysplasia-associated lesions or masses (DALMs) or sporadic adenomas. DALMs are frequently associated with associated carcinoma and are an indication for colectomy. Removal of the polyp is treatment of choice for sporadic adenomas. Differentiating between these 2 lesions is not always easy. The goal of this study was to distinguish DALMs from adenomas in patients with UC on a genetic basis. We evaluated genetic alterations in DALMs and compared them with a previously published set of dysplastic polyps in patients with UC that were considered adenomas for the following reasons: (1) polyps were located outside of current active disease; (2) polyps had histological features of sporadic adenomas; and (3) patients displayed a uneventful follow-up after polypectomy (UC-adenomas). In addition, adenomas not associated with UC were studied. Genetic alterations on chromosome 3p were assessed for the markers D3S1766, D3S2409, and D3S2387. LOH with or without microsatellite instability was found in 70%, 37%, and 57% of cases of DALM, respectively. In contrast, UC-adenomas lesions exhibited genetic alterations in 8.3%, 11.7%, and 15.3% for the respective markers. Spontaneous adenomas exhibited genetic alterations in 10.5%, 7.1%, and 0% of cases, which were not significantly different from the UC-adenoma results. These results indicate that UC-adenomas are genetically and biologically similar to sporadic adenomas and that UC-adenomas may biologically represent sporadic adenomas, supporting on a genetic basis the criteria chosen to diagnose adenomas in UC. Genetic markers on chromosome 3p may be useful in the differential diagnosis between DALM and UC-adenomas.

Dysplasia in Chronic Ulcerative Colitis: A Molecular Approach to Its Differential Diagnosis

Ulcerative colitis-related epithelial dysplasia represents a premalignant lesion, which may lead to the development of ulcerative colitis-related adenocarcinoma. The proper management of this condition requires proctocolectomy before the acquisition of the invasive phenotype. Patients with chronic ulcerative colitis, however, like the general population, may develop sporadic colorectal adenomas not related to the presence of the inflammatory bowel disease. These adenomas are also characterized by epithelial dysplasia, but their detection carries very different clinical implications. It is therefore essential to distinguish between chronic ulcerative colitis-related dysplasia and sporadic colorectal adenomas. The gross and histologic features do not provide a definite distinction between these two different types of dysplasia of the colonic epithelium. Recent developments in the molecular genetics may provide the necessary means. Int J Surg Pathol 8(1):11-16, 2000

Familial idiopathic adulthood ductopenia: a report of five cases in three generations

BACKGROUND/AIMS

Idiopathic adulthood ductopenia is a cholestatic liver disease of unknown etiology. Although most cases are sporadic, familial cases do occur.

METHODS

We describe a series of adult-onset bile duct depletion involving five members of an extended family spanning three generations. The proband, a 49-year-old man, presented in 1989 with asymptomatic elevation of liver enzyme tests. Investigations for chronic liver disease, including endoscopic retrograde cholangiopancreatography, were negative. Findings on liver biopsy progressed from normal in 1989 to striking loss of interlobular bile ducts in 1992. Ursodeoxycholic acid has resulted in improvement of liver enzyme tests. The proband's brother required a liver transplant at age 35 for cryptogenic cirrhosis. The proband's sister, age 42, has had intermittent jaundice and elevation of liver enzyme tests since 1971. Her liver biopsy findings progressed from normal in 1975, to striking bile duct damage by 1997. The proband's 21-year-old son has elevated liver enzyme tests and a liver biopsy consistent with idiopathic adulthood ductopenia. The proband's father had a liver biopsy at age 70 for investigation of a liver mass. It revealed extensive fibrosis and striking bile duct destruction.

RESULTS/CONCLUSIONS

This is the largest series of familial idiopathic adulthood ductopenia reported, and the first with multiple generations described. Genetics appears to play a role in some cases of adulthood ductopenia. Ursodeoxycholic acid may be beneficial in the treatment of this condition.

Interleukin-6 regulation of matrix metalloproteinase (MMP-2 and MMP-9) and tissue inhibitor of metalloproteinase (TIMP-1) expression in malignant non-Hodgkin's lymphomas

We showed previously that human malignant non-Hodgkin's lymphomas (NHL) degrade extracellular matrix (ECM) components through the action of metalloproteinases and that elevated expression of matrix metalloproteinase-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1) correlated with a poor clinical outcome in patients with NHL. In the present study we sought to investigate whether there is any correlation between the expression of gelatinases (MMP-2 and MMP-9), TIMP-1, and the expression of cytokines and growth factors such as interleukin-1beta (IL-1beta), IL-6, IL-10, tumor necrosis factor alpha (TNF-alpha), transforming growth factor beta (TGFbeta), and basic fibroblast growth factor (bFGF) in human NHL. In lymphoma tissues obtained from 32 patients, elevated expression of IL-6 correlated significantly with elevated messenger RNA (mRNA) levels of MMP-9, MMP-2, and TIMP-1. Moreover, in human lymphoid cell lines of B- and T-cell origin (Raji, Jurkat, and NC-37), IL-6 stimulated production of MMP-9 and MMP-2 but not TIMP-1. In the Matrigel invasion assay IL-6 significantly upregulated transmigration of Raji and Jurkat cells, which in turn was inhibited by recombinant human TIMP-1 and anti-MMP-9 and MMP-2 antibodies. We postulate that IL-6 may play a role in the clinical aggressiveness of human NHL by stimulating MMP production.

Mucosa-associated lymphoid tissue (MALT) lymphoma manifesting as multiple lymphomatosis polyposis of the gastrointestinal tract

There have been a number of previous case reports of lymphomas in the form of multiple mucosal polyps affecting variable lengths of colonic and intestinal mucosa. Invariably these have been classified histologically as mantle cell lymphomas. We report a case of this rare syndrome that illustrates many of its typical features but which demonstrates significant histological and immunophenotypic differences. A 67-yr-old man was referred with a 3-month history of altered bowel habit and a barium enema suggestive of extensive ulcerative colitis. At colonoscopy, diffuse umbilicated mucosal polyps were seen throughout the colon and a larger circumferential mass lesion at the ileocecal valve. Biopsies demonstrated a diffuse B-cell lymphoma consistent with "multiple lymphomatous polyposis" of the colon. Flow cytometry revealed CD25 positive/CD5 negative lymphoid cells confirming marginal B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type. Upper gastrointestinal investigations confirmed similar involvement of the stomach, duodenum, and small bowel. Helicobacter pylori was absent. Flow cytometry abnormalities consistent with marrow involvement were present. These features led to a diagnosis of stage IV marginal zone B-cell lymphoma of MALT type, presenting as multiple lymphomatous polyposis of the gastrointestinal tract. Three months of combination chemotherapy resulted in an excellent symptomatic and endoscopic response.

Increased gastrointestinal permeability is an early lesion in the spontaneously diabetic BB rat

The BB rat spontaneously develops autoimmune diabetes. Feeding these animals a hydrolyzed casein diet significantly reduces the incidence of this disease, suggesting that a dietary antigen is involved in the pathogenesis of this disease. In other syndromes associated with luminal antigens, including celiac and Crohn's disease, increased intestinal permeability has been suggested to play an etiological role. Therefore, the objective of this study was to evaluate whether increased permeability was also present in BB rats before disease development. By measuring gastrointestinal permeability, in animals on a regular or hydrolyzed casein diet, we were able to demonstrate that increased gastric and small intestinal permeability appeared before the development of both insulitis and clinical diabetes. Although hydrolysis of dietary protein significantly reduced the incidence of diabetes, it did not alter the small intestinal permeability abnormality, suggesting that this is an early event. Increased permeability appears to have an early role in the genesis of several immunological diseases and may represent a common event in these diseases.

Successful treatment of refractory type 1 autoimmune hepatitis with methotrexate

BACKGROUND/AIMS

Autoimmune hepatitis is a heterogeneous disorder that typically responds to glucocorticoids with or without azathioprine. Treatment options for patients not responding to standard therapy are limited.

METHODS

We describe a 52-year-old female who presented with jaundice, marked elevation in liver enzymes, positive antinuclear antibody and a liver biopsy consistent with autoimmune hepatitis. Liver enzymes did not normalize with prednisone alone. When azathioprine was added, the disease flared. The patient refused cyclosporine. Methotrexate 7.5 mg po per week resulted in normalization of liver enzymes, improved liver histology, and has maintained remission with a steroid-sparing effect.

RESULTS/CONCLUSION

In this patient methotrexate was used successfully to treat type 1 autoimmune hepatitis. This suggests that methotrexate may have a role in treatment of autoimmune hepatitis refractory to standard therapy.

Altered balance between matrix metalloproteinases and their inhibitors in experimental biliary fibrosis

A rat model of common bile duct ligation (BDL)-induced hepatic fibrosis was used to assess the expression and activities of collagen-degrading proteinases and their inhibitors during the progression of fibrosis. Expression of four members of the matrix metalloproteinase (MMP) family (MMP-2/gelatinase A, MMP-3, MMP-9/gelatinase B, and MMP-13) and three tissue inhibitors of metalloproteinases-1, -2, and -3 (TIMP-1, TIMP-2, and TIMP-3) were evaluated by Northern blot analysis of RNA from liver tissue isolated at 0, 2, 5, 10, 20, and 30 days after either a BDL or sham operation. In addition, we analyzed free gelatinase and TIMP activities by zymography and reverse zymography, respectively. We found that the proteolytic activities of MMP-2 and MMP-9 increased by 2 days after ligation, reached maximal levels at day 10, and remained high through the study period, whereas the gelatinolytic activities in plasma were unchanged. The increase in gelatinase activities was accompanied by an increase in the TIMP mRNA transcripts. TIMP-1 transcripts appeared at day 2, increased until day 10, and remained elevated throughout the study period. TIMP-2 and TIMP-3 transcripts become detectable on day 10 and remained stable afterwards. No corresponding increase in TIMP protein activity was detected by reverse zymography. This appears to result from the formation of TIMP/MMP complexes. These findings indicate a likely surplus in the BDL model of fibrosis of free gelatinases as compared with the TIMPs. Thus, excessive TIMP production is not a sufficient explanation for the observed extracellular matrix accumulation, but complex changes in the local MMP/TIMP balance may underlie the pathomechanisms of fibrosis.

Proteolytic activity of human non-Hodgkin's lymphomas

This study was conducted to assess the net proteolytic activity of human non-Hodgkin's lymphomas (NHLs). We have compared the extracellular matrix (ECM)-degradative abilities of human NHLs, reactive lymphoid hyperplasias, and established lymphoid cell lines using Matrigel invasion and elastin degradation assays. The inhibition studies allowed identification of the classes of proteinases involved in ECM degradation. Our results indicate that lymphocytes and other leukocytes derived from both human NHLs and reactive lymphoid hyperplasias are capable of Matrigel penetration, but only cells derived from the high-grade human NHLs degrade elastin in vitro. Established lymphoid cell lines (both malignant and Epstein-Barr virus immortalized) do not produce MMP-9, do not penetrate the Matrigel, and do not degrade elastin. Moreover, in human NHLs, elastolytic activity is blocked by metalloproteinase inhibitors, while inhibitors of the other classes of proteolytic enzymes have only minor effects. This study identifies metalloproteinases as the most important class of proteinases involved in ECM degradation by NHLs. The previous studies suggest that, within this class, MMP-9 represents the key enzyme that plays a role in the biological aggressiveness of human NHLs.

Conservative management of small adenomata in ulcerative colitis

OBJECTIVE AND METHODS

Patients with chronic ulcerative colitis may develop colitis-related dysplasia and/or sporadic adenomata. Differentiating between these two processes is important because they may dictate different therapeutic approaches. Although distinguishing features of sporadic adenomata versus colitis-related dysplasia have been suggested previously on an a priori basis, they have never been verified by follow-up analysis. We have identified six chronic ulcerative colitis patients whose discrete adenomata were managed conservatively, with subsequent continuation in their surveillance programs.

RESULTS

Mean patient age was 69 yr with a mean 21.3 yr of ulcerative colitis. Surveillance endoscopy of 63 patient-yr duration yielded 24 adenomata. A mean follow-up after the initial adenoma diagnosis was 7.2 yr with no carcinoma identified (including the examination of one prophylactic colectomy specimen). One patient, with a 34-yr history of ulcerative colitis and a single sporadic adenoma subsequently developed dysplasia of flat mucosa 14 months later.

CONCLUSIONS

Our findings concur with previous reports and indicate that small, discrete adenomata with morphology identical to those seen in the general population occur in patients with ulcerative colitis. Such lesions in patients older than 45 yr, with tubular or tubulovillous architecture and low-grade dysplasia, are effectively treated by polypectomy only and are not necessarily an indication for colectomy. However, sporadic adenomata and colitis-related dysplasia can develop metachronously. It is suggested that subsequent to a diagnosis of sporadic adenoma in a patient with chronic ulcerative colitis, surveillance should increase to colonoscopic examination every 6 to 12 months.

Bilioenteric anastomosis reverses hyperkinetic circulation in bile duct-ligated cirrhotic rats

BACKGROUND/AIMS

The chronic bile duct-ligated rat is used to study hemodynamic changes in cirrhosis but suffers from total biliary obstruction and deep jaundice. The extent of reversibility of hemodynamics and histology following bile flow reconnection is controversial. We aimed to characterize the hemodynamics and histology of bile duct-ligated cirrhotic rats in which bile flow was reconnected by a Roux-en-y choledochojejunostomy.

METHODS

Operations created four groups: double sham (control), bile duct ligated, and two reconnected groups. Cardiac index and regional blood flows were measured by radioactive microspheres 4 weeks following the last operation in the first three groups and 8 weeks afterwards in the second reconnected group. Liver histology was assessed by a computer-aided scoring program.

RESULTS

Cardiac index, mean arterial pressure, and systemic vascular resistance in the reconnected groups were different from bile duct-ligated rats and returned to control values. Portal pressures in the reconnected groups (4-weeks, 10.0 +/- 0.5 and 8-week, 9.7 +/- 0.6 mmHg) were significantly lower than in bile-duct-ligated rats (13.7 +/- 0.6) but remained elevated compared to controls (7.0 +/- 0.3). Portal pressure in the reconnected rats was correlated with cardiac index and mesenteric blood flow, r = 0.66 and r = 0.45, respectively. Liver histology was improved in the reconnected rats, with decreased bile duct proliferation, fibrosis and apoptosis.

CONCLUSIONS

We conclude that many of the histological features of secondary biliary cirrhosis are reversible after bilioenteric anastomosis. Furthermore, the hyperdynamic circulation is also largely reversible and is related to the degree of portal hypertension.

Paracoccidioidomycosis: case report and review

A previously well 59-year-old man presented with paracoccidioidomycosis, more than 15 years after leaving South America. He failed to respond to conventional therapies, first with oral itraconazole and then with amphotericin B plus sulfadiazine, and eventually died of recurrent arterial emboli possibly due to paracoccidioidomycotic aortitis. This patient's presentation demonstrates the difficulties that may be encountered in diagnosing and managing this disease. Paracoccidioidomycosis should be suspected in patients with an appropriate travel history who experience weight loss and have pulmonary, mucosal, and cutaneous lesions. This article comprehensively reviews the literature, with emphasis on epidemiology, clinical presentation, diagnosis, and therapy with imidazole antifungal medications.

Comparative analysis of the expression patterns of metalloproteinases and their inhibitors in breast neoplasia, sporadic colorectal neoplasia, pulmonary carcinomas and malignant non-Hodgkin's lymphomas in humans

Matrix metalloproteinases (MMPs) and their inhibitors (tissue inhibitors of metalloproteinases, TIMPs) play essential roles in the remodelling of the extracellular matrix (ECM). Results of in vivo and in vitro studies suggest that the balance between MMPs and TIMPs is altered in neoplasia, contributing to the invasive and metastatic properties of malignant tumours. In this study we have analysed the expression of five MMP genes and TIMP-1 and TIMP-2 in 37 benign and malignant lesions of human breast using Northern blot analysis. MMP-9 (92 kDa gelatinase) and MMP-11 (stromelysin 3) were most consistently expressed by carcinomas. Based on detection of either MMP-9 or MMP-11 mRNAs, we were able to distinguish between malignant and benign disease with a predictive accuracy of 90% with 94% sensitivity and 85% specificity. Subsequently, these results were compared with results for carcinomas of colon and lung and malignant non-Hodgkin's lymphomas (NHL). Elevated MMP-9 and TIMP-1 expression was observed in all four systems. MMP-11 characterised all carcinomas as well as carcinomas in situ but was not detectable in NHL. Our data therefore argue that there are remarkably similar patterns of specific functions involved in ECM remodelling that correlate with malignancy in different human tumours of different histogenesis. However, MMP-11 expression is a characteristic of tumours of epithelial origin that is not found in lymphoid neoplasia. Thus it suggests that MMP-11 may play a regulatory role in the invasion and metastasis of carcinomas.

End-stage liver disease developing with the use of methotrexate in heterozygous alpha 1-antitrypsin deficiency

We report a case of cirrhosis developing in a man who was heterozygous for alpha 1-antitrypsin deficiency and who was receiving methotrexate for severe rheumatoid arthritis. The alpha 1-antitrypsin phenotype PiMZ has been associated with cryptogenic cirrhosis. Our patient had no biochemical or histologic evidence of chronic liver disease during the first year of receiving methotrexate. We postulate that the PiMZ state may result in enhanced susceptibility to methotrexate-induced hepatic toxicity and should be screened for if liver function abnormalities occur during methotrexate therapy.

Immunoglobulin and T-cell receptor gene rearrangements in lesions of mucosa-associated lymphoid tissue

Twenty-one cases of mucosa-associated lymphoid tissue (MALT) lesions have been analyzed by Southern blot for immunoglobulin heavy chain (IgH) and T-cell receptor beta chain (TcR beta) gene rearrangements (GR). The sites included colon, stomach, liver, nasopharynx, salivary and lacrimal gland, conjunctiva, tonsil, breast, and lung. Two of the lesions (parotid and conjunctiva) were malignant lymphomas and one case showed lymphoproliferative disorder. In the cases of malignant lymphomas, IgH GR were detected, and in the case of lymphoproliferative disorder, both IgH and TcR beta genes were rearranged. Among the remaining 18 cases, 9 showed inflammatory infiltrate, 3 lymphoid hyperplasia, 3 atypical lymphoid hyperplasia, 1 carcinoma of the tonsil, 1 breast carcinoma, and one was a sample of normal Peyer's patches. Among these 18 cases, 3 showed TcR beta GR, 6 showed double IgH and TcR beta GR, and 4 IgH GR. Often multiple rearranged bands were observed, composing 10-30% of the total DNA analyzed. The control tissue (Peyer's patches) showed no GR. Because IgH and TcR beta GR are used to determine monoclonal proliferations of T and B lymphocytes, which occur in malignant lymphomas, it is vital to determine the specificity of such a test. This report stresses the fact that in MALT lesions false-positive results are not uncommon and therefore the results of IgH and TcR beta GR studies have to be interpreted with caution. The presence of multiple GR in the inflammatory lesions indicates proliferation of minor monoclonal populations that can be detected with the use of Southern blot technology.

Expression pattern of metalloproteinases and their inhibitors changes with the progression of human sporadic colorectal neoplasia

Several studies have implicated the extracellular matrix-degrading metalloproteinases (MMPs) as essential agents in tumor cell invasion and metastasis. In the present study, we have investigated the patterns of expression of a number of MMPs and their specific tissue inhibitors (TIMP-1 and TIMP-2) in human colonic tissue samples that represent various stages of progression from adenomas showing different degrees of dysplasia to adenocarcinomas. We assessed levels of mRNA by Northern blot analysis and the results were measured semiquantitatively by densitometry. In total, we analyzed nine adenomas of varying size and with varying degrees of dysplasia, three adenomas with adenocarcinoma (malignant polyps), and five adenocarcinomas. Although expression of MMP and TIMP mRNA was highly intercorrelated, transcripts for stromelysin 3 and TIMP-2 (high) showed the strongest relation to the neoplastic process. Detection of stromelysin 3 mRNA accompanied a diagnosis of severe dysplasia or malignancy, whereas levels of TIMP-2 (high) mRNA transcripts permitted finer distinctions on the neoplastic continuum. These data indicate changes within extracellular matrix acquired during the process of malignant transformation of human sporadic colorectal neoplasia.

Expression of metalloproteinases and their inhibitors in primary pulmonary carcinomas

Nine primary pulmonary carcinomas, one metastatic carcinoma, and two malignant pleural mesotheliomas have been analysed for the expression at the mRNA level of metalloproteinases (MPs) and tissue inhibitors of MPs (TIMPs). In situ hybridisation showed TIMP-1 and TIMP-2 transcripts predominantly over tumour stroma and gelatinases evenly distributed over both stromal and tumour cells. While both TIMP-1 and TIMP-2 were expressed in non-neoplastic lungs (NNL) as well as in carcinomas, stromelysin 3 (ST3), 92 kDa gelatinase and interstitial collagenase were expressed only by carcinomas. Expression of these MPs by carcinomas was independent of histologic type and such tumour features as fibrosis or necrosis. The consistent expression of ST3 by all of the carcinomas examined and absence of its expression in NNL indicates that ST3 production is likely associated with the malignant phenotype. However, since 92 kDa gelatinase and interstitial collagenase transcripts were found in some but not all tumour samples, their expression is not a uniform feature of pulmonary carcinomas. The possible prognostic significance of the expression of the latter two enzymes by carcinomas remains to be established.

Differentiation of human B-cell malignant lymphomas is independent of the octamer lymphoid specific binding factor (Oct-2)

We have shown previously that the presence and action of immunoglobulin gene promoter specific trans-acting factors correlates with the stages of 'differentiation' of human lymphoid neoplasms. The regulatory sequence described by us was located upstream of the octamer motif which is known to bind lymphoid specific trans-acting factor Oct-2. In the present study we attempted to establish if the Oct-2 factor was present in fresh human tissue of B-cell origin and if the levels of Oct-2 also correlated with the stages of human lymphoid differentiation. We applied DNA mobility shift assay using the same cases which we utilized in our previous work. We compared the levels of Oct-2 with the levels of ubiquitous octamer binding factor Oct-1. Oct-2 was present in all lymphoid cells of B-cell origin (from fresh surgical specimens and in long-term tissue cultured cells) with the exception of a pre-B-cell line NALM-6. The relative abundance of Oct-2 varied, however, and the ratio of Oct-2 to Oct-1 was variable in different types of B cells. This phenomenon did not correlate with the stages of differentiation of human lymphoid neoplasms. There was also no correlation between the expression of Oct-2 and levels of immunoglobulin-specific messenger RNAs. These findings indicate that the control of, immunoglobulin expression in relation to the differentiation of human B-cell neoplasms requires factors other than Oct-2.

Tissue inhibitor of metalloproteinases-1 (TIMP-1) RNA is expressed at elevated levels in malignant non-Hodgkin's lymphomas

Secreted metalloproteinases (MPs) and their specific inhibitors (TIMPs, tissue inhibitors of MPs) are important mediators of extracellular matrix metabolism. Previous studies have linked either excessive MP release or reduced TIMP-1 production to the invasive and metastatic phenotypes of cancer cells. In the present study we investigated the relationship between the expression of TIMP-1 and the clinical behavior of 28 non-Hodgkin's lymphomas. Northern blot analysis showed that levels of TIMP-1 mRNAs correlated directly with clinical aggressiveness: tumors in the high-grade category contained the highest levels of TIMP-1 transcripts approaching those found in maximally growth factor-stimulated fibroblasts in vitro. In situ hybridization localized the TIMP-1 expression to stromal cells of endothelial and fibroblastic origin. In contrast, transcripts hybridizing with metalloproteinase gene probes (interstitial collagenase and 72-Kd type IV collagenase) were expressed at very low levels in malignant lymphomas and their expression was not coordinately regulated with that of TIMP-1. The majority of tumors expressed either interstitial collagenase or 72-Kd type IV collagenase, and only a small number expressed both. Interstitial collagenase transcripts were only detected in high-grade tumors. The relative levels of TIMP-1 expression did not correlate with the degree of fibrosis of the tumors. Our data suggest the importance of tumor-stromal interactions in non-Hodgkin's lymphomas, and moreover, our results indicate a possible relationship between high-level, localized expression of TIMP-1 and the malignant phenotype of high-grade advanced-stage lymphomas.

Technical considerations for prophylactic mastectomy in patients at high risk for breast cancer

A study of 5 patients and 10 mastectomy specimens was performed to identify the extent of surgery necessary to completely remove all breast tissue in patients having prophylactic mastectomies. A standard total mastectomy performed for breast cancer was shown to frequently leave breast tissue within the superficial pectoralis major muscle and the lower skin flap. Frozen section analysis of margins was found to be essential to clear the axillary extension of the breast and lower skin flap in particular. The value of more extensive surgery to remove all glandular elements of the breast in the high-risk patient remains to be demonstrated.

The significance of pleural elastica invasion by lung carcinomas

Invasion of visceral pleura by primary lung carcinomas is an important parameter in staging. The complex histology of visceral pleura requires special elastic stains for proper evaluation, yet only approximately 10% of peripheral lung carcinomas seen in consultation (S.J.U.) are thus assessed. The objective of this study was to examine the prognostic importance of microscopic visceral pleura invasion by lung carcinomas. Retrospective analysis of 23 cases of peripheral T2, N0, M0 carcinomas with microscopic pleural invasion on elastic stains and a matched control group documented a statistically significant (P = 0.0236) difference in survival between squamous cell carcinoma subgroups. This study therefore suggests the need for histologic assessment of peripheral lung carcinomas for invasion of internal pleural elastic lamina.

Pleural multicystic mesothelial proliferation. The so-called multicystic mesothelioma

We report on the clinical and pathological features of a hitherto unrecognized multicystic and multifocal mesothelial lesion arising in the pleural cavity of a 37-year-old Caucasian woman. The lesions consisted of clusters of thin-walled cysts separated by connective tissue and lined by a single layer of flattened and cuboidal mesothelium. Mucin stains, immunohistochemistry, and electron microscopy were consistent with a mesothelial origin. The pathological features are identical to those of the previously reported multicystic mesotheliomas of the peritoneum. Although these multicystic peritoneal mesothelial lesions have been regarded as neoplasms, absent stromal extension, lack of mitotic activity, and (in this case) continuity with morphologically normal surrounding mesothelium are suggestive of a reactive process. The term "multicystic mesothelial proliferation" may therefore be more appropriate. Because these lesions may be detected as discrete pleural based masses on chest radiograph and CT scan, they may be submitted for frozen section during operative resection. It is therefore important to be aware of their existence, morphology, and differential diagnosis.

Pigment resembling atmospheric dust in Peyer's patches

Terminal ileal pigmentation was observed during colonoscopy, in surgically resected specimens, and autopsy cases. Microscopically, black pigment was seen within macrophages in the lamina propria and submucosa, closely related to the Peyer's patches. Three ilia from autopsies with no macroscopic pigmentation showed deposits following digestion and X-ray microanalysis. X-ray microanalysis of tissue sections and digestates revealed a heterogenous population of particles. Approximately one third of the particles contained calcium and phosphorus and were considered endogenous. The rest of the particles were predominantly aluminum and magnesium-rich silicates, which were considered exogenous. Analysis of particulate extracted from lungs and ilea of four autopsy cases demonstrated remarkable similarities in composition. These findings suggest that the ileal deposits are derived from atmospheric dust. This pigment is believed to migrate into the Peyer's patches through the M cells of the follicle associated epithelium, although other mechanisms for pigment deposition cannot be ruled out.

Novel region within the V kappa gene promoter is responsible for tissue and stage-specific expression of immunoglobulin genes in human lymphoid neoplasms

Immunoglobulin gene-specific transacting factors have been shown to play a role in lymphoid tissue-specific expression of immunoglobulin genes. The role of these factors in B-cell differentiation and stage-specific expression of these genes is, however, not fully understood. We have used a model of human lymphoid neoplasia to address this question. Different fragments of unrearranged human variable region of immunoglobulin kappa gene (V kappa) were used for cell-free in vitro transcription and DNA mobility shift assays. Previously described enhancement of in vitro transcription that was only seen with nuclear extracts derived from B-cell neoplasms corresponding to the late stages of B-cell differentiation was shown to be dependent on the actions of these factor(s) on the DNA region within the V kappa gene promoter. This region is located within the 920 bp fragment located 210 bp upstream from the coding region and this fragment represents a possible novel DNA region, which plays a role in the stage- and tissue-specific expression of immunoglobulin genes.

Human lymphoma differentiation concepts correlate with in vitro action of immunoglobulin gene-specific transcription factors

Lymphoid tissue-specific expression of immunoglobulin genes is regulated (in part) by gene-specific trans-acting factors. Whereas different classes of human B cell lymphoid neoplasms produce immunoglobulins in amounts that correlate with the stages of normal B cell differentiation, the pattern of expression of putative regulatory trans-acting factors in human lymphoid neoplasia is unknown. Nuclear extracts made from human lymphoid neoplasms were screened for their ability to enhance transcription of the unrearranged Kappa light chain immunoglobulin gene (V Kappa) in a whole cell in vitro transcription assay. Extracts from plasmacytomas, large noncleaved cell lymphomas, and Burkitt's lymphomas specifically enhance V Kappa gene transcription up to 22-fold, whereas no enhancement was achieved using extracts from lymphoid neoplasms corresponding to the earlier stages of normal B cell maturation. We suggest that these findings mean that the production of immunoglobulins by human lymphoid neoplasms correlates with the expression of immunoglobulin gene specific trans-acting factors.

Small colonic adenomas with adenocarcinoma. A retrospective analysis

The purpose of this study is to alert colonoscopists to a relatively high incidence of small colonic adenomas with invasive adenocarcinoma among a group of colonic adenomas with invasive adenocarcinoma removed colonoscopically. Retrospective analysis (1973 to 1983) documented nine such lesions that were 1 cm or smaller, representing 15 percent of all colonic adenomas with invasive adenocarcinoma removed during that period. These lesions had no distinctive gross features and could be easily confused with hyperplastic polyps. It is recommended that all colonic polyps be removed at colonoscopy regardless of their size, because even lesions 1 cm and smaller, with "benign" gross appearance, may harbor invasive adenocarcinoma.

Idiopathic small airways pathology in patients with graft-versus-host disease following allogeneic bone marrow transplantation

In a retrospective analysis (July 1979 to March 1984) of 120 allogeneic adult bone marrow transplant recipients, we identified seven patients with small-airway disease for whom no microbiologic agent was detected. Six had pulmonary function studies demonstrating air flow obstruction. Five of the seven patients had an open-lung biopsy showing pathologic changes within small airways; these varied from early bronchiolar wall damage to bronchiolitis obliterans. The inflammatory cell infiltrate was peribronchiolar, and consisted of polymorphonuclear leukocytes and lymphocytes in varying proportions. Three of the seven patients recovered following increased immunosuppressive therapy; the other four died. Because all seven patients had acute and chronic graft-versus-host disease, in the absence of any identifiable pathogen, we postulate that small-airway damage represents one of the facets of graft-versus host-disease. An additional analysis of 26 patients with respiratory symptomatology and available histologic material supports the hypothesis that small-airway disease in bone marrow transplant patients represents a risk factor for the subsequent development of respiratory opportunistic infections.

Small-airways disease in recipients of allogeneic bone marrow transplants. An analysis of 11 cases and a review of the literature

In a retrospective review of 116 consecutive allogeneic bone marrow transplants (BMT), severe obstructive airways disease was identified in 11 patients. Lung pathology demonstrated bronchiolitis in 9 patients and physiologic studies showed small-airways disease consistent with bronchiolitis in the other 2. None of the 5 patients with associated infection survived, while 3 of the 6 patients without an identified pathogen stabilized or improved. Analysis of the 11 cases presented and all 25 cases reported in the literature (1982 to 1985) supports the conclusion that graft-versus-host disease is a major risk factor for bronchiolitis in BMT recipients. Among the proposed mechanisms for the development of bronchiolitis after allogeneic BMT, the 2 most likely are graft-versus-host disease directly causing bronchiolitis, and increased immunosuppressive therapy given for graft-versus-host disease predisposing to viral bronchiolitis. The available evidence would suggest that it is prudent to obtain serial pulmonary function tests even in asymptomatic patients post-BMT, and particularly in those with chronic graft-versus-host disease, in the hope that early detection will allow for early intervention that will arrest or reverse the progression of the obstructive airways disease.

Leiomyosarcoma of the inferior vena cava presenting as Budd-Chiari syndrome

A case of a 72-year-old male with a leiomyosarcoma of the inferior vena cava causing Budd-Chiari syndrome is described. Percutaneous decompression of the portal system was attempted but with no success. At autopsy, a large tumor arising from and completely obstructing the inferior vena cava was found, histologically proven to be a leiomyosarcoma. Over 50 cases of leiomyosarcoma of the inferior vena cava have been reported in the literature, the majority of which occurred in women and 1/3 of which were associated with the Budd-Chiari syndrome. Histologically up to two mitotic figures per 10 high power fields have been scored. This case indicates the unreliability of a low mitotic index as an indicator of benign behavior of smooth muscle neoplasms of the venous system.

Characterization of a novel neuroglandular antigen (NGA) expressed on abnormal human melanocytes

Murine monoclonal antibodies (MAbs) were produced with reactivity to human malignant melanoma. Six MAbs, 3 of the IgGI (LS113, LS140, LS152) and 3 of the IgG2a (LS59, LS62, LS76) subclasses, were selected for their binding, with an identical pattern of reactivity, to a novel melanoma-associated antigen. As characterized by the enzyme-linked immunosorbent assay (ELISA), these MAbs were found to be positive on n-octyl-beta-D-glucopyranoside extracts of all 10 melanoma cell lines tested and on extracts of 22 metastatic melanoma tumors. The antibodies had minimal reaction with a panel of 14 normal adult tissue extracts. A degree of cross-reactivity was observed with 50% of 39 non-melanoma tumor extracts. The results obtained with the ELISA on cell line and tissue extracts were duplicated using the ABC method of peroxidase staining. The pattern of cross-reactivity, as demonstrated by the intense staining of paraffin-embedded and frozen tissue sections of normal, benign and malignant tissues, defines the recognized protein as a neuroglandular antigen (NGA). Immunoadsorbents made with the antibodies were used to purify the antigen shed from cultured melanomas. All 6 MAbs recognized this purified antigen while 5 other antimelanoma antibodies did not react with it. On gel electrophoresis this antigen is a highly glycosylated glycoprotein with a protein core of 21 kDa.

Mucosal changes associated with adenomatous colonic polyps

In order to assess the presence of morphologically recognizable colonic nonneoplastic mucosal alterations that may be associated with adenomatous transformation the authors undertook a retrospective analysis of 984 colonic polyps removed between 1979 and 1983. There were 708 adenomatous and 276 nonadenomatous polyps, all colonoscopically removed. In addition to adenomatous mucosa, three different mucosal patterns were recognized and labeled as transitional, eosinophilic, and, hyperplastic. Each polyp, but not the polyp's shoulder, was scored by two pathologists for the presence of these changes. Analysis of the data (Pearson's chi-square test) demonstrated a strong association between eosinophilic and transitional mucosa as well as between eosinophilic mucosa and adenomas. There was also a strong negative association between both eosinophilic and transitional mucosa and hyperplastic mucosa. On the basis of these data, it is postulated that transitional mucosa, representing a nonspecific reactive mucosal phenomenon, may precede eosinophilic mucosa, which subsequently may represent fertile soil for adenomatous transformation.

Inguinal intranodal blue nevus: a case report

Inguinal intranodal blue nevus is a rare lesion, but awareness of the condition will avoid a mistaken diagnosis of metastatic melanoma. The authors describe the case of a 40-year-old woman in whom an inguinal node blue nevus was discovered incidentally during radical vulvectomy for squamous cell carcinoma. They describe the characteristic light and electron microscopic features. With increased awareness of this lesion the authors believe it will be found in lymph-node chains other than the inguinal and axillary ones previously reported.

Coexisting pancreatic and breast adenocarcinomas: is there an association?

Two patients are reported with coexisting adenocarcinomas of pancreas and breast. One represents synchronous neoplasms, the other metachronous tumors diagnosed 7 years apart. The significance of these findings is discussed, including possible carcinogenic dietary factors common to both neoplasms. The potential problems associated with the histologic diagnosis of such coexisting tumors are stressed.

Papillary adenocarcinoma in situ of bladder

To the best of our knowledge papillary adenocarcinoma in situ of the bladder has not been reported previously. We describe a case of transitional cell carcinoma in situ of the bladder associated with papillary adenocarcinoma in situ. While it is believed that most nonurachal adenocarcinomas of the bladder originate within cystitis glandularis, such transition is difficult to document. We assume that severe dysplasia of a papillary adenomatous component adjacent to papillary adenocarcinoma in situ represents an intermediate morphological change between cystitis glandularis and adenocarcinoma. Electron microscopic evaluation of glandular epithelium indicates that it represents the process of aberrant differentiation rather than a metaplastic phenomenon.

Metamorphosis of dermal cylindroma: possible relation to malignant transformation. Case report of cutaneous cylindroma with direct intracranial invasion

A case of locally invasive cutaneous cylindroma is reported. This neglected scalp tumor, 6.5 cm in greatest dimension, initially invaded the calvaria at the time of the first operation. A recurrence infiltrated the dura and presented as an intracranial space-occupying lesion. No brain invasion was present and distant metastases were not documented. The patient remains well 2 1/2 years after tumor resection. Light and electron microscopic appearance of the recurrent tumor revealed distinct morphologic features, which may be of use in predicting the biologic behavior of cutaneous cylindromas. This case documents the low biologic aggressiveness of cylindroma and stresses the necessity of complete surgical excision of neoplasms with atypical morphologic features.

Organ specificity in the microsomal activation and toxicity of N-nitrosomethylbenzylamine in various species

The microsomal metabolism of the rat esophageal carcinogen N-nitrosomethylbenzylamine (NMBZA) at the methylene carbon atom to yield benzaldehyde was studied in various organs of a number of species to determine the role of metabolic activation in the carcinogenicity or toxicity of the nitrosamine. In the Sprague-Dawley rat, NMBZA was metabolized by microsomes from liver, lung, and esophageal mucosa. In the F344 rat and rabbit, metabolic activity was present in both liver and esophageal mucosa, the only tissues studied in these species. In contrast, in the Syrian hamster and BALB/cByJ mouse, NMBZA debenzylation was undetectable in the esophagus but occurred at relatively high rates in liver, lung, and kidney. The forestomach mucosa exhibited undetectable levels of activity in the Sprague-Dawley rat and BALB/cByJ mouse, although in the hamster, it was present at a very low level. Administration of a dose of NMBZA acutely toxic to the rat (18 mg/kg i.p.) resulted in significant cellular damage only to the rat esophageal mucosa, no other tissues examined in the rat, hamster, or mouse being affected. These observations, together with the available data on carcinogenicity of the nitrosamine in the rat and rabbit, suggest that in the esophagus, at least, metabolic activation of NMBZA is necessary to elicit its toxic and/or carcinogenic effect. However, NMBZA is also metabolized at a high rate in the liver of all species but is not toxic or carcinogenic in this tissue, suggesting that other factors besides metabolic activation must be involved in the resistance of hepatocytes to the effects of the nitrosamine. Microsomes prepared from human esophageal mucosa from six patients metabolized NMBZA at rates that were either undetectable or approximately 70 times lower than in the Sprague-Dawley rat.

Invasive aspergillosis in a "healthy" patient

A case of invasive aspergillosis complicated by the formation of an aspergilloma is described. The patient, a 48-year-old man, was apparently healthy except for mild alcoholic steatosis of the liver. A review of the literature revealed that 5 of the 14 previously reported cases of invasive aspergillosis in seemingly immunocompetent hosts were associated with liver disease. Immunologic investigation in this case revealed transient cutaneous anergy during the acute illness and normal lymphocyte function. Assessment of polymorphonuclear leukocyte function, however, showed abnormalities of phagocytosis as well as impairment of intracellular bactericidal activity. These abnormalities may have contributed to a relative immunodeficiency. Impairment of immune function may play a role in the pathogenesis of invasive aspergillosis in some apparently healthy patients.

Mixed hyperplastic adenomatous polyps--an underdiagnosed entity. Report of a case of adenocarcinoma arising within a mixed hyperplastic adenomatous polyp

We report a case of colonic adenocarcinoma arising within a polyp with mixed morphology of a hyperplastic polyp and tubular adenoma. Despite the relatively small size of the polyp, two isolated foci of adenocarcinoma in situ were present and tumor islands invaded the submucosa. Isolated areas, morphologically resembling hyperplastic glands, and varying degrees of atypia. Though rare, some hyperplastic polyps may be precursors of adenomas.

Giant cell carcinoma of pancreas with clear cell pattern in metastases

A case of mucin-positive giant cell carcinoma of the pancreas is presented. Clear cells were a prominent feature of the primary tumor and constituted the majority of the metastatic deposits, a finding not usually associated with pancreatic carcinoma. Results of ultrastructural and histochemical studies are presented, and the significance of a clear cell component in metastases is discussed.

Argyrophil granules in the human pituitary

In order to assess the value of the Grimelius silver method in adenohypophysial cell identification and adenoma diagnosis, 22 nontumorous adenohypophyses and 50 pituitary adenomas were investigated. Grimelius positivity was localized, as documented by mirror sections, predominantly in PAS and led hematoxylin positive cells; but a few negative cells contained argyrophil granules as well. The immunoperoxidase method revealed Grimelius positivity primarily in corticotrophs, thyrotrophs and gonadotrophs, and occasionally in somatotrophs and lactotrophs. Argyrophilia was readily demonstrated in 11 out of 13 corticotroph cell adenomas, in 1 out of 1 thyrotroph cell adenoma, in 5 of 11 null cell adenomas and in 4 out of 5 oncocytomas. No argyrophilia was detected in 5 growth hormone cell adenomas and 5 prolactin cell adenomas. One our of 5 mixed, growth hormone cell-prolactin cell adenomas, and 1 out of 5 acidophil stem cell adenomas showed Grimelius positivity. By electron microscopy, silver grains were localized in the secretory granules. It can be concluded that no specific hormonal products account for argyrophilia.

Intrasellar solitary plasmacytoma terminating in multiple myeloma: a report of a case including electron microscopical study

A case of multiple myeloma is reported that presented as a solitary plasmacytoma of the bone of the sella turcica. The diagnosis was established by electron microscopy in conjunction with the immunoperoxidase technique. The patient succumbed 37 months after the diagnosis was made. The relation between solitary plasmacytoma of bone and multiple myeloma is discussed. The differential diagnosis of intrasellar tumors may pose serious problems to the surgical pathologist. In difficult cases the value of the immunoperoxidase technique and electron microscopy is emphasized.