[The role of the pathologist in mammography screening]

Within the framework of mammography screening programmes the expertise of the pathologist is embedded in an interdisciplinary diagnostic and therapeutic procedure. The quality of histopathological diagnosis not only depends on the expertise of the pathologist, but also requires skillful co-operation with the radiologist and the gynecologist who are both responsible for determining the medical indications for further radiographic and surgical tests and must ensure appropriate tissue samples are taken for non-palpable lesions. Bearing this process in mind it becomes clear that increased expertise in interventional tissue sampling leads to histological samples which are more representative. If the samples are not representative, their histological evaluation does not permit a conclusive statement on the origin of tissue abnormalities shown by mammography. At the mammography unit in Wiesbaden it was demonstrated that breast tissue punches almost always allow a precise histological diagnosis of tissue abnormalities and are at the same time appropriate for additional immunohistochemistry, such as for hormone receptors on carcinoma cells. Non-representative tissue samples are the exception.

VEGF-A and i-NOS expression are prognostic factors in serous epithelial ovarian carcinomas after complete surgical resection

AIMS

Clinical stage at the time of diagnosis and achievement of complete macroscopic resection during initial surgery are key factors determining the outcome of ovarian cancer. However, prediction of outcome lacks accuracy and more reliable prognostic factors are required. Therefore, an analysis and evaluation of key angiogenic factors was carried out to determine their diagnostic and prognostic value in serous ovarian cancer.

METHODS

Expression levels of vascular endothelial growth factor (VEGF)-A, hypoxia-inducible factor (HIF)1-alpha and inducible nitric oxide synthase (i-NOS) were analysed by immunohistochemistry in a homogenous group of 112 patients with serous adenocarcinoma of the ovary. Vascular density as an indicator of angiogenesis was assessed using the Chalkley eyepiece method after staining for CD34. The correlation of these data with survival and established prognostic factors such as histological grade, Federation of Gynecology and Obstetrics (FIGO) stage, and residual tumour after surgery, was evaluated. Survival analyses, multivariate analyses and correlation tests were performed.

RESULTS

In the patient group with macroscopic complete tumour resection (R0) there was a significant correlation between VEGF-A and i-NOS expression. Kaplan-Meier analysis further revealed improved progression-free survival for R0 patients with VEGF-A-positive and i-NOS-negative tumours. The predictive relevance of VEGF-A regarding progression-free survival was sustained in multivariate analysis using FIGO stage, grading and resection status as fixed variables.

CONCLUSION

VEGF-A and i-NOS are prognostic markers for clinical outcome in serous ovarian cancer patients with macroscopic complete tumour resection (R0). Hence, pre-therapeutic assessment of VEGF-A as predictive factor for an antiangiogenic therapy might be of clinical value.

Proficiency testing of immunohistochemical biomarker assays in breast cancer

Steroid hormone receptor expression and HER2 status have become an integral part of histopathologic characterization of breast cancer and corresponding biomarker assays have gained important prognostic and predictive impact. Because testing inaccuracy could provide a major hazard to modern breast cancer therapy, a laboratory proficiency testing program has been implemented in Germany using tissue microarrays (TMAs). In four consecutive annual trials with 142 laboratories participating on average per trial, estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (Her2) were determined immunohistochemically by participating laboratories followed by central review of all immunostains. Performance strongly depended on the ambiguity of expression of the target molecule in the test samples. In clearly positive (Allred score 7-8; Her2 3+) or negative tissue samples, the majority of participants (86%) achieved concordance rates exceeding 85%. By contrast, low expression of ER or PR (Allred score 3-4) as well as Her2 status 2+ led to considerable lower concordance rates ranging from 41% (Her2 2+) to 75% (PR). Poor reproducibility was predominantly due to inadequate laboratory performance whereas interobserver agreement (weighted kappa statistics) usually was high (>0.81). Laboratories that participated in more than one of the four subsequent trials (n = 110) showed a highly significant improvement of performance. In conclusion, a TMA-based proficiency testing of biomarkers in breast cancer has been implemented in Germany over a 5-year period and revealed reliable assessment of unambiguously positive and negative test samples. Low-expressing tumor samples with regard to steroid hormone receptor expression and Her2 status 2+ led to inaccurate evaluations by up to 59% of participants. Regularly participating laboratories showed a significant improvement of performance.

Expression of alpha-methylacyl coenzyme A racemase in the dysplasia carcinoma sequence associated with Barrett's esophagus

Two different studies demonstrated alpha-methylacyl coenzyme A racemase (AMACR) to be a highly specific marker in Barrett's neoplastic lesions. Reactive atypia was positive in 3/30 cases in these studies. We present a retrospective study of early Barrett's adenocarcinoma treated with surgery (2000-2005, n=29; M:F=5:1, median age 67 years). We analyzed the role of AMACR expression in reactive and neoplastic lesions associated with the disease of 77 different specimens (60 biopsy and 17 surgical specimens) of these patients. In our cohort, 70% of cases demonstrated infiltration of the submucosa, 38% were poorly differentiated, and/or 31% demonstrated lymph vessel infiltration. We used a multi-tissue array, with reactive and neoplastic samples for each patient to analyze the immunoreactivity of AMACR. Barrett's epithelium that was negative for dysplasia and columnar epithelial cell changes indefinite for dysplasia (n=30) did not demonstrate AMACR immunoreactivity. AMACR immunoreactivity was demonstrated in 27% (8/30) of cases of Barrett's epithelium with columnar epithelial cell changes indefinite for dysplasia. Altogether 91% of cases with low-grade dysplasia were AMACR-positive and 96% of cases with high-grade dysplasia and early Barrett's adenocarcinoma were positive for AMACR. In summary, the sensitivity of AMACR expression in low-grade dysplasia and subsequent early Barrett's adenocarcinoma was significantly higher in our study compared with previous data. This might be a new diagnostic marker for dysplasia carcinoma sequence in Barrett's low-grade neoplastic lesions. Further studies are required to investigate this point with well-defined controls having at least 5-years follow-up.

[Acetone treatment of lymph node preparations in staging colorectal specimens]

Lymph node staging is the most important prognostic factor after radical surgery for colorectal carcinoma. The probability of correctly classifying a colorectal tumor increases with the number of lymph nodes harvested. This number varies with the methods used by the pathologist. An accurate examination of the surgical specimens is essential for the correct assessment of the lymph node status of the tumor. The purpose of this study was to evaluate an easy fat clearance method using pure acetone. A total of 188 surgical specimens of colorectal carcinoma were investigated. The first lymph node preparation was made using the manual method. Thereafter, the mesenteric fat tissue was treated with pure acetone for 16 h and subjected to a second lymph node examination. In 111 of the samples the required number of 12 lymph nodes for TNM classification was not reached by the manual preparation method. With the acetone treatment, 12 or more lymph nodes were found 91% of these samples (average 27 lymph nodes). In 29 samples (15%) additional lymph node metastases could be detected. In 16 samples (8% of all investigated samples) an upstaging of the pN status was necessary. This indicates the importance of our method for the optimal lymph node staging of colorectal carcinomas. Lymph node preparation after acetone treatment is an easy, low cost method resulting in a much larger number of lymph nodes for more accurate staging.

Pattern and clinical predictors of lymph node metastases in epithelial ovarian cancer

Para-aortic lymphadenectomy is part of staging in early epithelial ovarian cancer (EOC) and could be part of therapy in advanced EOC. However, only a minority of patients receive therapy according to guidelines or have attendance to a specialized unit. We analyzed pattern of lymphatic spread of EOC and evaluated if clinical factors and intraoperative findings reliably could predict lymph node involvement, in order to evaluate if patients could be identified in whom lymphadenectomy could be omitted and who should not be referred to a center with capacity of performing extensive gynecological operations. Retrospective analysis was carried out of all patients with EOC who had systematic pelvic and para-aortic lymphadenectomy during primary cytoreductive surgery. One hundred ninety-five patients underwent systematic pelvic and para-aortic lymphadenectomy. Histologic lymph node metastases were found in 53%. The highest frequency was found in the upper left para-aortic region (32% of all patients) and between vena cava inferior and abdominal aorta (36%). Neither intraoperative clinical diagnosis nor frozen section of pelvic nodes could reliably predict para-aortic lymph node metastasis. The pathologic diagnosis of the pelvic nodes, if used as diagnostic tool for para-aortic lymph nodes, showed a sensitivity of only 50% in ovarian cancer confined to the pelvis and 73% in more advanced disease. We could not detect any intraoperative tool that could reliably predict pathologic status of para-aortic lymph nodes. Systematic pelvic and para-aortic lymphadenectomy remains part of staging in EOC. Patients with EOC should be offered the opportunity to receive state-of-the-art treatment including surgery

BRCA1 germline mutation in a woman with metaplastic squamous cell breast cancer

BACKGROUND

Breast cancers arising in women with germline BRCA1 mutations are most likely to be estrogen receptor (ER), progesterone receptor (PR), and HER2/neu negative (so-called triple negative or basal-like breast cancers). Metaplastic carcinoma with pure squamous differentiation is a very rare histological subtype (0.1% of all breast cancers) and is usually ER, PR, and HER2/neu negative by immunohistochemistry. A BRCA1 germline mutation in squamous cell breast cancer has never been reported.

CASE REPORT

A 25-year-old woman was diagnosed with squamous cell cancer of the breast. Three years later, she developed contralateral breast cancer, also of the squamous cell subtype. Both tumors were triple negative. Because of the patient's history and her strong family history, genetic testing was recommended. The patient was found to be carrier of a BRCA1 germline mutation.

CONCLUSION

We report, to our knowledge, the first case of a BRCA1 mutation in a woman with metaplastic squamous cell breast cancer.

Lymphatic spread in resectable lung cancer: can we trust in a sentinel lymph node?

The aim of this study was to describe lymphatic spread in resected lung cancer patients and evaluate for the presence for a reliable sentinel lymph node. Onethousand and eighty-eight patients with NSCLC underwent resection. Twelve to sixteen percent of the patients with primaries in the upper lobes had an involvement in the upper mediastinum; in 12 %, it was subcarinal, in 6 % and 3 %, in the lower mediastinum at paraoesophageal and ligamentum pulmonale sites, respectively. The rate of "lymph node skipping" is between 31 and 74 %. An isolated involvement of mediastinal nodes is possible without involvement of the N-1 position. Irrespective of the location of the primary tumour, there is a high incidence of "lymph node skipping" because of the specific architecture of the pulmonary, hilar and medistinal lymph nodes. Therefore, a reliable sentinel lymph node in lung cancer cannot be defined. In conclusion, systematic lymph node dissection in anatomical compartments is the gold standard for evaluation of the exact pN stage. Furthermore, a complete R/O-resection is a prognostically relevant factor in the surgery of NSCLC.

VEGF-A and COX-2 expression correlate with platinum resistance in ovarian cancers

5062

Background: Regulators of angiogenesis such as VEGF-A and cell cycle such as p53 and COX-2 influence tumor behavior and response to chemotherapy. Methods: 114 patients with primary ovarian cancer treated in Frankfurt or Wiesbaden between 1999 and 2004 were examined. Primary surgery was followed by a platinum and taxane based chemotherapy in all patients. Expression of i-NOS, COX-2, VEGF-A, HIF-1 alpha was analyzed immunohistochemically using tissue micro arrays of primary tumor samples. Results were scored according to staining intensity and percentage of positive tumor cells resulting in an immune-reactive score (IRS) from 0 to 12. Vascularity was assessed using the Chalkley-Grid method after highlighting vessels with CD34 antibodies in whole tissue sections. These results were correlated with classical prognostic factors and survival. Non-parametric correlations were done using Spearman’s rho, correlations were significant at the 0,05 level (2-tailed). Results: The median age at the time of surgery was 63y (33–89y). The majority of the patients (85%) had advanced disease (FIGO III-IV). Tumor grading was G1 in 2%, G2 in 37%, and G3 in 61%. Expressions were as follows: i-NOS 60% positive (IRS ≥4); COX-2 50% positive (IRS ≥5); VEGF-A 50% strong (IRS ≥8), 32% moderate (IRS 4–7), 18% weak (IRS ≤4); HIF-1 alpha 37% positive (IRS ≥3), p53 33% weak (IRS ≤4), 67% strong (IRS >4); vascularity 41% low (≤5), 52% moderate (6–9), 7% high (>9). I-NOS correlated positively with COX-2 (p = 0,03), VEGF-A (p = 0,05), and p53 (p = 0,01). Grading correlated positively with HIF-1 alpha (p = 0,02) and vascularity (p = 0,01). Up to now none of the new parameters did show correlations with recurrence free survival (median follow-up 36 months). Platinum resistant tumors (time from primary diagnosis to relapse <12 months) were significantly more often negative for VEGF-A (p = 0,005) and COX-2 (p = 0,02). Conclusions: I-NOS correlates with markers of angiogenesis and cell cycle regulation. VEGF-A and COX-2 expression might predict platinum resistance in ovarian cancers.

No significant financial relationships to disclose.