[Familial adenomatous polyposis and thyroid cancer]

Familial adenomatous polyposis may exhibit extracolonic tumors which include thyroid carcinoma. It has been recently suggested that thyroid carcinomas associated with familial adenomatous polyposis show distinct histologic features different from sporadic follicular or papillary thyroid carcinomas. We report a case of thyroid carcinoma in a young girl affected by familial adenomatous polyposis, whose thyroid tumor exhibited some of these features. This finding confirms the peculiar histologic phenotype of the thyroid carcinomas associated with familial adenomatous polyposis. Alterations of the APC gene responsible for familial adenomatous polyposis may play a role in the development of these thyroid cancers.

Extensive spread of a squamous cell carcinoma in situ of the esophagus: an unusual case

A case of extensive squamous cell carcinoma in situ along the esophageal height in a 58-yr-old female is presented. After subtotal esophagectomy, the course was favorable 11 months later. The pathological study of the specimen showed that the tumor was confined to the epithelium. The lesion was located diffusely along the entire esophageal height and one-third of its circumference. Neither foci of dysplasia or inflammatory erosions nor metastatic nodes were observed. Problems pertaining to the terminology, histopathological interpretation, pathogenesis, and management of such unusual lesion are reviewed. The necessity of large radical resection of the esophagus was validated upon histological confirmation that the resected stump is cancer free.

Renal involvement in von Hippel-Lindau disease

Renal involvement in von Hippel-Lindau (VHL) disease has emerged as the most prevalent cause of death in this hereditary disorder. In a group of 43 VHL patients (23 unrelated families) with renal lesions we examined whether severity of renal disease is affected by parental inheritance and VHL subtype (1, without pheochromocytoma; 2, with pheochromocytoma). We also tested whether and how nephron-sparing surgery could be applied. Renal involvement comprised multiple cysts and bilateral and multifocal carcinomas (RCC) which were detected by screening in 38 patients, at 30.5 (14 to 62) years of age. The severity of the renal disease was similar in VHL type 1 (79% of the pedigrees) and 2 (21%). It was not influenced by the sex of the carrier. Twenty-nine patients were operated on at a mean age of 33.6 years: 21 patients (28 kidneys or 61% of all operated kidneys) underwent nephron-sparing surgery, 4 had complete ablation of involved kidneys and thus required dialysis, 3 had uninephrectomy and 1 had cyst fenestration. Vascular thrombosis was the most severe early complication. It occurred in 4 of 9 kidneys treated by ex vivo surgery. During a median follow-up of 29 months, local recurrence occurred in 5 of 21 (24%) patients treated by nephron-sparing surgery, whereas 2 developed metastasis. Chronic renal failure (creatinine > 120 mumol/liter) affected 11 patients; in 9 of them, it was due to sequelae of surgery. In conclusion, screening of RCC and nephron-sparing surgery are of value in VHL patients. However, indications of ex vivo surgery should be drastically restricted and renal sequelae are not uncommon. Renal followup is required because of the risk of recurrence.

Local staging of prostate cancer by endorectal MRI using fast spin-echo sequences: prospective correlation with pathological findings after radical prostatectomy

OBJECTIVE

To evaluate the accuracy of endorectal magnetic resonance imaging (MRI) with fast spin-echo sequences in the local staging of clinically localized prostate cancer.

PATIENTS AND METHODS

Seventy-one patients with a clinical T1 (18 patients) or T2 tumour (53 patients) underwent endorectal MRI 2-12 weeks before radical prostatectomy. Extraprostatic tumour was diagnosed if MRI showed signs of capsular penetration and/or invasion of the seminal vesicle and/or distal urethra or bladder neck. If the pathological examination showed a single positive margin with no periprostatic tissue, the tumour was classified as indeterminate and not as a T3 tumour.

RESULTS

Of the 25 cases of capsular penetration. MRI correctly identified 10 (sensitivity 42%, specificity 100%). Of the 14 cases with seminal vesicle invasion, MRI correctly identified six (sensitivity 43%, specificity 100%), but showed other signs of extraprostatic tumour spread in seven of the eight unidentified cases. Overall, MRI identified 16 of the 30 patients (53%) with occult extraprostatic spread of tumour; there was only one false-positive result. The sensitivity, specificity and accuracy of MRI were 53, 96 and 74%, respectively.

CONCLUSION

Endorectal MRI can reduce the rate of preoperative understaging from 42% to 22% and it can be used for a given individual because it can detect extraprostatic invasion with 96% specificity, ensuring that very few, if any, patients will be deprived of curative surgery.

Pituitary adenylate cyclase activating peptide and its receptors are expressed in human neuroblastomas

Vasoactive intestinal peptide (VIP) has been considered as an autocrine growth factor in neuroblastomas. Pituitary adenylate cyclase activating polypeptides (PACAPs) are newly recognized members of the VIP family of neurohormones. As compared to VIP, PACAP has been reported to be biologically more potent and more efficient in tissues expressing selective PACAP receptors rather than common VIP/PACAP receptors. PACAPs and VIP interact with the same affinity and stimulate adenylate cyclase activity with the same efficacy and potency on the VIP receptors, but PACAPs act also on a more selective PACAP receptor that also recognizes VIP but with a 100- to 1,000-fold lower affinity. Thus, depending on the type of receptors expressed at a cell surface, PACAP may be more potent and efficient than VIP. The capacity of 22 surgical specimens of neuroblastomas and of 5 established cell lines to synthesize PACAP and VIP and to synthesize and express PACAP receptors and VIP receptors was studied. Using the reverse transcriptase-polymerase chain (RT-PCR) method with specific primers, we detected the mRNAs coding for PACAP and VIP in 19 and 3 out of 22 samples, respectively. PACAP mRNA was expressed in 3 of the 5 cell lines studied and VIP mRNA in 4. Using the same techniques, PACAP and VIP receptors mRNA were detected in 21, and 13 of the 22 tumor samples and in 5 and 1 of the cell lines studied, respectively. The expression of the PACAP receptor was demonstrated by direct binding studies and/or by the relative potency of PACAPs and VIP to stimulate adenylate cyclase activity in 16 of the 22 tumors and in all the cell lines. In addition, there was no correlation between tumor stage and the expression of mRNA coding for the peptides and the receptors. The present results demonstrated that PACAP could also be a candidate as an autocrine regulator of neuroblastoma which a higher activity than VIP.

[Budd-Chiari syndrome secondary to post-traumatic stenosis of the inferior vena cava]

Budd-Chiari syndrome with inferior vena cava involvement is usually due to membranous obstruction; traumatic origin of inferior vena cava lesions is very rare. We report a case of Budd-Chiari syndrome in a 29 year-old man, 3 years after an abdominal trauma. Cavography showed 50% stenosis in the sushepatic portion of the inferior vena cava. After two unsuccessful percutaneous transluminal angioplasty procedures, a surgical resection of the stenotic vein was performed. The histological study of the stenotic segments showed that the three layers of the venous wall had been replaced by a dense fibrous tissue. No inflammation or thrombosis were found. This case of stenosis of the vena cava shows that histological examination can be used to assess the traumatic nature of the lesion, showing a different histological pattern from that of the membranous obstruction in which the basic structure of the venous wall is preserved.

Expression of bcl-2 oncoprotein in renal cell tumours

Expression of bcl-2 is associated with inhibition of apoptosis and extension of cell survival. The importance of apoptosis in relation to the development and progression of renal cell neoplasia remains undefined so far. In order to determine the expression of bcl-2 oncoprotein in normal and neoplastic renal cells, 37 renal tumours were investigated by immunolabelling, including 13 clear cell carcinomas, ten tubulopapillary carcinomas, four chromophobic renal cell carcinomas, and ten oncocytomas. Twenty-six samples of adjacent normal renal tissue served as controls. bcl-2 expression was correlated with cell proliferation activity as estimated by Ki67 antigen expression, and p53 protein expression in the tumour samples. The results demonstrate that in the normal kidney, positive bcl-2 immunostaining was present in glomerular parietal epithelial cells, in distal tubular cells, and in sparse proximal tubule cells. Renal cell tumours showed heterogeneous bcl-2 expression according to the tumour cell type. While the majority of carcinomas of clear cell type were usually negative or contained sparsely distributed positive cells, all tubulopapillary carcinomas were consistently positive for bcl-2. In oncocytomas and chromophobic carcinomas, there was a low percentage of bcl-2 immunoreactive tumour cells; some nuclear bcl-2 positivity was detected in one chromophobic tumour. These findings indicate variable bcl-2 oncoprotein expression in different types of renal cell tumours, with the highest level of expression in tubulopapillary carcinomas. No clear relationship was found between nuclear grade, cell proliferation activity, and level of bcl-2 expression. p53 protein was detected in only one tubulopapillary carcinoma.

[Adenocarcinoma on villous tumor of the rectum in an adolescent]

CASE REPORT--A 15-year 6-month-old boy suffered from isolated recurrent rectal bleeding. Rectoscopy and colonoscopy allowed to identify and to excise one large size villous polyp, which was the site of dysplasia and liberkühn adenocarcinoma. Transrectal ultrasonography showed thickened mucosa and submucosa and suspect adenopathy. Proctectomy, ganglionic curage and coloanal anastomosis were then performed; one of the excised adenopathies was metastatic. The patient died twelve hours after surgery from an unexplained cardiovascular collapse. CONCLUSIONS--Unspecific symptoms of colorectal cancer explain that its diagnosis is often delayed. Prognosis is poor related to the advanced stages at diagnosis and mucinous adenocarcinomas. Better knowledge of the clinical presentations and of high risk situations as polyposis, ulcerative colitis, hereditary non polyposis colorectal cancer could improve the prognosis.

Clinicopathological relevance of the association between gastrointestinal and sebaceous neoplasms: the Muir-Torre syndrome

The association between sebaceous neoplasms of the skin and visceral cancers, known as Muir-Torre syndrome, is described in three patients, including one with an extensive history of cancer in his family. The first patient, a 54-year-old man, developed multiple sebaceous adenomas, epitheliomas, and carcinomas in association with a colonic carcinoma 6 years after cardiac transplantation. Family history in this patient disclosed colon cancer in 17 relatives. The second patient was a 51-year-old man who had recurrent adenocarcinoma of the sigmoid colon, adenocarcinoma arising in Barrett's esophagus, and sebaceous epithelioma during a period of 15 years. The third patient was a 90-year-old man with a sebaceous adenoma followed 5 months later by adenocarcinoma of the sigmoid colon with liver metastases. Muir-Torre syndrome in 129 other patients published in the literature is reviewed. Although it is a rare disease, Muir-Torre syndrome requires recognition because skin lesions may be the first sign of the syndrome and this may lead to early diagnosis of associated visceral cancers. Moreover, because this syndrome appears to be inherited, family members should be screened for visceral cancer, especially colorectal adenocarcinoma.

Surgical pathology of adenocarcinoma arising in Barrett's esophagus. Analysis of 67 cases

Numerous reviews of adenocarcinoma arising in Barrett's esophagus have been reported, but detailed pathologic findings or survival analysis have rarely been provided. This retrospective study analyzed 67 patients (mean age, 64 years; male-to-female ratio, 10:1) with an adenocarcinoma arising in Barrett's esophagus treated by surgical resection. Prevalence of smokers was 63%, alcohol users, 45%, and patients with hiatal hernia, 73%. Five patients had another synchronous cancer, and seven patients, previous esophageal surgery. Forty percent of the tumors were well differentiated, 31% moderately differentiated, 15% poorly differentiated, 7% mucinous, and 6% composed of signet-ring cells. Depth of invasion in the esophageal wall was limited to mucosa in 13% of cases and submucosa in 18%. Invasive adenocarcinomas extended to the muscular layer in 12% of cases, to adventitia in 33%, and to periesophageal tissue in 24%. Vascular and perineural neoplastic invasion was present in 67 and 38% of cases. Regional lymph node involvement and distant metastases were found in 51 and 9% of cases. Overall, 1-, 2-, and 5-year survival rates were 63, 41, and 32%, respectively. Five-year survival rate was significantly better for patients with superficial cancer limited to mucosa or submucosa (82 vs. 12%) or without regional lymph node involvement (59 vs. 10%). Tumor differentiation, vascular and perineural invasion, extranodal spread, distant metastases, and resection margins status also had a significant prognostic value on univariate analysis. In a multivariate Cox regression analysis for overall survival, depth of invasion in the esophageal wall and regional lymph node involvement were independent prognostic factors. Careful pathologic staging is of value in determining the prognosis of patients with adenocarcinoma arising in Barrett's esophagus.

Composition of extracellular matrix and distribution of cell adhesion molecules in renal cell tumors

BACKGROUND

Cell to cell and cell to matrix interactions play a major role in tumor growth and invasion. Therefore, we studied the composition of extracellular matrices and the distribution of cell adhesion molecules in 50 renal cell tumors of various types and various grades of malignancy as compared with nontumoral kidney.

EXPERIMENTAL DESIGN

In the present study, we used immunolabeling with specific antibodies directed against the alpha 1, alpha 2, and alpha 3 chains of collagen type IV; laminin; heparan sulfate proteoglycan; fibronectin; collagen I; collagen III; the alpha 1, alpha 2, alpha 3, alpha 5, alpha 6, alpha v, beta 1, and beta 3 subunits of integrins; and ICAM-1, VCAM-1, and ELAM-1 molecules.

RESULTS

In clear cell type carcinomas (24 cases) the basal laminae surrounding the tumor islets contained the alpha 1 and alpha 2 chains of collagen type IV and heparan sulfate proteoglycan in all cases, and laminin in 96% of the cases. The alpha 3 chain of collagen IV was present in only one case, whereas fibronectin, collagen I, and collagen III were detected in nearly 50% of the cases. The tumor cells expressed alpha 3, alpha 6, and beta 1 integrin subunits in all cases, alpha 5 in 25%, alpha v beta 3 in 54%, and alpha 2 in none. ICAM-1 was detected in all cases, and VCAM-1 in 58%. The expression of the alpha 6 subunit was weak in 2 tumors of high grade, whereas the alpha v subunit was expressed in 7 of 14 low grade and in 7 of 10 intermediate and high grade tumors. In tubulopapillary carcinomas with chromophilic cells (12 cases), the most prominent findings were the presence of the alpha 3 chain of collagen IV in tumor basal laminae in 66% and the expression of the alpha 2 integrin subunit by the tumor cells in 58% of the cases, both features characterizing distal renal tubules. In chromophobic carcinomas (4 cases), the tumor basement membranes were tenuous and contained no fibronectin or interstitial collagens. The tumor cells expressed the alpha 6, alpha 2, alpha 3, beta 1, and alpha nu beta 3 integrin subunits but neither ICAM-1 nor VCAM-1 molecules. In oncocytomas (10 cases), the tumor basement membranes contained the alpha 1, alpha 2, and alpha 3 chains of collagen IV, laminin, and heparan sulfate proteoglycan. Fibronectin was not detected, whereas interstitial collagens were present in half of the cases. In all tumors, cells expressed the alpha 6 and beta 1 integrin subunits, whereas alpha 2, alpha 3, and alpha nu beta 3 were present in 30%, 60%, and 90% of the cases, respectively. ICAM-1 and VCAM-1 were not detected. The vascular endothelial cells of the stroma expressed the alpha 1, alpha 5, alpha 6, and beta 1 integrin subunits in all 50 of the studied tumors. In addition, ICAM-1 was detected in 84%, VCAM-1 in 50%, and ELAM-1 in 34% irrespective of tumor cell type, growth, or nuclear grade.

CONCLUSIONS

These results suggest that each type of renal cell tumor produces particular extracellular matrix components and expresses a characteristic repertoire of cell adhesion molecules, which could provide better understanding of the origin of these tumors. The expression of the alpha nu beta 3 integrin subunit was demonstrated in all types of renal cell tumors and was not found to be related to high grade tumors. Stromal vascular endothelial cells expressed activation molecules VCAM-1 and ELAM-1 in a significant number of cases in both benign and malignant tumors.

[Benign atypical cysts of the kidney: MRI aspects]

The aim of this study was to assess the magnetic resonance imaging (MRI) characteristics of 13 benign complex renal cysts using T1 and T2-weighted images and contrast-enhanced images. The results have been compared to CT and ultrasonographic findings in all cases and correlated with histopathologic data in 12 cases. Five groups have been defined according to the MR features. Group 1: homogeneous low signal intensity on T1-weighted images and homogeneous high signal intensity on T2-weighted images mimicking simple cyst (n = 2); group 2: homogeneous high signal intensity on both T1 and T2-weighted images mimicking hemorrhagic cyst (n = 1); group 3: caracterised by high signal intensity on T1-weighted images and fluid-iron level on T2-weighted images (n = 3); group 4: characterised by fluid-iron level on both T1 and T2-weighted images (n = 3); group 5: pseudotumoral feature: heterogeneous signal intensity and/or wall contrast enhancement (n = 3). Among the 13 indeterminate lesions on ultrasonography and CT, MRI was of diagnostic value in 8 cases, whereas the 5 remaining cases remained indeterminate on MR images. Our results suggest that MRI can be useful in the diagnosis of benign complex cyst of the kidney presenting as indeterminate cystic lesion on other modalities.

Expression of c-erbB-2 oncogene product in Barrett's adenocarcinoma: pathological and prognostic correlations

AIMS

To establish the prevalence of c-erbB-2 protein expression in a surgical series of Barrett's adenocarcinomas; and to correlate this expression with clinicopathological data and prognosis.

METHODS

Sixty six surgical specimens of Barrett's adenocarcinomas were included in this retrospective study. Blocks of the tumour and of non-dysplastic Barrett's mucosa were stained with a polyclonal antibody specific for the intracytoplasmic domain of the c-erbB-2 protein.

RESULTS

Seven of 66 tumours showed membrane staining for the c-erbB-2 protein. The non-dysplastic Barrett's mucosa was negative in all cases. There was no difference between c-erbB-2 positive and negative tumours with regard to mean age, sex ratio, percentage of alcohol misusers, percentage of smokers, tumour differentiation, depth of invasion, lymph node response, and proliferative activity, assessed by the percentage of tumour cells positive with the MIB-1 antibody directed against the Ki-67 antigen. All c-erb B2 positive tumours were of Lauren's intestinal type compared with negative c-erbB-2 tumours. Patients with c-erbB-2 positive tumours had a significantly poorer prognosis than patients with negative tumours.

CONCLUSIONS

The prevalence of Barrett's adenocarcinomas expressing c-erbB-2 found in this study (11%) was similar to that observed in published series of gastric adenocarcinomas. c-erbB-2 protein expression could be an important prognostic indicator in Barrett's adenocarcinoma.

Acute fatty liver of pregnancy after exposure to toluene. A case report

We describe a patient in whom acute fatty liver of pregnancy developed after long-term toluene exposure. Acute fatty liver of pregnancy was documented by a liver biopsy specimen stained with oil red O and observed under electron microscopy. Although the mother did well, she gave birth to a stillborn whose autopsy showed visceral congestion and placental infarction. This case raises the hypothesis of a possible relationship between toluene exposure and acute fatty liver of pregnancy.

Renal cell carcinoma containing fat: demonstration with CT

It is widely believed that demonstration of fat within a well-marginated renal tumor at computed tomography (CT) is highly suggestive of angiomyolipoma and can rule out renal cell carcinoma. The authors describe a patient in whom CT demonstrated a solid mass containing calcifications and small amounts of fat. Renal cell carcinoma was diagnosed at pathologic examination. The carcinoma had tubular and papillary architectural configurations associated with areas of osseous metaplasia located in the fibrous stroma of the tumor. Renal cell carcinoma should be considered in the differential diagnosis of well-marginated lipomatous renal tumors when intratumoral calcifications are identified at CT. Such calcified, fat-containing renal tumors must be evaluated with surgical exploration and treated as any other indeterminate renal tumors.

Adenomas arising in Barrett's esophagus with adenocarcinoma. Report of three cases

Adenocarcinoma of the esophagus is a well known complication of Barrett's esophagus, and results from a dysplasia-carcinoma sequence. This report describes 3 patients with adenomatous polyps arising in Barrett's esophagus. One patient presented with multiple sessile or pedunculated polyps giving a polyposis appearance; the other two patients had single polyps associated with distinct adenocarcinoma arising in Barrett's esophagus. Polyps consisted of adenomatous proliferation with adenocarcinoma in the 3 patients. Review of the literature identified twelve previously reported cases. These cases show that although rare, adenomas may arise in Barrett's esophagus, and are most likely premalignant lesions such as other adenomas of the gastrointestinal tract.

Esophageal squamous carcinoma in five patients with Barrett's esophagus

Adenocarcinoma of the esophagus is a well-known complication of Barrett's esophagus. This report describes five patients (three men and two women) with Barrett's esophagus and squamous carcinoma of the esophagus. All patients had hiatal hernia, and three had a history of tobacco and alcohol use. The tumors were located in the Barrett's mucosa in one case, at the squamocolumnar junction in two cases, and in the squamous-lined mucosa above the Barrett's mucosa in two cases. One patient also had focal adenocarcinoma associated with the squamous carcinoma of the esophagus. Review of the literature identified 11 previously reported cases. Occurrence of esophageal squamous carcinoma in Barrett's esophagus patients suggests a possible relationship between these two conditions, and the need for a careful evaluation of the squamous esophageal mucosa and the squamocolumnar junction at the time of endoscopy.

Adenocarcinoma of the lower esophagus and the esophagogastric junction

This report describes adenocarcinoma in patients with Barrett's esophagus (BE) and adenocarcinoma of the esophagogastric junction (EGJ) and the gastric cardia. Definitions, frequency, and general features of both conditions are described. The macroscopic features and microscopic findings are detailed for invasive adenocarcinoma and superficial (early) adenocarcinoma. Prognosis and follow-up are evaluated using flow cytometry as a factor of prognosis. Precancerous conditions and etiological factors are discussed. In addition, primary adenocarcinoma of the lower esophagus not associated with BE is considered. The precancerous lesions and precancerous markers in BE and in the cardia are examined, including type of dysplasia, histochemical study, and other lines of research.

A simple biological index for detection of alcoholic liver disease in drinkers

To make liver biopsy unnecessary in certain cases, PGA (P, prothrombin time; G, gamma-glutamyl transpeptidase; A, apoliprotein AI), a simple biological index combining a specific test for severe liver disease (prothrombin time), a sensitive test of alcoholic liver disease (serum gamma-glutamyl transpeptidase), and a test for liver fibrosis (serum apolipoprotein AI), was evaluated in a training sample of 333 drinkers and validated in 291 other drinkers. All patients underwent an intercostal liver biopsy, and the specimen was independently read by two pathologists. The PGA index varied from 0 to 12. When PGA was less than or equal to 2, the probability of cirrhosis was 0% and the probability of normal liver or minimal changes 83%. Conversely, when PGA was greater than or equal to 9, the probability of normal liver or minimal changes was 0% and the probability of cirrhosis 86%. These values did not vary between training and validation periods, between asymptomatic vs. symptomatic subjects or between PGA at admission vs. PGA 1 week later. This index could be useful for general practitioners in identifying subjects at high risk for severe alcoholic liver disease.

A simple biological index for detection of alcoholic liver disease in drinkers

To make liver biopsy unnecessary in certain cases, PGA (P, prothrombin time; G, gamma-glutamyl transpeptidase; A, apoliprotein AI), a simple biological index combining a specific test for severe liver disease (prothrombin time), a sensitive test of alcoholic liver disease (serum gamma-glutamyl transpeptidase), and a test for liver fibrosis (serum apolipoprotein AI), was evaluated in a training sample of 333 drinkers and validated in 291 other drinkers. All patients underwent an intercostal liver biopsy, and the specimen was independently read by two pathologists. The PGA index varied from 0 to 12. When PGA was less than or equal to 2, the probability of cirrhosis was 0% and the probability of normal liver or minimal changes 83%. Conversely, when PGA was greater than or equal to 9, the probability of normal liver or minimal changes was 0% and the probability of cirrhosis 86%. These values did not vary between training and validation periods, between asymptomatic vs. symptomatic subjects or between PGA at admission vs. PGA 1 week later. This index could be useful for general practitioners in identifying subjects at high risk for severe alcoholic liver disease.