Phase II randomized study of biomarker-directed treatment for non-small cell lung cancer (NSCLC): The BATTLE (Biomarker-Integrated Approaches of Targeted Therapy for Lung Cancer Elimination) clinical trial program

8024

Background: Treatment for patients (pts) with recurrent NSCLC has limited efficacy despite the use of new targeted agents. Identifying biomarkers to predict tumor response will help personalize therapy for individuals. Methods: Eligible pts had prior chemotherapy, ECOG PS 0–2, and when enrolled, required 2 fresh core needle biopsy specimens to test 11 biomarkers related to 4 molecular pathways in NSCLC: EGFR, Kras, and Braf gene mutation (PCR-based sequencing), EGFR and Cyclin D1 copy number analyses (FISH), and 6 proteins via IHC (VEGF/R and RXR receptors/Cyclin D1). Based on eligibility and tumor biomarker analyses, pts were randomized into 1 of 4 treatments: erlotinib (E) 150 mg qd; sorafenib 400 mg bid, vandetanib 300 mg qd; E 150 mg + bexarotene 400 mg/m2 qd. The primary endpoint is 8-week progression-free status. The first 97 pts were equally randomized, with subsequent pts adaptively randomized under a Bayesian framework. Results: Since 11/2006, 227 pts have been enrolled and 171 randomized and treated (median age 62 yrs, 89 males, 137 Caucasians, 11 Asians, 107 former and 38 never smokers). Accrual has proceeded well (average 9 pts per month). 112 of the biopsied lesions were lung, with a pneumothorax rate of 12.1% (15 of 124 pts; grade 1–2 only; lung, mediastinal and pleural sites). 168 pts (74%) have complete biomarker profiles and 7 (3%) have partial. Histology: adenocarcinoma (75%), squamous (11%), large cell (13%). Mutation frequency was 19% EGFR, 15.4% Kras, and 2.9% Braf. 2 tumors contained both EGFR and Kras mutations, and 2 cases had both Kras and Braf mutations. EGFR polysomy by FISH was 36.4%, and gene amplification 21%. Cyclin D1 amplification was 16.3%. Treatment-related adverse events (grade 3 or more) were 6.5%. Conclusions: We have demonstrated that biopsies are safe and feasible for biomarker-directed studies. The study continues enrollment to 200 evaluable pts at which point the results will be unblinded. BATTLE is one of the first studies in advanced lung cancer to prospectively utilize biomarker analysis of fresh biopsies to direct pt treatment, and is a step towards personalizing therapy in NSCLC. Supported by grant DoD W81XWH-6–1-0303.

No significant financial relationships to disclose.

Integrating microRNA and mRNA expression profiling using a novel algorithm identified a small set of unique genes upregulated in malignant pleural mesothelioma (MPM)

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Background: We employed a global profiling strategy using miRNA microarrays in MPM cell lines and archival tumor tissue. Methods: We isolated total RNA from 4 MPM cell lines, 2 control cell lines, and 16 tissue specimens from patients with resected MPM (n=8) and normal counterpart (n=8) patients as controls. Total RNA was labeled with Cyanine 3, then hybridized with Agilent human miRNA microarray v1 slides. Results: Preliminary miRNA profiles show up-regulation of 44 versus down-regulation of 29 miRNA's in MSTO-211H cancer cells compared to HCT-4012 (pleural telomerase-transformed control). Profiling of 16 tissue specimens (8 normal vs 8 MPM) revealed down-regulation of 11 miRNA's in MPM tumor tissue. To focus on relevant miRNA that regulate genes involved in carcinogenesis and progression, we identified > 1000 unique genes using the online targetscan 4.2 program ( http://www.targetscan.org ), which predicts biological targets of miRNAs by identifying the presence of conserved 8-mer and 7-mer sites that match the seed region of each miRNA. We then explored a novel screening strategy, which combines mRNA expression dataset with the miRNA dataset, to narrow the list of relevant miRNA's. We conducted gene expression profiling on the cell lines and MPM tissue samples with Affymetrix U133 plus 2.0 chips. Bioinformatic analysis was conducted with MeV: MultiExperiment Viewer software, data reduction techniques (Correspondance Analysis), hierarchical clustering methods, and Serial Analysis for Microarray (SAM), and showed up-regulation of ∼300 genes in MPM compared to normal tissues. We then computed of the ∼300 mRNA's up-regulated in MPM only 32 are recognized by the 11 down-regulated miRNA's using the targetscan 4.2 algorithm. Most of the miRNA's regulate single messages while ∼20 % of the messages are regulated by more than 1 miRNA's. Some of these targets include Ets variant 1 and Protein kinase C - epsilon. Conclusions: This innovative approach of selecting highly relevant miRNA is feasible and enables discovery of novel genes based on their ability to be bound by single or multiple miRNA's. Validation of our profiling studies using real-time PCR and protein analysis methods will be presented.

No significant financial relationships to disclose.

Phase II pilot study of neoadjuvant docetaxel and cisplatin followed by adjuvant erlotinib in patients with stage I-III non-small cell lung cancer (NSCLC)

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Background: Pts with early stage NSCLC, especially with nodal disease, have a poor prognosis despite curative intent therapy. It is unclear which pts may derive the benefit of chemotherapy. The primary endpoint of the study was to assess the tolerability of the regimen. In addition, the clinical response of the chemotherapy regimen as well as tumor biomarkers modulation will be examined. Methods: Pts had previously untreated, potentially surgically resectable, stage I-III NSCLC with ECOG performance status (PS) 0–1 and adequate laboratory parameters. After baseline tissue was obtained, chemotherapy was administered (docetaxel [T] 75 mg/m2 and cisplatin [P] 80 mg/m2 every 3 wks) for 3 cycles. Subsequently, pts underwent restaging, then planned definitive therapy with surgical resection. Pts were then offered treatment for 1 year with erlotinib (E) 150 mg PO daily. Bronchoscopic biopsies were performed at 6 months and 1 year post- surgery. Results: 41 pts were enrolled between 2/07 and 11/08. 3 were not eligible and did not receive treatment. Of the 38 eligible pts: median age was 65 years (42–80); 24 (63.2%) were male; 26 (68%) were PS 1. Stage IB 18% (7), IIB 37% (14), IIIA 39% (15), IIIB 5% (2). 31 pts completed all 3 cycles (35 pts completed at least 2 cycles). 32 pts underwent definitive surgical resection with 1 pt pending for surgery. 5 others did not undergo surgery: pneumonia (1), progressive disease (1), definitive chemo-radiation (3). For pts completing at least 2 cycles of chemotherapy, the radiographic response rate was 57% (20) by RECIST criteria with 40% (14) having stable disease. 1 pt had a complete pathologic response. 16 pts have started adjuvant E, 4 have completed 1 yr of treatment. Grade 3/4 toxicities included neutropenia (6 pts) and hypokalemia (4 pts). Blood and tissue specimens will be analyzed to assess sensitivity to chemotherapy. Conclusions: Neoadjuvant T and P is a tolerable and active regimen with an encouraging response rate in stage I- III resectable NSCLC. In addition to clinical characteristics, determining which patients will benefit from chemotherapy by analyzing their tumor biomarkers may help improve overall outcomes of curative lung cancer pts. Supported by grant DoD# W81XWH-07–1-0306.

[Table: see text]

Activated Src kinase is expressed in malignant pleural mesothelioma tumors; dasatinib inhibition leads to cytotoxicity, cell cycle inhibition, and prevention of invasion and migration

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Background: Malignant pleural mesothelioma (MPM) is a lethal disease with few effective therapeutic options. We sought to determine whether Src, a non-receptor tyrosine kinase, could be a new therapeutic target in MPM and to establish the potential therapeutic use of pharmacologic Src inhibitors in this disease. Methods: We analyzed four MPM cell lines (MSTO-211H, NCI-H28, NCI-H2052, and NCI- H2452) for immunohistochemical (IHC) expression of total and phosphorylated Src (Tyr 419, Tyr 530). These cell lines were treated with dasatinib, a Src inhibitor, and evaluated for apoptosis, cell cycle analysis, and migration and invasion. Downstream signaling events were studied by Western blot analysis. We also conducted IHC analyses with total Src, phosphorylated Src Tyr 419 (p-Src Tyr 419), and phosphorylated Src Tyr 530 on 46 archived MPM tumor specimens and correlated the biomarker results with the clinical outcome. Results: All four MPM cell lines expressed total and activated Src (p-Src Tyr 419). Three of the four cell lines were sensitive in vitro to cytotoxicity by dasatinib with inhibition of migration and invasion, cell cycle inhibition, and apoptosis. Treatment with dasatinib inhibited several pathways downstream of Src. In the archived MPM tumor specimens, Src protein was highly expressed on IHC analysis in tumor cells, but that expression did not correlate with overall or progression-free survival. However, expression of activated Src (p-Src Tyr 419) on the tumor cell membrane was higher in patients with stage 4 disease; the presence of metastasis correlated with higher membrane (P = 0.03) and cytoplasmic (P = 0.04) expression of p-Src Tyr 419. MPM nodal involvement at N1 was associated with the highest membrane expression of inactive Src (p-Src Tyr 530) (P = 0.02), whereas N2 disease was associated with the lowest expression. No gene mutations in Src exon 12 were found in the cell lines or tumor specimens. Conclusions: Activated Src may have an important role in survival, metastasis, and invasion in MPM, and targeting Src may be an important therapeutic strategy.

No significant financial relationships to disclose.

Clinical significance of HuR expression, an mRNA-binding protein in non-small cell lung cancer (NSCLC)

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Background: HuR is a nucleo-cytoplasmic shuttling protein that specifically binds to mRNA that has AU rich (ARE) sites at the 3’end and transports the RNA to the cytoplasm for protein translation. In addition to mRNA transportation, HuR plays a role in mRNA stabilization and protein translation. Preclinical studies have shown mRNA’s of several growth factors, cell-cycle regulators, and transcription-regulating proteins have ARE’s at the 3’end and bound by HuR. However, there has been reported no clinical data on HuR expression in NSCLC. Thus, in the present study, we assessed clinical significance of HuR expression in NSCLC. Patients and Methods: A total of 236 patients with completely resected p-stage I-IIIA, NSCLC, were reviewed, and HuR expression was evaluated immunohistochemically. Results (Table): HuR expression was seen in the nucleus and cytoplasm of tumor cells. Cytoplasmic HuR expression was positively correlated with tumor progression (p-stage, P<0.01), especially nodal metastasis, microvessel density (MVD), and COX-2 expression. Enhanced nuclear HuR expression was also correlated with tumor progression and COX-2 expression, but not with MVD. Positive cytoplasmic HuR expression was a significant factor to predict a poor prognosis in all patients (5-year survival rates: 85% for HuR-negative and 43% for HuR-positive patients; P<0.01) and in any p-stage/histology subset patients. Nuclear HuR expression status was also a significant prognostic factor in all patients, but not in all subsets. A multivariate analysis confirmed that cytoplasmic HuR status was an independent prognostic factor (hazard ratio [95% CI], 4.261 [2.109–8.609]; P<0.001). Conclusions: Cytoplasmic HuR expression was correlated with tumor progression, and was a significant and independent prognostic factor in correlation with enhanced COX-2 expression and increased tumor angiogenesis.

[Table: see text]

No significant financial relationships to disclose.

Prognostic role of promoter hypermethylation of death-associated protein (DAP) kinase and p16 genes in early-stage non-small cell lung cancer

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Background: Promoter hypermethylation is an epigenetic mechanism of gene silencing commonly observed in malignancies. Prior studies suggest that hypermethylation of DAP kinase and p16, genes involved in apoptosis and cell cycle regulation, respectively, are associated with poorer survival in NSCLC patients. In this study we investigate the prognostic role of DAP kinase and p16 promoter hypermethylation in a large cohort of early-stage NSCLC patients. Methods: Pathologic stage I and II NSCLC patients who underwent complete surgical resection between 1/97 and 12/01 at our institution and did not receive adjuvant therapy were identified. Formalin-fixed, paraffin-embedded tissue blocks were retrieved, and p16 and DAP kinase promoter methylation status was determined by methylation specific PCR. Two-sided statistical analyses were performed to determine associations between methylation status, clinicopathologic characteristics, and survival. Results: DAP kinase and p16 methylation status was observed in 36.3% (97 of 267) and 36.4% (95 of 261) cases, respectively. Subject characteristics: 55% female, 77% former/current smokers, 81% stage I, 19% stage II, 61% adenocarcinoma, 29% squamous carcinoma, 63% performance status (PS) 0, 37% PS 1,93% < 5% weight loss. Recurrent NSCLC and death occurred in 21.3% and 38% of cases, respectively. No significant associations were observed between DAP kinase methylation status and subject characteristics. P16 methylation was associated with moderate/high grade (p = 0.03). A higher frequency of p16 methylation was observed in ever vs never smokers (39% vs 28%, p = 0.17). Preliminary analyses do not demonstrate significant associations between methylation status and overall survival (p16 p = 0.13; DAP kinase p = 0.56) or disease-free survival (p16 p = 0.36; DAP kinase p = 0.71). Conclusions: In this relatively large cohort of early-stage NSCLC patients, we did not detect significant associations between p16 and DAP kinase promoter methylation and clinical outcome. Further subset analyses stratified by gender and histology will be performed. The prognostic role of these biomarkers in NSCLC remains unclear.

No significant financial relationships to disclose.

Amplification of HER-2/neu (erbB2) gene expression in gallbladder (GBC) and in bile duct cancer (BDC) (biliary tract cancer, BTC)

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Background: GBC and BDC (BTC) are uncommon in the United States, but are endemic in parts of South America and Asia. BTC are aggressive tumors with poor survival rates. Chemotherapy RR is <30%, and no survival benefit has been demonstrated. Improved understanding of the molecular carcinogenic mechanisms of BTC may lead to improved therapeutic regimens. Activation of HER-2/neu play a prominent role in the development of breast cancer. In this study, BTC patient (pt) specimens from the U.S., Chile, and Japan were examined the HER-2/neu immunohistochemical (IHC) expression and its gene amplification by fluorescence in situ hybridization (FISH). Methods: Specimens from 26 GBC patients (Chile, US), 12 BDC (USA), 6 cholecystitis (Chole.) (Japan) and 7 normal GB (Chile) were examined. pStage (AJCC) of the pt was: IA: 2, IB: 9, IIA: 7, IIB: 9, III: 3, IV: 4, unknown: 4. Histologic grade was G1 and G2 adenocarcinoma (adca): 22, G3 adca: 13, squamous cell carcinoma: 1, unknown: 2. All cases were screened for HER-2/neu by IHC (0–3+). HER-2/neu gene amplification (FISH (+)) (defined as a HER-2/CEP17 ratio of 2.0 or greater) was performed by double color Her-2/neu gene/chromosome 17 centromere (CEP17) FISH assays using PathVysion HER-2/neu DNA probe kit. Results: In BTC, HER-2/neu IHC 0, 1+, 2+ and 3+ scores were found in 0 (0%), 20 (53%), 11 (29%) and 7 (18%), respectively. In Chole., 3 of 6 (50%) showed 1+ while the remaining and normal GB were all negative for IHC. FISH on paraffin sections was considered successful on 36 (95%) of the 38 cases. HER-2/neu FISH (+) was detected in 7 of 36 (19%) (6 from 3+ cases and 1 from 2+ case) and none in Chole. and normal GB. There was a significant correlation between overexpression by IHC (2+ and 3+) and FISH (+) (Fisher’s exact test; P=0.0123), but no significant correlation between pStage, histologic grade and FISH (+). Conclusions: The HER-2/neu amplification was identified in 19% of BTC in comparison with the other organ cancer (breast cancer:20–25%, lung cancer: 4.5%, colorectal cancer; 2.4%, prostate cancer: 9.3%). There was a strong correlation between IHC overexpression and FISH (+). These data support therapeutic approaches using HER-2/neu targeted agents in BTC pt. HER-2/neu IHC may be a useful surrogate for its gene amplification.

No significant financial relationships to disclose.

Consensus statements from the Second International Lung Cancer Molecular Biomarkers Workshop: a European strategy for developing lung cancer molecular diagnostics in high risk populations

The Second Molecular Biomarkers Workshop was held at the Roy Castle International Centre for Lung Cancer Research in Liverpool, in June 2001 and it brought together experts in the clinical, epidemiological and molecular-pathology of lung cancer from Europe and the USA, to address issues surrounding the development of a European strategy for early lung cancer detection. The 2001 Workshop Breakout Groups concentrated on the current challenges in the early detection of lung cancer which need to be addressed in the light of the recent surge in interest in many countries for mounting new clinical trials to evaluate the utility of Spiral CT in early lung cancer detection. If population-based trials of CT screening are mounted it will also be a favorable clinical environment in which to evaluate efficiently recent advances in molecular screening and genotyping. The Workshop focused specifically on: a) clinical and molecular biomarkers, b) sputum as an early detection and diagnostic tool, c) validation of molecular markers prior to their use in early detection trials and d) ethical issues that have to be considered in early lung cancer detection trials. A distillation of the Workshop discussions is given in this article.

Molecular analysis of synchronous and metachronous tumors of the lung: impact on management and prognosis

Patients with pulmonary neoplasms have an increased risk for developing a second tumor of the lung, either at the same time or different times. It is important to determine if the second tumor represents an independent primary tumor (ie, a synchronous or a metachronous tumor, depending on whether it is present at the same time or a later time) or recurrence/metastasis, because it will significantly change the management and prognosis. Because the two tumors from the same patient are often morphologically similar, histologic examination alone may not be sufficient to distinguish between the two possibilities. We have attempted to approach this problem by microdissecting malignant cells and comparing patterns of loss of heterozygosity of multiple genes and chromosomal loci between paired tumors. We found that primary tumors of the lung and their metastasis share nearly identical patterns of loss of heterozygosity. In contrast, most synchronous and metachronous tumors as defined by the current arbitrary criteria appeared to be genetically different; therefore, they likely represented independent primary tumors. Rare synchronous tumors had similar genetic profiles, raising the possibility of recurrence/metastasis. Our data suggest that molecular analysis can help fingerprint tumors and has the potential to significantly impact management and prognosis of patients.

Human papillomavirus type 16 is detected in transitional cell carcinomas and squamotransitional cell carcinomas of the cervix and endometrium

BACKGROUND

The etiologic role of human papillomavirus (HPV) in a variety of squamous neoplasms, including malignant and premalignant lesions of the cervix, is well established. The presence of HPV, predominantly HPV types 16 and 18, in adenocarcinomas of the endometrium has also been reported, although less commonly. Although rare, transitional cell carcinoma (TCC) in the female genital tract, including such sites as the cervix, endometrium, and ovary, has been described. HPV, however, has not been previously studied in TCC of the female genital tract, the etiology of which is uncertain.

METHODS

Eight cases of primary TCC of the endometrium and six cases of primary TCC of the cervix were retrieved from the files of the Armed Forces Institute of Pathology and the University of Texas Southwestern Medical Center. Slides stained with hematoxylin and eosin were reviewed, and tumor tissue was obtained and analyzed for the presence of HPV types 6, 11, 16, 18, 31, and 33 by polymerase chain reaction (PCR).

RESULTS

HPV was detected by PCR in 4 of 6 TCCs of the cervix (67%) and in 2 of 8 TCCs of the endometrium (25%), using HPV general primers and specific primers to HPV type 16. PCR for HPV using specific primers to HPV types 6 and 11, 18, 31, and 33 were negative in all cases.

CONCLUSIONS

The results of this study demonstrated that HPV type 16 was present in a proportion of primary TCCs of the cervix and endometrium. These findings support the hypothesis that these rare neoplasms are similar, with regard to risk factors, to the more commonly occurring squamous cell carcinomas of the cervix, and suggest that HPV may play an etiologic role in at least a proportion of these tumors.

FHIT and FRA3B 3p14.2 allele loss are common in lung cancer and preneoplastic bronchial lesions and are associated with cancer-related FHIT cDNA splicing aberrations

We evaluated primary lung cancers, tumor cell lines, and preneoplastic bronchial lesions for molecular genetic abnormalities in the candidate tumor suppressor gene FHIT, which spans the FRA3B fragile site at 3p14.2. 3p14.2 allele loss was very frequent in 32 lung cancer cell lines [100% of small cell lung cancer and 88% of non-small cell lung cancer (NSCLC)] and 108 primary NSCLC cancers (45%), with numerous breakpoints indicating involvement of several distinct regions in the FRA3B site. 3p14 allele loss was least frequent in the adenocarcinoma subtype and occurred at the relatively late carcinoma in situ stage of preneoplastic bronchial lesions found in NSCLC patients. Homozygous deletions within the FHIT/FRA3B region were found in 6 of 135 (4.4%) thoracic cancer cell lines. Northern blot showed low or absent FHIT expression in most thoracic cancer cell lines tested, whereas reverse transcription-PCR showed that 59-62% exhibited aberrant FHIT transcripts but nearly always (93-100%) also expressing the wild-type transcripts. Aberrant transcripts included precise deletions of FHIT exons, insertion of non-FHIT sequences between exons and insertions replacing exons. Complete open reading frame single-strand conformational polymorphism analysis of 102 lung cancer cDNAs revealed only one nonsplicing mutation. Normal cells including bronchial epithelium, lung, and trachea expressed wild-type FHIT transcript and a variant transcript deleted for exon 8 but not the other aberrant transcripts, arguing against exon 8-deleted FHIT transcripts being tumor specific. Our findings support the conclusion that FHIT/FRA3B abnormalities are associated with lung cancer pathogenesis but that FHIT abnormalities differ from the types of mutations and lack of wild-type transcript found in classic tumor suppressor genes, and functional studies are needed to define the role of FHIT in thoracic tumorigenesis.

[Invasive extrapulmonary infections due to Streptococcus pneumoniae. Report of three fatal cases and review]

Streptococcus pneumoniae is a most important patogen in respiratory and meningeal infections. It is also a relevant agent of septic arthritis, pericarditis, acute endocarditis and spontaneous peritonitis in cirrhotic patients with ascites. It is less well known as a cause of infections in many other sites, including abdominal organs and soft tissues, which may be very severe. In this report, we describe three fatal cases (phlegmonous gastritis, cellulitis and primary peritonitis without pre-existing ascites) due to Streptococcus pneumoniae. In the last years it has become clear that this agent can cause infections at almost any body level, which is worth remembering. We review the literature and discuss some clinical aspects of two rare infectious syndromes, like primary peritonitis without previous ascites and phlegmonous gastritis.

[Epidermoid carcinoma of the cervix uteri: molecular abnormalities of p53 and rb genes]

The inactivation of p53 and rb genes has been implicated in the pathogenesis of cervix uteri carcinoma. Although this neoplasia presents high incidence and mortality rates in Chile, there are not studies about its molecular abnormalities. We investigated the frequency of loss of heterozygocity (LOH) at p53 and rb genes in 17 invasive squamous cell carcinomas of the cervix uteri, using microdissection technique from microslides and microsatellite sequences amplification by PCR. Moreover, we investigated the immunohistochemical expression of p53 protein in 30 invasive squamous cell carcinomas LOH was detected in 6/12 of informative cases (50%) at p53 gene and in 3/10 (30%) at rb gene. The p53 protein immunohistochemical expression was 47% (14/30 cases). LOH at p53 gene in cases without p53 protein immunohistochemical expression was observed. We concluded that p53 gene molecular abnormalities are important in the pathogenesis of squamous cell carcinoma of the cervix uteri, in contrast than LOH at rb gene.

[Proliferating cell nuclear antigen in cervical cancer and precursor lesions]

The aim of this study was to study the degree of cellular proliferation quantifying the immunohistochemical expression of the proliferating cell nuclear antigen. We assessed paraffin embedded samples of 25 infiltrating epidermoid cervical carcinomas, 76 precursor lesions (34 of low and 42 of high grade), 29 normal and 13 metaplastic epidermoid epithelia. Mean values of proliferating cell nuclear antigen expression were 13.7% in normal epithelia, 15.7% in epidermoid metaplasia, 37.1% in low grade precursor lesions (35.3% in condilomas and 38.8% in mild dysplasia), 48.7% in high grade lesions (47.9% in moderate dysplasias, 50.5% in severe dysplasias and 50% in carcinoma in situ) and 54.7% in infiltrating carcinoma. There were differences in proliferating cell nuclear antigen expression nd mitotic index between low grade precursor lesions and high grade lesions and infiltrating carcinoma. No correlation was observed between mitotic index and proliferating cell nuclear antigen expression. We conclude that infiltrating epidermoid cervical carcinoma and its precursor lesions have a high level of proliferative activity, demonstrated by a high percentage of cells in active phases of the cellular cycle.

[Gallbladder cancer in the IX Region of Chile. Impact of the anatomopathological study of 474 cases]

We studied prospectively 474 cases (83% female with a female:male ratio of 5:1) of gallbladder carcinoma diagnosed in a period of 7 years. Twenty two percent of patients were younger than 50 years old. Ninety percent of tumors were adenocarcinomas. In 1987, 45% of cases were diagnosed in metastases compared to 1993, when only 10% of tumors were diagnosed in such histological material. Thirty four percent of tumors were not macroscopically identified; all these inapparent tumors were advanced in 1987, whereas 53% were incipient in 1993. Moreover, inapparent tumors had a significantly lower degree of gallbladder wall infiltration and higher degree of differentiation. Well differentiated tumors had a lesser degree of wall infiltration. It is concluded that the careful histopathological study of gallbladder cancer has allowed a thorough knowledge of the natural history and clinical presentation of gallbladder carcinoma.

[Expression of p29, estrogen receptor related protein in primary breast carcinoma. Methodological, anatomoclinical, and DNA content analysis]

The aim of this work was to assess the immunohistochemical detection of a estrogen receptor related protein (p29) in 48 histological samples of primary mammary carcinoma and its relationship to clinical, morphological and ADN content parameters. p29 protein was positive in 62.5% of samples. Over 50% of samples had a moderate or intense immunohistochemical staining (staining index over 16) and 77% has a heterogeneous expression of p29 protein. Seventy six percent of p29 positive and 53% of p29 negative tumors had a proliferation fraction over 10% (determined by the S fraction with flux cytometry). No relationship between p29 expression and the analyzed anatomoclinical variables was found. These results highlight this immunohistochemical method as an alternative to more complex and difficult biochemical techniques. On the other hand, the good results obtained in formalin fixed tissues allow retrospective studies in mammary carcinoma samples.

[Proliferating cell nuclear antigen (PCNA) in patients with malabsorption syndrome: comparative study with morphometric parameters]

The study of small bowel mucosa is routine in the study of patients with malabsorption. We report 16 children aged from 8 months to 6 years old (2 with giardiasis, 8 with primary malnutrition and 5 with celiac disease) in whom a morphometric and PCNA immunostaining was performed in the small intestinal biopsy. Positivity for PCNA was found in the lower portion of the crypts reaching 156 microns of heigh in patients with giardiasis, 103 microns in primary malnutrition and 182 microns in celiac disease (p < 0.01 compared to primary malnutrition). A negative and significant correlation was found between the degree of architectural disorder (expressed the mucosal index) and the proliferative portion of the crypts (expressed as the percentage of PCNA(+) crypts. We propose these methods as complements to the small bowel mucosa histopathological study in the diagnosis of celiac disease, to assess the degree of architectural disorder and the proliferative activity.

[Laparoscopic cholecystectomy makes difficult the analysis of gallbladder mucosa. Morphometric study]

Laparoscopic gallbladder surgery damages gallbladder mucosa, impeding an adequate histological examination. We studied gallbladder samples coming from 56 conventional and 44 laparoscopic cholecystectomies performed in patients with chronic cholecystitis without signs of acute inflammation. The length of each examined sample and the length of the portion where superficial epithelia was not found was measured. No differences in sample length was found between both types of cholecystectomy. However; the segment with superficial mucosa was significantly shorter in the samples coming from laparoscopic surgery. Seventeen samples did not contain mucosa at all and 14 of these (82%) came from laparoscopic procedures. Eighty six percent of samples coming from laparoscopic surgery were considered inadequate for histological study compared to 36% of samples coming from conventional cholecystectomy. It is concluded that laparoscopic cholecystectomy hampers the study of gallbladder mucosa and may have an impact on the diagnosis of neoplastic gallbladder lesions.