Atypical primary epithelioid hemangioendothelioma of the heart

We report an unusual case of primary cardiac epithelioid hemangioendothelioma (EHE) with atypical features, which was treated by orthoptic transplantation with a good outcome for 10 years despite recurrent pulmonary and nodal metastases. EHE is a rare vascular tumor that belongs to the group of malignant proliferations from the new World Health Organization classification of soft tissue tumors. EHE may harbor atypical features that confer a more aggressive course, albeit better than that of conventional angiosarcomas. Histological examination of the primary cardiac tumor revealed a proliferation of large epithelioid tumor cells presenting atypical features and a mitotic index of 3 mitoses per 10 high power fields. In contrast, pulmonary metastases exhibited typical features of EHE, and CD 34 and CD 31 immunostainings strongly stained cytoplasmic vascular lumen. In this report, we illustrate the potential aggressiveness of the atypical variant of EHE and suggest that transplantation might be considered as an alternative therapy in the treatment of EHE of the heart.

Mycosis fongoïde syringotrope et pilotrope sans mucinose folliculaire

BACKGROUND

Mycosis fongoides rarely exhibits predilection for infiltration of hair follicles and eccrine glands. We report the case of a patient with cutaneous T-cell lymphoma with syringotropism and pilotropism without follicular mucinosis.

CASE REPORT

A 51-year-old man presented with erythematous infiltrated patches with alopecia and anhydrosis, cystic lesions, comedon-like lesions, follicular keratosis and an ulcer over the lower left leg. Clinical examination revealed no palpable adenopathy or hepatosplenomegaly. The patient complained about hypohydrosis. Histological examination of skin biopsies evidenced pilotropic cutaneous T-cell lymphoma without follicular mucinosis. Immunohistological examination and T-cell receptor B-chain gene rearrangement analysis showed a clonal population of T-cells. Moreover sweat glands and sweat ducts were infiltrated by atypical lymphocytes with syringolymphoid hyperplasia.

DISCUSSION

Syringolymphoid hyperplasia and folliculotropism without follicular mucinosis are rarely seen in mycosis fongoides. Deep biopsies of adnexal structures are required for this critical diagnosis and clonal rearrangement of TCR genes is a reliable means of assessing clonality. Syringolymphoid hyperplasia and pilotropism without mucinosis are variants of cutaneous T-cell lymphomas.

[Diagnosis of lung cancer. DNA microarrays in thoracic oncology]

DNA microarrays allow simultaneous measurement of the expression of several thousand genes in a biological specimen. This technique represents a major advance in the analysis of tumour biopsies. It may be used to refine the anatomical- pathological diagnosis at a molecular level and thus lead to better diagnostic and prognostic classification and improved therapeutic decisions.

Cell cycle regulators and benefit of adjuvant chemotherapy in patients with non-small cell lung cancer

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Background: The International Adjuvant Lung Cancer Trial (IALT) demonstrated that adjuvant cisplatin-based chemotherapy improves the 5-year survival rate of patients with completely resected non-small-cell lung cancer (NSCLC) by absolute 4.1% (N Engl J Med 350, 351–360, 2004). The purpose of our study was to determine whether cell cycle regulators are of prognostic and/or predictive value in NSCLC patients who were enrolled into IALT. Methods: Expression of cell cycle regulators and Ki-67 was immunohistochemically assessed in tumor specimens obtained from 778 IALT patients. Prognostic and predictive analyses were based on Cox models adjusted on clinical and pathological parameters. Results: Expression of p16, p27, cyclin D1, cyclin D3, cyclin E and Ki-67 was considered as positive in 37%, 40%, 74%, 37%, 55% and 29% of tumor specimens, respectively. None of these biomarkers was significantly associated with overall survival of the patients. However, there was a relationship of borderline significance between p27 status and benefit of cisplatin-based chemotherapy (test for interaction, p = 0.04). Patients with p27-negative tumors who were treated with cisplatin-based chemotherapy had a longer overall survival than patients from the observation group (hazard ratio for death [95% CI]: 0.71 [0.55–0.93]), whereas in patients with p27-positive tumors overall survival was not different between the two groups (hazard ratio for death [95% CI]: 1.11 [0.81–1.51]). In contrast to p27, the other cell cycle regulators and Ki-67 did not predict benefit of adjuvant cisplatin-based chemotherapy. Conclusions: NSCLC patients with p27-negative tumors appear to benefit most from adjuvant cisplatin-based chemotherapy following complete tumor resection. Thus, the predictive value of p27 should be confirmed in prospective trials.

No significant financial relationships to disclose.

Pulmonary involvement by Niemann-Pick disease. A report of six cases

AIMS

Although pulmonary involvement is a known cause of morbidity in Niemann-Pick disease, histological features in the lung are not well characterized. The purpose of this study is to document the histological features seen in pulmonary involvement by types B and C Niemann-Pick disease and to correlate them with clinical and imaging data.

METHODS AND RESULTS

Surgical lung biopsies from six patients (four with type B and two with type C disease) were reviewed and all showed diffuse endogenous lipid pneumonia, with lesser involvement of the interstitium by fibrosis and foamy macrophage accumulation. In type B disease only, there was also fine cytoplasmic vacuolation within the cytoplasm of ciliated epithelial cells. Neither disease showed foamy changes within pneumocytes. One patient had a bronchial cast removed on whole lung lavage. Electron microscopy showed abnormal lamellar inclusions within lysosomes of affected cells in type B disease. In patients with type C disease, biopsies were undertaken as part of investigations into acute respiratory failure in the context of multiorgan systemic presentation. Three patients with type B disease had clinical disease limited to the lung, all adults (mean age of 40 years) with unexplained diffuse parenchymal lung disease and mainly ground-glass shadowing on high-resolution computed tomography.

CONCLUSIONS

Niemann-Pick disease should be considered for any patient with unexplained diffuse endogenous lipid pneumonia, even when disease is limited to the lungs and presentation is during adulthood.

Pseudo-acrodermatite entéropathique secondaire à un déficit en acides aminés ramifiés au cours du traitement d’une leucinose

INTRODUCTION

Clinical pictures resembling acrodermatitis enteropathica have been described in acquired zinc deficiency and deficiencies of other nutrients such as biotin, essential fatty acids and amino acids as well as biotin metabolism disorders. We describe the case of an infant with maple syrup urine disease who developed an acrodermatitis-like syndrome due to iatrogenic valine and isoleucine deficiency.

CASE-REPORT

A diagnosis of maple syrup urine disease was made in a 5-month-old infant girl with severe neurologic disorders with extremely high levels of the three branched-chain amino acids (leucine, valine and isoleucine) in plasma and urine. Seven days after the start of therapy with a diet excluding these branched-chain amino acids, plasma isoleucine and valine concentrations were low while plasma leucine remained elevated. At the same time, a periorificial and acral dermatitis appeared together with diarrhea. Serum zinc concentrations were normal. A diagnosis of acrodermatitis enteropathica-like syndrome secondary to isoleucine and valine deficiency was suspected. Valine and isoleucine supplementation resulted in rapid resolution of the eruption.

DISCUSSION

Several cases of acrodermatitis enteropathica-like eruptions resulting from therapeutic protein restriction diets have been described in infants with different aminoacidopathies. The accompanying dermatosis was associated with a raised plasma leucine/isoleucine ratio and/or isoleucine deficiency, or valine deficiency. While the exact pathogenesis of the skin lesions has not been established, these observations show that branched-chain amino acids are essential for normal growth and differentiation of keratinocytes. The essential role of isoleucine is further substantiated by the fact that its presence is critical in keratinocyte culture media, with growth arrest occurring upon its depletion.

Atypical primary epithelioid hemangioendothelioma of the heart

We report an unusual case of primary cardiac epithelioid hemangioendothelioma (EHE) with atypical features, which was treated by orthoptic transplantation with a good outcome for 10 years despite recurrent pulmonary and nodal metastases. EHE is a rare vascular tumor that belongs to the group of malignant proliferations from the new World Health Organization classification of soft tissue tumors. EHE may harbor atypical features that confer a more aggressive course, albeit better than that of conventional angiosarcomas. Histological examination of the primary cardiac tumor revealed a proliferation of large epithelioid tumor cells presenting atypical features and a mitotic index of 3 mitoses per 10 high power fields. In contrast, pulmonary metastases exhibited typical features of EHE, and CD 34 and CD 31 immunostainings strongly stained cytoplasmic vascular lumen. In this report, we illustrate the potential aggressiveness of the atypical variant of EHE and suggest that transplantation might be considered as an alternative therapy in the treatment of EHE of the heart.

Comorbidities and Charlson score in resected stage I nonsmall cell lung cancer

Patients with nonsmall cell lung cancer (NSCLC) have been shown to have a higher prevalence of comorbidity associated with age and tobacco consumption. The objective of the present study was to determine the impact of comorbidity on survival after surgery of stage I NSCLC. In total, 588 consecutive patients operated on for a pathological stage I NSCLC between January 1, 1979 and December 31, 2003 were studied. Comorbidities were analysed individually. Overall comorbidity was assessed using the Charlson index of comorbidity (CCI). Survival data were collected for each patient from the date of operation, with a median duration of follow-up of 104 months. Survival analyses and Cox proportional hazards model analyses were used. The mean age of patients was 62.7 yrs, and 529 (89%) patients were male. The distribution of overall comorbidity severity was as follows. CCI grade 0: 47.1%; grade 1-2: 43.7%; grade 3-4: 8.3%; and grade > or =5: 0.8%. The 2, 3 and 5 yrs survival were 69, 62 and 50%, respectively. Multivariable analysis showed that T stage, age, a concomitant history of moderate-to-severe liver disease, a past history of cured cancer, cerebrovascular disease and CCI were independent predictors of survival (Hazard Ratio for CCI grade >2: 1.81; 95% confidence interval 1.25-2.63). In conclusion, comorbidity has a significant impact on survival after surgical resection of patients with stage I nonsmall cell lung cancer. The use of a validated index of comorbidity in prognostic analyses of resected nonsmall cell lung cancer is recommended.

Evolution et pronostic du carcinome basaloïde squameux des voies aéro-digestives supérieures

INTRODUCTION

The course and prognosis of basaloid squamous cell carcinoma (BSCC) are not well known.

OBJECTIVES

To study the course and prognosis in a population of BSCC patients.

MATERIALS AND METHODS

We analyzed a retrospective cohort of 49 patients with BSCC in comparison with a cross-matched population of 49 patients treated for well- to moderately differentiated squamous cell carcinoma (SCC).

RESULTS

The statistical analysis showed that survival in BSCC group was lower than in the SCC group. Local recurrence in the BSCC group was not higher than in the SCC group, but mortality by distant metastasis was six times higher than in the SCC population.

CONCLUSIONS

We consider BSCC patients as a high-risk population and we complete diagnosis explorations including a FDG-PET before curative treatment. We also recommend post-operative or exclusive radiotherapy which may be associated with concomitant chemotherapy.

[Tuberous sclerosis without mental impairment, diagnosed in adulthood]

INTRODUCTION

Tuberous sclerosis complex (TSC) is an autosomal dominant inherited phakomatosis, usually diagnosed in childhood and characterized by cutaneous and neurological tumors, the latter often leading to epilepsy and mental retardation.

EXEGESIS

We report a case of TSC diagnosed in a 33-year-old man, without any known family history of phakomatosis, presenting with facial angiofibromas, hypomelanotic macules, a giant-cell astrocytoma and retinal phakomas without any mental impairment or epilepsy.

CONCLUSION

TSC may occur in patients who do not have any family history of phakomatosis because de novo mutations are frequent. TSC may be diagnosed in adulthood since a high phenotypic variability is observed. Facial angiofibromas are highly suggestive of tuberous sclerosis complex. They should lead to brain imaging in search for astrocytoma, subependymal nodules and cortical tubers which number is directly correlated with the risk of seizures and the degree of mental impairment.

Telomerase activity in proximal and distal gastric neoplastic and preneoplastic lesions using immunohistochemical detection of hTERT

BACKGROUND

The incidence of distal (corpus and antrum) gastric adenocarcinoma is decreasing with a simultaneous increase in incidence of proximal (cardia) adenocarcinoma. Epidemiological studies suggest that they may represent different diseases but corroborative molecular data are scarce. Intestinal metaplasia may have a lower malignant potential in the proximal stomach but regardless of the locations, its specificity as a predictor of carcinoma is low.

AIMS

The aim of this study was to establish whether human telomerase reverse transcriptase expression differs at various points in proximal versus distal gastric carcinogenesis and to test the utility of human telomerase reverse transcriptase expression as a marker of cancer risk in intestinal metaplasia.

MATERIAL AND METHODS

Wax-embedded tissue from proximal and distal stomach including normal mucosa (n=86), intestinal metaplasia (n=83) and carcinoma (n=101) were used and slides were immunostained for human telomerase reverse transcriptase and pRb and scored semi-quantitatively.

RESULTS

The results showed that in both proximal and distal stomach, human telomerase reverse transcriptase expression rates increased from normal mucosa to cancer. High rates of human telomerase reverse transcriptase expression were seen in the proliferative zones of glands in intestinal metaplasia. In both the locations, loss of pRb expression correlated with higher human telomerase reverse transcriptase expression.

CONCLUSIONS

In conclusion, telomerase activity appears to be an early event in both proximal and distal gastric carcinogenesis and human telomerase reverse transcriptase is expressed in intestinal metaplasia. Telomerase re-expression may be facilitated by pRb inactivation.

Adenocarcinoma of the lung mimicking inflammatory lung disease with honeycombing

Pulmonary adenocarcinoma of the lung and its variants are well-defined entities, since the recent WHO classification of lung tumours. However, scant descriptions have been allocated to associated stromal changes, such as prominent inflammation and fibrosis, which can overshadow a tumoral proliferation and masquerade as a benign reactive process and this has not been recognised as a histopathological variant. The case of a 72-yr-old farmer who presented a multifocal well-differentiated adenocarcinoma that mimicked honeycomb lung with bronchiolectasis radiologically, on computed tomography scan and histologically at open lung biopsy, is reported. Histological pitfalls in the biopsy were represented by mild atypical cuboidal or columnar epithelial cells lining bronchiolar structures resembling florid bronchiolar metaplasia in a background of extensive fibrosis and inflammation, features that mimicked inflammatory honeycombing. However, histological analysis of the surgical resection of the main lesion, performed because of a clinical alteration of the patient, confirmed the diagnosis of multifocal adenocarcinoma of mixed subtype. A monomorphic proliferation of clear cells, lack of associated ciliated or squamous cells and presence of significant cytologic atypia gave a diagnosis of malignancy. This case illustrates how inflammatory and fibrotic changes may conceal a correct diagnosis of carcinoma and emphasises the importance of adequate sampling in such cases.

E-cadherin-beta-catenin adhesion complex in neuroendocrine tumors of the lung: a suggested role upon local invasion and metastasis

Dysfunction or loss of the intercellular adhesion complex E-cadherin-beta-catenin is frequent in non-small cell lung carcinomas in which E-cadherin and beta-catenin loss has been considered to be a molecular marker of tumor progression and poor prognosis. With an aim of evaluating the expression of the E-cadherin-beta-catenin complex and its prognostic role in neuroendocrine tumors (NET) of the lung, immunohistochemical analysis was performed in 102 NET, including 16 low-grade typical carcinoids, 8 intermediate-grade atypical carcinoids, 37 large-cell neuroendocrine carcinomas (LCNEC), and 41 small-cell lung carcinomas, both high-grade tumors. Impaired E-cadherin expression (loss or cytoplasmic delocalization) was observed in 80 (78%) of 102 samples, and impaired beta-catenin expression was noted in 74 (72%) of 102 cases. The impaired expression of E-cadherin and beta-catenin was observed with a higher frequency in high-grade tumors (87% and 83%, respectively) than in carcinoids (50% and 37%, respectively; P < 0.0001). Impaired expression of the E-cadherin and beta-catenin molecules also correlated with lymph node metastasis (P = 0.0001 and P = 0.0005, respectively) and with advanced stage disease (P < 0.0001 for both factors). Moreover, impaired E-cadherin expression directly correlated with an extensive disease in carcinoids and in LCNEC (P = 0.02 and P = 0.04, respectively) and with node metastasis in LCNEC (P = 0.01). Levels of E-cadherin and beta-catenin were correlated with each other, consistent with an internal regulatory loop. Our results indicate that down-regulation of the E-cadherin-beta-catenin complex plays a role in NET progression.

Imagerie des tumeurs carcinoïdes bronchiques : diagnostic et bilan d’extension loco-régionale

PURPOSE

To describe the imaging features of bronchial carcinoids and to define the role of CT as a diagnostic and pretherapeutic tool.

MATERIALS AND METHODS

We performed a retrospective study including 54 carcinoids. We evaluated and compared the clinical, radiographic, CT, fiberoptic, and pathologic data.

RESULTS

At presentation, the mean age was 48.5 years (14-81) and patients mainly complained of signs related to bronchial obstruction (55.7%). 72% of bronchial carcinoids were located in the proximal airway. CT showed calcifications in 26% of 54 cases and contrast enhancement in 60%. Typical carcinoids differed from atypical carcinoids in their size and lymph node extension. As compared to fiberoptic bronchoscopy, CT identified proximal carcinoids with exo-bronchial extension (7.4%), peripheral tumors (20.4%), and parenchymal complications. The sensitivity and predictive positive-value of CT for lymph node extension was 28% and 20%, respectively.

CONCLUSION

CT is a useful technique for diagnosing and localizing bronchial carcinoids. The results of CT in determining lymph node extension is disappointing, and should raise caution in case of localized treatment using fiberoptic bronchoscopy.