The alpha subunit of inhibin in adrenal cortical neoplasia

We analyzed 23 adrenal adenomas and 15 adrenal cortical carcinomas by immunolabeling for the alpha subunit of inhibin, and we then compared the results with the functional status of the neoplasms. We also studied 19 pheochromocytomas, 30 renal cell carcinomas, and 5 extra-adrenal paragangliomas, tumors posing differential diagnostic problems with adrenal cortical neoplasms. Immunolabeling was performed using automated immunohistochemical methods and an antibody directed against the alpha subunit. Tumors were semiquantitatively assessed for the number of positive cells. Immunopositivity was obtained in 18 (78%) of 23 adrenal cortical adenomas, 12 (80%) of 15 adrenal cortical carcinomas, 2 (11%) of 19 pheochromocytomas, 0 of 5 extra-adrenal paragangliomas, and 0 of 30 renal cell carcinomas. Immunoreactivity was strong in 7 (78%) of 9 adrenal cortical tumors from patients with Cushing's-related or virilizing symptoms. In contrast, only 4 (14%) of 29 tumors that were clinically nonfunctioning or associated with hyperaldosteronism demonstrated strong staining (P < .001). In clinically nonfunctioning tumors, there was a tendency for increased immunopositivity in tumors from patients with elevated levels of cortisol, androgen, or their precursors, with four of six tumors having at least moderate immunopositivity. Similar reactivity was present in only one of eight tumors from patients with normal laboratory values (P=.091). Moderate or strong immunopositivity was present in 9 (60%) of 15 adrenal cortical carcinomas, whereas of the pheochromocytomas, extra-adrenal paragangliomas, and renal cell carcinomas, only 1 (1.9%) of 54 showed moderate-to-strong reactivity. We conclude that moderate or strong immunoreactivity for the alpha subunit of inhibin occurs in adrenal cortical tumors from patients with Cushing's-related or virilizing symptoms. Immunolabeling for the inhibin alpha subunit is potentially useful in the differential diagnosis of neoplasms that include adrenal cortical carcinomas.

The diagnostic utility of inhibin staining in ovarian neoplasms

Previous immunohistologic studies have suggested that the antibody to the alpha subunit of inhibin is a sensitive marker of sex cord-stromal differentiation. However, detection has also been reported within both ovarian epithelial and germ cell tumors. To further study the normal tissue distribution of inhibin and the utility of its detection for the differential diagnosis of ovarian sex cord-stromal neoplasms, normal tissues and 225 lesions including sex cord-stromal lesions, ovarian epithelial and stromal cancers, ovarian and testicular germ cell tumors, metastases to the ovary, and non-ovarian cancers were analyzed using semi-automated immunohistochemistry. In normal tissues, immunostaining was found in cell subsets of the ovary, testis, adrenal gland, placenta, and kidney. All sex cord-stromal tumors were inhibin-positive and 37 of 50 (74%) cases exhibited at least moderate to strong immunostaining. Two cases originally diagnosed as adult granulosa cell tumors that were inhibin-negative were reassessed; diagnoses of endometrioid stromal sarcoma and endometrioid carcinoma with sertoliform features were rendered. In other primary or metastatic ovarian lesions or metastases to the ovary, weak to moderate immunostaining was found in only 4 of 84 (4.8%) cases, including ovarian clear cell carcinoma (2/2), uterine clear cell carcinomas metastatic to the ovary (1/3), and serous papillary carcinoma (1/2). Similarly, only 4 of 66 (6.1%) non-ovarian neoplasms exhibited weak immunostaining, including melanoma (1/5), uterine endometrioid carcinoma (1/2), transitional cell carcinoma (1/3), and breast adenocarcinoma (1/8). Only one case of a non-sex cord-stromal tumor had moderate or strong immunostaining. Based on these results, immunohistologic detection of the alpha subunit of inhibin is a useful adjunct in the differential diagnosis of sex cord-stromal neoplasms.

Validation of an in-office dental unit water monitoring technique

The authors conducted a study to determine the sensitivity, specificity and accuracy of HPC Samplers (Millipore Corp.) as compared with that of R2A agar and HPC agar when used to monitor dental unit water, or DUW, quality. Results were either a pass (200 colony-forming units per milliliter, or CFU/mL, or less) or a fail (greater than 200 CFU/mL). Of the 408 tests conducted, the results of the HPC Sampler agreed with R2A agar 377 times, for an accuracy rate of 92.6 percent. The authors recommend that clinicians consider using HPC Samplers, as they are a user-friendly, economical means of monitoring compliance of DUW quality.

Serous and mesothelial proliferations of the extraovarian peritoneum and pelvic lymph nodes

With rare exceptions, serous proliferations of the peritoneum are limited to women, whereas proliferations of mesothelial differentiation arise predominantly in men. The authors focus on the various types of serous and mesothelial proliferations of the peritoneum and pelvic lymph nodes. Discussion of each type focuses on clinical and morphologic features, histogenesis, differential diagnosis, and clinical outcome.

Homologous carcinomas of the breasts, skin, and salivary glands. A histologic and immunohistochemical comparison of ductal mammary carcinoma, ductal sweat gland carcinoma, and salivary duct carcinoma

Morphologic mimicry among human malignant neoplasms is a well-known phenomenon in surgical pathology; both undifferentiated and "committed" neoplasms may exhibit this trait. One particularly common group of histologic simulants includes ductal carcinomas of the breasts, the cutaneous appendages, and the salivary glands. One hundred three tumors in this structural cluster were analyzed microscopically and immunohistologically to codify points of potential pathologic similarity and difference. All the lesions were typified by irregularly permeative clusters and cords of atypical polygonal cells with variable luminal differentiation. A proportion of primary neoplasms in each site demonstrated in situ ductal components; in the absence of the latter elements, however, it was not possible to make topography-related morphologic distinctions among them. Immunostains for gross cystic disease fluid protein-15 (GCDFP-15), carcinoembryonic antigen, S100 protein, c-erbB-2 oncoprotein, estrogen receptor protein, and progesterone receptor protein also showed largely overlapping phenotypes in each of the three tumor categories, with selected exceptions. These differences were elucidated through paired chi 2 analysis and included a statistically significant infrequency of GCDFP-15 in eccrine sweat gland carcinomas, a paucity of carcinoembryonic antigen in breast cancers, and an absence of estrogen receptor protein in salivary duct carcinomas. Such findings may be useful in predefined differential diagnostic settings involving the distinction between primary and metastatic ductal cancers of the breasts, skin, and salivary glands. Nevertheless, because of the striking homologies between such tumors at structural and protein-synthetic levels of comparison, it is mandatory that all available clinicopathologic information be used in this context.

Cathepsin D and chromogranin A as predictors of long term disease specific survival after radical prostatectomy for localized carcinoma of the prostate

BACKGROUND

The accumulation of chromogranin A (Chr A) and cathepsin D (Cath D) gene products may be important in prostate carcinoma progression. This study assessed whether the levels of immunoreactivity for Chr A and Cath D are better predictors of disease specific survival than conventional pathologic parameters of the primary tumor such as Gleason score, capsular penetration, seminal vesicle invasion, and percent tumor in the specimen for patients with clinically localized prostate carcinoma managed by radical prostatectomy.

METHODS

Seventy-one patients with modified Jewett clinical stages A1 to B2 adenocarcinoma of the prostate underwent a radical prostatectomy after a negative metastatic workup. No neoadjuvant or adjuvant treatments were given and all disease recurrences and causes of death were recorded. Analysis of prostatectomy specimens was undertaken to determine the conventional pathologic parameters of the primary tumor and Chr A and Cath D immunohistochemical staining. Univariate and multivariate analyses were performed to determine the independent contributions of Chr A and Cath D in predicting survival.

RESULTS

On univariate analysis Chr A was the only variable that reached statistical significance for disease specific survival (P = 0.035). Cath D nearly reached significance with a P value of 0.079 for disease specific survival. On multivariate analysis, the only independent factor predicting disease specific survival was the Chr A staining score (P < 0.05). In patients with unequivocal foci of Chr A immunoreactivity, the 14-year disease specific survival was 50% compared with 68% for patients lacking such foci.

CONCLUSIONS

The level of Chr A immunohistochemical staining is a strong predictor of disease specific survival and is superior to standard pathologic prognostic factors. Such findings lay the groundwork for future prospective study of the utility of such markers on biopsy specimens to predict patient outcome.

Clear cell tumors of the lower respiratory tract

Clear cell tumors of the lower respiratory tract comprise a diverse group of lesions. The prototypical lesion is the benign clear cell tumor or "sugar tumor," a tumor of enigmatic histogenesis, whose name derives from the high glycogen content of the cells. Analogous to the salivary gland lesion of the same name, acinic cell tumors may also occur in the tracheobroncheal tree. The topic of "clear cell carcinoma" is discussed, which in the opinion of the authors does not constitute a distinct tumor entity. A discussion of potential lesion metastatic to the lung with clear cell histology is also presented. Histological details of the various entities are discussed, as well as the significant histochemical, immunohistological, and electron microscopic features; in particular, such findings that are relevant to differential diagnosis are stressed, including the distinction of primary and metastatic lesions.

Clear cell tumors of the alimentary tract and abdominal cavity

Clear cell neoplasms of the abdominal organs are represented by a variety of epithelial and mesenchymal neoplasms, of varying malignant potential. Several varieties of clear cell carcinomas, including those with tubulopapillary, hepatoid, colloid, or neuroendocrine features, have been described, as well as several benign epithelial neoplasms. These epithelial tumors have been reported in the gastrointestinal hollow viscera, as well as the liver, pancreas, and biliary tract. A second major consideration is the mesenchymal-derived gastrointestinal stromal tumors, which also may feature clear cells, and comprise a spectrum of biological behavior. Miscellaneous lesions include clear cell variants of melanoma and mesothelioma. This review includes histological details of the various entities, as well as important histochemical, immunohistological, and ultrastructural features. Pertinent differential diagnostic points are stressed, including distinction of the primary clear lesions from relevant metastatic neoplasms.

Clear cell tumors of unknown nature and origin: a systematic approach to diagnosis

Not infrequently, surgical pathologists encounter malignant neoplasms composed of clear cells, the sources and natures of which are indeterminate on the basis of conventional morphological study. In this context, it is frustrating that tumors of completely dissimilar lineage can show strikingly similar microscopic appearances; moreover, anatomic location provides few if any definitive clues to the likely final diagnosis in many cases of clear cell neoplasia. Because of these factors, it is necessary to systematically pursue the same approach to the pathological assessment of clear cell tumors, routinely considering not only clinical and radiologic details but also the possible application of immunohistology, electron microscopy, and cytogenetics. This review provides algorithmic schemes by which such techniques can be applied, as well as their potential drawbacks and limitations.

p53, bcl-2 and retinoblastoma proteins as long-term prognostic markers in localized carcinoma of the prostate

PURPOSE

The accumulation of p53 and bcl-2 gene products as well as the loss of the retinoblastoma (Rb) gene product have been associated with prostate cancer progression. We assessed whether the levels of immunoreactivity for p53, Rb and bcl-2 are better long-term predictors of disease specific survival than conventional pathological parameters of the primary tumor, such as Gleason score, capsular penetration, seminal vesicle invasion and percent tumor in the specimen, in patients with clinically localized prostate cancer treated with radical prostatectomy.

MATERIALS AND METHODS

A total of 71 patients with clinical stages A1 to B2 adenocarcinoma of the prostate underwent radical prostatectomy after a negative metastatic evaluation. No neoadjuvant or adjuvant treatments were given and causes of death were recorded. Prostatectomy specimens were analyzed to determine the conventional pathological parameters, and p53, Rb and bcl-2 immunohistochemical staining. Univariate and multivariate analyses were done to determine the independent contributions of p53, Rb and bcl-2 in predicting survival.

RESULTS

On multivariate analysis the independent factors predicting disease specific survival were p53 staining score (p < 0.001) and Rb staining score (p < 0.001). In patients with p53 immunoreactive tumors the 15-year disease specific survival was 38% compared to 87% for those with less immunoreactivity. Analysis of Rb immunoreactivity for 15-year disease specific survival yielded 92 and 66% high and low staining levels, respectively. Best subset analysis revealed that the combination of p53 score and Rb score yielded the best predictive value for disease specific survival.

CONCLUSIONS

p53 and Rb immunohistochemical staining scores were independent predictors of disease specific survival and were superior to conventional pathological prognostic factors of the primary tumor. These findings lay the groundwork for the prospective study of these markers in patients treated with radical prostatectomy.

gamma-Glutamyl transpeptidase in normal and neoplastic prostate glands

gamma-Glutamyl transpeptidase (GGT) is a cytoplasmic membrane-bound enzyme important in the metabolism of glutathione and other gamma-glutamyl compounds. It is present in highest levels in the kidney and is also expressed prominently in reproductive organs such as the prostate gland. Because GGT has never been examined in prostatic carcinoma, we used a new polyclonal antibody (GGT 129) for immunohistochemical localization of GGT in normal prostate gland and 72 prostatic carcinomas. The normal lining secretory cells of ducts and acini showed apical immunoreactivity for GGT, but the basal epithelial cells were negative. Most of the prostatic adenocarcinomas had GGT staining patterns and intensity similar to those of normal prostatic secretory cells, because the majority of neoplastic cells showed immunopositivity in more than 80% of the adenocarcinomas. In comparing the percentage of cells staining for GGT with clinicopathologic parameters, there was no correlation between the number of positive cells and the Gleason score, the percentage of intraglandular carcinoma, capsule penetration, or seminal vesicle invasion. Immunostaining for GGT lacks value as a prognostic factor and does not correlate with standard clinicopathologic parameters. GGT may be important, however, for growth and maintenance of both normal and neoplastic prostatic cells. Modulating GGT levels or administering drugs that can be activated by GGT may have therapeutic value.

Effect of lactation on insulin signal transduction in sheep adipose tissue and skeletal muscle

The molecular basis of the insulin resistance of adipocytes and skeletal muscle during lactation has been investigated in sheep. The number of insulin receptors per adipocyte or per unit membrane protein for skeletal muscle is unchanged by lactation. The ability of insulin to stimulate autophosphorylation of its beta-subunit was enhanced in adipocytes but not in skeletal muscle during lactation. This increased autophosphorylation was due, at least in part, to enhanced tyrosine phosphorylation and was found when both solubilised, immunoprecipitated insulin receptors and intact adipocytes were incubated with insulin. The ability of the insulin receptor kinase to phosphorylate other proteins did not appear to be altered by lactation; this was shown with lectin-purified insulin receptors using the artificial substrate, polyglutamyl tyrosine, and in intact adipocytes. Lactation had no effect on the ability of insulin to activate two key downstream kinases, mitogen-activated protein kinase and phosphatidyl inositol-3-kinase in adipocytes. The study thus shows that the insulin resistance of lactation in sheep is due to changes downstream of the receptor in both adipocytes and skeletal muscle.

Ovarian granulosa cell tumors with bizarre nuclei: an immunohistochemical analysis with fluorescence in situ hybridization documenting trisomy 12 in the bizarre component [corrected]

Granulosa cell tumors with bizarre nuclei (GCT-BN) are rare lesions with a prognosis apparently similar to that of conventional granulosa cell tumors (GCT-NOS). The immunohistochemical features of GCT-BN have not been described, and the exact nature of the bizarre nuclei (BN) is unclear. Thirteen GCT-BN were studied with antibodies to cytokeratin, vimentin, epithelial membrane antigen, muscle-specific actin, alpha smooth muscle actin, desmin, and S-100 protein. Six cases were also examined by fluorescence in situ hybridization for trisomy 12, a nonrandom chromosomal aberration found in a proportion of ovarian sex-cord stromal tumors. Histologically, 12 tumors (86%) contained BN areas interspersed with large areas of GCT-NOS. The remaining tumor contained only microscopic foci of GCT-NOS. Immunohistochemically, the tumors stained for vimentin (13 tumors), S-100 protein (11 tumors), muscle-specific actin (10 tumors), cytokeratin (eight tumors), alpha smooth muscle actin (eight tumors), and desmin (one tumor), but none stained for epithelial membrane antigen. Immunostaining results for the BN and GCT-NOS areas were concordant in eight (73%) of the 11 tumors in which both areas could be independently assessed. The remaining three tumors (27%) showed discordant results for only one of the eight markers used. In five patients, trisomy 12 was detected by fluorescence in situ hybridization in areas of BN but not in areas of GCT-NOS present in the same tumor. Trisomy 12 was also present in another BN tumor in which the foci of GCT-NOS were too small to be evaluated. We conclude that within GCT-BN, areas with BN are immunohistochemically similar to areas of GCT-NOS present in the same tumor. The finding of trisomy 12 in areas with BN but not GCT-NOS in the same tumor, however, suggests that cells with BN represent a genetically distinct clone of tumor cells arising within GCT-NOS.

Neuroendocrine Tumors of the Head and Neck: A Selected Review with Emphasis on Terminology

Virtually every variant of neuroendocrine neoplasia can occur, at least rarely, in the head and neck region. This review focuses on the terminology surrounding neuroendocrine carcinomas of the larynx and their distinction from morphologically similar but biologically distinctive neoplasms. It is suggested that rare typical laryngeal carcinoids be labeled as such. There is little evidence that these lesions are part of a morphologic continuum. In contrast, more common "carcinoid-like" carcinomas, previously referred to as "atypical carcinoids" are more appropriately labeled as "moderately differentiated neuroendocrine carcinomas." These neoplasms should, in turn, be distinguished from "small cell neuroendocrine carcinomas," although these latter two neoplasms do represent a morphologic and behavioral spectrum. Light microscopic and immunohistochemical features distinguishing neuroendocrine carcinomas of the larynx from paraganglioma, metastatic medullary carcinoma, malignant melanoma, and basaloid squamous cell carcinoma are presented. The second portion of this review outlines the clinicopathologic features of two head and neck neoplasms exhibiting varying degrees of neuroendocrine differentiation. Olfactory neuroblastomas have well-developed neuroendocrine differentiation, almost invariably arise from the olfactory mucosa, typically exhibit low-grade cytologic features, and may have protracted clinical course with an approximately 50% overall 5-yr survival. In contrast, sinonasal undifferentiated carcinoma is a microscopically high-grade neoplasm with minimal, abortive neuroendocrine features, a highly aggressive clinical course, and virtually 100% mortality. They can arise throughout the sinonasal region.

Angiosarcoma-like neoplasms of epithelial organs: true endothelial tumors or variants of carcinoma?

Past experience has shown the existence of tumors in various viscera that assume growth patterns that are usually associated with angiosarcomas of skin and soft tissue. The lineage of differentiation pursued by the former of these proliferations has been the subject of controversy, with some investigators concluding that "angiosarcomatoid" neoplasms of solid organs were, in actuality, variants of high-grade carcinomas. The latter statement does appear to have partial validity, inasmuch as immunohistologic, ultrastructural, and clinical data on "pseudovascular carcinomas" do support their basic identity with high-grade epithelial malignancies of the breasts, skin, and lungs. Those lesions show uniform reactivity for keratin and epithelial membrane antigen, but they fail to express von Willebrand factor, CD31, or CD34, which are regarded as endothelial determinants. On the other hand, however, angiomatoid neoplasms of the thyroid gland are more complex; some represent indisputable carcinomas, others manifest seemingly "pure" mesenchymal phenotypes, and still others display a mixture of epithelial and endothelial phenotypes at ultrastructural and protein-chemical levels of specialized investigation. At present, it must be acknowledged that the distinction between angiomatoid thyroid carcinomas and "true" thyroid angiosarcomas is an academic one, because the prognoses and treatments for these lesions are essentially identical.

Sinonasal intestinal-type adenocarcinoma: immunohistochemical profile and comparison with colonic adenocarcinoma

Sinonasal intestinal-type adenocarcinomas (ITAC), as their name implies, bear a striking resemblance to primary intestinal neoplasia. The value and limitations of immunohistochemistry in making this distinction have not been previously defined. We determined the immunohistochemical staining profile of 12 sinonasal ITAC and compared their staining with that of 12 histologically similar colonic adenocarcinomas. All ITAC stained for cytokeratin and epithelial membrane antigen. Additional positive reactions were as follows: B72.3, 11 of 12; Ber EP4, 11 of 12; Leu M1, 8 of 12; HMFG-2, 12 of 12; and BRST-1, weak staining in seven of 12 cases. All 12 ITAC were negative for vimentin, synaptophysin, and actin. Colonic carcinomas stained similarly for these markers. Three additional antigens differed in their expression in ITAC versus colonic tumors. Carcinoembryonic antigen was strongly present in only two of 12 ITAC, with focal positivity in six of 12 and no staining in four of 12 cases. In contrast, all 12 colonic adenocarcinomas were strongly positive for carcinoembryonic antigen. Chromogranin-positive cells were present and often numerous in nine of 12 ITAC, in contrast to only rare positive cells in three of 12 colonic tumors. Neuron-specific enolase was present in five of 12 ITAC but was absent from all colonic tumors studied. ITAC are less often and less strongly carcinoembryonic-antigen positive and more prone to exhibit divergent neuroendocrine differentiation. These features may be of some value in distinguishing ITAC and colonic metastases. Neuroendocrine differentiation in ITAC was associated with higher mortality. Of the five patients with ITAC having 1+ to 2+ chromogranin positivity, only one was free of disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Tuberculosis infection in U.S. Air Force dentists

PURPOSE

To determine if U.S. Air Force dentists have a significantly higher prevalence of infection from M. tuberculosis than a similar no-dentist group.

MATERIALS AND METHODS

A written survey instrument was sent to all active duty Air Force dentists and lawyers. The survey asked individuals to voluntarily and anonymously give information regarding positive tuberculin skin testing which was subsequently treated with antituberculosis medication. Only positive responses which occurred during the time the respondent was practicing as a dentist or lawyer in the Air Force were counted. Significant exposures were considered to have occurred in those persons who were evaluated by a physician and actually put on a course of antituberculosis medication.

RESULTS

The dentists returned 82.7% of the 1256 surveys sent, of which 2.37% indicated a significant exposure. The lawyers returned 79.6% of 1321 surveys, of which 1.47% were positive for significant exposure. Chi-square analysis indicated no significant difference between the two groups (P = 0.14).

Colorectal carcinoma in patients 30 years of age and younger

Thirty-seven cases of colorectal cancer in patients aged 30 years or younger have been treated at the University of Virginia Health Sciences Center from 1957 through 1992. The present series, comprising patients treated from 1978 through 1992, updates a series presented from our institution comprising patients treated from 1957 through 1977. For the 36-year series, 24 patients (65%) were female, and 13 (35%) were male. Sixteen patients (43%) were black, and 21 patients (57%) were white. Sites of tumor and their frequency were rectosigmoid, 14 (38%), left colon, five (14%), splenic flexure, two (5%), transverse colon, three (9%), hepatic flexure, two (5%), right colon, two (5%), and cecum, six (16%). Twenty-two patients (59%) presented with abdominal pain, whereas 15 (41%) presented with hematochezia or hemoccult positive stools. The average time of onset of symptoms to diagnosis was 2.3 months. Thirty-four of 37 patients (92%) presented with advanced stage disease. Only four patients had precancerous conditions: one each with Gardner's Syndrome, Turcot's Syndrome, ulcerative colitis, and villous adenoma. Twenty-five patients (68%) underwent surgery for cure, and ten (27%) received palliative procedures. Nothing could be done for two patients (5%). Twenty-one patients (57%) had mucinous histology, 13 (35%) had typical adenocarcinoma, one (3%) had small cell carcinoma, and histology was unavailable in two (6%). Nodes were negative in only 10 (27%) patients, of which only three had mucinous histology. There have been five 5-year survivors and three patients alive and disease free at last follow up, ranging from 30 months to 48 months.(ABSTRACT TRUNCATED AT 250 WORDS)