Immunoreactivity of a new CD5 antibody with normal epithelium and malignant tumors including thymic carcinoma

CD5, first recognized on subsets of lymphocytes, also is detected in thymic carcinoma but not in thymoma or other malignant tumors. We studied CD5 expression in 73 cases of malignant tumors of various organs, 22 cases of thymoma, and 7 cases of thymic carcinoma by immunohistochemistry using the new monoclonal anti-CD5 antibody, NCL-CD5-4C7, with a pressure cooker antigen retrieval method. All cases of thymic carcinoma showed positive staining for CD5, predominantly on the cell membrane. Two of 4 cases of atypical thymoma also showed focal positivity, whereas the other types of thymoma were negative. CD5 was detected in cases of malignant tumors other than squamous cell carcinoma and in the normal epithelium of their counterparts. Squamous cell carcinomas of various organs were negative for CD5. Malignant mesothelioma showed peculiar intracytoplasmic staining in contrast to the other tumors. The NCL-CD5-4C7 positivity in thymic epithelial tumors may support the hypothesis suggesting progression of atypical thymoma to thymic carcinoma. NCL-CD5-4C7 may be useful in the differential diagnosis of mediastinal tumors, especially between thymic carcinoma and metastatic squamous cell carcinoma of various primary sites, and for distinguishing malignant mesothelioma from adenocarcinoma of the lung by the different staining pattern.

Primary carcinomas of the thymus gland

Carcinomas of the thymus are now well recognized as distinctive but rare entities, and several clinicopathologic variants of such neoplasms have been described. These include keratinizing squamous cell carcinoma, nonkeratinizing squamous cell carcinoma, lymphoepithelioma-like carcinoma, neuroendocrine carcinoma, adenosquamous carcinoma, mucoepidermoid carcinoma, clear-cell carcinoma, papillary adenocarcinoma, adenocarcinoma not otherwise specified, basaloid carcinoma, and sarcomatoid carcinoma. The application of electron microscopy, immunohistology, and other adjunctive pathological techniques is effective in refining the differential diagnosis between primary thymic carcinoma (PTC) and several other histological simulators. However, the distinction between PTC and carcinomas that involve the thymic region by metastasis from other sites is a difficult one, and ultimately must be predicated on detailed clinical and radiographic information. Well-differentiated squamous carcinoma, low-grade mucoepidermoid carcinoma, and basaloid carcinoma of the thymus usually are associated with a favorable prognosis, but other variants are aggressive and require multimodality treatment approaches.

Postoperative radiotherapy for stage I thymoma: a prospective randomized trial in 29 cases

OBJECTIVE

To determine the effect of postoperative radiotherapy on stage I thymoma.

METHODS

Twenty-nine patients with stage I thymoma younger than 65 years, treated between August 1981 and January 1996 were included in this study. All patients were randomly assigned into two groups: surgery alone (13 patients) and surgery with postoperative radiotherapy (16). Staging was based on the surgical and pathologic criteria that the tumor had a complete capsule and without capsular invasion microscopically. Adjuvant radiotherapy was started within 4 weeks after surgery. Megavolage radiation, using the isocentric technique, was administered through an anterior field and/or two anterior oblique wedge fields. For the patients with lymphocytic predominant type, the dose was 50 Gy in 25 daily fractions for 5 weeks; for the patients with epithelial cell type or mixed type, the dose was 60 Gy in 30 daily fractions for 6 weeks. The survival rates were estimated by the Kaplan-Meier method.

RESULTS

There was no recurrence and metastasis in either group. No acute and late radiological injuries were found among the patients receiving radiotherapy postoperatively. The 5-year and 10-year survivals were both 92% for the patients treated by surgery alone. However, the survival rates for patients who received radiotherapy were both 88%. There was no difference in the survivals in these two groups. Of the 3 died patients, 1 died of myasthenia gravis and 2 of intercurrent illness. No significant correlation was found between myasthenia gravis and radiotherapy.

CONCLUSIONS

Postoperative radiotherapy is unnecessary for the patients with stage I thymoma. No relation is found between radiotherapy and myasthenia gravis.

Endobronchial brachytherapy for recurrent thymoma showing endobronchial polypoid growth

The authors report a case of recurrent thymoma displaying endobronchial polypoid growth. Initially, the patient had invasive thymoma with intracaval growth into the right atrium. He was treated with multimodality therapy consisting of chemotherapy, surgical resection, and radiotherapy (50.4 Gy). Both 3 years and 6 years after the initial treatment, the tumor recurred outside the reconstructed superior vena cava. The patient was treated with repeated radiotherapy (50.4 Gy and 40 Gy), and remission was achieved. Eight years after the first therapy, an endobronchial polypoid lesion was detected in the right upper lobe bronchus and was histologically found to be thymoma. Endobronchial high-dose rate brachytherapy (20 Gy at 3 mm/5 fractions) was carried out for palliation because the recurrent tumor occurred outside of the superior vena cava area, which had been reirradiated. After the treatment, the endobronchial tumor shrunk remarkably in size without adverse effects. No tumor regrowth has been noted after a follow-up of 10 months.

Mediastinal B-cell lymphoma: a study of its histomorphologic spectrum based on 109 cases

Mediastinal B-cell lymphoma (MBL) is a distinct variant of aggressive non-Hodgkin's lymphoma with characteristic clinical and biological features but less well-defined histomorphology. We reevaluated 124 biopsy specimens from 109 MBL patients of an Italian/French/German retrospective clinical study. MBL was primarily diagnosed on clinical and histological grounds in conjunction with the detection of CD20 expression by immunohistology. Cytologically, MBL features limited intralesional but considerable interindividual cytological diversity, ranging from medium-sized to very large, atypical cells. Sclerosis and necrosis are restricted to extrathymic and extranodal sites of involvement, predominantly the lung, as is angioinvasion, which predominantly affects larger vessels. The medium-sized and the large cell variants resemble marginal zone lymphoma variants, whereas the very large cell variant of MBL has not so far been found to have any extramediastinal counterpart. We conclude that MBL displays a broad morphological spectrum covering more than is implied by the term "diffuse large cell lymphoma." Because statistical analysis of cytological and histological criteria failed to correlate with prognosis in this comprehensive group of patients, we think it inadvisable further to subclassify MBL.

Primary neuroendocrine carcinomas of the thymus

Primary neuroendocrine carcinomas of the thymus are rare and comprise a wide spectrum of lesions ranging from well-differentiated to poorly-differentiated neoplasms. The classification of such tumors in the thymus is still controversial. By convention, the better-differentiated examples have been traditionally designated as thymic carcinoids and thought to represent the mediastinal counterpart of carcinoid tumors in other foregut locations. However, recent studies have shown that such neoplasms, when arising in the thymus, exhibit a much more aggressive behavior than those originating at other locations. We therefore consider these lesions to represent fully malignant neoplasms that fall within the spectrum of neuroendocrine carcinomas. The designation of well-, moderately-, or poorly-differentiated thymic neuroendocrine carcinoma is therefore favored for these tumors in the present review. Because such tumors may often adopt unusual morphological appearances, it is important to distinguish them from other more common conditions presenting at this location that may exhibit similar histological features. The clinicopathologic, immunohistochemical, and differential diagnostic features of these tumors in the mediastinum are discussed.

Hypermethylation of the cell cycle inhibitor p15INK4b 3'-untranslated region interferes with its transcriptional regulation in primary lymphomas

The cyclin-dependent kinase inhibitor p15INK4b has been shown to be involved in human and rodent tumors and seems to act as a tumor suppressor gene in hematological malignancies. Alterations of this gene in tumors include mainly homozygous deletions and hypermethylation of the CpG island in the promoter region. In this work, we describe a new area sensitive to methylation in the 3' untranslated region (UTR) of the murine p15INK4b gene. This region shows different levels of methylation depending on the tissues, being relatively highly methylated in brain and gut, and weakly methylated in liver, spleen or thymus. DNA methylation and expression is similar in both maternal and paternal alleles indicating no imprinting effect. Although methylation of the p15INK4b 3'-UTR is low in normal thymus, increased levels (up to 100%) of specific methylation in this region are found in up to 30% of radiation- or carcinogen-induced thymic lymphomas, correlating with decreased gene expression. Hypermethylation of the p15INK4b 3'-UTR frequently occurs in tumors with loss of heterozygosity (LOH) but without methylation of the promoter CpG island or intragenic mutations. Furthermore, in vitro CpG methylation of the 3'-UTR produces reduced levels of a luciferase reporter in cultured cells. Methylation of two CpG sites in a 120 bp region is sufficient to interfere with transcription of the reporter gene. These data suggest that although the levels of p15INK4b in normal tissues can be mainly determined by promoter regulatory elements, strong hypermethylation of the 3'-UTR can interfere with transcription. Thus, hypermethylation of the 3'-UTR may explain the lack of p15INK4b gene expression in a subset of tumors with no promoter methylation and could be a new alternative mechanism for tumor suppressor gene inactivation in tumorigenesis.

Somatostatin receptor scintigraphy and somatostatin therapy in the evaluation and treatment of malignant thymoma

PURPOSE

This report illustrates the potential diagnostic and therapeutic utility of somatostatin receptor scintigraphy and therapy with somatostatin.

METHODS

In-111 pentetreotide (In-111 octreotide), a somatostatin analog, was used to define the receptor status and the extent of disease in a case of malignant thymoma.

RESULTS

Subsequent treatment with nonradioactive somatostatin inhibited tumor growth.

CONCLUSION

In-111 octreotide may be useful to define tumor receptor status and may provide prognostic information useful in determining subsequent therapy.

Two cases of repeatedly recurrent atypical thymoma

Two cases of repeatedly recurrent thymoma with myasthenia gravis are detailed here. A 41-year-old woman had 5 recurrent thymomas, including local recurrences and lumbar and lung metastases; she was alive at the time of this writing, which was 22 years after her first surgery. A 36-year-old man had 3 recurrent thymomas, including local recurrence, dissemination, and lung metastasis; he was alive at the time of this writing, which was 16 years after his first surgery. Both recurrent lesions were diagnosed as "atypical thymoma" with moderate nuclear atypia. The patients with atypical thymoma must be followed up carefully due to a possible recurrence. Surgical treatment with chemoradiotherapy can lengthen their survival.

[A case of thymoma: histological and diagnostic aspects and surgical considerations]

The histological and diagnostic features of a thymoma case observed recently have been investigated in the present study. Comparing the case under investigation with the literature, the Authors conclude that the proper surgical approach is that indicated by Jaretsky. By means of a longitudinal sternotomy associated with minimal cervical incision, the whole mediastinal cellular tissue together with that of the thyroid inferior poles is easily removed. Moreover oncological and myastenic recurrences have a very low incidence in cases surgically treated with this procedure.

Bursting metastasis in thymic carcinoma

Thymic carcinomas (primitive malignant epithelial neoplasms of the thymus) are rare tumors which generally remain silent for long periods and rarely metastatize outside the chest. The authors present a case of a 49 year-old patient, with mediastinal mass complicated by pericardial effusion and rapidly extensive liver metastasis. Data in the literature indicate that completeness of the excision at initial operation is the most important prognostic factor, but the presence of necrosis, high number of mitosis and endolymphatic emboli in the specimens could indicate a poor prognosis, suggesting a tempestive treatment and a close follow-up.

Two cases of synchronous multiple thymoma

We report two cases of synchronous double primary thymoma without myasthenia gravis. These cases suggest the possibility of multicentric thymoma and confirm the validity of a complete thymectomy.

Thymic neuroendocrine tumor (thymic carcinoid): a clinicopathologic study in 15 patients

BACKGROUND

Thymic neuroendocrine tumor (carcinoid tumor) is rare, and prognosis for patients with this tumor has been difficult to predict.

METHODS

The medical records of 15 patients were reviewed, and the patients were classified according to tentative TNM classification and histologic grade.

RESULTS

Ten (66.7%) of 15 patients were male. Lymph node metastases were identified in 9 (60%) of 15 patients at the time of resection. There were one grade 1, nine grade 2, and five grade 3 tumors. Total resection was possible in 13 patients. Distant metastases developed in 10 (76.9%) of these 13 patients, although no local recurrence developed. Of these 10 patients, 6 died of distant metastases 5 to 25 months after the recurrence. Three patients are still alive, with metastases to the bone, spleen, and pleura 1 to 24 months after the diagnosis of recurrence. Two patients are presently tumor free (T1N0, grade 3 and T3N2, grade 2), but only 1 has survived beyond 5 years.

CONCLUSIONS

Thymic neuroendocrine tumor must be regarded as a malignant neoplasm that is prone to metastasize to mediastinal lymph nodes and to distant sites, even after total excision. Neither T and N classification nor histologic grade has been successful in predicting the outcome of a patient with this tumor. More aggressive management, including adjuvant therapies and reexcision of subsequent tumors, may result in increased survival.

Neoplasia of the respiratory tract

Tumors of the equine respiratory tract occur infrequently. An accurate diagnosis of neoplasia of the respiratory tract is critical because the prognosis is usually grave. The clinical signs and diagnostic procedures are discussed for tumors of the nasal and paranasal sinuses, nasopharynx/larynx, guttural pouch and thorax including lung, pleura, and thymus.

Strontium-89 (89Sr) analgesia for rare thymic carcinoid tumor with bony metastases

The authors report the cases of two patients in whom strontium-89 (89Sr) was used to relieve diffuse metastatic bone pain. The type of cancer involved, thymic carcinoid tumor, is itself rare and the risk of its metastasizing to the bone is very low. Both patients showed a measure of response to treatment, suggesting that this analgesic method has value for some patients. The marked benefit of one patient for a total of 9 months was attributable to two 89Sr injections, whereas the other patient improved for only 5 weeks after one injection.

[Metastatic lung tumor developing 15 years after resection of invasive thymoma]

A 57-year-old man with myasthenia gravis had undergone extended thymothymomectomy for invasive thymoma and postoperative irradiation 15 years ago. At present, an abnormal shadow on his left lung field on chest X-ray and an elevated SCC-Ag level led us to suspect primary lung cancer (squamous cell lung cancer). He underwent left lower lobectomy and partial resection of the upper lobe. After the operation, this tumor was identified pathologically as a thymoma. Comparing this tumor with the previous invasive thymoma, we concluded that the present lesion was a metastasis of the former thymoma. This case suggests that a metastatic lung tumor should be suspected when an abnormal shadow is detected on chest X-ray following extended thymothymomectomy for invasive thymoma.

Infantile hemangioendothelioma of the thymus with massive pleural effusion and Kasabach--Merritt syndrome: histopathological, flow cytometrical analysis of the tumor

Infantile hemangioendothelioma of the thymus is a rare disease. We describe a patient who developed a large anterior mediastinal mass, severe thrombocytopenia and massive pleural effusion at 1 month of age. Glucocorticosteroid and irradiation therapy had no effect on either the tumor size or clinical symptoms and the tumor was resected subtotally. Three months after the subtotal resection, the remaining tumor had almost disappeared and the symptoms had resolved. The patient has now been well for 1 year after surgery without evidence of recurrence. The tumor tissue was characterized by prominent vascular endothelial proliferation intermixed with a normal thymic structure, producing a picture consistent with that of an infantile hemangioendothelioma in the thymus. Immunohistochemically, the tumor cells showed positive staining for vimentin, factor VIII and CD34. The DNA stemline and proliferative activity were examined by flow cytometry, which revealed a diploid stemline with a low growth fraction. DNA content and cell cycle analyses of the tumor tissue may be useful for predicting the biological behavior of the tumor.

Thymic carcinoma arising in thymoma is associated with alterations in immunohistochemical profile

Thymic carcinoma is an uncommon tumor. Most cases appear to arise de novo, but in rare instances they can arise in thymomas. We report the clinicopathologic features and immunohistochemical profile of five cases of thymic carcinoma accompanied by a component of thymoma. Immunohistochemical studies were performed with the avidin-biotin-peroxidase complex method using monoclonal antibodies to p53(DO7), CD99(O13), epithelial membrane antigen, CD5(NCL-CD5-4C7), vimentin (V9), and cytokeratins 7, 8, 18, and 19. The patients consisted of three men and two women with a median age of 57 years. One patient had myasthenia gravis, and the other four presented with chest symptoms. One patient had concurrent adenocarcinoma of the lung with metastasis. Four of the patients died within 15 months. The thymomas consisted of two large polygonal cell thymomas, two squamoid thymomas, and one spindle cell thymoma. The malignant components included two undifferentiated carcinomas, one spindle cell carcinoma, one squamous cell carcinoma, and one clear cell carcinoma with squamous differentiation. There was no correlation between the histologic types of the thymoma and the thymic carcinoma. In three cases, excluding the two squamoid thymomas, the thymic carcinomas occurred in the necrotic areas of the thymoma. They showed upregulated expression of epithelial membrane antigen and cytokeratins 7, 8, 18, and 19, similar to the so-called "interface phenomenon" described in the invasion front of other types of carcinoma. Increased p53 protein expression was observed in all five carcinomas, and there was loss of CD99+ immature T lymphocytes. Among the thymic carcinomas, only the squamous component of the clear-cell carcinoma stained for CD5, a marker commonly expressed in thymic carcinomas. Paradoxically, a squamoid thymoma, but not its associated spindle cell carcinoma, expressed CD5, suggesting the acquisition of an "aggressive" phenotype by the squamoid thymoma, but with loss of the marker on malignant transformation. One undifferentiated carcinoma acquired vimentin immunoreactivity, whereas four other carcinomas and all five thymomas were negative. In conclusion, thymic carcinoma can arise in any histologic type of thymoma, including spindle cell thymoma, which is generally regarded as a benign neoplasm. The prognosis appears to be poor. Tumor necrosis in a thymoma should alert the pathologist to search for malignant change. The malignant change is commonly associated with increased expression of epithelial membrane antigen, cytokeratin subtypes, or p53 protein, and loss of CD99+ immature T lymphocytes, and is occasionally associated with a change in the expression of CD5 or vimentin.

Recurrence of stage I thymoma 32 years after total excision

Malignant thymomas are invasive and recur frequently, but noninvasive thymomas rarely do so. We report on a case of recurrent thymoma in a 50-year-old white man, 32 years after total excision of a stage I thymoma. We stress the importance of long-term follow-up in all patients.

Radioresponse of thymomas verified with histologic response

Patterns of radiologic response of 10 thymomas treated by preoperative radiotherapy (RT) (18-20 Gy/2 weeks) were determined in conjunction with histologic response. Changes in tumor volume were evaluated with CT scans obtained 5 to 36 days before and 14 to 24 days after the initiation of RT and before surgery. The extent of tumor volume reduction (TR) varied widely (40-78%), while the mean daily volume decrement expressed as a percentage of the pre-RT tumor volume correlated significantly with the pre-RT tumor volume. Histologically, the tumors, all of which were resected 17 to 33 days after RT initiation, generally consisted of predominant fibrous tissues, rare necrotic foci, and few epithelial cells. The TR did not correlate with pre-RT tumor volume, observation period, histologic subtype, or quantity of remaining epithelial cells. The TR of thymomas does not predict RT impact on tumor cells but does reflect the quantity of inherent tumor stroma.

Unusual presentation of mycosis fungoides as pigmented purpura with malignant thymoma

Thymoma is known to be associated with many lymphoreticular and nonlymphoreticular tumors. A woman who presented with patch stage mycosis fungoides with skin lesions resembling a pigmented purpura was found to have an anterior mediastinal mass on routine staging evaluation. A core needle biopsy of the mass revealed a lymphocyte predominant malignant thymoma. Review of the literature reveals many diseases with dermatologic manifestations associated with thymoma; however, malignant thymoma coexisting with mycosis fungoides has not previously been reported.

[A case of adenocarcinoma of the thymus]

We report an adenocarcinoma of the thymus in a 39-year-old male. The patient presented with chest pain, and the chest X-ray film and chest CT showed an abnormal mass in the mediastinum. A preoperative clinical diagnosis of invasive thymoma was suspected. The tumor was resected along with the pleura and pericardium. The pathological findings were compatible with those of adenocarcinoma of the thymus. Despite a thorough examination, no primary tumor could be found. An adenocarcinoma of the thymus is rare and to the authors knowledge there are few previous reports in the literature.

Mechanism of catecholamine-mediated destabilization of messenger RNA encoding Thy-1 protein in T-lineage cells

The Ig superfamily cell surface glycoprotein Thy-1 expressed on immune cells and neurons of rodents and humans is hypothesized to function in cell adhesion and signal transduction in T cell differentiation, proliferation, and apoptosis. This study analyzes effects of cAMP and catecholamines on transcriptional Thy-1 gene expression. Incubation of murine thymocytes or S49 mouse thymoma cells with dibutyryl-cAMP, 8-bromo-cAMP, cholera toxin, norepinephrine, or isoproterenol caused time- and concentration-dependent decreases in levels of Thy-1 mRNA assayed by Northern hybridization or T2 nuclease protection. After 4 h of treatment with 500 microM dibutyryl-cAMP or 8-bromo-cAMP, 1 nM cholera toxin, 100 microM norepinephrine, or 100 microM isoproterenol, Thy-1 mRNA levels were 60 to 96% lower than those of controls. Norepinephrine-mediated decreases in Thy-1 mRNA levels were prevented by the beta-adrenergic receptor antagonist propranolol (10 microM). Dibutyryl-cAMP and norepinephrine decreased the apparent half-life of S49 cell Thy-1 mRNA from >>6 h to 2 to 3 h, whereas nuclear run-on assays showed no cAMP or norepinephrine effect on de novo transcription of the Thy-1 gene. In mutant S49 cells lacking cAMP-dependent protein kinase A, neither dibutyryl cAMP nor norepinephrine affected Thy-1 mRNA levels. These observations show that exogenous cAMP and norepinephrine can induce decreases in steady state Thy-1 mRNA levels in T-lineage cells through posttranscriptional destabilization of Thy-1 mRNA, associated with protein kinase A-mediated protein phosphorylation. Catecholamine-mediated beta-adrenergic protein kinase A-dependent Thy-1 mRNA destabilization may be an example of a more general mRNA decay system regulating cellular responses to stress.