Asymptomatic glucagonoma presenting with an isolated hepatic nodule

A 37-year-old male patient, without any particular symptoms apart from moderate right upper quadrant postprandial pain, was found to have a liver mass identified as a glucagon-producing tumor. Plasma glucagon levels were slightly increased, whereas those of other gut peptides were within the normal range. Despite an extensive pre- and intraoperative diagnostic work-up, a presumed primary glucagonoma remained undetected. This unusual presentation with the absence of any symptoms typical of glucagonoma, as well as the presence of histopathological features characteristic of both benign and malignant forms of glucagonoma, make this case very peculiar. A clinically silent, apparently unrelated adenocarcinoma of the left colon was also found. The concomitant presence of a glucagonoma and a carcinoma of the large intestine has not been previously reported, and its significance remains unclear.

Multiple synchronous lung cancers and atypical adenomatous hyperplasia in Li-Fraumeni syndrome

AIM

We report a patient with Li-Fraumeni syndrome who developed multiple synchronous primary lung cancers together with atypical adenomatous hyperplasia, and discuss the pathogenesis of the lesions.

CASE DETAILS

A 57-year-old woman with Li-Fraumeni syndrome and a history of smoking was diagnosed as having multiple synchronous primary lung tumours, all of which were treated by surgical excision. Histological examination showed three separate well-differentiated adenocarcinomas and a single focus of atypical adenomatous hyperplasia. A constitutional mutation of the p53 gene had been identified, both in this patient and other members of her family.

CONCLUSION

Multiple synchronous primary lung tumours have not been reported before in association with this syndrome. With both smoking and Li-Fraumeni syndrome known to be associated with mutations in the p53 gene, a cumulative effect is suggested in this patient.

P53 protein immunohistochemical expression in colonic adenomas with and without associated carcinoma

OBJECTIVES

P53 protein immunohistochemical (IHC) expression was investigated in a series of colonic adenomas and carcinomas to determine the p53 immunohistochemical expression of adenomas in general compared with carcinomas, the difference in staining pattern between adenomas with associated carcinoma and those without associated carcinoma, and the difference in p53 staining in the usual adenomas (low-grade dysplasia) compared with those harboring high-grade dysplasia.

METHODS

The study involved a series of 20 adenomas without concurrent carcinoma (group 1 adenoma), 29 adenomas with concurrent carcinoma (group 2 adenoma), and 20 carcinomas. Sections of the paraffin-embedded tissues were stained with DO-7 p53 monoclonal antibody after microwave antigen-retrieval method. Cases with nuclear staining in > or = 20% of the tumor cells were considered positive.

RESULTS

Analysis of results showed that 65% of carcinomas and 37% of all adenomas were reactive with p53 IHC staining (p = 0.03). With respect to the adenomas, 30% of group 1 and 41% of group 2 adenomas were reactive for p53 protein (p = 0.42).

CONCLUSIONS

Our data demonstrate a statistically significant higher p53 expression rate in colonic carcinomas than in adenomas, and that adenomas with concurrent carcinomas are more frequently p53 positive than those without concurrent carcinoma, but this was not statistically significant. Also, p53 expression is more frequent and intense in adenomas with high-grade dysplasia (10/20, 50%) than in ordinary adenomas with low-grade dysplasia (8/29, 28%), which suggests a strong correlation between the degree of dysplasia in colonic neoplasia and p53 expression pattern.

A cutaneous case of giant cell angiofibroma occurring with dermatofibrosarcoma protuberans and showing bimodal CD34+ fibroblastic and FXIIIa+ histiocytic immunophenotype

Dei Tos and colleagues in 1995 reported a series of seven distinctive orbital tumors in adults which they named giant cell angiofibroma (GCA). The morphologic features are intermediate between giant cell fibroblastoma and solitary fibrous tumor with a richly vascularized, patternless spindle cell proliferation forming a collagenous or myxoid stroma with pseudovascular angiectoid spaces. The spindled tumor cells have large, rounded nuclei, sometimes with complex folded shape and pseudoinclusions. There also are multi- or mononuclear giant cells, and these tumor cells partly line so-called angiectoid spaces. Cells express human progenitor cell antigen CD34 and vimentin. One case in the buccinator fascia was also noted by the authors, but similar cutaneous lesions are thus far unknown. We report our experience with a polypoid tumor that ocurred on the thigh of a 49-year-old woman that conforms to the description of GCA. The tumor has variegated vessels admixed with patternless spindle and giant cell stroma with angiectoid spaces as well as areas of dermatofibrosarcoma protuberans (DFSP). Most tumor cells express vimentin and CD34, including giant and spindle cells lining angiectoid spaces. Focally up to 40% of the lesional cells express coagulation factor XIIIa with histiocytoid to highly dendritic cytosomes. The DFSP component is composed of admixed CD34+ and FXIIIa+ dendritic cells arranged in a storiform pattern. Tumor cells are negative for actin, desmin, S-100, and cytokeratin. The Ki67 proliferation index is 1% in GCA areas and 3% in DFSP areas; Ki 67 stains mainly fibroblasts. We conclude that this cutaneous GCA is a fibrohistiocytic tumor closely related to and representing a more organoid angioformative analog of GCF, with both being related histogenetically also to DFSP. These lesions represent part of a greater spectrum of fibrovascular tissue patterns, all probably derived from proliferations of interactive microvascular CD34+ fibroblasts and FXIIIa+ histiocytes.

Is steroid receptor profile in contralateral breast cancer a marker of independence of the corresponding primary tumour?

We compared oestrogen receptor (ER) and progesterone receptor (PgR) profiles between primary and corresponding contralateral breast cancer (CBC) to investigate whether CBC should be considered relapse of a primary or as a feature of the multicentric origin of breast cancer. We adjusted for patient age, menopausal status, histology and adjuvant therapy. In spite of the general application of a cut-off value to dichotomise ER and PgR, we considered them as continuous variables. Moreover, we considered as synchronous cancers only simultaneously occurring lesions. For 399 patients, ER and PgR receptor levels in primary and CBC did not differ significantly, but were significantly correlated within the same patient. The correlation was higher for synchronous than for metachronous lesions when considering ER, but not PgR. The correlation between ER and PgR levels in the same tumour (primary or CBC) appeared stronger than the correlation of either receptor type (ER or PgR) between primary and CBC. Age, histology and adjuvant treatment affected ER concentration, whereas age, menopausal status and histology affected PgR concentration. The analysis indicated that primary and CBC tend to be characterised by a similar steroid receptor profile. The finding may support the hypothesis of CBC as a second primary arising in a common predisposing milieu, rather than a primary-dependent contralateral lesion. In this light, the clinical management of patients with a bilateral breast cancer should be similar to that of a unilateral breast cancer.

Immunohistochemistry of p53 in sinonasal inverted papilloma and associated squamous cell carcinoma

Gene mutation of p53 is documented in head and neck cancer. No reports exist relating human sinonasal inverted papilloma (IP) and its transformation to squamous cell carcinoma (SCC). Using immunohistochemical techniques improved by an antigen retrieval method, p53 protein was analyzed in the following subjects: 16 IP, 12 SCC arising in IP, and 15 SCC alone subjects. Both the intensity (PI) and rate (PR) of positive p53 immunostaining were evaluated using a quantitative AutoCAD program. We correlated p53 protein expression with clinical features. p53 immunoreactivity is significantly lower in IP than in SCC specimens. Both the IP and SCC portions of IP synchronous SCC subjects showed similar p53 protein expression. SCC arising in IP shows a lower p53 immunoreactivity than SCC alone. Alteration of p53 protein may have an important role in the early stages of IP malignant transformation and prove a potential biomarker for risk assessment. Low p53 immunoreactivity, indicating the presence of a wild-type p53, may correlate with the prognosis for SCC arising in IP. However, further clinical trials are required to investigate this possibly worthwhile prognostic marker.

Clinicopathologic study of multiple primary superficial carcinoma of the esophagus

Endoscopic examination with iodine staining has led to the easy detection of multiple superficial esophageal carcinoma (MSEC). The purpose of this study was to better understand the characteristics of MSEC. Of 49 patients with multiple esophageal carcinomas, 19 had superficial carcinoma. Multiple esophageal carcinomas were more often found in superficial carcinomas (31.1%) than in advanced carcinomas (14.4%). Comparing the depth of invasion of multiple esophageal carcinomas, the secondary lesions represented relatively early stages. Ki-67-positive cells were seen significantly more frequently in the main lesion of MSEC than in the secondary lesions, but proliferating cell nuclear antigen positivity and p53 expression did not differ significantly. Since multiple carcinoma occurs more frequently, care should be taken to look for small secondary lesions when treating superficial esophageal carcinoma. Ki-67 immunohistochemistry suggested that tumor cells proliferate more slowly in secondary lesions than in main lesions of MSEC.

Prognostic markers of intravesical bacillus Calmette-Guérin therapy for multiple, high-grade, stage T1 bladder cancers

BACKGROUND

Prediction of a response to intravesical bacillus Calmette-Guérin (BCG) therapy for bladder cancer is clinically important. We determined whether several molecular markers have prognostic value in intravesical BCG therapy for multiple, high-grade, stage T1 bladder cancers.

METHODS

The expressions of p53 (clone D07), bcl-2 (100-D5), cathepsin-D (C5), c-myc(9E11), c-erbB-2 (CB11) and Ki-67 (MM1) were determined by immunohistochemistry in paraffin-embedded tissues from 32 multiple, T1, grade II-III bladder cancer patients (15 BCG responders, 17 nonresponders) who had undergone a single course of BCG therapy (Pasteur strain, 5 x 10(8) CFU weekly for 6 weeks) after complete removal of the tumors. The association between the expression of these markers and the response to BCG was assessed by univariate and multivariate analyses.

RESULTS

There was no difference in patient and tumor characteristics between the 2 groups. Using multivariate analysis, the only useful marker was p53, with the overexpression of the p53 protein inversely related to the response to BCG therapy (P = 0.0182).

CONCLUSION

Our results suggest that the status of p53 expression offers significant clinical information and may be a useful tool in the selection of suitable candidates for BCG therapy in multiple, high-grade stage T1 bladder cancer patients.

Trichoepithelioma with an adjacent basal cell carcinoma, transformation or collision?

Trichoepitheliomas (TEs) are benign follicular neoplasms that can be difficult to separate histologically from basal cell carcinomas (BCCs). It is important to make this distinction, because the treatments and prognoses differ for the two lesions. Previous reports have employed both histologic and immunohistochemical data in order to separate these two lesions. It is believed that transformation from a TE to a BCC is a rare event. We describe a case in which a single lesion with features of TE and BCC is present in a patient with multiple lesions of BCC.

Double adenomas with different pathological and hormonal features in the left adrenal gland of a patient with Cushing's syndrome

We report a 52-year-old women with Cushing's syndrome who presented with two adenomas in the left adrenal gland. One tumour appeared dark brown and the other appeared yellow on the cut surface. The non-neoplastic adrenal demonstrated marked cortical atrophy. Upon histological examination, the brown tumour was found to be composed of both compact and clear cells. In contrast, the yellow tumour was composed of clear cells associated with pseudoglandular formation and marked degeneration. Immunohistochemical studies demonstrated positive immunostaining of cytochrome P-450 specific for 17 alpha-hydroxylation (P-450c17) in the brown but not the yellow tumour. Other steroidogenic enzymes except for dehydroepiandrosterone sulphotransferase were detected in both tumours. The biochemical activities of 21-hydroxylase, 17-hydroxylase and 11 beta-hydroxylase in the brown tumour (6.10 nmol/mg protein/4 minutes, 1.87 nmol/mg protein/2 minutes and 5.71 mumol 11-OHCS formed/g protein/10 minutes, respectively) were much greater than those in the yellow tumour. Gel-supported three-dimensional native-state primary culture of the tumours demonstrated a much higher concentration of cortisol in the culture medium for the brown tumour (5750 nmol/l on 4th day). Vimentin expression was detected in both tumours but cytokeratin expression was detected only in the yellow tumour. The Ki67 labelling index in the brown tumour was greater than that in the yellow tumour. These results indicated that these two adenomas had different biological characteristics and the brown tumour was primarily involved in over-production of cortisol in this patient. When analysing unilateral multiple adrenocortical lesions, approaches using immunohistochemical studies for steroidogenic enzymes, enzyme activity assays and cell culture can help to define the steroidogenesis of individual adrenocortical lesions.

Field cancerisation and polyclonal p53 mutation in the upper aero-digestive tract

Field cancerisation of the aerodigestive tract is caused by chronic exposure to alcohol and tobacco, but the nature of the genetic alterations preceding overt malignancy is unknown. To identify potential field changes we have used a functional assay which tests the transcriptional competence of human p53 expressed in yeast. To increase the sensitivity and reliability of the technique for samples containing under 20% mutant p53, the 5' and 3'-ends of the p53 cDNA were examined separately. With this split form of the assay the tissue p53 mRNA acts as its own control for RNA quality. Mutations were detected in 87% (46/53) of tumours, reflecting the high sensitivity of the technique. Multiple biopsies of histologically normal tissue from the upper aero-digestive tract were tested and clonal p53 mutations were identified in 76% (38/50) of biopsies from patients presenting with multiple tumours compared with 32% (38/117) of biopsies from patients presenting with single tumours (P<0.000001). All patients (16/16) presenting with multiple tumours had at least one positive biopsy, compared with only 53% (19/36) of patients presenting with single tumours (P <0.001). This defines expansion of multiple clones of mutant p53-containing cells as an important biological mechanism of field cancerisation, and provides a means to identify patients likely to benefit from intensive screening for the development of new head and neck tumours.

Expression of high-affinity 67-kDa laminin receptors in primary breast cancers and metachronous metastatic lesions or contralateral cancers

The presence of high-affinity 67-kDa laminin receptors, detected immunohistochemically, was determined on 63 primary breast cancers and on metachronous metastatic lesions or contralateral cancers from the same patients. A disagreement was observed in two-thirds of the cases. In particular, laminin receptor content was significantly lower (P = 0.02) in local recurrences and slightly higher in lymph node metastasis than in the corresponding primary tumours.

Concurrent overexpression of cyclin D1 and cyclin-dependent kinase 4 (Cdk4) in intestinal adenomas from multiple intestinal neoplasia (Min) mice and human familial adenomatous polyposis patients

We postulated that increased expression of the cell cycle regulators cyclin D1 and cyclin-dependent kinase (Cdk) 4 may be involved in the development of intestinal adenomas associated with familial adenomatous polyposis (FAP). In the present study of multiple intestinal neoplasia (Min) mice and human FAP patients, the expression and distribution of cyclin D1, Cdk4, and cell proliferative activity (5-bromo-2'-deoxyuridine incorporation) in normal and adenomatous intestinal epithelium were investigated. Immunohistochemical analysis of Min mouse intestine revealed that cyclin D1 immunoreactivity in the intestinal epithelium was restricted to the adenomatous areas, with a significantly higher percentage of positively staining nuclei in high-grade dysplasia versus low-grade dysplasia (54.8 +/- 18.4% versus 34.6 +/- 16.9%, P = 0.016). Morphologically normal areas of intestinal epithelia were uniformly negative for cyclin D1 immunoreactivity. Cdk4 nuclear immunoreactivity was restricted to the crypt areas in morphologically normal small intestine and colon. Conversely, Cdk4 immunoreactivity was uniformly abundant in adenomatous areas regardless of the degree of dysplasia. Increased expression of cyclin D1 and Cdk4 in adenomas was accompanied by a significantly increased 5-bromo-2'-deoxyuridine incorporation rate in the same areas. Immunoblot analysis of lysates from surgical specimens revealed increased levels of cyclin D1 and Cdk4 in the majority of intestinal adenomas from human FAP patients in comparison to the adjacent grossly normal colonic mucosa. Our results indicate that overexpression of cyclin D1 and Cdk4 occurs in intestinal adenomas and is associated with increased cell proliferative activity in premalignant neoplastic cells. Increased cyclin D1 immunoreactivity is associated with more severe dysplasia. These data suggest that abnormal up-regulation of these important G1 cell cycle proteins is a relatively early event in intestinal carcinogenesis and that these changes may contribute to malignant progression within those lesions.

Multicentric metachronous pulmonary and intravagal paraganglioma: a case report with immunohistochemical findings

An unprecedented presentation of multicentric paraganglioma in a 48-year-old man is described. One of the paragangliomas, originally diagnosed as a carcinoid tumor, presented as a lung mass and was removed. Four years later, an intravagal paraganglioma was discovered. The lung and intravagal tumors had identical morphologic and immunoreactive characteristics. Both tumors consisted of chief cells (type 1) and sustentacular cells (type 2). The chief cells were immunoreactive with neuroendocrine markers (synaptophysin and chromogranin), but nonreactive with epithelial markers (CAM 5.2, high- and low-molecular-weight keratins, epithelial membrane antigen, and carcinoembryonic antigen). The sustentacular cells were positive for S100 protein. Although pulmonary carcinoids may mimic paragangliomas and occasionally contain sustentacular cells, the diagnosis was rejected because the tumor cells did not demonstrate reactivity with epithelial markers.

A case against the specificity of "cardiac" troponin-T

A case of a spurious rise in cardiac troponin-T in an 85 year old Caucasian man with myelodysplastic syndrome and multiple malignancies but with intact cardiac and renal function is reported. The patient presented to the accident and emergency department with fever and chest pain. Inconsistent laboratory findings in biochemical markers diagnostic of myocardial infarction were observed. Discrepant findings included a rise in the concentration of the cardiac specific marker troponin-T in the absence of an increase in creatine kinase (CK) isoenzyme MB activity. Somewhat surprisingly, there was a significant and consistent increase in CK isoenzyme BB activity. Awareness of the increase in troponin-T concentrations in patients with multiple clinical non-cardiac problems may prevent an erroneous diagnosis of myocardial infarction and avert institution of unduly aggressive treatment.

Cytokeratin profiles and mucin secretion in combined hepatocellular-cholangiocarcinoma. A case report

A case of a combined hepatocellular-cholangiocarcinoma (HCC-CC) is presented showing mucin production in both the HCC and the CC component. Immunohistochemical staining for cytokeratins 7 and 19 was performed and it is concluded that immunoreactivity for cytokeratin 7 and 19 is an additional criterion to the detection of mucin in making the diagnosis of a combined HCC-CC of the transitional type.

[Specifics of metabolic disorders in patients with "hormone-associated neoplastic" syndromes]

Overweight, lipidemia features, glucose tolerance and insulinemia were studied in 642 females suffering tumors of the corpus uteri, breast, ovary and large bowel, i.e. types of neoplasia which often occur and correspond to the syndrome of primary multiple "hormone-related" cancers. Beside certain obvious similarities in the said parameters established among patients with the said pathologies, the distinctions related, first of all, to degree of pernicious tumor process and, possibly, preoperative weight loss. Since no differences were found in manifestations of hormono-metabolic disturbances between cases of solitary and primary multiple neoplasms of the same localizations, it is suggested that carcinogenesis of both types might be caused by the same factors.

Mechanisms of multifocal breast cancer: an immunocytochemical study

The issue of whether multifocal breast cancer represents intramammary spread from a single primary tumor or multiple synchronous tumors remains unresolved. We have used a series of immunocytochemical markers, B72.3, DF3, c-erbB-2, SP-1, CEA, and p53, to attempt to answer this question. Of 24 cases with separate discrete synchronous tumors in the same breast, 10 were histologically and immunocytochemically identical, five were histologically similar but immunocytochemically different, two were histologically different but immunocytochemically identical, and in seven cases the tumors were different both histologically and immunocytochemically. In seven of the 24 cases lymph nodes containing metastatic tumor were also available; in each instance, the immunoreactivity of the metastasis was similar to one or other of the tumors in the breast. This study indicates that multifocal breast cancer may result from either intramammary spread from a single primary tumor or multiple synchronous primary tumors.

Secretory carcinoma of the breast associated with juvenile papillomatosis in a 12-year-old girl. A case report

A rare case of juvenile secretory carcinoma (SC) associated with juvenile papillomatosis (JP) is described. Tumor biopsy and fine needle aspiration cytology (FNAC) were performed in a 12-year-old girl who had noticed a painful right breast mass. One of the two types of tumor cells found on FNAC smears formed mainly sheets or clusters, intercellular spaces within the sheets and intracytoplasmic vacuolation. These cells, a few of which had a signet-ring cell appearance with completely disordered and randomly arranged nuclei, were considered to be SC cells. Cells of the other type were found in scattered papillary clusters and had well-defined cytoplasmic borders, uniform cell and nuclear size, and an orderly nuclear arrangement, suggesting a benign papillary lesion. Histologic examination of the tumor biopsy and breast quadrantectomy specimens revealed SC with JP. The cytologic, histologic and electron microscopic features of SC are described, and the relationship between SC and JP is discussed.

Adrenal androgen-secreting carcinoma in a fertile woman

The article reports on a case of functioning adrenal carcinoma in a woman of 40 with concomitant in situ carcinoma of the portio (CIN 3). She had had amenorrhoea for 14 months and early menopause was suspected. Hirsutism and other signs of virilization such as clitoromegaly and voice changes were detected upon hospitalization.. The characteristic of the clinical case is given by hormone production involving not only androgens of prevalently adrenal genesis (dehydroepiandrosterone, dehydroepiandrosterone sulphate and androstenedione), but also testosterone, more suggestive of a gonadal neoplasm. The adrenal carcinoma only produced androgens, as plasma cortisol and aldosterone concentrations were normal. Diagnosis of adrenal carcinoma was first made with hormone assays and then with the adrenal block test using dexamethasone, with adrenal ecography and abdomino-pelvic computed tomography (CT). When amenorrhoea is present and hirsutism and other signs of virilization occur ex-novo in a short period, in a woman of fertile age, a thorough endocrine study must be carried out. According to the hormone profile, the next diagnostic step should be aimed at detecting a prospective ovarian or adrenal neoplasm.

Renal and hepatic angiomyolipomas in a child without evidence of tuberous sclerosis

A renal neoplasia, displaying the typical features of angiomyolipoma (an admixture of smooth muscle cells, mature adipocytes and tangles of thick-walled blood vessels) was found in a nine-year-old boy. In addition, cytoplasmic crystalloid structures and HMB 45 positivity were found in smooth muscle cells. Similar findings were also observed in a small nodule of the liver. According to literature data, angiomyolipoma is very rare in children and almost exclusively associated with tuberous sclerosis. Our case suggest that the diagnostic hypothesis of angiomyolipoma can not be disregarded when a renal mass is identified in a young patient even in a clinical setting other than tuberous sclerosis.

Cushing's syndrome with cortisol hypersecretion from one of bilateral adrenocortical adenomas: report of a case

We report herein the case of a 40-year-old man with Cushing's syndrome, diagnosed by clinical manifestations and endocrinological studies, who was found to have bilateral adrenocortical adenomas, one of which hypersecreted cortisol. The Cushing's syndrome was therefore attributed to primary adrenocortical disease, and the right adrenal tumor was resected and histologically diagnosed as a so-called black adenoma. After resection of the right tumor, the left adrenal tumor showed no signs of cortisol hypersecretion for the 23 months of follow-up until the patient died of peritonitis subsequent to the rupture of a duodenal ulcer. The left adrenal tumor was examined at autopsy and found to be a cortical adenoma. These data imply that the adrenal adenomas developed primarily from the adrenal gland itself, and that one of the tumors was well differentiated and secreted excess hormones, while the other remained in cell proliferation without hypersecretion.

Management of contralateral testicular intraepithelial neoplasia in patients with testicular germ-cell tumor

Contralateral biopsies from 1810 consecutive patients with testicular germ-cell tumor were examined immunohistologically by staining for placental alkaline phosphatase. Contralateral testicular intraepithelial neoplasia (TIN; carcinoma in situ) was found in 89 patients (4.9%; 95% confidence interval, 3.9%-5.9%). Testicular atrophy was present in 45.9% of patients with TIN and in 13.1% of those without TIN (P < 0.01). There was a history of cryptorchidism in 16.2% of patients with TIN versus only 8.5% of those without TIN (P < 0.05). Patients with contralateral TIN presented at an earlier age (30.8 versus 33.3 years). In all, 23 patients with contralateral TIN had no specific risk marker. In 14 patients with contralateral TIN who had received local radiotherapy of 18-20 Gy to the testis, rebiopsy revealed the disappearance of TIN in all cases. Serum testosterone levels were within or above the normal range in 7 of 13 patients examined after local radiotherapy. Of 9 patients with contralateral TIN who had received chemotherapy, 2 were shown to have persistent TIN at rebiopsy. We conclude that all patients with testicular germ-cell tumor should be offered a contralateral biopsy. Local radiotherapy of the testis is the treatment of choice in patients with contralateral TIN.

Two competing influences that may explain concomitant tumor resistance

A second tumor inoculum is often inhibited in its growth by the presence in the recipient animal of an earlier implanted, growing tumor. The tumor resulting from the first inoculum may, paradoxically, continue to grow despite the simultaneous inhibition of the growth of the second inoculum, a phenomenon usually called "concomitant immunity." Evidence now suggests that the phenomenon can be observed in the absence of any recognizable type of immune reaction and might often be named more appropriately "concomitant tumor resistance." Consideration of a variety of probably related observations suggests that concomitant tumor resistance can best be explained by the competitive interaction of two opposing influences: a local diffusible, tumor-facilitating environment, produced by both tumor and normal tissues, that is counteracted by circulating inhibitors that are also produced by both tumor and by normal tissues. In an implanted small tumor, because of geometric considerations and diffusion, the action of the local facilitating environment is weak; in a larger tumor the local facilitating environment has a relatively greater influence and thus the larger tumor can continue to grow despite levels of circulating tumor inhibitors capable of inhibiting the smaller growth.

Fibrolamellar hepatocellular carcinoma coexistent with a hepatocellular carcinoma of common type: report of a case

A case of small fibrolamellar hepatocellular carcinoma (HCC) coexistent with a HCC of common type is herein reported. A 56-year-old man was diagnosed as having multi-nodular type HCC with liver cirrhosis. The serum alpha-fetoprotein (AFP) level was slightly increased. The patient underwent a partial caudate lobectomy and lateral segmentectomy. Histologically, both resected tumors were small HCCs measuring less than 2 cm in diameter. One was a fibrolamellar type located in the caudate lobe, while the other was the common type in the lateral segment of the liver. Positive immunohistochemical staining for AFP was observed in the tumor cells of the HCC of common type but was not observed in the fibrolamellar HCC. We also reviewed previously reported cases of fibrolamellar HCC in Japan, and discussed the clinicopathologic implications of this disease.

Adenocarcinoma in the lung in patients with breast cancer. A prospective analysis of the discriminatory value of immunohistology

In some patients with a history of breast cancer who also have masses in the lung, making a clinical distinction between primary pulmonary neoplasia and pulmonary metastasis of mammary carcinoma may be impossible. To ascertain whether immunohistologic studies could contribute to resolving this problem, the authors undertook a prospective study of 30 cases showing synchronous or metachronous adenocarcinomas in these two sites. A predefined panel of antibodies--as derived from published antigenic catalogs for breast and lung cancer--was applied to each case. Tumors were interpreted as metastases if they were positive for gross cystic disease fluid protein-15, estrogen receptor protein, or S-100 protein. Conversely, primary adenocarcinomas of the lung were defined by their expression of carcinoembryonic antigen and a lack of the other three determinants. Using these criteria, 15 lesions were classified as metastatic; 11 were categorized as primary pulmonary adenocarcinomas; and 4 cases were indeterminate in origin. Responses to corresponding therapeutic protocols generally supported the validity of the immunohistologic diagnoses; 8 of 15 patients treated for metastatic breast cancer were well at least contact, as were 5 of 11 patients who received therapy for primary carcinoma of the lung. These data suggest that immunohistology plays a useful role in distinguishing mammary from pulmonary adenocarcinomas.

p53 expression in three separate tumours from a patient with Li-Fraumeni's syndrome

The Li-Fraumeni cancer syndrome is a rare autosomal dominant syndrome, characterised by the occurrence of diverse mesenchymal and epithelial neoplasms at multiple sites. It has recently been shown that some of these individuals have a germ line mutation of the p53 tumour suppressor gene. The case of one member of such a family who has now developed three separate primary malignant tumours is reported. All three tumours expressed mutant p53 protein.

A case of biliary cystadenocarcinoma arising in the liver with a congenital retention of indocyanine green

A case of biliary cystadenocarcinoma that occurred in a 45-year-old woman is reported. Ultrasonography and computed tomography clearly revealed papillary projections in the cyst of the liver. Percutaneous transhepatic cystography showed connection between the cyst and the common bile duct. The tumor was surgically resected and proved to be a mucinous papillary adenocarcinoma arising from a biliary cystadenoma. The patient is doing well 4 years after surgery. Interestingly, this is the first reported case of a biliary cystadenocarcinoma in the liver with markedly diminished excretion of indocyanine green.

A patient with a prolactinoma associated with an aldosterone producing adrenal adenoma: differences in dopaminergic regulation of PRL and aldosterone secretion

A patient with a rare combination of prolactinoma and aldosterone producing adrenal adenoma (APA) was reported in relation to studies concerning dopaminergic regulation of PRL and aldosterone secretion. The patient is a 38-year-old female with plasma PRL and aldosterone concentrations (PAC) of 563 ng/ml and 54 ng/dl, respectively. A bolus of 10 mg of metoclopramide significantly increased plasma PRL in 6 normal subjects and in 4 patients with APA, whereas the responses were blunted in 7 patients with prolactinoma and in our patient. The response of aldosterone to metoclopramide was less than that of PRL, but similar in all studied subjects, indicating that the dopaminergic inhibition of aldosterone secretion is less than that of PRL in normal subjects and did not change in patients with APA or prolactinoma. Oral administration of 2.5 mg of bromocriptine suppressed plasma PRL significantly in all the subjects studied, but did not produce any consistent changes in PAC. Discrepancies in the response of PRL and aldosterone to metoclopramide and to bromocriptine suggest a difference in the dopaminergic regulation of PRL and aldosterone secretion in both normal subjects and patients with prolactinoma and APA. It is unlikely that reduced dopaminergic inhibition is the basis for hypersecretion of PRL and aldosterone in our patient.

Intraductal carcinoma of mammary-type apocrine epithelium arising within a papillary hydradenoma of the vulva. Report of a case and review of the literature

We report and immunohistochemically document the first (to the best of our knowledge) case of malignancy in which an intraductal carcinoma resembling apocrine breast cancer arose within a papillary hidradenoma of the vulva. Papillary hidradenoma is generally thought to originate from apocrine sweat glands, but a derivation from milk line remnants of the vulva should also be considered. Immunoreactivities for low- and high-molecular-weight cytokeratins, alpha-smooth-muscle-specific actin, carcinoembryonic antigen, S100 protein, and gross cytic disease fluid protein 15, an antigen of apocrine differentiation, show features that resemble those of an intraductal apocrine breast cancer. Positivity for gross cystic disease fluid protein 15 as well as the presence of estrogen and progesterone receptors suggest that tumor cells are controlled by ovarian steroid hormones. To our knowledge, no cases of malignancy arising from a papillary hidradenoma have been proved to date. Therefore, we also discuss previously reported cases of putative cancers that have developed in papillary hidradenomas. In the case presented herein, a local excision with a narrow rim of surrounding tissue was performed, and the patient was alive and well, without signs of recurrence, after 2 years of follow-up.

Prostatic carcinosarcoma: case report and review of literature

True carcinosarcoma of the prostate is a rare neoplasm, with only 9 cases well documented by immunocytochemistry and ultrastructural examination. We report a case of an unresectable pelvic tumor studied at autopsy. The primary prostatic neoplasm and pulmonary metastases were composed of well differentiated adenocarcinoma admixed with foci of leiomyosarcoma and osteosarcoma. The sarcomatous components showed reactivity with vimentin and desmin, did not express prostatic acid phosphatase (PAP) and prostate specific antigen (PSA), and contained myofilaments on electron microscopic examination. Positive staining of the carcinomatous component for PAP and PSA was noted. These findings confirm the mixed epithelial and mesenchymal components in primary and metastatic sites, and support the diagnosis of true prostatic carcinosarcoma.

In situ oncocytic change in association with multiple renal cell adenocarcinomas

We report a case of in situ oncocytic change in association with two low-grade renal cell adenocarcinomas and one contralateral low-grade oncocytic adenocarcinoma. The in situ oncocytic change showed abundant cytoplasmic mitochondria confirmed by ultrastructural examination and phosphotungstic acid-hemotoxylin staining. In addition, this in situ oncocytic change expressed cytokeratin CAM 5.2 in the absence of cytokeratin AE1/AE3, as reported in oncocytic renal cell adenocarcinomas. Further study of in situ oncocytic change identified in kidneys resected for adenocarcinomas with regard to follow-up and management of the contralateral kidney seems indicated.

Precocious puberty caused by an hCG-producing tumor of the septum pellucidum

A 6 year 9 month old boy with rapidly progressing precocious puberty was immunohistochemically and histologically diagnosed as having an hCG-producing mixed tumor consisting of choriocarcinoma and teratoma in the septum pellucidum. His serum hCG was elevated, but the serum LH was low as determined by LH immunoradiometric assay (IRMA). He did not exhibit a characteristic endocrinological pattern, e.g., high basal levels of LH and failure to respond with high LH levels to the LH-RH stimulation test using the conventional LH RIA method.

Multicentric papillary-cystic neoplasm of the pancreas

Two distinct papillary-cystic neoplasms were found in the pancreas of a young black woman. She presented to the hospital in her first trimester of pregnancy with the chief complaint of sharp right upper quadrant abdominal pain that radiated to the right shoulder. This was associated with jaundice, vomiting, and pruritus. On examination, a large, nontender, midepigastric abdominal mass was palpated. Serum liver enzyme levels were moderately to markedly elevated. An abdominal computed tomographic scan revealed a 9-cm solid and cystic mass located within the head of the pancreas with associated marked bile duct dilatation. A total pancreatectomy was performed. Gross examination of the specimen revealed two separate well-circumscribed tumors of unequal size. The larger one was found within the head of the pancreas and contained multiple hemorrhagic, cystic cavities. The smaller one, located within the tail, consisted primarily of solid tissue. Microscopic examination of both lesions revealed papillary-cystic neoplasms. To our knowledge, this is the first report of two synchronous papillary-cystic tumors of the pancreas and the first reported demonstration of the potential of this tumor for multicentricity.

Carcinoid tumor occurring in a mature testicular teratoma

A rare case of a primary testicular carcinoid tumor, occurring in a mature teratoma from a 33 year old man, was examined histochemically, immunohistochemically and by electron microscopy. Both argyrophil and argentaffin reactions were positive. Immunoreactive cells for 5-hydroxytryptamine (5-HT) and gastrin were present. Electron microscopy demonstrated neurosecretory-type granules. The English literature was reviewed and this revealed at least 6 similar cases.

Primary aldosteronism with cortisol overproduction from bilateral multiple adrenal adenomas

A 55-year-old woman with bilateral multiple adenomas showed hypertension, muscle weakness, hypokalemia, moon-like face and truncal obesity. Increased serum and urinary levels of aldosterone were observed. Serum cortisol level did not show a normal circadian rhythm. Microscopic examination of the resected tumors showed two types of adenoma cells; one (golden yellow tumor) was a large clear cell with foamy cytoplasm which possibly secreted aldosterone and the other (dark brown tumor) was an acidophilic cell with lipofuscin which might have produced cortisol. This is a very rare case of primary aldosteronism with Cushing's syndrome due to multiple bilateral adrenal adenomas.

Somatostatin receptor incidence and distribution in breast cancer using receptor autoradiography: relationship to EGF receptors

Somatostatin receptors (SS-R) were measured with in vitro receptor autoradiography using the SS analog 125I-[Tyr3]-SMS 201-995 as radioligand in 342 breast-tumor samples. In a group of 158 "small" tumor samples (mean section surface: 14 mm2 +/- 0.4; mean +/- SEM), 34 tumors (21%) were SS-R positive. In a group of 72 "large" tumor samples (mean size: 180 mm2 +/- 8; mean +/- SEM), 33 tumors (46%) were SS-R positive. In this second group, more than half of the tumors had a non-homogeneous distribution of SS-R, i.e., tumor regions within SS-R positive tumors were SS-R negative. In a group of 48 additional patients, we could show that primaries and their metastases, or double primaries from right and left breasts, or 2 primaries resected consecutively, could both occasionally be SS-R positive. Finally, in 71 SS-R-positive primary tumors, 18 tumor samples were found to have simultaneously Epidermal Growth Factor receptors (EGF-R); in 12 of these 18 cases, the 2 receptor types were not topographically overlapping. Whereas SS-R were located on tumor tissue, EGF-R were often seen on adjacent normal lobules and ducts. These results show that a subgroup of breast tumors contain SS-R, in several cases non-homogeneously distributed. Their location does not coincide with that of EGF-R. Metastasis of SS-R-positive primaries may be SS-R-positive, as are sometimes second primaries. For evaluation of SS-R incidence and distribution, autoradiography is of advantage, specially if it is performed on large tumor samples, since it allows precise identification of the tissue elements containing these receptors.

Bilateral gonadoblastoma producing steroid hormones in a patient with 45,X/46,XY gonadal dysgenesis

A case of bilateral gonadoblastoma in a phenotypic female with 45,X/46,XY gonadal dysgenesis is presented. Hormonal investigations revealed that serum testosterone, estradiol and beta-human chorionic gonadotropin decreased following excision of the tumors, but follicle-stimulating hormone and luteinizing homrone levels increased further. Immunohistochemical staining for testosterone and estradiol was positive in both Leydig and lutein-like cells in the tumor. It is suggested that gonadoblastoma is capable of producing testosterone and estradiol, and Leydig or lutein-like cells may be the actual source of these steroid hormones.

[Multiple adenoma of the adrenal cortex with the clinical picture of Cushing's syndrome]

The paper sums up the experience of the clinic in diagnosing and therapy of the Cushing syndrome due to multiple autonomous adrenal cortical adenomas. The observation was carried out in a group of 5 women between 15-44 years of age (31.7 on an average). In the clinical material including 225 cases of the Cushing syndrome, they amounted to 2.2 per cent. All the five patients had typical somatic symptoms, myasthenia, ++amenorrhea. In hormonal examinations the content of 17-OHCS in the 24-hour urine was only periodically increased, 17-KS was within the normal range. There was no inhibiting action of dexamethasone on the excretion of cortisol, even when the initial values of corticosteroids++ were normal. The concentration of ACTH in the blood (determined in 3 cases) was around low normal range. Three patients underwent computer tomography; in one case adrenal glands were of normal size, in the second case--the two glands were enlarged, in the third case--the right gland was much larger than the left one. Microscopic examinations showed the atrophy of adrenal cortex beyond the adenomas. In case of multiple adenomas of the left gland surgery was confined to unilateral adrenalectomy. Among the remaining 4 patients, 3 underwent simultaneous resection of the two glands. All the patients showed the regression of symptoms of the disease, except for the changes in bones. One patient did not turn up for further therapy after unilateral adrenalectomy because of partial improvement.

Leydig cell tumor of the ovary associated with endometrial carcinoma and containing 17 beta-hydroxysteroid dehydrogenase

A case of ovarian Leydig cell tumor associated with adenocarcinoma of the endometrium in a 66-year-old woman is described herein, the eighth such case published. Clinically, both masculinizing and feminizing symptoms were observed: an increase in facial hair growth, slight baldness, clitoromegaly, and postmenopausal genital bleeding. Three biopsies of the endometrium during a 5-month preoperative period showed atypical hyperplasia. Surgically resected material contained a Leydig cell tumor of the left ovary and focal adenocarcinoma in atypical hyperplasia of the endometrium. Serum levels of androgens and estrogens measured by radioimmunoassay decreased after removal of the tumor. Immunohistochemical studies revealed that the Leydig cell tumor contained testosterone, estrogens, and 17 beta-hydroxysteroid dehydrogenase (HSD) in the cytoplasm. This is the first report of a Leydig cell tumor in which the localization of 17 beta-HSD was demonstrated immunohistochemically.

Combined choriocarcinoma and adenocarcinoma of the lung

Combined choriocarcinoma and adenocarcinoma in the lung of a 71-year-old Japanese male is reported. In the upper lobe of the right lung (S1 + 2), a choriocarcinoma coexisted with an adenocarcinoma, but distinct metastatic lesions were noticed separately in the lungs, kidney, bone marrow and lymph nodes. Although immunohistochemical examination revealed intensely positive reactivity with anti-human chorionic gonadotropin (HCG) in trophoblastic cells, weak immunoreactivities were also observed in a few cells with anti-human placental lactogen (HPL), anti-pregnancy-specific beta glycoprotein (SPI), anti-epithelial membrane antigen (EMA), anti-carcinoembryonic antigen (CEA), anti-cytokeratin (keratin) and KM-93 (lung adenocarcinoma-associated antibody). In the adenocarcinoma, the tumor cells were positively stained for CEA, EMA, keratin and KM-93, but there were no positive reactivities for HCG, HPL and SPI. These findings suggest that primary choriocarcinoma of the lung may arise through dedifferentiation of adenocarcinoma.

Multiple extra-adrenal paragangliomas associated with catecholamine cardiomyopathy

We describe a patient with multiple extra-adrenal paragangliomas who presented with clinical features of a dilated cardiomyopathy. Hypertension was not a major feature of the illness despite excessive catecholamine secretion by the tumours. Following surgical resection the changes of dilated cardiomyopathy did not regress on echocardiography and the patient died of left ventricular failure.

Estrogen receptors in bilateral breast cancer

Estrogen receptor status, tumor histology, and the interval between the development of tumors were assessed in 99 patients with bilateral breast cancer. Tumors were first grouped into those simultaneously detected in both breasts or within 12 months of each other (synchronous bilateral breast cancer, of which there were 64) and second, those detected within more than 12 months of each other (asynchronous bilateral breast cancer, of which there were 35). Nineteen percent of all tumors were lobular carcinomas. Overall, the rate of receptor discordance between the two tumors was not significantly different from that previously reported between biopsies of primary tumor and metastases in patients with unilateral breast cancer. Synchronous receptor-positive tumors occurred significantly more frequently than expected, suggesting that the development of the two tumors was influenced by a common mechanism. In patients with asynchronous bilateral breast cancer there was a significantly longer interval between tumors if both were receptor-positive compared with concordant receptor-negative tumors and tumors with discordant receptor status. There was a significant discordance in the receptor status of asynchronous tumors when the histology also differed, indicating that the tumors in this group were likely to be separate primary tumors.

Metabolic changes in cerebral gliomas within hours of treatment with intra-arterial BCNU demonstrated by phosphorus magnetic resonance spectroscopy

A 40-year-old female with a recurrent mixed astrocytoma/oligodendroglioma was treated with intra-arterial BCNU at six week intervals. Phosphorus magnetic resonance spectroscopy was performed before, and on two occasions after her third treatment. Before treatment, phosphodiesters were 25% less than normal and intracellular pH was 7.14 (normal 6.97 +/- 0.02). Eight hours following treatment phosphocreatine and phosphodiesters were reduced by approximately 40% and pHi increased to 7.24. Thirty-two hours after treatment, phosphocreatine and phosphodiesters had reversed their decline, but pHi had increased further to 7.35. MRI and x-ray CT scans did not show any change during this period. This study demonstrates that chemical changes can be observed in a glioma by magnetic resonance spectroscopy shortly after chemotherapy in a clinical setting and before changes are observable by imaging modalities. This approach evidently offers a possible means of monitoring the acute metabolic response of tumours to chemotherapy or other forms of treatment by a non-invasive repeatable quantitative method.