Histopathologic findings predicting lymph node metastasis and prognosis of patients with superficial esophageal carcinoma: analysis of 240 surgically resected tumors

BACKGROUND

If it were possible to elucidate the histopathologic findings predicting lymph node metastasis and prognosis in superficial squamous cell carcinoma of the esophagus (SSCCE), they could be used as markers to identify patients who do not require additional surgical resection after endoscopic mucosal resection (EMR).

METHODS

Two hundred forty surgically resected SSCCEs were examined histopathologically. Histopathologic factors including vertical tumor invasion depth in the submucosal layer (VTIDsm), degree of nuclear atypia (low, one point; high, two points), growth pattern (expansive, one point; infiltrative, two points), and histologic grade (calculated by adding the latter two scores to obtain Grade 1, two points; Grade 2, three points; and Grade 3, four points) were evaluated to investigate the associations among these factors, lymph node metastasis, and prognosis.

RESULTS

No lymph node metastasis was found in 54 patients with carcinoma limited to the lamina propria. Their 5-year survival rate was 100%. Multivariate analysis of 186 carcinomas invading beyond the lamina propria showed that lymphatic permeation correlated with lymph node metastasis (P<0.0001) and the presence of lymph node metastasis and a high histologic grade were independent factors indicating a poor prognosis (P = 0.0061 and 0.023, respectively). In 53 patients whose tumors had invaded the lamina muscularis or slightly invaded the submucosa (VTIDsm <500 microm), no lymph node metastasis was found in the lymphatic permeation negative and blood vessel permeation negative patients with VTIDsm values <200 microm and histologic Grades 1 or 2.

CONCLUSIONS

Lymphatic permeation is a good predictor of lymph node metastasis in patients with SSCCE. Lymph node metastasis and the histologic grade are independent prognostic factors. Vessel permeation, VTIDsm, and histologic grade were found to be important factors for identifying patients who did not require additional surgical treatment after EMR.

Differences in diagnostic criteria for esophageal squamous cell carcinoma between Japanese and Western pathologists

BACKGROUND

Large discrepancies have been found between Western and Japanese pathologists in the diagnosis of adenoma/dysplasia versus carcinoma for gastric and colorectal glandular lesions. It is important to determine whether similar differences exist in the diagnosis of esophageal squamous lesions.

METHODS

Eleven expert gastrointestinal pathologists from Japan, North America, and Europe individually reviewed a set of microscopic slides containing 21 sections of biopsies and corresponding endoscopic mucosal resection specimens from Japanese patients with superficial esophageal squamous neoplastic lesions. The pathologists indicated the pathologic findings on which they based each diagnosis.

RESULTS

Invasion was the most important diagnostic criterion of carcinoma for the Western pathologists whereas nuclear and structural features were more important for the Japanese pathologists. For two sections showing low grade dysplasia according to most Western pathologists, the Japanese pathologists diagnosed suspected carcinoma in one case and definite carcinoma in the other. For nine sections with high grade dysplasia according to the Western pathologists, the Japanese pathologists diagnosed suspected carcinoma in two cases and definite carcinoma in seven cases. For six sections with suspected carcinoma according to most Western pathologists, the Japanese pathologists diagnosed suspected carcinoma in one case and definite carcinoma in five cases. Four sections showed definite carcinoma according to both the Western and Japanese pathologists. Thus, there was agreement among the Western and Japanese pathologists for only 5 of the 21 sections (kappa value, 0.04). However, when high grade dysplasia, noninvasive carcinoma, and suspected carcinoma were grouped together, the agreement was excellent (19 of the 21 sections; kappa value, 0.75).

CONCLUSIONS

In Japan, esophageal squamous cell carcinoma is diagnosed mainly based on nuclear criteria, even in cases judged to be noninvasive low grade dysplasia in the West. This difference in diagnostic practice may contribute to the relatively high incidence rate and good prognosis of superficial esophageal carcinoma in Japan. To improve the comparability of research data, the authors recommend that high grade dysplasia, noninvasive carcinoma, and suspected carcinoma be grouped together into one category of "noninvasive high grade neoplasia." [See editorial on pages 969-70, this issue.]

Involvement of jasmonate- and salicylate-related signaling pathways for the production of specific herbivore-induced volatiles in plants

We compared volatiles from lima bean leaves (Phaseolus lunatus) infested by either beet armyworm (Spodoptera exigua), common armyworm [Mythimna (Pseudaletia) separata], or two-spotted spider mite (Tetranychus urticae). We also analyzed volatiles from the leaves treated with jasmonic acid (JA) and/or methyl salicylate (MeSA). The volatiles induced by aqueous JA treatment were qualitatively and quantitatively similar to those induced by S. exigua or M. separata damage. Furthermore, both S. exigua and aqueous JA treatment induced the expression of the same basic PR genes. In contrast, gaseous MeSA treatment, and aqueous JA treatment followed by gaseous MeSA treatment, induced volatiles that was qualitatively and quantitatively more similar to the T. urticae-induced volatiles than those induced by aqueous JA treatment. In addition, T. urticae damage resulted in the expression of the acidic and basic PR genes that were induced by gaseous MeSA treatment and by aqueous JA treatment, respectively. Based on these data, we suggest that in lima bean leaves, the JA-related signaling pathway is involved in the production of caterpillar-induced volatiles, while both the SA-related signaling pathway and the JA-related signaling pathway are involved in the production of T. urticae-induced volatiles.

Reappraisal of orthodox histochemistry for the diagnosis of minimal deviation adenocarcinoma of the cervix

Minimal deviation adenocarcinoma (MDA), or adenoma malignum, of the uterine cervix is a diagnostically problematic disease because of the difficulty in differentiating it histologically from normal cervical glands. To evaluate the use of mucin phenotyping for differentiating MDA from other conditions, we performed alcian blue pH 2.5/periodic acid-Schiff (AB-PAS) staining and high iron diamine (HID)-AB staining on routinely processed sections of 11 MDAs, 20 unremarkable cervical glands, 9 cervical glandular hyperplasias occurring in association with mucinous ovarian tumors, and 41 conventional cervical adenocarcinomas. In all 11 MDAs and 11 conventional cervical adenocarcinomas, the tumor cell cytoplasm was stained diffusely red by PAS, indicating that MDA cells produce neutral mucin almost exclusively. The amount of acid mucins, both sulfomucin and sialomucin, was decreased markedly by HID-AB. For four MDAs, preoperative biopsy specimens also showed diffuse cytoplasmic neutral mucin. In contrast, the cytoplasm of constituent cells was stained purple to violet by AB-PAS in all unremarkable cervical glands and glandular hyperplasias, indicating that both acid and neutral mucins were produced in equal amounts, sulfomucin being stained predominantly by HID-AB. Of the 30 conventional cervical adenocarcinomas, 28 showed both acid and neutral mucins and two showed acid mucin only in goblet cells, or in part of the cytoplasm or cell surface of constituent cells, where acid mucin consisted predominantly of sulfomucin in 14 and sialomucin in 16. AB-PAS and HID-AB are simple and orthodox histochemical methods which are effective for differential diagnosis of MDA and can contribute to its early detection and treatment.

Prognostic relevance of a histological grading system using MIB-1 for adult soft-tissue sarcoma

Several histological grading systems have been proposed and found as strong indicators of outcome in soft-tissue sarcomas. However, a putative independent prognostic influence of recently developed biological and molecular markers remains to be established. This study investigated the prognostic relevance of a histological grading system based on the assessment of proliferative activity in adult soft-tissue sarcomas of the extremities, trunk, head, and neck. Tissue blocks from 95 of 108 patients without distant metastases or regional lymph node involvement were available. Immunohistochemical staining for MIB-1 and p53 was done on paraffin-embedded sections. All clinicopathologic and immunohistochemical variables and patient survival were assessed using univariate and multivariate analyses. Variables included histological grading based on the modified Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) system using the MIB-1 score for the estimation of the proliferative potential of the tumors. Variables associated with overall survival were tumor site in the trunk, head and neck, mitosis count, necrosis, MIB-1 score, FNCLCC grade, modified FNCLCC grade using the MIB-1 score, and stage (all p values <0.05). In multivariate analysis, the modified grade proved to be the most significant predictor of shortened overall survival, in addition to tumor site in the trunk, head, and neck. Overexpression of p53 did not correlate with increased risk of tumor mortality. Using MIB-1 to replace mitosis counts in the FNCLCC system improves grading of soft-tissue sarcomas, and this in conjunction with other important factors appear to be more accurate prognostic factors for survival, and for patient selection in investigational adjuvant treatment trials.

Differences in diagnostic criteria for esophageal squamous cell carcinoma between Japanese and Western pathologists

BACKGROUND

Large discrepancies have been found between Western and Japanese pathologists in the diagnosis of adenoma/dysplasia versus carcinoma for gastric and colorectal glandular lesions. It is important to determine whether similar differences exist in the diagnosis of esophageal squamous lesions.

METHODS

Eleven expert gastrointestinal pathologists from Japan, North America, and Europe individually reviewed a set of microscopic slides containing 21 sections of biopsies and corresponding endoscopic mucosal resection specimens from Japanese patients with superficial esophageal squamous neoplastic lesions. The pathologists indicated the pathologic findings on which they based each diagnosis.

RESULTS

Invasion was the most important diagnostic criterion of carcinoma for the Western pathologists whereas nuclear and structural features were more important for the Japanese pathologists. For two sections showing low grade dysplasia according to most Western pathologists, the Japanese pathologists diagnosed suspected carcinoma in one case and definite carcinoma in the other. For nine sections with high grade dysplasia according to the Western pathologists, the Japanese pathologists diagnosed suspected carcinoma in two cases and definite carcinoma in seven cases. For six sections with suspected carcinoma according to most Western pathologists, the Japanese pathologists diagnosed suspected carcinoma in one case and definite carcinoma in five cases. Four sections showed definite carcinoma according to both the Western and Japanese pathologists. Thus, there was agreement among the Western and Japanese pathologists for only 5 of the 21 sections (kappa value, 0.04). However, when high grade dysplasia, noninvasive carcinoma, and suspected carcinoma were grouped together, the agreement was excellent (19 of the 21 sections; kappa value, 0.75).

CONCLUSIONS

In Japan, esophageal squamous cell carcinoma is diagnosed mainly based on nuclear criteria, even in cases judged to be noninvasive low grade dysplasia in the West. This difference in diagnostic practice may contribute to the relatively high incidence rate and good prognosis of superficial esophageal carcinoma in Japan. To improve the comparability of research data, the authors recommend that high grade dysplasia, noninvasive carcinoma, and suspected carcinoma be grouped together into one category of "noninvasive high grade neoplasia." [See editorial on pages 969-70, this issue.]

Chronic myelomonocytic leukemia in a cat

A 1-year-old spayed domestic short-haired cat was referred with anorexia and weight loss. Hematologic findings indicated nonregenerative anemia, severe neutropenia and monocytosis. The feline leukemia virus (FeLV) antigen test was positive reaction by enzyme-linked immunosorbent assay. Dysgranulopoiesis with slight increase in blast cells were observed in bone marrow smears. On the basis of blood and bone marrow findings, the cat was diagnosed as chronic myelomonocytic leukemia (CMMoL), which possibly corresponds to a kind of the subtypes in human myelodysplastic syndrome (MDS).

Two patients with occupational asthma who returned to work with dust respirators

OBJECTIVES

To assess the efficacy of dust respirators in preventing asthma attacks in patients with occupational asthma (asthma induced by buckwheat flour or wheat flour).

METHODS

The effect of the work environment was examined in two patients with occupational asthma with and without the use of a commercially available mask or a dust respirator. Pulmonary function tests were performed immediately before and after work and at 1 hourly intervals for 14 hours after returning to the hospital.

RESULTS

In patient 1, environmental exposure resulted in no symptoms during and immediately after work, but coughing, wheezing, and dyspnoea developed after 6 hours. Peak expiratory flow rate (PEFR) decreased by 44% 7 hours after leaving the work environment, showing only a positive late asthmatic reaction (LAR). In patient 2, environmental exposure resulted in coughing and wheezing 10 minutes after initiation during bread making, and PEFR decreased by 39%. After 7 hours, PEFR decreased by 34%. The environmental provocation tests in both patients were repeated after wearing a commercial respiratory. This resulted in a complete suppression of LAR in patient 1 and of immediate asthmatic reaction (IAR) and LAR in patient 2.

CONCLUSIONS

Two patients with asthma induced by buckwheat flour or wheat flour in whom asthmatic attacks could be prevented with a dust respirator are reported. Dust respirators are effective in preventing asthma attacks induced by buckwheat flour and wheat flour.

Induced response of tomato plants to injury by green and red strains of Tetranychus urticae

We studied the induced response of tomato plants to the green strain and the red strain of the spider mite Tetranychus urticae. We focused on the olfactory response of the predatory mite Phytoseiulus persimilis to volatiles from T. urticae-infested tomato leaves in a Y-tube olfactometer. Tomato leaves attracted the predatory mites when slightly infested with the red strain, or moderately or heavily infested with the green strain. In contrast, neither leaves that were slightly infested with green-strain mites, nor leaves that were moderately or heavily infested with the red strain attracted the predators. We discuss the specific defensive responses of tomato plants to each of the two strains.

Bone marrow necrosis in a cat infected with feline leukemia virus

A one-year old castrated male cat was admitted to the hospital with vomiting and diarrhea. Laboratory examination revealed pancytopenia and positive for FeLV antigen. A bone marrow examination indicated necrosis of the nucleated cells. Based on these findings, the cat was diagnosed as bone marrow necrosis. Pancytopenia was effectively treated with corticosteroids. Re-examination of the bone marrow confirmed a recovery of normal hematopoietic cells with a infiltration of many macrophages. It is strongly suspected that the bone marrow necrosis in this case could be associated with a bone marrow suppression due to FeLV infection.

Effects of sodium cromoglycate on cytokine production following antigen stimulation of a passively sensitized human lung model

BACKGROUND

Interleukin-5 (IL-5) and tumor necrosis factor-alpha (TNF-alpha) play key roles in bronchial asthma. Sodium cromoglycate (DSCG) and dexamethasone (Dex) are used in the treatment of asthma as anti-inflammatory agents.

OBJECTIVE

We investigated whether DSCG inhibited the expression of IL-5 and TNF-alpha mRNA and proteins from isolated human lungs, and compared these findings with those of Dex.

METHODS

Human lung specimens were passively sensitized with sera from atopic patients, then preincubated in the presence of DSCG (10(-3), 10(-4), 10(-5) M) or Dex (10(-6) M) for 2 hours. The specimens were stimulated with Dermatophagoides antigen, then cultured for 48 hours. The supernatant was collected 1, 2, 4, 8, 24, and 48 hours to measure IL-5 and TNF-alpha by enzyme-linked immunosorbent assay. mRNA expression was examined by reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULTS

Tumor necrosis factor-alpha protein reached a peak level at 4 hours (156.57 +/- 18.29 pg/mL). Dex decreased TNF-alpha protein to 31.86 +/- 4.67 pg/mL (P < .001). There was also a decrease of TNF-alpha protein to 107.43 +/- 14.25 pg/mL by 10(-4) MD SCG (P < .001). Antigenic stimulation also increased the release of IL-5 protein at 4 hours and the peak level was observed at 24 hours (150.29 +/- 19.12 pg/mL). Dex decreased IL-5 protein to 28.57 +/- 5.27 pg/mL (P < .0001), 10(-4) M DSCG also decreased to 111.57 +/- 15.28 pg/mL (P < .05). RT-PCR analysis showed persistence of IL-5 and TNF-alpha mRNA expression from 1 to 24 hour after antigen stimulation. Dex but not DSCG inhibited IL-5 and TNF-alpha mRNA levels.

CONCLUSION

Our results showed that DSCG significantly inhibited IL-5 and TNF-alpha production by human lung specimens, suggesting that it acts as an anti-inflammatory agent.

A hematological study on thirteen cats with myelodysplastic syndrome

Hematological abnormalities were investigated in 13 cats with myelodysplastic syndrome (MDS). Examination of the peripheral blood samples from the 13 cats revealed anemia in 11 cats, leukopenia in 9 cats, and thrombocytopenia in 9 cats. Four cats had pancytopenia (30.8%) and 9 cats had bicytopenia (69.2%). Dysplastic changes of erythrocytes, neutrophils, and platelets in the peripheral blood were found in 5, 10 and 8 cats, respectively. Bone marrow examination of the 13 cats revealed that ratios of blast cells to all nucleated cells (ANC) ranged from 0 to 20%. Ratios of erythroid progenitor cells to ANC were more than 50% in 3 cats and less than 50% in 10 cats. Eosinophils accounted for more than 5% of non-erythroid cells in 10 cats. Dysplastic changes in the granurocytic, erythrocytic, and megakaryocytic cells in the bone marrow were found in 11, 7 and 5 cats, respectively. Dysplastic changes in these cats included giant neutrophils, ring-nucleated neutrophils, binuclear myelocytes, hypersegmented and hyposegmented neutrophils, megaloblastoid erythroblasts, multinucleated erythroblasts, micromegakaryocytes, and segmented multinucleated megakaryocytes. Virological examination indicated the presence of feline leukemia virus antigen in the peripheral blood from all of the 13 cats with MDS. The peripheral blood cytopenias and dysplastic changes in each blood cell lineage in the bone marrow were shown to be important for the diagnosis of MDS in cats.

Sodium cromoglycate inhibits antigen-induced cytokine production by peripheral blood mononuclear cells from atopic asthmatics in vitro

BACKGROUND

Several anti-allergic anti-inflammatory drugs are used for the treatment of asthma including glucocorticosteroids (GCS), sodium cromoglycate (SCG), leukotriene (LT) inhibitors, and LT receptor antagonists. The major mechanism of the anti-inflammatory action of GCS is inhibition of cytokine production by T-lymphocytes: however, the mechanisms of anti-inflammatory effects of SCG are still unclear.

OBJECTIVE

We elucidated the anti-inflammatory effects of SCG by investigating its effects on cytokine production by peripheral blood mononuclear cells (PBMCs) obtained from atopic asthmatics.

METHODS

Peripheral blood mononuclear cells were obtained from seven atopic asthmatics and sensitized with Dermatophagoides farinae (DJ) or concanavalin A (ConA). We compared the effects of SCG on interleukin (IL)-5 and interferon (IFN)-gamma production by sensitized PBMCs with that of dexamethasone (Dex). Based on their clinical concentrations, we compared the effects of 10(-6) to 10(-4) M of SCG to those of 10(-6) M Dex.

RESULTS

Stimulation with ConA increased the production of IL-5 and IFN-gamma. Dex significantly inhibited the production of both cytokines but SCG showed no inhibitory effects. On the other hand, Df stimulation increased IL-5 production only. Dermatophagoides farinae-induced overproduction of IL-5 was inhibited by SCG and Dex.

CONCLUSIONS

Our results suggested that SCG has antigen-specific anti-allergic inflammatory effects.

Extrathoracic solitary fibrous tumors: their histological variability and potentially aggressive behavior

The histological variability of solitary fibrous tumors may contribute to the difficulty in diagnosing these neoplasms, especially when they arise in extrathoracic sites. Like intrathoracic lesions, the behavior of extrathoracic solitary fibrous tumors is currently unpredictable because these types of tumor have only recently been recognized. This study therefore was undertaken to examine the clinical behavior and histological, immunohistochemical, and ultrastructural features of 24 extrathoracic solitary fibrous tumors with long-term follow-up. The patients comprised 10 men and 14 women, between 30 and 85 years of age (mean, 51 years). Ten tumors were located in the retroperitoneum or pelvis, 5 in the trunk, 4 in the extremities, 2 in the orbital region, and 1 each in the kidney, uterine cervix, and meninges. All of the tumors showed a classic morphological appearance, diffuse and strong immunoreactivity for both vimentin and CD34, and variable reactivity for bcl-2. All 7 cases examined ultrastructurally contained fibroblasts and myofibroblasts. Six tumors contained multinucleated giant cells, and in 4 cases these lined pseudovascular spaces with mononuclear cells, thus resembling giant cell angiofibroma and giant cell fibroblastoma. Other potentially similar spindle cell neoplasms mixed with adipose tissue, such as dendritic fibromyxolipoma, lipomatous hemangiopericytoma, cellular angiofibroma, and spindle cell lipoma, were considered in the differential diagnosis. One tumor displayed atypical histological features in the form of increased cellularity and nuclear pleomorphism, but this patient has remained free of disease for 14 years. Another 2 patients developed local recurrences at 6 months and 5 years, and a further patient developed pulmonary metastases that were diagnosed after 7 years. These tumors lacked any atypical histological features in the primary lesions. No patient has so far died of the disease. In conclusion, most extrathoracic solitary fibrous tumors appear to pursue a benign course, although, because some have the potential to recur or metastasize, careful long-term follow-up is necessary for all patients.

Sensitivity to the house dust mite and airway hyperresponsiveness in a young adult population

BACKGROUND

The pathogenic mechanisms of airway hyperresponsiveness (AHR) in asthma are unknown and only a few studies have examined the importance of sensitivity to antigens in AHR in young adults.

OBJECTIVE

We investigated the correlation between AHR and sensitivity to specific antigens, atopy, history of childhood asthma and spirometry in a young adult population.

METHODS

Based on the results of interviews with 447 students at our university, 308 non-smoker students were classified into six groups. Group 1 comprised subjects with intermittent mild bronchial asthma; group 2, subjects with history of childhood asthma; group 3, subjects with atopic disease, and a RAST score for Dermatophagoides farinae (Def) of > or = 2; group 4, normal subjects with a RAST score for Def of > or = 2; group 5, subjects with cedar pollinosis; and group 6, normal subjects. We measured AHR to methacholine (MCh), spirometry, immunoglobulin E-radioimmunosorbent test (IgE-RIST), IgE-radioallergosorbent test to six common antigens, eosinophil cationic protein (ECP), and eosinophil count in peripheral blood in each subject.

RESULTS

Airway hyperresponsiveness to MCh did not correlate with IgE-RIST, eosinophil count, or ECP. The highest AHR to MCh was present in groups 1 and 2 and lowest in groups 5 and 6. Multiple regression analysis showed that sensitivity to Def was the only factor that significantly influenced AHR to MCh. Airway hyperresponsiveness to MCh of groups with a RAST score for Def of 0/1 was lower than groups with a RAST score of 2 to 6. Airway hyperresponsiveness to MCh did not correlate with the degree of positivity to Def antigen among positive sensitized groups (RAST score 2 to 6).

CONCLUSIONS

Sensitivity to mite antigen may be important in the pathogenesis of AHR and Def is a major contributing antigen in young adults in Japan. Once asthma occurs, AHR remains positive for a long time even after the disappearance of asthma-related symptoms.

Fulminant nonocclusive mesenteric ischemia developing just after esophagectomy

Nonocclusive mesenteric ischemia (NOMI) is a poorly understood condition, marked by progressive ischemia of the intestine leading to infarction, sepsis and death. The mortality rate remains high. Three cases of NOMI occurred after esophagectomy at our facility. It was suspected, through investigation of these cases, that NOMI occurring after major surgical procedures like esophagectomy has a far more rapid and progressive clinical course and high mortality rate. Therefore, it should be distinguished from spontaneously developing NOMI. A huge water shift between the intravascular space and the extravascular space during and just after surgery is suspected to have played a major role in the development of post-operative NOMI. Diagnosis and treatment of NOMI after a major surgery are quite difficult.

Synovial sarcoma, histologically mimicking primitive neuroectodermal tumor/Ewing's sarcoma at distant sites

We report a case of synovial sarcoma (SS) showing unusual histology at distant sites. A 47-year-old man was aware of a tumor on the sole of his left foot. After preoperative chemotherapy with a diagnosis of SS, wide excision was performed. During postoperative chemotherapy, multiple tumorous lesions developed in the bone (including the whole spine) and both lungs. The patient died 1 year later. Histologically, the excised tumor of the foot showed a biphasic cellular pattern typical of SS, whereas at autopsy the bone and lung lesions were composed only of undifferentiated small round cells with cytoplasmic fibrillar processes. Homer-Wright rosettes were also observed. Immunohistochemically, 80% of the bone and lung tumor cells expressed MIC2 protein homogeneously. To clarify whether the bone and lung round cell tumors were metastatic lesions or second malignancies, especially primary primitive neuroectodermal tumor (PNET)/Ewing's sarcoma (ES), we performed reverse transcription-polymerase chain reaction (RT-PCR) analysis of tumor type-specific fusion gene transcripts. The SYT/SSX fusion transcript was identified in both the foot and lung lesions, whereas the EWS/FLI1 transcript was not detected in either lesion. Therefore, we concluded that the multiple bone and lung tumors were poorly differentiated metastatic tumors, which arose from the SS of the foot. We also conclude that the identification of chimeric fusion transcripts can be successfully applied to poorly differentiated sarcomas and will help in the differential diagnosis of tumors that cannot be distinguished by conventional morphological examinations. Also, it should be remembered that cytoplasmic staining for MIC2 protein may occur in sarcomas other than PNET/ES.

A case of menstruation-associated asthma: treatment with oral contraceptives

A menstrual rhythm has been documented for exacerbations of asthma, which may have important clinical relevance to the patient with severe asthma. We report the case of a 26-year-old patient with menstruation-associated asthma who showed a dramatic response to oral contraceptives. It was noted that falls in peak respiratory flow rate coincided with ovulation. We concluded that oral contraceptive therapy is useful in this particular group of asthmatic patients.

Histologic and immunohistochemical analysis of early submucosal invasive carcinoma of the colon and rectum

To investigate the development and progression of colorectal carcinoma, submucosal invasive carcinoma (SMC) with residual intramucosal neoplasm was studied histopathologically. Intramucosal neoplasm was confirmed by immunohistochemical staining against anti-alpha-smooth muscle actin antibody. Submucosal invasive carcinoma was classified into polypoid growth-type carcinoma (PGC) and non-polypoid growth-type carcinoma (NPGC), depending on the presence of intramucosal tumor proliferation. Tumors were > 15 mm in size in 78.2% of the PGC lesions studied, but the degree of submucosal invasion was minimal (invasion of the upper 500 microm of the submucosal layer) in 52.9% of the PGC lesions. Conversely, 64.4% of NPGC lesions were 15 mm in size and the degree of submucosal invasion was moderate or severe (involving the middle and deeper layer of the submucosa) for 72.9% of NPGC. In other words, lesions of NPGC were significantly smaller in size but showed deeper infiltration than PGC lesions. Furthermore, PGC was derived from intramucosal polypoid carcinoma (including carcinoma with adenoma) and was morphologically identical to polyp cancer as reported previously. However, NPGC was derived from the flat and/or depressed type of intramucosal carcinoma classified not as polyp type, but as the superficial type. Typical NPGC was, therefore, also of the superficial type. In addition, approximately 25% of PGC lesions were identified as having an adenoma-carcinoma sequence. There was no coexistence with adenoma in the NPGC lesions, suggesting de novo development. When the degree of histologic atypia in the two types of intramucosal carcinoma was compared, 74.7% of PGC lesions showed low-grade carcinoma, regardless of tumor size, while 62.7% of NPGC lesions showed high-grade carcinoma in the intramucosal lesion. Approximately 25% of carcinomas with low-grade atypia were positive for p53 (as were the high-grade lesions), but it was not expressed in the adenoma. Therefore, tumor development and the degree of invasion differed significantly between the two types of carcinoma.

Paraneoplastic vasculitis associated with esophageal carcinoma

We report a case of esophageal carcinoma associated with paraneoplastic vasculitis. A 69-year-old man suffered from low-grade fever and numbness of the lower limbs for 3 months before esophageal and gastric carcinomas were detected. Concurrent infection or collagen disease was ruled out following clinical and laboratory examinations. In April 1996, the gastric carcinoma was completely removed by endoscopic mucosal resection, but the symptoms remained. Three weeks later esophagectomy was performed for esophageal carcinoma after which time the fever and numbness disappeared. The esophageal carcinoma was a well-differentiated squamous cell carcinoma invading into the submucosal layer. Twenty-two lymph node metastases were found in 68 resected lymph nodes. Latent thyroid cancer was found. Histologically, vasculitis was detected in the esophagus, stomach and serratus anterior muscle. The distribution and degree of vasculitis were most pronounced in the esophagus. The concurrent onset and spontaneous resolution of fever and numbness after the removal of the esophageal carcinoma suggested a paraneoplastic origin. The majority of patients with malignant neoplasm-associated vasculitis had hematologic neoplasms. Cases of esophageal carcinoma associated with paraneoplastic vasculitis are extremely rare.

Clinicopathologic and immunohistochemical study of early colorectal cancer with liver metastases

Seven (3.3%) of 213 patients who underwent surgery for early colorectal cancer (invasion limited to no deeper than the submucosa) at the National Cancer Center Hospital, Tokyo, between 1986 and 1995 had synchronous (2 patients) or metachronous (5 patients) liver metastases. The average period from surgical resection of the primary colorectal cancer to the diagnosis of liver metastases was 25 months (range, 0-52 months). The clinicopathologic and immunohistochemical features of the primary lesions in these patients were compared with these features in the lesions in consecutive patients with early colorectal cancer who had no evidence of liver metastases within at least 5 years after colorectal resection. Venous invasion was more frequent in the primary lesions with liver metastases than in those without liver metastases (57% vs 0%; P = 0.0035). Expression of p53 and CD44v9 was more frequent in the primary lesions with liver metastases (71% and 100%) than in those without metastases (56% and 72%). In contrast, MUC2 expression was more frequent in the primary lesions without liver metastases (72%) than in those with metastases (43%). Venous invasion is considered to be closely related to liver metastasis, and the immunohistochemical expression of p53 and CD44v9 provides useful information for identifying those patients with early colorectal cancer who have a high risk of developing liver metastases.

Corticosteroid resistance in mild asthma: markers of persistent inflammation

BACKGROUND

Bronchial hyperresponsiveness (BHR) is an important feature of asthma. Glucocorticosteroids (GCS) reduce BHR, probably by suppressing allergic inflammation. There are, however, two groups of asthmatics with either GCS-responsive or non-responsive BHR to methacholine. We investigated the mechanism of non-GCS-responsive BHR in mild asthma.

METHODS

Non-GCS-responsive BHR asthma was defined as failure of reduction of BHR to methacholine after a 2-week course of oral prednisolone (30 mg/day). The expression of interleukin (IL)-4, IL-5, IFN-gamma mRNA in peripheral blood mononuclear cells, eosinophil count, serum cortisol, eosinophilic cationic protein (ECP), and spirometry were measured in five non-GCS-responsive BHR asthmatics and six patients with GCS-responsive BHR asthma before and after prednisolone therapy.

RESULTS

With the exception of serum ECP and expression of IL-5 mRNA, no significant differences were observed between GCS-responsive BHR and non-GCS-responsive BHR asthma. The mean ECP level was significantly higher in non-GCS-responsive BHR than in GCS-responsive BHR asthma before and after prednisolone therapy. Interleukin-5 mRNA was detected in all asthmatics before prednisolone therapy; however, after prednisolone therapy, IL-5 mRNA was only detected in non-GCS-responsive BHR asthmatics.

CONCLUSIONS

Our findings suggest that activation of eosinophils appears to persist in some asthmatics with non-GCS-responsive BHR due to continuous IL-5 production by lymphocytes.

Inhibitory effects of azelastine hydrochloride in alcohol-induced asthma

BACKGROUND

Alcohol-induced bronchoconstriction is due to high blood concentrations of acetaldehyde, a metabolic product of ethanol, which lead to the release of histamine from basophils and mast cells.

OBJECTIVE

We examined the inhibitory effects of azelastine hydrochloride, which inhibits histamine release and blocks H1 receptors, in alcohol-induced asthma.

METHODS

Subjects were 13 Japanese asthmatic patients. We measured the change in FEV1 after ingestion of 30 g of pure ethanol. Blood ethanol, acetaldehyde, histamine, leukotriene C4 (LTC4), and thromboxane B2 (TXB2) concentrations were also measured. Alcohol challenge test was repeated in responders after administration of azelastine for 1 week at 4 mg/day.

RESULTS

Of 13 asthmatic patients, five (38.5%) tested positive during an ethanol challenge test, represented by a fall more than 20% in FEV1. The responders had a high blood ethanol, and showed a rise in blood acetaldehyde and histamine concentrations, but not in LTC4 or TXB2. After azelastine treatment, there was no significant fall in FEV1 among responders. Neither the rise in blood ethanol nor blood acetaldehyde levels were blunted by treatment with azelastine, but the rise in blood histamine was blunted by this treatment.

CONCLUSION

Our results suggest that antihistamine agents may be effective against alcohol-induced asthma by both blocking H1 receptors and inhibiting histamine release.