PCNA and Ki-67 as prognostic markers in human parathyroid carcinomas

Evaluation of factors predicting postoperative recurrence and metastasis of parathyroid cancer: a single-center study

PURPOSE

The purpose of this study was to examine the postoperative clinical course of parathyroid carcinoma to determine factors that predict postoperative recurrence and distant metastasis.

METHODS

In this retrospective study, we included 38 patients with parathyroid carcinoma who received surgical intervention at Itoh Hospital between 1979 and 2020. Clinicopathologic characteristics (age, sex, intact PTH, serum Ca level, operation type, parathyroid weight, parathyroid size, histopathologic findings: vascular invasion, capsular invasion, necrosis, histological type, and Ki-67 staining) were used. The median follow-up observation period was 63.7 months.

RESULTS

Postoperatively, 5 patients (13.2%) developed distant metastasis or had localized recurrence, and 3 patients died (7.9%). The results of the univariate analysis revealed three factors affecting distant metastasis and recurrence, which were Ki-67 (p = 0.0041), the presence or absence of necrosis (p = 0.0163), and tumor weight (p = 00,189). Using the cutoff values obtained by ROC analysis, which were 4.1 for Ki-67 (sensitivity of 80% and specificity of 96.9%) and 4890 mg for tumor weight (sensitivity of 100% and specificity of 60.9%), we calculated the cumulative incidence of recurrence and distant metastasis by the three factors retained. We found that the presence of the three factors was associated with a high possibility of distant metastasis or recurrence during the 5-year follow-up period.

CONCLUSIONS

Three factors, Ki-67, necrosis, and tumor weight in parathyroid carcinoma, may predict outcomes of postoperative recurrence and distant metastasis.

Clinicopathological Profile of Primary Hyperparathyroidism with Special Reference to Ki-67 Labelling Index

Context

Primary hyperparathyroidism (PHPT) can occur due to a neoplastic process or hyperplasia. While the disease presentation is predominantly asymptomatic in developed countries, this is not the case yet in India. Differentiation of the type of lesion can only be done based on histomorphology but has its own challenges. Immunohistochemical markers like Ki-67 have been studied to aid in diagnosis but data on this is sparse from India.

Aims

The aim of this study is to assess the clinical, biochemical and pathological profile of PHPT and to analyse the differences in immunohistochemical marker Ki-67 among the various lesions.

Setting and Design

A descriptive study was carried out on 38 PHPT patients who were treated at our institute from January 2011 to March 2021.

Materials and Methods

Post-surgery, the causative lesions were categorised as adenoma (31), hyperplasia (5) and carcinoma (2). Clinical, biochemical, radiological and histopathological features of all lesions were collected and analysed. Ki-67 proliferation index was calculated. The various parameters were compared across the three groups of lesions and correlated with Ki-67 index.

Results

Out of 38 patients, 37 were symptomatic with skeletal symptoms being the most common followed by renal symptoms. There was no difference in clinical or biochemical parameters among the three types of lesions. Significant negative correlation was seen between serum iPTH and serum 25-OH Vitamin D levels (P0.006) The median Ki-67 index was found to be 0.40% in hyperplasia, 0.49% in adenoma and 5.84% in carcinoma.

Conclusion

PHPT still presents as an overtly symptomatic disease in India. Diagnosis of the nature of lesion depends on the accurate application of morphological criteria. A high Ki-67 index was not found to be an absolute marker of carcinoma, as it was also seen in a small proportion of atypical adenomas.

Immunohistochemistry in Diagnostic Parathyroid Pathology

Pathologists are usually readily able to diagnose parathyroid tissues and diseases, particularly when they have knowledge of the clinical information, laboratory findings, and radiographic imaging studies. However, the identification of parathyroid tissue or lesions can be difficult in small biopsies, ectopic locations, supranumerary glands, and in some oxyphil/oncocytic lesions. Widely available immunohistochemical studies such as chromogranin-A, synaptophysin, keratin, parathyroid hormone, thyroglobulin, and thyroid transcription factor-1 can help in difficult cases. One of the most difficult diagnostic aspects faced by the pathologist in evaluating parathyroid is distinguishing between parathyroid adenoma, particularly atypical adenoma, and parathyroid carcinoma. Many markers have and continue to be evaluated for diagnostic utility, and are even beginning to be studied for prognostic utility. Single immunohistochemical markers such as parafibromin and Ki-67 are among the most studied and most utilized, but many additional markers have and continue to be evaluated such as galectin-3, PGP9.5, Rb, bcl2, p27, hTERT, mdm2, and APC. Although not widely available in many laboratories, a panel of immunohistochemical markers may prove most useful as an adjunct in the evaluation of challenging parathyroid tumors.

Growth-stimulatory effect of resveratrol in human cancer cells

Earlier studies have shown that resveratrol could induce death in several human cancer cell lines in culture. Here we report our observation that resveratrol can also promote the growth of certain human cancer cells when they are grown either in culture or in athymic nude mice as xenografts. At relatively low concentrations (</=5 microM), resveratrol exerted a significant growth-stimulatory effect in the MDA-MB-435s human cancer cells, but this effect was not observed in several other human cell lines tested. Analysis of cell signaling molecules showed that resveratrol induced the activation of JNK, p38, Akt, and NF-kappaB signaling pathways in these cells. Further analysis using pharmacological inhibitors showed that only the NF-kappaB inhibitor (BAY11-7082) abrogated the growth-stimulatory effect of resveratrol in cultured cells. In athymic nude mice, resveratrol at 16.5 mg/kg body weight enhanced the growth of MDA-MB-435s xenografts compared to the control group, while resveratrol at the 33 mg/kg body weight dose did not have a similar effect. Additional analyses confirmed that resveratrol stimulated cancer cell growth in vivo through activation of the NF-kappaB signaling pathway. Taken together, these observations suggest that resveratrol at low concentrations could stimulate the growth of certain types of human cancer cells in vivo. This cell type-specific mitogenic effect of resveratrol may also partly contribute to the procarcinogenic effect of alcohol consumption (rich in resveratrol) in the development of certain human cancers.

Parathyroid carcinoma

Parathyroid carcinoma is a rare endocrine malignancy. The reported incidence is from 0.5 to 5% of primary hyperparathyroidism cases in various series. The cause is unknown, but clinical correlations with different genetic syndromes exist. Mutations in the HPRT2 gene seem to play a significant role in the pathogenesis of this disease. Men and women are equally affected, usually in the fourth or fifth decade of life. Most patients will present with signs and symptoms of hypercalcaemia. Cases of non-functioning carcinoma are exceedingly rare. Surgical resection is the most effective method of treatment and palliation. A significant proportion of patients will experience recurrence, and will need further surgical and, eventually, medical management of hypercalcaemia. The disease is progressive but slow growing. Most patients will require multiple operations to resect recurrent disease. The main cause of morbidity and mortality is the sequela of uncontrolled chronic hypercalcaemia rather than tumour burden. The current paper will review the epidemiology, pathogenesis, clinical presentation and diagnostic work-up of this disease. Surgical management in different scenarios is reviewed in detail, followed by other types of treatment and management of incurable disease.

Intrathyroidal Parathyroid Carcinoma as Cause of Hypercalcemia and Pitfall of Localization Techniques: Clinical and Biologic Features

OBJECTIVE

To describe an unusual case of intrathyroidal parathyroid carcinoma (PC), which was retrospectively diagnosed in a woman who underwent surgical treatment of a recurrent nodular goiter.

METHODS

We report the clinical and biologic features of an intrathyroidal PC, discuss the challenges with distinguishing PC from parathyroid adenoma, and review the related literature.

RESULTS

A 67-year-old woman sought medical attention for dysphagia attributable to the recurrence of a normal functioning multinodular goiter. Thyroid ultrasonography disclosed a 3-cm solid inferior nodule. Because she refused surgical treatment and a trial of levothyroxine was unsuccessful, periodic follow-up examinations were scheduled. At 1-year follow-up, hypercalcemia (12.1 to 12.6 mg/dL) and low phosphorus levels (2.0 to 2.3 mg/dL) were found, and parathyroid hormone (PTH) levels were profoundly increased (481 to 721 pg/mL). Neck ultrasonography showed a large hypoechogenic solid nodule, not clearly cleaved from the right thyroid lobe, which was possibly compatible with an enlarged parathyroid gland; however, a sestamibi scan was negative. During total thyroidectomy, intraoperative frozen sections of the intrathyroid nodule were compatible with nodular goiter with cellular pleomorphism. Final histologic examination showed cellular nests with nuclear pleomorphism and invasive behavior into the thyroid tissue and likely into the vessels, in conjunction with immunohistochemical negativity for thyroglobulin and strong positivity for PTH. These findings were highly suggestive of and supported the diagnosis of PC. Postoperatively, calcium levels normalized, and PTH values declined considerably but remained slightly increased. Vitamin D supplementation helped normalize the PTH levels. The patient has undergone follow-up for 5 years and has shown no morphologic or biochemical signs of tumor recurrence.

CONCLUSION

PC is a rare entity but should be suspected in patients with hypercalcemia, substantially increased PTH levels, and a neck mass. In such patients, techniques such as sestamibi scanning may fail to localize the neoplasm. Surgical treatment remains the preferred technique for an optimal outcome of the disease. Nevertheless, lifelong follow-up is necessary.

Effects of 2-methoxyestradiol on endometrial carcinoma xenografts

PURPOSE

We have previously demonstrated that 2-methoxyestradiol (2-ME) inhibits the growth of human endometrial cancer HEC-1-A and RL-95-2 cells in vitro. In this study, we examined the effects of 2-ME on human endometrial carcinoma in severe combined immune deficient (SCID) mice. The potential side effects of 2-ME on SCID mice were also investigated.

METHODS

Severe combined immune deficient mice were injected with HEC-1-A cells (1 x 10(6)/mouse) and a 18 day administration of 2-ME was followed after 1 week cell implantation. Tumor volume, weight, body weight and blood chemistry were determined. Tumor tissues were examined with an antibody against the proliferative cell nuclear antigen (PCNA) and Ki-67. Liver, spleen, kidney, heart, lung and uterus were screened by pathological examinations.

RESULTS

2-ME (100 mg/kg p.o.) did not inhibit the growth of human endometrial carcinoma as compared to control. Necrotic areas were similar in both 2-ME-treated and -untreated tumor tissues. The expressions of PCNA and Ki-67 were similar in 2-ME-treated and untreated tumor sections. The wet weight of uterus was increased to more than threefold. The epithelial cells and glands in endometrium were increased. No significant difference was detected in blood AST, ALT and BUN.

CONCLUSIONS

2-ME has no antitumor effects on human endometrial carcinoma in our animal model. Its proliferative effects on endometrium and uterus might limit its use in gynecological cancers.

Prognostic and predictive factors in endocrine tumours

This review encompasses the diagnostic features of malignancy, the routinely observable prognostic features and the prognostic and predictive features emerging from research techniques in the principal endocrine neoplasms: pancreatic and extrapancreatic endocrine cell tumours, thyroid and parathyroid neoplasia, adrenal cortical neoplasms and adrenal and extra-adrenal paragangliomas. While each endocrine tissue has its own set of diagnostic features for malignancy, and prognostic features once a diagnosis of malignancy has been established, there are a few common themes. For several endocrine neoplasms, definite recognition of malignancy can be difficult and may depend upon frank invasive or metastatic growth at presentation. Endocrine tissues are dynamic, with hyperplastic and regressive phenomena, some of which may mimic malignancy. Even when unequivocal features of malignancy are available for observation, their distribution in tissue may be very focal, necessitating thorough sampling. The accurate documentation of routinely observable histological features interpreted in the light of current literature has not been superseded by special techniques in the statement of diagnosis or prognosis in the vast majority of endocrine neoplasms.

Parathyroid carcinoma

BACKGROUND

Parathyroid carcinoma is a rare malignancy affecting 0.5-5 per cent of all patients with primary hyperparathyroidism. This article reviews the literature on the pathogenesis, pathology, clinical features, diagnosis and management of parathyroid carcinoma.

METHODS

A Medline search was performed and all relevant English language articles published between 1970 and 2005 were retrieved. The search words included 'parathyroid carcinoma', 'pathology', 'genetics', 'management' and 'radiotherapy'. Secondary references were obtained from key articles.

RESULTS AND CONCLUSION

The exact aetiology of parathyroid carcinoma remains obscure. Recently, the HRPT2 gene has been implicated in its pathogenesis and may prove to be a genetic target in future. Surgical resection is the accepted 'gold standard'. There is now a growing consensus on the use of adjuvant radiotherapy as it has been shown to provide a survival benefit.

Antiproliferative activity and toxicity of 2-methoxyestradiol in cervical cancer xenograft mice

2-methoxyestradiol (2-ME) is considered to be an effective anticancer compound for many types of tumors. We have previously demonstrated that 2-ME inhibits the growth of human cervical cancer HeLaS3 cells in vitro. In this study, we investigated the antitumoral effects of 2-ME on human cervical carcinoma in severe combined immune deficient (SCID) mice. The potential side effects of 2-ME on the SCID mice were also investigated. SCID mice were injected with HeLaS3 cells (3 x 10(6) to 4 x 10(6)/mouse) and a 15-day administration of 2-ME followed after a 1-week cell implantation. Tumor weight, volume, body weight, and blood chemistry were determined. Tumor tissues were examined with an antibody against the proliferative cell nuclear antigen and terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) staining. Liver, spleen, kidney, heart, and lung were screened by pathologic examinations. 2-ME (75 mg/kg p.o.) inhibited growth of human cervical carcinoma by 34% (P < 0.05) as compared with control. Necrosis was found in both 2-ME-treated and untreated tumor tissues, but the necrotic area was larger in 2-ME-treated mice. A low expression of proliferative cell nuclear antigen and an increased number of apoptotic cells were found in 2-ME-treated tumor sections as compared to those in controls. No significant difference was detected in blood chemistry. In addition, the liver showed hyperplastic Kupffer cells, hydropic swelling of hepatocytes, and liquefactive necrosis. The spleen showed an increased number of megakaryocytes and apoptotic cells after 2-ME treatment. Thus, 2-ME has an antitumor effect on human cervical carcinoma, and it is toxic to liver and spleen in this mouse model.

Best practice no 183. Examination of parathyroid gland specimens

The pathological examination of parathyroid glands is an essential component of the evaluation of hyperparathyroidism. Traditionally, this has involved intraoperative frozen sections during bilateral surgical exploration of the neck, to confirm removal of parathyroid tissue. With recent developments in imaging, some diseased glands can be localised preoperatively, enabling removal by minimally invasive, targetted surgery, with or without additional non-histological intraoperative procedures to confirm the removal of all hyperfunctioning parathyroid tissue. This article reviews these developments and describes the ideal approach to reporting parathyroid specimens.

One stage treatment of parathyroid cancer

AIM

To review the methods of treating parathyroid cancer in our series and report successful use of intraoperative frozen section to enable one stage surgical management.

METHOD

Seven cases of parathyroid cancer presented from 1991-2002. The presenting features, diagnosis and treatment are presented. They are separated into two groups based on method of referral and treatment.

RESULTS

Patients presented with symptoms of hypercalcaemia. Median corrected calcium was 3.49 mmol/l. Parathyroid hormone levels were raised in seven of eight cases, range 14.5-495 pmol/l. A high index of pre-operative suspicion and use of frozen section enabled a one step surgical procedure. Recurrence was impossible to treat successfully. Radiotherapy appeared successful for residual disease.

CONCLUSION

A high pre-operative index of suspicion for parathyroid carcinoma with use of frozen section at time of operation permits an optimal one step surgical procedure by en bloc resection followed by central lymph node excision. In cases where diagnosis has been made post-operatively radiotherapy may be beneficial.

Parathyroid carcinoma: an overview

Parathyroid carcinoma is a rare tumor that is responsible for <1% of cases of hyperparathyroidism in most parts of the world. An increased incidence of this tumor has been reported in patients with the hyperparathyroidism-jaw tumor (HPT-JT) syndrome, but the etiology of most other cases is unknown. Parathyroid carcinomas tend to occur a decade earlier than adenomas, and the sex ratio approaches unity in contrast to the female preponderance of adenomas. Most patients with carcinomas present with marked hypercalcemia and are more likely to have associated bone and renal disease than those with adenomas. Although fibrosis and mitotic activity are common in carcinomas, these features are not specific for malignancy. The diagnosis of carcinoma should be restricted to those tumors that show invasion of blood vessels, perineural spaces, soft tissues, thyroid gland, or other adjacent structures or to tumors with documented metastases. Mutations of the HRPT2 gene (1q21-q32), which are responsible for the HPT-JT syndrome, have been implicated in the development of a high proportion of parathyroid carcinomas. A subset of patients with mutation-positive carcinomas have germline mutations of the HRPT2 gene. This finding suggests that some patients with apparent sporadic parathyroid carcinomas may have the HPT-JT syndrome or a variant of this syndrome. Because of the high frequency of local recurrence following incomplete excision, an en bloc resection is the preferred surgical approach for treatment of parathyroid carcinomas.

Cytologic comparison of a primary parathyroid cancer and its metastatic lesions: A case report

We describe the fine-needle aspiration cytology features of a primary parathyroid cancer and of the local recurrent and distant metastatic lesions. The presence of prognostic factors Ki-67 and proliferating cell nuclear antigen (PCNA) was compared immunohistochemically between primary parathyroid carcinoma and related metastatic and recurrent foci. Flow cytometric DNA analysis was also performed to investigate any chromosomal abnormality of the parathyroid carcinoma. Cytologic examination of the endocrine tumor showed that it comprised a loose cohesive cluster and tumor cells with granular cytoplasm and mild nuclear atypia, but for purposes of cytodiagnosis, it is difficult to determine whether such a neoplasm is malignant on the basis of morphology alone. Immunohistochemical analysis showed that Ki-67 and PCNA labeling indices were higher in the recurrent and metastasized carcinomas than in the primary cancer, suggesting that neoplastic cells become more malignant in the recurrent and metastasized foci. To our knowledge, this is the first report describing not only cytopathologic but also immunocytologic differences between primary parathyroid cancer and the metastatic lesion.

Up-to-date on parathyroid carcinoma: analysis of an experience of 19 cases

BACKGROUND AND OBJECTIVES

Parathyroid carcinoma (PC) is a rare disease; experience with its management is limited. The aim of this retrospective study was to evaluate a relatively large series of patients suffering from PC.

METHODS

Since 1980, PC was diagnosed in the 4.7% of cases of primary hyperparathyroidism (HPT) (19 patients). Clinical and biochemical features, and surgical outcome were analyzed.

RESULTS

In patients with PC, the mean serum calcium was 3.34 mmol/L; the tumor size 30.5 mm. Malignancy was never diagnosed preoperatively. Thirty-two operations were performed; six patients underwent repeated surgery. Recurrence of HPT was observed in 100% of patients. The median disease-free interval was 15 months (range 2-74 months). Fifteen patients died because of the disease; median survival was 29 months (range 20-146 months). A significant correlation was found between late recurrences and prolonged survival; less advanced age and higher preoperative calcium levels predicted early recurrences.

CONCLUSIONS

Preoperative diagnosis of PC is difficult. Preoperative severe hypercalcemia should alert the surgeon. En bloc resection of the PC and the adjacent structures is the treatment of choice. Unfortunately, recurrences are common and long-term survival rate is low.

The management of parathyroid carcinoma

PURPOSE OF REVIEW

To summarize the current treatment approaches to parathyroid malignancy.

RECENT FINDINGS

Recent advances in molecular biology are aiding the understanding of the pathogenesis of this condition, and imaging modalities are contributing to localization of the abnormal parathyroid tissue.

SUMMARY

The treatment of parathyroid malignancy is overwhelmingly surgical, comprising an initial en bloc resection of the tumor and adjacent structures. The risk of tumor recurrence is high and may require several metastasis resections in order to control symptoms of hypercalcemia.

Apoptosis and proliferation of hepatocellular carcinoma in nude mice with percutaneous intratumor injection of Chinese herbal medicine "Star-99"

AIM

To probe the anti-cancer effect of ultrasound-guided local injection with Chinese traditional medicine "Star-99" in the treatment of hepatocellular carcinoma (HCC).

METHODS

Twenty-eight human hepatocellular carcinoma SMMC-7721 transplantation nude mice were randomly divided into Star-99 group containing (14 patterns), ethanol group (7 patients) and saline group (7 patterns ). Ten days after transplantation, the medicine was injected into the tumors of all the nude mice every 5 days. On day 20 after the first injection, the nude mice were killed. Immunohistochemistry assay was adopted to detect the expression of Ki-67 antigen in HCC. The tumor tissues were sent for flow cytometry (FCM) and DNA analysis. Apoptotic cells were visualized by TUNEL assay. All the experiments were carried out under double blind.

RESULTS

The Ki-67 Labeling index in Star-99 group (17±9 %) and ethanol group (21±11 %) was significantly lower than that in saline group (32±13 %) (P <0.05). The mean apoptotic index (AI: percentage of TUNEL signal positive cells) in Star-99 group (49±5 %) was significantly higher than that in ethanol group (12±2 %) and the saline group (10±4 %) (P <0.01). FCM and DNA analysis showed that the appearance rate of the apoptosis peak in Srar-99 group was 93 %, markedly higher than that in ethanol group (14 %) and saline group (0 %) (P <0.01).

CONCLUSION

Star-99 can inhibit cancer cells proliferation remarkably and induce the cancer cell apoptosis. It has strong effects of inhibiting and destructing cancer cells. Its curative effect is as good as the ethanol. Its major mechanisms can be as follows: (1) It can inhibit cancer cell proliferation. (2) It can induce cancer cell apoptosis. The mechanism of Star-99 is different from that of ethanol.The mechanisms of inhibiting cancer cell proliferation and inducing cell apoptosis is of great significance. This study will provide a new pathway for drug administration and an experimental basis for the treatment of HCC with traditional Chinese herbal. The study of Star-99 in the treatment of tumor is of profound significance and has good prospects.

Parathyroid neoplasms: clinical, histopathological, and tissue microarray-based molecular analysis

We studied 45 patients with typical and 8 with atypical parathyroid adenomas as well as 20 with parathyroid carcinomas. Clinical, pathological, and molecular analyses were conducted on all adenomas. Clinical data were analyzed for 20, histopathologic slides for 16, and tissue specimens for 8 patients with carcinoma. Molecular expression profiles were investigated by immunohistochemistry (IHC) for Ki-67, p53, mdm2, p21, Bcl-2, cyclin D1, and p27 on paraffin-embedded tissues arrayed on tissue microarrays. Trabecular growth and vascular, capsular, and soft-tissue invasion were characteristic of parathyroid carcinomas but not of typical adenomas. No adenomas recurred. Seventy-four percent of carcinomas recurred, most in the neck. Seventy-nine percent of patients with such illness died of disease after an indolent, multiply recurrent course responsive to repeated resections; the 5-year survival rate was 50%. High Ki-67 proliferative index was seen in 2% of adenomas and 25% of carcinomas, whereas p27 expression was present in 80% of adenomas and 18% of carcinomas. The molecular phenotype, p27(+)Bcl-2(+)Ki-67(-)mdm2(+), was observed in 76%, 29%, and 0% of typical and atypical adenomas and carcinomas, respectively. The complexity of molecular phenotypes increased with tumor aggressiveness. Parathyroid carcinoma is an aggressive disease with a propensity for multiple recurrences. It is characterized by capsular, vascular, and soft-tissue invasion. Recurrence portends poor outcome. Molecular markers, Ki-67 and p27, may distinguish parathyroid carcinoma from adenoma. The molecular phenotype, p27(+)Bcl-2(+)Ki-67(-)mdm2(+), appears to be unique to nonmalignant parathyroid tumors, and multimarker phenotypes are more complex in carcinomas.