Identification of gastroenteropancreatic neuroendocrine cells in normal and neoplastic human tissue with antibodies against synaptophysin, chromogranin A, secretogranin I (chromogranin B), and secretogranin II

Hirschsprung-associated enterocolitis: a comprehensive review

Hirschsprung-associated enterocolitis (HAEC) is an important cause of morbidity and the leading cause of mortality in patients with Hirschsprung disease. The pathophysiology of disease includes dysmotility of the enteric nervous system, dysbiosis of the microbiota, failure of the intestinal barrier, and impaired immunity. Common manifestations include fever, abdominal distension, lethargy, vomiting, and diarrhea. Given the non-specific signs and symptoms of HAEC, high clinical suspicion is warranted, especially in patients with risk factors. Diagnosis and management of HAEC depend on the severity of disease presentation. Several preoperative and postoperative modalities have been explored to prevent HAEC. The current review elaborates on the risk factors, pathogenesis, diagnosis, treatment, and prevention of HAEC.

Molecular classification and tumor microenvironment characteristics in pheochromocytomas

Pheochromocytomas (PCCs) are rare neuroendocrine tumors that originate from chromaffin cells in the adrenal gland. However, the cellular molecular characteristics and immune microenvironment of PCCs are incompletely understood. Here, we performed single-cell RNA sequencing (scRNA-seq) on 16 tissues from 4 sporadic unclassified PCC patients and 1 hereditary PCC patient with Von Hippel-Lindau (VHL) syndrome. We found that intra-tumoral heterogeneity was less extensive than the inter-individual heterogeneity of PCCs. Further, the unclassified PCC patients were divided into two types, metabolism-type (marked by NDUFA4L2 and COX4I2) and kinase-type (marked by RET and PNMT), validated by immunohistochemical staining. Trajectory analysis of tumor evolution revealed that metabolism-type PCC cells display phenotype of consistently active metabolism and increased metastasis potential, while kinase-type PCC cells showed decreased epinephrine synthesis and neuron-like phenotypes. Cell-cell communication analysis showed activation of the annexin pathway and a strong inflammation reaction in metabolism-type PCCs and activation of FGF signaling in the kinase-type PCC. Although multispectral immunofluorescence staining showed a lack of CD8+ T cell infiltration in both metabolism-type and kinase-type PCCs, only the kinase-type PCC exhibited downregulation of HLA-I molecules that possibly regulated by RET, suggesting the potential of combined therapy with kinase inhibitors and immunotherapy for kinase-type PCCs; in contrast, the application of immunotherapy to metabolism-type PCCs (with antigen presentation ability) is likely unsuitable. Our study presents a single-cell transcriptomics-based molecular classification and microenvironment characterization of PCCs, providing clues for potential therapeutic strategies to treat PCCs.

Current understanding of Hirschsprung-associated enterocolitis: Pathogenesis, diagnosis and treatment

Hirschsprung-associated enterocolitis (HAEC) was described in 1886 by Harald Hirschsprung and is a potentially deadly complication of Hirschsprung Disease. HAEC is classically characterized by abdominal distension, fever, and diarrhea, although there can be a variety of other associated symptoms, including colicky abdominal pain, lethargy, and the passage of blood-stained stools. HAEC occurs both pre-operatively and post-operatively, is the presenting symptom of HSCR in up to 25% of infants and varies in overall incidence from 20 to 60%. This article reviews our current understanding of HAEC pathogenesis, diagnosis, and treatment with discussion of areas of ongoing research, controversy, and future investigation.

Epigenetic modifier balances Mapk and Wnt signalling in differentiation of goblet and Paneth cells

The histone methyltransferase Mll1 controls intestinal secretory cell fate by promoting Wnt-driven Paneth and restricting Mapk-dependent goblet cell differentiation through regulation of Gata4/6 transcription factors

Differentiation and lineage specification are controlled by cooperation of growth factor signalling. The involvement of epigenetic regulators in lineage specification remains largely elusive. Here, we show that the histone methyltransferase Mll1 prevents intestinal progenitor cells from differentiation, whereas it is also involved in secretory lineage specification of Paneth and goblet cells. Using conditional mutagenesis in mice and intestinal organoids, we demonstrate that loss of Mll1 renders intestinal progenitor cells permissive for Wnt-driven secretory differentiation. However, Mll1-deficient crypt cells fail to segregate Paneth and goblet cell fates. Mll1 deficiency causes Paneth cell-determined crypt progenitors to exhibit goblet cell features by unleashing Mapk signalling, resulting in increased numbers of mixed Paneth/goblet cells. We show that loss of Mll1 abolishes the pro-proliferative effect of Mapk signalling in intestinal progenitor cells and promotes Mapk-induced goblet cell differentiation. Our data uncover Mll1 and its downstream targets Gata4/6 as a regulatory hub of Wnt and Mapk signalling in the control of lineage specification of intestinal secretory Paneth and goblet cells.

Histopathological Chromogranin A-Positivity Is Associated with Right-Sided Colorectal Cancers and Worse Prognosis

Simple Summary

Several factors are known to affect colorectal cancer (CRC) patient survival, including elevated platelet counts (thrombocytosis) and chromogranin A-positive neuroendocrine-cell differentiation (CgA⁺). Thrombocytosis can occur due to biochemical changes caused by the tumor itself (known as paraneoplastic thrombocytosis) or due to the bleeding of the tumor (reactive thrombocytosis). Our effort was primarily focused on (1) determining if CgA⁺ and paraneoplastic thrombocytosis combined can affect CRC and (2) finding out if there is a possible connection between the two. With the help of chromogranin A immunohistochemical staining, the measurement of circulating biochemical markers of paraneoplastic thrombocytosis (interleukin-6 and thrombopoietin) and chromogranins A and -B, indication was found that CRC combined with CgA⁺ has a well-distinguishable pathophysiology, compared to CRCs without CgA⁺. A possible, new subtype of CRC is proposed, which can be identified easily with chromogranin A immunohistochemical staining. However, its impact should be further studied.

Abstract

Background: Colorectal cancer (CRC) is known to be affected by paraneoplastic thrombocytosis and chromogranin A-positive neuroendocrine-cell differentiation (CgA⁺). Their combined effect has never been previously investigated. Methods: A prospective cohort pilot study of 42 CRC patients and 42 age- and sex-matched controls was carried out. Plasma interleukin-6, thrombopoietin, and serum chromogranin A and -B were measured; furthermore, tumor tissue was immunohistochemically stained for CgA⁺. Results: Twenty-seven and 15 patients were assigned to the chromogranin A-negative (CgA⁻) and CgA⁺ groups, respectively. Within the CgA⁺ group, right-sided tumors were more frequent (18.5% vs. 53.3%), no stage I cancer was found, and patients of this group were in worse general condition. Compared to control subjects, chromogranin A level was higher in the CgA⁺ group (p = 0.0086), thrombopoietin (p = 0.0040) and chromogranin B (p = 0.0070) in the CgA⁻ group, while interleukin-6 was high in both tumor groups (p ≤ 0.0090). Survival was significantly worse in the CgA⁺ group (hazard ratio: 5.73; p = 0.0378). Conclusions: Different thrombopoietin levels indicated distinct thrombocytosis types. Within the two CRC groups, serum levels of chromogranins changed in different directions suggesting two well-distinguishable pathophysiologies. Based on these observations we propose a new subtype of CRC, which can be characterized by chromogranin A-positive neuroendocrine-cell differentiation.

The functioning side of the pancreas: a review on insulinomas

PURPOSE

Insulinomas are a rare type of neuroendocrine tumors, originating in the pancreas, difficult to diagnose and to treat. Due to its rarity, insulinomas are a not well-known pathological entity; thus, the diagnostic process is frequently a medical challenge with many possible differential diagnoses. The diagnostic process varies between non-invasive procedures, such as the fasting test or imaging techniques, and invasive ones. Insulinomas are rarely malignant, but the glycemic imbalance correlated with this tumor can frequently alter the quality of life of the patients and the consequent hypoglycemia can be extremely dangerous. Moreover, insulinomas can be associated with different genetic syndromes, such as Multiple Endocrine Neoplasia 1, accompanied by other specific symptoms. There are many different treatment strategies, depending on the need to control symptoms or control diseases progression, the only curative one being surgery.

METHODS AND RESULTS

We reviewed the evidences present in the literature on insulinomas and reported its main clinical characteristics and management strategies.

CONCLUSION

The aim of this review of the literature is to present the current knowledge on insulinomas, exploring the main clinical characteristics, the diagnostic tools, and the therapeutic strategies.

Uniform and Robust Nuclear Expression of HES1 in Neuroendocrine Neoplasms

Introduction. Neuroendocrine neoplasms (NENs) are neoplasms that most commonly arise from gastrointestinal tract, pancreas, and lung. HES1 is a downstream target of Notch signaling pathway. The current literature about HES1 expression in NENs is sparse and inconsistent. Methods. In this study, we evaluated HES1 expression by immunohistochemistry in a total of 32 cases of NENs, including 13 well-differentiated neuroendocrine tumors from gastrointestinal tract, 10 cases of well-differentiated neuroendocrine tumors of pancreas, 9 cases from lung, including 4 cases of typical carcinoid, 1 case of atypical carcinoid, and 4 cases of neuroendocrine carcinoma. The intensity of the stain was scored from - to +++, and the distribution of the staining of HES1 was evaluated. Results. HES1 demonstrates uniform robust (+++) nuclear staining pattern in the tumor cells of all the NENs (32/32), regardless of the origin of the system and the grade of the tumor. Conclusions. HES1 is uniformly expressed in NENs with robust nuclear expression pattern. Our finding suggests that NOTCH1 or HES1 inhibitor is a potential therapeutic choice for neuroendocrine neoplasms.

Pancreatic neuroendocrine tumor: review of heterogeneous spectrum of CT appearance

OBJECTIVE

Pancreatic neuroendocrine tumors (PanNETs) are uncommon pancreatic neoplasms and can be a diagnostic challenge with heterogeneous spectrum of CT appearance. We review CT findings of PanNETs and other mimics.

CONCLUSION

PanNETs are typically hypervascular and have avid enhancement on arterial and venous phase images. However, dedicated pancreas protocol may be needed due to their sometimes atypical appearance including transient enhancement. Careful evaluation of CT findings will help differentiate PanNETs from their mimics, and can be used to establish the diagnosis of a PanNETs. Although an accurate diagnosis can be based on serological, urine, and CT scan findings, confirmation is made via pathological examination.

Chromogranin-A Expression in Neoplastic Neuroendocrine Cells and Prognosis in Colorectal Cancer

Aims

Chromogranin-A (CG), a cytoplasmic glycoprotein, is one of the markers most frequently used to identify the presence of neuroendocrine cells in the human gastrointestinal tract. Several authors have identified a subgroup of colorectal cancer patients with a severe prognosis whose tumors contained neuroendocrine CG-positive cells. In the present study, CG expression in 100 patients with colorectal adenocarcinoma treated from January 1983 to December 1988 with potentially curative surgery was analyzed and correlated with other prognostic factors and 5-year survival rate.

Methods

Samples tested immunohistochemically for CG were divided into three groups: I) negative; II) less than 1 CG-positive cell/mm2; III) more than 1 CG-positive cell/mm2.

Results

Of 100 patients with primary colorectal adenocarcinoma, 79% had tumors comprised of CG-negative cells, 17% had rare CG-positive cells, and 4% of cases could be classified in group III. No significant relation between CG expression and location of primary tumor, bowel wall infiltration, stage of disease or tumor grade according to Broders and Jass was observed. The 5-year survival was 53% and 52% for CG-positive and CG-negative lesions, respectively. Survival of patients with Dukes-Kirklin stage C and D was comparable in patients with CG-positive (33.3%) and CG-negative (30%) tumors.

Conclusions

CG expression cannot, at present, be recommended as a marker to identify prognostic subgroups in colorectal cancer patients.

Gastrin and Gastric Cancer

Gastric cancer although occurring in reduced frequency is still an important disease, partly because of the bad prognosis when occurring in western countries. This decline in occurrence may mainly be due to the reduced prevalence of Helicobacter pylori (Hp) infection, which is the most important cause of gastric cancer. There exist many different pathological classifications of gastric carcinomas, but the most useful seems to be the one by Lauren into intestinal and diffuse types since these types seldom transform into the other and also have different epidemiology. During the nearly 30 years that have passed since the groundbreaking description of Hp as the cause of gastritis and gastric cancer, a continuous search for the mechanism by which Hp infection causes gastric cancer has been done. Interestingly, it is mainly atrophic gastritis of the oxyntic mucosa that predisposes to gastric cancer possibly by inducing hypoacidity and hypergastrinemia. There are many arguments in favor of an important role of gastrin and its target cell, the enterochromaffin-like cell, in gastric carcinogenesis. The role of gastrin in gastric carcinogenesis implies caution in the long-term treatment with inhibitors of gastric acid secretion inducing secondary hypergastrinemia, in a common disease like gastroesophageal reflux disease.

25 Years of neuroendocrine neoplasms of the gastrointestinal tract

This paper provides a personal pathologist's view of how neuroendocrine tumors (NET) were perceived and defined in the last quarter of a century. In years when the Helicobacter pylori, omeprazole and the adenoma-carcinoma sequence in colon carcinogenesis significantly impacted on gastrointestinal (GI) pathology daily practice, neuroendocrine neoplasms of the GI tract passed from the original carcinoid definition to the current NET and neuroendocrine carcinoma (NEC) definitions. The development of different concepts, basic tumor biology knowledge, tools for pathology diagnosis and the various World Health Organization (WHO) classifications from 1980 through 2010 are briefly reviewed and discussed.

The clinical implications and biologic relevance of neurofilament expression in gastroenteropancreatic neuroendocrine neoplasms

BACKGROUND

Although gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) exhibit widely divergent behavior, limited biologic information (apart from Ki-67) is available to characterize malignancy. Therefore, the identification of alternative biomarkers is a key unmet need. Given the role of internexin alpha (INA) in neuronal development, the authors assessed its function in neuroendocrine cell systems and the clinical implications of its expression as a GEP-NEN biomarker.

METHODS

Functional assays were undertaken to investigate the mechanistic role of INA in the pancreatic BON cell line. Expression levels of INA were investigated in 50 pancreatic NENs (43 primaries, 7 metastases), 43 small intestinal NENs (25 primaries, 18 metastases), normal pancreas (n = 10), small intestinal mucosa (n = 16), normal enterochromaffin (EC) cells (n = 9), mouse xenografts (n = 4) and NEN cell lines (n = 6) using quantitative polymerase chain reaction, Western blot, and immunostaining analyses.

RESULTS

In BON cells, decreased levels of INA messenger RNA and protein were associated with the inhibition of both proliferation and mitogen-activated protein kinase (MAPK) signaling. INA was not expressed in normal neuroendocrine cells but was overexpressed (from 2-fold to 42-fold) in NEN cell lines and murine xenografts. In pancreatic NENs, INA was overexpressed compared with pancreatic adenocarcinomas and normal pancreas (27-fold [P = .0001], and 9-fold [P = .02], respectively). INA transcripts were correlated positively with Ki-67 (correlation coefficient [r] = 0.5; P < .0001) and chromogranin A (r = 0.59; P < .0001). INA distinguished between primary tumors and metastases (P = .02), and its expression was correlated with tumor size, infiltration, and grade (P < .05).

CONCLUSIONS

INA is a novel NEN biomarker, and its expression was associated with MAPK signaling and proliferation. In clinical samples, elevated INA was correlated with Ki-67 and identified malignancy. INA may provide additional biologic information relevant to delineation of both pancreatic NEN tumor phenotypes and clinical behavior.

Neuroendocrine neoplasms of the gut and pancreas: new insights

Neuroendocrine neoplasms arise in almost every organ of the body and are variably defined according to the site of origin. This Review focuses on neuroendocrine neoplasms of the digestive tract and pancreas. The 2010 WHO classification of tumors of the digestive system introduces grading and staging tools for neuroendocrine neoplasms. A carcinoid is now defined as a grade 1 or 2 neuroendocrine tumor and grade 3, small-cell or large-cell carcinomas are defined as neuroendocrine carcinoma. Epidemiological data show a worldwide increase in the prevalence and incidence of gastroentero-pancreatic neuroendocrine tumors in the past few decades, which is probably due to improved methods of detection of these tumors. The current diagnostic procedures and treatment options for neuroendocrine neoplasms are defined and summarized in the Review, although evidence-based data are lacking. Surgery remains the treatment mainstay and somatostatin analogues the basis for both diagnosis and therapy as the only 'theranostic' tool. Emerging compounds including chemotherapeutic agents, small molecules and biological therapies may provide new hope for patients.

Secretogranin III in human neuroendocrine tumours: a comparative immunohistochemical study with chromogranins A and B and secretogranin II

BACKGROUND

Different epitopes of the granin family of proteins, chromogranin (Cg) A, CgB and secretogranin (Sg) II, have been demonstrated in normal human pancreas, gastrointestinal tract, adrenal medulla and in several neuroendocrine tumours (NETs). SgIII has been recently reported in endocrine pancreas. The aim of the present study was to examine the expression of SgIII in different NETs and compare it with the expression of CgA, CgB and SgII epitopes.

MATERIAL AND METHODS

Tissue specimens from 47 NETs were analyzed. Antibodies to CgA 250-284, CgB 244-255, SgII 172-186 (C-terminal secretoneurin) and SgIII 348-361 were used for immunostaining.

RESULTS

SgIII was expressed in 41 of 47 NETs. The expression of SgIII agreed well with that of CgA, CgB and SgII, with exceptions of phaeochromocytomas, where more CgB and SgII immunoreactive cells were observed and parathyroid adenomas, which were only stained by CgA. In rectal NETs more cells expressed SgIII than CgA.

CONCLUSIONS

This is the first report on SgIII expression in various NETs. A majority of tumours studied displayed SgIII immunostaining, which indicates a functional relationship with the other granins.

Granins and granin-related peptides in neuroendocrine tumours

This review focus on neuroendocrine tumours (NETs), with special reference to the immunohistochemical analysis of granins and granin-related peptides and their usefulness in identifying and characterizing the great diversity of NET types. Granins, their derived peptides, and complex protein-processing enzyme systems that cleave granins and prohormones, have to some extent cell-specific expression patterns in normal and neoplastic NE cells. The marker most commonly used in routine histopathology to differentiate between non-NETs and NETs is chromogranin (Cg) A, to some extent CgB. Other members of the granin family may also be of diagnostic value by identifying special NET types, e.g. secretogranin (Sg) VI was only found in pancreatic NETs and phaeochromocytomas. SgIII has recently arisen as an important NET marker; it was strongly expressed in NETs, with some exceptions--phaeochromocytomas expressed few cells and parathyroid adenomas none. Some expression patterns of granin-related peptides seem valuable in differentiating between some benign and malignant NETs, some may also provide prognostic information, among which: well-differentiated NET types expressed more CgA epitopes than the poorly differentiated ones, except insulinomas, where the opposite was noted; medullary thyroid carcinomas containing few cells immunoreactive to a CgB antibody were related to a bad prognosis; C-terminal secretoneurin visualized a cell type related to malignancy in phaeochromocytomas. Further research will probably establish new staining patterns with marker functions for granins in NETs which may be of histopathological diagnostic value.

Recently identified a novel neuropeptide manserin colocalize with the TUNEL-positive cells in the top villi of the rat duodenum

We recently isolated a novel 40 amino acid neuropeptide designated manserin from the rat brain. Manserin is derived from secretogranin II, a member of granin acidic secretory protein family by proteolytic processing, as previously reported secretoneurin and EM66. Manserin peptide are localized in the endocrine cells of the pituitary. In this study, we further investigated the manserin localization in the digestive system by immunohistochemical analysis using antimanserin antibody. In the duodenum, manserin immunostaining was exclusively observed in the nuclei of top villi instead of cytosol as observed in neurons in our previous study. Interestingly, manserin-positive cells in the duodenum are colocalized with terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) positive cells, the cells whose DNA was damaged. Since the top villi of duodenum epithelial cells are known to undergo spontaneous apoptosis during epithelial cell turn over, and since other peptides such as secretoneurin and EM66 derived from SgII have been reported to be cancer-related, these results indicated that manserin peptide may have a role in apoptosis and/or cancer pathogenesis in the digestive organ.

Elevated cocaine- and amphetamine-regulated transcript immunoreactivity in the circulation of patients with neuroendocrine malignancy

CONTEXT

Cocaine- and amphetamine-regulated transcript (CART) codes for a peptide widely distributed in nervous and endocrine tissues. CART immunoreactivity (CART-LI) has been detected in human insulinomas.

OBJECTIVE

The objective of the study was to investigate the measurement of plasma CART-LI as a tumor marker of neuroendocrine malignancy.

DESIGN AND SUBJECTS

Plasma CART-LI levels were measured in 401 patients with a range of diagnoses: neuroendocrine malignancy (n = 131), after removal of neuroendocrine malignancy (n = 27), without any form of tumor or renal impairment (n = 192), with renal impairment (n = 17) and with nonneuroendocrine tumors (n = 34). Chromatography methods were used to investigate CART-LI circulating in human plasma.

RESULTS

The upper limit of normal calculated for CART-LI was 150 pmol/liter. Mean circulating plasma CART-LI among neuroendocrine tumor patients was 440 pmol/liter, 56% of subjects having levels greater than 150 pmol/liter. Measuring CART-LI in addition to chromogranin (Cg)-A improved the sensitivity for neuroendocrine malignancy from 85 to 91%, whereas combined use of CgA and CgB had a joint sensitivity of 89%. Of 38 patients with pancreatic neuroendocrine tumors, 71% had plasma CART-LI levels greater than 150 pmol/liter, increasing to 95% in those classified with progressive disease (n = 20, mean CART-LI 625 pmol/liter), compared with 80% for CgA. Chromatographic analysis suggests that circulating CART-LI is present as one major form, which may correspond to CART (62-102) or another unknown form.

CONCLUSIONS

We demonstrate CART-LI as a specific tumor marker in patients with a range of neuroendocrine tumors. Used in combination with CgA, CART-LI measurement has the potential to improve sensitivity in diagnosis and follow-up of neuroendocrine tumors, in particular progressive pancreatic neuroendocrine tumors.

Gastric large cell neuroendocrine carcinomas: a distinct clinicopathologic entity

The current histologic classifications of gastric cancers define only carcinoids and small cell carcinomas in the neuroendocrine (NE) category. This study aimed to characterize the histologic and clinical features of high-grade gastric NE carcinomas of nonsmall cell type, tentatively named large cell neuroendocrine carcinoma (LCNEC). Tumors with histologic features suspicious of NE differentiation were selected by a histologic review of 2835 resected gastric cancers, and those with a NE phenotype in > 50% and 1% to approximately 50% tumor cells assessed by expressing chromogranin A and/or synaptophysin were defined as LCNEC and adenocarcinoma with neuroendocrine differentiation (ACNED), respectively. One hundred ninety-nine tumors were selected and of the 109 positive for chromogranin A and/or synaptophysin, 42 and 44 met the criteria for LCNEC and ACNED, respectively. Generally, LCNECs demonstrated less predominant NE morphology than carcinoids, and could be roughly divided into solid (30 cases), tubular (7 cases), and scirrhous (5 cases) subtypes with reference to their main growth pattern. The prognosis of LCNECs was significantly worse than that of conventional adenocarcinomas (P < 0.0001). Thus, this study shows that the spectrum of gastric NE tumors is broader than has previously been recognized and LCNEC is not only a distinct histopathologic entity, but also a distinct clinical entity. Furthermore, the prognosis of ACNEDs was also significantly worse than that of adenocarcinomas (P < 0.0001), and some ACNEDs might actually have been LCNECs, and survival analysis showed that > 20% positivity of NE markers could be enough to characterize LCNEC, as long as light microscopic NE morphology was present in the tumor.

New insights into the pathogenesis of Hirschsprung's associated enterocolitis

The management of Hirschsprung's disease (HD) has made dramatic strides over the last 20 years. Research into the embryological development and migration of ganglion cell has enabled a greater understanding of the pathogenesis of the disease. Coupled with new techniques in surgery, such as laparoscopy-assisted pull-through and the transanal pull-through, this knowledge has led to improved outcomes for children with HD. However, although our appreciation of Hirschsprung's associated enterocolitis and its aetiology has increased, there are continued references in the literature to a multitude of theories of pathogenesis. The purpose of this review is to delineate the theories and demonstrate the evidence supporting or otherwise contradicting each other.

Calcitonin immunoreactivity in neoplastic and hyperplastic parathyroid glands: an immunohistochemical study

BACKGROUND

Previous studies have established that calcitonin (CT) and the calcitonin generelated peptide (CGRP) are synthesized and stored in subsets of hyperplastic parathyroid cells that also contain chromogranin B (Schmid, KW, et al. Lab Invest 73:90, 1995). The purpose of the current study was to determine whether other generic but variably expressed neuroendocrine markers, i.e., synaptophysin (SYN) and CD57 (Leu7), are also present in normal, hyperplastic, and neoplastic parathyroid tissue and to assess their relationships to the presence of CT.

DESIGN

Immunoperoxidase stains for chromogranin A (CgA), chromogranin B (CgB), SYN, CD57, and CT were performed on 54 hyperplastic, 17 neoplastic (adenoma), and 16 normal parathyroid glands. Sequential sections were stained with antibodies to CgA, CgB, SYN, CD57, and CT using standard avidin-biotin-peroxidase techniques.

RESULTS

CgA was diffusely expressed in all normal, hyperplastic, and neoplastic glands. In hyperplasia, CgB was variably expressed in 6 cases (11%), SYN in 6 (11%), CD57 in 15 (28%), and CT in 8 (15%). In adenomas, CgB was variably expressed in 3 (17%), SYN in 3 (17%), CD57 in 4 (23%), and CT in 4 (23%). All normal glands were negative for CgB, SYN, and CT, while CD57 was variably expressed in 17%. Of the 12 glands that were CT positive, 8 were also positive for CgB, 2 for SYN, and 9 for CD57. Four glands that were strongly and diffusely positive for CT were CgB and SYN negative.

CONCLUSIONS

CgB, SYN, and CD57 are markers for subsets of hyperplastic and neoplastic parathyroid glands. CT is also expressed in a significant proportion of hyperplastic and neoplastic parathyroid glands, and may be independent of the presence of CgB, SYN, or DD57. The significance of these findings in relationship to the abnormal calcium metabolism in patients with parathyroid hyperplasia remains to be determined.

Synaptic vesicle protein 2, A new neuroendocrine cell marker

Synaptic vesicle protein 2 (SV2) is a glycoprotein identified in the nervous system of several species, including man, but its occurrence in the human neuroendocrine (NE) cell system has not been investigated. By using a monoclonal antibody to SV2, immunoreactivities were demonstrated in NE cell types in human gastrointestinal tract, pancreas, anterior pituitary gland, thyroid, parathyroid, and adrenal medulla, and also in chief cells of gastric oxyntic mucosa. Immunoelectron microscopy of pancreatic islets revealed SV2 immunoreactivity in secretory granules. Comparison of SV2, synaptophysin, and chromogranin A immunoreactivity showed more SV2- and synaptophysin- than chromogranin A-immunoreactive cells in the antrum and pancreas. In the other gastrointestinal regions and in the other endocrine organs more SV2- than synaptophysin-immunoreactive cells were seen. More chromogranin A- than SV2-immunoreactive cells were observed in duodenum, colon, and parathyroid. Various NE tumors were examined and all contained SV2-immunoreactive cells. The staining patterns with the three markers agreed well, except in hindgut carcinoids, which showed strong SV2 immunoreactivity, weak synaptophysin but no chromogranin A immunostaining. In pituitary adenomas more cells were immunoreactive to SV2 than to the other two antibodies. In conclusion, SV2 is recognized as a further broad marker for NE cells and widens the arsenal of diagnostic tools for NE tumors. It is of special importance for identifying hindgut carcinoids.

Expression of the chemokine receptor CXCR2 in normal and neoplastic neuroendocrine cells

BACKGROUND

Chemokines effect their proinflammatory and growth regulatory roles through interaction with serpentine receptors. One such receptor, CXCR2, binds multiple CXC chemokines, including interleukin 8, GRO-alpha, GRO-beta, GRO-gamma, and NAP-2. We have previously identified CXCR2 expression on myeloid cells, notably mature granulocytes, and projection neurons.

OBJECTIVE

To determine the expression of CXCR2 by cells of the neuroendocrine system.

DESIGN

Archival specimens from normal neuroendocrine tissues and their malignant counterparts were analyzed by immunohistochemistry with monoclonal antibodies specific for CXCR1 and CXCR2.

RESULTS

Immunohistochemical analysis revealed high-level expression of CXCR2 by cells in the pituitary, adrenal medulla, pancreatic islets, thyroid C cells, scattered Kulchitsky cells in the bronchi, and counterpart neuroendocrine cells in the stomach, small bowel, colon, and appendix. Neuroendocrine neoplasms that demonstrated high-level CXCR2 expression included (1) primary carcinoids localized to the stomach, small bowel, colon, appendix, fallopian tube, ovary, and lung; (2) atypical carcinoids of the lung; (3) metastatic carcinoids; (4) pituitary adenomas; (5) pheochromocytomas; and (6) medullary carcinomas of the thyroid. Small cell lung carcinomas, large cell neuroendocrine carcinomas of the lung, small cell carcinoma of the cervix, Merkel cell carcinomas, neuroblastomas, and malignant melanomas lacked evidence of CXCR2 expression.

CONCLUSIONS

The expression of CXCR2 by normal neuroendocrine cells and neoplastic counterparts that have retained phenotypic features of this differentiation program suggests that chemokines may play an important role in functions that are characteristic of this cell type. In addition, this raises the possibility that chemokines may modulate secretion of biologically active products of these cells and their neoplastic counterparts.

New molecular aspects in the diagnosis and therapy of neuroendocrine tumors of the gastroenteropancreatic system

The nature and biology of neuroendocrine cells and of tumors derived therefrom have been the subject of intense research using cell biological and molecular approaches. Diagnostic procedures for establishing the diagnosis of a neuroendocrine tumor have been improved through the development of new serological markers and imaging procedures. Histopathological diagnosis has been refined by the introduction of a broad spectrum of marker proteins for different subtypes of neuroendocrine neoplasms. The high receptor specificity of somatostatin analogues such as octreotide or lanreotide has made these drugs valuable tools in diagnosis and therapy, and some of the achievements made as well as future directions are reviewed in this article. Another substance in use for therapy of neuroendocrine tumors is interferon-a, whose signal transduction mechanism has been investigated considerably during the past several years. In addition to biotherapy with somatostatin analogues and/or interferon-a, chemotherapy is an accepted strategy in the treatment of advanced neuroendocrine tumor disease derived from the foregut. In this context, streptozotocin has caught some attention due to its somewhat selective toxicity against neuroendocrine tumor cells. Some recent studies on the role of the glucose transporter isoform GLUT2 may provide insight into streptozotocin's action. The multiple endocrine neoplasia type-1 gene has recently been cloned, sequenced and identified as a gene potentially involved in the development of the familial cancer syndrome of multiple endocrine neoplasia type 1 (MEN-1). Mutations of this putative tumor suppressor gene have been described, and the abundance of mutations in MEN-1-related tumors as well as sporadic neuroendocrine tumors at MEN-1 locations have been demonstrated. Whether determination of MEN-1 mutations will be valuable for clinical routine is under investigation.

Proliferative populations in intestinal metaplasia: evidence of deregulation in Paneth and goblet cells, but not endocrine cells

In the small intestinal mucosa, four principal epithelial cell lineages are found - the Paneth, goblet, enterocytic, and endocrine cell lineages. These cell lineages are terminally differentiated, non-proliferative, and derive from multipotent stem cells near the bases of the crypts of Lieberkühn. Intestinal metaplasia of the stomach is considered to be a premalignant condition. Since proliferative populations in this condition are not well studied, this feature was examined using double-labelling immunohistochemical and histochemical methods; 20 paraffin blocks of small intestinal mucosa and 24 paraffin blocks of intestinal metaplasia of the human stomach were studied. Double-staining was carried out with MIB-1 as a proliferation marker, with Alcian blue for goblet cells, anti-chromogranin A for endocrine cells, and p-dimethylaminobenzaldehyde-nitrite for Paneth cells. Double-labelling showed that numerous Paneth cells and goblet cells in intestinal metaplasia were in the cell cycle, but endocrine cells appeared non-proliferative. Double-labelled Paneth or endocrine cells were not seen in the control small intestinal mucosa but scanty double-labelled goblet cells were observed in normal intestinal mucosa. In intestinal metaplasia of the stomach, there is evidence of cell-cycle deregulation in the goblet and Paneth cell lineages. These observations have considerable implications for the biology and histogenesis of Paneth cells, goblet cells, and endocrine cells, and the nature of intestinal metaplasia in the gastric mucosa.

PE-11, a peptide derived from chromogranin B, in the human brain

This study was performed to investigate the distribution of chromogranin B in the human central nervous system. We used an antiserum raised against a synthetic peptide (PE-11) present in the chromogranin B molecule. PE-11-like immunoreactivity was characterized by molecular size exclusion and reversed-phase high-performance liquid chromatography. Its localization was studied using immunocytochemistry. Only the free peptide and an N-terminally elongated peptide were detected by molecular size exclusion high-performance liquid chromatography, indicating that proteolytic processing of chromogranin B is quite extensive. PE-11-like immunoreactivity was present in differently shaped fibers, varicosities and neurons, but not in glial cells. Its density varied throughout the brain. An especially high density was observed in the bed nucleus of the stria terminalis, the central and cortical nuclei of the amygdala, the hypothalamus, the hippocampus, the raphe complex, the nucleus interpeduncularis, the nucleus of the solitary tract, and laminae I and II of the spinal cord. This study demonstrates a significant processing of chromogranin B and indicates that chromogranin B constitutes a precursor for smaller peptides which are derived by endoproteolytic processing. It provides the neuroanatomical basis to investigate the chromogranin B molecule as a widespread component of large dense-core vesicles in the human central nervous system.

Carcinoid tumor of the middle ear in a 28-year-old patient

Carcinoid tumor of the middle ear is an extremely rare condition. The origin of the tumor cells is still speculative and the closeness of relationship to adenomas of the middle ear has been a matter of discussion since the first description of this tumor entity in 1980. In this study we report a case of a 28-year-old male patient with a carcinoid tumor of the middle ear. We present the results of histomorphological, immunohistochemical and electron microscopic examinations and compare our findings to those of previously published cases.

Immunohistochemistry of pancreatic islet cell tumors in the ferret (Mustela putorius furo)

Twenty-two pancreatic islet cell tumors and normal pancreatic islets from ferrets were evaluated by immunohistochemistry for expression of the peptide hormones insulin, somatostatin, glucagon, and pancreatic polypeptide (PP) and the neuroendocrine markers chromogranin A (CgA) and neuron-specific enolase (NSE). In normal pancreatic islets, the majority of cells stained strongly with CgA and NSE. A cells, B cells, D cells, and PP cells stained strongly with glucagon, insulin, somatostatin, and PP, respectively. All 22 tumors stained with CgA and NSE. The proportion of cells within tumors staining for CgA was variable, but more than half of the cells stained positively in 18 of the tumors. The intensity of staining for CgA was strongly (reactivity equivalent to or greater than normal islet cells in adjacent tissue) in 11 moderate in six, and weak in five of the tumors. All tumors stained for NSE, with > or = 50% of the cells staining in 21 of the tumors, and the intensity of staining was strong in 18 of the tumors. Twenty of 22 tumors stained positively for insulin. with > or = 50% of the cells staining in 19 of them. The intensity of staining for insulin was strong in 12, moderate in seven, and weak in one of the tumors. Approximately < or = 1% of the cells in 15 of 22 tumors stained for somatostatin, five tumors stained for pancreatic polypeptide, and three tumors stained for glucagon. These data indicate that the majority of islet cell tumors of ferrets express immunohistochemically detectable insulin. CgA and NSE are both useful general markers for such tumors, including those that are insulin negatives. Commercially available antisera to CgA, NSE, insulin, glucagon, somatostatin, and PP work well in formalin-fixed, paraffin-embedded tissue for immunophenotyping islet cell tumors in the ferret.

Complex co-localization of chromogranins and neurohormones in the human gastrointestinal tract

Co-localization of chromogranin (Cg) A, B, and C has been studied in different neuroendocrine cell types in histologically normal mucosa from human gastrointestinal tract (corpus, antrum, duodenum, ileum, and colon) using single-, double-, and triple-immunofluorescence stainings. Virtually all enterochromaffin (EC) cells contained CgA, and those in the luminal two thirds of the antral mucosa and villi of small intestine often also contained CgB. A few EC cells in the duodenal crypts contained CgC. Most gastrin cells harbored both CgB and CgA, although rather more CgB than CgA, but some gastrin cells contained all three types, i.e., also CgC. Some CCK cells also contained all three chromogranins. Enteroglucagon cells in the duodenal villi contained CgA and some CgB. CgA (but not B or C) was found in some secretin, GIP, enteroglucagon/peptide YY, and neurotensin cells. A few somatostatin cells contained CgA but neither CgB nor CgC. CgA and C were found mainly in the basal cell region, whereas CgB occurred more diffusely throughout the cytoplasm. This varying distribution suggests that not all secretory granules contain CgA, or that CgB may occur in a nongranular form. The varying composition of the different chromogranins may reflect their complex functional roles in the widespread neuroendocrine system.

Secretoneurin: a new peptide in the human enteric nervous system

Secretoneurin is a functional neuropeptide derived from secretogranin II (chromogranin C). This proprotein is processed to varying degrees in neuroendocrine tissues. In the present study we established by gel filtration high performance liquid chromatography that in human intestinal wall and mucosa an antiserum against secretoneurin detects as the major immunoreactive moiety the free peptide secretoneurin. In the mucosa some larger immunoreactive peptides were also present, however, a significant amount of the intact proprotein secretogranin II could not be detected. By immunohistochemistry we studied the distribution of secretoneurin within the gut. Antibodies to protein gene product 9.5 and chromogranin A were used to identify all neurons and endocrine cells, respectively, whilst those to the peptides substance P, CGRP and somatostatin were used for the further characterization of individual secretoneurin-positive structures. Secretoneurin immunoreactivity was found in nerve fibres in all layers of the gut wall. In both myenteric and submucous plexuses, nerve fibres and the majority of ganglion cells were secretoneurin-immunoreactive. In the mucosa, some secretoneurin-positive nerve processes ran parallel to the basal membrane of epithelial cells, occasionally invading the epithelial layer. Secretoneurin immunoreactivity was found in endocrine cells, mostly D cells, in the following regions in descending order of density: stomach/duodenum; rectum; colon; ileum. Thus, secretoneurin is a new major peptide within the human enteric neuroendocrine system. Its presence in abundant myenteric ganglion cells may imply a role in the modulation of gastrointestinal motility. The chemotactic properties of secretoneurin and its possible localization in sensory fibres suggest that this peptide may be involved in the genesis of intestinal inflammation.

Immunohistochemical distribution of chromogranins A and B and secretogranin II in neuroendocrine tumours of the gastrointestinal tract

The aim of the present study was to investigate immunohistochemically the distribution of chromogranin A, chromogranin B, and secretogranin II in a series of 152 neuroendocrine tumours of the gastrointestinal tract. Tumour tissues from 25 argyrophil gastric carcinoids, 18 gastrin and 5 somatostatin-producing tumours, 4 'gangliocytic paragangliomas', 49 classical argentaffin and 2 L cell appendiceal carcinoids, 27 classical ileal carcinoids, 17 rectal carcinoids, and 5 poorly differentiated neuroendocrine tumours of the stomach and rectum were immunostained with antibodies against chromogranin A, chromogranin B, and secretogranin II. Chromogranin A was the major granin expressed in gastric carcinoids and in serotonin-producing carcinoids of the appendix and the ileum. In contrast, strong chromogranin B and secretogranin II immunoreactivity was found in rectal carcinoids, in which chromogranin A was rarely expressed. Since chromogranin A is a widely used marker for neuroendocrine differentiation, it is of diagnostic importance that some gastrin-producing tumours, 'gangliocytic paragangliomas', poorly differentiated neuroendocrine carcinomas, and appendiceal L cell carcinoids completely lacked chromogranin A positivity. It is concluded that the various neuroendocrine tumours of the gastrointestinal tract show distinctly different patterns of granin expression, probably reflecting their histogenetical origin.

Secretogranin II: molecular properties, regulation of biosynthesis and processing to the neuropeptide secretoneurin

Secretogranin II is an acidic secretory protein in large dense core vesicles of endocrine, neuroendocrine and neuronal tissues. It comprises, together with chromogranins A and B, the class of proteins collectively called chromogranins. In this review the physico-chemical properties, genomic organization, tissue distribution, synthesis regulation, ontogeny and physiological function of this protein are discussed. Secretogranin II gained interest recently for mainly three reasons: (1) secretogranin II is an excellent marker for the regulated secretory pathway due to its simple and specific metabolic labeling by inorganic sulfate; (2) secretogranin II occurs in a variety of neoplasms arising from endocrine and neuroendocrine cells and was shown to be a useful histological tumor marker for these cells; (3) secretogranin II is the precursor of the recently discovered neuropeptide secretoneurin which induces dopamine release in the striatum of the rat brain.

Circulating pancreastatin is a marker for the enterochromaffin-like cells of the rat stomach

BACKGROUND/AIMS

Peptides of the chromogranin family occur in peptide hormone-producing cells throughout the body. One source of such peptides is the enterochromaffin-like (ECL) cells, which constitute the predominant population of endocrine cells in the fundus (the acid-producing part) of the rat stomach. The purpose of this study was to examine whether ECL cells, which are controlled by gastrin, represent a major source of circulating pancreastatin, a fragment of chromogranin A.

METHODS

Rats underwent surgical procedures and treatments in which the ECL cells could be manipulated. The procedures included antrectomy, fundectomy, and gastrectomy (and adrenalectomy), and the treatments included fasting or feeding, gastrin-17 infusion, and administration of omeprazole or ranitidine. The concentrations of pancreastatin-like immunoreactivity (LI) and gastrin in the serum were determined by radioimmunoassay.

RESULTS

The serum pancreastatin-LI concentration was lowered by about 80% by fundectomy and gastrectomy; both of these procedures eliminated the ECL cell population. Adrenalectomy had no effect on the serum pancreastatin-LI concentration. Gastrin infusion, which activates the ECL cells, promptly increased serum pancreastatin-LI concentration. Refeeding after fasting and administration of omeprazole or ranitidine increased the serum pancreastatin-LI concentrations; these responses were prevented by antrectomy.

CONCLUSIONS

The concentration of circulating pancreastatin-LI reflects the activity of the ECL cells and the size of the ECL cell population in the rat stomach.

Immunohistochemical localization of chromogranins A and B and secretogranin II in normal, hyperplastic and neoplastic prostate

Routinely processed normal, hyperplastic and neoplastic prostatic tissue was immunohistochemically investigated with antibodies against chromogranin A and B and secretogranin II. In normal and hyperplastic prostates all three peptides were immunolocalized in scattered neuroendocrine cells situated within the glandular epithelium. In 17 prostatic carcinomas with pronounced neuroendocrine differentiation and in a case of prostatic carcinoid, chromogranin B was the major component whereas chromogranin A and secretogranin II were virtually absent in poorly differentiated (grade III) tumours. Neuroendocrine differentiation in prostatic cancer is most likely to be associated with a poor clinical outcome; thus, chromogranin B appears to be a useful marker in the histopathological diagnosis of these neoplasms.

The expression of keratins, vimentin, neurofilament proteins, smooth muscle actin, neuron-specific enolase, and synaptophysin in tumors of the specific glands in the canine anal region

Eight canine tumors originating from specific glandular structures in the anal region, as well as metastatic tumor tissue of two of these cases (case Nos. 7, 8), were immunohistochemically analyzed using various monoclonal antibodies (MoAbs) directed against human keratin types, vimentin, neurofilament proteins, and alpha-smooth muscle actin. These tumors also were stained for the broad-spectrum neuroendocrine markers neuron-specific enolase (NSE) and synaptophysin. In histologically normal canine anal structures, alpha-smooth muscle actin and NSE antibodies stained basally localized (probably myoepithelial) cells in the anal glands and the anal sac glands. NSE staining also was present in a limited number of luminal cells in both anal glands and anal sac glands. Synaptophysin labeling was not observed in any of these glandular structures. Histologically, the tumors were differentiated into well- and moderately differentiated perianal gland tumors (n = 5) and carcinomas without perianal gland differentiation (n = 3), corresponding to the so-called apocrine carcinomas of the anal region. Immunohistochemically, the perianal gland tumors could be differentiated from the carcinomas by marked differences in staining pattern with the various keratin MoAbs, particularly MoAbs directed against human keratin types 7 and 18. The keratin-staining characteristics of the carcinomas suggest a glandular luminal cell origin. Metastases of the carcinomas showed loss of some keratin-staining characteristics as compared with the primary tumor. Staining for NSE was only observed in solitary cells and small cell clusters in the carcinomas and their metastases, whereas the alpha-smooth muscle actin antibody did not react with the carcinoma cells. None of the tumors stained for neurofilament proteins or synaptophysin. An unequivocal neuroendocrine nature of the carcinomas could not be substantiated by our immunohistochemical study, although the presence of a population of neuroendocrine cells within these neoplasms seems likely. Because the immunohistochemical features of the carcinomas with respect to various keratin MoAbs and NSE are similar to those of the anal glands and the anal sac glands, both these glands might be considered as site of origin of these carcinomas.

Chromogranin A, secretogranin II and vasoactive intestinal peptide in phaeochromocytomas and ganglioneuromas

By means of immunohistochemistry we analysed the distribution of chromogranin A, secretogranin II and vasoactive intestinal peptide (VIP) in 16 phaeochromocytomas, two cases of combined phaeochromocytoma-ganglioneuroma and four adrenal ganglioneuromas. Chromogranin A was found in the majority of phaeochromocytes and in mixed phaeochromocytomas-ganglioneuromas. Secretogranin II was present to a lesser degree in phaeochromocytes, but strong immunostaining was found in most ganglion cells of phaeochromocytomas, in the ganglioneuroma component of combined tumours and in adrenal ganglioneuromas. Vasoactive intestinal peptide was present in some ganglion cells of phaeochromocytomas, in the ganglioneuroma component of mixed tumours and in three of four adrenal ganglioneuromas. On semi-adjacent sections a co-localization of VIP and secretogranin II was demonstrated. These results indicate that neuronal differentiation is accompanied by an increased immunohistochemical expression of secretogranin II. Therefore, secretogranin II may be a useful marker for ganglion cell differentiation.

Serum chromogranin A in the diagnosis and follow-up of neuroendocrine tumors of the gastroenteropancreatic tract

Hormonally active neuroendocrine tumors may easily be diagnosed by elevated serum levels of their specific peptides and hormonal products, but there are no reliable markers for neuroendocrine tumors without hormonal activity. Chromogranin A (CgA), a secretory protein of neuroendocrine cells, has recently been characterized as a valuable tissue marker in hormonally active and non-functioning neuroendocrine tumors. This study analyzes the role of CgA as a serum marker for different neuroendocrine tumors. Thirty-three patients with neuroendocrine tumors of the stomach (n = 7), the ileum (n = 18), and the pancreas (n = 8) were investigated. Serum CgA levels were analyzed by radioimmunoassay at the time of diagnosis and during follow-up under different therapeutic regimens. Serum CgA was elevated in 30 (91%) patients. Mean CgA serum levels varied with tumor location (pancreas: 7068 +/- 3008 ng/ml, ileum: 5381 +/- 1740 ng/ml, stomach: 529 +/- 179 ng/ml, x +/- SEM ng/ml) but did not differ between functioning and non-functioning tumors. Eight of 10 patients treated with either somatostatin or interferon-alpha showed changes of CgA concentrations corresponding to tumor growth. We conclude that CgA is a useful broad-spectrum tumor marker in gastroenteropancreatic neuroendocrine tumors. Its determination is especially recommended in tumors without hormonal activity.

Mucosal neuroendocrine cell abnormalities in the colon of patients with Hirschsprung's disease

We studied the distribution of mucosal neuroendocrine (NE) cells in the colon from 13 patients with Hirschsprung's disease (HD) and from 8 controls. Immunohistochemical studies were carried out using monoclonal and polyclonal antibodies against chromogranin A and synaptophysin (general markers of NE cells), 5-hydroxytryptamine (5-HT) (a marker of amine), peptide YY (PYY), and somatostatin (markers of neuropeptides). Chromogranin A immunoreactive cells were significantly increased in the aganglionic bowel compared with ganglionic bowel and controls (P less than .05). There was an increase in the number of synaptophysin immunoreactive cells in the aganglionic bowel compared with ganglionic bowel and controls but the results were not statistically significant. 5-HT immunoreactive cells were also significantly increased in the aganglionic bowel compared with ganglionic bowel and controls (P less than .05). The immunostaining for PYY demonstrated abundance of this NE cell type in the aganglionic bowel and this was highly significant compared with ganglionic bowel and controls (P less than .001). There was a significant increase in somatostatin immunoreactive cells in the aganglionic bowel compared with ganglionic bowel (P less than .01). The increase in neuroendocrine cells was found over the entire length of the aganglionic segment in rectosigmoid HD as well as in long-segment HD. These results demonstrating the increased levels of NE cells in the mucosa of aganglionic colon suggest that the NE cells may have a role in regulating the sustained contraction of the aganglionic intestine in HD.