Outcome for Pediatric Adreno-Cortical Tumors Is Best Predicted by the COG Stage and Five-Item Microscopic Score-Report from the German MET Studies

Background: Adrenocortical tumors (ACTs) encompassing the adrenocortical adenoma (ACA), carcinoma (ACC), and tumors of undetermined malignant potential (ACx) are rare endocrine neoplasms with a poor prognosis. We report on pediatric ACT patients registered with the Malignant Endocrine Tumor studies and explore the EXPeRT recommendations for management. Patients: Data from the ACT patients (<18 years) were analyzed. For the risk prediction, the patients were retrospectively assigned to the COG stages and the five-item score. Results: By December 2021, 161 patients with ACT (ACA n = 51, ACx n = 19, and ACC n = 91) had been reported (the median age at the diagnosis was 4.3 years with a range of 0.1−17.8), with lymph node and distant metastases in 10.7% and 18.9% of the patients with ACC/ACx. The mean follow-up was 4.5 years (with a range of 0−16.7). The three-year overall (OS) and event-free survival (EFS) rates were 65.5% and 50.6%. In the univariate analyses, the OS was impaired for patients aged ≥ 4 years (p = 0.001) with the initial biopsy (p = 0.016), tumor spillage (p = 0.028), incomplete tumor resection (p < 0.001), unfavorable histology (p = 0.047), and COG stages III/IV (p = 0.002). Multivariate analysis revealed COG stages III/IV and an unfavorable five-item score as independent negative prognostic factors for the EFS and OS. Conclusions: Age defines the clinical presentation and prognosis in pediatric ACTs. The outcome is best predicted by the COG stage and five-item score.

Epithelial X-Box Binding Protein 1 Coordinates Tumor Protein p53-Driven DNA Damage Responses and Suppression of Intestinal Carcinogenesis

BACKGROUND & AIMS

Throughout life, the intestinal epithelium undergoes constant self-renewal from intestinal stem cells. Together with genotoxic stressors and failing DNA repair, this self-renewal causes susceptibility toward malignant transformation. X-box binding protein 1 (XBP1) is a stress sensor involved in the unfolded protein response (UPR). We hypothesized that XBP1 acts as a signaling hub to regulate epithelial DNA damage responses.

METHODS

Data from The Cancer Genome Atlas were analyzed for association of XBP1 with colorectal cancer (CRC) survival and molecular interactions between XBP1 and p53 pathway activity. The role of XBP1 in orchestrating p53-driven DNA damage response was tested in vitro in mouse models of chronic intestinal epithelial cell (IEC) DNA damage (Xbp1/H2bfl/fl, Xbp1ΔIEC, H2bΔIEC, H2b/Xbp1ΔIEC) and via orthotopic tumor organoid transplantation. Transcriptome analysis of intestinal organoids was performed to identify molecular targets of Xbp1-mediated DNA damage response.

RESULTS

In The Cancer Genome Atlas data set of CRC, low XBP1 expression was significantly associated with poor overall survival and reduced p53 pathway activity. In vivo, H2b/Xbp1ΔIEC mice developed spontaneous intestinal carcinomas. Orthotopic tumor organoid transplantation revealed a metastatic potential of H2b/Xbp1ΔIEC-derived tumors. RNA sequencing of intestinal organoids (H2b/Xbp1fl/fl, H2bΔIEC, H2b/Xbp1ΔIEC, and H2b/p53ΔIEC) identified a transcriptional program downstream of p53, in which XBP1 directs DNA-damage-inducible transcript 4-like (Ddit4l) expression. DDIT4L inhibits mechanistic target of rapamycin-mediated phosphorylation of 4E-binding protein 1. Pharmacologic mechanistic target of rapamycin inhibition suppressed epithelial hyperproliferation via 4E-binding protein 1.

CONCLUSIONS

Our data suggest a crucial role for XBP1 in coordinating epithelial DNA damage responses and stem cell function via a p53-DDIT4L-dependent feedback mechanism.

Calibration of histological retina specimens after fixation in Margo's solution and paraffin embedding to in-vivo dimensions, using photography and optical coherence tomography

BACKGROUND

The extent of retinal tissue deformation by histological processing needs to be separately measured for every workup protocol. This work presents a simple approach for its quantitative assessment, and shows lateral and axial scaling factors for a common protocol. We calibrated histological measurements by in-vivo photographic and optical coherence tomographic (OCT) measurements, using retinal photocoagulation lesions as calibration markers.

METHODS

We evaluated four rabbit eyes that were examined histologically after fixation in Margo's solution (1 % paraformaldehyde:1.25 % glutaraldehyde), isopropanol dehydration, paraffin embedding and hematoxylin and eosin staining. Distances between 51 pairs of laser lesions were compared in photographs and on histological slides. Retinal thickness measurements were performed at 15 anatomically defined sites in these eyes, and related to anatomically matched OCT thickness measurements of six different rabbit eyes.

RESULTS

We found that the ratio of histological over photographic lesion distances was 1.17 (95 % CI 1.13-1.22), indicating 17 % lateral retinal stretching or expansion by the processing. Thickness measurements in histology were 65.6 % of the in-vivo thickness as measured in OCT, indicating 1/3 axial tissue compression or shrinkage.

CONCLUSIONS

We provide an analysis of retinal tissue deformation after fixation in Margo's solution and paraffin embedding. In spite of protocol optimization for reduced tissue deformation, the workup caused 1/3 axial compression/shrinkage and 17 % lateral elongation, which was unexpected. We show a simple way how to calibrate retina specimens by fundus photography and OCT, two methods that are readily available to most ophthalmologists. Our findings underline the necessity to calibrate specimens prior to morphometry.

[S3 guideline - diagnosis and treatment of gastric carcinoma: relevance for radiologic imaging]

The new German S3 guideline regarding stomach cancer includes a variety of innovations with respect to the diagnosis and treatment of adenocarcinoma of the stomach and the esophagogastric junction. The guideline has been strongly supported by the "oncology" guidelines program consisting of the "Deutsche Krebshilfe" and the German Cancer Society and the AWMF (Dr. M. Follmann). This guideline contains evidence-based treatment recommendations and quality indicators for guideline implementation and evaluation in order to improve broad medical care and to facilitate development and subsequent adjustment. The purpose of this article is to introduce the innovations with regard to radiological diagnosis and to discuss the latest literature on the subject.

[Multiple focal liver lesions of a 33 year-old female. Presentation of an unexpected differential diagnosis]

We report the case of a 33 year-old female with a history of 16 years of oral contraception who had been admitted to hospital for further diagnosis of multiple focal liver lesions; laboratory findings showed elevated levels of gamma-GT und AP. Diagnostic procedures showed no primary malignancy as possible reason for metastasis. All further imaging procedures compared with doppler-enhanced ultrasound did not help in diagnosis and lead to inconsistent results. Transcutaneous liver-biopsy showed normal liver histology. In laparoscopic biopsy the result was multifocal adenoma. Because of the rupture risk and potential malignant transformation and no change of sonomorphologic appearance within 12 months a liver-segment resection has been undertaken. Pathology revealed the diagnosis of a multifocal hyperplastic-adenomateous focal-nodular hyperplasia. This case shows that there is no need to use different methods of medical imaging redundantly. We favor a fine-needle double-puncture (lesion and extra-lesion) and tissue examination through an experienced pathologist. A total resection of the lesion is necessary in case of resting uncertainty to characterize its tissue characteristics.