Leiomyosarcoma of the inferior vena cava. Our experience and a review of the literature

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare malignant tumor, accounting for 2% of all LMSs. Less than 400 cases have been reported in literature. Computed tomography (CT) is the most accurate imaging method in assessing the location of the tumor within the IVC and magnetic resonance imaging (MRI) accurately identifies its extent and the potential for surgical resection. We present the case of a patient with inferior vena cava leiomyosarcoma (IVCL), for whom the pathological diagnosis was different from the initially expected one, the tumor appearance on pre-operative imaging mimicking renal cell carcinoma. The intraoperative difficulty of approaching renal hilum and IVC was a factor suggesting the vascular origin of the tumor, which was confirmed at pathological analysis. The extensive defect in the IVC after tumor excision led to the decision of complete transverse suturing of IVC, as significant collateral venous circulation was already present. Because IVCL is a rare disease, there is scarce data regarding the prognosis and treatment options. Long-term survival depends on the extent of the surgery. The need of vascular reconstruction is not always mandatory. Despite high recurrence rates, no consensus regarding adjuvant treatment exists yet. A multidisciplinary approach including surgical oncologists and vascular surgeons is mandatory to achieve the best patient outcomes. Perioperative planning, coordination and adherence to oncological techniques are critical.

Expression of Topoisomerase II-α protein in salivary gland tumors

Salivary glands give rise to approximately 30 histological distinct tumor types, which results in a diagnostic challenge for the pathologist. The present retrospective, immunohistochemical study aimed to evaluate the expression of Topoisomerase II-α, a nuclear enzyme, as a diagnostic and prognostic marker in benign and malignant salivary gland tumors, including leomorphic adenoma, mucoepidermoid carcinoma, acinic cell carcinoma and carcinoma ex-pleomorphic adenoma. A total of 59 cases of benign and malignant salivary gland tumors were included in the present study. Representative paraffin-embedded sections were immunostained for Topoisomerase II-α (Topo II-α). The expression level was semi-quantified for each case and then correlated with the histological diagnosis using hematoxylin and eosin-stained slides, grade of tumor and total survival. Significant differences were revealed between the expression level of Topo II-α in pleomorphic adenoma and mucoepidermoid carcinoma (P<0.001), carcinoma ex-pleomorphic adenoma (P<0.001), acinic cell carcinoma (P=0.005) and a group composed of all the malignant tumors (P<0.001). Cancer-specific survival rates were insignificantly increased in tumors expressing low levels of Topo II-α (P=0.464). Thus, the present study demonstrated different expression levels of Topo II-α in benign and malignant salivary gland tumors. These differing expression levels may act as valuable biomarkers for the correct histological diagnosis. Further studies conducted on a larger scale may lead to even more conclusive results.

West Nile virus outbreak in Israel in 2015: phylogenetic and geographic characterization in humans and mosquitoes

OBJECTIVES

West Nile Virus (WNV) is endemic in Israel and was responsible for several outbreaks in the past 16 years. The aim of the present study was to investigate the spatial distribution of WNV acute infections from an outbreak that occurred in 2015 in Israel and report the molecular and geographic characterization of WNV isolates from human cases and mosquito pools obtained during this outbreak.

METHODS

Using a geographical layer comprising 51 continuous areas of Israel, the number of WNV infection cases per 100 000 people in each area and the locations of WNV-infected mosquitoes in 2015 were analysed. Sequencing and phylogenetic analyses followed by geographic localization were performed on 13 WNV human isolates and 19 WNV-infected mosquito pools.

RESULTS

Substantial geographical variation in the prevalence of acute WNV in patients in Israel was found and an overall correlation with WNV-infected mosquitoes. All human patients sequenced were infected only with the Mediterranean subtype of WNV Lineage 1 and resided primarily in the coastal regions in central Israel. In contrast, mosquitoes were infected with both the Mediterranean and Eastern European subtypes of WNV lineage 1; however, only the Mediterranean subtype was found in mosquitoes from the coastal region in central Israel.

CONCLUSION

These results demonstrate differential geographic dispersion in Israel of the two WNV subtypes and may also point to a differential pattern of human infections. As a geographical bridge between Europe, Asia and Africa, analysis of WNV circulation in humans and mosquitoes in Israel provides information relevant to WNV infections in Eurasia.

A Novel Technique to Improve the Processing of Minute Ureteroscopic Biopsies

To examine the ability of a new specimen handling technique to improve histopathological yield of ureteroscopic biopsies, performed in patients with suspected upper tract urothelial carcinoma (UTUC). In a bi-center retrospective study we compared the results of the new tissue handling technique (group 1) with the standard technique (group 2). In the new technique, to achieve maximal tissue preservation, the specimen is mounted on filter paper prior to embedding in paraffin. Multivariate analysis was performed to determine which factors are associated with optimal histological results. We further compared the biopsies with the final specimen in a subgroup of patients who underwent nephroureterectomy (NU). Of 55 ureteroscopic biopsies, 1 biopsy from group 1 (new technique) and 3 biopsies from group 2 (standard technique) were inadequate for pathological examination. 51 UTUC specimens were analyzed. Tumor grade and stage were determined in 85% and 63% of the patients in group 1 and in 83% and 25% of group 2 (p=0.85 and p=0.007). Orientation was preserved in 82% of group 1 and 42% of group 2 (p=0.003). On multivariate analysis biopsy technique and biopsy diameter were found to predict stage determination (p=0.01 and p=0.007) and tissue orientation (p=0.005 and p=0.04). Among patients who underwent NU, stage concordance between the biopsy and final pathology was observed in 56% and 27% of the patients in group 1 and 2, respectively. The new processing technique for small UTUC forceps biopsies decreases the rate of biopsies with insufficient material and improves biopsy interpretation.

Gastritis in patients undergoing sleeve gastrectomy: Prevalence, ethnic distribution, and impact on glycemic

Laparoscopic sleeve gastrectomy (LSG) is a therapeutic option in severely obese patients. The aim of this study was to evaluate the presence of Helicobacter pylori (HP) gastritis and non-Helicobacter gastritis in the gastrectomy specimens, and its association to other variables.One hundred six sleeve gastrectomy specimens were examined histopathologically for the presence of gastritis and its relation to other factors like ethnicity, glycemic control, and postoperative complications.Twelve patients had HP gastritis, 39 had non-HP gastritis, and 55 had normal mucosa. There was a statistical difference between the Arab and Jewish Israeli patients in our study. Twenty-eight of the Arab patients had HP gastritis and 48% had non-HP gastritis. In the Jewish population 6% had HP gastritis and 34% had non-HP gastritis. The preoperative glycemic control was worse in the gastritis group with a mean HbA1c of 8.344% while in the normal mucosa group the mean HbA1c was 6.55. After operation the glycemic control reverted to normal in most the diabetic patients. There were few postoperative complications however, they were not related to HP.There is a high incidence of gastritis in obese patients. The incidence of gastritis in the Arab population in our study was higher than that in the Jewish population. The glycemic control before surgery was worse in patients with gastritis than in the normal mucosa group. HP bares no risk for postoperative complications after LSG and does not affect weight loss. However a larger cohort of patients must be studied to arrive at conclusive results.

Morphological changes in peri-prostatic sympathetic ganglion cells in aging males

A significant part of morbidity in elderly male patients involves the pelvic organs and their autonomic neural regulation. The aim of the current study was to report the histopathological changes in the peri-prostatic ganglia in elderly males. The sympathetic ganglia from 36 prostatectomy specimens, 26 due to carcinoma of the prostate and 10 prostates from total cystectomies for transitional cell carcinoma, were examined. The age range was 54-88 years. A total of 5,075 ganglion cells were counted in all the specimens. Pathological changes were identified in 1,696 neuron cells as follows: Neuronophagia in 746 neuron cells, neuron cell vacuolization (330 cells), satellite cells vacuolization (423 cells), cell pyknosis (148 cells) and nageotte nodules (49 cells). A number of these changes increased with age. All the changes were more marked in the peri-prostatic ganglion cells of patients with prostatic adenocarcinoma compared with those with benign prostate hyperplasia, which may be due to local environmental changes associated with the presence of malignancy.

Seminal Tract Amyloidosis: Synchronous Amyloidosis of the Seminal Vesicles, Deferent Ducts and Ejaculatory Ducts

Senile Seminal Vesicle Amyloidosis (SSVA) increases with age. Involvement of the whole seminal tract, i.e. the seminal vesicles, ejaculatory and deferent ducts was first reported by us in the International Symposium on Amyloidosis 1998. Since then we encountered four more cases of SSVA. In all these cases the ejaculatory and deferent ducts were also involved by amyloid. The amyloid was located mostly sub-epithelially, stained positively with Congo red, gave green birefringence under polarized light and was permanganate sensitive, slightly positive for lactoferrin immunostaining and negative for all known amyloid types. In recent years the amyloid was found to be derived from Semenogelin I, a major constituent of the seminal fluid which is present in the epithelial cells of the seminal vesicle and vas deference. This would explain the deposition of amyloid not only in the seminal vesicles but also in the deferent an ejaculatory ducts which transport the seminal fluid. In a review of the literature we found three more articles on SSVA in which the amyloid was not limited to the seminal vesicles alone. We propose to designate this type of amyloid as "Senile seminal Tract Amyloidosis" (SSTA) instead of "Senile Seminal Vesicle Amyloidosis (SSVA)".

Visualization of Grossly Undetectable Breast Tumors by Refixation in Lymph Node Revealing Solution

Introduction Breast lesions might be missed by the traditional method of inspection, palpation, and sectioning of the specimen. Lymph node revealing solution (LNRS) was first introduced by us as a fixative that enhances the retrieval of lymph nodes in breast carcinoma and other malignancies. This is a preliminary report of our experience with the use of LNRS in order to visualize malignant breast tumors that were not detected by the traditional method. Material and Methods Eight post-chemoradiation-treated tumors, 6 relumpectomy specimens, and 1 post mammotome lumpectomy with no grossly detectable residual tumor and 2 mastectomy specimens with multifocal tumors which were missed by the first inspection were postfixed in LNRS for 24 hours and sectioned. Results In some of the cases, small tumors up to 0.5 cm were visualized as white gray lesions. Carcinoma has been confirmed by histopathologic examination and the final diagnosis had to be changed. Conclusion Postfixation in LNRS enhances the visualization of grossly undetectable breast lesions and it is worthwhile to use it in problematic cases in order to arrive at a more accurate diagnosis.

The predictive value of dendritic cells in early squamous cell carcinoma of the tongue

OBJECTIVES

The aim of this study was to evaluate the relationship between dendritic cell density in early squamous cell carcinoma (SCC) of the tongue and patients' clinical outcome.

METHODS

Representative samples of low-risk SCC of the tongue (T1-2,N0,M0) from a homogeneous group of 18 patients following local complete excision and elective selective neck dissection, were immunostained with antibodies against S100 and CD1a. Dendritic cell density was analyzed by outcome.

RESULTS

Mean dendritic cell densities were 17 cells/HPF for tumoral S100 and CD1a counts, and 10 cells/HPF for peritumoral S100 and CD1a counts. Better disease-free survival was associated with low peritumoral S100- and CD1a- positive cell counts (p=0.006 and p=0.004, respectively), and with low tumoral S100- and CD1a- positive cell counts (p=0.037 and p=0.04, respectively). Lymphocytic response was decreased in tumors with high dendritic cell density (p=NS). There was no association of dendritic cell density with patient age, tumor size and depth of invasion.

CONCLUSIONS

These results may suggest an association between dendritic cell accumulation and functional immunologic impairment.

An Ancillary Tool for the Diagnosis of Amyloid A Amyloidosis in a Variety of Domestic and Wild Animals

Immunohistochemistry, the standard method for diagnosing amyloid A (AA) amyloidosis, is limited in animals because it requires a large array of animal-specific anti-AA antibodies, not commercially available. The Shtrasburg method (SH method) is a highly specific and sensitive technique, helping in the diagnosis and determination of AA amyloidosis in humans. The aim of this study is to determine whether the SH method is applicable in the diagnosis of AA amyloidosis in a variety of animals. Tissue samples were obtained from animals suffering from spontaneous or experimentally induced AA amyloidosis (mice, hamsters, guinea pigs, cheetahs, cats, cows, ducks, a dog, a goose, a chicken, and a turaco). Detection of the amyloid and quantitative evaluation were performed using Congo red staining, and specific AA typing was performed by the potassium permanganate technique. The studied tissues were subjected to the SH method, which confirmed the AA nature of the amyloid deposit, by displaying in polyacrylamide gel electrophoresis protein bands consistent with the molecular weight of the species-specific AA, in all the animals examined, except mice, hamsters, and guinea pigs. N-terminal analysis of these bands corroborated their AA origin. We conclude that the SH method may be used as an ancillary simple tool for the diagnosis of AA amyloidosis in a large number of domestic and wild animals. Moreover, our findings further increase the feasibility of applying this method in humans.

CD1a-positive dendritic cell density predicts disease-free survival in papillary thyroid carcinoma

OBJECTIVES

Dendritic cells are common in inflammatory processes and in papillary thyroid carcinoma (PTC). Previous studies of the predictive value of S100-positive dendritic cell density for PTC outcome yielded inconsistent results. This study investigated the association of dendritic cell density and PTC recurrence based on CD1a expression.

METHODS

Representative slides from 56 consecutive specimens of PTC were immunostained with anti-CD1a antibodies, and dendritic cell density was analyzed by disease-free survival.

RESULTS

Dendritic cells were abundant in the tumoral tissue and sparse in the normal peritumoral tissue. Peritumoral dendritic cell density >1.1 cells/HPF was inversely associated with the risk of recurrence. Similar results were obtained with tumoral dendritic cell density (>12 cells/HPF), although the statistical significance was marginal.

CONCLUSIONS

High CD1a-positive dendritic cell density is associated with improved disease-free survival in PTC. The specificity of anti-CD1a immunostain for activated dendritic cells may explain the better outcome prediction in this study than in studies using S100 protein.

A new Ki-67 / E-cadherin cocktail reduces inter-observer variation of the calculated proliferative index

The proliferative index in breast carcinoma is usually calculated by the percentage of the Ki-67 positive cells out of the total number of malignant cells. In order to reduce the inter-observer variability of the calculated proliferative index a cocktail of antibodies against E-Cadherin and Ki-67 (Ki/Cad Cocktail) is presented. The cocktail was applied on 59 cases of infiltrating duct carcinoma of breast and compared to the consecutive slides stained for Ki-67 alone. The Ki/Cad cocktail has the advantage that by adding the anti E-Cadherin antibody, all the malignant epithelial cells are highlighted and can be differentiated from other proliferating cells. Statistical analysis proved that the cocktail increases the inter-observer agreement from 89 % to 97 % as compared to the Ki-67 alone and also reduces the overlap between the cancer grades.

The role of s100-positive dendritic cells in the prognosis of papillary thyroid carcinoma

Dendritic cells are potent antigen-presenting cells, common in inflammatory processes. We sought to investigate dendritic cell expression in papillary thyroid carcinoma and the relationship of dendritic cell density with the extent of thyroiditis and prognosis. Specimens from 69 consecutive patients with papillary thyroid carcinoma were immunohistochemically stained for the S100 protein, and the number of positive dendritic cells was counted. Cells were sparse in normal thyroid tissue and common in areas of thyroiditis and papillary carcinoma. Dendritic cell density in papillary carcinoma correlated with the thyroiditis grade and dendritic cell density in surrounding areas of thyroiditis. High-grade thyroiditis (42% of patients) was inversely associated with 3-year recurrence. Dendritic cell density was not associated with disease-free survival. The lack of prognostic value of dendritic cell density is not compliant with the only other relevant study in the literature, and further research is required.

Expression of cyclin E in stage III colorectal carcinoma

Carcinogenesis is characterized by an abnormal regulation of the cell cycle. Regulators of the cell cycle such as cyclin E play an important role in neoplasia and may be correlated with prognosis. The clinical significance of the expression of cyclin E in stage III colorectal carcinoma has not yet been investigated. The expression of cyclin E was evaluated in 49 patients. Using a multivariate analysis, the expression of cyclin E in the tumor at diagnosis was compared with various clinicopathological variables, including age, gender, tumor site, tumor size, tumor differentiation and lymph node involvement. There were more node-positive cases in the cyclin E-negative group than in the cyclin E-positive group (P=0.003). However, there was no correlation between the degree of cyclin E expression and the clinical data. In conclusion, our data suggest that overexpression of cyclin E does not predict the clinical outcome in colorectal cancer stage III. Negative cyclin E staining may be associated with lymph node involvement.

Expression of estrogen receptor β1 in colorectal cancer: correlation with clinicopathological variables

Colorectal cancer (CRC) is a common malignancy in both genders with a high death rate, accounting for about 56,000 each year in the USA only. In this study we examined the differences in CRC between the genders. We also looked for differences in the staining of the tumors and adjacent colonic mucosa to estrogen receptor β1 and its possible prognostic value. Fifty-five specimens from patients who underwent resection of colon cancer in our institute were sectioned and stained for estrogen receptor β1. The histopathological slides were evaluated for positive staining in the tumor and the normal colonic mucosa as well. The results were statistically analyzed. Positive estrogen receptor β1 stain was found in the nuclei of the tumor cells. We noted positive stain also in the cytoplasm of the tumor cells. Similar findings were observed in the normal colonic mucosa. Statistically significant differences were found regarding the positivity of the staining between the deceased and surviving patients, men/women and those who had metastases vs. the non-metastatic ones. Our data suggest that there is an estrogen influence on the development and progression of colon cancer. Furthermore, it was found to be higher in the more severe cases.

Thyroid gland involvement in advanced laryngeal cancer: association with clinical and pathologic characteristics

BACKGROUND

Indications for thyroidectomy during laryngectomy are controversial. We examined whether clinicopathologic features can predict thyroid gland involvement, and the prognostic effect of thyroid gland involvement in patients undergoing total laryngectomy.

METHODS

The study set out to review preoperative assessment, operation findings, pathologic findings, and follow-up data.

RESULTS

Thyroid gland involvement was found in 11 of 53 patients (21%) undergoing total laryngectomy and thyroidectomy. Preoperative work-up failed to predict thyroid gland involvement. Thyroid gland involvement was associated with salvage procedures (p = .025), paratracheal metastases (p = .003), and poor overall survival (hazard ratio = 2.74, p = .008).

CONCLUSIONS

Thyroid gland involvement in patients undergoing total laryngectomy is frequent and is associated with poor prognosis. Preoperative assessment failed to predict thyroid gland involvement. We believe that thyroidectomy should be considered in cases with paratracheal lymphatic spread irrespective of tumor location within the larynx.

Vitamin D inhibits captopril-induced cell detachment and apoptosis in keratinocytes

BACKGROUND

Captopril, an angiotensin I-converting enzyme inhibitor, is a commonly prescribed antihypertensive drug. Its cutaneous side-effects include pemphigus vulgaris acantholysis and bullous pemphigoid-like cell-matrix detachment. This medication also triggers apoptosis in human keratinocytes. Calcitriol, the hormonally active vitamin D metabolite, protects keratinocytes from programmed cell death induced by various noxious stimuli.

OBJECTIVES

To examine if calcitriol protects proliferating keratinocytes from the damage inflicted by captopril.

METHODS

Autonomously proliferating HaCaT keratinocytes, used as a model for basal layer keratinocytes, were exposed to captopril. Cell detachment was examined visually by light microscopy. Cytotoxicity was assessed by Hoechst 33342 staining and lactate dehydrogenase release. Apoptotic death was assessed by monitoring caspase 3-like activity.

RESULTS

Cells exposed to captopril detached and became round. This process was accompanied by programmed cell death. From time-dependent monitoring of cell detachment and apoptosis, and examination of pan-caspase inhibitor effects on cell detachment we concluded that cell death is the consequence of cell detachment from the culture plate and not vice versa. Pretreatment with calcitriol significantly attenuated these events. The effects of calcitriol were already evident at 1 nmol L(-1) concentration of the hormone.

CONCLUSIONS

The results of this study show that calcitriol protects keratinocytes from captopril-induced cell detachment and apoptosis.

Histopathological changes of the nasal mucosa induced by smoking

Changes in the histopathology of the respiratory epithelium in response to cigarette smoking have been studied in depth in the lungs, but data on the nasal lining are lacking. The aim of the present retrospective study was to investigate the histological changes that occur in the nasal mucosa of smokers compared with non-smokers. The study group included 47 patients who underwent partial resection of the inferior turbinates. Archival nasal tissue samples were collected and examined by light microscopy: the number of goblet cells was counted, and the degree of inflammation, congestion, and edema was graded as mild, moderate, or severe. Epithelial thickness was measured as well. Findings were compared between smokers (n = 21) and non-smokers (n = 26). On statistical analysis, significant differences were found between the smokers and non-smokers in mean number of goblet cells in the nasal epithelium, 43.43 +/- 16.80 vs. 16.23 +/- 5.65 respectively (p < 0.0001), mean edema grade, 2.43 +/- 0.75 vs. 1.12 +/- 0.33 respectively (p < 0.0001), and mean epithelial thickness, 111.9 +/- 25.8 microm vs. 60.4 +/- 18.4 microm respectively (p < 0.0001). The corresponding mean values of congestion were 2 +/- 0.71 and 1.27 +/- 0.67 (p < 0.001), and of inflammation, 1.81 +/- 0.60 and 1.81 +/- 0.85 (NS). In conclusion, the histopathological findings in the nasal mucosa of smokers resemble reported findings in the bronchial respiratory epithelium. The main differences from non-smokers are greater goblet cell hyperplasia and thicker epithelium.

Upregulation of MMP-9 production by TNFalpha in keratinocytes and its attenuation by vitamin D

MMP-9, a member of the matrix metalloproteinase family that degrades collagen IV and processes chemokines and cytokines, participates in epidermal remodeling in response to stress and injury. Limited activity of MMP-9 is essential while excessive activity is deleterious to the healing process. Tumor necrosis factor (TNFalpha), a key mediator of cutaneous inflammation, is a powerful inducer of MMP-9. Calcitriol, the hormonally active vitamin D metabolite, and its analogs are known to attenuate epidermal inflammation. We aimed to examine the modulation of MMP-9 by calcitriol in TNFalpha-treated keratinocytes. The immortalized HaCaT keratinocytes were treated with TNFalpha in the absence of exogenous growth factors or active ingredients. MMP-9 production was quantified by gelatin zymography and real-time RT-PCR. Activation of signaling cascades was assessed by western blot analysis and DNA-binding activity of transcription factors was determined by EMSA. Exposure to TNFalpha markedly increased the protein and mRNA levels of MMP-9, while pretreatment with calcitriol dose dependently reduced this effect. Employing specific inhibitors we established that the induction of MMP-9 by TNFalpha was dependent on the activity of the epidermal growth factor receptor, c-Jun-N-terminal kinase (JNK), NFkappaB and extracellular signal-regulated kinase-1/2. The effect of calcitriol was associated with inhibition of JNK activation and reduction of DNA-binding activities of the transcription factors activator protein-1 (AP-1) and NFkappaB following treatment with TNFalpha. By down-regulating MMP-9 levels active vitamin D derivatives may attenuate deleterious effects due to excessive TNFalpha-induced proteolytic activity associated with cutaneous inflammation.

Expression of human DNA Topoisomerase II-alpha in squamous cell carcinoma of the larynx and its correlation with clinicopathologic variables

The aggressiveness of laryngeal squamous cell carcinoma (SCC) is unpredictable. Topoisomerase (Topo) II-alpha is an essential nuclear enzyme; its expression rises at the end of the S-G2/M phase and drops at completion of mitosis. This study sought to determine if Topo II-alpha expression can serve as a prognostic factor in laryngeal SCC. Specimens from 56 consecutive patients were immunohistochemically stained for Topo II-alpha, and the number of positive cells in the areas of highest staining was counted in 3 highpower fields (X400) (Topo II-alpha index). Differences in the Topo II-alpha index by the presence or absence of recurrence, tumor stage and grade, and disease course were analyzed statistically. On multivariate Cox regression analysis, the Topo II-alpha index (>70 or < or =70) (P = .008) and tumor grade (P = .034) independently predicted disease-free survival. These findings suggest that high Topo II-alpha expression may be a useful indicator of tumor aggressiveness and poor outcome in laryngeal SCC.

EGFR in Enamel Matrix Derivative-induced Gingival Fibroblast Mitogenesis

We previously reported that EMD (Enamel Matrix Derivative) induces proliferation of human gingival fibroblasts via activation of Extracellular Regulated Kinase (ERK), and this study assessed the possible mediatory role of EGFR (Epidermal Growth Factor Receptor) in this effect. Treatment of gingival fibroblasts with EMD resulted in tyrosine phosphorylation of the EGFR, as assessed by immunoblotting and ELISA, while EMD-induced ERK activation and thymidine incorporation were markedly inhibited (~ 40–50%) by a specific EGFR tyrosine kinase inhibitor. Using appropriate inhibitors, we established that EMD-induced EGFR activation is largely due to shedding of HB-EGF (Heparin-binding EGF) from the cell membrane via a metalloproteinase-mediated process. Finally, the addition of PP1, a Src family inhibitor, abrogated both EGFR phosphorylation and ERK activation. Taken together, these results indicate that, at least in human gingival fibroblasts, EMD-induced ERK activation and proliferation are partially due to a Src-dependent, metalloproteinase-mediated transactivation of EGFR.

Human topoisomerase II-alpha is highly expressed in sinonasal-inverted papilloma, but not in inflammatory polyp

Sinonasal-inverted papilloma is a benign tumour with a high rate of recurrence, but possible malignant transformation. Therefore, inves tigation of predisposition to malignant transformation of sinonasal-inverted papilloma gives clinicians the opportunity for adequate trea ment. Topoisomerase II-α (topoII-α) and Ki67 are markers of cell proliferation in both normal and neoplastic tissues and its level o expression could be used as a predictive parameter. Our goal was to investigate by immunochemistry the expression level of topoII-in inverted papilloma, inflammatory nasal polyp and normal sinonasal epithelium and to compare it with expression level of Ki67. TopoI α nuclear immunostaining showed a differential positivity in the investigated cases. The topoII-α index was 30.6 ± 12.8 in inverte papilloma, 10.7 ± 6.6 in the adjacent epithelium of inverted papilloma, but only 2.3 ± 2.0 in the normal sinonasal epithelium. The di ferences in topoII-α expression between inverted papilloma and normal sinonasal epithelia were statistically significant. In inflammator nasal polyp group, topoII-α index was 2.4 ± 2.1, and the difference in the topoII-α index between inverted papilloma and inflammator polyp group was also statistically significant. Nuclear immunostaining for Ki67 followed a similar variation. The Ki67 index was 50.0 ± 20. in inverted papilloma, 9.0 ± 6.6 in the adjacent epithelium of inverted papilloma and 2.4 ± 0.9 in normal sinonasal epithelium. The di ferences in Ki67 expression between inverted papilloma and either adjacent or normal sinonasal epithelia were statistically significan Significant correlation coefficients were found between topoII-α and epithelial thickness (r = 0.70, P > 0.0001), and between Ki67 inde and epithelial thickness (r = 0.71, P> 0.0001). In the inflammatory nasal polyp group Ki67 index was 5.9 ± 3.4. The difference in th Ki67 index between inverted papilloma and inflammatory nasal polyp groups was statistically significant. Significant correlation coeff cient was found between topoII-α index and Ki67 index in inverted papilloma (r = 0.42, P > 0.05). These results suggest that the inverte papilloma contains a significantly higher cell population with proliferative activity by comparison with normal sinonasal and inflamma tory polyp epithelia, showing a significant correlation between topoII-α and Ki67 expression, and indicating that topoII-α could be a independent prognostic factor for a putative malignant transformation.

Expression of epithelial cell adhesion molecule in gallbladder carcinoma and its correlation with clinicopathologic variables

Gallbladder carcinoma is rare and fatal, and conventional therapies have been disappointing. Epithelial cell adhesion molecule (EpCAM) serves as a prognostic marker in various carcinomas and is a target of antibody-based therapies. Our purpose was to examine the expression of EpCAM in gallbladder carcinomas in relation to tumor grade, disease stage, and patient survival. Gallbladder carcinoma tissue specimens from 25 patients attending our center between 1991 and 2004 were immunohistochemically stained for EpCAM. The intensity and extent of staining were analyzed, and the specimens were classified accordingly: (1) weak, weak or no EpCAM expression in less than 10% of the selected area; (2) moderate, moderate expression in 10% to 49% of the selected area; or (3) strong, heavy staining in 50% or more of the selected area. The correlation between EpCAM expression and clinicopathologic variables was analyzed statistically.EpCAM overexpression predicted decreased survival (P = .005), but EpCAM expression did not correlate with tumor grade (P = .28) or disease stage (P = .10). EpCAM expression in gallbladder tumors may serve as a prognostic factor for poor survival. Its detection may help clinicians select patients likely to benefit from novel molecular therapies.

Enamel matrix derivative protects human gingival fibroblasts from TNF-induced apoptosis by inhibiting caspase activation

Emdogain, a formulation of enamel matrix derivative (EMD), is used clinically for regeneration of the periodontium (tooth supporting tissues), but the molecular mechanisms of its action have not been elucidated. Several clinical studies suggested that EMD may also improve gingival healing after periodontal surgery and thus affect the fate of gingival fibroblasts (GFs). Since these cells are targets for local inflammatory mediators such as TNF, a pro-apoptotic cytokine, during the course of periodontal disease, we tested whether EMD protects human GFs (hGFs) from TNF-induced cytotoxicity. Quiescent primary hGFs were challenged with TNF (10-100 ng/ml) with or without EMD (100 microg/ml) pretreatment. Cell viability was assessed by neutral red staining, cell death by LDH release and apoptosis by caspase activity. Signaling pathways were evaluated by Western blotting and pharmacological inhibitors. TNF induced classical signs of apoptosis in hGFs, including typical cellular morphology and increased caspase activity. TNF-induced cytotoxicity was entirely caspase-dependent. Pretreatment (4-24 h) with EMD dramatically inhibited the activation of initiator and executioner caspases and enhanced hGF survival. Although TNF induced the activation of p38 MAPK, JNK, ERK and PI-3K signaling, these pathways were not crucial for EMD protection of hGFs. However, EMD increased the levels of c-FLIP(L), an anti-apoptotic protein located upstream of caspase activation. These data demonstrate, for the first time, that EMD protects hGFs from inflammatory cytokines and, together with our recent reports that EMD stimulates rat and human GF proliferation, could help explain the mechanisms whereby in vivo use of EMD promotes gingival healing.

Endoscopic laser surgery for subglottic stenosis in Wegener's granulomatosis

PURPOSE

Wegener's granulomatosis (WG) is a rare multisystem inflammatory disease, which infrequently involves the subglottic area and trachea. Treatment usually involves the use of immunosuppressive agents with corticosteroids. Some patients, however, continue to have symptoms of airway obstruction after clinical remission following the standard therapeutic regimen.

OBJECTIVE

To investigate laser treatment for subglottic stenosis in five patients suffering from WG.

MATERIALS AND METHODS

We endoscopically treated 5 patients with subglottic stenosis due to WG and airway obstruction by Nd:YAG and CO2 lasers. One of the patients had preoperative tracheostomy and after treatment was decannulated and could not breathe without dyspnea. Another patient required stenting of the subglottic area.

RESULTS

All five patients were able to breathe without dyspnea after the treatment. Three patients were treated with an Nd:YAG laser but needed repeated laser treatment every four to six months, whenever they complained of dyspnea. The other two patients were treated with a CO2 laser; one of these patients had preoperative tracheostomy and was treated twice by CO2 laser and decannulated, with no further difficulty in breathing. The follow-up period was 1-5 years.

CONCLUSIONS

Nd:YAG and CO2 lasers are recommended in the treatment of subglottic stenosis (SS) due to WG, particularly when the stenosis is in continuity or close proximity to the vocal cords.

Mid-term results of stapled hemorrhoidopexy for third- and fourth-degree hemorrhoids--correlation with the histological features of the resected tissue

BACKGROUND

Stapled hemorrhoidopexy is used to remove a circumferential strip of mucosa and submucosa about 4 cm above the dentate line, in order to restore the correct anatomical relationships of the anal canal structures. We evaluated the histological features of the resected tissue obtained after stapled hemorrhoidopexy with correlation to the short-term and mid-term results.

METHODS

This retrospective study evaluated 234 cases of stapled hemorrhoidopexy. Data concerning postoperative bleeding, anal pain, incontinence, stenosis, and recurrence of hemorrhoids were collected from hospital and outpatient clinic records. Histologic slides were examined for the type of epithelium, presence of muscle fibers, nerve endings, and degree of vascular ectasia.

RESULTS

Some 52% of the biopsies revealed on the surface a combination of glandular with squamous epithelium, meaning a stapling line at the level of the transitional zone/dentate line. Smooth muscle fibers were more frequent as the stapling line approached the level of the dentate line/transitional zone (p = 0.0028). Internal sphincter fibers were present in 36% of the cases, yet there were no cases of anal incontinence. Inclusion of merely squamous epithelium in the resected tissue correlated with severe postoperative pain persisting one week after surgery (p < 0.0001), whereas the concurrent presence of squamous and glandular epithelium correlated only with severe pain on the first postoperative day (p = 0.018). Nerve endings were more frequent in patients with anal pain one week after surgery (p = 0.02). The rate of recurrence of symptoms was 3%, which did not correlate with any of the histological parameters tested.

CONCLUSIONS

Though stapled hemorrhoidopexy is performed according to well-established technical guidelines, it is too difficult to be standardized.

Activin βA in term placenta and its correlation with placental inflammation in parturients having epidural or systemic meperidine analgesia: a randomized study

STUDY OBJECTIVE

To investigate the immunohistochemical localization of betaA subunit of activin A in human term placenta, as a marker for placental infection/inflammation and elevated temperature, in parturients laboring during two analgesic regimens.

DESIGN

Prospective, randomized controlled study.

SETTING

Delivery room.

PATIENTS

56 healthy, ASA physical status I and II primiparous women in labor.

INTERVENTIONS

Parturients were assigned to receive patient-controlled epidural analgesia (PCEA) with 0.2% ropivacaine or patient-controlled intravenous analgesia PCA with meperidine.

MEASUREMENTS

Histologic and immunohistochemical placental evaluation for white blood cell infiltration and activin betaA staining were made. Maternal temperature elevation above 37.6 degrees C and leukocytosis above 15,000/microL were recorded.

MAIN RESULTS

Temperature was not significantly increased in parturients receiving PCEA over those who received (PCA) with meperidine (31% vs 11%, respectively; P = 0.1). There was also no association between temperature elevation during epidural analgesia and increased white blood cell count (>15,000/microL) or presence of polymorphonuclear and/or lymphocyte aggregation in the placenta. Immunohistochemical staining with antisera against the betaA subunit of activin was present mainly in the placental cytotrophoblast, syncytiotrophoblast, and vascular endothelium, and was not associated with an increase in maternal temperature. No significant difference was noted between the two analgesic techniques with regard to maternal temperature elevation. Intrapartum temperature elevation was not associated with histologic signs of placental inflammation or with expression of activin betaA in the placenta.

CONCLUSION

Other mechanisms may be involved in the etiology of temperature elevation during labor.

Enamel matrix derivative stimulates human gingival fibroblast proliferation via ERK

Emdogain, a formulation of Enamel Matrix Proteins, is used clinically for periodontal regeneration to stimulate PDL (periodontal ligament), cementum, and bone formation. Its effects on gingival fibroblasts and tissue have not been thoroughly studied. Therefore, we investigated the mechanisms by which Emdogain affects the cell cycle of human gingival fibroblasts. Without serum, Emdogain (50 microg/mL) induced human gingival fibroblast entry into the S phase and DNA synthesis, but not completion of the cell cycle. With low serum concentrations (0.2-0.5%), Emdogain synergistically induced completion of the cell cycle, resulting in increased cell numbers. The mitogenic response to Emdogain depended on Extracellular Regulated Kinase (ERK) activation, which occurred in two waves, peaking after 15 min and 4 to 6 hrs, since it was abolished by U0126, a specific MAPK inhibitor. Inhibition of the second wave was sufficient to abrogate mitogenesis. This study characterized the mitogenic effect of Emdogain on primary human gingival fibroblasts, its cooperation with serum growth factors, and the key mediatory role of the ERK cascade.

A new scoring system using multiple immunohistochemical markers for diagnosis of uterine smooth muscle tumors

The diagnosis of uterine smooth muscle neoplasms by light microscopy is difficult. Multiple classification schemes have been proposed based on mitotic rate, nuclear atypia, and the presence or absence of necrosis. None of these classification systems has been entirely successful. This study was undertaken to evaluate the use of selected immunohistochemical and histochemical markers in differentiating these tumors, in addition to accepted morphologic criteria. Ten cases of each of the following: leiomyosarcomas (LMS), atypical leiomyomas (AL), cellular leiomyomas (CL) and usual leiomyomas (UL), were classically evaluated for histological diagnosis and were stained for Ki-67 (MIB-1), bcl-2 and p53 using monoclonal antibodies and the avidin-biotin peroxidase method, and argyrophilic nucleolar organizer region (AgNORs). The number of stained cells was counted in the most positively stained region in a 4 mm² square cover glass mounted on each slide. The mean value was calculated for each group of tumors. The data for Ki-67 (MIB-1), bcl-2, p53 and AgNOR staining respectively, were significantly higher in LMS by comparison to UL, CL or AL. Because many singular cases had superimposed data being difficult to diagnose, a new scoring system for pathological evaluation was created. The results obtained by this scoring system suggest that immunohistochemical markers Ki-67 (MIB-1), bcl-2, p53 together with the AgNOR staining could be useful, by the scoring system, as an adjunct to the current accepted morphologic criteria in differentiating smooth muscle tumors of the uterus.

Use of Er:YAG laser to improve osseointegration of titanium alloy implants--a comparison of bone healing

PURPOSE

The objective of this study was to compare the osseointegration of implants in rats in sites prepared with an Er:YAG laser with osseointegration in sites prepared using a conventional drill by assessing the percentage of bone-implant contact (BIC).

MATERIALS AND METHODS

Osteotomies were prepared with an Er:YAG laser in the tibiae of 18 rats (the test group) and drill-prepared with a 1.3-mm-wide surgical implant drill at 1,000 rpm with simultaneous saline irrigation in the tibiae of another 18 rats (the control group). Acid-etched titanium alloy implants (2 x 8 mm) were placed in the tibiae, engaging the opposite cortical plate. The Er:YAG laser was used with a regular handpiece and water irrigation (spot size, 2 mm; energy per pulse, 500 to 1,000 mJ; pulse duration, 400 ms; and energy density, 32 J/cm2). Nine animals from each group were sacrificed after 3 weeks of unloaded healing; the remainder were sacrificed after 3 months. The tissues were fixed and prepared for histologic and histomorphometric evaluation.

RESULTS

Statistical analysis showed significant differences between the 2 groups at both 3 weeks and 3 months. After 3 weeks of unloaded healing, the mean BICs (+/- SD) were 59.48% (+/- 21.89%) for the laser group and 12.85% (+/- 11.13%) for the control group. Following 3 months of unloaded healing, the mean BICs (+/- SD) were 73.54% (+/- 11.53%) for the laser group and 32.6% (+/- 6.39%) for the control group.

DISCUSSION

Preparation of the implant sites with the Er:YAG laser did not damage the interface; the healing patterns presented were excellent.

CONCLUSIONS

Based on the results of this study, it may be concluded that the Er:YAG laser may be used clinically for implant site preparation with good osseointegration results and bone healing and with a significantly higher percentage of BIC compared to those achieved with conventional methods.

Programmed cell death of stressed keratinocytes and its inhibition by vitamin D: The role of death and survival signaling pathways

The epidermis is confronted with multiple environmental and pathophysiological stresses. This study shows that TNFalpha, oxidative stress, hyperosmotic and heat shock induced both caspase-dependent and independent cell death in human HaCaT keratinocytes. The hormonal form of vitamin D, 1,25(OH)2D3, which is an autocrine hormone in the epidermis, protected the cells from all the examined stresses and pathways leading to cell death. We aimed to define the signaling pathways that determine the life-death balance of stressed keratinocytes and participate in their protection by 1,25(OH)2D3. As assessed by employing specific inhibitors, the survival pathways mediated by the EGF receptor, ERK, PI-3K or Src kinase, or basal transcriptional activity are important for unstressed cell survival. However, only the EGF receptor, PI-3K and the Src kinase pathways mediate the survival of stressed cells in a stimulus-specific manner. Inhibition of the p38 and/or the JNK death pathways reduced caspase activation induced by oxidative stress, hyperosmotic shock and TNFalpha. The protective effect of 1,25(OH)2D3 was not mediated by the examined survival pathways. 1,25(OH)2D3 inhibited the stress-induced activation of p38 and JNK. Since mimicking this effect by pharmacological inhibition resulted in the attenuation of caspase activation, we infer that these pathways are involved in keratinocyte protection by 1,25(OH)2D3.

Vitamin D Enhances Caspase-Dependent and Independent TNF-Induced Breast Cancer Cell Death

Calcitriol, the hormonal form of vitamin D, enhanced TNF-induced cytotoxicity in MCF-7 breast cancer cells. It increased the induction of caspase-3-like activity and TNF-induced caspase-independent cytotoxicity in the presence of a pan-caspase inhibitor. The antioxidants N-acetylcysteine, glutathione, lipoic acid, and ascorbic acid markedly reduced the effect of the hormone on TNF-induced caspase activation, attesting to the involvement of reactive oxygen species (ROS) in the cross-talk between the hormone and the cytokine. Calcitriol augmented the drop in mitochondrial membrane potential induced by TNF as assessed by the fluorescent probe JC-1. We postulate that the interaction of TNF and calcitriol on the level of the mitochondria underlies the enhancement of TNF-induced, ROS-mediated caspase-dependent and -independent cell death.

Mucinous adenocarcinoma of posterior urethra. Report of a case

Primary carcinoma of the male urethra accounts for less than 1% of malignancies in males. Mucinous adenocarcinoma of the urethra is extremely rare, and its biologic behavior is not well known. We report a case of mucinous adenocarcinoma showing the histologic features of colloid adenocarcinoma that appears to have evolved either by neoplastic degeneration of goblet cells found in the urethral epithelium or by malignant degeneration of persistent glandular elements of uretheritis cystica and glandularis.

13C-urea breath test for success of Helicobacter pylori eradication: study of 5885 Israeli patients

Helicobacter pylori (Hp) infection is highly prevalent in many countries and may cause gastritis, peptic ulcer disease, gastric cancer, and lymphoma. Successful eradication depends on the specific treatment used, patient compliance, and Hp antibiotic resistance. The primary aim was to characterize groups of patients with one or more failures of Hp eradication treatment. The secondary aim was to evaluate the factors that influence eradication failure. Between April 1, 1998, and December 31, 2001, 5885 patients were studied for the success of Hp eradication with the 13C-urea breath test (13C-UBT): 5442 after one course of treatment (Group I), 380 after two courses (Group II), and 63 after three courses (Group III). The 13C-UBT was positive in 27.8%, 37.4%, and 47.6% of patients in Groups I, II, and III, respectively (P(I-II) = 0.000, P(II-III) = 0.126). A combination of omeprazole, amoxicillin, and clarithromycin (OAC) was used in 31.3%, 27.4%, and 7.9% of Groups I, II, and III, respectively, and a combination of omeprazole, amoxicillin, and metronidazole (OAM) in 15.2%, 28.9%, and 28.6%, respectively. Regimens that contained clarithromycin were used in decreasing order in Groups I, II, and III, and regimens containing metronidazole, bismuth, or tetracycline, in increasing order. The only good prognostic factor for successful eradication was Israeli origin, while European-American and Asian-African origin, recurrence of symptoms, a history of duodenal ulcer, and chronic proton pump inhibitor (PPI) use did not favor successful eradication. Our results suggest that origin, history of peptic disease, and chronic PPI use are predictors of eradication failure.

Human DNA topoisomerase II-alpha expression in laparoscopically treated renal cell carcinoma

To investigate whether the expression of Topoisomerase II-alpha (TII-alpha) can serve as a prognostic factor in renal cell carcinoma (RCC), histological sections from 27 renal tumors were stained immunohistochemically for TII-alpha expression. The percentage of positive cells in the area of greatest staining was recorded as the TII-alpha index. TII-alpha nuclear staining was positive in all the samples except one. The mean TII-alpha index was 12.5 for grade 1, 44 for grade 2 and 113 for grade 3 tumors. The mean TII-alpha index was 22.3 in tumors which did not recur and 81 for tumors which recurred during the follow-up period. In this study, a higher TII-alpha index correlated with more aggressive tumor behaviour. However, a large cohort of patients should be assessed before drawing definitive conclusions.

An improved technique for mitosis counting

Mitosis counting remains one of the most valuable prognostic indicators in tumor pathology; however, as currently carried out it is time consuming and not reproducible. In this study, 6 different pathologists, using different microscopes, arrived at widely different mitotic counts on the same slide, ranging from 4 to 16. These differences were mainly due to the different field areas of the various microscopes used and the method used for counting and recording. In evaluating the most active 10 HPF, the count ranged from 10 to 19. Instead, when an average of 40 fields was recorded, the range was 4-11. Using the mitosis/volume index, which expresses the number of mitotic figures per mm2 of viable tumor, the counts ranged from 8 to 10, a marked improvement. However, this method is complicated and not "user-friendly.'' We suggest a variation of the technique by which a 2 mm2 rectangle is drawn on a cover slip and mounted under the microscope, centered on the most mitotically active area of the tumor. The mitoses in that area are counted (=n) and the percent of viable tumor (=x%) is estimated under low magnification. The number of mitoses per mm2 of viable tumor (cs-MAI) is then calculated according to the formula Cs-MAI=100n/2x. Using this modified method, the range of mitoses counted by the different observers was very narrow (9 to 11), and the time required for the counting was only 5-10 minutes.

Cholesterol granulomas in antrochoanal polyps: a clinicopathologic study

The purpose of this study was to investigate antrochoanal polyps with cholesterol granuloma (CG), which is a granulomatous reaction to cholesterol crystals that has been precipitated in the tissue. It is usually associated with chronic middle ear disease, common in the mastoid air cells, less common in the orbit and rarely found in the paranasal sinuses. The aim of this study was to analyze the etiology and pathological findings of antrochoanal polyps associated with cholesterol granuloma. This is a retrospective study of five cases of antrochoanal polyp with cholesterol granuloma, (four males and one female between 15 and 77 years of age) who presented with nasal obstruction, rhinorhea and snoring. The cases were clinically and histologically reviewed. Four patients were treated endoscopically and one by intranasal polypectomy without endoscope. There was no recurrence during the follow-up between 24 to 36 months (mean 31.2 months). Five uncommon cases with antrochoanal polyp with cholesterol granuloma are presented. The cholesterol granulomas consist of fibrous granulation tissue containing cholesterol crystals with surrounding foreign body giant cells. The pathogenesis of antrochoanal polyp with cholesterol granuloma is unclear, and further investigations are needed.

Expression of p53, Ki-67 and Bcl-2 in parathyroid adenoma and residual normal tissue

The aim of this study was to investigate the expression of Ki-67, bcl-2 and p53 in parathyroid adenomas and their residual rim of normal parathyroid tissue. Specimens from 26 parathyroid adenomas were studied by immunohistochemical analysis for Ki-67, bcl-2 and p53 expression. Positive findings were noted for p53 in 4 (15%) adenomas and none of the residual rims of normal parathyroid tissue (p = 0.055); for Ki-67 in 15 (56%) adenomas and none of the residual rims of normal parathyroid tissue (p = 0.00002); and for bcl-2 in 19 (73%) adenomas and 8 (31%) residual rims of normal parathyroid tissue (p < 0.01). The high rate of Ki-67 expression may indicate susceptibility of parathyroid adenomas to clonal proliferation. The weak immunoreactive expression of p53, combined with a relatively strong expression of bcl-2, may contribute to the characteristic slow progression of these tumors.

Transthoracic needle biopsy in the diagnosis of large-cell neuroendocrine carcinoma of the lung

To determine the effect of cytological diagnosis, fine-needle aspiration and brush cytology on lung tumors and core-needle biopsy, we retrospectively reviewed 11 cases of large-cell neuroendocrine carcinoma (LCNEC) found in our archives between the years 1997 and 2004. The preoperative cytological diagnosis of LCNEC is challenging because of the broad histologic similarity to other neuroendocrine tumors of the lung. The original cytologic diagnosis was LCNEC in nine of the cases while the remaining two were misdiagnosed as small-cell lung carcinoma. Smears were composed of clusters of intermediate-size cells with amphophylic cytoplasm, some with large nuclei and prominent nucleoli. In two of the cases there was discordance between the cytological findings and the immunohistochemical results. The cytological findings were correlated with histopathological observations.

Deleted-in-colon-cancer protein expression in patients with adenocarcinoma of the urinary tract and a history of colorectal cancer

OBJECTIVES

To assess whether immunostaining for deleted-in-colon-cancer (DCC) protein, a previously established prognostic marker in colon and bladder cancer, may assist in resolving the uncommon differential diagnostic dilemma of distinguishing primary from secondary urothelial adenocarcinoma.

METHODS

The study group consisted of 12 patients with adenocarcinoma involving the bladder or ureter and previously resected colorectal carcinoma between 1988 and 2002. All patients were initially considered to have primary urothelial transitional cell carcinoma, and the management strategy was conducted accordingly. The clinical data were recorded from the charts, and immunohistochemical staining for DCC was performed on formalin-fixed paraffin-embedded tissues containing the primary colorectal cancer and ensuing urinary tract tumor. Staining was defined as positive when at least 25% of the tumor cells were immunoreactive for DCC.

RESULTS

Of the 12 patients, 10 presented with bladder and 2 with ureteral adenocarcinoma. All secondary tumors originated from a primary carcinoma invariably located along the left colon or rectum. The overall 5-year disease-specific survival rate from the time of colectomy was 31% at a median follow-up of 50 +/- 8 months. Of the 12 patients, 5 (41%) had positive DCC immunoreactivity. In all cases, concordant expression of DCC was found in the primary colorectal cancer and the ensuing tumor in the urinary tract. The survival time from colectomy was significantly longer for the DCC-positive subgroup (median 59 months, 95% confidence interval 41 to 77) than in the DCC-negative subgroup (median 23 months, 95% confidence interval 13 to 37). Likewise, the time lag between colectomy and tumor recurrence in the urinary tract was significantly longer in the patients with DCC-positive tumors (median 35 months) than in those with DCC-negative tumors (median 10 months).

CONCLUSIONS

DCC immunoreactivity was consistently observed in secondary bladder or ureteral adenocarcinoma when the primary colorectal lesion expresses DCC, and thus may serve to establish the origin of the tumor. Positive DCC protein expression in secondary urinary tract adenocarcinoma of colorectal origin may identify a subset of patients with a relatively favorable prognosis. Additional studies are required to confirm our results.

Talc inhalation is a life-threatening condition

A case of rapidly progressive disease and pulmonary hypertension due to chronic cosmetic talc inhalation is presented. Although an uncommon cause of pulmonary hypertension, talc, especially through intravenous administration, should be included in the etiology of parenchymal pulmonary hypertension. In our case talc inhalation was inadvertent, causing fulminant disease leading to the patient's death. To our knowledge, this is the first case of inadvertent talc inhalation causing death in adult patient.