[Non-invasive precursor lesions of penile carcinoma : Differential diagnosis and treatment]

Clinical diagnosis of preinvasive malignant lesions of the penis is difficult and there are numerous differential diagnoses. Recent decades have been witness to several changes in the terminology of histopathological diagnoses. In the current World Health Organization classification, penile intraepithelial neoplasia (PeIN) is defined, of which several subtypes exist. Just like in invasive carcinoma, the principal classification of PeIN subtypes corresponds with pathogenesis and includes human papilloma virus (HPV)-related and non-HPV-related forms. Subdivision is important for prognosis. Several therapeutic options exist, including surgical and nonsurgical procedures.

[Endometrioid borderline tumor of the testis. A rare cause of cystic neoplasia]

Ovarian type surface epithelial carcinomas of the testis are rare and therefore mostly represent a surprising finding in diagnostic procedures. The most frequent is the serous subtype, while only a few cases of the endometrioid subtype have been reported in the literature. The case of a 73-year-old patient with an endometrioid type papillary cystic tumor of borderline malignancy is presented. The histopathological and immunohistochemical details of this rare tumor are discussed.

[Non-neoplastic alterations of the prostate. Why should pathologists know them?]

Non-neoplastic changes in the prostatic gland include inflammatory, atrophic, hyperplastic and metaplastic reaction patterns of the glandular epithelium and the fibromuscular stroma. Furthermore, histoanatomical structures from outside the prostatic gland are sometimes included in biopsy material. Knowledge of the morphological appearance of benign, reactive lesions is important in order to differentiate them from malignancies. To this aim knowing the precise location of tissue sampling as well as ancillary immunohistochemical investigations are often useful or necessary.

Prognostic relevance of Bcl-2 overexpression in surgically treated prostate cancer is not caused by increased copy number or translocation of the gene

BACKGROUND

Overexpression of anti-apoptotic Bcl-2 plays a role in prostate cancer progression, particularly in transformation to androgen-independent disease. Androgen-independent prostate cancers have been shown to harbor Bcl-2 gene copy number gains frequently suggesting that this genetic alteration might play a role in Bcl-2 overexpression. The relation of Bcl-2 overexpression and copy number gains or translocation of the BCL-2 gene in prostate cancer under hormone-naïve conditions is unknown.

METHODS

Prostate cancers of 3,261 hormone-naïve patients undergoing radical prostatectomy were arrayed in a TMA with one tissue core (diameter 0.6 mm) per tumor. Bcl-2 immunohistochemistry, analyzed for Bcl-2 expression level (negative, low, and high), was correlated with clinical, histopathological and molecular (Ki67, p53) tumor features, and biochemical failure. Cancers with high-level Bcl-2 expression were evaluated for genetic aberrations by fluorescence in situ hybridization (FISH).

RESULTS

Bcl-2 expression was significantly up-regulated in tumors with aggressive phenotype as indicated by high Gleason score (P < 0.0001), advanced stage (P < 0.0001), and high proliferation index (P = 0.0114). The different Bcl-2 expression levels translated into significantly different survival curves showing better outcome for patients with lower Bcl-2 levels. The prognostic information obtained from the anti-apoptotic Bcl-2 was independent from the proliferation index (Ki67) of the cancer. FISH analysis detected no copy number gains or translocation of the Bcl-2 gene.

CONCLUSION

Bcl-2 overexpression in prostate cancers under hormone-naïve conditions is not associated with increased copy numbers of the gene. This suggests that these frequently detected genetic alterations in androgen-independent tumors occur late in prostate cancer progression.

[Allogeneic stem cell transplantation for acute myeloid leukemia and HIV infection--case 3/2012]

HISTORY AND ADMISSION FINDINGS

A 27-year-old male patient with a past medical history of HIV presented with acute myeloid leukemia for allogeneic hematopoietic stem cell transplantation (HSCT). Highly active anti-retroviral therapy suppressed the viral load below detection threshold.

INVESTIGATIONS

There were no contraindications for allogeneic HSCT.

TREATMENT AND COURSE

Myeloablative conditioning consisted of total body irradiation and cyclophosphamide. Anti-thymocyte globulin, tacrolimus and mycophenolate mofetil were used for immunosuppression. Combined anti-retroviral therapy (nucleoside and nucleotide analog reverse-transcriptase inhibitor, boostered protease inhibitor, maraviroc and raltegravir) was maintained for allogeneic HSCT and viral load remained below detection threshold. No graft-versus-host disease or serious infectious complications occurred. The patient showed good graft function with stable hematopoiesis. Localized Kaposi's sarcoma was diagnosed six months after allogeneic HSCT and treated successfully with surgical excision and reduction of immunosuppression. Almost one year after allogeneic HSCT, the CD4+ cell count is rising and viral load remains below detection threshold with combined anti-retroviral therapy.

CONCLUSION

Allogeneic HSCT can be safely performed in HIV positive patients. Kaposi's sarcoma is a rare event after allogeneic HSCT and linked to strong immunosuppression.

Losses at chromosome 4q are associated with poor survival in operable ductal pancreatic adenocarcinoma

Here we tested the prognostic impact of genomic alterations in operable localized pancreatic ductal adenocarcinoma (PDAC). Fifty-two formalin-fixed and paraffin-embedded primary PDAC were laser micro-dissected and were investigated by comparative genomic hybridization after whole genome amplification using an adapter-linker PCR. Chromosomal gains and losses were correlated to clinico-pathological parameters and clinical follow-up data. The most frequent aberration was loss on chromosome 17p (65%) while the most frequent gains were detected at 2q (41%) and 8q (41%), respectively. The concomitant occurrence of losses at 9p and 17p was found to be statistically significant. Higher rates of chromosomal losses were associated with a more advanced primary tumor stage and losses at 9p and 18q were significantly associated with presence of lymphatic metastasis (chi-square: p = 0.03, p = 0.05, respectively). Deletions on chromosome 4 were of prognostic significance for overall survival and tumor recurrence (Cox-multivariate analysis: p = 0.026 and p = 0.021, respectively). In conclusion our data suggest the common alterations at chromosome 8q, 9p, 17p and 18q as well as the prognostic relevant deletions on chromosome 4q as relevant for PDAC progression. Our comprehensive data from 52 PDAC should provide a basis for future studies with a higher resolution to discover the relevant genes located within the chromosomal aberrations identified.

Schmincke's Tumor, Carcinoma of the Base of the Tongue c T1-2, cN2c M0 - A Case Report

Background

Lymphoepithelial tumors are the most common carcinomas of the nasopharynx. The non-differentiated tumor, also called Schmincke's tumor, is more prevalent in the African and Chinese population. The incidence of the tumor according to age peaks between 20 and 30 years of age, and after 60 years of age. The tumor is rarely located outside of the nasopharynx. Case Report: This report is about a 73-year-old female patient diagnosed with a tumor of the base of the tongue. The histological result shows a low-grade carcinoma of the squamous epithelium, a lymphoepithelial carcinoma.

Conclusion

Despite the tumor's rare manifestation outside the nasopharynx, one must also consider the non-differentiated carcinoma of lymphoepithelial matrix. Especially due to the well-known early tumor spreading, cervical lymph node swelling on both sides can be recognized as a possible early symptom. First-line therapy consists of primary radiation of the tumor's primary region and its lymphoid draining channels. Concomitant chemotherapy can be applied. In case of cervical tumor spreading, a neck dissection reduces the risk of local recurrence.

Analysis of expression of TGF-β1 receptor (ALK-1) in normal and tumor tissues by tissue microarrays

e22044

Background: TGF-β1 is an important angiogenic factor involved in different aspects of angiogenesis and vessel maintenance. TGF-β1 receptors consist of class I, class II and accessory receptors. Activin-like kinase I (ALK-1) is a class I TGF- β1 receptor which is almost exclusively expressed on endothelial cells. Hereditary hemorrhagic telangiectasia (HHT) is caused by mutations in the ALK-1 gene. Knock-out mice for ALK-1 die during gestation due to vascular malformation. ALK-1 may thus represent an attractive target for anti-angiogenic therapy. A therapeutic monoclonal antibody (PF-03446962) against ALK-1 has been developed which is currently in phase I testing. Here we describe target validation in normal and tumor tissue using tissue micro-arrays (TMAs). Methods: Normal tissue arrays comprised of 609 individual histological samples representing 76 human tissues. Multi-tumor arrays consisted of 3923 individual tumor samples from 87 tumor types. Consecutive sections of tissue arrays were stained for ALK-1 and CD31. CD31 immunohistology (IHC) was performed to ensure presence of vessels within tissue samples. ALK-1 staining was graded 0=absent, 1=weak, 2= moderate and 3=strong by an experienced pathologist blinded to tissue type. Results: ALK-1 staining of vessels in normal tissues was generally weak (mostly grade 1 and rarely grade 2) and was detectable in lymphatic tissues including tonsil, lymph nodes, thymus and spleen, lung, the entire GI tract including parotid, submandibular and sublingual glands as well as pancreas. ALK-1 positive vessels were also found within the female genital tract including placenta, uterus and ovary. In human tumor vessels ALK-1 expression showed high variability between tumor types. The highest ALK-1 expression rate was found in lung cancer (NSCLC 49%, SCLC 83%), neuroendocrine pancreas tumor (71%), colon cancer (50%), chondrosarcoma 50%, angiosarcoma 40% and NHL (44%). Conclusions: TMAs are an excellent tool to verify target expression in normal and tumor tissues. Results may be used to predict side effects of targeted therapy and to direct phase II testing of innovative agents in patients likely to respond.

[Table: see text]

Determination of microvessel density by real-time PCR in esophageal cancer: Correlation with histological methods, angiogenic growth factor expression and lymph node metastasis

10053

Background: Neoangiogenesis and lymphangiogenesis represent prognostic factors in human malignancies. Determination of microvessel density (MVD) by immunohistology is labor-intensive and subject to interobserver variability. We evaluated real time PCR to quantify MVD in primary tumor samples from patients with esophageal cancer. Methods: We performed real-time PCR analyzes of endothel-specific (VE-Cadherin, P1H12, VEGFR-2, tie-2), lymphendothel-specific (Prox, LYVE, VEGFR-3) antigens and of angiogenic growth factors (VEGF-A, VEGF-C, VEGF-D, Ang-1, Ang-2) in primary esophageal carcinoma tissue of 54 patients. These results were compared to MVD determined immunohistochemically by CD31 staining. Results: For validation, MNC samples spiked with HUVECs were analyzed by qPCR for VE-CAD and P1H12 yielding a linear correlation (r=0.99 and 0.96 respectively). Expression of endothelial markers was highly correlated in tumor samples, e.g. CD144 with CD146 τb=0.451, CD144 with VEGFR-2 τb =0.744 and CD144 with tie-2 τb=0.684 (p for all comparisons < 0.0001). QPCR results were compared to MVD determination by CD31 staining in a subgroup of 33 patients. The highest association between both methods was found for CD144 (τb=0.258, p=0.0379) and VEGFR-2 (τb=0.222, p=0.0745) indicating that immunohistology and qPCR yield comparable results. MVD was significantly linked to the expression of VEGF-A, -C,-D and Ang1 and Ang2 (p for all comparisons <0.0001). We analyzed expression of lymphendothelial cell antigens Prox, LYVE and VEGFR-3 for quantification of lymphatic vessels. A close association between the expression of different lymphendothelial factors was seen (LYVE with Prox τb=0.334, p=0.0021, LYVE with VEGFR-3 τb=0.450, p=0.0150). MVD and lymphvessel density was not linked. Lymph node metastases detected on surgical specimen were associated with MVD determined immunohistologically (p=0.003)or by qPCR (p=0.048) and to VEGF-C expression (p=0.04). Conclusions: QPCR analysis of CD144 and VEGFR2 represents a novel tool for quantification of MVD in tumor samples. Expression of VEGFR2 and VEGF-C is associated with lymph node metastasis in patients with esophageal carcinoma.

No significant financial relationships to disclose.

Transition zone cancers undermine the predictive accuracy of Partin table stage predictions

PURPOSE

The Partin tables represent the most widely used predictor of pathological stage in men with localized prostate cancer (PCa). The accuracy and performance of the tables have been tested across different populations. However, to our knowledge the potential limitations that may stem from differences between transition zone (TZ) and peripheral zone (PZ) prostate cancers has not been explored. We tested the predictive accuracy and performance of the Partin tables according to TZ vs PZ tumor predominance.

MATERIALS AND METHODS

Preoperative serum prostate specific antigen, clinical stage and biopsy Gleason sum data on 1,990 patients treated with radical retropubic prostatectomy were used to define the 2001 Partin probabilities of organ confinement and seminal vesicle invasion (SVI). Data on 1,320 patients who underwent staging pelvic lymphadenectomy and radical retropubic prostatectomy were used to define the probabilities of lymph node invasion (LNI) and organ confined disease (OC). ROC area under the curve was used to assess the predictive accuracy of the 2001 Partin tables relative to observed extracapsular extension (ECE), SVI, LNI and OC. Performance characteristics for each prediction were explored graphically with local regression, nonparametric smoothing plots. Results were compared between 222 TZ cancers and 1,768 PZ cancers.

RESULTS

The 1,990 radical retropubic prostatectomy specimens demonstrated ECE in 689 cases (34.6%) (TZ in 58 or 27.1% and PZ in 631 or 35.8%) and SVI in 224 (TZ in 13 or 6.1% and PZ in 211 or 11.9%). The 1,320 lymphadenectomy specimens demonstrated LNI in 56 cases (TZ in 2 or 0.9% and PZ in 54 or 4.6%). OC was found in 784 cases (59.4%) (TZ in 95 or 69.9% and PZ in 689 or 58.2%). Predictive accuracy was for ECE 76.4% (TZ 69.0% and PZ 77.2%), 78.0% for SVI (TZ 73.5% and PZ 78.3%), 78.6% for LNI (TZ 44.5% and PZ 79.9%) and 79.4% for OC (TZ 73.8% and PZ 80.0%).

CONCLUSIONS

The biological tumor characteristics of TZ PCa differ from those of PZ PCa. These differences appear to undermine the accuracy of pathological stage predictions.

Simultaneous tumour-like, atypical basal cell hyperplasia and acinar adenocarcinoma of the prostate: a comparative morphological and genetic approach

Basal cell tumours of the prostatic gland are rare, and the classification is difficult. In the present case report, a large, tumour-like proliferation of atypical basaloid cells was found incidentally in a prostatectomy specimen that otherwise contained a conventional acinar adenocarcinoma. The basaloid cells displayed a solid or adenoid-cystic growth pattern and strongly expressed high-molecular-weight cytokeratins and bcl-2. A high Ki-67 index was recorded within the atypical basaloid cells, by far exceeding the one counted in the conventional adenocarcinoma. However, there were no definite criteria for a malignant behaviour of the basal cell tumour. Comparative genomic hybridisation from microdissected tumour cells yielded losses at the short arms of chromosomes 8 and 12 in the conventional adenocarcinoma and a normal karyotype in the basal cell tumour. The pathological findings favoured the diagnosis of an atypical basal cell hyperplasia.

[Dysfunction of a kidney allograft with life-threatening results]

Post-transplant lymphoproliferative disease (PTLD) is a serious complication after organ transplantation. We describe the case of a 45-year old patient who developed an EBV associated B-cell lymphoma in a cadaveric renal allograft. This case underscores the importance of considering PTLD as possible differential diagnosis for allograft dysfunction. Careful diagnostic evaluation should be undertaken in patients who present with risk factors for development of PTLD such as high doses of immunosuppression for rejection therapy, suspicious EBV serologies or negative EBV serologies before transplantation. PTLD can be of donor or recipient origin. Independent of its origin PTLD needs an immediate therapy which depends on the histology of the lymphoma and on the clinical conditions of the patient. Therapeutic options are reduction of the immunosuppression, chemotherapy or radiation, administration of lymphocyte-specific antibodies or removal of the kidney allograft.

[Primary squamous cell carcinoma of the liver. Surprising findings in dysontogenetic liver cysts]

HISTORY AND CLINICAL FINDINGS

A 60-year-old woman presented with intermittent fever and pain in the right upper abdomen. The patient had spent the last 30 years in the Middle East and Africa.

EXAMINATION

Multiple hepatic lesions with cystic parts were demonstrated sonographically. Ecchinococcosis as well as amoebiasis had been excluded. Laboratory findings showed elevated levels of inflammatory parameters, lactate dehydrogenase (4107 U/l), squamous cell carcinoma antigen and CA -125. The liver enzymes were found to be within the normal range.

DIAGNOSIS

A squamous cell carcinoma was detected by liver biopsy. The search for a possible primary site elsewhere in the body yielded negative results, so that the tumor must be regarded as primary in the liver.

THERAPY

Because of the diffuse tumour growth surgical resection was impossible. The patient underwent chemotherapy. She died 9 month after the squamous cell carcinoma had been diagnosed.

CONCLUSION

This case report and a medline research indicate that hepatic neoplasms sometimes must be suspected in patients with liver cysts.

[Can nomograms derived in the U.S. applied to German patients? A study about the validation of preoperative nomograms predicting the risk of recurrence after radical prostatectomy]

In patients suffering from prostate cancer, preoperative nomograms, which predict the risk of recurrence may provide a helpful tool in regard to the counselling and planning of an appropriate therapy. The best known nomograms were published by the Baylor College of Medicine, Houston and the Harvard Medical School, Boston. We investigated these nomograms derived in the U.S. when applied to German patients. Data from 1003 patients who underwent radical prostatectomy at the University-Hospital Hamburg were used for validation. Nomogram predictions of the probability for 2-years (Harvard nomogram) and 5-years (Kattan nomogram) freedom from PSA recurrence were compared with actual follow-up recurrence data using areas under the receiver-operating-characteristic curves (AUC). The recurrence free survival after 2 and 5 years was 78% and 58%, respectively. The AUC of the Harvard nomogram predicting 2-years probability of freedom from PSA recurrence was 0.80 vs. Kattan-Nomogram 5-years prediction of 0.83. Thereby, the Kattan nomogram showed a significant higher predictive accuracy (p=0.0274). For that reason preoperative nomograms derived in the U.S. can be applied to german patients. However, we would recommend the utilization of the Kattan nomogram due to its higher predictive accuracy.

Pathological and clinical characteristics of large prostate cancers predominantly located in the transition zone

Prostate carcinomas located in the transition zone are suspected to behave differently from the more frequent peripheral zone cancers. In this study, large transition zone prostate cancers were investigated for pathological and clinical features. From 365 consecutive radical prostatectomy specimens, 73 cases were disclosed with tumours larger than 10 cm(3). Of these, 14 were predominantly (>70% tumour area) located in the transition zone. Pathological investigations included a complete histological work-up, immunohistochemistry for p53 and bcl-2, and interphase cytogenetics for chromosomes 7, 8, 17, and X. Despite large tumour volumes and high preoperative prostate specific antigen (PSA)-values, most tumours showed quite favourable pathological features. Only two of these patients suffered from a postoperative PSA-recurrence during a median follow-up of 50 months. For comparison, 36 cases that contained tumours predominantly located in the peripheral zone mostly displayed adverse prognostic signs and 68.8% of these patients suffered from postoperative PSA-recurrence. We conclude that the peculiar pathological and clinical characteristics of large prostate cancers in the transition zone might be important for prognostic considerations.

Differences in biopsy features between prostate cancers located in the transition and peripheral zone

OBJECTIVE

To identify the zonal location of prostate cancers before surgery, by analysing the mapping of ultrasonography-guided systematic sextant biopsies for differences between cancers located in the transition zone (TZ) and peripheral zone (PZ); and to compare the correlation between Gleason scores of needle biopsies and those of radical prostatectomy (RP) specimens.

PATIENTS AND METHODS

In all, 186 patients with TZ (46) and PZ cancers (140) underwent ultrasonography-guided systematic sextant biopsy and RP at the same institution. The clinical and pathological characteristics, and the anatomical location of positive biopsies, were determined and compared using t-tests and chi-square tests. Differences between Gleason scores of needle biopsies and those of RP specimens were evaluated and compared by Cohen kappa testing.

RESULTS

TZ cancers had a significantly lower rate of positive biopsies in the middle (63% vs 80%) and base (50% vs 80%) of the prostate than had PZ cancers. Positive biopsies were exclusively obtained from the apex in 19.6% of TZ and 5% of PZ cancers (P = 0.002). There was exact agreement between Gleason scores of needle biopsies and those of RP specimens in 15.2% of TZ (kappa = 0.02) and 55% of PZ cancers (kappa = 0.25), respectively.

CONCLUSION

Compared with PZ cancers, TZ cancers had a different anatomical pattern of positive biopsies, with lower rates in the middle and base of the prostate. The finding of positive biopsies exclusively in the apex favoured prostate cancer located in the TZ. Furthermore, the correlation between needle biopsy Gleason scores and those of the RP specimens was clearly lower in TZ cancers.

Numerical chromosomal aberrations in papillary renal cortical tumors: relationship with histopathologic features

Previous studies have indicated that a combined trisomy of chromosomes 7 and 17 is a constant finding in papillary renal cortical adenomas and that papillary renal cell carcinomas are marked by additional trisomies such as trisomy 12, 16, and 20. The aim of our study was to compare this cytogenetic classification of papillary renal cortical tumors with conventional histopathologic classification. We performed interphase cytogenetics with enumeration probes for chromosomes 7, 12, 16, 17, and 20 on 41 papillary tumors found in 21 nephrectomy and 10 autopsy kidneys. A total of 38 tumors harbored gains of chromosomes 7 or 17, and most of these showed a trisomic signal distribution. The three tumors with normal copy numbers for chromosomes 7 and 17 were a papillary grade-2 carcinoma, a small adenoma (both with distinctive oxyphilic cytoplasm), and a papillary carcinoma with focally clear cells. Gains for chromosomes 12, 16, or 20 were found in 21 tumors and were significantly associated with the presence of histologic criteria of malignancy ( P<0.0001). Histopathologic and cytogenetic features of malignancy were found in eight tumors smaller than 10 mm. There is a good agreement of cytogenetic and histopathologic criteria of malignancy in papillary renal cell tumors. Interphase cytogenetics might give useful additional information in cases of doubt or when only small biopsy specimens are available.

Multifocal distribution of pulmonary capillary haemangiomatosis

AIMS

We investigated a case of pulmonary capillary haemangiomatosis, a rare condition, to determine the extent of the pathological changes within the lungs. Systematic histological sampling has not previously been performed in this condition.

METHODS AND RESULTS

A 52-year-old woman with a history of ischaemic cardiomyopathy suffered from repeated respiratory infections, which were attributed to chronic pulmonary congestion. She died suddenly of fulminant pulmonary thromboembolism. An autopsy was performed and lung tissue was sampled at multiple sites. Beside passive congestion, the lungs showed well-circumscribed areas containing proliferations of small capillaries infiltrating the pulmonary septa and the walls of otherwise normal blood vessels and bronchi. The most severely affected areas were found to be in the periphery of both lower lobes. A diagnosis of pulmonary capillary haemangiomatosis was made.

CONCLUSIONS

This is the first case of pulmonary capillary haemangiomatosis in which systematic histological sampling has been performed. Mapping of lesions disclosed the multifocal distribution of pulmonary capillary haemangiomatosis in this patient.

Frequent p16/MTS1 inactivation in early stages of urothelial carcinoma of the bladder is not associated with tumor recurrence

OBJECTIVE

p16, located at chromosome 9p21, is a negative regulator of G1 cell checkpoint and functions as tumor suppressor gene. Only few data are available on the frequency and clinical relevance of p16 alterations in Ta, T1 transitional cell carcinoma (TCC) of the bladder. We investigated 40 patients with Ta, T1 TCC of the bladder for p16 alterations (mutations, homozygote deletions, allelic loss) or reduced p16 immunoreaction.

PATIENTS AND METHODS

DNA was prepared from microdissected tumor tissue from 40 patients with pTa, pT1 TCC of the bladder (pTa: 18 patients; pT1: 22 patients; grade 1: 7 patients; grade 2: 28 patients; grade 3: 5 patients). Mutation screening was performed using polymerase chain reaction (PCR), single-strand conformation polymorphism (SSCP) and direct sequencing at exon 1 and exon 2. Detection of homozygote deletions was performed using multiplex PCR. Immunohistochemistry (IHC) was performed using an anti-human monoclonal antibody (p16, Pharmingen). Allelic loss was detected by PCR using three different microsatellite markers (D9S161, D9S171, D9S319).

RESULTS

SSCP and direct sequencing revealed 3 cases of base substitution which turned out to be natural polymorphisms. Homozygote deletions were not detected in any case. p16 IHC revealed reduced p16 expression (<5% positive nuclei) in 10 patients; 30 patients had a positive reaction (> or =5% positive nuclei) and 10 patients a strong positive reaction (> or =50% positive nuclei). Thirteen of 37 informative cases revealed loss of heterozygosity (LOH) with at least one marker. After a median follow-up of 23 months, 15 patients suffered from disease recurrence. Statistical analysis using Kaplan-Meier analysis and the log-rank test did not reveal significant association of recurrence-free interval and detection of LOH (p = 0.34) or p16 IHC (p = 0.9).

CONCLUSIONS

We present a comprehensive evaluation of chromosome 9p21 alterations including p16 analysis and clinical follow-up data. Although p16 mutations and homozygote deletions are rarely detectable in Ta, T1 TCC, the reduction of p16 expression and the frequent hemizygote deletions at 9p21 suggest an early involvement of chromosome 9p and p16 in superficial TCC.

Expression of 17-1A antigen and complement resistance factors CD55 and CD59 on liver metastasis in colorectal cancer

Despite radical surgery, the prognosis for colorectal cancer patients with liver metastases has not changed markedly. Furthermore, no standard adjuvant therapeutic regimen has been developed. Adjuvant therapy with monoclonal antibodies (e.g., against 17-1A), which has been shown to be effective in preventing metastatic relapse in patients with Dukes' C colorectal cancer, might be a promising approach for these patients. However, the cytotoxic effects of monoclonal antibodies can be blocked by coexpression of complement resistance factors that inhibit antibody-dependent complement-mediated cytotoxicity. We therefore analyzed immunohistochemically the expression of 17-1A and the membrane-bound complement resistance factors CD55 and CD59 on metastatic tumor cells in the livers of 71 patients with colorectal carcinoma who had undergone resection of their metastases with curative intent. In 67 (94%) of 71 patients, liver metastases with homogeneous expression of 17-1A was seen. Heterogeneous expression of 17-1A was seen in four patients (6%). Heterogeneous expression of CD55 or CD59 was observed in 8 (11%) of 71 patients and 4 (6%) of 71 patients, respectively. None of the patients showed homogeneous expression of either CD55 or CD59. All patients with CD55 or CD59 expression showed homogeneous 17-1A expression, whereas none of the four patients with heterogeneous 17-1A expression was positive for CD55 or CD59. Our data indicate that 17-1A is widely expressed on liver metastases of patients with colorectal carcinoma. Therefore patients with completely resected liver metastases might be suitable candidates for adjuvant therapy with and-17-1A antibody since only a few of these lesions showed coexpression of complement resistance factors.

A validated strategy for side specific prediction of organ confined prostate cancer: a tool to select for nerve sparing radical prostatectomy

PURPOSE

Nerve sparing radical prostatectomy for prostate cancer should be restricted to patients who harbor tumors without capsular penetration. To our knowledge the selection criteria for nerve sparing radical prostatectomy are not clearly defined. We investigated a panel of preoperative tumor characteristics with respect to their ability to predict organ confined tumor growth for each lobe of the prostate to indicate unilateral or bilateral nerve sparing radical prostatectomy.

MATERIALS AND METHODS

Nine preoperative tumor characteristics in 278 patients with clinically localized prostate cancer were included in retrospective univariate and multivariate tree structured regression analysis. The association of clinical stage, serum prostate specific antigen (PSA), PSA density, and results of transrectal ultrasound and systematic sextant biopsy, including a quantitative assessment of cancer in the biopsies with organ confined tumor growth, was statistically evaluated. Except for serum PSA and PSA density preoperative characteristics were considered separately for each prostate lobe. Multivariate analysis results were validated prospectively in 353 patients.

RESULTS

On univariate analysis the number of positive biopsies was the most useful single parameter with a positive predictive value of 83% in 274 lobes and a negative predictive value of 55%, followed by mm. of tumor in the biopsy. Of all characteristics included in multivariate analysis only the number of biopsies with high grade cancer, the number of positive biopsies and serum PSA were independent for predicting organ confined cancer. When PSA was less than 10 ng./ml. and not more than 1 biopsy with high grade cancer was identified in a lobe, organ confined tumor growth was present in 86.1% of cases. On prospective validation the same criteria led to an 88.5% incidence of organ confined prostate cancer. Pooling the 2 most favorable groups led to 391 prostate lobes (70.8% of those investigated) with a positive predictive value of 82.1% (95% confidence interval 77.9% to 85.8%). Using the multivariate approach more prostate lobes were assigned to a favorable risk group than on univariate analysis. Clinical stage and simple Gleason grade did not contribute independent information for predicting organ confined disease.

CONCLUSIONS

Quantifying cancer and high grade cancer by systematic biopsy and serum PSA concentration are useful preoperative characteristics for predicting organ confined prostate cancer. Side specific analysis of these parameters is a flexible and reliable tool for selecting patients for nerve sparing radical prostatectomy.

Significance of high-grade prostatic intraepithelial neoplasia in needle biopsy specimens

OBJECTIVES

To examine the significance of high-grade prostatic intraepithelial neoplasia (HGPIN) in biopsy specimens.

METHODS

We performed sextant biopsies on a series of 83 cystoprostatectomy specimens removed for bladder cancer. For each case the number of foci and volume of both HGPIN and prostate cancer were assessed in the prostatectomy specimens and compared with the number of biopsy specimens involved by HGPIN.

RESULTS

We identified HGPIN in 82 (99%) of 83 prostatic glands, whereas prostate cancer was found in 41 cases (49%). Corresponding sextant biopsies harbored both HGPIN and prostate cancer in 6 cases (7%), whereas only HGPIN was diagnosed in 29 sextant biopsies (35%). There was a positive correlation between the number of biopsy specimens containing HGPIN and the volume and multifocality of HGPIN in the corresponding prostatic glands. Prostates with HGPIN on sextant biopsy contained prostate cancer significantly more often when compared to cases with no HGPIN on sextant biopsy. Frequency of concurrent prostate cancer was higher in cases with two or more biopsy specimens containing HGPIN than in cases with only one such biopsy specimen, but case numbers of these categories were too small to render this difference statistically significant.

CONCLUSIONS

The presence of HGPIN in sextant biopsies is a significant predictor of concurrent prostate cancer. Multifocality of HGPIN is a useful parameter in assessing the extent of HGPIN in the corresponding prostates. Its value in predicting a significantly increased risk of concurrent prostate cancer needs to be further investigated in larger case studies.

Relevance of p53 gene alterations for tumor recurrence in patients with superficial transitional cell carcinoma of the bladder

PURPOSE

The prognostic relevance of p53 protein accumulation in muscle-invasive bladder carcinoma is well documented, but the prognostic relevance of p53 alterations in superficial bladder tumors remains uncertain. Immunohistochemical data are divergent, possibly because of the use of nonstandardized techniques. We therefore investigated the relevance of p53 gene point mutations and loss of heterozygosity (LOH) for tumor recurrence. The results of this molecular analysis were compared with accumulation of the p53 protein as shown by immunohistochemistry.

MATERIAL AND METHODS

Representative tumor tissue was selected and microdissected from 40 patients (pTa, 18 patients; pT1, 22 patients; grade I, 7 patients; grade II, 28 patients; grade III, 5 patients). Polymerase chain reaction (PCR) was carried out with exons 5-8. All PCR products were screened for p53 mutations with temperature-gradient gel electrophoresis (TGGE). When mobility shift was observed, direct nucleotide sequencing was performed. Detection of LOH was performed with nonradioactive microsatellite analysis using three markers (TP 53, D17S513 and D17S786) on chromosome 17p. Immunohistochemistry was performed with the DO 7 antibody. Tumor samples with p53 accumulation of 5% or more positive nuclei were classified as positive. Univariate analysis for disease-free survival was performed using Kaplan-Meier analysis and the log-rank test.

RESULTS

TGGE and direct sequencing detected mutations in 10 of 40 patients (2 of 18 pTa and 8 of 22 pT1 patients). LOH was detected in 11 patients. Both a mutation and LOH were detected in 3 patients. p53 immunohistochemistry detected at least 5% positive nuclei in 28 of 40 patients (70%). After a median follow-up of 26 months 14 patients suffered disease recurrence. Whereas disease-free survival did not correlate with a mutation (p = 0.77, log-rank test), LOH (p = 0.2) or a mutation in combination with LOH (p = 0.23), a positive p 53 immunoreaction was significantly associated with short disease-free survival (p = 0.009).

CONCLUSION

Despite the relatively high percentage of patients with p53 gene alteration in this population no significant correlation between the detection of molecular alteration and disease recurrence could be found. We conclude that, in contrast to immunohistochemical accumulation, gene alterations play only a minor role in tumor recurrence of p53 in patients with superficial transitional cell carcinoma of the bladder, and that immunohistochemical accumulation of the p53 protein has to be explained by mechanisms other than gene mutations.

[Mucinous adenocarcinoma of the urachus. Case report and review of the literature]

We report on a 44-year-old man with the rare case of a mucin-positive carcinoma of the urachus. We performed extended partial cystectomy with regional staging lymphadenectomy of the obturator lymph nodes. Histological investigation revealed a mucin-positive carcinoma of the urachus with negative lymph nodes. For this case, we present symptoms, a plan for diagnosis, and treatment of these tumors.

Numerical aberrations of chromosome 8 and allelic loss at 8p in non-muscle-invasive urothelial carcinomas of the urinary bladder

OBJECTIVES

Cytogenetic and molecular studies indicate that the development and progression of bladder cancer involves multiple and complex genetic events. We screened 39 primary T(a )and T(1) transitional cell carcinomas of the urinary bladder for numerical changes of chromosome 8 and for the presence of relative allelic loss at 8p. The results were compared with the histopathologic stage and grade and with tumour recurrence.

METHODS

Thirty-nine paraffin-embedded transurethral resection specimens containing bladder cancer were examined by interphase cytogenetics with a probe specific for chromosome 8. DNA from tumour cells and normal tissue was prepared after microdissection. Allelic loss was assessed by PCR-based microsatellite analysis.

RESULTS

Numerical aberrations of chromosome 8 were present in 20 of the 39 cases (51.3%) and were significantly associated with a higher tumour grade and stage. Ten cases (25.6%) displayed allelic losses at 8p. Sixteen patients (41%) suffered from tumour recurrence, but Kaplan-Meier analysis and the log-rank test did not show any statistically significant correlation between tumour grade, stage, numerical aberrations of chromosome 8, allelic losses of 8p and freedom from disease recurrence.

CONCLUSIONS

In this group of patients with non-muscle-invasive bladder cancers, numerical and structural aberrations at chromosome 8 are associated with a higher tumour grade and stage, but not with tumour recurrence.

Detection rate of histologically insignificant prostate cancer with systematic sextant biopsies and fine needle aspiration cytology

PURPOSE

We evaluate the detection rate of insignificant prostate cancer and the rate of significant prostate cancer overlooked in the results of systematic sextant biopsy and fine needle aspiration biopsy of the prostate of asymptomatic men with serum prostate specific antigen concentrations less than 4.0 ng./ml.

MATERIALS AND METHODS

We analyzed specimens from 133 consecutive patients with a mean age of 60 years undergoing cystoprostatectomy for bladder cancer. Six systematic biopsy specimens and 2 fine needle aspiration cytology samples were taken from the prostate immediately after cystoprostatectomy. The specimens were step sectioned and examined for prostate cancer. Insignificant prostate cancer was defined as any cancer with an aggregate volume 0.5 cm.3 or less.

RESULTS

Incidental prostate cancer was found in 58 of the 133 patients (44%). Tumor volume was 0.5 cm.3 or less in 47 cases. Sextant biopsy detected 7 cancers, including 4 of 47 (9%) that were insignificant and 3 of 11 (27%) that were significant. Fine needle aspiration cytology also detected 7 cancers, including 3 (6%) and 4 (36%) that were insignificant and significant, respectively.

CONCLUSIONS

Systematic sextant biopsy and fine needle aspiration cytology each diagnose prostate cancer in about 5% of asymptomatic men who have normal digital rectal examination and serum prostate specific antigen less than 4.0 ng./ml. However, many of the cancers thus detected are insignificant and most of the significant cancers are missed. Therefore, routine screening of such patients with sextant biopsy or aspiration cytology does not appear to be justified.

Detection of loss of heterozygosity in the p53 tumor-suppressor gene with PCR in the urine of patients with bladder cancer

PURPOSE

Detection of loss of heterozygosity (LOH) has been described in various carcinomas on the basis of meticulous molecular techniques. Because of lack of simple and rapid techniques, LOH has not achieved common use in routine tumor diagnosis. A recently found variable number of tandem repeats (VNTR) segment in intron 1 of the p53 gene was described as highly polymorphic and therefore useful in detecting LOH. We used a rapid technique for detection of LOH in the p53 gene of patients with transitional cell carcinoma (TCC) of the bladder. The technique was based on the polymerase chain reaction (PCR) and agarose gel electrophoresis as described for other carcinomas previously. We evaluated whether TCC screening and surveillance could be performed detecting LOH in the urinary sediment.

MATERIALS AND METHODS

We investigated 29 patients with TCC of the bladder (pTa 12 patients; pT1 10 patients; pT2 - pT4 seven patients; grade 1 one patient; grade 2 19 patients; grade 3 nine patients). DNA was prepared by standard methods from white blood cells, tumor tissue, normal bladder mucosa, and urinary sediments. The amplification of the VNTR region was performed with PCR. PCR products were run in parallel lanes on 4.5% agarose gels.

RESULTS

Of the 29 patients, 23 (79.3%) were found to have two different alleles ("informative cases") for the VNTR region. Of the 23 informative cases LOH was detected in the tumor tissue of 10 patients (43.5%). Referring to the total population 10 of 29 patients (34.4%) revealed LOH. In all patients with LOH in the tumor, LOH was also detected in the urinary sediment. LOH was not detected in the histologically benign bladder mucosa.

CONCLUSION

We present a simple and rapid technique based on PCR and agarose gel electrophoresis for the detection of LOH in tumor and urinary sediment of patients with TCC of the bladder. The ability to detect LOH not only in tumor tissue but also in urinary sediment offers an attractive approach for noninvasive diagnosis and surveillance of bladder cancer patients.

[Prognostic markers for prostate cancer]

Careful consideration of therapy for prostate cancer needs an accurate analysis of prognostic markers to estimate success and benefit for the patient. Prognosis of prostate cancer is determined by the proportion of high grade cancer, many usually utilized prognostic characteristics were rejected by multivariate analysis as no independent prognostic information was delivered. For planning therapy it is crucial to estimate the proportion of high grade cancer as exact as possible. A standardized biopsy technique combined with a quantified analysis of the biopsy cores is most helpful to achieve this goal. The prognostic value of molecular biological and other factors is object of research, only a combination of some of these factors could be demonstrated so far to be superior to the estimation of the proportion of high grade cancer. However, at present their routine use in daily practise is precluded by a high technical and financial expense.

Allelic losses at 8p, 10q, 11p, 13q, 16q, 17p, and 18q in prostatic carcinomas: The impact of zonal location, Gleason grade, and tumour multifocality

Molecular genetic investigations have made it clear that the development and progression of prostate cancer is associated with losses of genetic material in certain chromosomal arms. However, there are only few data about the question of whether the zonal location, a higher Gleason grade, or multifocality of the tumour have any influence on the pattern of allelic losses. In the present study, 48 tumour foci from 32 radical prostatectomy specimens were investigated for allelic losses at chromosomes 8p, 10q, 11p, 13q, 16q, 17p, and 18q with a set of 20 microsatellite markers. The results were analysed for the zonal location of the tumour foci and the presence of a Gleason grade 4 differentiation. Overall, focal allelic losses at 8p, 10q, 11p, 13q, 16q, 17p, and 18q were observed in 62.5%, 17.2%,. 3.2%, 18.8%, 40%, 9.7%, and 22.6% of the 32 cases, respectively. Comparing the frequencies of allelic losses with the zonal location or the Gleason grade, no highly significant correlations were found at any chromosomal locus investigated. However, the observation of different patterns of allelic losses in 12 of 14 cases containing more than one tumour focus indicates a high rate of genetic heterogeneity. We conclude that allelic losses at the chromosomal loci investigated are not strongly associated with a specific zonal location or a higher Gleason grade of prostatic carcinoma. Genetic heterogeneity of multiple tumour foci within one gland might contribute to the difficulties in predicting the prognosis for this common malignancy.

Microsatellite alterations at chromosomes 9p, 13q, and 17p in nonmuscle-invasive transitional cell carcinomas of the urinary bladder

The clinical behavior of bladder cancer is difficult to predict and prognostic markers applicable to routinely processed tumor specimens clearly are needed. We screened 40 primary Ta and T1 bladder cancers for microsatellite alterations at 9p, 13q, and 17p with PCR, using nine polymorphic microsatellite markers. DNA was prepared after microdissection of paraffin-embedded transurethral resection specimens. PCR products were separated on sequencing gels, and allelic loss as well as band shifts was assessed by comparing alleles of control and tumor tissue. The results were correlated with grade, stage, and clinically documented tumor recurrence. Overall, allelic loss at 9p, 13q, and 17p was present in 35.1%, 25%, and 27.5% of cases, respectively. Whereas the frequency of allelic loss at 9p was nearly equally distributed throughout all tumor grades and stages, the occurrence of allelic loss at 13q and 17p correlated statistically significantly with higher grades and stage. Band shifts were observed in three cases. Of the 40 patients, 16 had tumor recurrence during a follow-up period of 3-49 months (median, 23 months). Kaplan-Meier analysis did not show any statistically significant correlation between allelic loss at either locus and tumor recurrence. The results confirm the role of alterations at 13q and 17p in the progression of bladder cancer. Allelic loss at 9p seems to be an early event in tumor development. However, the detection of alterations at the three chromosomal loci studied did not have any prognostic value regarding tumor recurrence in this group of patients.

Numerical chromosomal anomalies in latent adenocarcinomas of the prostate

BACKGROUND

Even the high incidence of clinically diagnosed prostate cancer is exceeded by the frequency of tumors detected at autopsy. However, there is some debate concerning the malignant potential of these so-called "latent prostate cancers." In this study, prostate cancers detected at autopsy were investigated for the presence of numerical aberrations of chromosomes 7, 10, 17, X, and Y.

METHODS

Prostates from 57 autopsies, performed on male patients aged 45 years or older, were histologically investigated for the presence of cancer. Interphase cytogenetics, an in situ hybridization method with chromosome-specific probes, was performed on paraffin sections.

RESULTS

Of the 57 specimens investigated, 23 contained foci of prostate cancer. Three prostates contained more than one tumor focus. Interphase cytogenetics could be performed successfully in 19 specimens. Of the 22 tumor foci investigated, 14 were disomic and 8 were nondisomic for the five chromosomes tested. Ploidy correlated significantly with the presence of a Gleason score of 7 or higher (P = 0.0109), but not with a tumor volume larger than 0.5 cm3, or with patient age over 75 years.

CONCLUSIONS

Some latent prostate cancers display a nondisomic chromosomal status and a low histologic differentiation in spite of a small tumor volume, suggesting a more aggressive potential in a subset of these tumors.

Interphase cytogenetic study of preoperative core biopsies for the prediction of early serum prostate specific antigen recurrence after radical prostatectomy of clinically localized prostate carcinoma

BACKGROUND

Current clinical and pathologic methods are imprecise in predicting the extent of prostate carcinoma progression. This study was conducted to evaluate the role of interphase cytogenetics (ICG) with chromosome enumeration probes relative to the role of conventional pathologic characteristics in the preoperative prediction of postoperative tumor classification and recurrence of elevated serum concentrations of prostate specific antigen (PSA).

METHODS

The authors performed ICG with enumeration probes for chromosomes 7, 17, and X on 6-microm sections of core biopsies from 75 patients with clinically localized adenocarcinoma of the prostate. Results were compared with pathologic findings (tumor classification, volume, and status of surgical margins) of the corresponding radical prostatectomy specimens and data on serum PSA measurements taken for 72 patients during a follow-up period of up to 42 months (mean, 19.8 months). In addition to ICG, biopsies were reviewed for primary, secondary, highest, and combined Gleason grades, number and bilaterality of positive biopsies, amount of carcinoma (percentage and core length of infiltration), amount of high grade carcinoma, and perineural invasion.

RESULTS

Chromosome categories were unevenly distributed among pathologic tumor classification groups (P = 0.0008) and between groups with positive and negative surgical margins (P = 0.0116). Tumors with aneusomic chromosome numbers had larger volumes than those with eusomy and tetrasomy (P = 0.0022). Kaplan-Meier analysis demonstrated that PSA recurrences (> or = 0.4 ng/mL) were more frequent and observed earlier in patients with detected chromosomal aneusomies than in those with eusomic and tetrasomic chromosome numbers (P < 0.0001). Cox regression analysis indicated that ICG was the most valuable independent factor in predicting PSA recurrences.

CONCLUSIONS

The detection of numeric chromosomal aberrations in preoperative core biopsies is an adverse prognostic sign. Grading based on the quantification of genetic changes might prove useful in the prognostic stratification of patients with clinically localized prostate carcinoma.

Numerical chromosomal aberrations in transition-zone carcinomas of the prostate

PURPOSE

Prostatic carcinomas arising in the transition zone (TZ) are thought to differ from the more frequent cancers of the peripheral zone (PZ) with regard to morphology and biologic behavior. It is unclear, however, whether the differences are reflected in genetic alterations.

MATERIALS AND METHODS

We assessed numerical aberrations of chromosomes 7, 8, 10, 17, and X with interphase cytogenetics in 10 radical-prostatectomy specimens containing exclusively TZ cancers larger than 0.5 cm.3 and in 10 additional specimens containing both TZ and PZ cancers larger than 0.5 cm.3 each.

RESULTS

Of the 20 TZ carcinomas, 9 were completely disomic, 5 were at least focally tetrasomic but not aneusomic, and 6 were focally aneusomic. Ploidy correlated well with tumor volume (p = 0.0083), grade (p = 0.0064) and surgical margins (p = 0.0141) but not with preoperative prostate-specific antigen. A strong correlation was observed between the presence of low grade tumor (Gleason grade 4 or 5) and a nondiploid chromosomal status (p = 0.0001). In 10 cases there were also foci of PZ cancer larger than 0.5 cm.3, of which 4 were disomic, 3 were tetrasomic at the most, and 3 were aneusomic. The mean tumor volumes of disomic and aneusomic cancers differed significantly between TZ and PZ carcinomas (p = 0.0336 and 0.0476, respectively).

CONCLUSIONS

Numerical chromosomal instability parallels tumor progression in TZ carcinomas of the prostate. However, our results indicate that PZ and TZ cancers differ in that the latter can reach larger volumes before histological dedifferentiation and aneusomy occur.