Should Treatment of Highly Differentiated Thyroid Carcinoma Be Conservative?

On the basis of three selected cases (one with clinically occult follicular and two with metastatic papillary carcinoma) the necessity of a comprehensive therapeutic concept even in highly differentiated thyroid cancer is stressed. Thyroid tissue and regional metastases should be eliminated by surgery, followed by radioiodine therapy in any event. Radiation teletherapy should be reserved to patients with invasive tumor growth exceeding the organ capsule, with lymph node metastases, and with massive angioinvasive growth.

[Prostate cancer. Part 2: Review of the various tumor grading systems over the years 1966-2015 and future perspectives of the new grading of the International Society of Urological Pathology (ISUP)]

The continued development of methods in needle biopsies and radical prostatectomy for treatment of prostate cancer has given special emphasis to the question of the prognostic relevance of the various systems of grading. The classical purely histological grading system of Gleason has been modified several times in the past decades and cleared the way for a new grading system by the prognostic grading of Epstein. Assessment of the old and also modified combined histological and cytological grading of Mostofi, the World health Organization (WHO) and the urologic-pathological working group of prostate cancer in connection with the Gleason grading (combined Gleason-Helpap grading), has led to considerably improved rates of concordance between biopsy and radical prostatectomy and to improved estimations of prognosis beside its contribution to the development of a more practicable grading system for clinical use.

[Importance of second opinions on histology of prostate biopsy specimens]

OBJECTIVE

The significance of a second opinion on the histological findings of prostate carcinomas as well as suspicious lesions on core needle biopsy specimens was studied in cases from the year 2008.

STUDY DESIGN

A total of 920 core needle biopsy specimens of the prostate were stained with H & E and when necessary immunohistochemical analyses were performed with basal cell markers p63, 34ßE12, PSA and AMACR (P504 S) and neuroendocrine markers such as synaptophysin and chromogranin. The modified Gleason grading system was used.

RESULTS

In 43.5% of suspicious lesions adenocarcinomas of the prostate were found. In 53.2% the findings of atypical small acinar proliferations or high-grade prostatic intraepithelial neoplasia (HGPIN) were confirmed with a recommendation of serum PSA and morphological controls. The suspicion of prostatic carcinoma could be confirmed in 87.2% by the diagnosis of adenocarcinoma. After Gleason grading 82.8% of all diagnosed carcinomas had scores 6 or 7(3 + 4) and belonged to the group of low grade carcinomas. High grade carcinomas were without diagnostic problems.

CONCLUSION

A second opinion on the histological analysis of suspicious lesions of the prostate as well as of confirmation of Gleason grading is a very important point of quality management of diagnostic steps of prostate carcinomas and may be helpful for different therapeutic strategies.

Die Wertigkeit des 2005 modifizierten Gleason-Gradings in der urologischen Diagnostik von Prostatakarzinomen

In several consensus conferences of the International Society of Urological Pathology (ISUP), the Gleason grading system of prostatic carcinomas was modified and adapted to the routine histological diagnostics of specimens of core needle biopsies and radical prostatectomies. The main results are the documentation of all histological patterns (primary, secondary, tertiary) and a shifting of the maximal Gleason score of biopsies from 6 to 7a (3+4) and of radical prostatectomies from 6 and 7 to 7a and 7b (4+3). Score 2 to 4 carcinomas do not exist in the peripheral prostate. pT2 prostatic carcinomas with good prognosis have a maximal score of 7a; pT3 carcinomas with poor prognosis have a most frequent score of 7b. The agreement of the Gleason scores of core needle biopsies and radical prostatectomy specimens is more than 80%. Inter- and intraobserver reproducibility is better than after the conventional Gleason grading. The prognostic value of scores 6 and 7a may be similar. The border between low- and high-grade prostatic carcinoma may be probably Gleason score 7a and 7b. The prognostic value of score 6 should be changed to score 7a in the different therapeutic options for prostatic carcinomas.

Kleine suspekte Prostataläsionen

Punch biopsies have been taken from the prostate with increasing frequency in recent years, with a resulting increase in the number of diagnoses made. To check the diagnosis of "small two- or three-gland carcinoma" we prepared new H and E sections and, when the atypical glands were no longer available, also performed immunohistochemical analyses in 1,041 cases referred to our uropathology consultation service, comparing the diagnoses supplied by the referring doctors with the final diagnoses. In 61.6 of these cases histology confirmed the diagnosis of adenocarcinoma of the prostate; the diagnosis recorded when the basal cell marker was absent and the tumour marker P504S was strongly expressed was atypical microglandular proliferation or suspected carcinoma. Previous diagnoses of prostatic carcinoma were confirmed in 99% of cases. In this way we also confirmed a further 27.9% of cases of prostate carcinoma in the grey area of diagnoses endorsed "suggestive" or "suspected". The patients concerned were thus spared multiple screening biopsies and were assigned for definitive treatment.

Therapieinduzierte Tumorregression des Prostatakarzinoms

Regressive changes following pretreatment of prostate cancer may represent a big challenge for the histopathologist not familiar with the assessment of pretreated specimens. Characteristic changes after antiandrogen therapy in non-malignant prostate tissue include glandular atrophy, basal cell prominence and/or basal cell hyperplasia as well as a hypercellular stroma. Morphologic changes in prostate cancer include cytoplasmic clearing and vacuolization, nuclear pyknosis and even complete cell destruction. On the glandular level, changes are characterized by various degrees of involutional changes, ranging from almost non-regressive tumor glands to complete glandular disruption with scattered isolated tumor cells dispersed in the stroma. Knowledge about these changes, the selective use of immunohistochemistry as well as a very thorough histological workup is essential for the correct assessment of these specimens.

[Prostatic adenocarcinoma--still a diagnostic problem]

Although the diagnosis of usual prostatic adenocarcinoma is not difficult by itself, problems may occur with diagnosis of small carcinomas in punch biopsies. Often small groups of suspicious glands are found with indistinct basal cell layer and lack of immunohistochemical expression of cytokeratin clone 34betaE12 or p63. Despite disturbed architecture, carcinoma cannot be diagnosed without cytological criteria of malignancy, especially prominent nucleoli. This is not only a frequent problem in routine diagnostic slides but also in consultation cases. The consequence of the diagnosis "suspicious" is repeat biopsy after an interval of 6-12 months. Recently, a new marker for prostatic carcinoma an alpha methyl CoA-racemase (P504S) has been tested. P504S is overexpressed in carcinoma-cells of the prostate. Together with negative basal cell marker P63 and positive reaction of P 504S this imunohistochemical combination confirms the diagnosis in 35-45% of so called suspicious prostate biopsies. Facit: this group of patients have now a distinct diagnosis and must have a definite treatment without repeat biopsy.

[New WHO classification of urothelial carcinoma of the urinary bladder]

The WHO classification of urothelial carcinomas of the urinary bladder (1999) presents the papillary urothelial neoplasia of low malignant potential (PUNLMP) as a new entity in between the papillomas and the papillary urothelial carcinomas. This neoplasia shows a typical basal palisading, a low mitotic rate, and a low MIB-1-proliferation index. The PUNLMP is said to have an increased risk of development of recurrent papillary lesions with the possibility of malignant transformation. At present, there is an intensive discussion on this new entity. The participants of a meeting on the consensus classification on urothelial tumors held in Ancona in 2000 have meanwhile split in two discussion groups. One favors the new WHO classification with the papillary urothelial carcinomas G I, G II, and G III, but without PUNLMP, whereas the other group favors the consensus classification of 1998 with papillomas, papillary urothelial neoplasia of low malignant potential, and non invasive as well as invasive low-grade and high grade papillary urothelial carcinomas. Future long term prospective studies will show the significance of PUNLMP compared to well differentiated non invasive papillary urothelial urinary bladder carcinoma G I (G Ia). Otherwise, there is no significant difference in the classification of carcinomas and non epithelial lesions compared with the previous classification of 1973. The new WHO does however discriminate the minimally invasive papillary urothelial carcinomas in those with infiltration of the lamina propria above the muscularis mucosae (pT1a), the infiltration of the lamina muscularis mucosae (pT1b), and the extension beyond the muscularis mucosae (pT1c). The recurrence rate increases from stage pT1b. This substaging may be of therapeutical relevance.

[Extensive bilateral lower leg muscle necrosis after nasal application of heroin. Macroscopic and histologic findings in a 23-year-old man]

Rhabdomyolysis is one of the less known complications of heroin abuse. A case of lower leg muscle necrosis after nasal application of heroin is reported with repeated resection of the necrotic muscles. Superinfection with a methicillin-resistant Staphylococcus aureus (MRSA) strain was present. After 4 weeks, bilateral amputation could not be avoided. We regard a direct toxic effect of the heroin as the most probable mechanism of the muscular damage, with possible influence of the reduced oxygen delivery due to central respiratory and circulatory depression.

[Extreme cardiomegaly]

We report the case of 65 year old male patient with extreme heart enlargement. The patient was admitted to the hospital due to acute bleeding from varicose veins of the cardia. The endoscopic treatment by means of hemostatic clips and fibrine was successful. However the patient died two weeks later without having any complaints. The heart of the patient weighed 1350 g. Multiple coronary bypasses were found. There was also a recent myocardial infarction. The adoptive pathophysiologic changes accompanying extreme cardiomegaly are discussed. Numerous cases have been recorded of unusually large hearts, which in a few instances have even exceeded the one reported here. The analysis of observations reported in the literature reveals that rheumatic myocarditis and syphilitic aortitis were responsible for the majority of cases with extreme cardiac hypertrophy. Valvular deformities were also frequent findings. The occurrence of extreme cardiac enlargement in an elderly patient associated with multiple coronary bypasses has been not described so far.

Nonepithelial neoplasms of the urinary bladder

Nonepithelial tumors are rare in the urinary bladder, but their exact classification is very important in the differential diagnosis between these tumors and epithelial lesions. In the new WHO classification and in the third series of the Armed Forces Institute of Pathology (AFIP) "Atlas of Tumor Pathology" on urinary bladder tumors, various mesenchymal tumors, mixed epithelial and mesenchymal tumors and myofibroblastic proliferations are summarized. In the following we will describe the histology, immunohistology, and cytogenetics of nonepithelial tumors and lesions.

Neuroendocrine differentiation and short-term neoadjuvant hormonal treatment of prostatic carcinoma with special regard to tumor regression

OBJECTIVES

Neuroendocrine (NE) differentiation in prostate cancer is believed by some authors to play an important role in the development of androgen resistance. However, there is little knowledge about the impact of short-term neoadjuvant hormonal therapy on NE differentiation and on whether the degree of tumor regression is linked with the extent of NE differentiation.

METHODS

NE cells were detected by immunohistochemistry using a chromogranin A antibody. The densities of NE cells in 20 pretreated and 20 nonpretreated radical prostatectomy specimens were compared. Furthermore, we compared the NE cell density in tumors with variable degrees of regression.

RESULTS

The median percentage of tumor cells showing NE differentiation did not significantly differ between pretreated and nonpretreated specimens (0.61%, range 0.0-2.4%, vs. 1.47%, range 0.0-6.8%; p = 0.9896). Twelve nonregressive/slightly regressive tumor foci and 12 strongly regressive tumor foci were assessed. The NE cell density did not differ significantly (p = 0.1227).

CONCLUSIONS

Short-term neoadjuvant hormonal therapy does not induce relevant clonal propagation of NE cells. The degree of tumor regression following short-term neoadjuvant hormonal therapy does not correlate with the extent of NE differentiation.

Expression of vascular endothelial growth factor (VEGF) and VEGF receptor Flk-1 in benign, premalignant, and malignant prostate tissue

Vascular endothelial growth factor (VEGF) is one of the most potent mitogenic, highly specific tumor angiogenic factors, which acts via binding to 2 specific tyrosine kinase receptors. There are few studies analyzing VEGF receptor expression in prostate cancer cells, and results are contradictory. In an immunohistochemical study, we analyzed VEGF and VEGF receptor fetal liver kinase (Flk)-1 expression in benign glands, high-grade prostatic intraepithelial neoplasia (HGPIN), and prostatic carcinomas of different Gleason scores, obtained from 21 radical prostatectomy specimens. In all benign glands, VEGF and Flk-1 expression was confined almost exclusively to the basal cell layer (proliferative cell compartment). In HGPIN, labeling was no longer confined to the basal cell layer, but also was seen in all neoplastic secretory cells. All carcinomas stained positive for both markers. There was a trend for increasing labeling intensity with increasing cellular dedifferentiation. We concluded that tumor growth stimulated by the VEGF-Flk-1 system is promoted not only by neoangiogenesis, but also by tumor cell autostimulation. The VEGF-Flk-1 system may have an important role in the process of malignant transformation and tumor progression.

[Sudden cardiac death from unrecognized cardiac sarcoidosis]

Sarcoidosis is a systemic disease of young adults. Cardiac involvement is rarely diagnosed clinically. It presents with arrhythmias, conduction disorders, increasing myocardial insufficiency, or sudden death. We report a 42-year-old man with cardiac conduction disturbances of unknown cause who died of sudden cardiac death. Sarcoidosis with prominent cardiac involvement was diagnosed only at autopsy. Cardiac sarcoidosis should be considered in young patients with unexplained conduction disorders.

Limiting the diagnosis of atypical small glandular proliferations in needle biopsies of the prostate by the use of immunohistochemistry

Prostatic biopsies containing small glandular formations suspicious of, but not diagnostic for, carcinoma represent a diagnostic dilemma, as they cannot be definitely identified as either benign or malignant. The term 'atypical small acinar proliferation' (ASAP) in the differential diagnosis of carcinoma has recently evoked considerable discussion. This study has tried to assess the biological potential of ASAP by further immunohistochemical (IHC) analysis. Biopsy-proven cases of ASAP (n=114) were analysed, in which consecutive sections still contained the suspicious lesion. IHC studies were undertaken with anti-cytokeratin 34betaE12 and the proliferation marker MIB-1. Staining with 34betaE12 revealed a complete basal cell layer in 25 cases (21.9%), a fragmented layer in 58 cases (50.9%), and absence of basal cells in 31 cases (27.2%). MIB-1 labelling indices (LIs) in these three groups were significantly higher than in benign prostatic tissue (p<0.001) and reached the level of low-grade prostatic carcinoma (p>0.05). The suspicious morphology of ASAP on haematoxylin and eosin-stained slides was supported by the finding of elevated proliferative activity. Subgroups were revealed by immunohistochemical assessment of basal cell status and cases without basal cells were diagnosed as carcinoma. Nevertheless, rebiopsy is recommended if radical surgery is planned, to exclude insignificant cancer. Cases with a complete or fragmented basal cell layer were regarded as non-malignant. Whether a fragmented basal cell layer reflects a technical artefact or transition to carcinoma is unknown, but the proliferative activity of both lesions was increased and corresponded to that of low-grade prostatic carcinoma. In these cases, therefore, at least clinical follow-up is strongly recommended and repeat biopsies are encouraged.

Acute measles gastric infection

We describe the case of a 44-year-old man who was referred for gastroscopy because of abdominal pain. During endoscopy, inflammatory changes of the antrum and corpus mucosa were clearly visible, and biopsy samples from the antrum and corpus mucosa were taken. At histology, routine hematoxylin and eosin staining showed characteristics indicative of so-called ex-Helicobacter pylori-gastritis that had developed after antibiotic treatment 2 years ago. Additional large, bizarre inclusion bodies and clusters of multinucleated giant cells were located in the surface epithelium and within the lamina propria. These giant cells had an appearance similar to that of Warthin-Finkeldey cells, which can be found during the prodromal phase of measles infection. Anti-measles virus immunochemistry showed a strong positivity for measles virus antigen within the giant cells. Based on these results, the final diagnosis of morbilliform gastritis was made. To our knowledge, no case of measles gastritis has been described in the literature. Our case report confirms the systemic character of measles virus infection and confirms that measles viral replication can involve the gastric mucosa in addition to the conjunctiva, lung, and intestina.

Immunohistochemical analysis of the proliferative activity of neuroendocrine tumors from various organs. Are there indications for a neuroendocrine tumor-carcinoma sequence?

Small-cell neuroendocrine carcinomas (NECs) of the prostate are believed not to derive from benign orthotopic NE epithelial cells. Instead, an origin from a putative stem cell is actually the most favored concept. Whether this concept can also be applied to neuroendocrine tumors (NETs) of other organs, especially whether there are indications for well-differentiated NET-NEC sequence, is subject of the present study. A double-labeling technique for the proliferation marker MIB-1 and the NE markers chromogranin A (ChrA) and synaptophysin (SNP) was used for the immunohistochemical analysis of 45 well-differentiated NETs, 16 well-differentiated (low-grade) NECs, and 63 high-grade NECs of the esophagus, stomach, small intestine, appendix, colon, lung, prostate, and urinary bladder. The lowest proliferative activity was found in NETs (0.85% of tumor cells), and the highest activity was found in high-grade NECs (72.5%). The expression of ChrA was highest in NETs and lowest in high-grade NECs. None of the NETs and only sporadic cells in low-grade NECs showed double labeling (up to 0.05%). Up to 50% of the tumor cells in high-grade NECs were positive for MIB-1 and SNP. The percentage of double-labeled cells ranged between 0.9 and 39.6 (mean 9.7). No double-labeled cells were found in the normal epithelium adjacent to the tumors. Transitions from NET to NEC could not be observed. NETs and low-grade NECs differ in their proliferative activity from high-grade NECs, suggesting that they may arise from different precursor cell populations.

Nondetected tumor (pT0) after prolonged, neoadjuvant treatment of localized prostatic carcinoma

OBJECTIVES

135 patients with stage T1-3N0M0 prostatic carcinoma were submitted to prolonged PSA-monitored neoadjuvant endocrine treatment (PPNET). The rate of pT0 reports was three times higher (15%) than after the standard 3-month therapy (5%). The present work was done to elucidate the initial characteristics of these tumors, to see if additional workup of these prostatectomy specimens is able to detect tumor vestiges and, if so, to describe their morphology.

METHODS

The original clinical and histopathological data of 20 pT0 cases were reviewed and an additional histopathological workup of the prostatectomy specimens was done.

RESULTS

The majority of patients had initially small (9 patients cT1, 8 patients cT2, 3 patients cT3) and well-differentiated tumors (18 patients Gleason score <7). Microscopic assessment of 4,503 slides revealed very small tumor remnants (mean volume 0.2 ml) in 13 of the 20 prostatectomy specimens. Severe tumor regression was seen in 3 cases, slight to moderate regression in 10 cases.

CONCLUSIONS

A pT0 report following detailed routine histopathological workup has to be regarded as a maximal therapeutic effect, but not as tumor elimination. PPNET clearly increases the rate of pT0 reports, implicating that the conventional 3 months of pretreatment does not exploit the possibilities of neoadjuvant therapy.

Assessment of basal cell status and proliferative patterns in flat and papillary urothelial lesions: a contribution to the new WHO classification of the urothelial tumors of the urinary bladder

In 1999, the World Health Organization (WHO) published a new classification of papillary urothelial tumors of the urinary bladder. Intended to represent a reproducible, easy-to-use classification system that better separates patients with true malignancies (bladder cancer) from those patients who are at an increased risk for developing bladder cancer, problems in the differential diagnosis of various lesions remained. Probably the most critical distinction is between papillomas, papillary urothelial neoplasms of low malignant potential (lmp), and grade I papillary carcinomas. Conversely, problems in the distinction between reactive atypia, atypia of unknown significance, and dysplasia, as well as the distinction of dysplasia from carcinoma in situ (CIS), are unresolved. Whether urothelial basal cell status assessment on hematoxylin and eosin-stained slides completed by cytokeratin immunohistochemistry with anticytokeratin clone 34betaE12 may help to improve some of the previously mentioned diagnostic dilemmas was investigated. Basal cell status assessment was helpful in the differentiation between dysplasia and CIS. In dysplasia, CK IHC showed a predominantly basal labeling pattern, whereas in CIS, labeling of all urothelial layers was seen. Basal cell status assessment could separate 2 groups of pTa GIb papillary carcinoma. Group 1 with a continuous basal CK labeling and a low MIB-1 labeling index (LI) was compared with group 2, with a diffuse labeling pattern and a significantly higher MIB-1 LI. Whether group 1 carcinomas should better be assigned to the group of papillary urothelial neoplasms of lmp is discussed.

[Revisions in the WHO histological classification of urothelial bladder tumors and flat urothelial lesions]

Recently the World Health Organization published a new classification of urinary bladder tumors which is intended to take into account better the biology of the various lesions and to better distinguish between clearly benign and malignant lesions. We examine the possible diagnostic and clinical impact of the new classification, including recent immunohistochemical findings. Papillary urothelial lesions include papillomas, papillary neoplasms of low malignant potential, and papillary carcinomas. Flat urothelial lesions include hyperplasia, reactive atypia/atypia of unknown significance, dysplasia, and carcinoma in situ. Invasive patterns of papillary carcinomas are discussed, with special emphasis on lamina muscularis mucosae substaging. The most important feature of the new classification is its differentiation of two types of low-grade, noninvasive papillary urothelial lesions: papillary neoplasm of low malignant potential vs. papillary carcinoma. Long-term follow-up studies are needed to determine the clinical significance of this differentiation.

[Suspicious acinar proliferations of the prostate]

A variety of small acinar lesions of the prostate may mimick prostate cancer. In the central and transition zone of the prostate atypical adenomatous hyperplasia (AAH) has to be differentiated from low grade carcinoma (Gleason score 2-6). In the dorso-peripheral zone high grade PIN (prostatic intraepithelial neoplasie) and ASAP (atypical small acinar proliferations) represent the most important mimicers of carcinoma. High grade PIN has to be differentiated from intraductal carcinoma, ASAP on the other hand may mimic low grade carcinoma. The significance of basal cell type cytokeratin immunhistochemistry (IHC) in the differentiation between ASAP and low grade carcinoma of the prostate is assessed by additional MIB-1 IHC. The status of the basal cell layer in ASAP was shown to be variable (complete, fragmented and partial loss). Independently from the status of the basal cell layer the mean MIB-1 proliferation index of ASAP was significantly higher than of clearly benign lesions and did not differ from that of low grade carcinoma. Taking into account the high detection rate of carcinoma in repeat biopsies, close clinical follow up of patients with ASAP should be recommended.

Atypical acinar proliferations of the prostate

Small acinar lesions of the prostate may mimic prostate cancer. In the central and transition zone of the prostate, atypical adenomatous hyperplasia (AAH) must be differentiated from low grade carcinoma (Gleason score 2-5). In the dorso-peripheral zone, high grade prostatic intraepithelial neoplasia (PIN) and atypical small acinar proliferations (ASAP) are the most important lesions mimicking carcinoma. Further differentiation is necessary between high grade PIN and intraductal carcinoma. ASAP, on the other hand, may mimic low grade carcinoma. The significance of basal cell type cytokeratin immunohistochemistry (IHC) in the differentiation between ASAP and low grade carcinoma of the prostate was substantiated by additional MIB-1 IHC. The status of the basal cell layer in ASAP was found to be variable (complete, fragmented and absent). Independent of the status of the basal cell layer, the mean MIB-1 proliferation index of ASAP was significantly higher than that of clearly benign lesions and did not differ from that of low grade carcinoma. As carcinoma is frequently detected in rebiopsies, close clinical follow up of patients with ASAP is advisable.

Neuroendocrine differentiation in prostatic carcinomas: histogenesis, biology, clinical relevance, and future therapeutical perspectives

Since the introduction of immunohistochemistry, there is an increasing interest in neuroendocrine (NE) differentiation in prostatic carcinomas. Focal NE differentiation in prostatic adenocarcinomas is a very frequent finding. It is subject of numerous studies, since a negative impact on prognosis and an important role in antiandrogen therapy failure are suspected. NE-differentiated small-cell carcinoma is a very rare tumor comprising 0.5-2% of all prostatic carcinomas. Nevertheless, although very rare, it is of clinical importance because it is one of the most aggressive tumors of the prostate with a very poor prognosis. This review is focused on actual concepts of histogenesis, cell biology, clinical implications, and possible future therapeutic perspectives of these two tumor entities.

Undifferentiated carcinoma of the prostate with small cell features: immunohistochemical subtyping and reflections on histogenesis

To investigate the histogenesis of undifferentiated carcinoma of the prostate with small cell features we analysed the expression of neuroendocrine (NE) markers, the androgen receptor (AR), and prostate-specific antigen (PSA) in 19 undifferentiated carcinomas of the prostate. The proliferative activity (MIB-1/Ki67) of the tumours was examined, and the clinical data reviewed. The results identified two groups: carcinomas in group 1 were positive for PSA and AR and negative for NE markers. The mean MIB-1 labelling index (LI) was 34.8% and the mean serum PSA value 56.4 ng/ml. Two of the 7 patients died within 12 months after tumour diagnosis. The tumours in group 2 were NE differentiated small cell carcinomas (SCC), which were negative for PSA and AR. The mean MIB-1 LI was 82.6% and the mean serum PSA value 7.1 ng/ml. Seven of the 10 patients died between 2 and 12 months after tumour diagnosis. Positive staining for NE markers in combination with negative staining for PSA and AR and a high MIB-1 LI substantiated the diagnosis of a NE-SCC. We suggest that this tumour has a stem cell origin and does not derive from a dedifferentiated adenocarcinoma or from benign NE cells of the prostatic epithelium. This clear distinction of NE-SCC from NE-negative undifferentiated carcinoma is in accordance with the differing biological behaviour and response to therapy of the two tumour entities.

Comparative immunocytochemical assessment of isolated carcinoma cells in lymph nodes and bone marrow of patients with clinically localized prostate cancer

After radical prostatectomy for clinically localized prostate cancer, biochemical progression is seen in up to 40% of the patients due to persistent local and/or systemic remnants. Isolated disseminated carcinoma cells, undetectable by current staging methods, are of special interest as potential precursors of subsequent overt metastases. In the present study, immunohistochemistry (IHC) was performed to evaluate simultaneously the frequency of occult carcinoma cells in both lymph nodes (LNs) and bone marrow (BM) obtained from the iliac crests of 45 prostate cancer patients with untreated stage T(1-3) pN0 M0 prostatic carcinoma. IHC using monoclonal antibodies (MAbs) against epithelial cytokeratins was performed on 521 paraffin-embedded LNs histopathologically classified as tumorfree (pN0), as well as on BM cytospin preparations. To confirm the prostatic origin of positive cells in LNs, additional IHCs for prostate-specific antigen (PSA) and epithelial glycoproteins were performed. In total, isolated tumor cells in LNs and/or BM were detected in 17 of the 45 patients. Parameters such as tumor stage, grade and volume of the primary tumor as well as blood serum PSA levels could not detect patients harboring disseminated single tumor cells in LNs or BM. Following a median observation time of 24.9 months, no significant correlation between IHC positivity and PSA progression as a measure of early relapse was observed. Although the overall incidence of occult tumor cell spread corresponds to similar incidence of relapses after radical prostatectomy as reported by others, the fate of these cells needs to be evaluated in longer follow-up studies.

Proliferative pattern of exophytic and superficially invasive and noninvasive low-grade urothelial carcinomas

In urothelial low-grade carcinomas of the bladder stage pT1, prognosis in general is good. In a subset of these tumors infiltrating beyond the lamina muscularis mucosae, prognosis clearly worsens. Unfortunately, evaluation of the lamina muscularis mucosae often is very difficult or even impossible because of its incomplete extension. In an immunohistochemical study on 131 pTa and pT1 urothelial tumors without provable lamina muscularis mucosae, we evaluated the proliferative activity with the monoclonal antibody MIB-1 and the expression pattern of cytokeratins of high molecular weight with the monoclonal antibody 34betaE12. The highest proliferative indices were found in tumors with a diffuse expression pattern of MIB-1 and 34betaE12. A preliminary analysis of follow-up data showed that 70.6% of the pT1 GIb-GIa tumors that recurred showed a diffuse expression pattern for both markers. Whether these patients are candidates for a doser follow-up or even for a more radical therapy has to be subject to further follow-up studies.

Differential diagnosis of glandular proliferations in the prostate. A conventional and immunohistochemical approach

A variety of small acinar lesions of the prostate can mimic prostate cancer in punch biopsies and in transurethral resection material. The first part of this review deals with differential diagnostic problems of the central and transition zone, including atypical adenomatous hyperplasia of the prostate, atrophic processes, sclerosing adenosis, basal cell hyperplasia, and low-grade adenocarcinoma. The second part deals with differential diagnostic problems in the peripheral zone: prostatic intraepithelial neoplasia, postatrophic hyperplasia, Cowper's glands, seminal vesicles, and ductal and intraductal carcinoma. Finally, atypical and small acinar proliferations are described. Diagnostic perspectives are discussed. proliferations (ASAP) that cannot be integrated into any of the well-established diagnostic entities [1, 16, 22, 41]. The relevant glandular proliferations of the central, transitional and peripheral zones of the prostate are discussed here with reference to the related carcinomas.

[Single ventricle (cor trilocular biatriatum). A case report]

Univentricular hearts represent rare complex cardial malformations. We report a case of a 34-year old male with single ventricle, two atria, tricuspid atresia, large atrial septal defect, complete transposition and pulmonary valvar stenosis. There were no signs of chronic pulmonary hypertension. Intensive clinical analysis of the cardiac malformation was first performed at the age of five years. Conclusion was that the patient would have no benefit from operation. The patient had nearly normal live conditions with a profession, family and some sportive activities like squash. He died of sudden cardiac death. The malformation was examined by sequential segmental analysis and in comparison with the embryonic development. Special features are emphasized. Clinical picture, prognosis and therapy are reported from literature. During the last years development of cardiac surgery achieved good results. Special morphologic constellations, as in our case, may be the reason that conservative therapy can be sufficient for prolonged survival with good quality of life.

[Uterine leiomyosarcoma with subsequent pregnancy]

Leiomyosarcoma are malignant tumors showing smooth muscle differentiation, they are rare, representing only about 25 percent of all uterine sarcomas and mixed malignant tumors and slightly more than 1 percent of all corporeal malignant tumors. Usually they arise in postmenopausal women and are not known to be related to the known risk factors for endometrial carcinoma (nulliparity, obesity, diabetes mellitus, hypertension, etc.) or carcinosarcoma (prior radiation therapy). They may occur in uteri that also bear typical benign leiomyomas, but leiomyosarcoma rarely can be proven to have arisen in or from benign leiomyomas. We report on two premenopausal women with leiomyosarcoma--out of totally 31 cases in our clinic from 1975-1995 who got pregnant after surgical treatment preserving the uterus. The patients are alive without evidence of disease 3 and 6 years after surgical resection.

[A fulminant course of infection after splenectomy]

A report is given of two patients with a history of splenectomy many years previously due to traumatic rupture. No vaccination was given to either patient. From a state of good health, both patients developed fulminant, therapy-resistant sepsis with proof of Streptococcus pneumoniae in the blood culture. Autopsy findings were similar to Water-house-Friderichsen-syndrome. In conjunction with the history of splenectomy, the final pathological diagnosis was a so-called OPSI syndrome. This postsplenectomy sepsis is discussed further.

[Prognostic factors of prostatic carcinoma]

The histological classification or typing of prostate carcinoma combined with histological grading according to Gleason or WHO with nucleolar subgrading are the most important prognostic factors in carcinoma of the prostate. Prostatic cancer is the most common malignancy in adult males and is the second-most-common cause of cancer death in the USA. The histological Gleason grade may be reduced if only a small amount of tumor tissue is present in the core needle biopsy, in contrast to the combined histological and cytological grading according to WHO with nucleolar subgrading. When there is sufficient carcinomatous tissue in the core needle biopsy, there is no difference from that in radical prostatectomy tissue, because most cases of prostatic carcinoma are highly malignant. DNA cytometry, immunohistochemical analysis with Ki67/Mib1 or molecular pathological studies with the tumor suppressor gene p53 or apoptosis suppressing oncoprotein bcl2 and the density of blood capillaries may be helpful as additional prognostic factors, but only together with the results of the primary histological section. For comparison of grading results with the international literature both grading systems should be used according to Gleason and WHO with nucleolar subgrading.

Osteoclast-like giant cell tumour of the pancreas presenting as a pseudocyst-like lesion

A 57-year-old male patient presented with a cystic lesion in the tail of the pancreas, which was considered to be a pseudocyst. He was treated by cystojejunostomy but one year later a tumour was found to have invaded the stomach and jejunum. This was an osteoclast-like giant cell tumour containing a small area of typical ductal adenocarcinoma. Immunohistochemical staining revealed that the pleomorphic tumour cells were positive for cytokeratin, epithelial membrane antigen, vimentin and the proliferation marker MIB-1. The osteoclast-like giant cells and some small histiocytic cells stained for leukocyte common antigen and histiocytic markers and were negative for MIB-1. At autopsy, tumour rests were found in the pancreas but there were no metastases. Osteoclast-like giant cell tumours of the pancreas may present as cystic lesions and should be included in the differential diagnosis of pseudocysts.

Relationship between atypical adenomatous hyperplasia (AAH), prostatic intraepithelial neoplasia (PIN) and prostatic adenocarcinoma

Two histopathologic lesions are considered putative precursors of prostate cancer, but the supportive evidence for one (prostatic intraepithelial neoplasia, or PIN) is much greater than the other (atypical adenomatous hyperplasia, or AAH). High grade PIN is the most likely precursor of carcinoma, arising in the peripheral zone, but probably does not account for well-differentiated cancer arising in the transition zone. The biological significance of atypical adenomatous hyperplasia of the prostate (AAH) is inconclusive at the time. The histological and cytological features of AAH are intermediate between BPH and low grade carcinoma, suggesting that AAH may be a precursor of well differentiated transition; zone carcinoma. In the recent time new findings on morphogenetic aspects of normal and abnormal prostatic growth i.e. stem cell models are discussed and topics about grading and proliferative activities, frequency and histological changes associated with aging as well as clinical relevance of PIN and AAH. This paper reviews the results and discussion at the second international consultation meeting on PIN in Mayo Clinic, Rochester, Nov. 3-4 th. 1995, following the first international consultation meeting of AAH and PIN and origin of the prostatic carcinoma in Ancona, Sept. 11-12 th 1994.

[Fulminant infection outcome after splenectomy]

A report is given of two patients with a history of splenectomy many years previously due to traumatic rupture. No vaccination was given to either patient. From a state of good health, both patients developed fulminant, therapy-resistant sepsis with proof of Streptococcus pneumonlae in the blood culture. Autopsy findings were similar to Waterhouse-Friderichsen-syndrome. In conjunction with the history of splenectomy, the final pathological diagnosis was a so-called OPSI syndrome. This postsplenectomy sepsis is discussed further.

Lethal complications in a case of sigmoid diverticulitis. A case report

A 61-year-old female complaining of arthralgia was repeatedly treated with antibiotics and also with prednisolone. A chronic polyarthritis was assumed. In hospital, leukocytosis of 21.000 was found one day before death as well as moderate anemia. Colonoscopy was rejected by the patient. A computer tomography revealed destructive arthritis of the symphysis, vertebral osteochondrosis L5/S1, and sigmoid diverticulosis. The patient died with clinical signs of central dysregulation. At autopsy, a covered perforation of a sigmoid diverticulum with purulent peridiverticulitis was found. The 5th lumbal vertebra and the symphysis showed hematogenic abscesses. Microabscedating pneumonia, purulent meningitis and hypophysitis, and mycotic aneurysm of the basilar artery with lethal rupture were further results of hematogenic spread. Death was caused by massive subarachnoidal hemorrhage. This history is not untypical for elder patients with complicated diverticular disease. The intestinal perforation is often clinically occult due to only few and unspecific symptoms which cannot be exactly attributed to the colon. In the last ten years, we have found lethal complications of sigmoid diverticulitis at a frequency of 0.32% (5 cases in 1.557 subsequent autopsies). The clinical differential diagnosis included diverticulitis in none of the cases. This underlines the importance of autopsies for quality control in medicine, because modern diagnostic methods such as computer tomography were not able to give the correct diagnosis in these cases.

Enzyme activities in tissue of human benign prostatic hyperplasia after three months' treatment with the Sabal serrulata extract IDS 89 (Strogen) or placebo

OBJECTIVE

The mechanism of action of plant extracts used for the medical treatment of human benign prostatic hyperplasia (BPH) is still unknown. In this prospective, randomized, double-blind trial, we investigated the possible influence of the Sabal serrulata extract IDS 89 (Strogen) on epithelial and stromal enzyme activities of BPH tissue.

METHODS

18 patients with BPH were randomly assigned to receive 3 x 2 capsules Strogen uno (320 mg/capsule) (n = 8) or placebo (n = 10) daily for 3 months. The activity (Vmax and Km) of 5 alpha-reductase. 3 alpha-HSORred, 3 beta-HSORred, and creatine kinase was determined in mechanically separated epithelium and stroma of human BPH.

RESULTS

The multivariate correlation analysis revealed a positive correlation between therapy and the following enzyme alterations: (1) In epithelium, the substrate affinity of the 5 alpha-reductase decreased slightly (increase of Km value). (2) In stroma, the Vmax value of the 3 alpha-HSORred increased statistically distinctly, leading to a moderate increase of Vmax/Km. (3) In stroma, the Vmax value of the 3 beta-HSORred increased moderately, but not statistically significant. (4) In stroma, the Vmax value of creatine kinase increased significantly, leading to a statistically distinct increase of Vmax/Km.

CONCLUSION

This double-blind, placebo-controlled clinical trial with the S. serrulata extract IDS 89 revealed significant biochemical changes at the cellular level of BPH tissue. However, the alterations are merely moderate, their biochemical causes and consequences regarding the pathophysiology of BPH rather uncertain. Therefore, more studies are needed before plant extracts like IDS 89 become valid candidates likewise synthetic substances already used for medical treatment of human BPH.

[Experiences from consultation in prostatic diseases]

With the introduction of the terms atypical adenomatous hyperplasia (AAH) and prostatic intraepithelial neoplasia (PIN), the spectrum of prostatic diseases has been distinctly enlarged. With more sophisticated diagnostics, however, diagnostic and differential diagnostic problems grow more important. At the institute of pathology in Singen, this issue is reflected by the increasing use of the uropathologic consultation service since 1989. The purpose of this paper is to demonstrate typical diagnostic and differential diagnostic problems in the pathology of the prostate on the basis of this consultation service. 573 submitted prostatic cases were evaluated and the final diagnoses were compared to the preliminary diagnoses by the primary pathologist. Frequent differences could be detected in the 3 following groups: 1. Differentiation of sclerosing adenosis versus well differentiated adenocarcinoma 2. Differentiation of AAH versus well differentiated adenocarcinoma 3. Differentiation of high grade PIN versus poorly differentiated adenocarcinoma 4. Differentiation of glandular G II a versus G II b carcinomas. Possible decision guidelines are presented.

Effects of the selective metabotropic glutamate receptor agonist, L-CCG-I, on acquisition of a Morris task by rats

L-Glutamate, a major excitatory neurotransmitter in the central nervous system, plays an important role in a variety of neuronal events associated with learning and memory, neuronal plasticity, neurotoxicity, and neurodegeneration. We assessed the effects of L-CCG-I ((2S,3S,4S)-alpha-(carboxycyclopropyl)glycine), a conformationally restricted glutamate analogue, in a standard Morris water escape task with young adult rats. L-CCG-I is considered to be a selective agonist of the metabotropic glutamate receptor. Vehicle, 5, 50, or 500 nmol L-CCG-I was injected intra-cerebroventricularly (i.c.v.) into the right lateral ventricle 30 min before the start of each of five daily acquisition sessions. The data indicate that L-CCG-I had a centrally mediated mode of action; rats treated with 500 nmol L-CCG-I were clearly impaired in acquiring the standard Morris water escape task. The no-effect dose was 5 nmol.

Cell kinetic studies on prostatic intraepithelial neoplasia (PIN) and atypical adenomatous hyperplasia (AAH) of the prostate

To investigate possible cell kinetic relations between benign prostatic hyperplasia (BPH), atypical adenomatous hyperplasia (AAH), prostatic intraepithelial neoplasia (PIN) and carcinoma, cell kinetic analyses were performed using radiolabelled DNA-precursors (3H-thymidine autoradiography), immunohistochemistry (proliferation marker Ki67/MIB1 and/or PCNA) and silver staining of nucleolar organizer regions (AgNOR). All methods yielded the lowest values for BPH and AAH, while maximal values were found in carcinoma of high malignancy. PIN was equal to GII-carcinomas, while AAH was between BPH and carcinoma of low malignancy. This investigation ranks BPH, AAH, low grade carcinoma, PIN and high grade carcinoma in order using different methods of cell kinetic analysis. The preneoplastic character of PIN is apparent whereas the character of AAH remains uncertain.

Working standards in prostatic intraepithelial neoplasia and atypical adenomatous hyperplasia

All participants agreed with the use of the terms low and high grade PIN, without treatment in the case of an isolated PIN lesion. The term, definitions and biology of atypical adenomatous hyperplasia (AAH) was discussed without reaching a consent among American and European participants. As a compromise, the designation of AAH-Adenosis was accepted as a working formulation that needs further research.