Molecular analysis in cytological samples obtained by endobronchial or oesophageal ultrasound guided needle aspiration in non-small cell lung cancer

INTRODUCTION

Cytological samples obtained by endobronchial ultrasound (EBUS) are capital for diagnosis, staging and molecular profile in non-small cell lung carcinoma (NSCLC).

OBJECTIVE

To assess the success rate of complete, partial and individual of molecular analysis in samples obtained by EBUS-guided transbronchial needle aspiration (TBNA) and/or by oesophageal ultrasound-guided fine needle aspiration with an echobronchoscope (EUS-B-FNA) in patients with NSCLC.

METHODS

Prospective study including 90 patients with non-squamous NSCLC, or non-smoking squamous. Cytological samples were classified into two groups. Group 1: PEN membrane slide and/or cell blocks for the determination of mutations of EGFR, KRAS, ERBB2 and BRAF. Group 2: silane coated slides or cell blocks for rearrangements of ALK, ROS1 and MET amplification.

RESULTS

The success rate was 78.6% for 4 molecular alterations (EGFR, KRAS, ALK and ROS1), and 44% for 7 determinations. The individual success rate for EGFR was 97%, KRAS 96.3%, ALK 85%, ROS1 82.3%, ERBB2 71.4%, BRAF 67.7% and MET 81.1%. There were no significant differences (p=0.489) in the number of molecular analyses (1-3 vs. 4) in group 1, depending on the types of samples (cell block vs. PEN membrane slide vs. cell block and PEN membrane slide).

CONCLUSIONS

In patients with NSCLC, the cytological material obtained by ultrasound-guided needle aspiration is sufficient for individual and partial molecular analysis in the vast majority of cases. Membrane slides such as cell blocks are valid samples for molecular analysis.

Identification of oestrogen, progesterone receptor and human epidermal growth factor receptor 2 expression in mediastinal metastases of breast cancer obtained by endobronchial ultrasound-guided transbronchial needle aspiration

BACKGROUND

In breast cancer patients, the expression statuses of oestrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) are crucial in the choice of treatment. Receptor expression in metastatic lesions can differ from the primary tumour. The aim of our study was to analyse the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) to obtain samples allowing the identification of ER, PR and HER2 expression in patients with mediastinal metastases of breast cancer.

PATIENTS AND METHODS

The clinical files of all patients with a final diagnosis of breast cancer mediastinal metastases diagnosed by EBUS-TBNA in our institution were retrospectively analysed. The ability of EBUS-TBNA to obtain samples that allowed hormone receptor and HER2 expression analysis was calculated.

RESULTS

Twenty-four patients were included. ER, PR and HER2 assessments could be performed in 22, 20 and 22 patients, respectively. In 20 of the 24 patients it was possible to investigate all three types of receptor expression. In the remaining four cases, where ER, PR or HER2 expression tests could not be performed, it was due to a lack of tissue. In cases with adequate results for EBUS-TBNA and the primary tumour agreement was greater for ER (16/19) and HER2 (12/14) than PR (8/17). Based on receptor status, there was a change in the choice of treatment for five patients.

CONCLUSION

In patients with breast cancer mediastinal metastases, ER, PR and HER2 expression can be assessed in samples obtained by EBUS-TBNA whenever a sufficient tissue sample is collected.

Stem cell-like transcriptional reprogramming mediates metastatic resistance to mTOR inhibition

Inhibitors of the mechanistic target of rapamycin (mTOR) are currently used to treat advanced metastatic breast cancer. However, whether an aggressive phenotype is sustained through adaptation or resistance to mTOR inhibition remains unknown. Here, complementary studies in human tumors, cancer models and cell lines reveal transcriptional reprogramming that supports metastasis in response to mTOR inhibition. This cancer feature is driven by EVI1 and SOX9. EVI1 functionally cooperates with and positively regulates SOX9, and promotes the transcriptional upregulation of key mTOR pathway components (REHB and RAPTOR) and of lung metastasis mediators (FSCN1 and SPARC). The expression of EVI1 and SOX9 is associated with stem cell-like and metastasis signatures, and their depletion impairs the metastatic potential of breast cancer cells. These results establish the mechanistic link between resistance to mTOR inhibition and cancer metastatic potential, thus enhancing our understanding of mTOR targeting failure.

Representativeness of nodal sampling with endobronchial ultrasonography in non-small-cell lung cancer staging

The objective of our study was to determine the procedure-related requirements of mediastinal node sampling with endobronchial ultrasonography with real-time transbronchial needle aspiration (EBUS-TBNA) that would provide negative predictive value (NPV) for the identification of stage III disease in non-small-cell lung cancer (NSCLC) high enough to consider the technique equivalent to cervical mediastinoscopy. Representative EBUS-TBNA was defined as a sampling procedure obtaining satisfactory samples from normal nodes in regions 4R, 4L and 7 or diagnosing malignancy in mediastinal nodes. NPV was estimated using the results of postsurgical staging in patients who underwent surgery as a reference. Two-hundred ninety-six patients staged with EBUS-TBNA were included. Representative samples from regions 4R, 4L and 7 showing nonmalignant cytology were obtained from 98 patients (33.1%) and EBUS-TBNA detected N2/N3 disease in 150 (50.7%). Accordingly, an EBUS-TBNA procedure accomplishing the representativeness criteria required for sampling was attained in 248 of the participating patients (83.8%). The NPV of the procedure in this setting was 93.6%, with false-negative results only found in 5 patients, four of them with nodal metastasis out of the reach of EBUS-TBNA (regions 5, 8 and 9). In conclusion, representative sampling of regions 4R, 4L and 7 is achieved in more than 80% of patients staged using EBUS-TBNA, and in the procedures that attain this requirement a NPV >90% for mediastinal malignancy is reached, a figure equivalent to cervical mediastinoscopy.

Monitorization of primary therapy (PT) by additional imaging methods in locally advanced breast cancer (LABC)

10580

Introduction: The response of locally advanced breast cancer (LABC) to Primary therapy (PT) may be monitored clinically and by mammography (MG). Magnetic resonance (MR) and 99mTc-sestamibi scintimammography (SMM) are increasingly being used. The aim of this study was to determine whether MG, MR and SMM are accurate indicators of tumour response to PT and whether they are predictors of histological response. Patients and Methods: A prospective observational study was approved at our institution and 52 patients( p) with core biopsy diagnostic of LABC and written consent were enrolled (mean age 52 years, SD 13) All p had clinical, MG, MR, SM assessment pre- and post- PT. Primary chemotherapy based on anthracyclines was administered as follows: 19 p FEC, 17 p AC-Docetaxel, 8 p Gemcitabine- Doxorubicine- Paclitaxel, 1 p FEC- Docetaxel and 1 p Carboplatin- VP16. 6 p were treated with hormone-therapy. RECIST criteria were considered for clinical response assessment and the same criteria was adapted for imaging and pathologic response. Results: After PT 33 tumours were considered not suitable for breast-conserving surgery. Based on histopathological findings, 10 (19%) lesions showed complete pathologic response, 30 (58%) partial response, 12 (23%) stabilization. No progression was detected. Clinical assessment of tumour complete response agreed with pathology in 40 of 52 tumours (78%), and with MG in 39 (78%). Correlation between MG and pathological findings was observed in 42 p (84%). Correlation between MR and pathological findings was observed in 42 p (82%). Correlation between SMM and pathological findings was observed in 31 p (66%). Among patients with complete pathologic remission, 9 of ten patients achieve a complete response by MR and SMM. Conclusion: In conclusion, our results don’t show that MR and SMM add any benefit to the diagnostic arsenal for predicting histopathological complete response to PT. However these new diagnostic methods should be considered in selected cases.

No significant financial relationships to disclose.

Breast hemangioma mimicking carcinoma

Breast hemangiomas are rare, and usually appear as well-delimited round or oval nodules at mammography. We report a case of a woman with a breast hemangioma, which mammographic features simulated malignancy, and present its pathologic correlation. Hemangiomas are benign vascular tumors that are rarely present in the breast, usually found incidentally on microscopy of biopsy material for other. They are occasionally detected by mammography, presenting as well-delimited round, lobulated nodules, sometimes with calcifications. We present the mammographic findings and pathologic correlation in a case of breast hemangioma with an atypical radiological manifestation, simulating a carcinoma. To our knowledge, this is the first reported case with these radiologic characteristics.

Improved diagnosis of hepatic perfusion disorders: value of hepatic arterial phase imaging during helical CT

The liver has a unique dual blood supply, which makes helical computed tomography (CT) a highly suitable technique for hepatic imaging. Helical CT allows single breath-hold scanning without motion artifacts. Because of rapid image acquisition, two-phase (hepatic arterial phase and portal venous phase) evaluation of the hepatic parenchyma is possible, improving tumor detection and tumor characterization in a single CT study. The arterial and portal venous supplies to the liver are not independent systems. There are several communications between the vessels, including transsinusoidal, transvasal, and transplexal routes. When vascular compromise occurs, there are often changes in the volume of blood flow in individual vessels and even in the direction of blood flow. These perfusion disorders can be detected with helical CT and are generally seen as an area of high attenuation on hepatic arterial phase images that returns to normal on portal venous phase images; this finding reflects increased arterial blood flow and arterioportal shunting in most cases. Familiarity with the helical CT appearances of these perfusion disorders will result in more accurate diagnosis. By recognizing these perfusion disorders, false-positive diagnosis (hypervascular tumors) or overestimation of the size of liver tumors (eg, hepatocellular carcinoma) can be avoided.

Sentinel node biopsy as a practical alternative to axillary lymph node dissection in breast cancer patients: an approach to its validity

BACKGROUND

Sentinel node biopsy (SNB) has been proposed as an alternative to axillary lymph-node dissection (ALND) in breast cancer. Before implementing SNB in our practice, we wished to test its validity by comparing it to the standard ALND, both in our hands and with other reported series.

PATIENTS AND METHODS

One hundred thirty-two patients were included prospectively. SNB and immediate ALND were performed. For SNB, a technetium-colloid was used to produce preoperative lymphoscintigraphy and intraoperative gamma-probe search for the SN. Serial sectioning and immunostains were used on the SN. A comprehensive review of the literature was done in order to run a meta-analysis of diagnostic tests using a summary receiver operating characteristic curve (SROC) to calculate the pooled parameters of sensitivity and associated 95% confidence interval (95% CI), including our own data.

RESULTS

Our technical success rate was 96%. Local sensitivity was 96%, with a 95% CI from 85%-99%. Seven patients were upstaged by the SNB. A literature search identified 18 studies published from 1996-1999. Estimates of sensitivity ranged from 83%-100%. The pooled data meta-analysis gave a global sensitivity of 91%, with a 95% CI from 89%-93%. The area under the global SROC curve was 0.9967.

CONCLUSIONS

The minimally invasive SNB was shown to be a practical alternative to ALND. We propose to use local as well as global sensitivity and associated 95% CI to test the validity of SNB in the clinical setting. Due to limitations of ALND as the golden standard, SNB can in fact be considered a more accurate method for nodal staging.

Effect of olive oil on early and late events of colon carcinogenesis in rats: modulation of arachidonic acid metabolism and local prostaglandin E(2) synthesis

BACKGROUND

Animal model studies have shown that the colon tumour promoting effect of dietary fat depends not only on the amount but on its fatty acid composition. With respect to this, the effect of n9 fatty acids, present in olive oil, on colon carcinogenesis has been scarcely investigated.

AIMS

To assess the effect of an n9 fat diet on precancer events, carcinoma development, and changes in mucosal fatty acid composition and prostaglandin (PG)E(2) formation in male Sprague-Dawley rats with azoxymethane induced colon cancer.

METHODS

Rats were divided into three groups to receive isocaloric diets (5% of the energy as fat) rich in n9, n3, or n6 fat, and were administered azoxymethane subcutaneously once a week for 11 weeks at a dose rate of 7.4 mg/kg body weight. Vehicle treated groups received an equal volume of normal saline. Groups of animals were colectomised at weeks 12 and 19 after the first dose of azoxymethane or saline. Mucosal fatty acids were assessed at 12 and 19 weeks. Aberrant crypt foci and the in vivo intracolonic release of PGE(2) were assessed at week 12, and tumour formation at week 19.

RESULTS

Rats on the n6 diet were found to have colonic aberrant crypt foci and adenocarcinomas more often than those consuming either the n9 or n3 diet. There were no differences between the rats on the n9 and n3 diets. On the other hand, administration of both n9 and n3 diets was associated with a decrease in mucosal arachidonate concentrations as compared with the n6 diet. Carcinogen treatment induced an appreciable increase in PGE(2) formation in rats fed the n6 diet, but not in those fed the n3 and n9 diets.

CONCLUSIONS

Dietary olive oil prevented the development of aberrant crypt foci and colon carcinomas in rats, suggesting that olive oil may have chemopreventive activity against colon carcinogenesis. These effects may be partly due to modulation of arachidonic acid metabolism and local PGE(2) synthesis.

[Selective biopsy of the sentinel ganglion in patients with breast cancer. Initial results]

BACKGROUND

Sentinel-node biopsy is meant to excise the first-echelon node from a primary tumor, which is the one that most probably harbors early metastases.

PATIENTS AND METHODS

We report our results in 35 patients with breast cancer, using a radiotracer by peri-tumoral injection, pre-surgical scintigraphy and intraoperative mapping with a gamma probe.

RESULTS

The technical success rate was 97%, negative predictive value 95.2%, accuracy 97%, and added value to staging 40%.

CONCLUSION

Compared with the conventional lymph-node staging procedure for breast cancer, sentinel-node biopsy with pre-surgical scintigraphy seems a good practical choice.

Protease inhibitor-containing regimens compared with nucleoside analogues alone in the suppression of persistent HIV-1 replication in lymphoid tissue

OBJECTIVE

Lymphoid tissue provides a reservoir where HIV can persist. However, therapies incorporating a protease inhibitor can target this reservoir. This study was designed to investigate the relative long-term effects on lymph-node viral load and cellular architecture of regimens containing multiple nucleosides alone or in combination with protease inhibitors.

METHODS

Axillary lymph-node biopsies from 12 patients with undetectable viraemia (viral load < 20 copies/ml: mean CD4 cells 525 x 10(6)/l) for a mean period of 25 months (range, 10-52 months) were investigated for the presence of HIV by in situ hybridization and coculture. Four patients were receiving multiple nucleoside analogues alone or in one case with a suboptimally dosed protease inhibitor (group I). Protease inhibitor was added to the regimen of seven patients at least 6 months prior to lymph-node biopsy (group II). Standard flow cytometry and virological data were obtained from peripheral blood every 3 months.

RESULTS

By in situ hybridization, more productively infected CD4+ T cells were found in the lymph nodes of group I patients treated with nucleoside analogues alone. Very low numbers of productively infected lymph node cells were detected in the protease inhibitor-treated group II. No trapping of virions on the follicular dendritic cell (FDC) network was detectable in protease inhibitor-treated patients. In contrast, large deposits of FDC-bound virions were observed in three out of five patients from group I. Virus cultures from lymph node cells were positive in these three group I patients compared with only one out of seven patients from group II. Sequencing reverse transcriptase and protease genes from these isolates revealed typical mutations conferring resistance to the previously administered nucleoside analogue. A more preserved lymph node architecture and less signs of immunopathological change were also observed in protease inhibitor-treated patients.

CONCLUSIONS

Undetectable plasma viraemia using the ultrasensitive PCR assay for prolonged periods of time does not always reflect complete HIV-1 suppression within the lymphoid compartment. Our results suggest that protease inhibitor-containing regimens target HIV reservoirs in lymphoid tissue more effectively and preserve or restore lymph node architecture.

Liver cell atypias: a comparative study in cirrhosis with and without hepatocellular carcinoma

Various criteria have been proposed for the identification of early neoplastic changes in the setting of both small hepatocellular carcinomas and macroregenerative nodules. In this study we have applied those criteria to cases of liver cirrhosis without tumour (group I) and hepatocellular-carcinoma-associated cirrhosis (group II) to assess their discriminatory value in these two situations. Group I included 50 liver biopsies with uncomplicated cirrhosis while group II encompassed 48 liver biopsies of cirrhotic nodules adjacent to hepatocellular carcinomas. The histological changes sought were large cell dysplasia, small cell dysplasia, cytoplasmic basophilia, small microacinar structures, peripheral distribution of nuclei, nuclear irregularities and thickened liver cell plates. These changes were also assessed in macroregenerative nodules (nine in group I and seven in group II). None of these changes was useful to discriminate between group I and group II cirrhotic nodules when assessed separately. On the other hand, cirrhotic nodules showing three or fewer changes were never associated with malignancy, whereas those exhibiting four or more alterations were often located in the vicinity of a tumour. Acinar structures, thickened cell trabeculae, peripheral distribution of nuclei and nuclear irregularities seem to be the most specific indicators of proximity to a hepatocellular carcinoma. Similar results were obtained for macroregenerative nodules. These results may be helpful as guidelines to the probability of having a hepatocellular carcinoma elsewhere in livers containing atypical cirrhotic nodules, and may also prove valuable in the selection of appropriate material for investigating early molecular events in hepatic carcinogenesis.

p53 immunoreaction in hepatocellular carcinoma and its relationship to etiologic factors. A fine needle aspiration study

OBJECTIVE

To determine immunohistochemically the expression of mutant p53 phosphoprotein in hepatocellular carcinoma (HCC) and its possible relationship to several etiologic factors.

STUDY DESIGN

The study group consisted of 62 samples of HCC, grades 2, 3 and 4, obtained by fine needle aspiration cytology. The associated risk factors detected in these patients were as follows: ethanol abuse, ethanol abuse plus hepatitis B virus (HBV) or hepatitis C virus (HCV) infection, HBV infection, HCV infection, non-A/ non-B hepatitis, hemochromatosis and obesity.

RESULTS

Mutant p53 expression was identified in 22% of HCC and seemed to correlate with tumor grade. Positive immunostaining was frequently associated with a history of alcohol abuse (42%) and also with viral infection (HBV, 21%; HCV, 7%; non-A/non-B hepatitis, 7%).

CONCLUSION

Mutant p53 seems to intervene in the progress of HCC through various grades of increasing malignancy. The association we found between alcohol intake and mutant p53 expression may deserve further investigation.

Fine-needle aspiration biopsy of metaplastic carcinoma of the breast: report of a case with abundant myxoid ground substance

Metaplastic carcinoma (MC) is an uncommon neoplasm of the breast. There are several variants of MC depending on the dominant histologic pattern. The components include over infiltrating ductal carcinoma, extensive squamous differentiation and spindle cell proliferation with or without chondroid or asseous heterologous elements. In FNA smears, only 57% of cases show both ductal carcinoma and metaplastic component. Thus, in almost one half of the cases, the diagnosis is not possible by FNA. Often it is difficult to define the epithelial or sarcomatous character of malignant cells. We describe a case of metaplastic carcinoma of the breast studied by fine-needle aspiration cytology in which myxoid ground substance was the dominant feature in the cytology smears. The rest of the material was composed of scanty isolated atypical cells with large and irregular nuclei. It is important to bear in mind the diagnosis of MC and make a careful search for atypical cells when the cytological smears are mainly composed of myxoid ground substance.

Expression of CD44H and CD44v3 in normal oesophagus, Barrett mucosa and oesophageal carcinoma

AIMS

To examine CD44H and CD44v3 expression in normal gastric and small bowel mucosa, normal and Barrett oesophagus, and oesophageal epithelial malignancies (squamous cell carcinoma and adenocarcinoma).

METHODS

Ninety five specimens, comprised of 40 of normal oesophageal, gastric and small bowel mucosa, 22 of Barrett oesophagus (two with dysplastic changes), 20 of resected adenocarcinomas, and 13 of squamous cell carcinoma, were evaluated. The samples were fixed in formalin and subsequently stained with anti-CD44H and anti-CD44v3 monoclonal antibodies using the avidin-biotin peroxidase technique.

RESULTS

In contrast to normal oesophagus, which showed positivity for both CD44 epitopes (CD44H and CD44v3) in the basal third of the epithelium, antral and intestinal subtypes of Barrett oesophagus expressed CD44H only, the distribution being focal in non-dysplastic and diffuse in dysplastic Barrett mucosa. Similarly, normal antral glands and small bowel epithelium were focally immunopositive for CD44H at the base of the crypts. All squamous cell carcinomas were diffusely positive for both isoforms, whereas 75% (15/20) of the adenocarcinomas expressed CD44H and 60% (12/20) expressed CD44v3.

CONCLUSIONS

CD44H is expressed in the proliferating areas of both normal squamous epithelium and Barrett mucosa. CD44H expression seems to increase progressively in dysplasia and infiltrating carcinoma, similar to the process described in the stomach. CD44v3 expression, usually not observed in normal or neoplastic gastric mucosa, was present in normal squamous epithelium and oesophageal squamous cell carcinoma. CD44v3 immunoreactivity was also identified in 60% of adenocarcinomas. These findings suggest that CD44v3 may play a role in the development of oesophageal carcinoma of both squamous and glandular types.

Spontaneous aortocaval fistula: CT findings with pathologic correlation

We present a case of aortocaval fistula (ACF) secondary to spontaneous rupture of an atherosclerotic infrarenal aortic aneurysm into the inferior vena cava that was initially diagnosed with computed tomography (CT). This is believed to be the first report of this condition with CT demonstration of the exact site of fistula and CT-pathologic correlation. We retrospectively reviewed the CT findings of another two cases of ACF and the previous literature.

Proliferating cell nuclear antigen expression in normal, regenerative, and neoplastic liver: a fine-needle aspiration cytology and biopsy study

Information about a tissue's proliferative activity can be obtained from the immunocytochemical investigation of proliferating cell nuclear antigen (PCNA), an auxiliary protein of DNA polymerase delta expressed by cycling cells. To determine whether a relationship exists between morphology and PCNA expression in normal, regenerative, and malignant neoplastic hepatocytes, this study was undertaken on 48 fine-needle aspiration cytology (FNAC) cell blocks from eight normal livers, eight cirrhotic livers, and 32 hepatocellular carcinomas (HCCs), as well as on 41 needle or wedge biopsy specimens from 10 normal livers, 13 cirrhotic livers, one focal nodular hyperplastic liver, and 17 HCCs. Anti-PCNA monoclonal antibody PC10 was applied to formalin-fixed, paraffin-embedded tissue using the avidin-biotin method. Proliferating cell nuclear antigen immunoreactivity was evaluated as follows: absent; minimal, less than 5% positive nuclei; grade 1, 5% to 25% positive nuclei; grade 2, 26% to 50% positive nuclei; grade 3, 51% to 75% positive nuclei; and grade 4, 76% to 100% positive nuclei. In both the FNAC and biopsy series normal and regenerative livers were either completely negative or minimally immunoreactive (under 5% positive nuclei). In contrast, all well-differentiated HCC cases exhibited over 15% positive nuclei. Most well-differentiated HCCs were grade 1 (85.7% in the FNAC series and 76.92% in the biopsy series) and the majority of moderately differentiated HCCs were grade 3 (63.63% in the FNAC series, but only 50% in the biopsy series). Therefore, absent or minimal PCNA immunoreactivity seems to be a useful adjuvant to discriminate normal/regenerative liver from HCC, whose degree of differentiation tends to correlate with the level of PCNA expression. These observations apply to both the FNAC and biopsy series, which yielded very similar data.