Advanced-stage mycosis fungoides: role of the signal transducer and activator of transcription 3, nuclear factor-κB and nuclear factor of activated T cells pathways

BACKGROUND

The malignant mechanisms that control the development of cutaneous T-cell lymphoma (CTCL) are beginning to be identified. Recent evidence suggests that disturbances in specific intracellular signalling pathways, such as RAS-mitogen-activated protein kinase, T-cell receptor (TCR)-phospholipase C gamma 1 (PLCG1)-nuclear factor of activated T cells (NFAT) and Janus kinase (JAK)-signal transducer and activator of transcription (STAT), may play an essential role in the pathogenesis of CTCL.

OBJECTIVES

To investigate the mechanisms controlling disease development and progression in mycosis fungoides (MF), the most common form of CTCL.

METHODS

We collected 100 samples that were submitted for diagnosis of, or a second opinion regarding, MF between 2001 and 2018, 80% of which were in the early clinical stages of the disease. Formalin-fixed paraffin-embedded tissues were used for histological review and to measure the expression by immunohistochemistry of surrogate markers of activation of the TCR-PLCG1-NFAT, JAK-STAT and NF-κB pathways. Folliculotropism and large-cell transformation were also examined.

RESULTS

NFAT and nuclear factor kappa B (NF-κB) markers showed a comparable activation status in early and advanced stages, while STAT3 activation was more frequent in advanced stages and was associated with large-cell transformation. Consistently with this observation, STAT3 activation occurred in parallel with MF progression in two initially MF-negative cases. A significant association of NFAT with NF-κB markers was also found, reflecting a common mechanism of activation in the two pathways. Genomic studies identified nine mutations in seven genes known to play a potential role in tumorigenesis in T-cell leukaemia/lymphoma, including PLCG1, JAK3 and STAT3, which underlies the activation of these key cell-survival pathways. A higher mutational allele frequency was detected in advanced stages.

CONCLUSIONS

Our results show that STAT3 is activated in advanced cases and is associated with large-cell transformation, while the activation of NFAT and NF-κB is maintained throughout the disease. These findings could have important diagnostic and therapeutic implications. What's already known about this topic? Mycosis fungoides is characterized by a clonal expansion of T cells in the skin. The mechanisms controlling disease development and progression are not fully understood. What does this study add? An association of the nuclear factor of activated T cells and nuclear factor kappa B pathways was found, which could reflect a common mechanism of activation. These pathways were activated in early and advanced stages at the same level. Signal transducer and activator of transcription 3 activation was associated with large-cell transformation and was more frequent in advanced stages. A genomic analysis of cutaneous T-cell lymphoma-associated genes was performed. Nine mutations were detected. What is the translational message? These results could have important implications for the treatment of MF in the near future.

Aspiration cytology of 147 adnexal cysts with histologic correlation

OBJECTIVE

To assess the usefulness of cytology in the diagnosis of 147 histologically established adnexal cysts.

STUDY DESIGN

Retrospective, macro-microscopic study based on fluid aspirated from 132 ovarian and 15 extraovarian cysts and projected as a cytohistologic correlation.

RESULTS

Typical macroscopic features were identified in 76% of endometriotic cysts, in 53% of mucinous neoplasms and in 67% of dermoid cysts. Cytology helped to identify 67% of nonneoplastic and 56% of neoplastic cysts. The lowest diagnostic sensitivities were observed in functional cysts and benign serous neoplasms (50%), while the highest were shown by endometriotic cysts (76%) and malignant epithelial neoplasms (71%). Inadequate samples were obtained from all types of cysts, even malignant ones (two mucinous cystadenocarcinomas). Diagnostic cytology was useless in extraovarian cysts (33% sensitivity). An adult granulosa cell tumor was erroneously diagnosed as a follicular cyst by cytologic examination.

CONCLUSION

Examination of the cyst fluids obtained by aspiration demonstrated low sensitivity, with 43% of inadequate samples obtained from all types of cysts. Malignant cystic neoplasms may be overlooked in inadequate samples. Our study also revealed that specificity in this type of analysis is high in inadequate samples, provided that the technique is carried out correctly.

[Eosinophilic cholecystitis associated with rupture of hepatic hydatid cyst of the bile ducts]

Eosinophilic cholecystitis is a rare finding characterized by an inflammatory infiltrate composed primarily of eosinophils. We report a case of eosinophilic cholecystitis associated with hepatic hydatic cyst ruptured into the biliary tract. The release of hydatid cyst content into the biliary tract may have induced a hypersensitivity reaction with numerous eosinophils in the gallbladder wall.

[Blue nevus of the prostate]

The presence of melanin in the prostatic gland's stroma is a histopathological finding of extreme rarity. It receives the name of blue nevus as a result of its similitude to the skin's blue nevus. The paper describes the finding of melanin stores in the fibromuscular stroma of a patient's prostate and reviews the theories on its source.

[Incidence and mortality of laryngeal neoplasms. Soria, 1950-1989]

Age-adjusted mortality and incidence rates for larynx cancer were calculated in Soria (urban and rural areas), for the 1950-89 and 1981-89 periods respectively. Both mortality and incidence rates were higher in urban area (p less than 0.01), and in males (p less than 0.01). There has been no increase in the mortality trend for the 1950-89 period. Age-adjusted incidence rates for men in Soria are higher respect to those reported in other countries. Soria and Murcia rates are the lowest in Spain larynx cancer records, being Asturias rates the highest in the world (20.6 per 100,000 population).

[Mortality trends in gynecologic tumors in Soria. 1950-1985]

We have carried out in the province of Soria neoplastic mortality tendency curves for tumors in the breast, uterus and ovaries, on the basis of their adjusted rates of mortality during four periods: three decades (1950-59/60-69/70-79) and one six-year period (1980-85). We have observed an increased risk of mortality due to breast tumors in women, which is statistically significant (p less than 0.01) in the global provincial figure, which has gone from an adjusted rate of 6.08 deaths per 10(5) women in 1950-59 to 14.25 in the years 1980-85. We have also detected an increased risk of ovarian tumors in the provincial total, rising from 0.48 to 2.0 deaths per 10(5) women, while those located in the uterus show a virtually stable mortality over the 36 years under study (5.89/1950-59) (5.24/1980-85) x 10(5) women. In relation to other existing figures, our rates are, in the case of breast and ovarian tumors, similar to the global Spanish figures and lower than those for Cataluña and Navarra. In the case of tumors of the uterus, the adjusted mortality rates are lower than the national average and lower than any other Spanish figures available.

[Geographic study of cancer of the stomach in Spain in relation to agricultural activities]

The Spanish provinces with the highest risk of gastric cancer (CG) are in the Castilian meseta, where grain raising predominates. In other countries, high risk areas also correspond to inland, high altitude regions, and in some cases, like Chile, abundant fertilizer consumption. The present study attempts to relate the risk of this tumor in Spain to different types of agricultural activity. Pearson's linear correlation coefficient was calculated between the mortality rate due to gastric cancer in each of the 50 Spanish provinces and the different types of farming and cattle raising activities. The correlation with grain raising on nonirrigated land was positive and significant for mortality in both men (p less than 0.001) and women (p less than 0.01). The correlation between mortality from gastric cancer and cattle raising, particularly sheep, was also positive and significant in both sexes (p less than 0.001). The proportion of the irrigated and nonirrigated fields dedicated to fruit trees correlated negatively with mortality in both sexes, also with a significant difference (p less than 0.01). The authors suggest the need for further epidemiological investigation in Spain, particularly in areas of high risk of gastric cancer, to identify precisely the risk factors that could be related to agricultural activities.

[Mortality trends caused by neoplasms of the digestive system. Soria, 1950-1985]

The deaths caused by tumours of the digestive system (oesophagus, stomach, colon-rectum, gallbladder and pancreas) recorded in the province of Soria between 1950 and 1985 have been analyzed according to risk and mortality rates. Standardized (adjusted) rates in relation to sex and site of residence (urban-rural) of the deceased were calculated for the decades 1950-1959, 1960-1969, 1970-1979 and the period between 1980 and 1985. Standard errors were calculated to establish confidence limits according to Miettinen's method. The data were obtained from the death certificates of the various registries of the Soria province, including name and surnames, sex, age and site of the tumour according to the 9th revision of the International Classification of Diseases. There is a significant decrease in the mortality risk for tumours of the stomach in both sexes (p less than 0.01) and in liver tumours in females (p less than 0.01). On the other hand, there is an increased risk in both sexes for pancreatic cancer (p less than 0.05 M, p less than 0.01 F) and for oesophageal tumours in men (p less than 0.05). Similarly, during 1980-1985 men were at a significantly greater risk of dying from oesophageal, gastric and liver cancer (p less than 0.01) as well as rectum and colon (p less than 0.05). As far as stomach tumours are concerned there are significant differences between rural and urban areas both in males (p less than 0.01) and in females (p less than 0.05).

[Mortality trends in respiratory tract tumors. Soria, 1950-1985]

From 1950 to 1985, we have ascertained the causes of deaths caused by respiratory tract tumors of the: mouth, nose, pharynx, larynx, trachea, bronchi, lungs and pleura. They have been grouped by sexes and divided among three decades (1950-1979) and a six-year period (1980-1985), Gross Rates (G.R.) and Standard Rates (S.R.) with relation to said parameters to plot their Death Rate Tendencies. An increasing death rate is observed in men as related to tumors of the bronchi and lungs, with a higher risk statistics which are quite significant from 1950 to 1985. On the other hand, there is a decrease in the deaths of both sexes due to neoplasias of the larynx. With regard to the oral tumors, there has been a minimum increase in the men over the last few years, the female death rate being practically nil. There are differences between men and women which are quite significant statistically with regard to death rates related to tumors of the mouth, larynx, Bronchi and lungs. Nevertheless, given the method for collecting data, it can only be used as a guide, due to the turns affecting the sources of information.

[Histopathologic evaluation of death certificates in Soria in 1985]

The aim of this paper is to evaluate the quality of the Death Certificates by means of the Death Statistics Bulletins, in their NEOPLASIC aspect in the year 1985 in the Province of Soria, determining the histopathologic confirmation of the deaths by means of the neoplasic patients' records in the two existing Pathology Services. An overall histologic verification of 80.76% is observed in the cases with an I.C. of +/- 4.79. In the case of BREAST, HEMATOLOGIC, OROPHARYNX, ENDOMETRIUM, ESOPHAGUS, OVARIAN, LARYNX and VULVA tumors, it is 100%. Whereas it is 14.3% in HEPATIC Tumors. Of the total of deaths registered in said year, the percentage of deaths caused by malignant neoplasias is over 26%, more than a fourth of which were Gastric. The preparation of the Death Certificates should be modified so that they can be objectively evaluated epidemiologically without bias or mistakes.

[Trends in urologic neoplasm mortality and incidence (prostate, bladder, and kidney). Soria, 1950-1988]

The mortality rate for urological tumors in the province of Soria, Spain, was recorded from 1950 to 1988, as well as its incidence for the period 1981-1988. We classified data according to sex, age groups, tumor site and type, and patient residence (urban/rural). Rates were adjusted for the foregoing parameters and decades (1950-1959, 1960-1969, 1970-1979, 1980-1988) and compared with those of other national and international registries. Prostate, bladder and kidney tumors in men showed an increased mortality rate for the period 1950-1988 which was statistically significant (p less than 0.01), whereas the female mortality rate for this period hardly changed and remained very low. A higher risk potential was observed for bladder tumors for the urban than for the rural areas, with a significant difference for mortality and incidence for both sexes (p less than 0.01). There was also a higher incidence for tumors of the prostate in the urban areas (p less than 0.01). Like most registries, there was a prevalence of bladder tumors in males, in both areas, in mortality and incidence (p less than 0.01). Comparison with other national registries show our mortality and incidence rates are lower for both sexes. Comparison with international registries show this province has a medium-low risk for prostatic tumors and medium risk for bladder tumors in males and females. The risk potential for renal tumors could not be compared objectively. The incidence/mortality ratio (I/M) (adjusted rates) shows prognosis is good for bladder tumors (better in women than in men), poor for prostatic tumors, and bad for renal tumors.

[Correlation of the risk of gastric cancer in the province of Soria and the nitrate content of drinking water]

Diverse previous epidemiological studies have associated the risk of gastric cancer (CG) with the nitrate content of drinking water in certain high risk areas in Columbia and Denmark, but in other countries no relation has been found and the topic is still controversial. In the present study and analysis is made of the differential risk of gastric cancer in the province of Soria (Spain) in terms of mortality and incidence in each of the natural regions of this province, investigating an eventual correlation with the nitrate content of the drinking water. Although the maximum nitrate content found barely exceeded the maximum limits suggested by the WHO, these values have a statistically significant positive linear correlation with the adjusted mortality (p less than 0.01) and incidence rates of gastric cancer in men (p less than 0.05). The authors discuss the need for further investigation of the topic in Spain since the nitrate values encountered might not reflect the true magnitude of environmental nitrate exposure, or there could be other factors related to agricultural work in the grain-producing regions where the maximum rates of gastric cancer in men are recorded.

[Relationship among the neoplasm incidence and mortality rates in the province of Soria. 1981-85]

During the years 1981 to 1985, every single death and neoplastic illness in the province of Soria was recorded, and tabulated in relation to age, sex, location, and place of residence. Adjusted Rates (Direct method) were obtained for all locations, both in mortality and in incidence, as well as their Standard Errors. The deceased and the neoplastically ill were grouped in areas--Urban an Rural--in order to establish risk differences in both areas, the intervals of confidence being established according to the Miettinem method. The neoplastic risk is always higher in males, both incidence and Global Mortality being statistically significant (p less than 0.01), as well as most of the locations. Gastric tumors have the highest rate of incidence (global and in males) and mortality (global and in both sexes), with higher presence in rural areas than in urban ones (p less than 0.05). On the other hand, in males, there is a higher incidence in urban areas of Lung Tumors (p less than 0.01) and Larynx (p less than 0.05). The latter, in males, and in the bladder in both sexes, have the highest survival ratio (Standard rate of incidence/Standard rate of mortality).