Variable heavy chain gene analysis of follicular lymphomas: correlation between heavy chain isotype expression and somatic mutation load.

The expansion of follicular lymphomas (FLs) resembles, both morphologically and functionally, normal germinal center B-cell growth. The tumor cells proliferate in networks of follicular dendritic cells and are believed to be capable of somatic hypermutation and isotype switching. To investigate the relation between somatic mutation and heavy chain isotype expression, we analyzed the variable heavy (V(H)) chain genes of 30 FL samples of different isotypes. The V(H) genes of the FLs were heavily mutated (29.3 mutations on average). In addition, isotype-switched lymphomas contained more somatic mutations than immunoglobulin M-positive lymphomas (33.8 mutations per V(H) gene versus 23.0, respectively). In all but one of the FLs, the ratios of replacement versus silent mutations in the framework regions were low, independent of the absolute number of somatic mutations and the level of intraclonal variation. Analysis of relapse samples of 4 FLs showed no obvious increase in somatic mutation load in most FLs and a decrease in intraclonal variation in time. In 3 of 4 cases, we obtained evidence for selection of certain subclones, rather than clonal evolution. Our findings question if intraclonal variation is always a reflection of ongoing somatic hypermutation. This may have implications for the concept of antigen-driven lymphomagenesis. (Blood. 2000;95:2922-2929)

Conventional bladder wash cytology performed by four experts versus quantitative image analysis.

Bladder wash cytology provides superior results for the detection of bladder malignancies than does voided urine analysis. Image analysis systems have been developed for quantification of cytologic features. In this study, routine bladder wash cytology is compared with an automated image analysis system (QUANTICYT). We studied a random set of 100 bladder wash samples from a population of 1614 patients in follow-up after bladder cancer. Four experienced pathologists interpreted the same 100 Papanicolaou-stained slides. Cytologic and image analysis results were compared for prediction of a cystoscopic lesion, histologic abnormalities, and tumor recurrence. After application of receiver operating characteristic curves, prediction of a cystoscopic lesion by cytology and image analysis was comparable. Both the image analysis system and the cytologic examination detected all of the high-grade lesions. Image analysis was superior to cytologic analysis for the prediction of tumor recurrence after normal findings at cystoscopic examination.

[Potential cornea, heart valve, bone and skin donors in 5 Dutch hospitals far outnumber actual donors]. / Aantal potentiële hoornvlies-, hartklep-, bot- en huiddonors in vijf Nederlandse ziekenhuizen veel groter dan aantal daadwerkelijke donors.

OBJECTIVE: To determine the number of potential cornea, heart valve, bone and skin donors among patients who died in Dutch hospitals, in comparison with the number of actual donors. DESIGN: Descriptive. SETTING: Five hospitals in the western part of the Netherlands. MATERIAL AND METHODS: The medical records of patients who died in 1989 were reviewed. Children younger than 4 weeks were excluded from the study. On the basis of criteria used by the Eurotransplant and Bio Implant Services Foundations and those of the skin bank of the Dutch Burns Foundation, it was determined if the deceased were medically suitable as cornea, heart valve, bone or skin donor. RESULTS: Data were collected on 2150 of 2369 deceased (90.8%), mean age 69.5 (17.0) (SD) years. Medical criteria for cornea donation were met in 72% of the cases, 6.8% of these became actual donors. The figures for heart value donors were 4.3% and 9.7% respectively, and for bone donors 2.7% and 0%. The percentage of potential skin donors could not be determined, because essential data were missing from the medical records. After extrapolation the number of donors among all patients who died in Dutch hospitals in 1989 amounted to 35,046 potential cornea donors, 2,093 potential heart valve donors and 1,314 potential bone donors. CONCLUSION: Only a very small proportion of the potential tissue donors were referred to Eurotransplant and Bio Implant Services. Therefore, waiting lists for tissue transplantation are not necessary.

The effect of estriol on the cytology of urethra and vagina in postmenopausal women with genito-urinary symptoms.

In a double-blind, randomised trial, 62 postmenopausal women with genito-urinary symptoms were treated with oestriol or matching placebo for 4 weeks. Estriol (Synapause-E3, Nourypharma Nederland) was given orally for 4 weeks in a single daily dose (8 mg/day first week, 4 mg/day second and third week, 2 mg/day fourth week). The influence of estriol on the vaginal and urethral epithelium was assessed by using the karyopycnotic index and the maturation value. As we expected, it was confirmed that estriol has a remarkably beneficial effect on the vaginal epithelium. This also applies to the epithelium of the urethra, although the effect is much less obvious.

Prognostic factors in bladder carcinoma: histologic parameters and expression of a cell cycle-related nuclear antigen (Ki-67).

A total of 316 biopsies from patients with bladder carcinoma who entered a trial of the genito-urinary group of the European Organization for Research and Treatment of Cancer (EORTC) were reviewed. The histological data were subsequently correlated with the clinical course. A strong correlation between the number of mitoses and the time of first recurrence, muscle invasion, and death was noted. Next the expression of Ki-67 in frozen sections from 49 transitional cell carcinomas (TCCs) and the DNA content of the tumour cells were determined. The frequency of Ki-67-positive tumour cells increased with tumour grade and stage. Grade II TCCs and superficially infiltrating TCCs showed a wide range of Ki-67 scores. There was a significant difference in Ki-67 score between non-infiltrating (Ta) and superficially infiltrating (T1) grade II TCCs. All DNA-aneuploid carcinomas but also 15 out of 36 DNA-diploid tumours contained more than 10 per cent Ki-67-positive cells. Only some of these tumours were DNA-aneuploid or -tetraploid. The results indicate that the number of Ki-67-positive cells in grade II tumours may be a useful aid in separating grade II TCCs with a favourable prognosis from those with a poor clinical outcome.

Cytokeratin expression patterns in metastatic transitional cell carcinoma of the urinary tract. An immunohistochemical study comparing local tumor and autologous metastases.

The cytokeratin (CK) expression patterns of local, ie, primary or recurrent, high-grade-malignant transitional cell carcinomas (TCCs) of the human urinary tract and autologous lymphogenic and hematogenic metastases (n = 33) were compared. Special attention was paid to CK expression in the tumor invasion front and other areas where tumor-stroma interaction occurred to visualize cell populations with a metastatic phenotype. For this purpose, polypeptide-specific monoclonal antibodies to CKs 4, 7, 8, 10, 13, 14, 16, 17, 18, and 19 were used, employing the immunoperoxidase method. Results show that: 1) An increased expression of CK8 and CK18 is seen in the TCC tumor cells at the interface with peritumoral stroma in the tumor invasion front and with intratumoral stroma ('interface phenomenon'). Other than reflecting a quantitative change, this phenomenon might be explained by unmasking of CK8 and CK18 epitopes occurring in these regions. 2) Although in general the expression of CK13 in local TCC is decreased with increase of histopathologic parameters for progression, ie, grade and stage, an extensive proportion of CK13-positive tumor cells still can be found in some TCCs, even in metastases. 3) Morphologically recognizable types of aberrant differentiation in TCC, i.e., pseudosarcomatous or squamous differentiation and marked loss of differentiation, show altered expression of many of the CKs studied.

Flow cytometric and histomorphometric analysis of limitations of clinical breast cytomorphometry.

The clinical value and limitations of a previously described cytomorphometric method, based on nuclear size and anisonucleosis, for evaluation of routine fine-needle aspiration of the breast were assessed in a series of 313 histologically investigated primary breast lesions. Limitations were analyzed by histomorphometry and DNA flow cytometry in 116 consecutive cases of histologically confirmed breast carcinoma. Eighty per cent of histologically proven malignant tumours were classified cytomorphometrically as malignant and no false-positive results were encountered. For benign lesions a benign cytomorphometric classification was reached in 66% of the cases. Histomorphometry showed that on the whole the assignment of histologically malignant tumours to a non-malignant cytomorphometric classification was determined by smaller nuclei and not by sampling error. Tumours assigned to a malignant cytomorphometric classification had on average significantly higher DNA indices than did tumours not assigned to a malignant cytomorphometric classification (P less than 0.001). The mean-nuclear areas in cytomorphometry and histomorphometry were strongly correlated with DNA indices indicated by DNA flow cytometry (P less than 0.001 for both). The present findings show that this cytomorphometric method is appropriate for routine quality control of a cytological diagnosis of malignancy in FNA of the breast. However, an inconclusive result in 15-25% of the tumours is inevitable.

[Neurofibromatosis and a tumor of Vater's papilla]. / Neurofibromatosis en een tumor bij de papil van Vater.

A male aged 57 is reported with neurofibromatosis presenting with a tumour in the periampullary region. Pathologic examination revealed a neuroendocrine tumour of the carcinoid type. A review of the literature suggests that neurofibromatosis patients are at significant risk for developing a periampullary tumour which is nearly always of neuroectodermal origin. To date, surgical excision is the only curative therapy. Therefore, early diagnosis is of major importance. In all patients with neurofibromatosis presenting with jaundice, gastrointestinal bleeding or abdominal pain, a periampullary tumour should be considered. A review is presented of the latest developments concerning the DNA-based mutation causing this disorder. In family members, DNA linkage studies should be carried out, and they should be periodically screened, e.g. with gastroduodenoscopy.

Cytomorphometry as quality control for fine needle aspiration. A study in 321 breast lesions.

Material collected by fine needle aspiration (FNA) in 321 histologically examined primary breast lesions of previously untreated patients was analyzed by morphometry. The mean nuclear area (MNA) and its standard deviation (SD) were calculated for 50 cells in each case. Four subclasses were defined on the basis of the MNA and SD: benign (less than 10% probability of malignancy), doubtful benign (10% to 49%), doubtful malignant (50% to 90%) and malignant (greater than 90% probability of malignancy). FNA samples showing signs of acute inflammation or only apocrine metaplastic cells were not suitable for analysis by this morphometric method and were excluded. In 274 (85.4%) of the cases, the measurements allowed a definite morphometric conclusion, with predictive values of 99.5% and 100% for the histologically malignant and benign aspirates, respectively. The probability of malignancy in the doubtful malignant group was almost 86%. The morphometric method described is quick, easy to perform and well suited for use in routine daily practice; furthermore, it does not require expensive equipment. The ease of the technique and its high predictive value make this method appropriate for use as a quality control procedure in FNA cytology.

Epstein-Barr virus in a CD8-positive T-cell lymphoma.

In contrast to its role in B-lymphomagenesis, Epstein-Barr Virus (EBV) only incidentally has been associated with T-cell lymphomas. In the present report we describe a fourth patient with EBV-related T-cell lymphoma. The patient presented with an angio-immunoblastic lymphadenopathy (AILD)-like T-cell lymphoma. Serology was compatible with chronic Epstein-Barr (EBV) infection. After a 1-year period of waxing and waning lymphadenopathy, this lymphoma evolved to an aggressive CD8+ Immunoblastic T-cell lymphoma. A relationship with the chronic EBV infection was indicated by the finding of EBV genome in the tumor tissue by Southern blot analysis. Moreover, EBV nuclear antigen (EBNA) was detected in situ within individually defined CD8+ tumor cells by two-color immunofluorescence. Two alternative possibilities, namely that EBV primarily played a role in lymphomagenesis of the AILD-like T-cell lymphoma or that the virus was an additional oncogenic event in the final process of tumor progression to the immunoblastic lymphoma, are discussed.

Distribution of cytokeratin polypeptides in human transitional cell carcinomas, with special emphasis on changing expression patterns during tumor progression.

The expression of cytokeratin (CK) polypeptides was studied in 59 transitional cell carcinomas (TCC) of the urinary tract of different grade and stage. Using a panel of 14 polypeptide-specific monoclonal CK-antibodies we identified immunohistochemically 8 different CKs separately, ie, CKs 4, 7, 8, 10, 13, 14, 18, and 19, while in immunoblotting studies CK5 expression was detected indirectly by using the antibody RCK102, recognizing CK5 + 8. In low-grade TCCs (G1-G2), the CK distribution was comparable to that in normal urothelium, however with a variable expression of CK13 in the different tumors and a uniform distribution of CK7. In higher-grade TCCs (G3), a decrease in CK13 expression was observed, particularly in the areas of muscle invasion. Furthermore, the appearance and increasing expression of CK14 (not present in normal urothelium or G1 TCCs) with higher grade and stage was striking. With tumor progression changes in epitope configurations of CK8 and CK18 were detected, as concluded from immunohistochemical assays with the panel of monoclonal antibodies for each of these two CKs. In extreme cases this resulted in differential staining patterns of the invasive and noninvasive components within one tumor. In 7 of 32 G3 TCCs, some of which showed areas with evident squamous differentiation, a decrease in the expression of CK7 and/or CK8 was seen. We conclude that tumor progression in TCCs is associated with discrete changes of CK expression, which can be detected using monoclonal antibodies.

Argyrophilic proteins of the nucleolar organizer region in bladder-tumours.

The introduction of a simple one-stage silver nitrate stain as a method of displaying nucleolar organizer regions (NOR's) in formalin-fixed tissue has made it possible to examine the significance of these structures in tumour pathology. In the current study argyrophilic proteins of the NOR's were studied in 39 consecutive patients with bladder tumours. The results indicate that the counting of silver staining particles is only of limited value in grading bladder tumours and that this method is not superior to other additional grading techniques such as histo-morphometry and flow cytometry.

Pheochromocytoma-induced hypertensive encephalopathy revealing MEN-IIa syndrome in a 13-year old boy. Implications for screening procedures and surgery.

In the multiple endocrine neoplasia (MEN) type II syndrome, pheochromocytomas become manifest at a later age than medullary thyroid carcinomas (MTC) do. The present report concerns a 13-year-old boy, belonging to a MEN-IIA kindred, who was admitted because of convulsive seizures related to hypertensive encephalopathy. A pheochromocytoma was suspected immediately and appropriate medical therapy was initiated. A right adrenal pheochromocytoma was removed, as well as a pheochromocytoma of an accessory right adrenal gland. Today, three years later our patient is still asymptomatic and the results of the thyroid C-cell provocative tests remain normal. This case clearly justifies the conclusion that periodic investigation of MEN-II family members to detect both medullary thyroid carcinoma and pheochromocytoma should begin early in life, as the latter may be the initial life-threatening expression of the disease. Long-term follow-up of patients treated with unilateral adrenalectomy will permit better definition of the risk of contralateral recurrence in such cases.

Distribution of cytokeratin polypeptides in epithelia of the adult human urinary tract.

Cytokeratin expression was studied in the epithelia lining the normal human urine conducting system using immunohistochemistry on frozen sections employing a panel of 14 monoclonal antibodies. Eleven of these anticytokeratin antibodies reacted specifically with one of the 19 human cytokeratin polypeptides. Profound differences were found in the cytokeratin expression patterns between the different types of epithelium in the male and female urinary tract. In the areas showing morphological transitions of transitional epithelium to columnar epithelium and of nonkeratinizing squamous epithelium to keratinizing squamous epithelium gradual shifts of cytokeratin expression patterns were observed, often anticipating the morphological changes. However, also within one type of epithelium, i.e. the transitional epithelium, two different patterns of cytokeratin expression were found. Expression of cytokeratin 7 was homogeneous in the transitional epithelium of renal pelvis and ureter but heterogeneous in the transitional epithelium of the bladder. Furthermore, intraepithelial differences in cytokeratin expression could be shown to be differentiation related. Using a panel of chain-specific monoclonal antibodies to cytokeratins 8 and 18 conformational and/or biochemical changes in the organization of these intermediate filaments were demonstrated upon differentiation in columnar and transitional epithelium.

Can cytomorphometry replace histomorphometry for grading of bladder tumours?

Cytomorphometry, using various cytopreparatory techniques on bladder washings and histomorphometry on the resected bladder tumours, was used in an attempt to answer the question: Can cytomorphometry replace histomorphometry for grading of bladder tumours? For the analysis of quantitative data, a probit model was used. Three out of the four cytomorphometric methods provided data supportive to the histomorphometry. Using one of the four cytomorphometric methods was sufficient to enhance grading accuracy and all were equally good. Two cases of high grade carcinoma in situ were properly identified by cytomorphometry (as judged on the follow-up data) but the concurrent resected papillary tumours were low grade. These findings indicate that cytomorphometry is a useful method in bladder tumour grading. In some cases it is preferable to histomorphometry.

Radiation appendicitis: demonstration with graded compression US.

In a patient who had received presurgical radiation therapy for extensive rectal carcinoma, ultrasonography with graded compression disclosed an inflamed appendix. The patient had no clinical signs of acute appendicitis. At laparotomy for resection of the rectal carcinoma, the appendix appeared grossly abnormal and was removed. Pathologic examination showed severe radiation enteritis of the appendix. The sonographic appearance of radiation appendicitis closely resembled that of acute appendicitis.

Clinical significance of pepsinogen A isozymogens, serum pepsinogen A and C levels, and serum gastrin levels.

Gastric mucosal pepsinogen A phenotype, serum pepsinogen A level, serum pepsinogen C level, serum pepsinogen A/pepsinogen C ratio, and serum gastrin level were evaluated as potential markers for gastric cancer or its precursors in 19 healthy volunteers and 341 patients from the gastroscopy program. Gastric cancer, atrophic gastritis, and intestinal metaplasia of the stomach were associated with pepsinogen A phenotypes, characterized by an intense fraction 5, and with a low serum pepsinogen A level (less than 25 micrograms/l), a low serum pepsinogen A/pepsinogen C ratio (less than 1.5), and a high serum gastrin level (greater than 79 ng/l). The specificity of pepsinogen A phenotypes with an intense fraction 5 for gastric cancer or its precursors was 95.1% with a sensitivity of 20.4%. The sensitivity and specificity of the noninvasive tests were evaluated with the receiver operating characteristic. For clinical purposes, a serum pepsinogen A/pepsinogen C ratio less than 1.8 is the most suitable test, with a sensitivity of 74% and a specificity of 76% for gastric cancer or its precursors, with a reference population of patients with benign gastric disorders. However, the sensitivity and specificity of the single or combined tests are too low for population screening purposes.

Use of cytomorphometry and cytology in the diagnosis of transitional-cell carcinoma of the upper urinary tract.

Because of the rise in incidence of upper urinary tract tumors, there is a need for a simple and reliable method for diagnosing these tumors, especially in people in a "high-risk" group. This retrospective study showed the usefulness of cytology and cytomorphometry in making the diagnosis of transitional-cell carcinoma of the upper urinary tract. The study also emphasized that the methods of collection and processing are of the utmost importance: the cytologic evaluation of ureteral catheterized urine specimens gave 100% accuracy as compared with a 40% false-negative rate in the cytologic diagnosis of voided urine specimens. A higher accuracy of urinary cytology for the diagnosis of upper urinary tract lesions clearly requires selective catheterization of the ureter. Objective cytomorphologic grading of the urinary cytology specimens was shown to compare favorably with histologic grading. Cytomorphologic grading not only can offer important information in determining the prognosis and in planning treatment but can also assist in quality control of other diagnostic methods and can help to resolve apparent diagnostic discrepancies.