Feasibility of fluorescence lymph node imaging in colon cancer: FLICC.

BACKGROUND: In colon cancer, appropriate tumour excision and associated lymphadenectomy directly impact recurrence and survival outcomes. Currently, there is no standard for mesenteric lymphadenectomy, with a lymph node yield of 12 acting as a surrogate quality marker. Our goal was to determine the safety and feasibility of indocyanine green (ICG) fluorescence imaging to demonstrate lymphatic drainage in colon cancer in a dose-escalation study. METHODS: A prospective pilot study of colon cancer patients undergoing curative laparoscopic resection was performed. At surgery, peritumoural subserosal ICG injection was done to demonstrate lymphatic drainage of the tumour. A specialized fluorescence system excited the ICG and assessed lymphatics in real time. The primary outcome was the feasibility of ICG fluorescent lymphangiography for lymphatic drainage in colon cancer. Secondary outcomes were the optimal protocol for dose, injection site, and ICG lymphatic mapping timing. RESULTS: Ten consecutive patients were evaluated (six males, mean age 69.5 years). In all, lymphatic channels were seen around the tumour to a varying extent. Eight (80%) had drainage to the sentinel node. In all cases where the lymphatic map was seen, there was no further spread 10 min after injection. In 2 patients (20%), additional lymph nodes located outside of the proposed resection margins were demonstrated. In both cases the resection was extended to include the nodes and in both patients these nodes were positive on histopathology. Factors contributing to reduced lymphatic visualization were inadequate ICG concentrations, excess India ink blocking drainage, and inflammation from tattoo placement. CONCLUSIONS: ICG can be safely injected into the peritumoural subserosal and demonstrate lymphatic drainage in colon cancer. This proof of concept and proposed standards for the procedure can lead to future studies to optimize the application of image-guided precision surgery in colon cancer. Furthermore, this technique may be of value in indicating the need for more extended lymphadenectomy.

Using fluorescence lymphangiography to define the ileocolic mesentery: proof of concept for the watershed area using real-time imaging.

Recent advances in mesenteric science have demonstrated that the mesentery is a continuous structure with a 'watershed' area at the mesenteric apex between the right colon and terminal ileum, where lymphatic flow can proceed either proximally or distally. With this new understanding of the anatomy, functional features are emerging, which can have an impact on surgical management. Fluorescence lymphangiography or lymphoscintigraphy with indocyanine green allows real-time visualization of lymphatic channels, which highlights sentinel lymph nodes and may facilitate identification of the ideal margins for mesenteric lymphadenectomy during bowel resection for colon cancer. By using this novel technology, it is possible to demonstrate a watershed area in the ileocolic region and may facilitate more precise mesenteric dissection. In the present study, we provide proof of concept for the ileocolic watershed area using fluorescence lymphangiography.

Multi-centre Raman spectral mapping of oesophageal cancer tissues: a study to assess system transferability.

The potential for Raman spectroscopy to provide early and improved diagnosis on a wide range of tissue and biopsy samples in situ is well documented. The standard histopathology diagnostic methods of reviewing H&E and/or immunohistochemical (IHC) stained tissue sections provides valuable clinical information, but requires both logistics (review, analysis and interpretation by an expert) and costly processing and reagents. Vibrational spectroscopy offers a complimentary diagnostic tool providing specific and multiplexed information relating to molecular structure and composition, but is not yet used to a significant extent in a clinical setting. One of the challenges for clinical implementation is that each Raman spectrometer system will have different characteristics and therefore spectra are not readily compatible between systems. This is essential for clinical implementation where classification models are used to compare measured biochemical or tissue spectra against a library training dataset. In this study, we demonstrate the development and validation of a classification model to discriminate between adenocarcinoma (AC) and non-cancerous intraepithelial metaplasia (IM) oesophageal tissue samples, measured on three different Raman instruments across three different locations. Spectra were corrected using system transfer spectral correction algorithms including wavenumber shift (offset) correction, instrument response correction and baseline removal. The results from this study indicate that the combined correction methods do minimize the instrument and sample quality variations within and between the instrument sites. However, more tissue samples of varying pathology states and greater tissue area coverage (per sample) are needed to properly assess the ability of Raman spectroscopy and system transferability algorithms over multiple instrument sites.

Type 1 autoimmune pancreatitis and IgG4-related sclerosing cholangitis is associated with extrapancreatic organ failure, malignancy, and mortality in a prospective UK cohort.

OBJECTIVES: Type I autoimmune pancreatitis (AIP) and IgG4-related sclerosing cholangitis (IgG4-related SC) are now recognized as components of a multisystem IgG4-related disease (IgG4-RD). We aimed to define the clinical course and long-term outcomes in patients with AIP/IgG4-SC recruited from two large UK tertiary referral centers. METHODS: Data were collected from 115 patients identified between 2004 and 2013, and all were followed up prospectively from diagnosis for a median of 33 months (range 1-107), and evaluated for response to therapy, the development of multiorgan involvement, and malignancy. Comparisons were made with national UK statistics. RESULTS: Although there was an initial response to steroids in 97%, relapse occurred in 50% of patients. IgG4-SC was an important predictor of relapse (P<0.01). Malignancy occurred in 11% shortly before or after the diagnosis of IgG4-RD, including three hepatopancreaticobiliary cancers. The risk of any cancer at diagnosis or during follow-up when compared with matched national statistics was increased (odds ratio=2.25, CI=1.12-3.94, P=0.02). Organ dysfunction occurred within the pancreas, liver, kidney, lung, and brain. Mortality occurred in 10% of patients during follow-up. The risk of death was increased compared with matched national statistics (odds ratio=2.07, CI=1.07-3.55, P=0.02). CONCLUSIONS: Our findings suggest that AIP and IgG4-SC are associated with significant morbidity and mortality owing to extrapancreatic organ failure and malignancy. Detailed clinical evaluation for evidence of organ dysfunction and associated malignancy is required both at first presentation and during long-term follow-up.

The use of molecular imaging combined with genomic techniques to understand the heterogeneity in cancer metastasis.

Tumour heterogeneity has, in recent times, come to play a vital role in how we understand and treat cancers; however, the clinical translation of this has lagged behind advances in research. Although significant advancements in oncological management have been made, personalized care remains an elusive goal. Inter- and intratumour heterogeneity, particularly in the clinical setting, has been difficult to quantify and therefore to treat. The histological quantification of heterogeneity of tumours can be a logistical and clinical challenge. The ability to examine not just the whole tumour but also all the molecular variations of metastatic disease in a patient is obviously difficult with current histological techniques. Advances in imaging techniques and novel applications, alongside our understanding of tumour heterogeneity, have opened up a plethora of non-invasive biomarker potential to examine tumours, their heterogeneity and the clinical translation. This review will focus on how various imaging methods that allow for quantification of metastatic tumour heterogeneity, along with the potential of developing imaging, integrated with other in vitro diagnostic approaches such as genomics and exosome analyses, have the potential role as a non-invasive biomarker for guiding the treatment algorithm.

A randomised controlled trial of ALA vs. Photofrin photodynamic therapy for high-grade dysplasia arising in Barrett's oesophagus.

Photofrin photodynamic therapy (PDT) is a licenced treatment for Barrett's oesophagus (BE) with high-grade dysplasia (HGD) but causes strictures and photosensitivity and complete reversal of dysplasia (CR-HGD) by 50 % at 5 years. 5-Aminolaevulinic acid (ALA) is an alternative treatment with non-randomised data suggesting 85 % CR-HGD and a low risk of side effects. We aimed to compare efficacy and side effect profile between the drugs. A single-centre randomised controlled trial was conducted. Presence of HGD was confirmed on three occasions by two specialist GI pathologists. Stratification was by length of BE and extent of dysplasia. Standard protocols for ALA and Photofrin-PDT were followed. Endoscopic follow-up with 2-cm four-quadrant biopsy was at 6 weeks, 4 months, and then annually. All adverse event data were collected. Sixty four patients were randomised, 34 ALA and 30 Photofrin-PDT. Median follow-up is 24 months. On intention-to-treat analysis, CR-HGD was 16/34 (47 %) with ALA-PDT and 12/30 (40 %) with Photofrin-PDT. The overall cancer incidence was 14 % (9/64). On sub-group log-rank analysis, for BE ≤ 6 cm, CR-HGD was significantly higher with ALA-PDT than Photofrin-PDT (χ(2) =5.39, p=0.02). Strictures and skin photosensitivity were significantly more common after treatment with Photofrin-PDT than ALA-PDT (33 vs. 9 % and 43 vs. 6 %, respectively, p<0.05). The rate of buried glands with either drug was significantly higher post-PDT (48 % of patients) than pre-PDT (20 %). ALA-PDT has a better risk profile than Photofrin-PDT. In patients with BE length ≤ 6 cm, preliminary results show ALA-PDT is associated with significantly higher CR-HGD. In longer segments of BE, neither PDT drug is sufficiently efficacious to warrant routine use.

Radiofrequency ablation is effective for the treatment of high-grade dysplasia in Barrett's esophagus after failed photodynamic therapy.

Endoscopic radiofrequency ablation (RFA) is an effective treatment for high-grade dysplasia in Barrett's esophagus in ablation-naïve patients, but no studies have evaluated its use in patients in whom ablative therapy has previously failed. We describe 14 patients with residual high-grade dysplasia following aminolevulinic acid or Photofrin (porfimer sodium) photodynamic therapy (PDT). An overall complete reversal of dysplasia was achieved in 86 % with a combination of RFA and rescue endoscopic mucosal resection. The median total follow-up is 19 months. The rate of strictures was 7 % (1/14) and there was a low rate of buried glands (0.5 % follow-up biopsies). These data suggest RFA is both safe and effective for eradication of high-grade dysplasia in patients in whom PDT has failed.

Patient preferences and treatment safety for uncomplicated vulvovaginal candidiasis in primary health care.

BACKGROUND: Vaginitis is a common complaint in primary care. In uncomplicated candidal vaginitis, there are no differences in effectiveness between oral or vaginal treatment. Some studies describe that the preferred treatment is the oral one, but a Cochrane's review points out inconsistencies associated with the report of the preferred way that limit the use of such data. Risk factors associated with recurrent vulvovaginal candidiasis still remain controversial. METHODS/DESIGN: This work describes a protocol of a multicentric prospective observational study with one year follow up, to describe the women's reasons and preferences to choose the way of administration (oral vs topical) in the treatment of not complicated candidal vaginitis. The number of women required is 765, they are chosen by consecutive sampling. All of whom are aged 16 and over with vaginal discharge and/or vaginal pruritus, diagnosed with not complicated vulvovaginitis in Primary Care in Madrid.The main outcome variable is the preferences of the patients in treatment choice; secondary outcome variables are time to symptoms relief and adverse reactions and the frequency of recurrent vulvovaginitis and the risk factors. In the statistical analysis, for the main objective will be descriptive for each of the variables, bivariant analysis and multivariate analysis (logistic regression).. The dependent variable being the type of treatment chosen (oral or topical) and the independent, the variables that after bivariant analysis, have been associated to the treatment preference. DISCUSSION: Clinical decisions, recommendations, and practice guidelines must not only attend to the best available evidence, but also to the values and preferences of the informed patient.

Treatment of hyper-IgG4 disease with sequential corticosteroids and tamoxifen - case report and review of the literature.

We report a patient with multifocal fibrosclerosis presenting as sialadenitis, hepatic fibrosis, and retroperitoneal fibrosis with renal failure. His medical management consisted of prednisone (4 months at 40 mg daily, then tapered down to 5 mg daily for another 14 months) and 18 months of tamoxifen. He responded clinically and radiographically to this regimen, and remains in clinical remission 10 months after discontinuing medical therapy. Subsequent histologic examination of submandibular gland tissue revealed strong staining for IgG4-positive plasma cells. To our knowledge, this is the first case of confirmed multifocal hyper-IgG4 disease to be successfully treated with sequential corticosteroids and tamoxifen.

Gastrointestinal Kaposi's sarcoma: CD117 expression and the potential for misdiagnosis as gastrointestinal stromal tumour.

AIMS: Gastrointestinal Kaposi's sarcoma (KS) may mimic gastrointestinal stromal tumours (GISTs) histologically. Studies have shown that KS outside the gastrointestinal (GI) tract may express CD117, an antibody usually used to support a diagnosis of GIST. The aim was to evaluate the clinicopathological features of GI KS, including the expression of CD117 with and without antigen retrieval. METHODS AND RESULTS: Fourteen GI KS were assessed histologically, 12 of which were also subjected to immunohistochemistry for CD34, human herpesvirus (HHV) 8, DOG1 and CD117. CD117 immunohistochemistry was performed with and without antigen retrieval. All cases showed an infiltrative spindle cell tumour. Lamina propria infiltration, lymphoplasmacytic inflammation, extravasated red blood cells and haemosiderin were typical histological features. In all cases tumour cells were positive for CD34 and HHV8, but negative for DOG1. CD117 was positive in four of 12 cases without antigen retrieval and 10 of 12 cases with antigen retrieval. CONCLUSIONS: The microscopic distinction of GI KS from GIST can be difficult. Clues that raise the possibility of GI KS include young patient age, a history of immunosuppression, lamina propria infiltration, lymphoplasmacytic inflammation, extravasated red blood cells and haemosiderin deposition. Use of the immunomarkers CD117 (without antigen retrieval), HHV8 and DOG1 may aid in the distinction between GI KS and GIST.

Hodgkin's disease with an intrasinusoidal pattern of infiltration. A report of two cases.

The histological distinction between Hodgkin's disease (HD) and anaplastic large cell lymphoma (ALCL) may be difficult but is important as the two conditions have different clinical behaviours, prognoses and responses to therapy. Morphological appearances that have been emphasised as favouring the diagnosis of ALCL rather than HD include the identification of neoplastic cells permeating sinusoidal spaces. We document two cases of Hodgkin's disease with classical morphological and immunohistochemical features of nodular-sclerosis subtype (HDNS) but with striking sinusoidal involvement by neoplastic cells. In each case, the CD30 positive/CD15 positive immunophenotype of the neoplastic cells was characteristic of HD without expression of any of the other antigens normally associated with ALCL. HD is generally considered to be a morphological diagnosis and, in those laboratories in which it is not possible to use wide panels of antibodies for the confirmation of the diagnosis, the identification of sinusoidal infiltration by the neoplastic cells in HD may lead to the mistaken impression of ALCL.

Quantitative expression of CD23 and its ligand CD21 in chronic lymphocytic leukemia.

BACKGROUND AND OBJECTIVES: Cells from the great majority of patients with chronic lymphocytic leukemia (CLL) express CD23. A recent histologic study has shown that CD23 is expressed more strongly in the proliferating centers of the lymph nodes, where the large prolymphocytoid cells are located. The aim of our study was to quantify the expression of CD23 and CD21 in small and prolymphocytoid cells from patients with CLL and B-cell lymphomas, and correlate this expression with clinical parameters. DESIGN AND METHODS: Using quantitative flow cyto-metry we analyzed the antigen density of CD23 and CD21 in: 1) 101 cases of chronic lymphocytic leukemia, 84 typical, 14 with increased prolymphocytes (CLL/PL) and 3 atypical, 2) 15 cases of CD23 positive B-cell lymphoma with circulating lymphoma cells and 3) 8 normal subjects. The results were correlated with morphology and clinical staging. RESULTS: Cells from CLL and CLL/PL have a significantly higher number of CD23 molecules than normal and lymphoma B-cells (p<0.001 and p<0.001, respectively). Differences were not significant for CD21. CLL and CLL/PL cases had similar values of CD23 and CD21 molecules, but analysis at a single level showed that prolymphocytes in typical CLL and CLL/PL expressed significantly higher CD23 (p=0.001, p=0.006) and CD21 (p=0.001, p=0.001) than small lymphocytes. There was no correlation between CD23 or CD21 antigen density and clinical stages although there was a trend for a brighter CD23 in stage C patients. INTERPRETATION AND CONCLUSIONS: Since interaction between CD23 and CD21 is important for B-cell activation, proliferation and tumor formation, findings that both molecules are upregulated in prolymphocytes suggest that this is the proliferating cell component in CLL and underline the association between progression and increased prolymphocytes in typical CLL and CLL/PL.

Leomiosarcomas cutáneos: estudio clinicopatológico e inmunohistoquímico de cinco casos / Cutaneous leiomyosarcomas: clinicopathological and immunohistochemical study of five cases

Objetivos: Los leiomiosarcomas superficiales (de la piel y tejido subcutáneo) son neoplasias poco frecuentes, de ditinto comportamiento biológico según se localicen en la dermis o hipodermmis. Recientemente se ha propuesto su subclasificación en dos patrones histológicos: nodular y difuso. Material y Métodos: Presentamos cinco casos de leiomiosarcomas cutáneos primarios diagnosticados en nuestro Departamento entre 1991 y 1998 y revisamos la literatura, centrándonos en los hallazgos inmunohistoquímicos y en el diagnóstico diferencial. Resultados Cuatro pacientes eran varones y uno, mujer; sus edades oscilaban entre los 34 y 85 años (media 56,6). En cuatro casos las lesiones eran solitarias, y un paciente presentó lesiones múltiples; se localizaron en las extremidades (tres en las superiores y uno en las inferiores) y en el tronco. Desde el punto de vista histológico dos tumoraciones se localizaban exclusivamente en la dermis y tres afectaban además al tejido celular subcutáneo. Se identificó un patrón de crecimiento nodular en tres casos, difuso en uno y mixto en otro. La inmunohistoquímica mostró en todos los casos positividad para al menos uno de los tres marcadores de diferenciación muscular utilizados (desmina, SMA y HHF35), siendo la actina de músculo liso (SMA) positiva en el 100 por ciento de los casos. Las queratinas y la proteína S100 fueron negativas en todos los casos, encontrándose células dendítricas S100 positivas atrapadas por el crecimiento tumoral en dos casos. En cuanto a la evolución, actualmente tres pacientes se encuentran libres de enfermedad, sin datos e recidiva o metástasis. Dos fallecieron, pero sólo uno de ellos a consecuencia de la evolución de un leiomiosarcoma cuatro años después del diagnóstico inicial. Conclusiones: Consideramos que es necesario utilizar un panel de anticuerpos amplioi en el diagnóstico de estos tumores (SMA, HHF35, desmina, proteína S100 y citoqueratinas) dada la distinta expresión de estos anticuerpos en los leiomiosarcomas. Además, en todos los casos está indicado reaizar un estrecho seguimiento clínico (AU)

A case of soft tissue mesenchymal chondrosarcoma metastatic to skin, clinically mimicking keratoacanthoma.

We report the first case of metastatic involvement of the skin by a soft tissue mesenchymal chondrosarcoma (MS). A 64-year-old man presented 15 months after resection of a 7.0 cm MS from his left forearm with a rapidly growing, erythematous nodule on the left side of the upper lip. The lesion was clinically interpreted as a keratoacanthoma. The histologic appearance was identical to that of the soft tissue MS; an immunohistochemical stain for CD99 was positive. Lung and bone metastases were subsequently documented. Our case expands the differential diagnosis of malignancies with cartilaginous differentiation that can involve the skin.