Store-and-forward diagnostic telepathology of small biopsies by e-mail attachment: a feasibility pilot study with a view for future application in Thailand diagnostic pathology services.

Diagnostic telepathology by electronic mail (e-mail) attachment is relatively simple and incurs minimal cost. We assessed its accuracy and practical aspects in routine diagnostic pathology. Using 100 small biopsy specimens, a total of 1,488 images were digitized by one pathologist and sent as e-mail attachments from Nara Medical University, Japan, to a pathologist at Rajavithi Hospital, Thailand. His diagnoses were compared with his conventional light microscopy interpretation at a later date. The average total turnaround time spent on each case was 215 minutes, far less than the several days required by conventional post. There were two clinically significant errors. One was a diagnostically difficult case of colonic dysplasia, which was called carcinoma with telepathology. The other was a signet ring cell carcinoma of the stomach which was undetected with telepathology. Microscopy objective magnification and digital image quality may have played a role in impairing interpretation in both cases. Store-and-forward telepathology provides acceptable efficacy, a comparatively faster turnaround time than post and could be applied in routine work within Thai pathology services.

Cutaneous mastocytosis associated with a mixed germ cell tumour of the ovary: report of a case and review of the literature.

A 10-year-old girl with a mixed germ cell tumour of the ovary, treated by surgery and chemotherapy, developed cutaneous mastocytosis approximately 8 months after starting chemotherapy. This is the sixth report of a germ cell tumour associated with mastocytosis. c-kit receptor point mutations, including Asp816Val and Val560Gly were absent in a biopsy specimen obtained from lesional skin.

Recombinant human bone morphogenetic protein-2 potentiates the in vivo osteogenic ability of marrow/hydroxyapatite composites.

A composite of marrow mesenchymal stem cells (MSCs) and porous hydroxyapatite (HA) has bone-forming capability. To promote the capability, we added recombinant human bone morphogenetic protein-2 (BMP) to the composite. The bone formation was assessed by rat subcutaneous implantation of 4 different kinds of implants, i.e., HA alone, BMP/HA composites, MSCs/HA composites, and the composites containing BMP (MSCs/BMP/HA). Both HA and the BMP/HA composites did not show bone formation at any time after implantation. The MSCs/HA composites showed moderate bone formation at 4 weeks and extensive bone formation at 8 weeks. The MSCs/BMP/HA composites showed obvious bone formation together with active osteoblasts at 2 weeks and more bone formation at 4 and 8 weeks. The MSCs/BMP/HA composites demonstrated high alkaline phosphatase and osteocalcin expression at both the protein and gene levels. These results indicate that the combination of MSCs, porous HA, and BMP synergistically enhances osteogenic potential and provides a rational basis for their clinical application in bone reconstruction surgery.

Enhancement of the in vivo osteogenic potential of marrow/hydroxyapatite composites by bovine bone morphogenetic protein.

A composite of marrow mesenchymal stem cells and porous hydroxyapatite (HA) has in vivo osteogenic potential. To investigate factors enhancing the osteogenic potential of marrow/HA composites, we prepared a bone morphogenetic protein (BMP) fraction from the 4M guanidine extract of bovine bone by heparin-sepharose affinity chromatography. Marrow/HA composites or composites containing marrow mesenchymal stem cells, BMP, and HA (marrow/BMP/HA composites) were implanted subcutaneously in 7-week-old male Fischer rats. BMP/HA composites and HA alone were also implanted. The implants were harvested after 2, 4, or 8 weeks and were prepared for histological and biochemical studies. Histological examination showed obvious de novo bone formation together with active osteoblasts at 2 weeks, as well as more extensive bone formation at 4 and 8 weeks in many pores of the marrow/BMP/HA composites. The marrow/HA composites did not induce bone formation at 2 weeks, but there was moderate bone formation at 4 weeks. At 2 weeks, only marrow/BMP/HA composites resulted in intensive osteogenic activity, judging from alkaline phosphatase and osteocalcin expression at both the protein and gene levels. These results indicate that the combination of marrow mesenchymal stem cells, porous HA, and BMP synergistically enhances osteogenic potential, and may provide a rational basis for their clinical application, although further in vivo experiment is needed.

In vivo osteogenic capability of cultured allogeneic bone in porous hydroxyapatite: immunosuppressive and osteogenic potential of FK506 in vivo.

Fischer or ACI rat marrow cells were obtained from femoral shafts and were cultured to confluence in Eagle's minimal essential medium (EMEM) supplemented with 15% fetal bovine serum. After trypsinization, the cells were subcultured on porous hydroxyapatite (HA; Interpore 500) blocks in the presence of beta-glycerophosphate and 10 nM dexamethasone (Dex). After 2 weeks of subculture, a mineralized bone matrix with osteogenic cells developed on the HA pore surfaces. ACI or Fischer cultured bone tissue/HA constructs were implanted subcutaneously into the backs of Fischer rats and the immunosuppressant FK506 was given to the rats for 4 weeks. Implants were harvested 4 weeks and 8 weeks after insertion. At 4 weeks, the ACI constructs (allografts) showed high levels of osteogenic parameters (alkaline phosphatase [ALP] activity and osteocalcin content) and bone formation was observed together with active osteoblasts without obvious accumulation of inflammatory cells. At 8 weeks, active osteoblasts and progressive bone formation were still observed, while osteogenic parameters remained high and osteocalcin messenger RNA (mRNA) was detected. Without FK506 administration, the allografts showed neither bone formation nor osteocalcin mRNA and there were only trace levels of the osteogenic parameters. In the case of Fischer constructs (isografts), extensive bone formation was detected and all the osteogenic parameters were higher with FK506 than without FK506 at both 4 weeks and 8 weeks. These results indicate that cultured bone tissue/HA constructs possess a high osteogenic potential, even as allografts, and that FK506 not only has an immunosuppressive action, but also promotes bone formation.

In vivo osteogenic durability of cultured bone in porous ceramics: a novel method for autogenous bone graft substitution.

BACKGROUND: Bone marrow cells differentiate into bone-forming osteoblasts when cultured in medium supplemented with 15% fetal bovine serum, ascorbic acid, beta-glycerophosphate, and dexamethasone. METHODS: To investigate in vivo osteoblastic activity and bone matrix formation by cultured bone marrow cells, Fischer rat marrow cells were cultured for 2 weeks in porous hydroxyapatite (HA) and then subcutaneously implanted into 7-week-old male syngeneic rats. The implants were harvested after 8 and 52 weeks for biochemical and histological analyses. RESULTS: At both times, formation of lamellar bone accompanied by regeneration of marrow were seen in many of the HA pores. When a fluorochrome (calcein) was administered at 50 weeks after implantation, it was detected in the pores of implants harvested at 52 weeks. Osteoclastic resorption followed by new bone formation was seen in some pores at 52 weeks, indicating that bone remodeling was continuing. The alkaline phosphatase activity of implants harvested at 52 weeks was comparable to that at 8 weeks, whereas the osteocalcin content of the implants harvested at 52 weeks was about twice that at 8 weeks. CONCLUSION: These results demonstrated that there was persistent in vivo osteogenic and hematopoietic activity in the prefabricated bone/HA constructs, and indicated that normal bone tissue was regenerated after grafting of the constructs, which were brittle before implantation. Tissue engineering using HA and cultured marrow cells culture may provide an alternative method of bone transplantation for patients with skeletal disorders, although further in vivo and in vitro experiments are needed.

Overexpression of the ERK/MAP kinases in oral squamous cell carcinoma.

Mitogen-activated protein kinase (MAPK) is a serine-threonine kinase that is activated by various extracellular stimuli. Extracellular signal-regulated kinases (ERK1 and ERK2), an MAPK subfamily, are activated by many oncogenes, such as ras and raf, and they induce cell proliferation. myc is also an oncogene and one of the targets of ERKs. Mutations of ras and overexpression of myc were found in various human cancers, and ERKs were also reported to play a role in carcinogenesis. In this study, we examined 39 biopsy specimens of oral squamous cell carcinoma (OSCC) and 5 of normal gingival mucosa for the expression of ERK protein and the proliferation marker, MIB-1 (Ki-67 antibody). Thirteen OSCC specimens and five normal gingival biopsies were also examined for the expression of ERKs mRNA by in situ hybridization. Double staining for ERKs and MIB-1 was also performed. Histologically, 18 patients (46%) were diagnosed with well-differentiated SCC, 17 (44%) with moderately differentiated SCC, and 4 (10%) with poorly differentiated SCC. The histologic grade correlated with the MIB-1 index. The localization of ERK1 was similar to that of ERK2. Positive signals for ERK proteins were localized in superficial keratinocytes in normal gingival mucosa, whereas these mRNAs were weakly positive in the basal and spinous layer. Basal and suprabasal cells were positive for MIB-1. In well-differentiated and moderately differentiated OSCC, positive signals for ERK mRNA and proteins were found at higher levels than in normal gingival mucosa in keratotic cells around cancer pearls. Some cells showed positive signals for ERKs and MIB-1. Furthermore, most cancer cells in poorly differentiated SCC were positive for both ERK and MIB-1. The histologic grade was statistically related to the percentage of cells positive for both ERK and MIB-1. This suggested that ERKs might be related to proliferation in OSCC.

Analysis of gene expression in osteogenic cultured marrow/hydroxyapatite construct implanted at ectopic sites: a comparison with the osteogenic ability of cancellous bone.

We investigated the in vivo osteogenic ability of cultured marrow cells subcultured in porous hydroxyapatite. This osteogenic ability was compared with that of cancellous bone grafts. Fresh marrow cells were obtained from young adult rat femora and cultured in a standard medium for 10 days, then trypsinized and used to make constructs of porous hydroxyapatite (HA) and cultured marrow cells. An additional 2-week culture (subculture) was performed for the construct in standard medium with and without the addition of dexamethasone (Dex). The 2-week subcultured constructs then were implanted into subcutaneous sites of syngeneic rats. These implants and the rat cancellous bone were harvested and prepared for gene expression analysis of alkaline phosphatase (ALP) and osteocalcin (OC) as well as for histological analysis. ALP and OC mRNAs could be detected in Dex-treated subcultured constructs 1 week after implantation with an increase at 2 weeks, comparable to the observation in cancellous bone. Histological analysis showed active bone formation even 1 week postimplantation. In contrast, the subcultured constructs without the addition of Dex did not show bone formation, and only small levels of ALP and OC mRNAs were found. These results indicate that the bone tissue formed by grafting the Dex-treated construct of cultured marrow cells and hydroxyapatite possesses a high osteoblastic activity comparable to that of viable cancellous bone. Thus the prefabricated osteogenic subcultured marrow/HA construct may be applicable in bone reconstructive surgery.

Application of the polymerase chain reaction for the diagnosis of malignant lymphoma of the nasal and oral cavities.

Difficulties are often encountered in the diagnosis of malignant lymphoma of the oral and nasal cavities by histology and immunohistochemistry because these malignancies may be complicated by inflammation and necrosis. In the present study, immunoglobulin heavy chain (IgH) and T-cell receptor (TCR) gene rearrangements were examined by the polymerase chain reaction (PCR) in formalin-fixed and paraffin-embedded specimens obtained from 18 patients; the advantages of this method were evaluated. Twelve of these patients were diagnosed as having malignant lymphoma and six had tumors highly suggestive of malignant lymphoma. Fourteen (78%) of the 18 cases were diagnosed as malignant lymphoma histologically and immunohistochemically. Sixteen (89%) of the 18 cases were shown to be monoclonal by PCR. The four cases that could not be histologically or immunohistochemically diagnosed as malignant lymphoma showed monoclonal gene rearrangement by PCR. As a result, six patients suspected of having a malignant lymphoma were diagnosed as having one. The diagnosis of malignant lymphoma by PCR alone still has various problems. However, when the results of PCR are evaluated together with histopathological and immunohistochemical results, PCR makes a useful contribution to the diagnosis of malignant lymphomas of the nasal and oral cavities.

Human marrow cells-derived cultured bone in porous ceramics.

From four patients (mean age, 60 years; range 51-76 years), 3 ml of bone marrow was collected from the ilium. The marrow was cultured to concentrate and expand the marrow mesenchymal cells on a culture dish. The cultured cells were then subcultured either on another culture dish or in porous areas of hydroxyapatite ceramics in the presence of dexamethasone and beta-glycerophosphate (osteogenic medium). The subcultured tissues on the dishes were analyzed by scanning electron microscopy (SEM), and subcultured tissues in the ceramics were implanted intraperitoneally into athymic nude mice. Vigorous growth of spindle-shaped cells and a marked formation of bone matrix beneath the cell layers was observed on the subculture dishes by SEM. The intraperitoneally implanted ceramics with cultured tissues revealed thick layer of lamellar bone together with active osteoblasts lining in many pore areas of the ceramics after 2 months. The in vitro bone formation on the culture dishes and in vivo bone formation in porous ceramics were detected in all cases. These results indicate that we can assemble an in vitro bone/ceramic construct, and due to the porous framework of the ceramic, the construct has osteogenic potential similar to that of autologous cancellous bone. A significant benefit of this method is that the construct can be made with only a small amount of aspirated marrow cells from aged patients with little host morbidity.

Increased expression of extracellular signal regulated kinase 1 after axotomy in the dorsal motor nucleus of the vagus nerve and the hypoglossal nucleus.

The extracellular signal regulated kinases (Erks) cascade is a major signalling system by which cells transduce extracellular signals into intracellular responses. To obtain information about the role of Erks in retrograde neuronal reaction, we investigated the changes of Erk 1 and Erk 2 with in situ hybridization and immunohistochemical study in the dorsal motor nucleus of vagus nerve, which shows degenerative changes, and the hypoglossal nucleus, which shows regenerative changes, of adult rats after axotomy. The expression of mRNA and protein of Erk 1 increased between 7 and 28 days after axotomy both in the vagal and hypoglossal nuclei, however, there was no remarkable change in those of Erk 2. The increased expression of Erk 1 is common to both regenerative hypoglossal and degenerative vagal neurons. These findings indicate that Erk 1 is closely related with the retrograde neuronal reaction but whether neurons are destined to survive or die depends on some other factors.

[Autopsy findings of retroperitoneal cystic tumor and peliosis hepatis in lymphangiomyomatosis].

A 40-year-old woman who worked as a nurse and had suffered from progressive exertional dyspnea for about 14 years underwent open lung biopsy with surgical treatment for pneumothorax. The diagnosis was lymphangiomyomatosis and she was treated with danazol to suppress ovarian function. Her condition improved temporarily, but she died of respiratory failure when she was 47 years old. The survival time after the onset of respiratory symptoms was 21 years, and after the biopsy it was 8 years. At autopsy a retroperitoneal cystic tumor was found (9 x 7 x 5 cm), which had been evident clinically. Histologic examination showed that the tumor was an extrapulmonary manifestation of the lumphangiomyomatosis lesion. Some paraaortic lymph nodes has similar lesions. Aggregates of small red spots were seen on acute surface of the liver. These were diagnosed as peliosis hepatis, they may have been caused by the danazol.

Self-setting hydroxyapatite cement as a carrier for bone-forming cells.

To investigate the feasibility of using self-setting hydroxyapatite cement as a carrier for marrow cells having a high osteogenic ability, a porous form of this cement was fabricated and combined with cultured marrow cells. Marrow cells were obtained from the femurs of a seven-week-old male Fischer 344 rat and cultured in Eagle's MEM containing 15% fetal bovine serum for ten days before being combined with the porous cement or with Interpore 200 hydroxyapatite as a control. The composites were subcutaneously implanted into syngeneic rats and harvested after six weeks. In both types of implants, active osteoblasts together with bone formation were detected in contact with the pore surfaces. No cartilage formation was observed in any of the pores. Both types of implants with and without marrow cells caused very little foreign body reaction. These results indicate that self-setting hydroxyapatite cement containing marrow cells possesses a high osteogenic ability and may be useful as a bone graft substitute as well as a novel delivery system for bone-forming cells.

Epstein-Barr virus in the proliferative diseases of squamous epithelium in the oral cavity.

The presence of Epstein-Barr virus was analyzed in 79 cases of oral epithelial proliferative diseases by polymerase chain reaction, in situ hybridization for Epstein-Barr virus-deoxyribonucleic acid and Epstein-Barr virus-encoded small messenger ribonucleic acid and immunohistochemistry for Epstein-Barr virus latent membrane protein. These lesions were histologically categorized as invasive squamous cell carcinoma (n = 36), carcinoma in situ (n = 10), verrucous carcinoma (n = 4), leukoplakia (n = 19), and papilloma (n = 10). Epstein-Barr virus genomes were detected in 19 squamous cell carcinoma (52.8%), four carcinoma in situ (40%), and one leukoplakia (5.3%); none of the verrucous carcinoma or papilloma cases were positive with polymerase chain reaction. By deoxyribonucleic acid in situ hybridization, positive signals were observed in the nuclei of cancer cells in 10 cases, in infiltrating lymphocytes in three, and both in one case. In patients with carcinoma in situ, only a single case was positive. In one case of leukoplakia positive signals were found in upper and middle layer squamous cells. The results by Epstein-Barr virus-encoded small messenger ribonucleic acid in situ hybridization revealed the same distribution as that by deoxyribonucleic acid in situ hybridization. Latent membrane protein was expressed only in the epithelial cells of leukoplakia but not in cases with squamous cell carcinoma and carcinoma in situ. These findings suggest that Epstein-Barr virus infection of oral squamous epithelium may be carcinogenic; alternatively, the virus may merely exist in epithelial cells of squamous cell carcinoma, carcinoma in situ, and leukoplakia as a passenger.

[A case of so-called carcinosarcoma of the lung].

A 65-year-old male was admitted to our institute because of bloody sputum. A tumor in right S6 was detected by X-ray, CT and MRI. Bronchoscopic study showed that the right lower bronchus was occluded by the tumor, in which non-epithelial malignant cells were detected. Therefore right bilobectomy was performed. This tumor was a pedunculated endobronchial type measuring 6 x 4 x 3cm. Histologically, the tumor presented carcinomatous (squamous cell carcinoma and adenocarcinoma) and sarcomatous elements. Immunohistologically, many malignant cells were positively stained by vimentin and muscle-actin, which suggested differentiation from muscle components.

Paraganglioma of the posterior mediastinum: value of magnetic resonance imaging.

A case of paraganglioma arising in the posterior mediastinum in a 29-year-old man diagnosed by magnetic resonance imaging is reported. Excision of mediastinal paraganglioma is often hazardous because of its rich vascular supply and tendency to involve surrounding structures. Magnetic resonance imaging is valuable for the preoperative diagnosis of this vascular tumor as well as for determination of its resectability and appropriate surgical procedure.

[Clinicopathological study of methicillin-resistant Staphylococcus aureus detected by pulmonary microbial culture in autopsied cases].

Microbial culture of lung specimens from 569 autopsied cases from 1986 to 1989 revealed methicillin-resistant Staphylococcus aureus (MRSA) in 28 cases, which were subsequently analyzed clinicopathologically. The number of MRSA positive cases has markedly increased in recent years (2 cases in 1986, 2 in 1987, 6 in 1988, 18 in 1989). The most frequent underlying disease was neoplasm, which was seen in 17 cases. Of non-neoplastic diseases, liver cirrhosis and diffuse panbronchiolitis were prevalent. Twenty-four cases had received a course of antibiotic therapy. Antibiotics frequently administered were third-generation Cephem and Imipenem/cilastatin sodium (used in 20 cases). Antibiotics o which MRSA was sensitive were administered in only one case (minocycline). Sputum culture was performed in only 10 cases, 5 of which were MRSA positive. MRSA had acquired resistance to fosfomycin and ofloxacin. Histological examination revealed complication by pneumonia in 19 cases. In 7 of these 19 cases, MRSA was the only pathogen detected. Pulmonary MRSA infection detected at autopsy is frequently seen in patients with terminal stage cancer, but it is frequently not diagnosed and is undertreated. This may be a factor responsible for the recent marked increase in the proportion of MRSA in pathogens causing infection within medical institutions.

[Etiological examination of idiopathic interstitial pneumonia and lung cancer in autopsy cases].

In order to investigate the etiology of usual interstitial pneumonia (UIP) and UIP with lung cancer (LC), autopsy findings in 18 cases of UIP with LC and 11 cases of uncomplicated UIP were clinicopathologically compared with the environmental factors of smoking habits and occupation. UIP with LC was highly correlated with smoking, especially heavy smoking and with occupations in which dust is inhaled, such as electrical installation and ceramic production, indicating that these environmental factors are important background factors in the complication of UIP with IC. Pathologic examination of cases of UIP with LC (6 squamous cell carcinomas, 5 small cell carcinomas, 4 adenocarcinomas, and 3 large cell carcinomas, 2 of which showed pulmonary double carcinoma revealing a slight correlation between fibrosis and primary site of LC and a slightly greater correlation of squamous cell carcinoma and small cell carcinoma to smoking habits and inhalation of dust. In terms of the correlation between UIP and LC among autopsy cases, the environmental factors proved to be more significant than the fibrotic findings. These environmental factors are thought to merit consideration as common predisposing factors in the development of LC and its complication with UIP.

[Clinicopathological features of metastatic pulmonary calcinosis with malignant neoplasm].

Metastatic pulmonary calcinosis is a rare complication seen in malignancies accompanied by hypercalcemia, or chronic renal failure. We reviewed the clinicopathological findings of 8 cases of metastatic pulmonary calcinosis accompanied malignancy revealed at autopsy. The underlying diseases were malignant lymphoma in 3 cases (adult T cell lymphoma in 2 cases), multiple myeloma in 2, lung cancer in 2, and acute myelocytic leukemia in 1, all cases were complicated by hypercalcemia and renal failure. Chest X-ray revealed almost normal findings in 2 cases, bilateral diffuse infiltrates in 4, bilateral infiltrates in the apex in 1, and right atelectasis in 1. Bone scintigraphy was performed in 4 cases, and revealed warm pulmonary uptake in 1 patient with multiple myeloma and 1 with lung cancer, but normal findings in the 2 other cases. Histopathological examination revealed diffuse alveolar septal edema and fibrosis due to calcium deposition, which were considered to be the cause of respiratory failure. Metastatic pulmonary calcinosis is a rare but a serious complication in malignancies accompanied by hypercalcemia and renal failure, and bone scintigraphy seems to be a useful method for its diagnosis.