BCL2 gene abnormalities define distinct clinical subsets of follicular lymphoma.

AIMS: Follicular lymphoma (FL) arising primarily in the skin has recently been proposed as a distinct entity on the basis of a low incidence of t(14;18)(q32;q21) and bcl-2 expression, with a very high percentage of patients surviving more than 5 years. However, cases of t(14;18)(q32;q21)-positive primary cutaneous FL (PCFL) and examples of t(14;18)(q32;q21)-negative FL at nodal and other extranodal sites, are well documented. The aim of this study was to test the hypothesis that there is a subtype of FL lacking t(14;18)(q32;q21), which preferentially involves certain sites but is not restricted by anatomical location. METHODS AND RESULTS: A cohort of 47 stage 1 FL was stratified according to the presence or absence of t(14;18)(q32;q21) using conventional cytogenetics, polymerase chain reaction and interphase fluorescence in situ hybridization. Compared with t(14;18)(q32;q21)-positive cases, FL lacking the translocation were less likely to express CD10 or bcl-2 (P<0.01), made up a significantly greater proportion of cases arising at extranodal sites (P<0.001) and had a significantly better overall and disease-specific 5-year survival (P<0.01). CONCLUSIONS: These results support the concept of a subtype of FL lacking t(14;18)(q32;q21), characterized by low-intensity bcl-2 expression, a predilection for extranodal sites, particularly the skin, and a more favourable outcome than t(14;18)(q32;q21)-positive FL.

Nuclear and cytoplasmic bcl-2 expression in endometrial hyperplasia and adenocarcinoma.

The bcl-2 proto-oncogene, which inhibits programmed cell death (apoptosis), has recently been found to be cyclically expressed in human endometrium. In order to investigate its role in endometrial hyperplasia and neoplasia, bcl-2 expression was studied in 25 cases of endometrial carcinoma and 20 cases of endometrial hyperplasia (eight simple, two complex, and ten atypical hyperplasias). Uniform intense cytoplasmic bcl-2 expression was found in all cases of non-atypical hyperplasia, and less strong positivity in eight out of ten cases of atypical hyperplasia. In well-differentiated carcinomas, nine out of ten showed weak to moderate bcl-2 expression, whereas six out of seven poorly differentiated carcinomas were bcl-2-negative. Moderately differentiated tumours were an intermediate group, with six out of eight being positive. Widespread localization of bcl-2 protein to the chromosomes of dividing cells was also demonstrated, regardless of cytoplasmic bcl-2 expression, with rare staining of interphase nuclei. Our findings suggest a role for bcl-2 in the natural history of endometrial neoplasia and studies are needed to determine its usefulness as a prognostic marker. The finding of bcl-2 localization to chromosomes has important implications for its mode and site of action.

Intraosseous secondary calcium salt crystal deposition: an artefact of acid decalcification.

We previously observed, in decalcificated bone specimens, intraosseous crystal deposits with morphological and analytical similarity to calcium pyrophosphate dihydrate. We have now been able, by a combination of more detailed morphological studies of these and similar cases, and by infrared spectroscopy in three cases, to show that this is, in fact deposition of the secondary calcium salts brushite and monetite, occurring as an artefact during formic acid decalcification. Our earlier postulate of bone as an additional primary crystallization site for calcium pyrophosphate dihydrate is effectively disproved. This artefact deserves wider recognition.

Optimization of immunohistochemical staining of proliferating cells in paraffin sections of breast carcinoma using antibodies to proliferating cell nuclear antigen and the Ki-67 antigen.

Antibodies to proliferating cell nuclear antigen (PCNA) and the MIB-1 antibody to the Ki-67 antigen were titrated to optimize identification of proliferating cells in formalin-fixed paraffin-embedded tissue from a series of 40 human breast carcinomas. Cell culture studies have previously demonstrated that immunostaining for both PCNA and the Ki-67 antigen produces strong granular nuclear staining during S phase. PC10, other anti-PCNA antibodies (PC2, PC5, PC8 and 19F4) and MIB-1 were used at the minimum dilution which allowed a clear distinction between cells with strong and weak staining. With the anti-PCNA antibodies, nickel-cobalt enhancement of the reaction product was found to augment the granular nature of nuclear staining, corresponding more closely to patterns observed in cell culture studies. No enhancement was found to be necessary for MIB-1. The labelling indices of all these antibodies were compared with S phase fraction (SPF) obtained by DNA flow cytometry in the same cases. The PC10 labelling indices which included only strongly stained cells correlated well with SPF, but counting all strongly and weakly stained cells showed a poor correlation. With MIB-1, counting strongly stained as well as all stained cells produced labelling indices which correlated well with SPF, the former tending to be lower and the latter higher. None of the other anti-PCNA antibodies showed any advantage in application over PC10. Thus, PC10 and MIB-1, applied with care, can be correlated with S phase fraction in paraffin processed tissue sections of breast carcinomas.

Pathological prognostic factors in the second British Stomach Cancer Group trial of adjuvant therapy in resectable gastric cancer.

The second British Stomach Cancer Group trial was a prospective randomised controlled trial of adjuvant radiotherapy or cytotoxic chemotherapy after gastrectomy for adenocarcinoma. It recruited between 1981 and 1986. No survival advantage has been demonstrated for the patients receiving either type of adjuvant therapy compared with those undergoing surgery alone. We report on 436 patients randomised into the trial together with 203 patients, who did not fulfil the trial criteria, referred to the trial. A univariate (log-rank) analysis of pathological factors obtained from the local referring centres showed that tumour size, macroscopic type, number os sites involved, depth of invasion, involvement of resection lines and lymph nodes and histological grade were significant determinants of survival. Histological review by two experienced histopathologists found that the Lauren classification and histological grade, but not the Ming classification, were significant prognostic factors. The degree of lymphocytic and eosinophilic infiltration and presence of dysplasia assessed by one of the pathologists showed a significant correlation with survival. However, inter-observer correlation for these histological parameters and grade was poor. Multivariate analysis identified only depth of invasion, resection line and nodal involvement as significant independent pathological variables influencing survival. This study confirms the need for expert preparation of the resected specimen to obtain the important information on depth of invasion and nodal status and also reveals some variation in histological assessment, particularly grading, in gastric carcinoma.

p53 immunoreactivity is uncommon in primary cutaneous lymphoma.

p53 gene mutation appears to play an important role in the development of systemic lymphoma, and may be associated with tumour progression. Its role in cutaneous lymphoma is currently unknown. We examined p53 expression in 55 biopsies of cutaneous lymphoma, including patch-, plaque- and tumour-stage mycosis fungoides (MF), T- and B-cell lymphoma and lymphomatoid papulosis. Strong, homogeneous p53 expression, thought to correlate most closely with p53 gene mutation, was seen in only three cases; in a plaque and tumour from a patient with tumour-stage MF, in plaque-stage MF in a patient without tumours, and in one case of CD30+ large-cell anaplastic lymphoma. These data suggest that p53 gene mutation is not a critical step in the development of the majority of primary cutaneous lymphomas.

Fat necrosis presenting as obscure abdominal mass: birefringent saponified fatty acid crystalloids as a clue to diagnosis.

AIMS: To describe the birefringent saponified fatty acid crystalloids seen in pancreatic fat necrosis. METHODS: A histological review, including polarising microscopy, of three cases of subacute or subclinical acute pancreatitis was performed. Histochemical analysis using Nile blue sulphate for lipid, Holczinger's copper rubeanate for fatty acids, and Alizarin Red S for calcium was performed in one case. Scanning electron microscopy and x-ray energy dispersive spectroscopic micro-analysis were performed in two cases. Necropsy pancreatic tissue, surgical archival tissue from cases of pancreatitis, and pancreatic and adipose tissue permitted to autolyse together in the laboratory, were also examined. The autolysed tissue was also examined histochemically. Stained and unstained sections were mounted in DPX and Canada balsam. Surgical material showing traumatic fat necrosis was reviewed. RESULTS: In each of the three cases there were subtle clues to subclinical pancreatitis. In neither surgical case was the true nature of the mass apparent to the operator. Histological analysis in all cases showed ghost adipocytes containing numerous polarising crystalloids, as well as some basophilic debris. Microanalysis showed calcium but no other substantial heavy element signals. Histochemical analysis showed a labile, polar, acidic lipid and the crystalloids behaved as calcium salts of free fatty acid. The crystalloids were not seen in archival material mounted in Canada balsam. No crystalloids were seen in traumatic fat necrosis. CONCLUSIONS: Little recognised, strongly birefringent, saponified free fatty acid crystalloids occurring in pancreatic fat necrosis may survive routine processing, and can point to the origin of obscure mesenteric masses related to subclinical pancreatitis.

The prognostic value of individual histologic grading parameters in small lingual squamous cell carcinomas. The importance of the pattern of invasion.

BACKGROUND: The histologic grading of the deep invasive margin of oral squamous cell carcinoma recently has been shown to have prognostic value, but previous series have not been homogeneous enough to allow grading parameters to be assessed individually. METHODS: Forty-seven small lingual carcinomas limited to the lateral border of the tongue and treated by radiotherapy were graded histologically at their deep invasive front. Clinical and grading parameters were correlated by statistical tests performed by permutational techniques. RESULTS: Carcinoma recurred locally in 6 patients, and metastases developed in 19. Local recurrence correlated with Broders' grade (P = 0.0143), keratinization (P = 0.017) and pattern of invasion (P = 0.0195). Metastasis had a highly significant correlation with Broders' grade (P < 0.001), pattern of invasion (P < 0.001), and invasive front grading total score (P < 0.001). Seven of 8 carcinomas with diffuse infiltrating patterns metastasised, whereas only 4 of 25 with large islands or a broad infiltrating pattern metastasized. CONCLUSIONS: The usefulness of the deep invasive front grading system for small lingual carcinoma was demonstrated. The pattern of invasion was the component of the grading system that had the closest correlation with metastasis and recurrence in this type of carcinoma.

Observer variation and discriminatory value of biopsy features in inflammatory bowel disease.

If skilled histopathologists disagree over the same biopsy specimen, at least one must have an incorrect interpretation. Thus, disagreement is associated with, although not the cause of, diagnostic error. The present study aimed to determine the magnitude of variation among 10 observers with a special interest in gastrointestinal histopathology. They independently interpreted the same biopsy specimens for morphological features which may discriminate between patients with Crohn's disease and ulcerative colitis and normal subjects. Thirty of 41 features had agreement measures significantly better than expected by chance (p < 0.05). The range of agreement in the 45 observer pairs over the final diagnosis was 65-76%. There was good agreement in discriminating between normal slides and those showing confirmed inflammatory bowel disease. For normal slides, however, the term nonspecific inflammation was often applied and without any consistency. In addition, true Crohn's disease slides were often and consistently thought to be ulcerative colitis. Having identified 11 important discriminatory morphological features, two multiple regression analyses were then carried out to produce a scoring system for inflammatory bowel disease. These results suggest there is considerable room for improvement in the reliability of colonic biopsy specimen interpretation and that this could probably be achieved using more exact definitions of morphological features and diseases.

Posttransplant skin cancer: a possible role for p53 gene mutation but not for oncogenic human papillomaviruses.

BACKGROUND: Loss of p53 tumor suppressor function is a critical step in the development of diverse malignancies, including skin cancers in nonimmunosuppressed patients where UV-specific p53 gene mutations have been identified. In tumors associated with human papillomavirus (HPV), such as cervical carcinoma, p53 may be inactivated instead by binding to a viral oncoprotein. OBJECTIVE: Our purpose was to examine the hypothesis that HPV may play an analogous role in the development of posttransplant skin cancer. METHODS: p53 Immunoreactivity, suggestive of p53 gene mutation, was examined by immunocytochemistry. Oncogenic HPV DNA was detected by polymerase chain reaction. RESULTS: Comparable p53 immunoreactivity was seen in skin tumors from both transplant and nontransplant patients. HPV DNA was not demonstrated in any tumor specimen. CONCLUSION: Our data do not implicate oncogenic HPV in posttransplant skin cancer. p53 Gene mutation, rather than HPV-induced p53 degradation, may be more significant in the development of these tumors.

Pulmonary sarcoidosis presenting as a granulomatous tattoo reaction.

A 29-year-old man presented with nodular skin lesions localized to areas of navy-blue pigmentation within a tattoo. Light microscopy demonstrated well-defined epithelioid granulomata in close relation to blue and black pigment. Although the patient was asymptomatic, a chest X-ray showed bilateral pulmonary shadowing, and histology of a transbronchial biopsy specimen showed features compatible with a diagnosis of sarcoidosis. X-ray energy dispersive spectroscopy identified copper and titanium in the tattoo pigment. These elements were not found in tissue from the lung biopsy. The cutaneous eruption resolved with oral steroid therapy. Our observations suggest that the granulomatous reaction in the tattoo was a manifestation of sarcoidosis, rather than a specific reaction to pigment.

Primary T cell lymphoma of the liver in a patient with Felty's syndrome.

We describe a case of primary T cell lymphoma of the liver developing in a patient with Felty's syndrome (FS). We discuss the possible relationship of the two conditions with particular reference to liver disease in FS, and the role of the T cell in RA.

Amyloid arthritis associated with IgM kappa lymphoplasmacytoid lymphoma.

Amyloid arthritis is an uncommon cause of locomotor disease and may closely resemble RA. Macroglobulinaemia is rarely associated with amyloidosis and there has been only one report of amyloid arthritis in this setting, the patient having had Waldenstrom's macroglobulinaemia. We report the occurrence of amyloid joint disease in the course of an IgM kappa B-cell dyscrasia which evolved over 16 years to an overt lymphoplasmacytoid lymphoma.