Germline mutation and aberrant transcripts of WWOX in a syndrome with multiple primary tumors.

Multiple primary tumors are defined by the presence of two or more independent primary tumors in the same or different organs of an individual patient. However, the underlying genetic cause for the development of multiple primary tumors is largely unknown. In the study, we report a rare case with four synchronous distinct histological cancer types in a 26 years old Chinese female. In the patient, whole-exome sequencing identified a homozygous germline insertion mutation in WWOX which encodes the DNA repair-related enzyme, WW domain containing oxidoreductase. The mutation was found in a heterozygous state in her parents and brother without any cancer phenotype thus far. Surprisingly, we found multiple novel aberrant WWOX transcripts in the patient's normal colon tissue. The patient's colon metastasis from clear cell adenocarcinoma of the ovary showed a nonhypermutated profile enriched for C-T transition, and harbored somatic pathogenic mutations of HRAS, BRCA2, SMAD4, CHEK2, and AKT1 genes. To our knowledge, this is the first study reporting WWOX gene aberrations in a young patient with the early occurrence of multiple primary tumors. © 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Erlotinib for coexisting typical bronchial carcinoid and advanced lung adenocarcinoma: does the epidermal growth factor receptor mutation status matter?

Adenocarcinoma (AC) is the most common type of primary pulmonary malignancy. Lung carcinoid, however, is a rare neuroendocrine tumor. Their coexistence is extremely uncommon. We report the unique case of synchronous advanced lung AC of the right upper lobe (stage IIIB) and typical endobronchial carcinoid tumor in the contralateral lower lobe in a 49-year-old white female who had never smoked. PET-computed tomography scan revealed a fluorine-18-fluorodeoxyglucose-avid AC lesion, whereas the carcinoid tumor was fluorine-18-fluorodeoxyglucose occult. After two lines of platinum-based combination chemotherapies and radiotherapy, the AC progressed, and oral tyrosine kinase inhibitor therapy with erlotinib was initiated in third line. On erlotinib, the AC remained stable for 50 months until disease progression, whereas the carcinoid completely regressed. Molecular testing of the rebronchoscopied AC revealed an exon 19 deletion mutation in the epidermal growth factor receptor (EGFR) gene, whereas the carcinoid was retrospectively EGFR mutation negative. The patient eventually succumbed to ileus caused by intra-abdominal spread of disease, surviving a remarkable 80 months with good performance status throughout most of the follow-up period. To the best of our knowledge, this is the first reported case of synchronous primary lung cancers with different EGFR mutation status, describing an unexpected response of an EGFR-wild-type carcinoid to third-line erlotinib.

Multiple primary lung cancer displaying different EGFR and PTEN molecular profiles.

We present a case of multiple primary lung cancer(MPLC) displaying heterogeneous EGFR and PTEN molecular profiles. Considering the physical condition of patients, the patient underwent surgical resection of the right lung lesion displaying gefitinib-insensitive and continued gefitinib treatment for the gefitinib-sensitive lesions in the left lung. As far as we know, this is the first report documenting a case of an integrated therapy strategy using surgical resection with gefitinib treatment for MPLC displaying different EGFR and PTEN molecular profiles. The patient has been in progression free survival up to now. Our experience could provide a treatment strategy for patients with similar disease.

Multiple ß-catenin mutations in hepatocellular lesions arising in Abernethy malformation.

An 18-year-old man underwent liver transplantation due to an Abernethy malformation associated with multiple hepatocellular nodules including one which was rapidly enlarging and was suspicious for malignant transformation. Analysis of the explanted liver showed a spectrum of multiple hepatocellular nodules ranging in appearance from focal nodular hyperplasia, hepatocellular adenoma and to a well-differentiated hepatocellular neoplasm borderline for hepatocellular carcinoma. Mutational analysis revealed wild-type ß-catenin expression in the background liver and some nodules, whilst different variants were present in other lesions irrespective of their morphological appearance. No telomerase reverse transcriptase (TERT) promoter mutation was identified. Abernethy malformations can lead to independent genetic events which can result in ß-catenin mutations associated with malignant transformation of hepatocellular nodules. When following up such patients, one must therefore have a high index of suspicion, particularly if radiological surveillance reveals a change in the nature of hepatic lesions.

GSTM1, GSTT1 and GSTP1 Genetic Variants in Multiple Urologic Cancers.

INTRODUCTION: Glutathione S-transferases (GSTs) are phase 2 enzymes responsible for catalyzing the biotransformation of a wide variety of electrophilic compounds, having a crucial role in the detoxification of active metabolites of procarcinogens produced by phase 1 reactions, tying them to glutathione and promoting their excretion in the urine. OBJECTIVES: we evaluated GSTM1, GSTT1 and GSTP1 genotypes in patients diagnosed with multiple malignancies, of which at least one was found in the prostate, bladder or kidney. MATERIALS AND METHODS: GSTM1, GSTT1 and GSTP1 genotypes were genetically assessed in 34 patients with multiple urologic cancers and 23 patients with urologic cancer associated with another type of cancer. RESULTS: in the group of patients with multiple urologic cancers, GSTT1 null genotype was found in 26.4% of patients compared to 0% in controls, 82.35 % of patients and 47% of witnesses carried at least one GSTM1 or GSTT1 null genotype, and in the group with different cancers, GSTM1 null genotype was found in 52.1% of patients compared to 4.3% witnesses in the control group; GSTT1 null genotype was found in 34.7% of patients compared to 4.3% of witnesses, atleast one GSTM1 or GSTT1 null genotype was found in 73.9% of patients compared to 8.6% of controls. CONCLUSIONS: GSTT1 null genotype is a risk factor for patients with more primitive urologic malignancies (bladder, prostate and kidney); GSTM1 or GSTT1 null genotype is more frequent in patients with multiple urologic tumors; GSTM1 and GSTT1 null genotypes are risk factors in patients with different types of cancer, with at least one affecting the urinary system.

15-hydroxyprostaglandin dehydrogenase in colorectal mucosa as a potential biomarker for predicting colorectal neoplasms.

15-Hydroxyprostaglandin dehydrogenase (15-PGDH) is downregulated during the early stages of colorectal carcinogenesis. The aim of the present study was to investigate the potential role of 15-PGDH in normal-appearing colorectal mucosa as a biomarker for predicting colorectal neoplasms. We obtained paired tumor and normal tissues from the surgical specimens of 32 sporadic colorectal cancer patients. mRNA expression of 15-PGDH was measured using a quantitative real-time PCR assay. We evaluated the association between 15-PGDH mRNA expression in normal-appearing mucosa, the presence of synchronous adenoma, and the cumulative incidence of metachronous adenoma. The relative 15-PGDH expression of normal-appearing mucosa in patients with synchronous adenoma was significantly lower than in patients without synchronous adenoma (0.71 vs 1.00, P = 0.044). The patients in the lowest tertile of 15-PGDH expression in normal-appearing mucosa were most likely to have synchronous adenoma (OR: 10.5, P = 0.024). Patients with low 15-PGDH expression in normal-appearing mucosa also demonstrated more advanced stage colorectal cancer (P = 0.045). However, there was no significant difference in the cumulative incidence of metachronous adenoma according to 15-PGDH mRNA expression in normal-appearing mucosa (P = 0.333). Hence, 15-PGDH in normal-appearing colorectal mucosa can be a useful biomarker of field effect for the prediction of sporadic synchronous neoplasms.

PTEN losses exhibit heterogeneity in multifocal prostatic adenocarcinoma and are associated with higher Gleason grade.

Prostatic adenocarcinoma is an epithelial malignancy characterized by marked histological heterogeneity. It most often has a multifocal distribution within the gland, and different Gleason grades may be present within different foci. Data from our group and others have shown that the genomic deletion of the phosphatase and tensin homolog deleted on chromosome 10 (PTEN) tumor suppressor gene and the disruption of the ETS gene family have a central role in prostate cancer and are likely to be associated with Gleason grade. In this study, prostate cancer samples were systematically analyzed to determine whether there was concordance between PTEN losses and TMPRSS2-ERG fusion rearrangements, within or between foci in multifocal disease, using well-annotated tissue microarrays (TMAs) consisting of 724 cores derived from 142 radical prostatectomy specimens. Three-color fluorescence in situ hybridization analysis of both the PTEN deletion and the TMPRSS2-ERG fusion was used to precisely map genetic heterogeneity, both within and between tumor foci represented on the TMA. PTEN deletion was observed in 56 of 134 (42%) patients (hemizygous=42 and homozygous=14). TMPRSS2-ERG fusion was observed in 63 of 139 (45%) patients. When analyzed by Gleason pattern for a given TMA core, PTEN deletions were significantly associated with Gleason grades 4 or 5 over grade 3 (P<0.001). Although TMPRSS2-ERG fusions showed a strong relationship with PTEN deletions (P=0.007), TMPRSS2-ERG fusions did not show correlation with Gleason grade. The pattern of genetic heterogeneity of PTEN deletion was more diverse than that observed for TMPRSS2-ERG fusions in multifocal disease. However, the marked interfocal discordance for both TMPRSS2-ERG fusions and PTEN deletions was consistent with the concept that multiple foci of prostate cancer arise independently within the same prostate, and that individual tumor foci can have distinct patterns of genetic rearrangements.

15-Hydroxyprostaglandin Dehydrogenase in Colorectal Mucosa as a Potential Biomarker for Predicting Colorectal Neoplasms

15-Hydroxyprostaglandin dehydrogenase (15-PGDH) is downregulated during the early stages of colorectal carcinogenesis. The aim of the present study was to investigate the potential role of 15-PGDH in normal-appearing colorectal mucosa as a biomarker for predicting colorectal neoplasms. We obtained paired tumor and normal tissues from the surgical specimens of 32 sporadic colorectal cancer patients. mRNA expression of 15-PGDH was measured using a quantitative real-time PCR assay. We evaluated the association between 15-PGDH mRNA expression in normal-appearing mucosa, the presence of synchronous adenoma, and the cumulative incidence of metachronous adenoma. The relative 15-PGDH expression of normal-appearing mucosa in patients with synchronous adenoma was significantly lower than in patients without synchronous adenoma (0.71 vs 1.00, P = 0.044). The patients in the lowest tertile of 15-PGDH expression in normal-appearing mucosa were most likely to have synchronous adenoma (OR: 10.5, P = 0.024). Patients with low 15-PGDH expression in normal-appearing mucosa also demonstrated more advanced stage colorectal cancer (P = 0.045). However, there was no significant difference in the cumulative incidence of metachronous adenoma according to 15-PGDH mRNA expression in normal-appearing mucosa (P = 0.333). Hence, 15-PGDH in normal-appearing colorectal mucosa can be a useful biomarker of field effect for the prediction of sporadic synchronous neoplasms.

Synchronous carotid body and thoracic paraganglioma associated with a germline SDHC mutation.

Paraganglionic tumors are rare. A germline mutation responsible for a familial pattern of paragangliomas (PGLs) has been identified on the genes encoding for the subunits of succinate dehydrogenase (SDH). Manifestations of those with a succinate dehydrogenase subunit C (SDHC) germline mutation have been almost exclusively reported as single head and neck paragangliomas (HNPGLs). We present a 32-year-old man with a familial SDHC mutation who manifests synchronous PGLs of the carotid body and the thoracic aortopulmonary window. To our knowledge, this is the first report of such a presentation for this mutation.

BRCA1, BRCA2 and CHEK2 c.1100 delC mutations in patients with double primaries of the breasts and/or ovaries.

BACKGROUND: Previous publications and utilisation of risk models for BRCA1 and BRCA2 mutation identification suggests that multiple primary disease in an individual is a strong predictor of a BRCA1/2 mutation and that this is more predictive than the same cancers occurring in close relatives. METHODS: This study assessed the pathological mutation detection rates for BRCA1, BRCA2 and the CHEK2c.1100 delC mutation in 2022 women with breast cancer, including 100 with breast/ovary double primary and 255 with bilateral breast cancer. RESULTS AND DISCUSSION: Although detection rates for mutations in BRCA1/2 are high at 49% for breast/ovarian double primary and 34% for bilateral breast cancer, the differential effect of multiple primaries in an individual appears to have been overestimated, particularly in those families with only a few malignancies. Nonetheless, bilateral breast cancer does differentially enhance detection rates in strong familial aggregations. CHEK2 1100 DelC mutation rates were lower in bilateral than for unilateral cases at 0.8% compared to 2%. The detected mutation rates for isolated double primary breast and ovarian cancer was 14% (3/22) compared to 17% (17/99) for the same two primaries in two close relatives in families with no other cases of breast/ovarian cancer. Risk models may need to be adjusted if further studies corroborate these findings.

Loss of heterozygosity of succinate dehydrogenase B mutation by direct sequencing in synchronous paragangliomas.

Extraadrenal pheochromocytomas and paragangliomas are rare entities within the pediatric population. We report the presentation of three synchronous extra-adrenal abdominal paragangliomas in an adolescent boy who carries a germline mutation in the succinate dehydrogenase B (SDHB) gene. Loss of heterozygosity of this allele was demonstrated by direct sequencing of DNA from two of his tumors, confirming loss of tumor suppressor function in the pathogenesis of these paragangliomas.

Xanthoma of bone associated with lipoprotein lipase deficiency.

Lipoprotein lipase (LPL) deficiency is an extremely rare congenital metabolic disorder with an accumulation of chylomicrons in the blood. We encountered a patient with an LPL deficiency leading to multiple bone xanthomas associated with hyperlipidemia. Radiographs and MRI of the humerus and femur revealed symmetrical bone lesions, and there is a possibility that these symmetrical lesions may therefore be a characteristic feature for this disorder.

Loss of expression of protein kinase a regulatory subunit 1alpha in pigmented epithelioid melanocytoma but not in melanoma or other melanocytic lesions.

Pigmented epithelioid melanocytoma (PEM) is a recently described entity comprising most cases previously described as "animal-type melanoma" and epithelioid blue nevus (EBN) occurring in patients with the multiple neoplasia syndrome Carney complex (CNC). Mutations of the protein kinase A regulatory subunit type 1alpha (R1alpha) (coded by the PRKAR1A gene) are found in more than half of CNC patients. In this study, we investigated whether PEM and EBN are related at the molecular level, and whether changes in the PRKAR1A gene status and the expression of the R1alpha protein may be involved in the pathogenesis of PEM and other melanocytic lesions. Histologic analysis of hematoxylin and eosin-stained sections and immunohistochemistry (IHC) with R1alpha antibody were performed on 34 sporadic PEMs, 8 CNC-associated PEMs from patients with known PRKAR1A mutations, 297 benign and malignant melanocytic tumors (127 conventional sections of 10 compound nevi, 10 Spitz nevi, 5 deep-penetrating nevi, 5 blue nevi, 6 cellular blue nevi, 2 malignant blue nevi, 3 lentigo maligna, and 86 melanomas of various types); in addition, 170 tissue microarray sections consisting of 35 benign nevi, 60 primary melanomas, and 75 metastatic melanomas, and 5 equine dermal melanomas, were examined. Histologic diagnoses were based on preexisting pathologic reports and were confirmed for this study. DNA studies [loss of heterozygosity (LOH) for the 17q22-24 locus and the PRKAR1A gene sequencing] were performed on 60 melanomas and 7 PEMs. IHC showed that R1alpha was expressed in all but one core from tissue microarrays (169/170), and in all 127 melanocytic lesions evaluated in conventional sections. By contrast, R1alpha was not expressed in the 8 EBN from patients with CNC and PRKAR1A mutations. Expression of R1alpha was lost in 28 of 34 PEMs (82%). R1alpha was expressed in the 5 equine melanomas studied. DNA studies correlated with IHC findings: there were no PRKAR1A mutations in any of the melanomas studied and the rate of LOH for 17q22-24 was less than 7%; 5 of the 7 PEMs showed extensive 17q22-24 LOH but no PRKAR1A mutations. The results support the concept that PEM is a distinct melanocytic tumor occurring in a sporadic setting and in the context of CNC. They also suggest that PEM differs from melanomas in equine melanotic disease, further arguing that the term animal-type melanoma may be a misnomer for this group of lesions. Loss of expression of R1alpha offers a useful diagnostic test that helps to distinguish PEM from lesions that mimic it histologically.

Cyclooxygenase-2 in sporadic colorectal polyps: immunohistochemical study and its importance in the early stages of colorectal tumorigenesis.

Cyclooxygenase-2 (COX-2) is one of the important targets for the chemoprevention of colorectal cancer by non-steroidal anti-inflammatory drugs (NSAIDs). To evaluate the role of COX-2 in early stages of colorectal tumorigenesis, we immunohistochemically investigated the frequency and localization of COX-2 in sporadic colorectal polyps that showed various histology using a commercially available monoclonal antibody. A total of 105 colorectal polyps were examined. These included 33 low-grade adenomas (LGAs), 28 high-grade adenomas (HGAs), 32 HGAs with p53 overexpression (HGAs-p53), and 12 cases of carcinoma in adenoma (CIA). Regarding the immunohistochemical expression of p53, MIB-1, and CD63, histological classification was made for each case. COX-2 was expressed in neoplastic epithelial cells and interstitial macrophages that were distributed mainly in the superficial areas of polyps. COX-2 labeling indices (LIs) were 8.2% in LGAs, 6.3% in HGAs, 0.9% in HGAs-p53, and 0.6% in the carcinomatous components of CIAs. COX-2 LIs were significantly higher in adenomas, including LGAs and HGAs, than in HGAs-p53 and CIAs (p < 0.001). Within CIAs, significantly higher COX-2 LIs were obtained in the adenomatous components than in the carcinomatous components (p < 0.05). The size of polyps was not correlated with COX-2 expression irrespective of their histology. The results show that COX-2 might be involved in early stages of colorectal tumorigenesis. Colorectal adenomas could be a target for the chemopreventive strategy irrespective of their sizes.

Correlation of the genotypes for N-acetyltransferases 1 and 2 with double bladder and prostate cancers in a case-comparison study.

BACKGROUND: The arylamine N-acetyltransferases play a major role in the metabolic activation of carcinogenic amines that are present in cigarette smoke and a variety of other exogenous sources. The objective of this study was to determine the association of rapid or slow arylamine N-acetyltransferase (NAT) genotypes with smoking history and the risk for developing both bladder and prostate cancer. PATIENTS AND METHODS: The subjects analyzed were a case group of 17 double-cancer patients and 34 age-matched controls who had benign prostatic hypertrophy, but were asymptomatic for prostate or bladder cancers. Genotyping of NAT1 and NAT2 alleles was done by restriction fragment length polymorphism and/or sequencing of NAT genes amplified from genomic DNAs by the polymerase chain reaction (PCR). RESULTS: No significant correlation was found between NAT1 genotypes, double cancer, and smoking history. While NAT2-smoking interaction gave an odds ratio of only 1.70 (p = 0.117), a disproportionate number of cancer cases were genotypically rapid: 12 of 17 cancer cases vs. 13 of 34 controls (odds ratio 3.88; p = 0.040). CONCLUSION: Rapid NAT2 genotype correlated significantly with the development of double prostate-bladder cancer.

Thymidine phosphorylase activity in liver tissue and its correlation with multifocal occurrence of hepatocellular carcinomas.

BACKGROUND: In hepatocellular carcinoma (HCC), new tumors develop in the residual liver within a few years after hepatectomy. However, the biological risk factors of multifocal occurrence of cancers remains unclear. In this study, the thymidine phosphorylase (TP) activity, which is known as an angiogenic factor, of cancerous and non-cancerous liver tissues in HCC was analyzed to determine its suitability as a biological marker of the multifocal occurrence of HCCs. MATERIALS AND METHODS: Fresh tissues (tumor: HCC and adjacent liver tissue: N-HCC) from 63 patients with HCC and normal liver tissues (NL) from 6 patients without HCC were obtained. The TP activities of the tissues were analyzed by an enzyme-linked immunosorbent assay (ELISA). RESULTS: The mean TP activity of 63 HCCs (136 U/mg protein) was higher than that of 63 N-HCCs (81 U/mg protein) and that of 6 NLs (47 U/mg protein, p < 0.001). Multifocal occurrence of HCCs were detected in 17 patients. In these 17 patients, the mean TP activity of HCCs (145 U/mg protein) was not different from that of HCCs from the remaining 46 patients (133 U/mg protein, p = 0.272), however the mean TP activity of N-HCCs (110 U/mg protein) was significantly higher than that of N-HCCs from the remaining 46 patients (71 U/mg protein, p = 0.038). Moreover, only a high TP activity of N-HCCs was detected as a significant risk factor of multifocal occurrence of HCCs. CONCLUSION: Patients who have tumors with high TP activity in the non-cancerous livers may have a risk of multifocal occurrence of HCCs in the residual liver.

Thyroperoxidase: a tumor marker for post-therapeutic follow-up of differentiated thyroid carcinomas? Results of a time course study.

Serum thyroperoxidase (TPO) and serum human thyroglobulin (hTg) were studied in 80 patients with differentiated thyroid carcinoma after thyroidectomy before and after the first therapeutic radioiodine application ("radioiodine thyroid ablation") and, in some cases, after the second radioiodine application. Eighteen patients with an autonomous adenoma were studied in the same manner. The values of TPO and hTg in 25 persons without thyroid impairment were used as controls. In 34 of 50 evaluable cases, TPO levels behaved as hTg during follow-up studies: The majority (n= 30) of these patients showed an increase in TPO and hTg serum levels immediately after radioiodine therapy, followed by a decrease approximately 3 days later. However, in 16 of 50 patients, the TPO and hTg serum levels showed different patterns of change both before and after radioiodine therapy. In six of seven patients with extensive postoperative residues and high anti-hTg levels, distinctly elevated TPO values were associated only by slightly elevated thyroglobulin values. There was no rise of TPO in autonomous adenoma except in patients treated with thyroid depressants. We assumed that TPO levels could serve as an "indicator" for destruction of thyroid cells or thyroid carcinoma cells and an aid in screening cases of false-negative hTg values.