Christian Ensinger

Prognostic significance of Ep-CAM AND Her-2/neu overexpression in invasive breast cancer.

To assess the frequency and prognostic impact of Ep‐CAM and Her‐2/neu overexpression in patients with breast cancer and to determine its relationship with other prognostic markers, 205 breast cancer patients with a median follow‐up of 10.8 years were enrolled in this retrospective study. Overexpression of Ep‐CAM and Her‐2/neu in tumor tissue samples was assessed by immunohistochemistry. Tumors presenting a Her‐2/neu 2+ staining were additionally analyzed by FISH to exclude false positive results. Ep‐CAM and Her‐2/neu overexpression was found in 35.6% and 19.5% of the tumor samples, respectively. Both Ep‐CAM and Her‐2/neu overexpression were predictive for poor disease‐free (DFS) and disease‐related overall survival (DROS). Concurrent Ep‐CAM and Her‐2/neu overexpression was present in 13.2% of tumor specimens and had an additive negative impact on DFS and DROS. This minority of patients had a median time to relapse of only 34 months, whereas the median time to relapse was not reached in the patient population without Her‐2/neu and Ep‐CAM overexpression. By multivariate analysis Ep‐CAM overexpression proved to be an indicator of poor prognosis, independent of tumor size, histologic grade, hormone receptor expression and Her‐2/neu overexpression. In conclusion, overexpression of Ep‐CAM and Her‐2/neu complement each other as predictors for poor prognosis in patients with invasive breast cancer. Determination of these tumor markers should help in assigning breast cancer patients to 1 of 3 distinct risk categories.

Production of trophoblastic hormones by transitional cell carcinoma of the bladder: Association to tumor stage and grade

Cancer registration statistics of economically advanced countries indicate that bladder carcinoma incidence ranks fourth in men and eighth in women, but a reliable tumor marker for predicting the disease course is still lacking. We designed an immunohistochemical study to comprehensively assess the trophoblastic hormone production profile of transitional cell carcinoma (TCC) of the bladder. Moreover, we correlated histological differentiation and tumor stages with marker expression and, finally, evaluated a potential tumor origin of hCGbeta core-fragment (hCGbetacf). To this end, formalin-fixed, paraffin-embedded tumor tissues from 104 patients with urothelial neoplasms of various histological grades (23 GI, 24 GII, and 38 GIII) and stage (19pTis, 21pTa, 29pT1, and 35pT2-T4) were analyzed by the immunoperoxidase technique using our own well-characterized monoclonal antibodies against the glycoprotein hormones human chorionic gonadotropin (hCG) and its derivatives hCGalpha, hCGbeta, hCGbetacf, luteinizing hormone (LH, LHbeta), follicle-stimulating hormone (FSH, FSHbeta), and the protein hormones placental lactogen (hPL) and growth hormone (hGH-V/N). Overall, trophoblastic hormone immunoreactivity was found in 36% of TCC. Detailed analysis showed 35% hCGbeta, 17% hCGbetacf, 9% hCGalpha, 4% hCG, and 2% hPL-positive cases. The tumors produced neither GH-N, placental GH-V, nor the pituitary gonadotropins FSH/FSHbeta and LH/LHbeta. Marker positivity significantly increased with high-grade lesions (26% GI- v 55% GIII-TCC) and advanced tumor stages (24% pTa v 63% > or = pT2). Hormone immunoreactivity was frequently observed in highly proliferating areas. Our findings, together with recent structural and clinical studies, strongly suggest that these hormones, or derivates thereof, might act as local tumor growth factors. Normal urothelium, urothelial papillomas, and carcinoma in situ showed no positive reactions. All tumors producing hCG-derived molecules were negative for the concommitantly analyzed neuroendocrine markers chromogranin A, synaptophysin, and neuron-specific enolase (NSE). In summary, one third of TCC ectopically produce trophoblastic hormones, which is specifically correlated with stage and grade. Apart from hCGbeta (97% of the marker-positive cases), the intracellular occurrence of hCGbetacf, apparently the second most frequently produced marker, was surprising, and there was also a lesser degree free hCGalpha and intact holo-hormone expression. The placental protein hormones PL and GH-V are not appropriate tumor marker candidates. Finally, our histogenetic findings support a metaplastic origin of the hCG producing choriocarcinomatous phenotype of some TCC.

Retrospective evaluation of carcinoid tumors of the appendix in children

Carcinoids of the appendix are rare in children and are usually diagnosed incidentally on histologic investigation following appendectomy for appendicitis. To investigate the significance of the diagnosis of appendiceal carcinoid in children, we conducted a retrospective study of the treatment and follow-up of 36 children with histologically confirmed carcinoid tumors of the appendix. Between 1970 and 2000 a total of 36 patients (25 girls, 11 boys) were diagnosed with appendiceal carcinoid. The median age of the patients at diagnosis was 12.3 years (range 6–16 years). The indication for appendectomy was acute lower right quadrant pain in 27 cases and chronic right lower quadrant pain in 9 patients. In 27 specimens the tumor was localized at the apex, in 7 at the midportion, and in 2 at the base of the appendix. The median tumor diameter was 6 mm (range 3–17 mm). Concomitant severe appendicitis was diagnosed in 14 patients 2 with a perforated appendicitis. In only one tumor were mucin-producing cells detectable. After a median follow-up of 10 years (range 2 months to 30 years) all patients were tumor-free. None of the patients had a synchronous or metachronous noncarcinoid malignant tumor. Appendiceal carcinoids are usually asymptomatic, and the indication for surgical Intervention is acute or chronic abdominal pains in the right lower quadrant. For most patients the prognosis is excellent after appendectomy. As in adults, appendectomy is the appropriate treatment.RésuméLes tumeurs carcinoïdes de l’appendice sont rares chez l’enfant et sont diagnostiqués habituellement de façon fortuite sur la pièce d’appendicectomie réalisée pour syndrome appendiculaire. Afin d’évaluer la signification du diagnostic de tumeur carcinoïde chez l’enfant, nous avons réalisé une étude rétrospective du traitement et du suivi chez 36 enfants porteurs d’une tumeur carcinoïde de l’appendice. Entre 1970 et 2000, on a fait le diagnostic de tumeur carcinoïde de l’appendice chez 36 patients, 25 filles et 11 garçons, dont l’âge médian au moment du diagnostic a été de 12.3 ans (extrêmes: 6–16 ans). L’indication de l’appendicectomie a été une douleur aiguë de la fosse iliaque droite dans 27 cas et une douleur chronique de la fosse iliaque droite chez 9 patients. En ce qui concerne la localisation de la tumeur, sur 27 pièces, la tumeur a été localisée à la pointe dans 18 cas, dans la portion moyenne pour sept cas, et chez deux, à la base. La médiane du diamètre a été de 6 mm (extrêmes: 3–17 mm). Chez 14 patients on a diagnostiqué une appendicite sévère concomitante, deux fois avec perforation. On a détecté des cellules riches en mucine dans une seule tumeur. Après un suivi d’une médiane de 10 ans (extrêmes: 2 mois-30 ans,) tous les patients étaient sans tumeur. Aucun des patients n’a eu de tumeur maligne non carcinoïde synchrone ou métachrone. Les tumeurs carcinoïdes de l’appendice sont habituellement asymptomatiques et l’indication d’intervention chirurgicale est la douleur aiguë ou chronique de la fosse iliaque droite. Pour la plupart des patients, le pronostic est excellent après appendicectomie. Comme chez l’adulte, l’appendicectomie est le traitement approprié.ResumenEn el niño los tumores carcinoides de apéndice son muy raros y se diagnostican al efectuar el estudio histopatolôgico del apéndice extirpada por apendicitis. Para averiguar la transcendencia clïnica del carcinoide apendicular infantil, se realiza un estudio retrospectivo del tratamiento y evolución clïnica de 36 niños con diagnôstico de carcinoide apendicular confirmado histopatológicamente. Entre 1970 y 2000, 36: 25 niñas y 11 niños, fueron diagnosticados de carcinoma apendicular. La edad media de los pacientes fue 12.3 años (rango 6–16 años). La indicación de apendicectomia vino dada, en 27 casos por dolor agudo en el cuadrante inferior derecho y en 9 por molestias crónicas. En 27 especïmenes el tumor estaba situado en el apex, en 7 en la porción media y en 2 en la base apendicular. El diámetro medio del tumor fue de 6 mm (rango 3–17 mm). En 14 casos el carcinoide coincidïa con una apendicitis aguda y en 2 con apendicitis perforada. En sólo un tumor se detectaron células productoras de mucina. Tras un seguimiento medio de 10 anos (rañgo 2 meses-30 años) todos los pacientes estaban sanos. Ninguno desarrolló tumores malignos no carcinoides ni sincrónicos ni metacrónicos. Los carcinoides apendiculares son, por lo general, asintomáticos y la indicación quirúrgica se establece por dolor agudo o crónico en el cuadrante inferior derecho. Para la mayoría de los pacientes el pronóstico, tras apendicectomía, es excelente. Al igual que en los adultos, la apendicectomía constituye el tratamiento de elección.

99mTc-EDDA/HYNIC-TOC and 18F-FDG in thyroid cancer patients with negative 131I whole-body scans

Several studies have reported on the expression of somatostatin receptors in patients with differentiated thyroid cancer (DTC). The aim of this study was to evaluate the imaging abilities of a recently developed technetium-99m labelled somatostatin analogue, 99mTc-EDDA/HYNIC-TOC (99mTc-TOC), in terms of precise localisation of disease. The study population comprised 54 patients (24 men, 30 women; age range 22–90 years) with histologically confirmed DTC who presented with recurrent or persistent disease as indicated by elevated Tg levels after initial treatment. All patients were negative on the iodine-131 post-therapy whole-body scans. Fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG PET) was performed in a subgroup of 36 patients. The study population consisted of two groups: Group A (n=22) comprised patients with disease recurrence as shown by elevated Tg levels but without detectable pathology. In group B (n=32), pre-existing lesions were known. Among the 54 cases, SSTR scintigraphy was true positive in 33 (61.1%), true negative in 4 (7.4%) and false negative in 17 (31.5%) cases, which resulted in a sensitivity of 66%. A total of 138 tumour foci were localised in 33 patients. The fraction of true positive 99mTc-TOC findings was positively correlated (P<0.01) with elevated Tg levels (higher than 30xa0ng/ml). Despite two false positive findings, analysis on a lesion basis demonstrated better diagnostic efficacy with 18F-FDG PET (P<0.001); however, it also revealed substantial agreement between the imaging techniques [Cohen’s kappa of 0.62 (0.47–0.78)]. In conclusion, scintigraphy with 99mTc-TOC might be a promising tool for treatment planning; it is easy to perform and showed sufficient accuracy for localisation diagnostics in thyroid cancer patients with recurrent or metastatic disease.

EpCAM is predominantly expressed in high grade and advanced stage urothelial carcinoma of the bladder

Background: EpCAM is an adhesion molecule of the basolateral membranes in a variety of epithelial cells. Over-expression has been detected in many epithelial tumours and has been associated with high stage, high grade and a worse survival in some tumour types. Aims: To assess the prognostic value of EpCAM in urothelial carcinoma of the bladder. Methods: EpCAM expression was analysed by immunohistochemistry using a monoclonal antibody (clone VU-1D9) on a tissue microarray comprising 99 urothelial carcinomas of the bladder diagnosed between 1994 and 1997. Results: A significant relationship between high grade, advanced stage, and EpCAM expression was found, and expression of EpCAM was associated with a worse overall survival when compared to EpCAM negative tumours (pu200a=u200a0.033). Multivariate analysis showed that EpCAM expression was not an independent prognostic factor for overall survival in urothelial carcinoma of the bladder. Conclusion: EpCAM expression is associated with advanced stage, high grade and poor overall survival in urothelial carcinoma of the bladder, but lacks an independent prognostic significance. The strong association with high grade tumours suggests a possible role during tumour progression and makes EpCAM a potential target for antibody mediated therapy.

Epidermal Growth Factor Receptor as a Novel Therapeutic Target in Anaplastic Thyroid Carcinomas

Abstract: Anaplastic thyroid carcinoma (ATC) is one of the most aggressive human malignancies, with a median survival of up to 6 months. Such a bad prognosis under the present treatment procedures suggests the need for novel approaches in the management of this disease. Since some epidermal growth factor receptor (EGFR) inhibitors are now in clinical trials and few data are available concerning EGFR expression in anaplastic thyroid carcinomas, we tried to estimate a possible overexpression of this receptor in a larger tumor series. Twenty‐five ATCs, including 3 ATCs with poorly differentiated thyroid carcinoma (PDTC) parts, were immunohistochemically investigated with a mouse monoclonal antibody directed against EGFR (EGFR pharmDX kit). The tumors revealed primarily a distinct membranous staining pattern, and in several tumor cells an additional cytoplasmic reactivity could be observed. The anaplastic carcinomas presented with 5 of 25 (20%) without EGFR reaction, 10 of 25 (40%) with reactivity, and 10 of 25 (40%) with overexpression of the receptor. All ATCs with PDTC parts (100%) showed EGFR overexpression. Cytoplasmic reactivity was observed in 56% of all ATCs. A significant correlation was calculated for EGFR overexpression and cytoplasmic staining (P= 0.036). Concerning receptor overexpression, ATCs were significantly different from ATCs with PDTC parts (P= 0.023). For the first time, we present EGFR overexpression in ATC in a larger tumor series, demonstrating that EGFR overexpression is a common finding in ATC. For at least one‐third of all anaplastic thyroid carcinomas, EGFR seems to be a promising agent for the targeted molecular therapy of these extraordinarily aggressive tumors.

EpCAM overexpression in thyroid carcinomas: a histopathological study of 121 cases.

Epithelial cell adhesion molecule (EpCAM) is expressed by a broad variety of carcinoma cells. It is recognized by the monoclonal antibody 17-1A, which has already been applied for immunotherapy of several carcinoma types in preclinical and small clinical studies. In the present study the immunohistochemical properties of 17-1A were evaluated in 121 cases of thyroid carcinomas of follicular cell origin, comprising of 75 differentiated (DTC; 35 papillary and 40 follicular carcinomas), 24 poorly differentiated (PDTC) and 22 anaplastic thyroid carcinomas. Overexpression of EpCAM, as recently defined, was found with a distinct membranous staining pattern in 81.3% of DTCs and in 66.6% of PDTCs. In contrast, all anaplastic thyroid carcinomas (0%) completely lacked EpCAM expression. Normal thyroid tissue presented with weak and heterogeneous EpCAM staining. This study demonstrates EpCAM overexpression as a common finding in DTCs and PDTCs, and thus these tumors as possible novel targets for EpCAM-directed immunotherapy. Our findings suggest that patients with recurrent or advanced tumor disease and metastatic spread could benefit from this modern therapeutic regime, especially after insufficient radioiodine therapy.

Her2/neu overexpression in differentiated thyroid carcinomas predicts metastatic disease

To investigate the prognostic value of Her2/neu expression in differentiated thyroid carcinomas 103 patients were retrospectively investigated. All of them received surgical and an identical follow-up treatment. The patients with papillary and follicular thyroid cancer were further separated into two groups concerning their clinical development, including one group without distant metastasis (follow-up of minimum 8xa0years). The second group presented with distant metastases as a sign of an aggressive behaviour. Her2/neu was immunohistochemically detected on sections from formalin-fixed, paraffin-embedded tissues using c-erbB-2/Her-2/neu oncoprotein Ab-17 monoclonal antibody (mAb). In statistical analysis using the Mann-Whitney U-test and χ2 test, Her2/neu protein overexpression was significantly correlated with prognosis. Both tumour entities without distant metastases showed significantly less cytoplasmic immunostaining than patients with development of metastases. Concerning the clinical outcome, Her2/neu overexpression may be regarded as a prognostic factor in differentiated thyroid carcinomas. Moreover, in addition to standard radio-iodine elimination therapy, application of Herceptin could lead to new successful therapeutic concepts for a number of patients with progressive thyroid cancer.

Periacinar retraction clefting in proliferative prostatic atrophy and prostatic adenocarcinoma

Aims: To evaluate the presence and extent of periacinar retraction clefting in proliferative prostatic atrophy and carcinoma in radical prostatectomy specimens. Methods: Atrophic foci and neoplastic glands were analysed in specimens from 50 patients who underwent radical prostatectomy. Analysed atrophic glands were classified in two main groups, proliferative atrophy (PA) and proliferative inflammatory atrophy (PIA); each group was subclassified into simple atrophy (SA) and postatrophic hyperplasia (PAH). According to the presence and extent of periacinar retraction clefting, atrophic and neoplastic glands were classified as: group 1, glands without clefts or with clefts affecting ⩽50% of gland circumference; group 2, glands with clefts that affected >50% of the circumference in <50% of examined glands; and group 3, glands with clefts that affected >50% of the circumference in ⩾50% of examined glands. Results: Forty-four (88.0%) atrophic foci were without periacinar clefts or clefts were present in less than half of the gland circumference (group 1). In 6 (12.0%), atrophic foci clefts affected >50% of gland circumference (groups 2 and 3). Forty-five (90.0%) carcinomas were with clefts which affected more than 50% of gland circumference (groups 2 and 3); and in five carcinomas only, clefts were not found or affected <50% of gland circumference (group 1). Conclusion: Results indicate that periacinar retraction clefting represents a reliable criterion in differential diagnosis between proliferative atrophy and carcinoma.

Colonic perforation associated with leukocytoclastic vasculitis caused by Sirolimus toxicity following renal transplantation.

Target of Rapamycin (TOR) inhibitors have been introduced in clinical transplantation during the past decade. Common side effects of TOR inhibitors include diarrhea and abdominal discomfort, acne, pancytopenia and wound healing disturbances because of the antiproliferative effects [1,2]. Furthermore, ulcers within the oral cavity have been described. A 35-year-old male patient with phosphoribosyl transferase inhibitor deficiency underwent his fourth kidney transplantation after three failures because of recurrent disease. At this time the patient had developed 66% preformed antibodies, however, the crossmatch was negative. Initial immunosuppression consisted of Tacrolimus, Sirolimus (SIR) and steroids. One week later, the patient developed acute vascular rejection (C4d positive signal on renal biopsy), which was treated with bolused steroids (500 mg of methylprednisolone on three consecutive days) and extensive plasma exchange. This was followed by multiple sessions of immunoapheresis over 6 weeks. Ganciclovir prophylaxis was given for 3 months. Tacrolimus dose was reduced and mycophenolic acid was added and the patient was kept on quadruple drug therapy. The remaining course was uncomplicated; the graft recovered and functioned well. Sixteen-months post-transplant, the patient developed respiratory tract infection and was prescribed Clarithromycin by his general practitioner. Few days later, he presented with severe abdominal pain, fever and watery diarrhea accompaigned by deterioration of the renal graft function. Colonoscopy showed multiple ulcers at various parts of the colon. Histology revealed unspecific ulcerations – no cause for the lesions could be identified, enteric pathogens such as Salmonella, Clostridium difficile and Rotavirus were excluded [3,4]. Repeated testing for cytomegalie virus (CMV) or Ebstein-Barr-virus (EBV) replication were also negative. Conservative treatment with metronidazol and ciprofloxacin was initiated; C-reactive protein and leukocyte count decreased and the patient’s condition and the renal graft function improved. The following day SIR level was measured, which was as high as 25 ng/dl. The agent was immediately withdrawn. After initial improvement, the patient’s condition deteriorated again and he finally developed acute abdomen with graft failure. Abdominal X-ray demonstrated massive intraperitoneal air and CT scan identified a thickened colonic wall and sigmoid perforation (Fig. 1). The sigmoid colon was resected and antibiotic therapy was changed to piperacillin/tazobactam (4.5 g q 8 h). After initial improvement, the patient developed sepsis and died because of multiorgan failure. Autopsy showed a steatosed liver, active colitis with multiple ulcers and ulceration at the cardioesophageal junction. Histology of colonic and gastric ulcers revealed atypical inflammatory changes within the wall with signs of vasculitis (Fig. 2). The blood vessels within the mesenterium were infiltrated by fibrin deposits. The histological features were consistent with leukocytoclastic vasculitis (LCV). The ulcerations were suspected to be of ischemic origin because of the vasculitis. Leukocytoclastic vasculitis is a necrotizing vasculitis with segmental areas of transmural infiltration and disruption of the vessel architecture by neutrophils with fibrinoid necrosis [5]. It is known to be caused by autoimmune diseases, infections and drugs. SIR is absorbed from the upper gastrointestinal tract and 50% of the drug is metabolized in the gut mucosa [6]. As LCV mainly involved mesenteric blood vessels, causing ischemic ulcers within the dependent colonic segments, colonoscopic biopsies could not identify the process. LCV has been described primarily in the skin but many patients present with systemic manifestations involving joints, kidneys and the gastrointestinal tract. SIR associated cutaneous LCV has been reported after kidney–pancreas and lung transplantation and in children [7,8,9]. It is tempting to suspect, that the required intensified immunosuppression in this patient also contributed to the development of LCV. SIR has been shown to be a useful agent in transplantation, however, SIR toxicity must be considered as a possible differential diagnosis in patients presenting with severe abdominal pain and/or gastrointestinal ulcers. Physicians must be educated on the potential drug interaction of SIR and some antimicrobial agents such as macrolides.