Erhard Bierhoff

Risk Factors for Relapse in Clinical Stage I Nonseminomatous Testicular Germ Cell Tumors: Results of the German Testicular Cancer Study Group Trial

PURPOSE To prospectively assess potential risk factors for relapse in clinical stage I nonseminomatous germ cell tumors of the testis (CS I NSGCT). PATIENTS AND METHODS From September 1996 to May 2002, 200 patients with CS I NSGCT were prospectively assigned to retroperitoneal lymph node dissection (RPLND), and risk factor assessment was performed within a multicenter protocol. One hundred sixty-five patients had an adequate minimum follow-up of 12 months (mean, 34.5 months) or had pathologic stage II. RESULTS Pathologic stage II disease was found in 27.9% of patients. Only 0.6% of patients relapsed in the retroperitoneum after confirmation of pathologic stage I disease. With reference pathology, vascular invasion (VI) was most predictive of stage in multifactorial analysis (accuracy, 65.1%). However, the positive predictive value (PPV) of VI to predict patients who have metastatic disease or relapse during follow-up was only 52.7%. With absent VI, low-risk patients had a negative predictive value (NPV) of 76.9%. With a combination of several risk factors, the PPV increased to 63.6% and the negative predictive value increased to 86.5%. CONCLUSION Even with an optimal combination of prognostic factors and reference pathology, more than one third of patients predicted to have pathologic stage II or relapse during follow-up will not harbor metastatic disease and, therefore, would be overtreated with adjuvant therapy. However, patients at low risk may be predicted at an 86.5% level, and thus, surveillance in highly compliant patients would be a valuable option. For high-risk patients, further reduction of adjuvant treatment is necessary.

Deletion of Trp‐557 and Lys‐558 in the juxtamembrane domain of the c‐kit protooncogene is associated with metastatic behavior of gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) typically express high levels of the Kit‐receptor. The majority of GISTs carry mutations in the c‐kit protooncogene clustering in exon 11. The significance of c‐kit mutations for the biological behavior of GISTs is still under discussion. We evaluated 55 sporadic GISTs with available follow‐up data for c‐kit mutations in the juxtamembrane domain and detected mutations in 35 cases (63.6%). We found a mutational hotspot in codons 557 (tryptophan) and 558 (lysine) preferentially in histomorphologically malignant tumors. In the group of GISTs carrying c‐kit mutations, 16 of 21 malignant, but only 3 of 8 benign GISTs and 3 of 6 lesions with uncertain malignant potential, carried mutations of Trp‐557 and/or Lys‐558. We investigated whether mutations in these 2 amino acids had an impact on biological behavior. Trp‐557 and/or Lys‐558 were mutated in all 15 metastatic GISTs carrying c‐kit mutations but only in a minority of nonmetastatic tumors. A combined deletion of Trp‐557 and Lys‐558 occurred exclusively in 8 metastatic GISTs. We conclude that in addition to histomorphological evaluation determination of mutations in exon 11 may be an additional parameter for predicting the metastatic risk of GISTs and may be important for the decision that patients will need close clinical follow‐up or further adjuvant treatment with kit antagonists.

c-kit mutations in gastrointestinal stromal tumors occur preferentially in the spindle rather than in the epithelioid cell variant.

Gastrointestinal stromal tumors (GISTs) coexpress CD34 and the Kit tyrosine-kinase receptor (CD117). A subset of GISTs carry gain-of-function mutations of the c-kit proto-oncogene in its juxtamembrane domain. The relationship between the mutational status and histological as well as immunohistochemical features has not been assessed in detail. 36 GISTs and 14 other gastrointestinal mesenchymal tumors were investigated for their morphology and immunophenotype as well as for the presence of c-kit mutations. DNA was extracted from formalin-fixed, paraffin-embedded tissue. Exons 9, 11, 13, and 17 of c-kit were analyzed by SSCP. Bands with altered mobility were excised, reamplified, and sequenced. C-kit mutations in Exon 11 encoding the juxtamembrane domain were identified in 19 cases (52.8%), with deletions in 12 cases, insertions in 3 cases (2 of these as duplications), and point mutations in 4 cases. The mutations clustered between Codons 553 and 561, pinpointing the critical region for deregulated Kit receptor activation. In both Exons 9 and 13, single mutations could be identified, whereas no mutations were found in Exon 17. There were c-kit mutations in 66.6% of benign GISTs (14/21), 83.3% of the malignant (5/6), and 40% of the cases of intermediate malignancy (2/5). A low frequency of mutations in benign GISTs, as reported previously by other researchers, could not be observed in our panel. Interestingly, all GISTs with c-kit mutations displayed a spindle cell phenotype, whereas mutations were absent in all 7 tumors with an epithelioid component (P = .03). This finding suggests a relationship between c-kit mutation and histological subtype in GISTs.

Stromal nodules in benign prostatic hyperplasia

OBJECTIVE Stromal nodules from benign prostatic hyperplasia (BPH; n = 375 from autopsy, n = 100 from biopsy specimens) were investigated with regard to cytoskeletal components, topography, vascularization, leukocytic infiltrates, and proliferative activity. METHODS The nature of stromal nodules was studied by histopathology and immunohistochemistry, using antibodies against alpha-actin, desmin, myosin, vimentin, BMA-120, factor VIII, CD3, CD4, CD20, CD34, CD45RO, CD68, PCNA, and MiB1. RESULTS The findings lead to an extended classification of stromal nodules in BPH: immature mesenchymal (IM; 8.8%), fibroblastic (FB; 65.2), fibromuscular (FM; 21.6), and smooth muscular (SM; 4.4%). The different types occurred in all age decades in a similar distribution (FB > FM > IM > SM). Topographical studies (modified zonal subdivision of McNeal) revealed stromal nodules predominantly in the transitional zone (n = 286), less in the central zone (n = 78), occasionally in the peripheral zone (n = 11), and predominantly in the periurethral (n = 287) and less in the intermediate (n = 84) and subcapsular (n = 4) regions. The different types of nodules presented a distinct vascular pattern. FB, FM, and SM nodules showed significantly increased diffuse infiltrates of T lymphocytes-mainly T helper cells (mean 73%)-and an increase of B lymphocytes. Proliferative activity in the nodules was not observed. Stromal nodules were not observed in normal nonhyperplastic prostates; they only occurred in combination with hyperplastic nodular glandular proliferates. CONCLUSIONS The findings are suggestive of a maturational sequence of stromal nodules in BPH and of a possible significance of immunocompetent cells in the development of stromal nodules and further suggest that both stroma and epithelium of the prostate respond with nodular hyperplasia to the stimulus, which causes BPH.

Morphological analogies of fetal prostate stroma and stromal nodules in BPH

A “reawakening” of ontogenetic processes in the development of BPH is still in debate. Therefore, morphological analogies of fetal prostate stroma and nodular stromal proliferates in BPH were investigated.

MIB-1 immunohistochemistry in clinical Stage I nonseminomatous testicular germ cell tumors predicts patients at low risk for metastasis†

The clinical Stage I of nonseminomatous germ cell tumors (NSGCT) is inaccurate in 30% of patients. In previous studies on tumor biologic risk factors, low tumor proliferation rates predicted a group of patients at low risk for occult metastatic disease. The goal of this study was to confirm the immunohistochemical assessment of tumor proliferation using MIB‐1 (Ki‐67 receptor) in a different patient cohort with different investigators to prove the methods reliability.

Genomic deletions in the BRCA1, BRCA2 and TP53 regions associate with low expression of the estrogen receptor in sporadic breast carcinoma

Sporadic breast carcinoma is associated with multiple genetic alterations. The clinical relevance of these alterations, however, needs further clarification. In the present study we analyzed 266 spontaneously arising breast carcinomas for allelic losses in the BRCA1 and TP53 regions on chromosome 17, the BRCA2 region on chromosome 13, the ATM (mutated in ataxia‐telangiectasia) region on chromosome 11 and on the chromosomal arms 7q and 16q. In addition the following clinical and pathological parameters were evaluated: age at diagnosis, tumor size, presence or absence of regional and distant metastases, hormone‐receptor status, histopathological classification and tumor grading. The analysis of genetic and clinical observations revealed significant associations: absence of expression of the estrogen receptor was linked to a high rate of allelic losses of markers in the BRCA1, TP53 and BRCA2 regions. Expression of the progesterone receptor coincided with allelic loss on the long arm of chromosome 16. High‐grade malignant lesions and ductal differentiation were frequently associated with allelic losses in the proximal portion of chromosome 17q. The accumulation of multiple allelic deletions was linked to high‐grade malignant tumors, to tumor size, and to loss of expression of the estrogen receptor. Our data point to a relationship between clinically relevant prognostic factors and specific genomic deletions in the BRCA1, BRCA2 and TP53 region. Int. J. Cancer 74:322‐325, 1997.

Clinical course and histopathologic risk factor assessment in patients with bilateral testicular germ cell tumors

OBJECTIVES To determine whether the clinical course or the histopathologic risk factor assessment of the secondary tumor justifies early detection of the premalignant testis, since only 5% of contralateral testicular biopsies in the case of a testicular tumor reveal a testicular intraepithelial neoplasia (TIN). METHODS From 1975 to 1997, 30 patients with bilateral germ cell tumors were treated; histologic and clinical data were available in all patients. In 12 patients, histopathologic re-evaluation and immunohistochemical staining of both tumors was performed for risk factor analysis. RESULTS At the time the primary tumor was diagnosed, the mean patient age was 28 years. The metachronous secondary tumors were detected after a mean of 5.6 years. Seminoma was the predominant histologic finding in primary (53%) and secondary (56%) tumors. Eighty-three percent of patients had clinical Stage I (Lugano classification) disease at the diagnosis of the secondary tumor and 17% Stage II. Only 3 of 12 secondary tumors showed vascular invasion. The proliferation analysis (MIB-I score) showed a mean proliferation rate of only 34% within the primary and 26% within the secondary tumors. CONCLUSIONS The results of our study show that the low clinical stage and good outcome associated with a histologic low-risk score of the secondary tumor does not mandate contralateral biopsy to detect TIN at the time of diagnosis of the first tumor.

Optical coherence tomography: its role in daily dermatological practice.

Optical coherence tomography (OCT) is a non‐invasive, tomographic imaging technique which generates high‐resolution in‐vivo images up to mid‐dermal layers. Due to continuous technological improvements, OCT is moving from research projects into daily dermatological practice. It can complement other imaging methods like high‐frequency ultrasound or confocal microscopy. There is a wide variety of indications for OCT. In addition to aiding in the diagnosis and clinical monitoring of inflammatory dermatoses, OCT is a very useful and feasible technique in dermato‐oncology.

Risk factors for relapse in stage I non-seminomatous germ-cell tumors: Preliminary results of the German multicenter trial

Risk factor analysis to identify low‐risk patients for occult metastatic disease (vascular invasion, percentage embryonal carcinoma, MIB‐I proliferation rate) yields reliable results if performed by experts. A correct prediction is possible at the 90% level. Similar accuracy, however, may be achieved if the computed tomography (CT) staging is optimized and the evaluation performed by an experienced investigator. The combination of both methods (biological risk factor analysis and CT staging) may virtually exclude the risk of relapse in a limited number of patients. However, so far, no risk factor that is able to reliably predict occult metastatic disease or relapse in clinical stage I patients has been identified in prospective trials. The preliminary results of the current German Multicenter Trial suggest an inferior value of prediction for low‐risk patients if risk factor analyis and/or CT staging is performed in non‐specialized centers. Int. J. Cancer 83:828–830, 1999.