J. C. E. Underwood

Expression of vascular endothelial growth factor by macrophages is up-regulated in poorly vascularized areas of breast carcinomas.

Angiogenesis is essential to the growth and metastasis of solid tumours. Vascular endothelial growth factor (VEGF) is a potent pro‐angiogenic cytokine that is overexpressed in malignant tumours such as invasive carcinoma of the breast. The low oxygen tensions (hypoxia) present in these tumours are known to up‐regulate the expression of VEGF by tumour cells. Human macrophages also respond to hypoxia by increasing their release of VEGF in vitro, although the effect of hypoxia on VEGF expression by macrophages in vivo has yet to be demonstrated. The present study compared the expression of VEGF by macrophages in areas of low and high vascularity in 24 invasive breast carcinomas (12 lobular, 12 ductal). The cellular distributions of VEGF protein, CD31 (vessels), and CD68 (macrophages) were compared in sequential sections for each tumour. In ten tumours, both tumour cells and macrophages were immunoreactive for VEGF protein. Use of non‐isotopic in situ hybridization to localize VEGF mRNA showed that these cell types also expressed VEGF mRNA. No significant differences in the cellular distribution of VEGF protein were found between lobular and ductal carcinomas. In all tumours, macrophages accumulated in higher numbers in poorly vascularized than in highly vascularized areas. In VEGF‐positive tumours, macrophages were immunoreactive for VEGF only in avascular areas where tumour cells also expressed VEGF. This suggests that VEGF expression by these two cell types may be regulated by the same microenvironmental stimuli in breast carcinomas. In addition, significantly more macrophages were present in poorly vascularized areas of VEGF‐positive than VEGF‐negative tumours. This suggests that VEGF may exert a chemotactic action on macrophages in vivo and guide their migration into avascular tumour sites. Copyright

Clinical, educational, and epidemiological value of autopsy.

The autopsy is now often regarded as of marginal use in modern clinical practice. In this Review we contend that the autopsy remains an important procedure with substantial, if largely underused, potential to advance medical knowledge and improve clinical practice. Many doctors lack familiarity with autopsy practices, and are insufficiently aware of the benefits for not only bereaved families but also present and future patients. In this Review, which has an international perspective, we consider the ascent and decline of the autopsy, the legal frameworks that govern its use, the value and potential pitfalls of alternatives to the conventional method, and the autopsys role in undergraduate medical education. We also draw attention to the continuing ability of autopsies to improve the completeness and reliability of death certification, which is important for public-health strategies and for some bereaved families.

Oestrogen receptors in benign epithelial lesions and intraduct carcinomas of the breast: an immunohistological study

We examined 198 breast lesions, representing commonly encountered benign epithelial proliferative disorders, lobular carinoma in situ and intraduct carcinoma, immunohistologically for oestrogen receptors (ER). A mixture of three ER monoclonal antibodies—H222, D75 and D547—was used on sections of routinely processed and paraffin‐embedded tissue blocks. Over 65% of the benign and malignant lesions showed some evidence of ER expression and significant staining was recorded by two observers in 28–31% of fibroadenomas, 18–28% of ductal epithelial hyperplasias, 30–40% of sclerosing adenosis cases, 38–45% of papillomas, 60% of in situ lobular carcinomas and 42–45% of intraduct carcinomas. Apocrine metaplastic cells and myoepithelial cells showed absent or only weak staining. Amongst intraduct carcinomas, less than 20% of comedo carcinomas and over 50% of cribriform, papillary and solid variants showed significant ER staining.

Cavitation of mesenteric lymph nodes: a rare complication of coeliac disease, associated with a poor outcome

Five cases are presented, all of which showed peculiar cavitation of mesenteric lymph nodes. Clinically, three presented with abdominal symptoms, a mass or obstruction, warranting laparotomy. Two patients showed cavitating mesenteric lymph nodes at autopsy. Lymph nodes were enlarged with central, partly cystic degeneration; milky fluid exuded from the cut surface. In each case, investigation showed intestinal villous atrophy and splenic atrophy; coeliac disease was confirmed by response to gluten withdrawal. Three patients died, two from cachexia and the other from pneumonia; the other two are alive and well one year and six years after presentation. Review of the literature shows 12 previously reported cases, with a mortality of about 50%. The diagnosis is made by the histopathologist, alerting appropriate treatment. The pathogenesis is unknown.

Long-Term Prognostic Significance of Persisting Histological Activity Despite Biochemical Remission in Autoimmune Hepatitis.

Objectives:Biochemical remission is widely considered a satisfactory treatment end point in autoimmune hepatitis (AIH). The significance of persisting histological activity despite biochemical remission is unknown. We aimed to assess the frequency and prognostic significance of persisting histological inflammation in patients with AIH who had achieved biochemical remission with treatment.Methods:We studied 120 patients (median age at diagnosis 57 years; 81% female) with AIH by International Criteria (59% definite), who received immunosuppressive treatment and underwent a follow-up liver biopsy after at least 6 months of sustained biochemical remission (defined as normal serum ALT and globulin).Results:Fifty-five patients (46%) had persisting histological activity (Ishak histological activity index (HAI) ≥4). These patients had higher serum ALT (24 vs. 18 IU/l, P=0.003) and AST (27 vs. 23 IU/l, P=0.03) at the time of follow-up biopsy, compared with patients who achieved histological remission (HAI ≤3). They had less frequent regression of fibrosis on follow-up biopsy compared with those achieving histological remission (32 vs. 60%, P=0.004) and had excess mortality (standardized mortality ratio 1.4 vs. 0.7, P<0.05). The excess mortality was due to liver disease. On multivariate analysis, persisting histological activity was independently associated with all-cause death/transplantation (HR 3.1 (95% CI 1.2–8.1); P=0.02); an association with liver-related death/transplantation fell short of significance (HR 9.7 (95% CI 0.84–111.6; P=0.07).CONCLUSIONS:Persisting histological activity, despite biochemical remission, is frequent in patients with treated AIH and is associated with lower rates of fibrosis regression and reduced long-term survival.

Immunohistology of oestrogen receptor and D5 antigen in breast cancer: correlation with oestrogen receptor content of adjacent cryostat sections assayed by radioligand binding and enzyme immunoassay.

Two monoclonal antibodies recognising epitopes associated with oestrogen receptor protein were evaluated against the assayable soluble oestrogen receptor concentration in a series of 149 breast carcinomas. One antibody (anti-ER) recognises the hormone binding unit of oestrogen receptor and gives nuclear staining; the other antibody (anti-D5) was raised to a component of soluble oestrogen receptor and gives cytoplasmic staining. To minimise variations attributable to tumour heterogeneity and sampling error immunohistology using the two monoclonal antibodies, radioligand binding assays, enzyme immunoassays, and quantitative histology were done on adjacent frozen sections. Thirty nine per cent, 48%, 54%, and 43% of the tumours were found to be oestrogen receptor positive by radioligand binding assay, anti-ER and anti-D5 immunohistology, and enzyme immunoassay, respectively. Strong correlations (p less than 0.0005) were found between anti-ER immunohistology and the radioligand binding assay. Only weak correlations were found between anti-D5 immunohistology and the results of other assay methods for oestrogen receptor. Nuclear staining of human breast cancers with the anti-ER monoclonal antibody thus seems to be an acceptable alternative to biochemical assays, with the additional advantage of showing intercellular and regional heterogeneity for oestrogen receptor content.

Prognostic significance of Akt, phospho-Akt and BAD expression in primary breast cancer

Apoptotic markers in breast cancer are reported to have prognostic significance. The aim of this study was to assess the prognostic value of Akt, phospho-Akt and BAD expression in primary tumours from breast cancer patients. Expression of phospho-Akt did not correlate with menopausal status, nodal involvement or tumour size, although there was a significant correlation between phospho-Akt and oestrogen receptor status and tumour grade. No association was found between phospho-Akt and BAD. However, a significant correlation was found between Akt and BAD. Akt and phospho-Akt expression did not correlate with either disease-free survival (DFS) or overall survival (OS). Conversely, BAD immunostaining correlated significantly with increasing tumour size and with oestrogen receptor (ER) immunostaining in both frozen and paraffin sections. Expression of BAD appeared to be nucleolar in addition to its cytoplasmic and nuclear staining. Comparison of immunohistochemical staining on frozen sections and paraffin sections showed a reasonable concordance in Akt and BAD immunoreactivity. However, the results showed for the first time that strong BAD expression is related to a favourable prognosis but is not an independent prognostic factor. In conclusion, these results could provide the basis for understanding how Akt, phospho-Akt and BAD expression contributes to the prognosis of invasive breast cancer.

Immunohistological demonstration of progesterone receptor in breast carcinomas: correlation with radioligand binding assays and oestrogen receptor immunohistology.

The validity of determining the progesterone receptor status of breast carcinomas with a monoclonal antibody was investigated by comparison with data from a radioligand binding assay on adjacent cryostat sections of 103 tumours. Significant nuclear staining for progesterone receptor was observed in 37 (36%) of the tumours studied and this showed a close correlation with the results of radioligand binding assays for progesterone receptor. In three progesterone receptor positive tumours there was an apparent paradoxical absence of oestrogen receptor; progesterone receptor normally depends on the presence of oestrogen receptor, but these rare tumours may be essentially progesterone receptor positive. It is concluded that this monoclonal antibody is an appropriate reagent for use in the immunohistological determination of progesterone receptor status of breast carcinomas; that it advantageously identifies both the occupied and unoccupied receptor sites; and that it provides information about tumour cell heterogeneity with respect to receptor status.

Increased hepatic androgen receptor expression in female rats during diethylnitrosamine liver carcinogenesis: A possible correlation with liver tumor development

This study investigated the relationship between liver tumor development and androgen-receptor expression in diethylnitrosamine hepatocarcinogenesis in Wistar rats (SUAH substrain). Random liver samples were assayed by an isoelectric focusing method, with [3H]mibolerone as androgenic radioligand. After 16 wk of oral diethylnitrosamine treatment there was a greater than 20-fold increase in hepatic androgen receptor concentration in female rats (control group 0.3 +/- 0.07 fmol/mg cytosol protein; test group 8.36 +/- 0.96 fmol/mg cytosol protein; p less than 0.001, unpaired Students t-test). This coincided with, and may be related to, an accelerated development of neoplastic nodules or hepatocellular carcinoma, or both. Male rats showed slower tumor development and no change in androgen receptor concentrations. This model is the first to demonstrate significantly increased androgen sensitivity in experimental hepatic carcinogenesis analogous to increased androgen receptor expression in human hepatocellular carcinoma. It may provide insight into steroid hormone sensitivity in developing tumors, and a means of testing potential therapeutic use of hormonal manipulation in human liver cancer.

Feasibility of new prognostic classification for rectal cancer.

Sixty slides from 60 blocks taken from 30 colonic carcinomas were circulated twice to six histopathologists of varying experience. Five of the six pathologists showed a good to excellent intraobserver agreement for assessment of the character of the invasive margin (0.44 less than kappa less than 0.82), which was not significantly affected by sampling (0.40 less than kappa less than 0.56, comparing both slides from each tumour) or observer (five of six pathologists agreeing on 46 of 60 slides). Pathologists were unreliable in assessing peritumoural lymphocytic infiltrates, with only two pathologists achieving moderate levels of intraobserver agreement (-0.03 less than kappa less than 0.52). The interobserver agreement for peritumoural lymphocytic infiltrates was also low (kappa less than 0.29) between the three most experienced pathologists. The assessment of peritumoural lymphocytic infiltrates was significantly affected by sampling, the two pathologists with the lowest intraobserver variation achieving kappa values of 0.21 and 0.10 between the 30 paired slides from each tumour. The character of the invasive margin was reliably assessed, was not dependent on sample, and added useful prognostic information, but peritumoural lymphocytic infiltration is not a reproducible observation and may therefore not add useful prognostic information in routine use.