Michael L. Cibull

Investigation into the histogenesis of congenital epulis of the newborn.

Five previously unreported cases of congenital epulis of the newborn are presented. All five cases were on the anterior maxillary alveolar ridge. Four were removed at 2 days of age and one at 7 weeks. Light microscopy demonstrated large eosinophilic granular cells within vascular fibrous connective tissue. Immunohistochemical studies revealed a positivity for vimentin and neuron specific enolase. Cytogenetic evaluation performed on one case was normal. Estrogen and progesterone receptors were absent in the one case so studied. Electron microscopy demonstrated tumor cells that were filled with autophagosomes. Cellular organelles were significantly reduced and inversely related to the number of cytoplasmic autophagosomes. Many of the autophagosomes contained collagen precursors. Poorly formed junctional complexes were seen. Occasional tumor cells demonstrated long processes that contained contractile microfilaments, pinocytosis, and areas of exocytosis. These studies suggest the tumor cells represent early mesodermal cells that express pericytic and myofibroblastic features that undergo cytoplasmic autophagocytosis.

c-Abl and Arg are activated in human primary melanomas, promote melanoma cell invasion via distinct pathways, and drive metastatic progression

Despite 35 years of clinical trials, there is little improvement in 1-year survival rates for patients with metastatic melanoma, and the disease is essentially untreatable if not cured surgically. The paucity of chemotherapeutic agents that are effective for treating metastatic melanoma indicates a dire need to develop new therapies. Here, we found a previously unrecognized role for c-Abl and Arg in melanoma progression. We demonstrate that the kinase activities of c-Abl and Arg are elevated in primary melanomas (60%), in a subset of benign nevi (33%) and in some human melanoma cell lines. Using siRNA and pharmacological approaches, we show that c-Abl/Arg activation is functionally relevant because it is requiredfor melanoma cell proliferation, survival and invasion. Significantly, we identify the mechanism by which activated c-Abl promotes melanoma invasion by showing that it transcriptionally upregulates matrix metalloproteinase-1 (MMP-1), and using rescue approaches we demonstrate that c-Abl promotes invasion through a STAT3 → MMP-1 pathway. Additionally, we show that c-Abl and Arg are not merely redundant, as active Arg drives invasion in a STAT3-independent manner, and upregulates MMP-3 and MT1–MMP, in addition to MMP-1. Most importantly, c-Abl and Arg not only promote in vitro processes important for melanoma progression, but also promote metastasis in vivo, as inhibition of c-Abl/Arg kinase activity with the c-Abl/Arg inhibitor, nilotinib, dramatically inhibits metastasis in a mouse model. Taken together, these data identify c-Abl and Arg as critical, novel, drug targets in metastatic melanoma, and indicate that nilotinib may be useful in preventing metastasis in patients with melanomas harboring active c-Abl and Arg.

Ultrasound-Guided Fine-Needle Aspiration of Clinically Negative Lymph Nodes Versus Sentinel Node Mapping in Patients at High Risk for Axillary Metastasis

BackgroundSonographically directed fine-needle aspiration is a less invasive and less costly alternative to sentinel node (SN) mapping in breast cancer patients at high risk for metastatic disease but with clinically negative axillae.MethodsRadiographic, cytological, and histological diagnostic data on breast primary tumors from 114 consecutive SN candidates were prospectively assessed for clinicopathologic variables associated with an increased incidence of axillary metastases. Patients in whom these variables were identified underwent sonographic examination of their axillae followed by fine-needle aspiration when abnormal nodes were detected. SN mapping was performed in patients with normal axillary sonogram results or negative cytological results. Patients with positive cytological results proceeded to complete axillary dissection. Final axillary histological outcomes from patients not meeting the high-risk criteria were recorded. Additionally, a cost analysis was performed in which the costs of ultrasonography and ultrasound-guided fine-needle aspiration of the axilla were compared with those of SN mapping.ResultsAccording to our selection criteria, a third of the patients with clinically negative axillae (37 of 114; 32%) were considered at high risk for axillary metastases. Fifty-nine percent of these patients (22 of 37) had metastatic disease on final histological analysis. Forty percent (15 of 37) of high-risk patients were spared SN mapping, with a reduction in health care costs of 20% in this patient population. Eighty-seven percent of patients not meeting high-risk criteria were SN negative.ConclusionsThis study suggests that in patients at increased risk for axillary metastases, the use of sonographic evaluation of the axilla in combination with fine-needle aspiration is not only clinically justified, but also cost-effective.

Sentinel node micrometastasis in breast carcinoma may not be an indication for complete axillary dissection.

The decision whether to proceed with complete axillary node dissection based on sentinel node status is clear for patients with negative or macrometastatic disease. However, the course of action based on sentinel node micrometastasis remains controversial. We reviewed 358 cases from 6/1999 to 7/2003. All sentinel nodes were evaluated at three levels by frozen section, touch preparation, and scrape preparation. Micrometastasis was defined as tumor deposits between 0.2 and 2 mm. Size, grade, and lymphvascular invasion of the primary tumor, as well as number, status, size of metastatic disease, and presence of extranodal capsular extension of sentinel and nonsentinel nodes were recorded. Of the 358 cases, 89 had positive sentinel nodes, 29 of which represented micrometastases. Only one (3%) of the 29 cases contained a nonsentinel node with macrometastasis. In 60 of the 89 cases sentinel nodes contained macrometastases. Of these, 38 cases (63%) had metastatic tumor in nonsentinel nodes. Intraoperative consult was performed in 53 of the 89 cases with positive sentinel nodes. Only 1 of the 19 (5%) intraoperative consult cases with micrometastatic sentinel nodes had positive nonsentinel nodes, while 21 of 34 (62%) of macrometastatic sentinel nodes at intraoperative consult had tumor in nonsentinel nodes. No single variable studied discriminated between micro- vs macrometastatic disease. At intraoperative consult, macrometastatic disease was present in all three diagnostic preparations, while diagnostic material in micrometastatic sentinel nodes was usually present in only one modality. This analysis suggests that the risk of finding tumor in nonsentinel nodes differs significantly between cases with micro (3%)- vs macro (63%)-metastatic disease in sentinel nodes. This holds true for cases assessed by intraoperative consult. Considering the known morbidity of complete axillary dissection, assessments of risk vs benefit of undertaking this procedure should be performed on a case-by-case basis in patients with sentinel node micrometastases.

Single focus of adenocarcinoma in the prostate biopsy specimen is not predictive of the pathologic stage of disease

OBJECTIVES To determine whether a very small focus of prostate cancer in a needle biopsy specimen correlates with organ-confined disease or with favorable disease parameters. METHODS Of 598 needle biopsies of the prostate performed from January 1990 through June 1994, 49 specimens (8.2%) contained a microscopic focus (less than 2 mm in length of the entire biopsy core specimen) of adenocarcinoma. For these 49 patients, the clinical and pathologic features were correlated. RESULTS Of these 49 patients, 27 (55.1%) underwent either radical prostatectomy, with or without pelvic lymph node dissection (26), or pelvic lymph node dissection alone (1). Seven of these 27 patients (25.9%) had extraprostatic disease: lymph node involvement (1), positive surgical margins (5), or seminal vesicle invasion (1). Ten of the 49 patients (20.4%) underwent radiotherapy, and 12 (24.5%) chose hormonal therapy. The pathologic stage for these 22 patients could not be ascertained. However, despite the limited amount of disease in the biopsy specimen, 2 patients treated with radiotherapy suffered a relapse (mean interval to recurrence, 11.5 months), and 3 patients treated with hormonal therapy (early or delayed) had bony metastasis at the time of diagnosis. Overall, 12 of the 49 patients (24.5%) had unfavorable disease (as defined by extraprostatic disease on pathologic specimen, relapse after radiotherapy, or bony metastasis at the time of diagnosis). CONCLUSIONS These findings suggest that a microscopic focus of prostatic adenocarcinoma in a needle biopsy specimen, per se, does not predict the pathologic stage or the biologic behavior of a tumor.

The Critical Role of Axillary Ultrasound and Aspiration Biopsy in the Management of Breast Cancer Patients with Clinically Negative Axilla

BackgroundSonographic evaluation of the axilla can predict node status in a significant proportion of clinically node-negative patients. This review focuses on the value of ultrasound followed by ultrasound-guided cytology in assessing the need for sentinel node mapping and conservative versus complete axillary dissections.DesignBreast primaries from 168 sentinel node candidates were prospectively assessed for clinicopathologic variables associated with increased incidence of axillary metastases. Patients were classified accordingly, and those at a higher risk underwent ultrasound of their axillae, followed by aspiration biopsy if needed. Sentinel node mapping was performed in all low-risk patients, and in high-risk patients with normal axillary ultrasounds or negative cytology. Final axillary status was compared in terms of nodal stage, number of positive nodes, and size of metastasis.Results112 patients were at high risk for nodal disease (67%), with a statistically significant lower probability for remaining node-negative and a statistical significantly higher risk for having more than one positive node. All patients with more than three positive nodes were detected by ultrasound-guided cytology. High-risk patients with final positive axillae missed by ultrasound or ultrasound guided cytology had tumor deposits measuring ≤5 mm.ConclusionExtent of axillary dissections can be decided based on the risk for axillary metastases: sentinel node mapping for low-risk patients; less-aggressive axillary dissections for high-risk patients with negative ultrasound and/or negative cytology; and a standard dissection for high-risk patients with positive cytology.

Long-Term Preservation of Adipose Aspirates After Conventional Lipoplasty

BACKGROUND Optimal cryopreservation permits the long-term storage of living cells or tissues that may have potential clinical applications. Unfortunately, there are no successful studies on the long-term preservation of adipose aspirates for possible autologous fat grafting. OBJECTIVE The purpose of the current study was (1) to test our hypothesis that adipose aspirates obtained from conventional lipoplasty could be preserved and stored at low temperature (below -85 degrees C) by means of an optimal cryopreservation technique and (2) to develop a novel approach to effectively preserve adipose aspirates for future applications. METHODS The middle layer of adipose aspirates obtained from conventional lipoplasty was collected after centrifugation and each specimen was then randomized into 3 groups: the control group, fresh adipose aspirates without preservation; experimental group 1, simple cryopreservation with liquid nitrogen only; and experimental group 2, optimal cryopreservation with cryoprotective agents consisting of a combination of dimethyl sulfoxide (DMSO) and trehalose. Cryopreservation of adipose aspirates was conducted with controlled slow cooling and fast rewarming rates. Fresh or cryopreserved adipose aspirates in each group were evaluated by viable adipocyte counts, glycerol-3-phosphate dehydrogenase (G3PDH) assay, and routine histology. RESULTS Significantly more viable adipocytes and better cellular function of adipose aspirates were found in the experimental group 2 compared to the results in the experimental group 1. CONCLUSIONS Our results indicated that an optimal cryopreservation approach that utilizes a combination of DMSO and trehalose as cryoprotective agents appears to provide good long-term preservation of adipose aspirates obtained from conventional lipoplasty, albeit not as ideal as fresh specimens. An in vivo study will be conducted to confirm the results from our present in vitro study.

Proliferating cell nuclear antigen in prostatic adenocarcinoma: Correlation with established prognostic indicators

OBJECTIVE The utility of an antibody to proliferating cell nuclear antigen (PCNA), a growth-specific nuclear protein, was assessed as a prognostic variable for prostatic adenocarcinoma. Its expression was correlated with established prognostic indicators, including tumor grade, stage, prostatic-specific antigen (PSA), and percent of tumor in the gland at excision. METHODS Forty archival needle biopsies containing a minimum of four hundred tumor cells were analyzed. Immunoperoxidase staining of paraffin sections was performed for PCNA (PC10) after pretreatment in antigen retrieval solution. A proliferative index (PI) for each case was derived using image analysis with measurement of at least four hundred twenty-five nuclei. RESULTS PI values ranged from 2.4 to 31.3 percent. Mean PI values varied significantly (ANOVA, p = 0.005) among cases with dominant Gleason grade (DGG) of 3 (mean PI = 9.3%), 4 (mean PI = 13.7%), and 5 (mean PI = 18.8%). By t test, significant differences were noted for PI in cases with DGG 2 and 3 versus those with DGG 4 and 5 (p = 0.0065). PI for cases with DGG 3 versus 5 showed significant difference (p = 0.0017). Tumors of Gleason scores 5 to 7 differed significantly from those with scores 8 to 10 (p = 0.014). A statistical relationship for PI and PSA, clinical stage, and percent tumor at resection could not be established by linear regression. CONCLUSIONS These findings suggest that additional study of the PI, as determined by PCNA immunohistochemistry and image analysis, may be warranted to determine its usefulness as an adjunctive parameter in prostate adenocarcinoma. This technique may be particularly useful in needle biopsies where limited tumor may render assessment of grade difficult.

c-Abl and Arg induce cathepsin-mediated lysosomal degradation of the NM23-H1 metastasis suppressor in invasive cancer

Metastasis suppressors comprise a growing class of genes whose downregulation triggers metastatic progression. In contrast to tumor suppressors, metastasis suppressors are rarely mutated or deleted, and little is known regarding the mechanisms by which their expression is downregulated. Here, we demonstrate that the metastasis suppressor, NM23-H1, is degraded by lysosomal cysteine cathepsins (L,B), which directly cleave NM23-H1. In addition, activation of c-Abl and Arg oncoproteins induces NM23-H1 degradation in invasive cancer cells by increasing cysteine cathepsin transcription and activation. Moreover, c-Abl activates cathepsins by promoting endosome maturation, which facilitates trafficking of NM23-H1 to the lysosome where it is degraded. Importantly, the invasion- and metastasis-promoting activity of c-Abl/Arg is dependent on their ability to induce NM23-H1 degradation, and the pathway is clinically relevant as c-Abl/Arg activity and NM23-H1 expression are inversely correlated in primary breast cancers and melanomas. Thus, we demonstrate a novel mechanism by which cathepsin expression is upregulated in cancer cells (via Abl kinases). We also identify a novel role for intracellular cathepsins in invasion and metastasis (degradation of a metastasis suppressor). Finally, we identify novel crosstalk between oncogenic and metastasis suppressor pathways, thereby providing mechanistic insight into the process of NM23-H1 loss, which may pave the way for new strategies to restore NM23-H1 expression and block metastatic progression.

Mycosis fungoides: Initial diagnosis via palatal biopsy with discussion of diagnostic advantages of plastic embedding

The authors present an example of mycosis fungoides which was initially diagnosed from a palatal biopsy. The distinctive nuclear morphology of the tumor cells, with a discussion of their diagnostic importance, is presented. The advantages of plastic-embedded formalin-fixed tissue are delineated.