Neil A. Abrahams

Prognostic importance of resection margin width after nephron-sparing surgery for renal cell carcinoma

OBJECTIVES To examine the relationship between the width of the resection margin and disease progression in renal cell carcinoma (RCC) after nephron-sparing surgery (NSS). During NSS for RCC, it is standard practice to excise the tumor along with a surrounding margin of normal parenchyma (margin of resection) to ensure complete resection of the neoplasm. However, no agreement has been reached on how wide the margin of resection should be. METHODS We retrospectively reviewed the histopathologic sections and medical records of 69 patients with localized RCC who had undergone NSS between 1976 and 1988 to determine whether the resection margin, tumor size, TNM stage, and Fuhrman nuclear grade were associated with disease progression (defined as local tumor recurrence or metastasis). The mean postoperative follow-up interval was 8.5 years. RESULTS No association was found between the width of the resection margin and disease progression (P = 0.98, log-rank test). Both TNM stage and Fuhrman nuclear grade correlated with disease progression. Patients with T1-T2 tumors had lower progression (P <0.001, log-rank test), and increased Fuhrman nuclear grade correlated with more disease progression (P <0.001, log-rank test). CONCLUSIONS The width of the resection margin after NSS for RCC does not correlate with long-term disease progression. A histologic tumor-free margin of resection, irrespective of the width of the margin is sufficient to achieve complete local excision of RCC.

Adenocarcinoma of the small bowel: A study of 37 cases with emphasis on histologic prognostic factors

AbstractPURPOSE: Primary small-bowel adenocarcinoma is uncommon. There are few large studies that have evaluated the prognostic impact of clinical and pathologic parameters. The purpose of this study was to perform a comprehensive analysis of the Cleveland Clinic experience with small-bowel adenocarcinoma, with emphasis on histopathologic parameters as prognostic indicators. METHODS: Thirty-seven cases of primary small-bowel adenocarcinomas resected at the Cleveland Clinic between 1978 and 1999 were retrospectively studied. Metastatic tumors and those arising from the biliary system were excluded from analysis. Clinical and pathologic data were recorded and their impact on prognosis was evaluated by either Kaplan-Meier or Cox proportional hazards analysis. RESULTS: The cohort included 25 males, and the age range was 24 to 82 (mean, 56) years. Tumor location was duodenum (18), jejunum (10), ileum (2), and site not specified (7). Patients most frequently presented with abdominal pain (48 percent), anemia (39 percent) and small-bowel obstruction (33 percent). Underlying conditions included Crohn’s disease (4) and familial adenomatous polyposis (2). Overall survival was 52 and 47 percent at 5 and 10 years, respectively, with a mean follow-up of 50.5 (range, 0.5–184) months for all patients. Features found to be negative prognostic factors for survival were positive surgical margins (P < 0.001), extramural venous spread (P < 0.001), lymph node metastases (P = 0.038), poor tumor differentiation (P = 0.015), depth of tumor invasion (P = 0.023), and history of Crohn’s disease (P < 0.001). Age, gender, tumor size, growth pattern, lymphocytic host response, and adjuvant therapy did not affect survival. CONCLUSIONS: Pathologic features, including positive surgical margins, extramural venous spread, positive lymph nodes, poor tumor differentiation, depth of tumor invasion, and history of Crohn’s disease, are of major prognostic significance in small-bowel adenocarcinoma. Although many of these prognostic features are similar to the ones used for colorectal adenocarcinoma, they are easily applicable and reproducible for small-bowel adenocarcinomas. This is important considering the often dismal prognosis of small-bowel adenocarcinoma.

Posttransplant Lymphoproliferative Disorders in Lung Transplant Patients: The Cleveland Clinic Experience

PTLD is a well-recognized complication of organ transplantation. Large series of heart, renal, and liver transplants have been examined for the incidence and behavior of PTLD. However, reports of the incidence and characteristics of PTLDs in lung transplant (LTx) patients are few. We report our experience with PTLDs in a large series of LTx recipients at a single institution and compare them to other solid organ transplant recipient PTLDs seen at our institution. Twenty-eight patients were found to have PTLD, of whom 8 were lung transplant recipients. We evaluated nine PTLD specimens from these 8 patients for their histology, immunophenotype (CD20, CD3, EBV-LMP1), EBER status by in situ hybridization, and clinical features. The incidence of PTLD was 3.3% (8/244 patients). The time to development of PTLD, after transplant, was short (median time, 7 mo). All were of B-cell lineage. Overall, EBV was demonstrated in 77.7% (7 of 9 specimens) of PTLDs. All specimens tested for clonality were found to be monoclonal. Five patients died, with a median time to death of only 4.6 months. PTLDs in LTx patients are EBV-associated B-cell, predominantly monoclonal lymphoid lesions similar to other solid organ transplant PTLDs. Compared with other solid organ transplant recipients with PTLD at our institution, PTLDs in LTx patients have a propensity to involve the transplanted organ (P = .001, Fishers exact test), occur earlier after transplant (P = .003, Wilcoxon test), and have a shorter survival (P = .002, log rank test). Reasons for this may include the relatively higher level of immunosuppression required in these patients and limited options in decreasing it. Although the incidence is low, careful early monitoring of lung transplantation patients is warranted because of the poor prognosis of patients developing this complication.

Validation of cytokeratin 5/6 as an effective substitute for keratin 903 in the differentiation of benign from malignant glands in prostate needle biopsies.

Aims:  Keratin 903 (also known as anti‐cytokeratin antibody 34βE12) is widely used to differentiate benign glands from malignant glands in prostate needle biopsies. However, it is subject to considerable staining heterogeneity. We sought to evaluate the use of cytokeratin 5/6 (CK5/6) as an effective alternative to K903 in the evaluation of prostate needle biopsies in clinical practice.

Pulmonary hemangiomas of infancy and childhood: report of two cases and review of the literature.

Pulmonary hemangiomas are exceptionally rare in childhood and more so in infancy. They may involve the airways or the parenchyma, and may be localized or multifocal. We present two cases of pulmonary capillary hemangiomas. The first case is a localized form of capillary hemangioma that was resected from an 8-week-old infant with signs of respiratory distress. A computed tomography scan showed a cystic mass initially thought to be an intrapulmonary bronchogenic cyst. A segmental resection was performed and examination revealed a localized capillary hemangioma without cystic or cavernous features. The second case is an example of a multifocal capillary hemangioma from a 9-year-old child who presented clinically with clubbing of fingers and toes and radiologically had multiple discrete nodules localized to the right lung. The clinical and pathological features of the cases are discussed together with a review of the literature. The distinction from other vascular neoplasms of childhood is briefly described. Although rare, pulmonary hemangiomas should be entertained in the diagnosis of both solid and cystic intrapulmonary lesions of childhood and infancy.

Angiogenic Polypoid Proliferation Adjacent to Ileal Carcinoid Tumors: A Nonspecific Finding Related to Mucosal Prolapse

Case reports have highlighted angiogenic polypoid proliferation in the mucosa adjacent to ileal carcinoid tumors, describing them as granulation tissue polyposis and florid angiogenesis. Some authors have proposed that the ileal carcinoid tumors themselves produce growth factors that cause the change. The purpose of this study was to determine the frequency of angiogenic polypoid proliferation in a large cohort of resected ileal carcinoid tumors compared with control groups.Search of the Cleveland Clinic and Summa Health System pathology files (1985 to 1999) yielded 65 resected ileal carcinoid tumors. Mucosal abnormalities adjacent to the ileal carcinoid tumors were graded 0 to 4+. Twenty ileal resection margins from colonic carcinoma cases served as normal controls. Ileal mucosa adjacent to 22 noncarcinoid neoplasms were also examined.The mucosa adjacent to 54/65 ileal carcinoid tumors (83%) showed mucosal abnormalities (vs. 3/20 normal controls), including mucosal edema, capillary ectasia, muscularis mucosae hypertrophy, fibrosis/smooth muscle proliferation within the lamina propria, club-shaped villi, and intramucosal capillary proliferation. Forty ileal carcinoid tumor cases (61%) showed some degree of angiogenic polypoid proliferation characterized by club-shaped villi and prominent intramucosal capillaries, with 17 (26%) graded as 3+ or 4+. Angiogenic polypoid proliferation was associated with hypertrophy of the muscularis mucosae, lamina proprial fibrosis/smooth muscle proliferation, and capillary ectasia similar to that described with gastrointestinal mucosal trauma/prolapse. This trauma/prolapse change was identified in 45 cases (69%) and was graded 3+ or 4+ in 23 (35%). Seventeen (77%) of the noncarcinoid neoplasms showed trauma/prolapse changes, with 7 (32%) graded as 3+ or 4+. Angiogenic polypoid proliferation also correlated with trauma/prolapse change in the noncarcinoid neoplasm controls. Neither APP (P =.24) nor the prolapse changes (P =.33) were found to be statistically different between the two tumor groups.Angiogenic polypoid proliferation of the adjacent ileal mucosa is common in patients with ileal carcinoid tumors and with noncarcinoid neoplasms. Angiogenic polypoid proliferation almost invariably coexists with fibromuscular change and capillary ectasia within the lamina propria, suggesting that mucosal trauma/prolapse plays a role in the histogenesis. The association of angiogenic polypoid proliferation with a variety of different neoplasms makes it unlikely that the tumors themselves secrete growth factors.

Chapter 23 – Prostate Cancer on the Internet: Review 2002

This chapter presents a review of the current Internet sites on prostate cancer. The Internet is a rich and valuable source of current information for patients and physicians. The volume of information available is staggering, but there is great heterogeneity in terms of accuracy, relevance, and most importantly, timeliness of updates. The medical community has begun to address concerns of accuracy and quality of information on the Internet. Many published articles have systematically reviewed websites in other fields of medicine, such as pathology, radiology, breast cancer, and molecular medicine, but there is a paucity of articles specifically evaluating websites that provide information on prostate cancer. Several search engines were used for this review, which found that medically relevant websites on prostate cancer are usually at or near the end of the results list. This probably represents a bias in favor of groups that pay to have their websites listed and thus are placed at the top of the lists. A number of web-based tools have been developed to evaluate the quality of health-related information on the Internet; however, these have been found to be complicated and difficult to use.