Raffaele Pingitore

Expression and Mutational Status of c-kit in Small-Cell Lung Cancer Prognostic Relevance

Purpose: The c-kit protein, also known as CD117, is a member of the type III receptor tyrosine kinase family. Kinase activity has been implicated in the pathophysiology of many tumors, including small-cell lung carcinoma (SCLC). Autocrine or paracrine activation of c-kit by its ligand has been postulated for lung cancer, but this receptor can also be activated by mutations of the c-kit gene. We examined c-kit expression and mutational status in SCLC to verify its putative expression and genetic alterations, as well as its eventual prognostic impact. Experimental Design: We studied 60 SCLC samples to determine the mutations of the coding region of the gene; the exons 9 and 11 were analyzed by PCR-single-strand conformational polymorphism and automated sequencing. Moreover, c-kit expression was evaluated in 55 samples by immunohistochemical method. Results: Expression of c-kit was demonstrated in about 40% of SCLC samples. Two mutations in exon 9 and three mutations in exon 11 were found. Kaplan-Meier analysis revealed no prognostic significance of c-kit expression for survival. Conclusions: In our series, the expression of c-kit and its mutational status failed to appear relevant or to have a significant impact on survival; this makes the therapeutic approach with an inhibitor of tyrosine kinase more difficult in SCLC until a sure demonstration of c-kit implication is obtained for this tumor.

Angiogenesis in intracranial meningiomas: immunohistochemical and molecular study

Much of the morbidity of intracranial meningiomas is related to the degree of tumour vascularity and the extent of peritumoural vasogenic oedema. Several studies have shown that vascular endothelial growth factor (VEGF) is up‐regulated in meningiomas, although its relationship with tumour vasculature is still unclear. In order to better understand the angiogenic assessment of intracranial meningiomas, we analysed its vascular pattern, both as number and as morphologic configuration of microvessels. Moreover, we investigated the mRNA‐VEGF expression, relating this expression to vascular pattern. A total of 40 intracranial meningiomas, classified as benign (31 cases), atypical (7 cases), and anaplastic (2 cases) were analysed. RT‐PCR analyses of mRNA‐VEGF and competitive‐PCR were performed. VEGF expression and microvessel density (MVD) were also immunohistochemically investigated. Grade II–III meningiomas showed numerous small microvessels (mean: 34), while the majority of Grade I showed few larger vessels (mean: 13.09) (P = 0.000003). A microvessel pattern overlapping into atypical subtype was found in eignt of the 31 (25.8%) Grade I meningiomas. A significant association was found between grading and vascular pattern (P = 0.0002), as well as between the MVD and the immunohistochemical expression of VEGF (P = 0.0005). The expression of mRNA agreed with the immunohistochemical expression of the protein (P < 0.0001). A total of 39 cases expressed the 121 VEGF isoform and, among these, 28 cases also expressed the 165 isoform. Only 9 cases expressed both isoforms 165 and 189. Grade II and III meningiomas showed a preponderant expression of soluble isoforms (121 and 165). These results prompt us to speculate that the microvessel pattern could underlie a higher metabolic demand, probably due to a rapid growth with a consequent worse clinical behaviour of the tumour. In this sense, the vascular pattern may be used as a prognostic factor, in order to mostly focus attention on those Grade I meningiomas which have a higher likelihood of either recurrence or development of perilesional oedema. The pattern of vasculature itself seems to be dependent on the types of VEGF isoforms: the Grade II–III meningiomas (that presented numerous microvessels) expressed the soluble isoforms 121 and 165, while the isoform 189 was more frequently detected in Grade I meningiomas.

Meningioma-associated brain oedema: the role of angiogenic factors and pial blood supply

AbstractBackground: Approximately 60% of meningiomas are associated with perilesional brain oedema. Several aspects have been evaluated in order to understand the pathophysiological mechanisms of oedema (age, sex of the patient, size and location of the tumour, histotype, grading), although at present they have yet to be completely clarified. We focused on pial blood supply, microvascular density (MVD) and angiogenic growth factors (i.e. vascular endothelial growth factor – VEGF) in order to evaluate their putative role in the development of brain oedema. Methods: We retrospectively studied 55 patients with intracranial meningiomas. Computerized tomography (CT) and angiographic studies were obtained in all cases. The angiograms provided an accurate differentiation between pial and dural blood supply, concomitantly with its semi-quantitative evaluation. The location and the volume of oedema, in relation to the meningioma surface, was evaluated using CT scans, as an oedema index (E/I). We also determined the expression of VEGF and MVD using standard immunohistochemical methods. Results: Thirty-two out of 55 meningiomas presented peritumoural oedema, with an angiographic blush ranging from 2 to 4; VEGF protein was expressed in 27 out of 32 cases, independent of grade or histotype of tumours. In all patients, MVD ranged from 4 to 33.3 vessels (median value: 10.6).A significant relationship was found between the expression of VEGF and MVD (p = 0.0003) and between VEGF and E/I (p = 0.0023).Moreover, the E/I ratio was related to the blush (p = 0.0005). A significant association was also present between VEGF expression and pial blush (p = 0.0001). Conclusion: Our data confirm the central role of VEGF and pial blood supply in the pathogenesis of peritumoural oedema and support the hypothesis that the development of oedema in meningioma is vasogenic in type.

Salivary gland involvement in a case of dermal eccrine cylindroma of the scalp (turban tumor). Report of a case with lung metastases.

The onset of sweat gland and salivary gland tumors in the same patient is a rare association known only for a few years. The case is reported of a man who died at 63 with lung metastases and bearing a turban and salivary tumor (both of the eccrine cylindroma dermal type). This « cutaneous and salivary neoplastic syndrome » may be explained by a common stem cell in different organs.

CD34 microvessel density and VEGF expression in basal and squamous cell carcinoma.

Angiogenesis is a central process in the growth of solid tumors. The purpose of our study was to analyze the angiogenic pattern in squamous and basal cell carcinomas and to point out differences in microvessel density that could explain their different biological behaviour. Thirty-nine skin tumors (26 basal and 13 squamous cell carcinomas) were analyzed. In all samples, the microvessels density (MVD) and the levels of vascular endothelial growth factor mRNA (VEGFmRNA) were analyzed, together with the inter-relationship between these two variables. Using the median value of the entire series (33 vessels per 2.22 mm2), tumors with low and high MVD were identified. The majority of cancers with high vascularization belonged to the squamous histotype (12 of 39), while 19 of the 26 basal cell carcinomas showed a lower number of microvessels than the median value (p = 0.0001). The median value of VEGFcDNA quantitation allowed us to distinguish tumors with high VEGF expression (> 470 molecules cDNA) from those with low (< or = 470 molecules) VEGF expression: 20 of the 26 basal cell carcinomas showed low VEGF expression, while 11 of the 13 squamous cell carcinomas showed high VEGFcDNA levels (p = 0.0003). Moreover, a significant association between a high microvessel density and high VEGFmRNA levels (p = 0.006) was found. Furthermore, when studying VEGF expression by immunohistochemistry, we obtained similar results and noted a correlation with VEGFmRNA expression (p < 0.0001). The association between high vascularization, high VEGF levels, and squamous cell histotype suggests the possible role of neoangiogenesis in determining the more aggressive biological behaviour of this type of cancer.

Immunohistochemical study of 49 cutaneous melanomas: p53, PCNA, Bcl-2 expression and multidrug resistance

Aims and Background Thickness and level of invasion are the main morphological elements for an approximate but not sufficiently sensitive prognostic evaluation of cutaneous melanomas. By using immunohistochemical methods it is possible to detect biological markers related to prognosis. We have studied p53, PCNA, Bcl-2 and P-gp expression in 49 primary cutaneous melanomas. Materials We used the immunophosphatase APAAP immunohistochemical method. The percentage of labeled cells (according to four classes of positivity: <5%; 5-25%; 25-50%; >50%) and the localization of immunoreactivity were expressed for each marker. Statistical analysis was performed to determine the correlations between markers and level or thickness of melanomas. Results We found a good correlation between p53 expression and melanoma thickness (P <0.005), PCNA and P-gp expression. No relationship was observed between Bcl-2 expression and the different variables considered or other markers. Conclusions Our data seem to indicate an unfavorable prognostic role of higher nuclear p53 expression. However, we believe that our results need to be integrated with patients’ clinical follow-up and with the study of the expression of these markers in benign melanocytic lesions to gain more accurate information about their prognostic significance.

Bilateral synchronous testicular involvement in multiple myeloma. Case report and review of the literature.

The authors describe a case of synchronous bilateral involvement of the testes in a 70-year-old patient seven years after the onset of an IgG k IIIA multiple myeloma. Ultrasonographic and postoperative immunohistochemical studies were performed. A complete review of the literature shows the rarity of testicular plasmacytoma. The present one is the second reported case of syncronous involvement of the testes.

Dynamic markers based on blood perfusion fluctuations for selecting skin melanocytic lesions for biopsy

Skin malignant melanoma is a highly angiogenic cancer, necessitating early diagnosis for positive prognosis. The current diagnostic standard of biopsy and histological examination inevitably leads to many unnecessary invasive excisions. Here, we propose a non-invasive method of identification of melanoma based on blood flow dynamics. We consider a wide frequency range from 0.005–2 Hz associated with both local vascular regulation and effects of cardiac pulsation. Combining uniquely the power of oscillations associated with individual physiological processes we obtain a marker which distinguishes between melanoma and atypical nevi with sensitivity of 100% and specificity of 90.9%. The method reveals valuable functional information about the melanoma microenvironment. It also provides the means for simple, accurate, in vivo distinction between malignant melanoma and atypical nevi, and may lead to a substantial reduction in the number of biopsies currently undertaken.

Multiple pyogenic granuloma of the penis in a four-year-old child: a case report

Pyogenic granulomas are common, acquired, benign vascular lesions of the skin and mucous membranes that can develop both spontaneously and traumatically. We present a unique case of a four-year healthy, uncircumcised boy with multiple pyogenic granuloma on the mucous face of the penis foreskin. Although penile multiple pyogenic granulomas have previously been described in adults, there are no reports of similar problems in children. In this patient, the pathogenesis of the lesions is probably trauma related as reported in the anamnesis. Therapeutic options are discussed.

Choroid plexus carcinoma : a new case associated with a novel TP53 germ line mutation

The choroid plexus is a highly specialized structure projecting into the lateral ventricle and consisting of a vascularized fibrous stroma covered by epithelial cells of neuroectodermal origin. This specialized epithelium very rarely gives rise to neoplasms, which mainly affect young children and present in sporadic fashion. Choroid plexus tumours (CPT) are in fact rare epithelial brain neoplasms accounting for 0.4–0.8% of all brain tumours and for approximately 1% of paediatric brain tumours [1,2]. Histologically, CPT are classified into benign choroid plexus papilloma (CPP), atypical CPP and malignant choroid plexus carcinoma (CPC) [3]. The survival rate of patients with CPP is significantly higher; nevertheless, a few cases of CPP have been reported to pursue a more aggressive course with intracranial and/or spinal seeding; progression from CPP to CPC has also been reported [1,4]. Most CPT occur sporadically; nevertheless, they can also occur in association with hereditary syndromes such as Aicardi’s syndrome [5] or, more frequently, Li–Fraumeni syndrome (LFS) [3]. The p53 tumour suppressor gene (TP53) is the most commonly mutated gene in human cancers. It regulates cell proliferation and DNA repair by inhibiting the cell cycle at G1/S, so that loss of its function may lead to aberrant cell kinetics and tumour growth [6]. Germline mutations in TP53 characterize patients with LFS, a rare hereditary tumour syndrome commonly associated with a variety of malignancies including sarcoma, breast cancer, leukaemia and adrenal cortical carcinoma [7]. Among the paediatric cancers arising within the LFS, rhabdomyosarcoma and CPC are the two most frequent histotypes [8]. Up to date, 17 cases of CPC have been described in the literature occurring in association to a TP53 germline mutation [8–19]. We have identified a hitherto undescribed TP53 germline mutation associated with CPC in a 3-month-old boy, in the absence of a clear tumour predisposition syndrome. The infant presented with vomiting, weight loss and somnolence. The first, non-enhanced, CT scan demonstrated marked and active hydrocephalic enlargement of the supratentorial ventricular system and a lobulated hyperdense mass, with rare and minute calcified foci, arising within the occipital horn and the posterior atrium of the right lateral ventricle; magnetic resonance imaging (MRI) confirmed the intraventricular lobular neoplasm, occupying and enlarging the aforementioned ventricular sections and showing transverse largest diameters of about 3.4 ¥ 2.9 ¥ 2.9 cm (Figure 1). Moderate peri-trigonal vasogenic oedema was also present. The mass appeared iso-intense on T1 weighted images (T1 WI) and of intermediate signal, with multiple areas of signal void, on T2 gradient recalled echo images (GRE-T2*), showing marked and spreading enhancement after administration of paramagnetic contrast material. Diffusion weighted imaging (DWI) and MR spectroscopy (MRS) complemented MRI: DWI revealed an iso-intense mass with multiple small hypo-intense ‘cystic-like’ areas; MRS demonstrated a pathological alteration of the spectral pattern, with complete absence of N-Acetyl Aspartate, marked depletion of Creatine compounds, elevated levels of Choline and lipids. According to the previously reported findings [20], a radiologic diagnosis compatible with CPC was made. The tumour was completely removed through a transparietal route to the lateral ventricle, even if a local invasion of the brain parenchyma was present at the lateral wall of the ventricle. The post-surgical period was uneventful and, 42 months after the surgery, the child is alive and well. Histologically, the lesion demonstrated the typical morphology of CPC with irregular papillae (Figure 2A) lined by cytologically malignant cells and surrounded by sheets of epithelioid-looking cells occasionally forming perivascular rosettes. Mitotic figures, including atypical mitoses, were often observed, as well as necrotic areas. By immunoperoxidase staining (Ventana Medical Systems, Inc.), the tumour cells showed positivity for cytokeratin 8 and 18, S100, vimentin, and focally for synaptophysin. The MIB-1 proliferative index was about 20% and strong p53 nuclear staining was seen in the overwhelming majority of tumour cells (Figure 2B).