Triantafyllia Koletsa

Differential Response of Immunohistochemically Defined Breast Cancer Subtypes to Anthracycline-Based Adjuvant Chemotherapy with or without Paclitaxel

Background The aim of the present study was to investigate the efficacy of adjuvant dose-dense sequential chemotherapy with epirubicin, paclitaxel, and CMF in subgroups of patients with high-risk operable breast cancer, according to tumor subtypes defined by immunohistochemistry (IHC). Materials and Methods Formalin-fixed paraffin-embedded (FFPE) tumor tissue samples from 1,039 patients participating in two adjuvant dose-dense sequential chemotherapy phase III trials were centrally assessed in tissue micro-arrays by IHC for 6 biological markers, that is, estrogen receptor (ER), progesterone receptor (PgR), HER2, Ki67, cytokeratin 5 (CK5), and EGFR. The majority of the cases were further evaluated for HER2 amplification by FISH. Patients were classified as: luminal A (ER/PgR-positive, HER2-negative, Ki67low); luminal B (ER/PgR-positive, HER2-negative, Ki67high); luminal-HER2 (ER/PgR-positive, HER2-positive); HER2-enriched (ER-negative, PgR-negative, HER2-positive); triple-negative (TNBC) (ER-negative, PgR-negative, HER2-negative); and basal core phenotype (BCP) (TNBC, CK5-positive and/or EGFR-positive). Results After a median follow-up time of 105.4 months the 5-year disease-free survival (DFS) and overall survival (OS) rates were 73.1% and 86.1%, respectively. Among patients with HER2-enriched tumors there was a significant benefit in both DFS and OS (log-rank test; p = 0.021 and p = 0.006, respectively) for those treated with paclitaxel. The subtype classification was found to be of both predictive and prognostic value. Setting luminal A as the referent category, the adjusted for prognostic factors HR for relapse for patients with TNBC was 1.91 (95% CI: 1.31–2.80, Walds p = 0.001) and for death 2.53 (95% CI: 1.62–3.60, p<0.001). Site of and time to first relapse differed according to subtype. Locoregional relapses and brain metastases were more frequent in patients with TNBC, while liver metastases were more often seen in patients with HER2-enriched tumors. Conclusions Triple-negative phenotype is of adverse prognostic value for DFS and OS in patients treated with adjuvant dose-dense sequential chemotherapy. In the pre-trastuzumab era, the HER2-enriched subtype predicts favorable outcome following paclitaxel-containing treatment.

Mutational analysis of the BRAF, RAS and EGFR genes in human adrenocortical carcinomas

The serine/threonine kinase B-Raf plays a key role in the Ras/Raf/MEK/ERK pathway that relays extracellular signals for cell proliferation and survival. Several types of human malignancies harbor activating BRAF mutations, most frequently a V600E substitution. The epidermal growth factor receptor (EGFR), a transmembrane tyrosine kinase (TK) receptor that mediates proliferation and survival signaling, is expressed in a wide variety of normal and neoplastic tissues. EGFR inhibitors have produced objective responses in patients with non-small cell lung carcinomas harboring activating EGFR TK domain somatic mutations. We evaluated the presence of mutations in BRAF (exons 11 and 15), KRAS (exons 1 and 2), NRAS (exons 1 and 2), and EGFR (exons 18-21) in adrenal carcinomas (35 tumor specimens and two cell lines) by DNA sequencing. BRAF mutations were found in two carcinomas (5.7%). Four carcinomas (11.4%) carried EGFR TK domain mutations. One specimen carried a KRAS mutation, and another carried two NRAS mutations. No mutations were found in the two adrenocortical cell lines. BRAF- and EGFR-mutant tumor specimens exhibited stronger immunostaining for the phosphorylated forms of the MEK and ERK kinases than their wild-type counterparts. EGFR-mutant carcinomas exhibited increased phosphorylation of EGFR (Tyr 992) compared with wild-type carcinomas. We conclude that BRAF, RAS, and EGFR mutations occur in a subset of human adrenocortical carcinomas. Inhibitors of the Ras/Raf/MEK/ERK and EGFR pathways represent candidate targeted therapies for future clinical trials in carefully selected patients with adrenocortical carcinomas harboring respective activating mutations.

Somatostatin receptor expression in non-medullary thyroid carcinomas.

OBJECTIVEPeptide receptor radionuclide therapy (PRRT) is dependent upon binding of radiolabelled peptides to their respective receptor expressing cells. The main objective of this study was to characterize the expression of somatostatin receptor (SSTR) subtypes in non-medullary thyroid cancers in order to be able to recommend the use of PRRT as a treatment option in patients with progressive local or metastatic disease.DESIGNWe constructed tissue microarrays from paraffin blocks prepared from 47 cases of non-medullary thyroid carcinomas and related normal thyroid tissue. Immunohistochemical staining was performed with five different polyclonal SSTR antibodies.RESULTSSSTR subtypes sst2 and sst3 were expressed in all non-medullary thyroid carcinomas, sst1 and sst5 in 75%, and sst4 in 38%. Coexpression of more than three subtypes was detected in 36 of the 47 cases. The expression of SSTR sub-types in normal thyroid tissue was low or absent.CONCLUSIONSNon-medullary thyroid carcinomas frequently express all SSTR subtypes. This expression provides a basis for further studies with the aim of exploring PRRT as a possible new treatment for iodine-131 refractory metastatic non-medullary thyroid carcinomas.

Ciliated hepatic foregut cyst communicating with the gallbladder

Dear Editors: Ciliated hepatic foregut cyst (CHFC) has previously been considered to be a rare lesion. However, in the last 15 years, the advent of radiological procedures has resulted in the publication of a number of case reports as well as three case series [1, 3, 4], suggesting that this entity has been underreported because it is usually asymptomatic. CHFC has a strong predilection for segment IV of the liver (medial segment of left lobe) and is lined by respiratory-type epithelium, similar to that seen in bronchogenic and esophageal cysts. Therefore, CHFC is believed to be of maldevelopmental origin, arising from remnants of the embryonic foregut, which, in addition to the liver, also forms the tracheobronchial tree, esophagus and other organs. Review of the literature has disclosed seven cases of CHFC located in the gallbladder wall [1, 2]. No communication between the cyst and the gallbladder lumen was found in any of these cases. To our knowledge, this is the first report of a CHFC connected to the gallbladder through a patent duct. A 39-year-old woman presented with colicky pain in the right upper quadrant of the abdomen, which was accompanied by nausea. There was no fever or jaundice. Murphy’s sign was positive. The patient’s past medical history was remarkable for appendectomy at 18 years of age and lithiasis of the right kidney at 19 years. Laboratory findings on admission were unremarkable, including: white blood cell count 7320 per mm, hematocrit 44.9%, hemoglobin 14.9 g/dl, platelets 221 10 per mm, bilirubin 0.69 mg/dl, aspartate aminotransferase 19 U/l (nl: 0–37 U/l), alanine aminotransferase 16 U/l (nl: 0–41 U/l), alkaline phosphatase 58 U/l (nl: 40–129 U/l), gamma glutamyl transferase 23 U/l (nl: 8–61 U/l), albumin 3.99 g/dl and globulin 2.67 g/dl. Testing for hepatitis B surface antigen and hepatitis C antibody was negative. Serum levels of carcinoembryonic antigen, CA 19–9 antigen and CA 50 antigen were within normal ranges. Abdominal ultrasonography showed a cystic structure in the liver measuring 64 31 mm. The gallbladder and large bile ducts appeared normal. No other pathology was noted. Abdominal computed tomography scan suggested that the cystic structure was multilocular and was closely associated with the gallbladder (Fig. 1A). On magnetic resonance imaging, the cyst was localized in segment V of the liver, in close relation to the gallbladder, and measured 51 50 mm. On surgery, it was found that the gallbladder and the cyst communicated through a short duct measuring approximately 2 cm, which was located at the junction of the body and neck. An additional duct, connecting the cyst with the cystic duct, was visualized on intraoperative cholangiography. The cyst contained bile and bile sludge. The gallbladder, its connection to the cyst and portions of the cyst wall were resected. The common bile duct was explored and was found to be free of stones or bile sludge; a Kehr T-tube was placed. A portion of omentum was then placed in the residual cavity. No stones were identified within the gallbladder. On gross examination, the gallbladder measured 7.5 2.7 cm, had a wall thickness of 0.3 cm and was lined by velvet-like, green-tan mucosa with yellow specks. The connecting duct, measuring 0.1–0.2 cm in diameter, was identified. The portions of cyst wall that were received for examination were flat, gray-tan tissue fragments, measuring up to 3.1 cm in greatest dimension. Histological examination showed a multilocular cyst with a fibrous wall, which was lined by ciliated, pseudostratified, columnar epithelium (Fig. 1B). Occasional goblet cells were present. The fibrous tissue contained T. Koletsa · V. Tzioufa · P. Hytiroglou ()) Department of Pathology, Aristotle University Medical School, 540 06 Thessaloniki, Greece e-mail: phitir@med.auth.gr Tel.: +30-231-0999218 Fax: +30-231-0999229

Synovial sarcoma of the heart

Sir, Synovial sarcoma (SS) is the fourth most common type of soft-tissue sarcoma, and usually occurs in the paraarticular regions of the extremities [10]. Despite its name, this tumor is uncommon in joint cavities, while it may be encountered in areas with no apparent relationship to synovial structures, such as the parapharyngeal region, abdominal wall, pleura and heart. In a search of the literature, we identified only nine cases of primary SS of the heart [1, 2, 3, 4, 6, 7, 8, 9], four of which arose in the right atrium and formed polypoid masses [1, 4, 8, 9]. SSs are composed of two distinct types of cells: epithelial cells, resembling those of carcinoma, and spindle cells, similar to those of fibrosarcoma [10]. Depending on the relative prominence of the two cellular elements and the degree of differentiation, SSs are classified into four categories: biphasic, monophasic fibrous, monophasic epithelial, and poorly differentiated. Whereas the biphasic type is readily recognizable by the coexistence of the two cell types, the diagnosis of the other three types of SS often requires the input of immunohistochemical and molecular methods. SS is characterized by a specific chromosomal translocation, t(X;18)(p11.2;q11.2), involving the SYT gene on chromosome 18 and one of the SSX genes (SSX1, SSX2 or SSX4) on the X chromosome. We report a case of monophasic fibrous SS of the right atrium. The patient was a 28-year-old man who presented with facial edema, distention of neck veins and systemic hypertension (170/120 mmHg). His past medical history was unremarkable. Magnetic resonance imaging of the chest revealed a polypoid mass in the apex of the right atrium, which on echocardiogram measured 2.9 cm in greatest dimension. Transesophageal echocardiogram confirmed the presence of an atrial tumor extending to the superior vena cava. Work-up of the patient was negative for metastases. A sternotomy was performed; the tumor was excised in pieces and sent for histological examination. On gross examination, the tumor fragments were polypoid, white-pink and soft. The cut surfaces had myxoid or elastic consistency. Frozen section examination revealed a high-grade spindle-cell sarcoma. On permanent sections, the tumor had myxoid areas of moderate cellularity alternating with densely cellular areas. The neoplastic cells were arranged in sheets and interlacing fascicles (Fig. 1A). They contained moderately pleomorphic, hyperchromatic nuclei and a small amount of cytoplasm. Mitotic activity was high; three to six mitotic figures per high power field were found in many areas (Fig. 1B). There were multiple small foci in which the tumor cells had ovoid or roundish shape and appeared more cohesive than the surrounding spindle cells, forming clusters. The neoplastic cells infiltrated the wall of the right atrium. Immunohistochemical stains were performed on paraffin sections with a standard streptavidin-biotin peroxidase method. The tumor cells were diffusely positive for vimentin. The majority of tumor cells were also positive for bcl-2 oncoprotein. The cells in the cohesive clusters were additionally positive for epithelial markers, including cytokeratin cam5.2, cytokeratin AE-1/AE-3 (Fig. 1C) and epithelial membrane antigen (Fig. 1D). Some spindle cells showed mild positivity for smooth muscle actin. Stains for desmin, myoglobin, S-100 protein, CD34 antigen, factor VIII-related antigen, CD99 antigen and CD117 antigen were negative. The presence of SYT-SSX fusion transcripts was assessed using a reverse-transcription polymerase chain reaction (RT-PCR) method [5] on RNA extracted from paraffin-embedded tumor tissue. RNA extracted from a case of biphasic synovial sarcoma of the thigh was used as T. Koletsa · V. Kotoula · P. Hytiroglou · C. S. Papadimitriou ()) Department of Pathology, Aristotle University Medical School, 540 06 Thessaloniki, Greece e-mail: kpapadim@med.auth.gr Tel.: +30-2310-999204 Fax: +30-2310-999229

Cervical epidural plasmacytoma presenting as ascending paraparesis.

BACKGROUND CONTEXT Spinal epidural plasmacytomas are very rare and are usually localized in the cervicothoracic and lumbar spines. PURPOSE To present the first case of cervical dural plasmacytoma and discuss the treatment options for this entity. STUDY DESIGN Case report and review of the literature. METHODS A 45-year-old man presented with gradually progressive legs to arms numbness preceded by upper respiratory tract infection and followed by rapid flaccid quadriparesis over 1 week. Because of the above symptoms, he was initially thought to have Guillain-Barré syndrome, but this diagnosis was ruled out by an emergency normal nerve conduction studies and needle electromyography. Cervical magnetic resonance imaging revealed an enhancing epidural mass at the C4-C7 level on T1-weighted images and increased signal on T2, causing spinal cord compression. Complete surgical evacuation was performed. Subsequent histology revealed plasmacytoma associated with anaplastic multiple myeloma, and the patient was referred to the hematology department for further treatment. RESULTS Follow-up at 9 and 13 months after surgery revealed complete remission of the primary disease (multiple myeloma). The patient was neurologically improved and ambulatory with unilateral support. CONCLUSION The reported case describes the first epidural extramedullary plasmacytoma isolated in the cervical spine in the English literature. Emergent neuroimaging and surgery can dramatically affect prognosis of this rare spinal neoplasm.

Mesectodermal leiomyoma of the ciliary body: Report of a case and review of the literature

Mesectodermal leiomyoma of the ciliary body is a rare benign tumor with double (muscular and neural) differentiation. This neoplasm is considered to originate from the ciliary body smooth muscle, a neural crest derivative. We report a case of mesectodermal leiomyoma of the right eye occurring in a 53-year-old woman, who presented with significant decrease of visual acuity. A malignant melanoma was highly suspected on clinical evaluation, and the globe was enucleated. The tumor measured 1.2cm in greatest dimension, and consisted of spindle and ovoid cells with abundant fibrillary cytoplasmic processes. Immunohistochemical stains revealed positivity for smooth muscle actin, caldesmon, neuron-specific enolase, and CD56 antigen. A review of the 23 cases thus far reported in the literature shows a striking predilection for women, as well as significant difficulties in differentiating this tumor from malignant melanoma on clinical grounds.

Angiomatoid fibrous histiocytoma with cystic structures of sweat duct origin

Angiomatoid fibrous histiocytoma is an unusual soft tissue tumor, mostly arising in the subcutaneous fibro‐adipose tissue of children and young adults and measuring a few centimeters in greatest dimension. Reported herein is a unique case of angiomatoid fibrous histiocytoma containing epithelium‐lined cystic structures. This large tumor (12 cm) was located in the subcutaneous tissue of the left leg of a 28‐year‐old woman. The cystic structures were variably sized and were lined by a double cell layer with areas of squamous metaplasia. Their overall histological features suggested a sweat duct origin. Immunohistochemical stains confirmed such origin, demonstrating an inner epithelial and an outer myoepithelial (smooth muscle actin and cytokeratin 17 positive) cell layer. The present case is illustrative of a mechanism of sweat duct dilatation that may occur during the growth of neoplasms involving the dermis and subcutis, resulting in formation of tumors with unusual histological features.

A case of a primary cutaneous plasmacytoma presenting in adolescence.

Primary cutaneous plasmacytoma is defined as monoclonal proliferation of plasma cells that arises primarily in the skin without evidence of systemic disease. We present an extremely rare case of a young adult diagnosed with solitary plasmacytoma. A 20-year-old woman presented with a pruritic erythematosquamous indurated plaque on the inner aspect of her right thigh. She had undergone a biopsy 5 years ago, and under the diagnosis of Nekam disease, she was treated with topical steroids followed by intralesional injections of triamcinolone acetonide. A new skin biopsy revealed infiltration of the epidermis by small T lymphocytes while plasma cell accumulations were found in the dermis. Immunostains for light and heavy chains [kappa, lambda, immunoglobulin (Ig) G, IgA, and IgM] demonstrated IgG/κ monoclonality of the plasma cells. On molecular analysis, T-cell receptor and immunoglobulin heavy chain rearrangements were polyclonal. Serum protein electrophoresis, immunofixation, and quantitative assessment of serum Igs were normal. Bone marrow biopsy, skeletal survey, and body computed tomography scan were unremarkable. A diagnosis of primary solitary cutaneous plasmacytoma was made. The lesion was removed surgically, and the patient remains in remission up to now. Primary cutaneous plasmacytoma represents only 2%-4% of extramedullary plasmacytomas. The rarity and the nonspecific presentation of cutaneous plasmacytomas does not allow a definite clinical diagnosis. Only histopathology reveals the typical pattern of a dense monomorphic dermal plasmacytic infiltrate, whereas immunohistochemistry shows monoclonality of the neoplastic cells.

Detection of centroblasts in H&E stained images of follicular lymphoma

This paper presents a complete framework for automatic detection of malignant cells in microscopic images acquired from tissue biopsies of follicular lymphoma. After pre-processing to remove noise and suppress small details, images are segmented by using intensity thresholding, in order to detect the cell nuclei. Subsequently, touching cells are being separated using Expectation Maximization algorithm. Candidate centroblasts are then selected for classification by using size, shape and intensity histogram criteria. Finally, candidates are classified by using a Linear Discriminant Analysis classifier. The application of the methodology in a generated dataset of microscopic images, stained with Hematoxylin and Eosin, showed promising results by detecting in average 82.58% of the annotated malignant cells.