• The accuracy of the sentinel node procedure after excision biopsy in squamous cell carcinoma of the vulva.

      Crosbie, Emma J; Winter-Roach, Brett; Sengupta, Partha; Sikand, Kanwal A; Carrington, Bernadette M; Murby, Brian; Slade, Richard J; Department of Gynaecological Oncology, The Christie NHS Foundation Trust, Wilmslow Road, Manchester, M20 4BX, UK. (2010-12)
      INTRODUCTION: Restricting inguinofemoral lymphadenectomy to patients with malignant nodes would reduce treatment-related morbidity in vulval cancer patients. A prospective study was conducted to determine the diagnostic accuracy of the Sentinel Lymph Node (SLN) procedure in vulval cancer patients referred following either diagnostic or excision biopsy. METHODS: Patients with clinical stage I and II squamous cell carcinoma of the vulva underwent SLN identification with peri-scar/lesional injection of (99m)Technetium-labelled nanocolloid (pre-operative lymphoscintigraphy and intra-operative use of a hand-held probe) and intra-operative blue dye. Radical excision of the vulval tumour or scar and formal inguinofemoral lymphadenectomy was then performed as necessary. SLN were processed separately and further examined at multiple levels to exclude micrometastases (H&E/cytokeratin staining) if negative on routine analysis. Clinical follow-up was carried out to identify and treat recurrences or treatment-related morbidity. RESULTS: Thirty-two women took part. Fifteen were referred following excision biopsy and seventeen following diagnostic biopsy of their primary vulval tumour. One or more SLN was successfully detected intra-operatively in 31 patients (97%) and 45 groins. An SLN could not be identified intra-operatively in one case (re-excision of scar). On average, more SLN were identified in patients with their primary vulval lesion in situ compared with those whose tumour had previously been excised (2.6 vs. 1.8, p = 0.03). Midline tumours were more likely (15/17) than lateral tumours (1/15) to have bilateral SLN identified pre-operatively. Two patients with midline tumours previously excised had unilateral SLN. Seven patients (23%) and ten groins had inguinofemoral lymph node metastases. The SLN procedure correctly identified inguinofemoral metastases in six patients (nine groins). In one case (midline tumour, re-excision of scar) the sentinel node was positive on one side but false negative on the other. CONCLUSIONS: The SLN procedure may be used to identify malignant groins in selected patients with vulval cancer. The extent to which previous vulval surgery might influence the accuracy of the SLN procedure deserves further investigation.
    • Aggressive angiomyxoma of the vulva and perineum: a case report.

      Umeadi, Uchenna P; Ahmed, Ahmed S; Winter-Roach, Brett; Murphy, James V; Shenjere, Patrick; Slade, Richard J; Christie Hospital NHS Foundation Trust, Manchester, UK. ucheup@hotmail.com (2008-10)
    • Alveolar rhabdomyosarcoma with neuroendocrine/neuronal differentiation: report of 3 cases.

      Houreih, Mohammad Adib; Lin, Amy Y; Eyden, Brian P; Menasce, Lia P; Harrison, James; Jones, David R; Folberg, Robert; Chejfec, Gregorio; Banerjee, Saumitra S; Department of Histopathology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom. (2009-04)
      The aim of this study is to report the clinicopathologic characteristics of 3 cases of alveolar rhabdomyosarcoma with neuroendocrine/neuronal differentiation. Specimens of 3 cases of alveolar rhabdomyosarcoma were studied using histologic, immunohistochemical, ultrastructural, and molecular genetic techniques. The patients were a 19-year-old man with metastatic alveolar rhabdomyosarcoma in a groin lymph node, a 16-year-old girl with alveolar rhabdomyosarcoma of the perineum, and a 20-year-old man with recurrent orbital alveolar rhabdomyosarcoma. Microscopically, case 1 was composed of compact sheets of medium to large tumor cells. Cases 2 and 3 were small blue round cell tumors. Cases 1 and 3 were solid throughout, whereas case 2 demonstrated alveolar and solid architecture. By immunohistochemistry, the following markers were positive: desmin (3/3), myogenin (3/3), synaptophysin (3/3), and chromogranin (2/3). Ultrastructurally, sarcomeric filaments were seen in all cases, while neuroendocrine granules were detected only in case 1. PAX:FKHR fusion transcript was identified in case 2, case 3 had a variant PAX3 transcript, and case 1 was negative. The data presented expands the known differentiation of alveolar rhabdomyosarcoma.
    • Analysis of circulating tumor cells in patients with non-small cell lung cancer using epithelial marker-dependent and -independent approaches.

      Krebs, Matthew G; Hou, Jian-Mei; Sloane, Robert; Lancashire, Lee J; Priest, Lynsey; Nonaka, Daisuke; Ward, Timothy H; Backen, Alison C; Clack, Glen; Hughes, Andrew; et al. (2012-02)
      Epithelial circulating tumor cells (CTCs) are detectable in patients with non-small cell lung cancer (NSCLC). However, epithelial to mesenchymal transition, a widely reported prerequisite for metastasis, may lead to an underestimation of CTC number. We compared directly an epithelial marker-dependent (CellSearch) and a marker-independent (isolation by size of epithelial tumor cells [ISET]) technology platform for the ability to identify CTCs. Molecular characteristics of CTCs were also explored.
    • Are There Myofibroblasts in Normal Bladder?

      Eyden, Brian P; Department of Histopathology, The Christie NHS Foundation Trust, Manchester M20 4BX, United Kingdom. (2009-03-31)
    • Basement-membrane-related peri-vascular matrices not organised as a basal lamina: distribution in malignant tumours and benign lesions.

      Eyden, Brian P; Yamazaki, Kazuto; Menasce, Lia P; Charchanti, A; Agnantis, N J; Department of Histopathology, Christie Hospital NHS Trust, Manchester, United Kingdom. Brian.Eyden@christie-tr.nwest.nhs.uk (2000-10)
      Peri-vascular matrices having a finely textured granular substructure have been identified in 27 human lesions: these were mostly malignancies but included benign tumours and reactive processes. The matrices were defined as stromal components surrounding endothelium and pericytes, and lying between vessels and adjacent lesional cells. They were identified as having a finely textured, uniform and moderately dense substructure, and differed from a conventional basal lamina expected at these sites by the absence of the typical lamina densa/lamina lucida configuration. By light microscope immunohistochemistry, vessels stained positively for laminin and collagen IV, two of the main proteins characterising a conventional basal lamina. The present observations emphasise the following. 1) The proteins laminin and collagen IV can be found in peri-vascular locations which have a finely textured granular substructure, and which have clearly defined ultrastructural differences from a conventional basal lamina. 2) While conventional light microscope immunohistochemistry demonstrates the presence and cellular location of proteins, electron microscopy is helpful for giving information on their physical organisation. 3) Peri-vascular granular matrices have a widespread distribution in malignant tumours but also exist in benign tumours and reactive lesions. This paper briefly discusses the possible functions of these matrices as modulators of cell biological processes.
    • Benign schwannoma in paranasal sinuses: a clinico-pathological study of five cases, emphasising diagnostic difficulties.

      Sheikh, Hamid Y; Chakravarthy, R P; Slevin, Nicholas J; Sykes, Andrew J; Banerjee, Saumitra S; Department of Clinical Oncology, Christie Hospital NHS Trust, Manchester, UK. hamid.sheikh@christie-tr.nwest.nhs.uk (2008-06)
      OBJECTIVES: To highlight the difficulty in making a correct diagnosis of benign schwannoma in the paranasal region, to raise awareness of this rare condition, and to suggest the most appropriate treatment. METHOD: Retrieval of cases retrospectively from archives of the histopathology department of a major UK cancer centre with central review of all cases. RESULTS: Five cases were identified since 1990 and clinical and pathological features are summarised. Median follow up of patients was 8.1 years. Radiological appearances of local bone invasion and histological features of tumour unencapsulation and hypercellularity could give the mistaken impression of malignant disease and lead to unnecessary over-treatment. CONCLUSION: Central pathological review and clinical awareness is required. Although local recurrence can occur, the prognosis is excellent. The treatment of choice is local excision. Radiotherapy can be considered, but in most cases it would incur unnecessary morbidity.
    • Carcinoma versus cytokeratin-positive lymphoma: a case report emphasizing the diagnostic role of electron microscopy.

      Eyden, Brian P; Chakrabarty, Bipasha; Hatimy, Umi; Department of Histopathology, The Christie NHS Foundation Trust, Manchester, UK. brian.eyden@christie.nhs.uk (2009)
      Lymphoma diagnosis rarely needs electron microscopy (EM), but one area where it can be useful is in the distinction of cytokeratin-positive lymphoma from carcinoma. The authors describe such a case, where difficulties were encountered due to lack of antibody specificity, distinguishing reactive from tumoral cells, and suboptimal sampling for EM. The tumor was in a lymph node next to the right submandibular gland in a 69-year-old man. This was a malignant tumor, composed of sheets of monomorphic large round cells. Interpretation on the part of a team of pathologists who examined this tumor was divided. On histological sections, the differential diagnosis was between carcinoma and lymphoma, which was modified to cytokeratin-positive lymphoma versus carcinoma since tumor cells were found to be cytokeratin-positive. EM of tumor retrieved from formalin showed plasmablastic features, in keeping with lymphoma with plasmablastic differentiation, one of the light microscopy diagnoses. The moderately strong positivity of cytokeratin and the positivity for Ber-EP4, however, supported carcinoma, and further sampling for EM was carried out, specifically on a cytokeratin-positive area of the wax block. Tonofibrils were found, supporting carcinoma. The final diagnosis was undifferentiated carcinoma with unknown primary site. The study emphasizes the need to take into account the imperfect specificity of cytokeratin, which can be found in several hemolymphoid neoplasms, to distinguish reactive from neoplastic cells, and to secure appropriate sampling for EM. This is one of the occasions where dewaxing (of an immunohistochemically defined wax block) offers positive advantages, despite compromised structural preservation, in the search for diagnostically important organelles.
    • CD30-positive T-cell lymphoproliferative disorder of the oral mucosa--an indolent lesion: report of 4 cases.

      Agarwal, Monica; Shenjere, Patrick; Blewitt, Robert W; Hall, Gillian; Sloan, Philip; Pigadas, N; Banerjee, Saumitra S; University Hospitals of Morecambe Bay NHS Trust, Lancaster, United Kingdom. (2008-07)
      Four cases of CD30-positive T-cell lymphoproliferative disorder (CD30+ LPD) of the oral mucosa are described. This article aims to draw attention to this entity and to emphasize its usual benign clinical behavior despite its resemblance to T-cell lymphoma. All the patients were adults. Three of the lesions were on the dorsal surface of the tongue and 1 affected the buccal mucosa. All biopsies showed a dense lymphoid infiltrate composed of CD30+ atypical T cells with a polymorphous infiltrate in the background, which included eosinophils. In 1 case, monoclonal T-cell expansion was detected by molecular techniques. Three cases tested for Epstein-Barr virus were all negative. It is concluded that primary CD30+ T-cell LPD of the oral mucosa can be regarded as the oral counterpart of cutaneous CD30+ LPD such as lymphomatoid papulosis or anaplastic large cell lymphoma. Recognition of the condition is important to avoid overtreatment.
    • Clinical quantitation of immune signature in follicular lymphoma by RT-PCR-based gene expression profiling.

      Byers, Richard J; Sakhinia, Ebrahim; Joseph, Preethi; Glennie, Caroline; Hoyland, Judith A; Menasce, Lia P; Radford, John A; Illidge, Timothy M; Department of Histopathology and Manchester Molecular Diagnostic Center, Manchester Royal Infirmary, Central Manchester, UK. r.byers@manchester.ac.uk (2008-05-01)
      Microarray gene expression profiling studies have demonstrated immune response gene signatures that appear predictive of outcome in follicular lymphoma (FL). However, measurement of these marker genes in routine practice remains difficult. We have therefore investigated the immune response in FL using real-time polymerase chain reaction (PCR) to measure expression levels of 35 candidate Indicator genes, selected from microarray studies, to polyA cDNAs prepared from 60 archived human frozen lymph nodes, in parallel with immunohistochemical analysis for CD3, CD4, CD7, CD8, CD10, CD20, CD21, and CD68. High levels of CCR1, a marker of monocyte activation, were associated with a shorter survival interval, and high levels of CD3 with better survival, while immunohistochemistry demonstrated association of high numbers of CD68(+) macrophages with a shorter survival interval and of high numbers of CD7(+) T cells with a longer survival interval. The results confirm the role of the host immune response in outcome in FL and identify CCR1 as a prognostic indicator and marker of an immune switch between macrophages and a T cell-dominant response. They demonstrate the utility of polyA DNA and real-time PCR for measurement of gene signatures and the applicability of using this type of "molecular block" in clinical practice.
    • Comparison of serum cortisol measurement by immunoassay and liquid chromatography-tandem mass spectrometry in patients receiving the 11β-hydroxylase inhibitor metyrapone.

      Monaghan, Phillip J; Owen, L J; Trainer, Peter J; Brabant, Georg E; Keevil, B G; Darby, Denise; Biochemistry Department, The Christie NHS Foundation Trust, Withington, Manchester M20 4BX, UK. phillip.monaghan@nhs.net (2011-09)
      The accurate measurement of cortisol by immunoassay is compromised by the potential for cross-reactivity of reagent antibodies with structurally related steroids present in serum. This susceptibility is potentiated when normal steroid metabolism is altered pharmaceutically by antisteroidogenic drugs utilized in the management of Cushing's syndrome to moderate cortisol production. The clinical implications of falsely elevated cortisol results include over-treatment and unrecognized hypoadrenalism. To investigate the effect of the 11β-hydroxylase inhibitor metyrapone on serum cortisol assay, a comparison of measurement by immunoassay versus liquid chromatography-tandem mass spectrometry (LC-MS/MS) was conducted.
    • Cribriform-morular variant of papillary thyroid carcinoma: molecular characterization of a case with neuroendocrine differentiation and aggressive behavior.

      Cameselle-Teijeiro, José; Menasce, Lia P; Yap, Beng K; Colaco, Rovel J; Castro, Patricia; Celestino, Ricardo; Ruíz-Ponte, Clara; Soares, Paula; Sobrinho-Simões, Manuel; Department of Pathology, Clinical University Hospital, Galician Health Service, University of Santiago de Compostela, Santiago de Compostela, Spain. (2009-01)
      We describe an especially aggressive case of cribriform-morular variant (C-MV) of papillary thyroid carcinoma (PTC) in a 42-year-old man with familial adenomatous polyposis who died with lung and brain metastases 17 months after thyroidectomy. The angioinvasive neoplasm combined a mixture of trabecular, solid, cribriform, and follicular patterns of growth with CD10+ morules. Follicles were devoid of colloid, and the nuclear features typical of PTC were present in some areas and missing in others. Tumor cells were positive for thyroid transcription factor-1 and, in 40% of the tumoral mass, also were positive for chromogranin and synaptophysin and were negative for thyroglobulin and calcitonin. Strong nuclear staining for beta-catenin was found in all tumor cells, as was positivity for p53 and cyclin D1. In addition to the germline heterozygous APC Ex 2-3 duplication mutation, a somatic homozygous silent p. Thr1493Thr gene variant was found in the neoplastic cells along with RET/PTC rearrangement. This tumor represents the first case of C-MV of PTC showing neuroendocrine differentiation.
    • Diagnosis of alveolar rhabdomyosarcoma in effusion cytology: a diagnostic pitfall.

      Thiryayi, S A; Rana, D N; Roulson, J; Crosbie, P; Woodhead, M; Eyden, Brian P; Hasleton, Philip S; Manchester Cytology Centre, Manchester Royal Infirmary, Oxford Road, Manchester, UK. sakinah.a.t@hotmail.co.uk (2010-08)
    • Divergent differentiation in malignant melanomas: a review.

      Banerjee, Saumitra S; Eyden, Brian P; Christie Hospital NHS Foundation Trust, Manchester, UK. (2008-01)
      The aim of this review was to document and discuss diagnostic problems associated with divergent differentiation ('metaplastic change') in malignant melanomas, defined as the development in these tumours of morphologically, immunohistochemically and/or ultrastructurally recognizable non-melanocytic cell or tissue components. Types of divergent differentiation reported in malignant melanoma include: fibroblastic/myofibroblastic, Schwannian and perineurial, smooth muscle, rhabdomyosarcomatous, osteocartilaginous, ganglionic and ganglioneuroblastic, neuroendocrine and probable epithelial. Divergent differentiation is certainly a rare phenomenon and, when it occurs, can be missed by unwary pathologists and lead to diagnostic uncertainty. A carefully chosen immunohistochemical panel and the input of electron microscopy can help to clarify the nature of the cellular differentiation of these tumours and lead to a correct final diagnosis. The clinical significance of such aberrations is uncertain, nor are the underlying mechanisms as yet well defined.
    • Divergent differentiation in urothelial carcinoma and other bladder cancer subtypes with selected mimics.

      Shanks, Jonathan H; Iczkowski, Kenneth A; Department of Histopathology, The Christie NHS Foundation Trust, Manchester, UK. jonathan.shanks@christie.nhs.uk (2009-06)
      Conventional urothelial carcinoma accounts for most carcinomas of the urinary tract lining. However, neoplastic urothelium has the capacity to demonstrate enormous plasticity. A variety of unusual architectural patterns of urothelial carcinoma, such as the nested, microcystic and inverted variants, can be mistaken for reactive processes or benign tumours. Others such as the micropapillary, plasmacytoid and discohesive variants, can mimic metastatic tumour from other sites. The micropapillary variant in particular is more aggressive. In addition, urothelial carcinoma has a propensity to demonstrate divergent differentiation with glandular, squamous, small cell neuroendocrine, lymphoepithelioma-like, sarcomatoid or other elements. Pure squamous carcinoma or adenocarcinoma (the latter in particular) can be difficult to distinguish from contiguous or metastatic spread. Some variants have prognostic and potential therapeutic implications. Molecular genetic evidence has emerged recently supporting a close relationship between urothelial carcinoma and various divergent elements. Sarcomatoid carcinoma and its differential diagnosis with other spindle cell lesions of urinary tract will be covered in a separate review.
    • Early changes in the haemostatic and procoagulant systems after chemotherapy for breast cancer.

      Kirwan, C C; McDowell, G; McCollum, C N; Kumar, Shant; Byrne, Ged J; Department of Surgery, South Manchester University Hospitals Trust, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK. (2008-10-07)
      Venous thromboembolism (VTE) following breast cancer chemotherapy is common. Chemotherapy-induced alterations in markers of haemostasis occur during chemotherapy. It is unclear how rapidly this occurs, whether this is upregulated in patients developing VTE and whether changes predict for VTE. Markers of haemostasis, functional clotting assays and vascular endothelial growth factor were measured before chemotherapy and at 24 h, 4 days, 8 days and 3 months following commencement of chemotherapy in early and advanced breast cancer patients and in age- and sex-matched controls. Duplex ultrasound imaging was performed after 1 month or if symptomatic. Of 123 patients, 9.8% developed VTE within 3 months. Activated partial thromboplastin time (APTT), prothrombin time (PT), D-dimer, fibrinogen, platelet count, VEGF and fibrinogen were increased in cancer. Fibrinogen, D-dimer, VEGF and tissue factor were increased, at baseline, in patients subsequently developing VTE. D-dimer of less than 500 ng ml(-1) has a negative predictive value of 97%. Activated partial thromboplastin time, PT and thrombin-antithrombin showed significantly different trends, as early as within 24 h, in response to chemotherapy in patients subsequently developing VTE. Markers of coagulation and procoagulants are increased, before chemotherapy, in patients who subsequently develop VTE. A group of patients at minimal risk of VTE can be identified, allowing targeted thrombopropylaxis to the higher risk group.
    • An EMA negative, desmin positive malignant mesothelioma: limitations of immunohistochemistry?

      Salman, W D; Eyden, Brian P; Shelton, D; Howat, A; Al-Dawoud, A; Twaij, Z; East Lancashire Hospitals, UK. walidsalman@gmail.com (2009-07)
      Histopathologists in the current environment of medical negligence and litigation are more likely to use immunohistochemical investigations in their day-to-day practice to support their diagnosis and avoid future litigation. The caveat is that relying on immunohistochemistry is a double-edged sword and pathologists should be familiar with its limitations. We present a case of primary malignant peritoneal mesothelioma with an unusual immunohistochemical profile-desmin positive, EMA negative-and wish to highlight the importance of cautiously interpreting immunohistochemistry profiles when they do not fit the clinical history and histological appearance.
    • Epithelioid sarcoma: a case report with ultrastructural confirmation of myofibroblastic differentiation based on fibronexus junctions.

      Eyden, Brian P; Wang, Guofeng; Yao, Li Fang; Department of Histopathology, The Christie NHS Foundation Trust, Manchester, UK. (2009)
      Epithelioid sarcoma is an uncommon but well-described malignancy, which is found predominantly in the soft tissues of the young and middle-aged, and which pursues an indolent to aggressive course. It shows a degree of both mesenchymal and epithelial differentiation. Myofibroblastic differentiation has been recorded in epithelioid sarcoma for some time, the evidence being based mainly on the presence of smooth-muscle-type myofilaments and, more recently, on alpha-smooth-muscle actin and muscle-specific actin immunostaining. Myofibroblastic differentiation based on the stricter criterion of the fibronectin fibril/fibronexus junction has not so far been demonstrated except for a single atypical case with spindle-cell morphology and a cytokeratin-negative immunophenotype. The authors describe a conventional epithelioid sarcoma showing myofibroblastic differentiation based on the presence of fibronectin fibrils and fibronexus junctions. The patient was a 35-year-old Chinese male with a tumor that initially developed on his left forefinger: it recurred, then metastasised first to the left arm and eventually to the scalp. Histologically, the tumors had the typical features of epithelioid sarcoma: by immunohistochemistry, cytokeratin, epithelial membrane antigen, and vimentin were positive. By electron microscopy, rough endoplasmic reticulum, intermediate filaments, peripheral myofilaments, and fibronexus junctions were observed. This is the first epithelioid sarcoma of conventional histological type to show myofibroblastic differentiation on the basis of the more stringent criterion of the fibronexus. The findings are discussed in relation to the unusually varied differentiation reported for this tumor.
    • Epstein-Barr virus (EBV) genotypes among human immunodeficiency virus (HIV)-related B-cell lymphomas and B-cell post-transplant lymphoproliferative disorders (B-PTLD)--late-onset lymphomas, especially in the HIV setting, are associated with type-B-EBV.

      Ibrahim, H; Menasce, Lia P; Pomplun, S; Burke, M; Bower, M; Naresh, K; Departments of Histopathology, Hammersmith Hospital and Imperial College, London, London, UK. (2010-09)
      We investigated 26 B-cell post-transplant lymphoproliferative disorders (B-PTLD) and 15 human immunodeficiency virus-related aggressive B-cell lymphomas (HIV-BCL) from England that were associated with Epstein-Barr virus (EBV) for the polymorphic sequences of the EBV-encoded nuclear antigen 3C (EBNA3C) gene to distinguish the two different EBV strains. Type-A-EBV was identified in 92% of B-PTLDS and in 53% of HIV-BCL (P = 0.003). Among HIV-BCL, patients associated with type-B-EBV had been HIV positive for significantly longer when compared to those associated with type-A (P = 0.037) although there were no correlations with ethnicity, CD4 cell counts or plasma HIV viral load.
    • Estimation of renal function -- what is appropriate in cancer patients?

      Barraclough, Lisa H; Field, Catherine; Wieringa, Gilbert E; Swindell, Ric; Livsey, Jacqueline E; Davidson, Susan E; Department of Clinical Oncology, Christie Hospital, Manchester, UK. lisahelenbone@hotmail.com (2008-12)
      AIMS: To compare the accuracy of renal assessment in patients with cancer using radioisotope glomerular filtration rate (GFR), urine collection for creatinine clearance, Cockroft-Gault, Modification of Diet in Renal Disease (MDRD) and Wright formulae. MATERIALS AND METHODS: Measurements of isotope GFR from 367 patients were compared with estimates from the described methods (Cockroft-Gault, MDRD, Wright). An analysis including a further 252 patients with an isotope GFR < or = 50 ml/min was also carried out. RESULTS: The Wright formula was the most accurate form of estimating renal function for the first study group. The formulae were similar in accuracy in the second study group. CONCLUSIONS: The Wright formula is the most accurate form of estimation of renal function in comparison with the isotope GFR for cancer patients. When there is a large proportion of patients with a low isotope GFR (< or = 50 ml/min), the formulae have similar accuracy.