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Inflammatory bowel disease (IBD) patients in apparent clinical remission who present with irritable bowel syndrome (IBS)-like symptoms pose a diagnostic and therapeutic dilemma that is called post-IBD IBS. When associated with a diarrheal IBS presentation, this clinical syndrome is known as post-IBD IBS-D.We review and describe the literature regarding the clinical overlap of IBD and IBS. We discuss prevalent theories regarding the pathophysiology of post-IBD IBS-D and whether this presentation represents coincident inherent IBS-D, IBS-D triggered by IBD, or an even more subtle level of IBD activity that is unrecognized by available laboratory modalities. We also discuss observations that post-IBD IBS-D patients harbor significantly increased colon mucosal eosinophils and appear to respond to a GI-hypoallergenic diet and budesonide therapy.The symptoms overlap between IBD and IBS complicates diagnosis and subsequent management of patients with post-IBD IBS-D. In addition to current theories regarding the pathophysiology of this condition such as alterations in mucosal inflammation, the microbiota, mucosal permeability, and gut-brain interactions. This new avenue of eosinophilic colopathy and therapy directed toward food-derived immune response in patients with post-IBD IBS-D deserves additional investigation.

Inflammatory bowel disease (IBD) is a chronic inflammatory condition driven by diverse genetic and nongenetic programs that converge to disrupt immune homeostasis in the intestine. We have reported that, in murine intestinal epithelium with telomere dysfunction, DNA damage-induced activation of ataxia-telangiectasia mutated (ATM) results in ATM-mediated phosphorylation and activation of the YAP1 transcriptional coactivator, which in turn up-regulates pro-IL-18, a pivotal immune regulator in IBD pathogenesis. Moreover, individuals with germline defects in telomere maintenance genes experience increased occurrence of intestinal inflammation and show activation of the ATM/YAP1/pro-IL-18 pathway in the intestinal epithelium. Here, we sought to determine the relevance of the ATM/YAP1/pro-IL-18 pathway as a potential driver of IBD, particularly older-onset IBD. Analysis of intestinal biopsy specimens and organoids from older-onset IBD patients documented the presence of telomere dysfunction and activation of the ATM/YAP1/precursor of interleukin 18 (pro-IL-18) pathway in the intestinal epithelium. Employing intestinal organoids from healthy individuals, we demonstrated that experimental induction of telomere dysfunction activates this inflammatory pathway. In organoid models from ulcerative colitis and Crohn's disease patients, pharmacological interventions of telomerase reactivation, suppression of DNA damage signaling, or YAP1 inhibition reduced pro-IL-18 production. Together, these findings support a model wherein telomere dysfunction in the intestinal epithelium can initiate the inflammatory process in IBD, pointing to therapeutic interventions for this disease.

Background A systemic evaluation of immune cell infiltration patterns in experimental acute pancreatitis (AP) is lacking. Using multi-dimensional flow cytometry, this study profiled infiltrating immune cell types in multiple AP mouse models. Methods Three AP models were generated in C57BL/6 mice via cerulein (CAE) injection, alcohol and palmitoleic acid (EtOH + POA) injection, and alcohol diet feeding and cerulein (EtOH + CAE) injection. Primary pancreatic cells and splenocytes were prepared, and multi-dimensional flow cytometry was performed and analyzed by manual gating and computerized PhenoGraph, followed by visualization with t-distributed stochastic neighbor embedding (t-SNE). Results CAE treatment induced a time-dependent increase of major innate immune cells and a decrease of follicular B cells, and TCD4+ cells and the subtypes in the pancreas, whereas elicited a reversed pattern in the spleen. EtOH + POA treatment resulted in weaker effects than CAE treatment. EtOH feeding enhanced CAE-induced amylase secretion, but unexpectedly attenuated CAE-induced immune cell regulation. In comparison with manual gating analysis, computerized analysis demonstrated a remarkable time efficiency and reproducibility on the innate immune cells and B cells. Conclusions The reverse pattern of increased innate and decreased adaptive immune cells was consistent in the pancreas in CAE and EtOH + POA treatments. Alcohol feeding opposed the CAE effect on immune cell regulation. Together, the immune profiling approach utilized in this study provides a better understanding of overall immune responses in AP, which may facilitate the identification of intervention windows and new therapeutic strategies. Computerized analysis is superior to manual gating by dramatically reducing analysis time.

Autoimmune hepatitis (AIH) is a chronic inflammatory immune-mediated hepatic pathology of unclear etiology. The mechanisms initiating and driving autoimmune inflammation of the liver and the loss of hepatic tolerance are still elusive. Several studies have documented the involvement of genetic factors and triggering agents such as toxic injury, treatment with immune-modifying drugs, or previous viral infections with perhaps strongest evidence for the hepatitis C virus. Rarely, AIH has been reported to develop after hepatitis A virus infection. We describe a case of de novo AIH in a patient with a history of recent hepatitis A virus infection.

Context.—The cause of pancreatic acinar metaplasia (PAM) at the distal esophagus/esophagogastric junction is still controversial. Whereas some authors believe it is congenital, others believe it is acquired because of inflammation of the gastric cardia, and more recently it was proposed to be due to chronic proton pump inhibitor use based on a study in rats.Objective.—To determine whether there is correlation between chronic proton pump inhibitor use and PAM in humans. We also investigated the correlation between several clinical and pathologic factors and PAM.Design.—Four hundred forty-four consecutive biopsies from the distal esophagus/esophagogastric junction were reviewed for the presence of PAM, which was then correlated with several clinical and pathologic findings.Results.—Pancreatic acinar metaplasia was found in 71 patients (16%). Pancreatic acinar metaplasia was significantly associated with patient age younger than 51 years (P < .001), chronic carditis (P = .01), and chronic proton pump inhibitor use (P = .008). Surprisingly, we also found significant association between PAM and chronic nonsteroidal anti-inflammatory drug use (P < .001). These associations, including that with chronic nonsteroidal anti-inflammatory drug use, remained significant in multivariate analysis.Conclusions.—Our findings confirm the previous reports of significant association between PAM and chronic carditis and the findings from animal studies of association with chronic proton pump inhibitor use. The strong association with chronic nonsteroidal anti-inflammatory drug use has not been previously reported and warrants further studies.

The incidence of hepatocellular carcinoma (HCC) is on the rise worldwide. Although the incidence of HCC in males is considerably higher than in females, the projected rates of HCC incidence are increasing for both sexes. A recently appreciated risk factor for HCC is the growing problem of nonalcoholic fatty liver disease, which is usually associated with obesity and the metabolic syndrome. In this study, we showed that under conditions of fatty liver, female mice were more likely to develop HCC than expected from previous models. Using an inducible knockout model of the tumor-suppressive isoform of hepatocyte nuclear factor 4 alpha (“P1-HNF4α”) in the liver in combination with prolonged high fat (HF) diet, we found that HCC developed equally in male and female mice as early as 38 weeks of age. Similar sex-independent HCC occurred in the “STAM” model of mice, in which severe hyperglycemia and HF feeding results in rapid hepatic lipid deposition, fibrosis, and ultimately HCC. In both sexes, reduced P1-HNF4α activity, which also occurs under chronic HF diet feeding, increased hepatic lipid deposition and produced a greatly augmented circadian rhythm in IL6, a factor previously linked with higher HCC incidence in males. Loss of HNF4α combined with HF feeding induced epithelial–mesenchymal transition in an IL6-dependent manner. Collectively, these data provide a mechanism-based working hypothesis that could explain the rising incidence of aggressive HCC. Significance: This study provides a mechanism for the growing incidence of hepatocellular carcinoma in both men and women, which is linked to nonalcoholic fatty liver disease.

Pancreatic ductal adenocarcinoma (PDAC) is the third leading cause of cancer-related death in the United States. Despite the high prevalence of Kras mutations in pancreatic cancer patients, murine models expressing the oncogenic mutant Kras (Kras

Introduction Inflammatory bowel disease (IBD) patients in remission who present with irritable bowel syndrome with diarrhea (IBS-D) like symptoms pose a diagnostic and therapeutic dilemma that is called post-IBD IBS-D. This syndrome was first reported by Isgar et al. who documented IBS-type symptoms in 33% of their patients with chronic ulcerative colitis (CUC) in remission in 1983. In their meta-analysis of 13 studies incorporating 1,703 patients, Halpin and Ford in 2012 calculated a pooled prevalence of 35% for IBS symptoms among IBD subjects in remission. The post-IBD IBS-D syndrome represents a source of considerable stress, incurs morbidity and impairs quality of life of these patients. The etiology of this syndrome is unknown and may be multifactorial such as environmental, psychological, GI motility disarray, genetic components and possibly by gut microbiome. Methods We conducted a retrospective, single-center study of patients with history of IBD and IBS-D like symptoms. The demographic characteristics, type of IBD, colonoscopy, biopsy findings and empirical medical management outcome were analyzed. Results We have found significantly increased mucosal eosinophils (>50 HPF in both side of the colon examined) in our patients with post-IBD IBS-D syndrome. In this study, 15 CUC patients and 20 Crohn’s disease patients with this syndrome were investigated and showed no clinical, serological, mucosal or microscopic IBD activity. These patients had non-bloody diarrhea (5–20 x daily), lower abdominal cramps (%90), mild weight loss (4–6 lbs) and fecal incontinence (%25) who were placed on the GI-hypoallergenic diet and budesonide therapy. Sixty seven percent of these 35 patients with post-IBD IBS-D responded well clinically to this management. Increased mucosal eosinophils in these patients with post-IBD IBS-D may have eosinophilic colopathy that may be related to intestinal permeability disarray. The epithelium in these IBD patients who are in remission may have the production of pro-inflammatory cytokines by the eosinophils, especially IL-23 and IL-33. This interesting area investigation is in progress by our research faculty. Conclusion In summary, this is an exciting new finding that significantly increased mucosal eosinophils in our patients with post-IBD IBS-D syndrome may have a new avenue, eosinophilic colopathy. Interestingly, these patients have responded to the GI-hypoallergenic diet and budesonide therapy. Obviously, we need more patients in the near future with longer follow-up and we hope that the other investigators may confirm our findings.

Limited studies have shown that some patients with pancreatic adenocarcinoma (PAC) may benefit from treatment with tamoxifen. PAC has been shown to be largely negative for estrogen receptor alpha (ER-alpha). The aim of this pilot study was to investigate ER-beta expression in human PAC. Sections of tissue microarray with 18 evaluable cases of human PAC were stained by immunohistochemistry (IHC) for ER-beta1, ER-beta2, ER-beta5, and Cyclin A. The levels of ER-beta isoform expression and the S-phase fraction (SPF) were determined using quantitative digital image analysis. Higher mean and median ER-beta2 levels correlated with male sex (p = 0.057 and p = 0.035, respectively), older age (p = 0.005 and p = 0.006, respectively), and lower pT stage (p = 0.008 and p = 0.009). Mean and median ER-beta5 levels correlated negatively with SPF (p = 0.021 and p = 0.047, respectively). Mean ER-beta1 expression did not correlate with any of the above mentioned clinicopathologic factors. The findings in this pilot study, although should be considered preliminary, suggest that some ER-beta isoforms may play a role in the biology of PAC. Additional larger studies are needed to confirm our findings, and to determine whether ER-beta may be considered for future targeted therapy.

Increased esophageal cyclooxygenase-2 (COX-2) expression has been associated with Barrett’s esophagus (BE); however, it is unknown whether COX-2 expression varies among patient groups with different clinical or socio-demographic factors. We conducted a case–control study among eligible patients scheduled for elective esophagogastroduodenoscopy and patients eligible for screening colonoscopy recruited from primary clinics. We compared 39 BE tissue samples and 47 squamous tissue samples from BE cases and 240 squamous tissue samples from controls. Clinical and socio-demographic data were prospectively collected. Immunohistochemical staining for esophageal COX-2 was performed and scored. The median COX-2 score was significantly higher in BE tissue than squamous tissue from cases or controls (p

Question: A 48year-old Hispanic man developed melena after 25 days of hospitalization. He was initially brought to the emergency department after a motor vehicle accident that resulted in hemopneumothorax, multiple fractures, and blunt abdominal trauma. No past medical history was reported. After emergent endotracheal intubation and chest tubes placement, he underwent splenectomy, subtotal colectomy, and distal ileum resection. In the intensive care unit (ICU), he developed septic shock requiring broad-spectrum antibiotics, vassopressors, corticosteroids, and hemodialysis. Repeat laparotomy on day 9 revealed colocolostomy disruption, requiring additional bowel resection. Vassopressors and steroids were stopped after 5 days. His course was complicated by pulmonary embolism and persistent hyperglycemia. Multiple intra-abdominal washouts were required and abdominal cavity was closed on day 24. On day 25, melena was noted. He was tachycardic, afebrile, and normotensive. Surgical wound was clean, and abdominal examination revealed diffuse tenderness. Hemoglobin acutely dropped from 9 to 6.7 g/dL. Anticoagulation was stopped and an inferior vena cava filter placed. Upper endoscopy showed diffuse friable mucosa of the entire stomach. Large exudative ulceration was found in the gastric body (Figure A) from where biopsy specimens were taken. Other, scattered, clean-based ulcers were seen in the antrum and fundus (Figure B). The esophagus and duodenum were normal. A representative histopathology is provided (Figure C, D). What is the diagnosis? Look on page 1136 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Aims The purpose of this study was to determine prospectively whether p53 protein accumulation in biopsies of Barrett's metaplasia (BM) is a predictor of malignant progression, without relying on dysplasia grading. Methods and results Sections of formalin fixed paraffin embedded tissue from the initial biopsies of 275 patients with BM, who had no high grade dysplasia (HGD) or esophageal adenocarcinoma (EAC), were stained for p53 by immunohistochemistry. Mean follow up was 41 months. p53-positive biopsies were divided into 4 groups: scattered positive cells, multifocal scattered positive cells, aggregates of positive cells, and multifocal aggregates of positive cells. Kaplan-Meier analysis with the log-rank test was used to determine the rate of progression to high grade dysplasia (HGD)/ esophageal adenocarcinoma (EAC). Of the 275 patients, 227 had initial biopsies completely negative for p53 and of these one (0.4%) progressed to HGD/EAC; none of 24 (0%) patients with scattered positive cells and none of 4 (0%) of patients with multifocal scattered positive cells progressed. By contrast, 5 of 16 (31.25%) patients with aggregates of positive cells and 3 of 4 (75%) of those with multifocal aggregates of positive cells progressed to HGD/EAC. Kaplan-Meier analysis with log rank statistics showed the difference in progression rate between the five groups to be highly significant (p

Inflammatory bowel disease (IBD) is an idiopathic disease that is typically characterized by chronic inflammation of the gastrointestinal tract. Recently much effort has been devoted to the development of novel diagnostic tools that can assist physicians for fast, accurate, and automated diagnosis of the disease. Previous research based on Raman spectroscopy has shown promising results in differentiating IBD patients from normal screening cases. In the current study, we examined IBD patients in vivo through a colonoscope-coupled Raman system. Optical diagnosis for IBD discrimination was conducted based on full-range spectra using multivariate statistical methods. Further, we incorporated several feature selection methods in machine learning into the classification model. The diagnostic performance for disease differentiation was significantly improved after feature selection. Our results showed that improved IBD diagnosis can be achieved using Raman spectroscopy in combination with multivariate analysis and feature selection.

Human papillomavirus (HPV) is strongly associated with squamous esophageal cancer. The potential role of HPV in Barrett's esophagus (BE) has been examined but remains unclear. The aim of the study was to determine the prevalence of HPV in esophageal and gastric tissues obtained from patients with and without BE. We designed a cross-sectional study was conducted with prospective enrollment of eligible patients scheduled for esophagogastroduodenoscopy (EGD). All participants had biopsies of endoscopic BE, squamous-lined esophagus, and stomach. Immunohistochemistry (IHC) on formalin-fixed and paraffin-embedded tissue was conducted using monoclonal antibodies. Polymerase chain reaction (PCR) for HPV was performed on DNA extracted from esophageal biopsies snapped frozen within 30 minutes after endoscopic capture. The Roche HPV Linear Array Assay with PGMY primers that has high sensitivity for detecting 37 types of HPV was used. A total of 127 subjects were included: 39 with definitive BE had IHC done on samples from non-dysplastic BE, squamous esophagus, gastric cardia, and gastric body; and 88 control patients without BE had IHC done on squamous esophageal samples, gastric cardia, and gastric body. HPV was not detected in any of the samples in either group. For confirmation, HPV DNA PCR was performed on randomly selected samples from 66 patients (both esophagus and BE from 13 patients with BE, and 53 esophagus from patients without BE); no sample had HPV DNA detected via PCR in the presence of adequate quality control. HPV infection does not play a role in the formation of non-dysplastic Barrett's esophagus in men in the United States.

Background: The pathogenesis of breast cancer in very elderly women is of interest, because estrogen levels are likely to be extremely low during the development of the disease. Estrogens have opposing effects on the pathogenesis of breast cancer and osteoporosis. In an effort to understand the significance of estrogens in the pathogenesis of breast cancer in this group, we examined the association between breast cancer and osteoporosis in women at least 85 years old, taking body mass index (BMI) and hormone receptors status into consideration. Methods:Clinical records of consecutive elderly women (≥ 85 y/o) who underwent breast cancer surgery at Tokyo Metropolitan Geriatric Hospital (BC) and control women of the same age group (Cont) were reviewed; osteoporosis and BMI status in both groups were recorded and compared. The status of estrogen receptor (ER) and progesterone receptor (PR) of breast cancers was examined immunohistochemically and compared between BC with and without osteoporosis (BC-OP and BC-nonOP, respectively). Results:Frequency of osteoporosis was significantly lower among BC than Cont. There was no difference in BMI measured after 85 y/o between BC and Cont; however, percentage of women, whose BMI measured when they were in their sixties or seventies was ≥ 20% higher than BMI measured when they were 85 y/o or older, was significantly higher among BC than Cont (31% and 2%, respectively. P = 0.0001). ER positivity of breast cancer did not differ between BC-OP and BC-nonOP, whereas PR positivity was significantly higher among BC-nonOP than BC-OP (P = 0.0359). Discussion: The inverse relationship between the incidence of breast cancer and osteoporosis suggests an important role for estrogens in the pathogenesis of breast cancer in the very elderly women. Our finding that one third of BC had ≥ 20% higher BMI when they were in their sixties or seventies suggests they may also had elevated serum estrogens during these earlier years, because increased BMI has been reported to be associated with increased serum estrogens in postmenopausal women. Expression of PR is regulated by estrogen-ER signaling, and PR positivity is considered to reflect the effectiveness of estrogen-ER pathway. Significant difference of PR positivity between BC-nonOP and BC-OP suggests the more importance of estrogens in BC-nonOP than BC-OP. Conclusion:Estrogens seem to play an important role in the pathogenesis of breast cancers in very elderly women, especially without osteoporosis. With increasing aging population in developed countries, those findings may have implications for breast cancer prevention in this age group. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-17-04.

Purpose The clinicopathologic importance of a second estrogen receptor (ER), ER-β, in breast cancers has been intensely studied; however, there is still no real consensus regarding the clinical utility of an ER-β assay, probably because of the lack of standardized methodology, the presence of several ER-β isotypes (ER-β1-5, and so on), and, more importantly, the lack of convincing data on whether the ER-β status provides clinically useful information over what is already provided by the traditional ER-α/progesterone receptor (PR) assay. A large and systematic study is needed to address these important issues. Patients and Methods Archival materials of 442 invasive breast cancers from women treated with adjuvant tamoxifen monotherapy and with a long follow-up period (median, 11.1 years) were subjected to immunohistochemical study using three commercially available anti–ER-β antibodies that detect ER-β1-3 (ER-βN), ER-β1, and ER-βcx (ER-β2). Results Positive staining for ER-βN or ER-β1 was associated with significantly better survival. By contrast, ER-βcx status did not influence survival. In multivariate analysis, ER-β1 status emerged as an independent predictor of recurrence and mortality. ER-β1 status was significantly associated with survival in postmenopausal, but not premenopausal, women. Importantly, ER-β1 positivity was associated with significantly better survival in patients with ER-α–negative/PR-negative or ER-α–negative/PR–negative/human epidermal growth factor receptor 2–negative (triple-negative) tumors, which are widely believed to be hormone unresponsive, have poor prognosis, and require chemotherapy. Conclusion Immunohistochemical examination of ER-β1 in addition to ER-α and PR is clinically important in patients with breast cancer treated with tamoxifen monotherapy. Further studies are needed to confirm our findings.

Background Bcl-2 plays an anti-apoptotic role, resulting in poor clinical outcome or resistance to therapy in most tumor types expressing Bcl-2. In breast cancer, however, Bcl-2 expression has been reported to be a favorable prognostic factor. The positive correlation of Bcl-2 with estrogen receptor (ER)/progesterone receptor (PR) status, and endocrine therapy frequently given for hormone receptor-positive tumors, may obscure the independent pathobiological role of Bcl-2. We constructed a large systematic study to determine whether Bcl-2 has an independent role in breast cancer. Methods Bcl-2 expression was immunohistochemically evaluated and compared with other clinicopathological factors, including clinical outcome, in 1081 breast cancer cases with long follow-up, separately analyzing 634 cases without any adjuvant therapy and 447 cases with tamoxifen monotherapy. The χ2-test for independence using a contingency table, the Kaplan-Meier method with the log-rank test, and a Cox proportional hazards model were used for the comparison of clinicopathological factors, assessment of clinical outcome, and multivariate analyses, respectively. Results In both patient groups, Bcl-2 expression strongly correlated with positive ER/PR status, low grade, negative human epidermal growth factor receptor 2 (HER2) status, and small tumor size, as previously reported. Bcl-2 expression did not independently predict clinical outcome in patients with ER-positive and/or PR-positive tumors or in those who received tamoxifen treatment; however, it was an independent unfavorable prognostic factor in patients with ER-negative/PR-negative or triple-negative (ER-negative/PR-negative/HER2-negative) tumors who received no adjuvant therapy. The latter was even more evident in postmenopausal women: those with hormone receptor-negative or triple-negative tumors lacking Bcl-2 expression showed a favorable outcome. Conclusion Bcl-2 expression is an independent poor prognostic factor in patients with hormone receptor-negative or triple-negative breast cancers, especially in the absence of adjuvant therapy, suggesting that the anti-apoptotic effect of Bcl-2 is clearly exhibited under such conditions. The prognostic value of Bcl-2 was more evident in postmenopausal women. The present findings also highlight Bcl-2 as a potential therapeutic target in breast cancers lacking conventional therapeutic targets such as triple-negative tumors. The favorable prognosis previously associated with Bcl-2-positive breast cancer probably reflects the indirect effect of frequently coexpressed hormone receptors and adjuvant endocrine therapy.

Of putative specific markers for diffuse malignant mesothelioma, nuclear staining with Zymed polyclonal calretinin antibody has shown the best specificity to date for epithelial diffuse malignant mesothelioma versus adenocarcinoma. We compared specificity and sensitivity of this polyclonal antibody for diagnosis of diffuse malignant mesothelioma with a new monoclonal antibody from DAKO. One hundred eighteen adenocarcinomas and 111 diffuse malignant mesotheliomas-70 epithelial, 22 sarcomatous, and 19 biphasic-were immunostained with calretinin antibodies from Zymed (polyclonal rabbit, prediluted, PAD:DC8) and DAKO(monoclonal mouse, 1:100, clone DAK Calret 1) using manufacturer-recommended procedures. Cases were blinded and assessed for nuclear versus cytoplasmic staining, percent positive cells, and background. Both antibodies showed similar positive predictive values for diffuse malignant mesothelioma by nuclear staining (Zymed=95%; DAKO=97%). False positives in 4 (3.4%) and 2 (1.7%) adenocarcinomas, respectively, stained greater than 10% of cells. Sensitivity for epithelial malignant mesothelioma was slightly less for DAKO antibody (Zymed=80%; DAKO=73%). Neither antibody performed well on sarcomatous malignant mesothelioma (Zymed=2/22; DAKO=1/22). Both antibodies are useful in the diagnosis of epithelial malignant mesothelioma, although monoclonal antibody is slightly less sensitive.

BACKGROUND The growth and dissemination of tumors has been associated with angiogenesis, which is regulated by a group of polypeptide factors including vascular endothelial growth factor-C (VEGF-C). VEGF-C binds its receptor, vascular endothelial growth factor receptor-3 (VEGFR-3) to promote growth of tumor-associated lymphatic vessels. METHODS In this study, microarray technology was used to build tissue arrays of normal prostate, benign prostate hyperplasia (BPH) and prostate carcinomas (PCa) using tissues from 640 patients. Slides were sectioned and stained with a polyclonal antibody to VEGFR-3 using a standard immunoperoxidase method and digitized. Immunoreactivity was scored using a 0–3+ semiquantitation scoring system for both intensity and percentage. The sum index was obtained by totaling the scores. RESULTS VEGFR-3 is expressed in normal prostate, BPH, and PCa, but VEGFR-3 expression is up-regulated in PCa. We also found that VEGFR-3 is correlated with pre-operative prostate-specific antigen (Pre-PSA), Gleason score, and lymph node metastasis. The recurrence-free 5-year survival in cases with lower sum index (0–3) was significantly higher than that in cases with higher sum index (4–6) (77.3, 69.6%, respectively, P = 0.037) by Kaplan–Meier actuarial model. CONCLUSIONS Our data suggest that VEGFR-3 expression is associated with tumor progression and may play an important role in facilitating lymphatic spread of PCa; high-level of VEGFR-3 expression in prostate cancer cells increases the risk of biochemical recurrence in prostate cancer patients treated by radical prostatectomy. © 2003 Wiley-Liss, Inc.

Summary Background : Gastro-oesophageal reflux has been shown to induce oxidative DNA damage. Aim : To determine whether oxidative DNA damage, detected in oesophageal biopsies by simple immunohistochemical staining, correlates with gastro-oesophageal reflux disease as determined by pH monitoring. Methods : The study included 47 patients with reflux symptoms who had oesophageal biopsy and 24-h pH monitoring studies performed within 3 months of each other with no variation in treatment in the time between the two procedures. Sections of formalin-fixed and paraffin-embedded oesophageal biopsies were stained for 8-hydroxy-2′-deoxyguanosine using the standard immunoperoxidase method. Positive nuclear immunoreactivity was considered to indicate oxidative DNA damage. Results : Seven (33%) of the 21 cases with normal 24-h pH monitoring results were negative for oxidative DNA damage, compared with only two (8%) of the 26 cases with abnormal 24-h pH results (P = 0.058, two-sided Fisher's exact test). Five of the patients with normal 24-h pH results had oesophageal biopsies performed within 24 h of the monitoring procedure and, of these, four (80%) were positive for oxidative DNA damage, including a case in which both biopsy and 24-h pH monitoring were performed on the same day whilst the patient was on proton pump inhibitor therapy. All cases with normal 24-h pH results and positive oxidative DNA damage showed features of reflux on routine morphological evaluation. Conclusions : Oxidative DNA damage can occur in the absence of acid reflux and despite adequate antisecretory therapy. This may indicate that other agents, such as bile, can induce oxidative DNA damage in an acid-suppressed environment. The significant discordance between oxidative DNA damage and 24-h pH results makes the determination of oxidative DNA damage a poor surrogate marker for 24-h pH monitoring.

The incidence of esophageal adenocarcinoma in White males has been reported to be increasing. The aims of this study were to determine: 1) the incidence trends of esophageal carcinoma in the United States with an emphasis on histologic type, sex, and ethnicity, 2) whether the reported increase in stage IV tumors can be confirmed, and 3) survival trends and factors affecting survival.Data from the SEER program of the National Cancer Institute with submission dates 1973-98 were used. Data on Hispanics were available for analysis only for the years 1992-98. Statistical analysis was performed utilizing SEER*Stat and SAS statistical software packages.The incidence of adenocarcinoma in White males is still rising (7.8%/year, P0.0001); however, the same trend was observed for White females (6.48%/year; P0.0001). Hispanic males (3.91 %/year; P0.02), and Hispanic females (9.4%/ year; P0.04). The incidence of squamous cell carcinoma has been steadily declining in White males and females and in Black females since 1973, with the incidence showing a dramatic and significant decline in Black males beginning in 1992 (8.53%/year; P = 0.0009). Stage 4 carcinoma is declining in incidence. Survival of patients with esophageal carcinomas has been improving. In a Cox multivariate model, independent prognostic factors in esophageal carcinoma included tumor stage, tumor type, gender, race, age at diagnosis, and year of diagnosis.1) The incidence of adenocarcinoma continues to rise in White males and females, but also in Hispanics, while squamous cell carcinoma is declining; 2) the incidence of stage 4 carcinomas has been declining, and 3) survival has been steadily improving, independently of all other risk factors.

The goal of this study is to evaluate endoscopic Raman spectroscopy as a noninvasive technique to determine histological inflammatory status of colitis. Colon mucosal composition was investigated in vivo from patients with ulcerative colitis (UC) and from age- and body mass index (BMI) matched controls using endoscope-coupled Raman spectroscopy. The results were co-registered with histological assessment of inflammatory status at the same locations. Substantial decreases (50-60%) in the content of phosphotidylcholines (PCs) and total lipids were observed in inflamed colon tissue (histology grade 1, 2 and 3) compared to those from the quiescent (histology grade 0) and from the controls. No significant difference was observed in lipids or PC contents between control and grade 0, or among grades 1 – 3. The degree of lipid unsaturation increased in the inflamed tissue regardless of disease severity. The inflammation-associated alterations in lipids and PC are observed independent of BMI or the anatomical locations for data collection. Multivariate analysis using support vector machine (SVM) algorithm classified the spectra of the controls or the inactive colitis from those of inflamed tissue with a sensitivity of 83.5% and 97.1% respectively. Our results showed that mucosal lipid content is related to the microscopic disease activity, and thus could serve as a valuable spectral marker to differentiate active colitis from the quiescent.

337 Background: There have been several limited trials in which tamoxifen efficacy was tested in patients with pancreatic adenocarcinoma (PAC). Most of these studies were small series of patients with unresectable PAC and reported mixed results. In these studies, patients were not stratified by estrogen receptor status because estrogen receptor beta (ER-b) had not yet been identified, and PAC did not express the traditional ER-alpha. Recent studies showed that the effects of estrogens, phytoestrogens and tamoxifen on PAC cell lines depended on ER-b expression. The aim of this study was to investigate ER-b expression in human PAC and whether such expression correlates with any clinicopathologic parameters. Methods: Sections of tissue microarray containing 18 formalin fixed and paraffin embedded human PAC were stained by immunohistochemistry (IHC) using monoclonal antibodies to ER-b isoforms 1, 2, and 5 (ER-b1, ER-b2, and ER-b5, respectively), and for Cyclin A. The levels of ER-b isoform expression in tumor cells and the S-phase fraction (SPF) were determined using a quantitative digital image analysis solution (OTMIAS). Results: All isoforms were expressed in PAC, although at different levels. Higher mean ER-b2 levels correlated with male sex (p = 0.057), older age (p = 0.005), and lower pT stage (p = 0.008), but not with grade, pN stage, or SPF. Mean ER-b5 levels correlated negatively with SPF (p = 0.021), but not with sex, age, grade, pT or pN. Mean ER-b1 expression did not correlate with any of the above mentioned clinicopathologic factors. Conclusions: ER-b1, ER-b2, and ER-b5 are expressed in PAC. Higher ER-b2 and ER-b5 levels of expression are significantly correlated with lower tumor pT stage and with lower SPF, respectively, suggesting that they may play a tumor suppressive role in PAC. The association between ER-b2 levels and patient sex and age suggest that it could be influenced by endogenous/exogenous hormonal exposure.

It has been reported that the incidence of intrahepatic cholangiocarcinoma (ICC) has increased in the USA, while extrahepatic cholangiocarcinoma (ECC) has decreased or remained stable. However, neither the recent trends nor the effects of the misclassification of Klatskin tumors are known.Using the Surveillance, Epidemiology, and End Results program databases, we calculated the average annual age-adjusted incidence rates (AA-IRs) of ICC and ECC in 4-year time periods (1992-1995, 1996-1999, 2000-2003, 2004-2007). These AA-IRs were calculated with misclassified as well as correctly classified Klatskin tumors. AA-IRs were also calculated based on age, sex, and race. Multivariable Poisson regression models were used to evaluate the secular trends of ICC and ECC.The AA-IR of ICC was 0.92 in 1992-1995 and 0.93 in 2004-2007, while the AA-IR of ECC increased from 0.70 in 1992-1995 to 0.95 in 2004-2007. There was no significant trend in AA-IR of ICC (p = 0.07), while there was a significant increase in ECC across the 4-year time periods (p0.001). Klatskin tumors comprised 6.7% of CCs with approximately 90 and 45% misclassified as ICC during 1992-2000 and 2001-2007, respectively. Adjusted Poisson models showed no significant differences in the temporal trend of ICC or ECC due to misclassification of Klatskin tumors.The incidence of ICC has remained stable between 1992 and 2007 with only slight fluctuations, while the incidence of ECC has been increasing. Misclassification of Klatskin tumors does not appear to play a significant role in the trends of CCs.

BACKGROUND The malignant Hodgkin and Reed–Sternberg (H/RS) cells of Hodgkin disease (HD) express CD30 and CD40 receptors that can activate nuclear factor kappa B and transduce survival signals. The authors have reported previously that the B lymphocytes of HD express CD30 ligand (CD30L, CD153). Furthermore, they and others have reported previously that the CD40L survival pathway is augmented in patients with B-cell malignancies, as CD40L was constitutively expressed by the malignant B cells and infiltrating T cells, and sera from those patients contained elevated levels of soluble CD40L. In this study, the authors investigated the hypothesis that the survival of H/RS cells was similarly promoted by an augmented CD40L signals in HD patients. METHODS The expression of CD40L on lymphocyte subsets of patients with classic HD was determined by two-color fluorescent-activated cell sorter analysis. Serum soluble CD40L levels were determined by enzyme linked immunosorbent assay. RESULTS CD40L was constitutively expressed on both the T and B cells of HD patients but was more prominently expressed on the B lymphocytes. Soluble CD40L was detected in the serum of 17 of 37 patients (45%) and was higher than 1 ng/mL in 4 patients (10%). Both interleukin (IL)-4 and IL-10, which are known to be secreted by H/RS cells and surrounding T cells, up-regulated CD40L expression on normal B cells. CONCLUSIONS Thus, the expression of CD40L and CD30L on the B cells of HD patients suggests that B lymphocytes may play a role in the regulation of H/RS cell growth in vivo. Depriving H/RS cells from CD30L and CD40L survival signals by eliminating B cells from HD lesions may be of therapeutic value. Cancer 2002;94:1–5. © 2002 American Cancer Society.

Barrett's esophagus occurs more frequently than previously anticipated. Detection of Barrett's esophagus is by endoscopic biopsy in which normal squamous epithelium of the esophagus is replaced by a specialized columnar epithelium of any length. Patients with more than five years of gastroesophageal reflux symptoms, particularly those 50 years of age or older, should have upper endoscopy to detect Barrett's esophagus. With recognition of Barrett's esophagus as a premalignant lesion, the crucial issue is surveillance for detection of dysplasia. Although the natural history of dysplasia is incompletely defined, it is clear that patients with dysplasia have a higher risk for adenocarcinoma than those without dysplasia. Dysplasia is not the ideal marker for selecting patients at high risk for adenocarcinoma, however; recent studies have shown that p53 protein accumulation appears to be earlier and more specific/sensitive marker of malignant potential in Barrett's esophagus. Management of Barrett's esophagus often involves a multidisciplinary evaluation and its current status is reviewed.

Esophageal and colorectal adenocarcinomas overexpress Fas ligand (FasL), which can protect them from immune surveillance. The aim of this work was to determine whether FasL expression, and therefore FasL-dependent immune evasion, occurs early during malignant transformation in Barrett's metaplasia (BM) of the esophagus, and in the large intestine. Sections of formalin-fixed and paraffin-embedded tissue from esophageal and large bowel biopsies and resection specimens were immunostained for FasL using standard immunoperoxidase technique. The percentage of positive cells was correlated with the degree of dysplasia in BM and with the size and villous architecture of colorectal adenomas. In BM, FasL was detected in 55% of cases negative for dysplasia, and was associated with inflammation in almost all positive cases. By contrast, all cases of BM (100%) with low- or high-grade dysplasia were FasL-positive. In the large intestine, 25% of small adenomas were negative for FasL, and FasL overexpression was significantly more frequent in larger adenomas and in adenomas with tubulovillous or villous morphology. Our results suggest that (1) FasL overexpression is acquired early during malignant transformation of BM and the large bowel and (2) FasL overexpression occurs relatively earlier during malignant progression of BM than the large bowel, probably as a result of the preceding repeated inflammation.

The Houston Society of Clinical Pathologists educational activity culminates in the Spring Symposium, held every year in April in Houston, Texas. The guest faculty is sponsored by the institutions that form the famed Texas Medical Center and the University of Texas Medical Branch in Galveston. The articles selected for this special section are based on presentations at the symposium and at sponsoring institutions and will appear in 2 parts: part I is in this issue of the ARCHIVES, and part II will be in the July issue. The special section comprises 8 articles written by distinguished, nationally and internationally recognized experts in gastrointestinal (GI) and liver pathology from the United States and Canada. In this issue, part I of the special section will include 4 articles: ‘‘Esophagitis: Old Histologic Concepts and New Thoughts,’’ ‘‘Molecular and Histologic Considerations in the Assessment of Serrated Polyps,’’ ‘‘IgG4-Related Disease of the Gastrointestinal Tract: A 21st Century Chameleon,’’ and ‘‘Neuroendocrine Tumors of the Luminal Gastrointestinal Tract.’’ In the next issue of the ARCHIVES, part II will also include 4 articles: ‘‘Difficult Diagnostic Problems in Pancreatobiliary Neoplasia,’’ ‘‘Pathophysiology and Diseases of the Terminal Pathways of the Biliary System,’’ ‘‘Hepatic Granulomas: A Review With Emphasis on Infectious Causes,’’ and ‘‘DrugInduced Liver Injury.’’ Each of these topics poses certain challenges to the practicing surgical pathologist. Authors are allowed to express their personal opinions and preferences in these articles. Although some readers may disagree with some of the opinions presented in these reviews, I believe most readers (including myself) will benefit from the personal experiences of these highly regarded and respected authors. I hope you enjoy reading this section and find the information presented useful in your daily practice.

BACKGROUND Increased expression of Glut1 and Glut3 has been reported in many human cancers, including nonsmall cell lung carcinoma (NSCLC). The aim of this study was to determine the biologic significance of Glut1 and Glut3 overexpression in Stage I NSCLC. METHODS Using immunohistochemistry and polyclonal anti-Glut1 and anti-Glut3 antibodies, the authors immunostained sections of formalin fixed, paraffin embedded tissues from 289 Stage I NSCLCs. The Kaplan-Meier survival method, the log rank test, and Fisher's exact test were used for statistical analysis. RESULTS Of the 289 cases, 49 (17%) were negative for both Glut1 and Glut3, 239 (83%) were Glut1 positive, 61 (21%) were Glut3 positive, 179 (62%) were positive for Glut1 but negative for Glut3, 1 (0.3%) was positive for Glut3 but negative for Glut1, and 60 (21%) were positive for both Glut1 and Glut3. Only 1 of 50 Glut1 negative tumors (2%) was positive for Glut3, whereas 60 of 239 Glut1 positive tumors (25%) were positive for Glut3 (P < 0.0001). Glut1 or Glut3 were detected more often in poorly differentiated and undifferentiated tumors (P

Our aim was to determine the sensitivity andspecificity of p53 accumulation as a marker of malignantpotential in Barrett's metaplasia (BM). One hundredeighty biopsies from 61 patients with BM were evaluated for p53 accumulation by immunohistochemistry.Of 25 patients with LGD, 9 had p53-positive biopsies,and of these 5 (56%) developed HGD/CA, whereas 16 hadp53-negative biopsies and none (0%) developed HGD/CA after similar follow-up times (P = 0.0108). Asa marker of malignant potential in BM, p53 accumulationhas a sensitivity of 100%, specificity of 93%, and apredictive value of a positive test of 0.56, compared to sensitivity of 100%, specificity of 64%, andpredictive value of a positive test of 0.2 for ahistologic diagnosis of LGD. We conclude that: (1) p53accumulation is more specific and has better predictive value for subsequent development of HGD/CA thanhistologic diagnosis of LGD. (2) Patients with LGD andp53-positive biopsies are more likely to develop HGD/CA;therefore, they should be followed up more closely than those with LGD and p53-negativebiopsies.

Radiofrequency ablation (RFA) with HALO system has been developed as a new treatment option for Barrett's esophagus (BE). It had been observed that some patients had esophageal eosinophilia (EE) infiltration after RFA. The incidence and features of EE after RFA were systematically determined. From a prospectively compiled database, data on 148 patients who underwent RFA for BE were analyzed. Biopsies were taken pre- and post-RFA from the BE segment, and histological sections of the biopsy specimens were stained with hematoxylin and eosin, and examined by a gastrointestinal pathologist. The incidence of EE post-RFA was then determined. Of the 148 patients, 120 (81%) were men, 137 (92%) were white, 64 (43%) were overweight and 49 (33%) obese, and 128 (86%) were over 50 years of age or more. Four (2.7%) of the patients developed post-RFA EE, but none had symptoms of eosinophilic esophagitis. All patients except one had a history of seasonal allergies. All four were taking proton pump inhibitor before and after RFA. Two patients with EE drank alcohol, one of which was a smoker. EE is a potential adverse event of RFA for BE. The absence of esophageal dysfunction symptoms suggests a different clinicopathological entity from eosinophilic esophagitis. Further studies should be done to assess its clinical significance, if therapy is needed, or if it may eventually lead to eosinophilic esophagitis.

TGFβ has been shown to suppress tumor growth in vitro through interaction with TGFβ type II receptor (TGFβ-RII). Although a significant percentage of breast carcinomas have been shown to express TGFβ, TGFβ expression was not found to influence survival of patients with breast cancer. In order to determine whether the lack of influence of TGFβ expression on the biologic behavior of breast cancer is due to lack of or infrequent expression of TGFβ-RII, we studied the expression of TGFβ-RII in 11 1 cases of invasive breast carcinoma by immunohistochemistry. The percent of breast cancer cells which stained for TGFβ-RII was subjectively scored as 0 (negative), >10%, 10–25%. 25–50%, and >50%. Of the invasive breast carcinomas, 81 (73%) were completely negative, 22 (20%) had 40% of the cells positive, and only 3 (3%) had >50% of the cells positive for TGFβ-RII. In benign breast tissue in the same tissue sections, myoepithelial cells were always positive for TGFβ-RII, whereas stromal cells were negative, and benign epithelial cells were rarely positive. We conclude that TGFβ-RII is consistently expressed in myoepithelial cells of the human breast, and rarely in epithelial cells, and that the infrequent expression of TGFβ-RII by invasive breast carcinomas, may explain why TGFβ expression does not appear to influence the outcome of patients with breast cancer.

Background: The “cell of origin” for pancreatic “ductal” neoplasia remains uncertain. Selective activation of Kras in the acinar cell compartment robustly generates mPanIN lesions, while similar activation in pancreatic ductal epithelial cells produces minimal change. These differences are notable considering in human tumorigenesis, mutational oncogene activation is postulated to occur in either single cells or small numbers of cells, followed by clonal expansion and tumor initiation. We have interrogated the comparative ability of adult pancreatic acinar and duct cells to respond to oncogenic Kras using Hnf1b:CreERT2 and Mist1:CreERT2 mice, and applied comprehensive bioinformatics analysis to identify mechanisms of duct cell-specific Kras resistance. Hypothesis and Methods: We hypothesized that duct cell-specific changes in gene expression would mediate the relative resistance of ductal epithelial cells to Kras-mediated transformation. To identify these changes, we studied the initiation and progression of pancreatic cancer with unprecedented temporal and spatial resolution. Our approach allows for the direct visualization and FACS-based isolation of specific cell populations in which oncogenic Kras has been activated. We have activated KrasG12D and a membrane-tethered GFP in a number of adult pancreatic cell types including the acinar, ductal and centroacinar cells. Using FACS-based isolation and visualization, we have generated whole transcriptome signatures of how the different cell types respond to Kras over time. Our comprehensive bioinformatic approach involves the identification of genes that are increased or decreased at different time points after the induction of oncogenic Kras expression. Results: Kras activation in the adult acinar cells resulted in brisk PanIN formation, while no evidence of pancreatic neoplasia was observed for up to 6 months following isolated Kras activation in Hnf1b+ duct cells. By comparing gene expression changes occurring following Kras activation in acinar vs. duct cells, we identified a panel of candidate duct cell-specific Kras resistance genes. These included Bcl-2, p21, Stk3, Plkha1, Slc9a9 and Pdcd10. Identification of upregulated Bcl-2 and p21 expression following Kras activation in duct cells, but not acinar cells, suggested involvement of the p53 pathway as a cell type-specific suppressor of pancreatic neoplasia. We recently published that biallelic expression of mutant p53R172H in cooperation with KrasG12D led to the development of pancreatic cancer from ductal cells. We are now investigating both autocrine and paracrine signaling mechanisms of mutant p53 oncogenic transformation in human derived ductal epithelial cells. This abstract is also being presented as Poster A17 Citation Format: Kishore Polireddy, Audrey Hendley, Melissa A. Pruski, Kelly Lafaro, Mamoun Younes, Anirban Maitra, Florencia McAllister, Christine A. Iacobuzio-Donahue, Wasim A. Dar, John S. Bynon, Steven D. Leach, Jennifer M. Bailey.{Authors}. Mutant p53 promotes adenocarcinoma in pancreatic ductal cells. [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2016 May 12-15; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2016;76(24 Suppl):Abstract nr PR03.

Background. Accurate preoperative diagnosis of tumors of the ampulla of Vater is difficult because ampullary biopsies have a high false-negative rate. Recently, it has been suggested that p53 mutations in tumors of the ampulla of Vater are associated with the transformation of adenomas and low grade carcinomas to high grade carcinomas. The purpose of this study was to determine the extent of p53 protein accumulation in tumors of the ampulla of Vater, and to determine whether p53 accumulation can be detected in false-negative biopsies. Methods. Using a monoclonal anti-p53 antibody, sections of 4 normal ampullas, 5 adenomas, 17 carcinomas, and 9 initial biopsies of 9 of the tumors of the ampulla of Vater that had no morphologic evidence of carcinoma were immunostained. Results. None of the 4 normal ampullas (0%), 2 of 5 adenomas (40%), and 16 of 17 carcinomas (94%) were positive for p53. This p53 positivity was present through all stages of ampullary carcinoma. Of the nine initial biopsies negative for carcinoma, seven were positive for p53 and, of these, six (86%) were found to be carcinomas upon resection. Conclusions. 1) The molecular events leading to p53 accumulation in tumors of the ampulla of Vater occur early in the neoplastic process. 2) Tumors of the ampulla of Vater with biopsies negative for malignancy but positive for p53 are very likely to be carcinomas.