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Sunitinib is a highly potent, selective vascular endothelial growth factor-receptor types 1 to 3, platelet-derived growth factor (PDGF)-R-alpha, and PDGF-R-ss. Preclinical data suggest that sunitinib (SU11248) has antitumor activity that may result from both inhibition of angiogenesis and direct antiproliferative effects on certain tumor cell types. Sunitinib resulted in tumor shrinkage in 80% of patients who had failed treatment with Bevacizumab and 13% of patients demonstrated an objective Response Evaluation Criteria in solid Tumors (RECIST) in a study presented at the 2006 American Society of Clinical Oncology (ASCO) meeting. We report the first published pathological evidence of sunitinib's effect on recurrent renal cell carcinoma. This was seen in a patient with renal cell carcinoma who developed a renal fossa recurrence 2 years following radical nephrectomy. Tumor shrinkage was evident in the nephrectomy bed after treatment with sunitinib. The pathology of the resected retroperitoneal mass and its implications are discussed.

Objectives: To report cases of primary neuroendocrine tumours (NETs) of the kidney, including carcinoid tumour, large cell neuroendocrine carcinoma (LCNEC) and small cell carcinoma (SCC), which show a wide range of NE differentiation and biological behaviour, and are exceedingly rare., Patients and Methods: The clinicopathological features of all nine renal NETs diagnosed during a 7-year period were reviewed., Results: Six carcinoids, two SCC and one LCNEC were identified from 2780 kidney tumours. No patient had carcinoid syndrome or other NE symptoms. Three of six carcinoids and no SCC/LCNEC arose in horseshoe kidneys. The mean size of the six carcinoids and three SCC/LCNEC was 4.8 cm and 12.2 cm, respectively. No carcinoid had tumour necrosis or mitosis. By contrast, three SCC/LCNEC had extensive tumour necrosis and brisk mitosis. All renal NETs were positive for synaptophysin but were variably positive for chromogranin and CD56. Three of six carcinoid tumours were confined to the kidney, and four of five patients were disease-free at a mean (range) of 26 (6-74) months. One patient with nodal metastases has had no recurrence and another died with liver metastases. Three patients with SCC/LCNEC each presented with locally advanced disease and extensive lymphadenopathy; two of them died from distant metastasis or local tumour progression, and the third is currently alive with disease., Conclusions: Various NETs can occur in the kidney, but rarely. Renal carcinoids have a variable clinical course; SCC and LCNEC are associated with poor clinical outcomes. The diagnosis of NETs, especially LCNEC, requires awareness of their rare occurrence and prudent use of immunohistochemical NE markers.

Objectives: Serum prostate specific antigen (PSA) screening has led to clinical and pathologic stage migration. We examined patients treated by radical prostatectomy between 1987 and 2005 to establish temporal trends in pathologic stage migration as assessed by the proportion of patients with nonorgan-confined disease (NOCD)., Methods: Step-sectioned prostatectomy specimens of 3364 consecutively treated patients were evaluated by year. The data were modeled by joinpoint regression, and the optimal model was selected by a Bayesian information criterion., Results: From 1987 to 2005, the population underwent pathologic stage migration toward more organ-confined tumors (P <0.0001). The proportion of patients with NOCD exhibited changes in trend at 1992 and 1995. After widespread implementation of PSA screening, stage migration accelerated between 1992 and 1995. Since 1995, stage migration has substantially slowed but continues at an annual change of -4.2% (P = 0.0027)., Conclusions: The presence of NOCD at prostatectomy has declined substantially in the PSA era. Recent slowing in this trend suggests a diminishing effect of PSA screening on pathologic stage migration.

Objectives: To examine the relationship between preoperative prostate-specific antigen (PSA) and pathologic characteristics of the prostate gland and prostate cancer at radical prostatectomy in patients with clinically localized disease in the early (1993 to 1998) and late (1999 to 2004) PSA eras., Methods: From January 1, 1993 to December 31, 2004, 2067 patients aged 40 to 80 years with clinically localized prostate cancer underwent radical prostatectomy without neoadjuvant therapy at the Cleveland Clinic. The correlation among the preoperative PSA level, prostate volume, percentage of Gleason pattern 4/5, surgical Gleason score, and cancer volume was calculated using Pearson's and Spearman's tests for the early (1993 to 1998) and late (1999 to 2004) PSA eras. Logistic regression analyses were performed to identify independent predictors of the percentage of Gleason pattern 4/5 and cancer volume during each era., Results: In both eras, the PSA level correlated positively with the percentage of Gleason pattern 4/5, surgical Gleason score, and prostate volume, with nearly identical r values. The PSA level also correlated with the cancer volume in the late PSA era (the only era for which cancer volume data were available). In the multivariate model, biopsy Gleason score, clinical T stage, and PSA level were independent predictors of percentage of Gleason pattern 4/5 in both eras and of cancer volume in the late PSA era., Conclusions: Even in the late PSA era, the preoperative PSA level has retained its predictive value for the percentage of Gleason pattern 4/5 and cancer volume. The PSA level continues to have prognostic value for men with clinically localized prostate cancer treated by radical prostatectomy.

Background: The objective of the current study was to determine the histologic and molecular changes that occurred in patients with high-risk, localized prostate cancer (PCa) after neoadjuvant docetaxel chemotherapy., Methods: Patients who had locally advanced PCa (serum preoperative [initial] prostate-specific antigen [iPSA] level >or=15 ng/mL, or clinical >or=T2b disease, or biopsy Gleason score [GS] >or=8) and no evidence of metastatic disease received 6 doses of intravenous docetaxel (40 mg/m(2)) administered weekly for 6 weeks followed by radical prostatectomy (RP). The Wilcoxon signed-rank test was used to compare pretreatment and posttreatment markers., Results: Twenty-eight patients completed chemotherapy and underwent RP at the Cleveland Clinic; none achieved a pathologic complete response. Pretreatment diagnostic prostate biopsies (PBx) were reviewed in all patients, and unstained sections of formalin-fixed tissue were available from 11 patients. The median patient age was 62 years (range, 49-72 years), and the median iPSA was 6.8 ng/mL (range, 2.5-24 ng/mL). At a median follow-up of 49.5 months (range, 23-72 months), 12 patients (43%) remained clinically and biochemically free of disease with no additional therapy, and 16 patients (57%) had biochemical failure. The pretreatment GS was 6 in 2 patients (7%), 7 in 10 patients (36%), 8 in 11 patients (39%) and 9 in 5 patients (18%). Two patients (7.1%) had organ-confined disease, and 23 patients (82.1%) had extraprostatic extension. Four patients (14.3%) had positive lymph nodes, and 11 patients (39.3%) had seminal vesicle involvement. Immunohistochemical (IHC) staining for a panel of markers involved in various cellular functions (alpha-methylacyl-coenzyme A racemase [AMACR], beta-tubulin I, beta-tubulin III, cyclin D1, p27, p21, Ki-67, p53, Bcl-2, and an apoptosis detection kit [ApopTag]) was performed on a tissue microarray that contained the posttreatment (RP) tissue specimens and on the PBx specimens, if available. When the IHC staining patterns were compared between PBx and RP specimens using the Wilcoxon signed-rank test, only p53 expression (P = .017) and Bcl-2 expression (P = .014) were found to be increased significantly after neoadjuvant docetaxel treatment. However, after performing the Bonferroni adjustment, these differences were no longer significant (P > .005). Ki-67, ApopTag, beta-tubulin I, and beta-tubulin III expression levels also were increased after treatment; however, the differences were not found to be statistically significant. The expression levels of AMACR, p27, p21, and cyclin D1 were comparable in pretreatment and posttreatment specimens., Conclusions: The current results indicated that, although it will require longer follow-up studies and larger numbers of patients to ascertain the value of neoadjuvant treatment, the negative findings of the current study may explain the lack of clinical response in patients who received neoadjuvant docetaxel for PCa. Although the results were subject to interpretation limits based on the study size, the increased expression of p53 and Bcl-2 that was detected after treatment using the Wilcoxon signed-rank test suggested that the apoptotic pathway may be an important target for this drug, and further investigation is warranted., ((c) 2007 American Cancer Society.)

Objectives: No consensus exists regarding the prognostic value of tumor volume (TV) in predicting biochemical recurrence (BCR) of prostate cancer, especially late in the prostate-specific antigen (PSA) era. We assessed this relationship in a large cohort of patients treated at one institution with standardized pathologic assessment from 1998 to 2005., Methods: Data were collected for 1833 patients undergoing radical prostatectomy for clinically localized prostate cancer since 1998. Patients receiving neoadjuvant or adjuvant therapy or with node-positive disease were excluded. Along with the routine pathologic assessment, TV was prospectively assessed in all specimens. BCR was defined as two consecutive PSA levels of 0.2 ng/mL or one PSA level of greater than 0.2 ng/mL., Results: Although a larger TV correlated with lower rates of biochemical relapse-free survival in patients with a surgical Gleason score of 7 (P <0.0001) and surgical Gleason score of 8 or greater (P = 0.0459), the biochemical relapse-free survival rate at 4 years for low, medium, and extensive surgical Gleason score 6 or less tumors was 95%, 96%, and 97%, respectively (P = 0.65). In a multivariate model, including TV, initial PSA, EPE, seminal vesicle invasion, and surgical Gleason score, the TV predicted for BCR (P = 0.0176)., Conclusions: The results of this large study suggest that a large TV is an independent predictor of BCR in patients with tumors of specimen Gleason score 7 or higher. In contrast, most grade 6 tumors will be organ confined, even if of high volume, and TV will not predict for BCR in these patients.

Objective: To investigate the detection rate and extent of high-grade prostatic intraepithelial neoplasia (HGPIN) and atypical glands (AG) suspicious for prostate cancer, and the cancer risk in subsequent biopsies, diagnosed by a first 24-core saturation biopsy, as although the optimum extent of biopsy is controversial there is a trend to increase the number of cores taken, and apart from detecting prostate cancer, identifying HGPIN and AG is associated with a greater risk of finding cancer in subsequent biopsies, thus warranting a closer follow-up., Patients and Methods: The study included 100 men with consecutive first-time saturation biopsies; the indications for biopsy were an abnormal digital rectal examination and/or a serum prostate-specific antigen (PSA) level of >2.5 ng/mL. Each biopsy specimen was reviewed retrospectively by two pathologists to confirm the histological diagnosis. The number and percentage of cores positive for HGPIN, bilateral involvement and multifocality (HGPIN involving two or more cores) were recorded in each case. The presence of AG and cancer was also recorded. An extended (10-12 cores) repeat biopsy was available in 23 patients., Results: The median (range) age and PSA level of the patients was 63 (41-80) years and 4.9 (1.5-67.0) ng/mL, respectively. Of the 100 patients, 34% had normal findings (benign prostatic tissue, BPT), 39% had cancer, 26% had HGPIN and cancer, 22% had HGPIN alone, and 5% had AG. Repeat biopsies were available in nine of the 22 (41%) patients with HGPIN, four of five with AG, and 10 of the 34 (29%) with BPT. The median (range) interval between the first and second biopsy was 13 (4-36) months. Prostate cancer was detected at the second biopsy in a third of patients with isolated HGPIN on the first biopsy, and one of the four with AG. None of the patients with BPT had cancer on re-biopsy. The cancer detection rate was significantly greater in patients with multifocal than in those with unifocal HGPIN (80% vs none, P = 0.010). The median number of cores and percentage of tissue involved by HGPIN was 3.5 (2-5) and 1.0 (0.5-1.2)%, respectively, in patients with cancer detected in repeat biopsies, compared to 1.0 (1-3) and 0.2 (0.2-0.6)% in patients without cancer on repeat biopsy (P = 0.023 and 0.015, respectively)., Conclusion: Identifying multifocal HGPIN on first saturation biopsy is associated with an overall cancer detection rate of 80% on repeat 10-12-core biopsy. Although there were few patients, the detection of multifocal HGPIN warrants additional searches for concurrent invasive carcinoma by repeated biopsy.

Background: Epidermal growth factor receptor (EGFR) is overexpressed in the majority of clear-cell renal cell carcinomas (RCCs). The prognostic significance of EGFR overexpression after nephrectomy, however, is controversial because of different methods used in the immunohistochemical (IHC) evaluation of EGFR expression., Patients and Methods: In this study, we evaluated EGFR expression and its prognostic significance using 3 IHC evaluation methods. A tissue microarray composed of 44 cases of clear-cell RCC was stained for the patterns of EGFR overexpression, including membranous, cytoplasmic (EGFR-c), and total (membranous and cytoplasmic), and the percentage of cells positive for EGFR overexpression were recorded. An EGFR composite score was calculated by multiplying the total EGFR overexpression score (0-3) and percentage of positive cells., Results: Membranous EGFR overexpression was detected in 38 of 44 cases (93.2%), with moderate to strong staining (scores 2 and 3) in 35 cases (79.5%). EGFR-c was detected in 28 cases (63.6%), with moderate to strong staining (scores 2 and 3) in 16 cases (36.4%). EGFR-c was significantly associated with pathologic stage (P = 0.003) and Fuhrman nuclear grade (P = 0.042). Epidermal growth factor receptor composite score correlated with pathologic stage (P = 0.045) but not Fuhrman nuclear grade. However, EGFR expression did not correlate with overall survival or disease recurrence., Conclusion: This study demonstrates that the prognostic value of EGFR overexpression differs significantly when different methods are used to evaluate EGFR expression by IHC. Future studies should use standardized methods to evaluate the EGFR staining pattern and intensity and the percentage of positive cells in order to clarify the prognostic significance of EGFR overexpression in clear-cell RCC.

Introduction: Renal metastasis by non-small cell lung cancer is uncommon and usually described at autopsy., Case Presentation: We report the rare case of a 77-year-old man with localized non-small cell lung carcinoma who underwent extirpative surgery and 2 years later presented with gross hematuria and was noted to have a large infiltrating renal mass on computed tomography., Conclusions: In patients with a prior history of resected localized non-small cell lung carcinoma, presence of a renal lesion should prompt the clinician to consider the possibility of metastasis. Further evaluation should consider this scenario.

Focal atrophy is extremely common in prostate specimens. Although there are distinct histologic variants, the terminology is currently nonstandardized and no formal classification has been tested for interobserver reliability. This lack of standardization hampers the ability to study the biologic and clinical significance of these lesions. After informal and formal meetings by a number of the authors, focal atrophy lesions were categorized into 4 distinct subtypes as follows: (i) simple atrophy, (ii) simple atrophy with cyst formation, (iii) postatrophic hyperplasia, and (iv) partial atrophy. In phase 1 of the study, pathologists with varying levels of experience in prostate pathology were invited to view via the Internet a set of "training" images with associated descriptions of lesions considered typical of each subtype. In phase 2 of the study, each participant provided diagnoses on a series of 140 distinct "test" images that were viewed over the Internet. These test images consisted of the 4 subtypes of atrophy and images of normal epithelium, high grade prostatic intraepithelial neoplasia, and carcinoma. The diagnoses for each image from each pathologist were compared with a set of "standard" diagnoses and the kappa statistic was computed. Thirty-four pathologists completed both phases of the study. The interobserver reliability (median kappa) for classification of lesions as normal, cancer, prostatic intraepithelial neoplasia, or focal atrophy was 0.97. The median kappa for the classification of atrophy lesions into the 4 subtypes was 0.80. The median percent agreement with the standard diagnosis for the atrophy subtypes were: simple 60.6%, simple with cyst formation 100%; postatrophic hyperplasia 87.5%; partial atrophy 93.9%. The lower percentage for simple atrophy reflected a propensity to diagnose some of these as simple atrophy with cyst formation. Seven pathologists completed the phase 2 analysis a second time, and their intraobserver reproducibility was excellent. Three of 4 pathologists with low agreement with the standard diagnosis for simple atrophy improved their scores after repeating the analysis after re-examination of the "training set" of images. In conclusion, these criteria for variants of focal prostate atrophy may facilitate studies to examine the relation between various patterns of prostate atrophy and prostate cancer.

Objectives: To report a series of patients with mucinous (colloid) adenocarcinoma (MC) at prostatectomy who were treated at a single institution from 1987 to 2005. MC is a rare form of prostate cancer reported in some cases to have a more aggressive clinical course than conventional adenocarcinoma (AC)., Methods: Radical prostatectomy specimens with mucinous features were identified from a database of 3613 consecutive patients. Each case was reviewed again by a single pathologist who confirmed the diagnosis of MC in 14 patients. MC was defined by the presence of pools of extracellular mucin in more than 25% of the tumor. Eighteen additional cases were identified in which the mucinous component occupied only a small portion of the tumor and were referred to as AC with focal mucin (AFM). The biochemical and overall survival of 26 patients with MC or AFM who had completed > or = 6 months of follow-up was analyzed using Kaplan-Meier estimates., Results: No patients with MC or AFM died of disease, and 11 (91.7%) of 12 patients with MC and 9 (64.3%) of 14 patients with AFM were clinically and biochemically free of disease. No significant difference was found in biochemical recurrence or overall survival between those with MC or AFM and a matched group of patients with AC., Conclusions: We report what we believe to be the largest published series of cases of MC (n = 14) with a median overall follow-up of 6.4 years. MC appears to behave clinically in a similar fashion to AC, with no statistically significant difference in biochemical failure or survival.

Background: Prostate basal cell lesions can have architectural and cytologic atypia that mimic prostate adenocarcinoma. Immunohistochemical stains for basal cell markers are most helpful in the differential diagnosis. All of the published studies show basal cell lesions are positive for basal cell keratins, whereas adenocarcinoma is negative for both. We reported two cases of prostate basal cell lesions with negative basal cell keratin expression by immunohistochemistry., Study Design: We reported the histologic and immunohistochemical profiles of two cases of basal cell lesions of the prostate., Results: Histologically, both cases were highly suspicious for prostate adenocarcinoma with infiltrative growth pattern and significant nuclear atypia. The atypical glands in both cases were negative for basal cell keratins. However, both lesions were positive for another basal cell marker, p63, confirming that they were basal cells in origin, rather than prostate adenocarcinoma., Conclusion: Prostate basal cell lesions can occasionally be negative for basal cell keratins by immunohistochemistry and therefore may be misdiagnosed as prostate adenocarcinoma. We recommend using both p63 and basal cell keratins simultaneously in the workup of atypical prostate lesions to avoid such a misdiagnosis.

Purpose: We evaluated whether intraoperative real-time TRUS navigation during LRP can decrease the incidence of positive surgical margins., Materials and Methods: Since March 2001, 294 patients with clinically organ confined prostate cancer undergoing LRP have been retrospectively divided into 2 groups, including group 1-217 who underwent LRP without TRUS from March 2001 to February 2003 and group 2-77 who have undergone LRP with TRUS since March 2003. Various baseline parameters were similar between the groups. Before March 2001 the senior surgeon had already performed more than 50 cases of LRP, thus, gaining reasonable familiarity with the technique., Results: Compared to group 1, group 2 had a significantly decreased rate of positive surgical margins in patients with pT3 disease (57% vs 18%, p = 0.002). Positive margin rates also decreased in our overall experience (29% vs 9%, p = 0.0002). Intraoperative TRUS correctly predicted pT2 and pT3 disease in 85% and 86% of patients, respectively. Of the 54 TRUS visualized hypoechoic lesions at sites corresponding to biopsy proven cancer extracapsular extension was suspected in 31, leading to a real-time recommendation of calibrated wider, site specific dissection to achieve negative surgical margins., Conclusions: Intraoperative TRUS monitoring during LRP allows individualized, precise dissection tailored to the specific prostate contour anatomy, thus, compensating for the muted tactile feedback of laparoscopy. In what is to our knowledge the initial experience real-time TRUS guidance significantly decreased the incidence of positive surgical margins during LRP. In the future this concept of rectum based, intraoperative real-time navigation may facilitate a more sophisticated performance of radical prostatectomy.

Ribonuclease L (RNase L) is an important effector of the innate antiviral response. Mutations or variants that impair function of RNase L, particularly R462Q, have been proposed as susceptibility factors for prostate cancer. Given the role of this gene in viral defense, we sought to explore the possibility that a viral infection might contribute to prostate cancer in individuals harboring the R462Q variant. A viral detection DNA microarray composed of oligonucleotides corresponding to the most conserved sequences of all known viruses identified the presence of gammaretroviral sequences in cDNA samples from seven of 11 R462Q-homozygous (QQ) cases, and in one of eight heterozygous (RQ) and homozygous wild-type (RR) cases. An expanded survey of 86 tumors by specific RT-PCR detected the virus in eight of 20 QQ cases (40%), compared with only one sample (1.5%) among 66 RQ and RR cases. The full-length viral genome was cloned and sequenced independently from three positive QQ cases. The virus, named XMRV, is closely related to xenotropic murine leukemia viruses (MuLVs), but its sequence is clearly distinct from all known members of this group. Comparison of gag and pol sequences from different tumor isolates suggested infection with the same virus in all cases, yet sequence variation was consistent with the infections being independently acquired. Analysis of prostate tissues from XMRV-positive cases by in situ hybridization and immunohistochemistry showed that XMRV nucleic acid and protein can be detected in about 1% of stromal cells, predominantly fibroblasts and hematopoietic elements in regions adjacent to the carcinoma. These data provide to our knowledge the first demonstration that xenotropic MuLV-related viruses can produce an authentic human infection, and strongly implicate RNase L activity in the prevention or clearance of infection in vivo. These findings also raise questions about the possible relationship between exogenous infection and cancer development in genetically susceptible individuals.

Lymphangiogenesis, detected by antibodies specific for lymphatic endothelial cells, has been associated with regional lymph node metastases and poor prognosis in carcinomas of head and neck, breast and uterine cervix, but remains largely uninvestigated in prostate adenocarcinoma. We evaluated the lymphatic vessel density and lymphatic vessel invasion by prostate cancer cells in the intratumoral, peritumoral and normal prostate tissue compartments in cancer-bearing prostate glands and correlated them with lymph node metastases, Gleason score and other pathological parameters. Lymphatic vessels were detected by immunohistochemical stain using an antibody specific for the lymphatic endothelial cells (clone D2-40) on 33 radical prostatectomies. In all, 26 patients had lymph node dissection, and 14 of them had lymph node metastasis. The lymphatic vessel density and lymphatic vessel invasion were then recorded for each of the three compartments microscopically. Lymphatic vessel density in the intratumoral, peritumoral and normal prostate compartments was 0.91+/-0.80, 1.54+/-0.68 and 1.58+/-0.96/mm2, respectively. The intratumoral lymphatic vessel density was significantly lower than that of the peritumoral and normal prostate compartments, and the latter two were not significantly different. The lymphatic vessel density of the three compartments was not significantly different between cases with and without lymph node metastasis. The peritumoral lymphatic vessel density correlated inversely with the Gleason score. Lymphatic vessel invasion was present in significantly higher percentage of cases with lymph node metastasis (9/14, 62.3%), as compared to those without lymph node metastasis (1/12, 8.3%, P<0.01). The peritumoral lymphatic vessel invasion had a better correlation with the presence of lymph node metastases than intratumoral lymphatic vessel invasion. There is no evidence of lymphangiogenesis in prostate adenocarcinoma. Peritumoral lymphatic vessel invasion correlates with regional lymph node metastases, suggesting that the peritumoral lymphatic vessels are functionally important and identification of lymphatic vessel invasion in this compartment implies a high probability of regional lymph node metastases.

Purpose: We reported on the results of a sequential cohort study comparing office based saturation prostate biopsy to traditional 10-core sampling as an initial biopsy., Materials and Methods: Based on improved cancer detection of office based saturation prostate biopsy repeat biopsy, we adopted the technique as an initial biopsy strategy to improve cancer detection. Two surgeons performed 24-core saturation prostate biopsies in 139 patients undergoing initial biopsy under periprostatic local anesthesia. Indication for biopsy was an increased PSA of 2.5 ng/dl or greater in all patients. Results were compared to those of 87 patients who had previously undergone 10-core initial biopsies., Results: Cancer was detected in 62 of 139 patients (44.6%) who underwent saturation biopsy and in 45 of 87 patients (51.7%) who underwent 10-core biopsy (p >0.9). Breakdown by PSA level failed to show benefit to the saturation technique for any degree PSA increase. Men with PSA 2.5 to 9.9 ng/dl were found to have cancer in 53 of 122 (43.4%) saturation biopsies and 26 of 58 (44.8%) 10-core biopsies. Complications included 3 cases of prostatitis in each group. Rectal bleeding was troublesome enough to require evaluation only in 3 men in the saturation group and 1 in the 10-core group., Conclusions: Although saturation prostate biopsy improves cancer detection in men with suspicion of cancer following a negative biopsy, it does not appear to offer benefit as an initial biopsy technique. These findings suggest that further efforts at extended biopsy strategies beyond 10 to 12 cores are not appropriate as an initial biopsy strategy.

A 69-year-old man with clinical Stage T1cN0M0 prostate cancer underwent radical prostatectomy, revealing negative surgical margins, focal capsular penetration, and negative lymph nodes and seminal vesicles. Five years later, his prostate-specific antigen level had increased to 0.2 ng/mL, and digital rectal examination revealed a palpable submucosal mass in the rectum that was confirmed by colonoscopy and transrectal ultrasonography. Excisional biopsy revealed prostatic adenocarcinoma similar in appearance and grade to the initial needle biopsy. This case report illustrates an extremely rare needle tract adenocarcinoma implantation after needle biopsy of the prostate.

Purpose: Laparoscopic partial nephrectomy (LPN) with hilar clamping represents the various challenges associated with warm ischemia. We tested the feasibility, and acute and chronic outcomes of LPN using a potassium-titanyl-phosphate (KTP) laser without vascular hilar clamping in the survival calf model., Materials and Methods: Six Jersey calves weighing 76 to 94 kg underwent a total of 12 staged bilateral transperitoneal laser LPNs of the mid/lower pole using an 80 W KTP laser, including left kidney chronic LPN with 1-month followup in 6 and right kidney acute LPN with immediate sacrifice in 6. Two techniques (ablative vaporization in 5 subjects and wedge resection in 7) were evaluated. Renal parenchymal resection and hemostasis were achieved only with the laser without any adjunctive hemostatic sutures or bioadhesives. Retrograde pyelography, renal arteriography and histological analyses were performed., Results: All 12 procedures were successful performed laparoscopically without open conversion and 11 (92%) were done without hilar clamping. Mean total operative time was 2.9 hours (range 1.5 to 5) and mean blood loss was 119 cc (range 25 to 300). Mean lasing time was 56 minutes (range 20 to 100) with an average energy use of 54 kJ. Mean preoperative and postoperative hemoglobin (10.38 and 10.52 gm/dl) and serum creatinine (0.46 and 0.4 gm/dl, respectively) were similar. At 1-month followup there was no evidence of urinary leakage or arteriovenous fistula., Conclusions: This initial study of laparoscopic KTP laser partial nephrectomy without hilar clamping confirms its technical feasibility in most cases and good short-term outcomes. This success of laser LPN in the robust survival calf model with its human-sized kidney holds promise for future clinical application.

Purpose: Although laparoscopic partial nephrectomy (LPN) has emerged as an effective treatment option in select patients with a solid renal tumor, scant data are available on cystic renal tumors. We report our experience with LPN in 50 patients with a cystic renal lesion., Materials and Methods: Of 284 patients undergoing LPN at our institution since August 1999 preoperative computerized tomography identified a suspicious cystic lesion in 50 (17.6%) (group 1). Data were retrospectively compared with those on 50 matched, consecutive patients undergoing LPN for a solid renal mass (group 2). All patients with Bosniak II/IIF cysts were advised to undergo watchful waiting. Surgery was offered if the cyst changed in character or if that was the patient preference., Results: Median tumor size was 3 cm in group 1 and 2.6 cm in group 2 (p = 0.07). Groups 1 and 2 were comparable in regard to perioperative parameters. In patients with Bosniak II (9), IIF (4), III (12) and IV (21) cysts final histopathology revealed renal cell carcinoma in 22%, 25%, 50% and 90%, respectively. All 100 patients had a negative surgical margin. No patient in group 1 had intraoperative puncture/spillage of the cystic tumor. In group 1 during a mean followup of 14 months (range 1 month to 3 years) 1 patient had retroperitoneal recurrence at 1 year despite negative surgical margins during initial LPN., Conclusions: Surgical outcomes of LPN for suspicious cystic masses are similar to those of LPN for solid tumors. However, extreme caution and refined laparoscopic technique must be exercised to avoid cyst rupture and local spillage.

Purpose: Hemostasis represents a primary challenge during laparoscopic partial nephrectomy (LPN). We typically clamp the renal artery/vein en bloc and perform LPN expeditiously under warm ischemia conditions. We evaluated Helix Hydro-jet assisted LPN without renal hilar vascular control in the survival calf model., Materials and Methods: Staged bilateral LPN using the Hydro-jet was performed without renal hilar vessel control in 10 survival calves (20 kidneys). Parenchymal hydrodissection was performed with a high velocity, ultracoherent saline stream at 450 psi through a small nozzle with integrated suction at the tip. The denuded intrarenal parenchymal blood vessels were precisely coagulated with a BIClamp bipolar instrument and transected. Followup involved biochemical, radiological and histopathological evaluation at designated sacrifice intervals of 1 and 2 weeks, and 1, 2 and 3 months, respectively., Results: All LPNs were completed successfully without open conversion. Of 20 LPNs 18 (90%) were performed without hilar clamping. Pelvicaliceal suture repair was necessary in 5 of 10 chronic kidneys (50%). Mean Hydro-jet(R) partial nephrectomy time was 63 minutes (range 13 to 150), mean estimated blood loss was 174 cc (range 20 to 750) and mean volume of normal saline used for hydro-dissection was 260 cc (mean 50 to 1,250). No animal had a urinary leak. Histological sections from the acute specimen revealed a thin (1 mm) layer of adherent coagulum at the amputation site with minimal thermal artifact. At 2 weeks a layer of adherent fibro-inflammatory pseudomembrane with giant cell reaction was seen., Conclusions: In this more stringent and robust survival calf model Hydro-jet assisted LPN can be performed without hilar vessel control, thus, completely avoiding warm ischemia. This approach has the potential to decrease the level of technical difficulty inherent in LPN.

Histologic subtyping of RCC has been shown to be of prognostic value; therefore, it is important to classify malignant epithelial tumors of the kidney correctly and also to differentiate them from benign ones. Overlapping morphologic features of renal tumors sometimes make histologic subtyping difficult. The accurate diagnosis and classification of RCC are based on cytoarchitectural features and require correlation with immunophenotype and cytogenetic characteristics. RCC Ma and CD10, two markers with relative renal specificity, have been used to confirm a diagnosis of suspected RCC and can facilitate the accurate diagnosis of metastatic RCC, in particular, in FNA. Although CCRCC and PRCC share most immunomarkers, CK7 and AMACR expression can be helpful in the differential diagnosis of challenging histologic variants of the two. In addition, E-cadherin aids in the distinction between types 1 and 2 PRCC. Useful markers in the differential diagnosis between ChRCC and CCRCCare CK7, RCC Ma, CD10, VIM, CD117, parvalbumin, and E-cadherin. We propose CK7/CK20/CD15 as a useful primary immunopanel to differentiate ChRCC from ONC reliably.

Background: Urothelial papilloma of the bladder is an uncommon entity when using restrictive diagnostic criteria., Design: We retrospectively studied 34 patients who were diagnosed with urothelial papilloma of the bladder using the criteria of the 1998 WHO/ISUP classification system. Six cases were in-house and the remaining 28 were referred from other institutions as consults to one of the authors. In all cases, the diagnosis of papilloma was the first manifestation of urothelial neoplasia., Results: The mean age of the patients at diagnosis was 57.8 years (range, 23-87 years). The male-to-female ratio was 2.4:1 (24 males and 10 females). The tumor size averaged 3.3 mm (range, 1-20 mm; median, 2 mm). Simple papillary fronds were seen in all cases; in 5 cases the additional finding of secondary budding off of small fronds from larger ones was also seen. In all cases, the fronds had a round morphology; yet in 4 cases elongated fronds were also noted. In 5 cases, dilated lymphatics within the fibrovascular fronds were apparent. One case had foamy histiocytes within the fibrovascular stalks. In all cases, the lining consisted of normal-appearing urothelium without hyperplasia, dysplasia, and/or mitotic figures. Some of the distinctive histologic features seen were changes in the umbrella cells: vacuolization (n = 4), prominence with cytologic atypia (n = 2), eosinophilic syncytial morphology (n = 1), apocrine-like morphology (n = 1), and mucinous metaplasia (n = 1). Follow-up was available in 26 cases with a mean follow-up for those without evidence of progression of 28.9 months (range, 3-127 months). Three patients (8.8%) developed recurrent papilloma 4, 15, and 18 months after the initial diagnosis of papilloma; 1 of these patients also showed progression to noninvasive low-grade urothelial carcinoma at the time of recurrence (15 months). Three patients (8.8%) progressed to higher-grade disease: 2 to noninvasive low grade urothelial carcinoma (11 and 15 months after the original diagnosis) and 1 to a papillary urothelial neoplasm of low malignant potential at 104 months and a noninvasive low-grade urothelial carcinoma at 141 months from the initial diagnosis of papilloma. None of the patients demonstrated progression to either lamina propria (T1) or muscularis propria (T2) invasion. Two patients died of unrelated causes. None of the patients died of bladder cancer., Conclusion: Patients with urothelial papillomas have a low incidence of recurrence and rarely progress to develop urothelial carcinoma. It seems reasonable to avoid labeling these patients as having cancer. It remains to be studied whether and when patients with papillomas who have no evidence of recurrence or progression no longer need to be followed.

Inflammatory myofibroblastic tumor (IMT) of the bladder is an uncommon myofibroblastic spindle cell proliferation. Because of its cytologic features and infiltrative nature, it may be difficult to distinguish histologically from sarcomatous proliferations such as sarcomatoid urothelial carcinoma, leiomyosarcoma, and embryonal rhabdomyosarcoma. Recently, anaplastic lymphoma kinase (ALK) gene translocations or ALK protein expression in IMT has been reported, especially in patients of relatively young ages. However, there are only a few reports mentioning IMT of the bladder. We sought to determine the frequency of ALK expression among IMTs of the urinary bladder. We examined 16 cases of IMTof the bladder in 14 patients to elucidate the incidence of ALK-1 expression by immunohistochemistry and its diagnostic usefulness. The age of patients with IMT ranged from 18 to 76 years, with an average age of 42.8 years. The tumors from 10 of 14 patients (12 of 16 cases) were positive for ALK-1. ALK-1-positive cases ranged in age from 18 to 73 years (mean, 39.2 years; median, 38 years) and ALK-1-negative cases from 41 to 76 years (mean, 41.5 years; median, 44.5 years). Two locally recurrent cases were positive for ALK-1 in both the primary and recurrent lesion. ALK-1 immunostaining was detected only in the cytoplasm, with granular or subplasmalemmal linear features, suggesting ALK gene translocation. ALK-1 immunostaining was also performed in 8 sarcomatoid urothelial carcinomas, 5 genitourinary leiomyosarcomas, and 2 stromal tumors of uncertain malignant potential of the prostate, all of which were negative. These results support that ALK-1 immunostaining is useful to differentiate IMT from other malignant spindle cell neoplasms of the bladder. There were no histologic differences between ALK-1 positive and negative IMTs.

Purpose: We describe the technique and our evolving outcomes of laparoscopic extended pelvic lymphadenectomy for bladder cancer., Materials and Methods: Since 1999 laparoscopic radical cystectomy with pelvic lymphadenectomy and intracorporeal urinary diversion has been performed in 22 patients. The initial 11 patients underwent limited dissection (group 1) and the subsequent 11 consecutive patients underwent extended lymphadenectomy (group 2). Our split-and-roll technique of laparoscopic extended pelvic lymphadenectomy has evolved to achieve lymphatic tissue clearance by bilaterally skeletonizing the genitofemoral nerve, external iliac artery, external iliac vein, obturator nerve, hypogastric artery, common iliac artery and pubic bone., Results: Extended lymphadenectomy added 1.5 hours of operative time. The median number of nodes retrieved was 3 and 21 in groups 1 and 2, respectively (p = 0.001). Three patients per group were found to have positive nodal disease. In 1 patient undergoing extended dissection injury to a deep pelvic vein was managed by intracorporeal suturing and resulted in 200 ml blood loss. Two other patients had deep venous thrombosis. At a mean followup of 11 months (range 2 to 43) there were no port site recurrences., Conclusions: Laparoscopic extended pelvic lymphadenectomy for bladder cancer can be performed with anatomical boundaries and nodal yields commensurate with those of current recommendations for open surgery.

Prostate-specific antigen (PSA) screening has resulted in a profound clinical stage migration. Extracapsular extension (ECE) presents a poor prognosis after radical prostatectomy (RP). In this study the trends in rate of ECE for cancers detected by PSA screening between 1987, when PSA screening became routine in the United States, and 2001, were examined. The clinical outcome of patients (total 1505; 888 clinical Tlc, 614 clinical T2, and 3 clinical T3) with prostate cancer diagnosed by PSA screening and treated with RP without neoadjuvant hormonal therapy was analyzed. The primary outcome variable was ECE rate with respect to year of treatment for a given tumor stage, preoperative PSA level, biopsy Gleason score, and surgical Gleason score. Logistic regression analysis was used to identify predictors of ECE. Biochemical relapse-free survival (bRFS) by year of treatment was analyzed by Kaplan-Meier Curve. Rate of ECE decreased from 65.8 to 25.2% during the 15-year study duration. Multivariate analysis of clinical tumor stage, age, preoperative serum PSA level, and Gleason score confirmed that year of treatment was an independent predictor of ECE. Six-year bRFS rates (by years of treatment) were 75.1% for 1987 to 1994 and 82.6% for 1995 to 2001 (P-value = 0.0022). PSA screening has resulted in a downward pathological stage migration. These observations demonstrate improved biochemical failure rates in more recently treated patients., (Copyright 2004 Elsevier Inc.)

Objectives: To perform a Phase II trial of docetaxel administered on a weekly schedule for 6 weeks before radical prostatectomy (RP) in patients with locally advanced prostate cancer., Methods: Treatment consisted of six doses of docetaxel 40 mg/m(2) intravenously administered weekly for 6 weeks followed by RP. Eligibility criteria included clinical Stage T2b, prostate-specific antigen (PSA) level 15 ng/mL or greater or Gleason sum 8 or greater, and no evidence of metastatic disease. The primary endpoint was feasibility and drug-related and surgical-related toxicities. Secondary endpoints included pre-RP PSA level, local response, pathologic outcomes, and time to PSA failure., Results: Twenty-nine patients were entered; 80% completed all 6 weeks of therapy and 97% underwent RP. The median PSA level was 12 ng/mL (range 2.5 to 43.3), the median Gleason sum was 8 (range 6 to 9), and all had Stage T2b or greater disease. A statistically significant reduction in the prechemotherapy versus postchemotherapy mean PSA level was observed (12.00 +/- 1.86 ng/mL versus 8.42 +/- 1.63 ng/mL, P <0.03), with 79% of patients experiencing some reduction and 24% a more than 50% reduction in PSA level in response to docetaxel alone. No unexpected toxicities and no intraoperative complications occurred. Pathologic analysis demonstrated residual carcinoma in all cases. Three patients (11%) had organ-confined disease, and 26 (93%) had achieved an undetectable PSA postoperatively. At a median follow-up of 23 months (range 1.5 to 36), 20 patients were disease free with no additional therapy., Conclusions: This trial establishes the baseline effect of short-course high-dose docetaxel alone on locally advanced prostate cancer. Additional study of this paradigm with other agents alone and in combination with docetaxel seems warranted.

In the Gleason grading system for prostatic cancer only the two most prevalent patterns are reported, although a third (tertiary) pattern grade may be present. We compared the pathologic stage of 227 radical prostatectomies with tertiary pattern 5 to the pathologic stage of 604 radical prostatectomies lacking a tertiary component. Gleason score 3 + 4 tumors with a tertiary pattern of 5 were more likely to present with higher stage disease than those Gleason score 3 + 4 tumors without a tertiary component (P = 0.012) and at a stage similar to Gleason score 3 + 5 tumors. Gleason score 4 + 3 tumors with a tertiary pattern of 5 were less likely to be organ-confined than Gleason score 4 + 3 tumors (P = 0.02) and less likely to have lymph node metastases than Gleason score 4 + 4 tumors (P = 0.027). However, Gleason score 4 + 4 with a tertiary pattern of 5 were indistinguishable from Gleason score 4 + 4 tumors. The relative effects of a tertiary pattern of 5 were greatest when the primary and secondary stages were low but become obscured by the already aggressive nature of advanced primary and secondary patterns. Therefore, except for very high-grade tumors, tertiary scoring of prostatic adenocarcinoma at radical prostatectomy should be reported as it has prognostic significance.

Expression of the alpha-methylacyl-CoA racemase (AMACR) gene has recently been demonstrated by several groups to be markedly elevated in prostate cancer cells with little expression in benign prostate tissue and has been suggested as a molecular marker of prostate cancer on needle biopsy. There is scant data, however, as to the sensitivity and specificity of AMACR in the diagnosis of small foci of cancer on needle biopsy. A total of 209 needle biopsies of the prostate with small foci (<5% of a core) of prostatic adenocarcinoma were identified. A total of 175 cases were received in consultation by one of the authors (140 from a single institution and 35 from different outside institutions) and 34 cases were from our hospital file. Immunohistochemistry for high molecular weight cytokeratin and p63 was performed in all cases to confirm the diagnosis of cancer. Only AMACR staining that was significantly stronger than that of background benign glands was considered positive; 88% of all cases of prostate cancer were positive for AMACR. The sensitivity varied among the different groups: 100% for the in house cases, 87.1% for the cases from a single institution, and 80% for cases from different outside institutions. The mean percentage of stained glands in positive cases was 95.9%, with 150 (71.8%) cases showing 100% of the glands positive and 25 (12.0%) cases showing no staining. Because negative staining for basal cell markers, especially in a small focus of atypical glands, is not necessarily diagnostic of prostate cancer, positive staining for AMACR can increase the level of confidence in establishing a definitive malignant diagnosis. However, the sensitivity of AMACR staining may vary in specimens from different pathology laboratories, possibly related to differences in fixation and processing. It is important to optimize the staining technique for each laboratory and recognize that some small cancers on needle biopsy may be AMACR negative.

It is unknown how long postradiation atypia of benign prostate glands persists and whether the type of radiation is a factor. Forty-four cases consisting of 37 needle biopsies and 7 transurethral resections of the prostate seen in consultation (January 1997 to September 2000) were studied. In two men (5%), the cases were initially sent without a history of radiotherapy. Thirteen patients had minimal cancer (one core) with the remaining showing no residual tumor. Twenty patients were treated with interstitial radiotherapy (brachytherapy) (IRT), 17 with external beam radiation (XRT), and 7 with a combination of both (CT). The time interval between the treatment and tissue sampling ranged from 8 to 72 months (mean 3 months). Slides were reviewed blindly to the type of radiation and the time interval. Radiation-induced atypia in nonneoplastic glands, stromal fibrosis, and vascular changes was scored separately 0-3, with 0 showing no radiation injury and grade 3 showing prominent nuclear atypia, stromal fibrosis, and vascular hyalinization. We derived a combined score for the epithelial atypia from 0 to 300 (% of glands x grade) for each biopsy. For each case, an overall grade from 0 to 3 was given separately for the stromal and vascular changes. Cases were divided into three groups based on time between treatment and biopsy: <24 months (n = 14), between 24 and 48 months (n = 19), and >48 months (n = 11). Because the scores for epithelial atypia with IRT and CT were the same, we combined them into one group. There was more atypia in cases treated with IRT/CT (mean score 190) than XRT (mean score 105) (p <0.00001). There was also a greater degree of stromal fibrosis with IRT/CT than XRT (p <0.04). There was no correlation between the type of treatment and the effect on vessels. There was no change over time in epithelial atypia in men treated with IRT/CT. With XRT, there was less epithelial atypia in cases biopsied >48 months after treatment (mean score 57) compared with those with a shorter interval between biopsy and treatment (mean score 132) (p = 0.02). Radiation atypia in benign prostate glands may persist for a long time after the initial treatment, resulting in a significant pitfall in evaluating prostate biopsies. Prominent radiation effect (100% of the glands showing grade 2 and 3 atypia) was detected up to 72 months in one of the patients treated with IRT. In some cases, the clinician may not be aware of a prior remote history of radiation or does not relay this history to the pathologist. The pathologist must recognize radiation atypia without relying on the clinician to provide this history. The type of radiation therapy (IRT/CT vs XRT) is a major factor in the degree and duration of postradiation epithelial atypia.

It is important to identify T1-substage breast carcinomas (BCs) which are inherently aggressive, so that these can be managed more assertively. The purpose of this study was to distinguish those T1 BCs with the potential to metastasize to axillary lymph nodes from those lacking that ability by multiparametric analysis of several clinicopathologic features. The authors studied 197 patients with invasive BC who had undergone modified radical mastectomy; 161 tumors were ductal and 26 were lobular BCs. The study group was stratified by age into two groups:

Radiation therapy results in significant morphological changes in prostatic carcinoma, including decreased cancer size, acinar shrinkage and distortion, cytoplasmic vacuolization, and nuclear pyknosis. Benign acini usually display enlarged, atypical cells with hyperchromatic nuclei. These changes confound the evaluation of limited postradiation samples. The glycoprotein A-80 is known to be upregulated in prostatic intraepithelial neoplasia (PIN) and prostatic carcinoma. In this study, we assessed the expression of A-80 in radiation-treated prostatic carcinoma. Paraffin sections from 64 postradiation prostatic carcinomas obtained at salvage prostatectomy were immunostained with a monoclonal antibody to A-80; selected sections were doubly immunostained with antibodies to A-80 and various cytokeratin polypeptides. All cases showed readily detectable and often intense staining in the cytoplasm of cancer cells and in intraluminal material of malignant acini. The extent and intensity of the reactions were independent of cancer size and grade. Strong reactions were seen in preserved and distorted acini, clear cell areas, single cancer cells, and in colloid pools with few or no recognizable cancer cells. PIN was present in 34 cases (53%), of which 27 (79%) stained strongly for A-80; atrophic and hyperplastic acini generally did not stain, irrespective of the degree of cellular atypia. The A-80 glycoprotein appears remarkably durable and is readily demonstrable in postradiation prostatic carcinoma despite profound architectural and cytologic changes. This characteristic may prove useful in evaluating small samples for confirmation of diagnosis and determination of extent of residual or recurrent prostatic carcinoma after radiation therapy.

Cancer progression occurs because of imbalance in the processes of proliferation, differentiation and programmed cell death. In prostate cells, these processes are regulated at least in part by androgens. Structural alterations occur in a variety of genes regulating such processes. In order to obtain meaningful information on the biologic behavior of prostate cancers, it is important to assess androgen dependence and alterations in key genes regulating cell cycle kinetics as well as the aberrant response in cellular proliferation and death that such genetic events bring about. Most genetic alterations resulting in cancer progression alter normal cell cycle progression. Assessment of cell division cycle alterations by means of quantitative methods may have prognostic value, while interference with cell cycle regulatory proteins may result in powerful therapeutic tools. Here we review the methodologies utilized in the assessment of cell cycle kinetics and the abnormalities in proliferation and apoptosis encountered in prostate cancer. In addition, alterations in novel, important genes likely to have an impact on the behavior of prostate cancer and its precursor lesions are discussed. Molecular assessment of genetic alterations in genes that play a pivotal role in prostate cancer coupled with quantitative cytometry of cell kinetics may be utilized for a more precise evaluation of biologic behavior of prostate neoplasms.

Mitogen-activated protein (MAP) kinases are key elements of the signalling systems needed to transduce different extracellular messages into cellular responses. At least three parallel MAP kinase pathways have been identified: one, stimulated by serum and growth factors to activate extracellular signal-regulated protein kinases (ERKs) by dual tyrosine and threonine phosphorylation, triggers cell proliferation or differentiation; the other two, induced by a variety of cellular stresses to activate c-jun N-terminal kinases (JNKs) and reactivating kinase (p38/RK), result in growth arrest and induction of apoptosis. Mitogen-activated protein kinase phosphatases (MKPs) inactivate MAP kinases through dephosphorylation and, thus, can modulate the MAP kinase pathways. Expression of JNK-1, ERK-1, p38/RK and MKP-1 proteins was investigated by immunohistochemistry and expression of MKP-1 mRNA by in situ hybridisation in 50 cases of high-grade prostatic intraepithelial neoplasia (PIN), thought to represent the precursor of prostate cancer. The frequency of apoptotic cells was also determined in these cases. Overexpression of the three MAP kinases and MKP-1 mRNA was found in all cases of high-grade PIN compared with normal prostate. Immunoreactivity for MKP-1 protein was found to be as intense as in normal glands in 30% and weaker in 56% of the PIN cases. Fourteen per cent of PIN cases did not stain with MKP-1 antibody. The proportion of apoptosis was significantly higher (P < 0.008) in PIN lesions that did not express MKP-1 protein than in those that did. These results are consistent with our previous demonstration of preferential inhibition of the apoptosis-related kinases by MKP-1 and further support the contention that MKP-1, even in PIN, may shift the balance existing between cell proliferation and death. When expressed, it may inhibiting those pathways that lead to apoptosis.

Although in situ hybridization has been in use for almost 30 years, its technically demanding nature, the requirements for optimal tissue fixation and preservation, and the turnaround time for the experiments have prevented this technique from becoming widely used in the surgical pathology setting. The use of nonisotopic reporter molecules, the possibility of performing hybridization on archival material, and very recently, automation of the procedure have brought in situ hybridization to the forefront of diagnostic and experimental pathology. We describe our experience with nonradioactive, automated in situ hybridization, compare the technique with traditional manual procedures, and briefly outline its potential applications in diagnostic pathology and in the research setting.

The principal mode of treatment of advanced (late stage) prostate cancer is androgen ablation. Although the response rate to hormonal ablation is high, relapse ultimately leading to death occurs in the majority of patients in remission from outgrowth of androgen-independent tumor cells. High-grade and high-stage cancers are more likely to progress to androgen independence. This study was undertaken to analyze the expression level of androgen receptor (AR) protein in prostatic carcinomas in relationship to grade and stage of disease. AR protein expression was assessed in 40 archival cases of prostate carcinoma by automated immunohistochemical techniques with standardized development times. Positive nuclei were quantitated by computer-assisted image analysis. Eighty-five percent of the prostatic carcinomas showed high levels of expression, defined as having AR present in more than 50% of the cells by light microscopy. Results of image analysis demonstrated that the variability of AR protein content per unit nuclear area increased with increasing grade (P < .03), regardless of cell size. High-grade prostatic intraepithelial neoplasia (PIN), present in 17 (42.5%) of the 40 cases, showed markedly reduced AR nuclear staining, compared with low-grade PIN or normal prostate. We show that AR content in prostate tumor cells becomes more variable with increasing Gleason score. In high-grade PIN, the in situ precursor of invasive prostate cancer, AR expression is either downregulated and/or restricted to the cytoplasm, but it is not heterogeneous. These data suggest that the heterogeneity in the expression of the receptor increases with progression of invasive prostate cancer and might in part account for a variable response to endocrine therapy.

Breast carcinomas < or = 1 cm in size (T1a,b) are being detected more frequently as a result of screening. Because traditional prognostic parameters are either lacking (tumor size) or rare (nodal metastases), a marker(s) is needed to identify the subset of patients who could benefit from adjuvant therapy. A retrospective series of 202 patients with stage T1a,b invasive breast carcinomas was evaluated. The clinicopathological features (age, histological grade, extensive in situ carcinoma, hormone receptor status, and nodal metastasis) as well as microvessel density and the expression of c-erb-B2, p53, MIB-1/Ki-67, and cdc25B were assessed. In addition, expression of the cell cycle inhibitor p27 was evaluated. Nineteen patients (18% of patients who had axillary dissection) had locoregional lymph node metastases. Forty-two % of them died of disease (median survival, 112 months), whereas mortality was 11% in node-negative patients (median survival, 168 months; P = 0.0055). Patients with low p27 expression had a median survival of 139 months (17% mortality) versus 174 months (9% mortality) in the group with high p27 expression (P = 0.0233). Lack of p27 was associated with poor prognosis when node-positive patients were excluded (P = 0.0252). Nodal status and low p27 were found to be the only independent prognostic parameters by both univariate and multivariate analysis, with relative risks of dying of disease of 4.9 (P = 0.001) and 3.4 (P = 0.0306), respectively. Assessment of p27, which yields prognostic information in node-negative patients, could be useful to identify patients with small, invasive breast carcinomas who might benefit from adjuvant therapy.

Many mitogens and human oncogenes activate extracellular regulated kinases (ERKs), which in turn convey proliferation signals. ERKs or mitogen-activated protein (MAP) kinases are inactivated in vitro by MAP kinase phosphatases (MKPs). The gene encoding one of these MKPs, MKP-1, is a serum-inducible gene and is transcriptionally activated by mitogenic signals in cultured cells. As MKP-1 has been shown to block DNA synthesis by inhibiting ERKs when expressed at elevated levels in cultured cells, it has been suggested that it may act as a tumor suppressor. MKP-1 mRNA and MAP kinase (ERK-1 and -2) protein expression was assessed in 164 human epithelial tumors of diverse tissue origin by in situ hybridization and immunohistochemistry. MKP-1 was overexpressed in the early phases of prostate, colon, and bladder carcinogenesis, with progressive loss of expression with higher histological grade and in metastases. In contrast, breast carcinomas showed significant MKP-1 expression even when poorly differentiated or in late stages of the disease. MKP-1, ERK-1, and ERK-2 were co-expressed in most tumors examined. In a subset of 15 tumors, ERK-1 enzymatic activity as well as structural alterations that might be responsible for loss of function of MKP-1 during tumor progression, were examined. ERK-1 enzymatic activity was found to be elevated despite MKP-1 overexpression. No loss of 5q35-ter (containing the MKP-1 locus) was detected by polymerase chain reaction in metastases compared with primary tumors. Finally, no mutations were found in the catalytic domain of MKP-1. These data indicate that MKP-1 is an early marker for a wide range of human epithelial tumors and suggest that MKP-1 does not behave as a tumor suppressor in epithelial tumors.

The aim of this study was to investigate the effect of microwave oven heating for antigen retrieval on the immunoreactivity of human prostate carcinoma androgen receptor (AR) in tissue sections. Formalin-fixed, paraffin-embedded tissue sections were microwaved at 5-min intervals for a total of 15, 20, 25, 30, 35 minutes at maximum power (700W). The monoclonal antibody F39.4.1 directed against human AR was used at a 1:10 dilution. Without microwave oven heating, prostatic tissue did not exhibit any AR immunoreactivity. Moderate positivity appeared after three 5-minute cycles of microwave heating. The intensity of immunoreactivity improved progressively with heating times of 20 and 25 min up to an optimum time of 30 minutes, when nuclear staining was most intense with the absence of background staining and without loss of morphological details. While antigen retrieval is effective in restoring antigenicity in a variety of setting, the length of time prostate tissue is exposed to microwave radiation is critical in order to obtain optimal AR immunostaining. AR immunostaining reliably permitted evaluation of the distribution and intensity of positively stained nuclei and the distinction of the various cell types in archival material.

The frequency and location of apoptotic bodies (AB) were evaluated in hematoxylin- and eosin-stained sections of 12 radical prostatectomies from patients with prostatic adenocarcinoma pre-treated for 3 months with total androgen ablation. Results were compared with an untreated age-, morphology- and stage-matched control group. Treated prostates showed involutional changes, with cytoplasmic vacuolization and chromatin changes ranging from mild to severe condensation, similar to that observed in apoptosis. In treated benign prostatic epithelium, the mean number of AB was 1.64% (standard error (SE), 0.19%), 6.3 times greater than in the untreated group (mean, 0.26%; SE, 0.03%). AB were more frequent in the basal cell layer than in the lumenal cell layer, whereas in the untreated group, AB were almost exclusively found in the basal cell layer. In treated prostatic intraepithelial neoplasia (PIN present in 10 cases), the mean number of AB was 1.74% (SE, 0.04%), which was 2.56 and 2.32 times greater than in untreated low grade PIN (mean, 0.68%; SE, 0.15%) and high grade PIN (mean, 0.75%; SE, 0.11%), respectively. In treated and untreated PIN, the number of AB was greatest in the basal cell layer, less in the intermediate cell layer and lowest in the cell layer bordering the lumen. The mean number of AB in the 12 treated cancers was 1.35 times greater than in untreated cancers (1.80% [SE, 0.12%] versus 1.33% [SE, 0.32%], respectively). The number of AB in treated cases of the acinar pattern of cancer (present in 7 cancer cases) was 1.78 times greater than in untreated cases, and in treated cases of the cribriform pattern of cancer (present in four cases), the mean number of AB was 1.39 times greater than in untreated cases. The number of AB was greatest in the outermost cell layer, with progressive decrease in layers closer to the lumen. In the one treated case with solid/trabecular pattern of cancer, the number of AB was 1.08 times greater than in untreated cases. The gland lumina was rich in macrophages, sloughed secretory cells with degenerative features and AB. The number of AB in the lumina increased from normal epithelium through PIN to cancer, and was greater in treated cases than in untreated cases.

Nucleolar-related features were quantified in toluidin blue-stained smears from 36 brain tumors in order to improve our knowledge of the nucleolar frequency, size and margination. It was observed that low-grade astrocytic tumors had high percentages of nucleolated cells but the nucleoli were mostly single with maximum nucleolar diameter smaller than 2.00 microns. The percentages of marginated nucleoli were also low, ranging between 3.00% and 30.00% (only one case had a higher percentage). The high-grade tumors, i.e. anaplastic astrocytomas and glioblastomas, did not significantly differ from low-grade astrocytomas in their percentages of nucleolated nuclei, but they showed a higher number of nuclei having three or more nucleoli and the mean nucleolar diameter was in general bigger than 2.00 microns. Glioblastomas had marginated nucleoli much more frequently than anaplastic astrocytomas, the percentage in all but one case being higher than 30.00%. The percentage of marginated nucleoli was much higher in glioblastomas than in metastases, while the nucleoli were bigger in the latter group. A wide range of values for most of the nucleolar-associated parameters was observed in the remaining non-astrocytic brain tumors. Our results, showing differences in nuclear number, size and margination in different brain tumors, lead us to consider it worthwhile to investigate nucleolar-related features and their relationships using a quantitative approach.

This paper evaluates the use of quantitative methods to accurately assess cell proliferation and death in untreated and treated prostate lesions. The analysis of proliferating cell nuclear antigen (PCNA)-stained nuclei allow precise evaluation of the proliferating cells and exact identification of their location in the progression of untreated prostatic intraepithelial neoplasia (PIN) to prostatic adenocarcinoma (PAC). The evaluation of the frequency and location of apoptotic bodies (ABs) gives accurate information on the apoptotic phenomenon in PIN compared to normal prostate (NP) and PAC. In fact, the frequency of ABs increases from NP to PIN to PAC and parallels that observed with PCNA. However, the AB-related values were approximately one-eighth to one-tenth of those obtained with PCNA immunostaining. Combination endocrine therapy (CET) decreases the proliferative activity and enhances the apoptosis phenomenon in NP, PIN, and PAC. This might indicate that CET could induce a certain degree of regression not only of PAC, but also of PIN.

Expression and location of Proliferating Cell Nuclear Antigen immunostaining in epithelial nuclei were assessed on histological sections from 32 cases of invasive adenocarcinoma of the prostate gland: 20 untreated and 12 treated with combination endocrine therapy or CET. The PCNA-positive nuclei showed homogeneous or granular types of staining or a mixture of both, and a gradation in the intensity of staining. Nuclei with homogeneous patterns appeared darker brown than the lighter granular and mixed patterns. Darker nuclei were more frequently noted, mainly among the epithelial cells adjacent to the stroma, in the untreated cases. In contrast, nuclei with pyknotic chromatin, unstained and corresponding to apoptotic bodies, were more frequently seen in the treated patients. For the untreated invasive adenocarcinomas, the mean proportion of PCNA-stained epithelial nuclei in the 10 cases with an acinar pattern (small and large) was 8.86% (SE 0.23%). The mean value in the 5 cases with a cribriform pattern was 11.76% (SE 0.52%), that is, greater than in the acinar pattern, and decreased from the nuclei in the basal position, or adjacent to the stroma, toward the lumen: 14.40% (SE 0.61%) in the basal position, 11.84% (SE 1.30%) in the intermediate and 9.26% (SE 0.66%) in the lumenal. In the 5 cases with a solid/trabecular pattern, the proportion of PCNA-positive nuclei was 15.74% (SE 2.30%), that is, higher than in all the other patterns, and decreased from the cell layer adjacent to the stroma (17.60%, SE 2.92%) toward the other layers (13.88%, SE 1.71%).(ABSTRACT TRUNCATED AT 250 WORDS)

The aim of this study was to emphasise the importance of the measurement sites in tumours from the biological point of view. In particular, two distinct aspects regarding locations were investigated for Proliferating Cell Nuclear Antigen (PCNA) expression in the cribriform adenocarcinoma of the prostate as an example. The first aspect was the identification of the most suitable part of the tumour nodule to be analysed, that is, periphery or marginal zone vs central. The second aspect consisted of the precise location of the objects in relation to the histologic pattern and its components, such as the different cell layers in the cribriform pattern. The results obtained showed that the proportion of PCNA-immunostained nuclei in the marginal zone of the tumour decreased from the basal position, or adjacent to the stroma, towards the lumen: 14.40% (standard error, SE, 0.61%) in the basal position, 11.84% (SE 1.30%) in the intermediate and 9.26% (SE 0.66%) in the lumenal position. In the central zone of the tumour the trend of value changes was similar to that obtained in the marginal zone. However, the proportions were lower and the differences statistically significant. In conclusion, the degree of PCNA expression is related to both locations. Thus, adequate information on the biology of the lesions can only be obtained when the precise site of the objects to be evaluated is identified. Otherwise, misleading results about the lesions being measured can be derived.

The aim of our study was to assess the frequency and location of apoptotic bodies (ABs) in haematoxylin and eosin-stained sections of prostatic intraepithelial neoplasia (PIN) and then to compare the patterns with those in benign prostatic hyperplasia (BPH) and prostatic invasive adenocarcinoma (PAC). ABs were identified in all epithelial cell layers of the ducts, acini and tumour islands, as well as in the lumina contained in such structures. In the epithelial cell layers, ABs were found in general in the intercellular space and occasionally in the cytoplasm of epithelial cells. The frequency of ABs increased from BPH through PIN up to PAC. The proportions of ABs in PIN lesions of low grade (PINlow) and high grade (PINhigh) were greater than in BPH, the values decreasing from the nuclei in the basal position towards those in the luminal layer. In PINlow, the mean category values were 0.85% (standard error, SE, 0.311%) in the basal, 0.623% (SE 0.065%) in the intermediate and 0.474% (SE 0.138%) in the luminal position. In PINhigh, the mean category values were 1.006% (SE 0.16%) in the basal position, 0.713% (SE 0.182%) in the intermediate and 0.618% (SE 0.172%) in the luminal position. The proportions of ABs in adenocarcinoma with cribriform pattern decreased from the basal towards the luminal layer, as for PIN: 1.806% (SE 0.346%) in the basal position, 1.15% (SE 0.172%) in the intermediate and 0.886% (SE 0.137%) in the luminal position. In the solid/trabecular adenocarcinomas, the mean category value in the cell layer adjacent to the stroma was 2.154% (SE 0.203%), whereas in the other cell layers it was 2.052% (SE 0.239%). In small and large acinar adenocarcinomas, the proportions of positive nuclei were 1.022% (SE 0.1%) and 0.922% (SE 0.163%), respectively. The evaluation of the frequency and location of ABs gives accurate information on cell death in PIN in comparison with BPH and PAC.

The lesser diameter of the fibers, separately of type 1 and type 2 fibers, and the capillary density evaluated as number of capillaries/area and number of capillaries/fiber were quantitatively estimated in muscle biopsies from 12 patients with systemic sclerosis. Nine patients with polymyositis or rheumatoid arthritis and six patients with muscle dystrophy and neurogenic atrophy served as controls. The results showed that patients with systemic sclerosis had low values of the lesser diameter of the fibers. This reduction was most obvious in type 2 fibers. The capillaries were also significantly reduced when compared with the control groups. When considering the capillaries/fiber ratio, seven out of eight patients with values lower than 0.7 belonged to the systemic sclerosis group. In systemic sclerosis the capillary density values were not significantly correlated with those of the lesser diameters of the fibers.

The diagnostic value of nucleolar margination, defined as the percentage of nucleoli touching the nuclear membrane, was investigated in 359 cytological preparations of benign and malignant lesions of the thyroid, breast, prostate and central nervous system. Premalignant lesions of the uterine cervix and non-invasive papillary carcinomas of the bladder were also examined. It was observed that the percentages in benign lesions were, in general, lower than in the malignant and that the values increased progressively with increasing grade in the cervix and bladder. When the overlap index was calculated, this gave exact information on the usefulness of nucleolar margination in distinguishing benign from malignant lesions, particularly in the prostate and thyroid and, to a lesser extent, in the breast and central nervous system. As for lesions of different grades, the calculation of the index allowed the identification of two subgroups, one corresponding to low grades (mild cervical dysplasia or urothelial papillary carcinoma of grade 1), the other subgroup to high grades (severe cervical dysplasia and carcinoma in situ, or papillary carcinoma of grade 3). Moderate dysplasia cases and grade 2 papillary carcinomas do not appear as separate intermediate categories but rather show values falling into the range of either the higher or lower grades. The margination values obtained from the cytological preparations corresponded well to those in the histological slides obtained from the resected specimens. In conclusion, nucleolar margination appears to be a feature which is easy to evaluate in a reproducible way and useful in cytological diagnosis.