Reliable identification of small cell lung cancer in cytological specimens by immunocytology

BACKGROUND: A reliable diagnosis of small cell lung cancers (SCLC) is of high clinical relevance. We investigated whether immunocytology substantially improves the diagnostic accuracy of conventional cytology in diagnosing SCLC. PATIENTS AND METHODS: 162 carcinomatous specimens clinically suspected to originate from pulmonary neoplasms were investigated by cytology and immunocytology. Immunocytology was performed on smears using HEA125 and pancytokeratin antibodies as epithelial markers and MOC-1 as SCLC probe. RESULTS: As histologically clarified, 114 specimens corresponded to pulmonary neoplasms (SCLC = 51; non-small cell lung cancer: NSCLC = 59; mixed SCLC/NSCLC = 2; carcinoid = 2), 48 to nonpulmonary adenocarcinomas. By conventional cytology tumor cells were clearly detected in 93 (57.4%) and suspected in another 43 (26.5%) cases (83.9% overall sensitivity). Considering SCLC samples, tumor cells were diagnosed or suspected in 36 (70.5%), not identified in 10 (19.6%), and misdiagnosed as hematological malignancy in 5 cases. Only 2 specimens were accurately diagnosed as SCLC. Using the epithelial antibodies all samples were identified as carcinomatous. MOC-1 stained all but one SCLC, both SCLC/NSCLC, and both carcinoids. One SCLC brush smear was MOC-1 negative, containing only squamous epithelium. 3 pulmonary adenocarcinomas stained falsely positive, all nonpulmonary carcinomas MOC-1 negative. CONCLUSION: Immunocytology substantially improves the diagnostic accuracy of cytology in diagnosing SCLC with a diagnostic sensitivity of 98% and specificity of 97%.     

Quantitative molecular diagnosis of peritoneal lavage fluid for prediction of peritoneal recurrence in gastric cancer

We developed a quantitative multiple-marker RT-PCR assay for sensitive detection of free cancer cells in the peritoneal cavity and examined the significance of this molecular diagnostic technique for detection and prediction of peritoneal dissemination in patients with gastric cancer. Preoperative peritoneal lavage fluid samples obtained from 129 patients with gastric cancer were subjected to RT-PCR assay with primers specific for carcinoembryonic antigen (CEA) and cytokeratin-20 (CK-20), and conventional cytological examination with Papanicolaou staining. The multi-marker RT-PCR assay was positive in 59 of 129 (46%) gastric cancer patients, whereas conventional cytology was positive in only 9 of 129 (7%) patients. Thirty-two of 129 (22%) patients suffered disease recurrence after surgery. Twenty-one of these patients were confirmed to have had peritoneal recurrence. Although conventional cytology was positive on peritoneal washes in only 9 patients, the RT-PCR assay was positive in 20 of these 21 patients. Furthermore, in cases with negative cytology, patients with PCR-positive findings in peritoneal lavage fluid had a significantly poorer prognosis than those with negative PCR, mainly because of peritoneal recurrence. Our results suggest that the multiplex RT-PCR assay for CEA and CK-20 was highly sensitive for detection and might be useful for prediction of peritoneal dissemination in gastric cancer.     

Immunocytochemically detected free peritoneal tumour cells (FPTC) are a strong prognostic factor in gastric carcinoma

We prospectively investigated the prognostic significance of free peritoneal tumour cells (FPTC) in a series of 118 patients with completely resected gastric carcinoma. Immunocytochemistry with the monoclonal antibody Ber-Ep4 was performed on cytospins from intraoperative peritoneal lavage specimens. Twenty-three patients (20%) had FPTC which was significantly correlated with pT and pN categories, stage, tumour size, lymphatic invasion, Laurèn and WHO classifications and perigastric adipose tissue metastases. The median survival time for all FPTC positive compared with negative patients was significantly shorter (11 compared with >72 months), with estimated 5-year survival rates of 8% vs. 60%. None of the patients with FPTC had an early gastric cancer. In advanced tumour subgroups without and with serosal invasion (n = 59 and 35), there were 19% and 34% with FPTC. Multivariate survival analysis showed nodal status, FPTC, mesenteric lymphangiosis, and lymph node metastasis to the compartment III to be independent prognostic factors with relative risks of 6.6, 4.5, 2.9 and 2.2 respectively. Recurrent disease occurred in 91% of FPTC-positive and in 38% of FPTC-negative patients. FPTC had a positive predictive value of 91% and a specificity of 97% for tumour recurrence. FPTC is a strong negative, independent prognostic indicator for survival in gastric carcinoma.     

Peritoneal cytology in the surgical evaluation of gastric carcinoma

Many patients undergoing surgery for gastric carcinoma will develop peritoneal metastases. A method to identify those patients at risk of peritoneal recurrence would help in the selection of patients for adjuvant therapy. Peritoneal cytology has received little attention in the West, but may prove a useful additional means of evaluating patients with gastric cancer. The aims of this study were to evaluate sampling techniques for peritoneal cytology in patients with gastric cancer, to assess the prognostic significance of free peritoneal malignant cells and to discover the effect of the operative procedure on dissemination of malignant cells. The study is based on 85 consecutive patients undergoing surgical treatment of gastric cancer and followed up for 2 years or until death. Peritoneal cytology samples were collected at laparoscopy, and at operation prior to resection by intraperitoneal lavage and serosal brushings. After resection, samples were taken by peritoneal lavage, imprint cytology of the resected specimen and post-operatively by peritoneal irrigation via a percutaneous catheter. Malignant cells were diagnosed by two independent microscopists. Preoperative peritoneal lavage yielded malignant cells in 16 out of 85 cases (19%). The yield of free malignant cells was increased by using serosal brushings (by four cases) and imprint cytology (by two cases); all of the cases had evidence of serosal penetration. One serosa-negative case exhibited positive cytology in the post-resection peritoneal specimen in which the preresection cytology specimen was negative. Survival was worse in the cytology-positive group (chi2 = 25.1; P< 0.0001). Among serosa-positive patients, survival was significantly reduced if cytology was positive, if cases yielded by brushings and imprint cytology were included (log-rank test = 8.44; 1 df, P = 0.004). In conclusion, free peritoneal malignant cells can be identified in patients with gastric cancer who have a poor prognosis; the yield can be increased with brushings and imprint cytology in addition to conventional peritoneal lavage. Evaluation of peritoneal cytology by these methods may have a role in the selection of patients with the poorest prognosis who may benefit most from adjuvant therapy.     

p53 and VEGF expression are independent predictors of tumour recurrence and survival following curative resection of gastric cancer

This study was undertaken to determine the value of tumour microvessel density (MVD) and the expression of p53 and vascular endothelial growth factor (VEGF) as prognostic markers in patients with gastric cancer operated on for cure. In all, 156 patients with curatively resected gastric cancer constituted the basis of this blinded retrospective evaluation. Patients were treated with either surgery alone (n=53) or surgery plus adjuvant chemotherapy (n=103). Tumour MVD, p53 expression, and VEGF expression were assayed using immunohistochemical techniques. After a mean follow-up of 43 months, 64 (41%) patients had died and 55 (35%) patients developed tumour recurrence. Positive correlations between MVD and both p53 (P=0.005) and VEGF (P=0.005) expression were observed. Both MVD >/=100 (P=0.05) and positive VEGF expression (P<0.02) were associated with shorter disease-free survival, and positive VEGF expression (P=0.01) was also associated with shorter overall survival. Multivariate analysis confirmed that, in addition to the pathological tumour stage, lymph node ratio, the extent of lymphadenectomy and perineural invasion, p53 expression, and VEGF expression were independently associated with both disease-free survival (P<0.0005 and 0.02, respectively) and overall survival (P<0.02 and 0.01, respectively). Finally, patients whose tumours did not show p53 expression had a survival benefit compared to those expressing p53 when treated with adjuvant chemotherapy (P=0.01).This investigation demonstrates that p53 expression and VEGF expression are independent prognostic factors for both disease-free survival and overall survival in patients with curatively resected gastric cancer, and that p53 status may also influence response to chemotherapy.     

Long-term prognostic value of conventional peritoneal cytology after curative resection for colorectal carcinoma

BACKGROUND: This study was undertaken to evaluate the long-term prognostic significance of conventional peritoneal cytology in patients with advanced colorectal carcinoma after curative resection. METHODS: A review was performed of 189 patients who underwent curative resection for pT3/T4 carcinoma of the colon and upper/middle rectum between March 1987 and December 1991. Patient outcomes were reviewed retrospectively. Peritoneal cytology was performed before manipulation of the tumor. Intraoperatively, 50 ml of saline were instilled and 20 ml were reaspirated for cytology. In all patients, Papanicolaou and Giemsa stainings were performed to detect intraperitoneal free tumor cells. RESULTS: The median follow-up was 103 months. Malignant cells were identified in peritoneal washings from 11 patients (5.8%). Of the 11 patients with positive cytology, six (54.5%) developed recurrence and peritoneal recurrence was observed in four (36.4%). In contrast, of the 178 patients with negative cytology, 46 (25.8%) developed recurrence and peritoneal recurrence was observed in four (2.2%). The peritoneal recurrence rate was significantly increased (P = 0.0004) in the patients with positive cytology. The cancer-specific 10-year survival rates for the patients with positive and negative cytology were 45.5 and 80.3%, respectively (P = 0.0051). Multivariate analysis (Cox proportional hazard model) revealed that peritoneal cytology (positive: P = 0.0256) and lymph node metastasis (pN2: P = 0.0004) were independent predictors of cancer-specific survival. CONCLUSION: Conventional peritoneal cytology serves as a new prognostic marker after curative resection in patients with advanced colorectal carcinoma. It appears to be a useful diagnostic procedure for predicting recurrence, especially peritoneal recurrence.     

Peritoneal wash cytology in gastric carcinoma. Prognostic significance and therapeutic consequences

Background and Aims

The prognosis of patients with gastric cancer is poor, even following curative resection, and is related primarily to the extent of disease at presentation. In locally advanced gastric tumors, peritoneal lavage cytology (PLC) is a relevant prognostic factor. The Authors present their results of peritoneal washing cytology, evaluating the prognostic value of this technique, and discussing the clinical impact.

Patients and Methods

From July 2003 to May 2008, results of PLC in 64 patients with histologically proven primary gastric adenocarcinomas were analyzed. At laparotomy the abdomen was irrigated with 200 ml of normal saline, and ≥50 ml were aspirated and examined by means of cytology and immunocytopathology.

Results

PLC was positive in 7 cases (11%). Overall, 86% of patients with a positive PLC had a pT3/pT4 tumor and 100% with a positive PLC had an N-positive tumor (p < 0.001); 71% of patients with a positive PLC had a grade G3/G4 tumor (p = 0.001). At a median follow-up of 32 months, the cumulative 5-year survival was 28%. The median survival of patients presenting positive PLC (19 months) was significantly lower than that of patients with negative peritoneal cytology (38 months) (p = 0.0001). Multivariate analysis identified cytology as a significant predictor of outcome (p = 0.018).

Conclusions

Results in the present series demonstrated that patients with a positive peritoneal cytology had advanced disease and poor prognosis, thus indicating that patients with locally advanced gastric cancer should undergo staging laparoscopy and PLC examination in order to select those requiring more aggressive treatment.Future therapeutic strategies should include PLC examination in preoperative staging, in order to select patients for more aggressive treatment.     

A clinicopathological study of asymptomatic gastric cancer.

The clinicopathological profiles of 419 patients with asymptomatic gastric cancer (AGC) first detected by gastric screening, were reviewed and compared with those of the 1727 patients with symptomatic gastric cancer (SGC). The incidence of AGC increased gradually and has amounted to 30% of the total resected cases in recent years. About 75% of AGC cases were of early cancer and 84% were negative for lymph node metastases. In contrast, only 33% of SGC cases were of early cancer and 57% were node positive. Curative resection was done in 97% of AGC and 75% of SGC. The cumulative 5 and 10 year survival rates of patients with curatively resected AGC were 85.2% and 72.2%, respectively, while those for patients with SGC were 66.8% and 55.4%. These data demonstrated that most patients with asymptomatic gastric cancers could expect a curative resection, i.e. have a better clinical outcome, than those with symptomatic cancer.     

The presence of bone marrow cytokeratin-immunoreactive cells does not predict outcome in gastric cancer patients

The independent prognostic significance of isolated tumour cells in bone marrow is still a matter of debate. This study evaluated the possible association of bone marrow micrometastases with tumour progression and prognosis in patients affected by gastric cancer. Bone marrow aspirates from both iliac crests were obtained from 114 consecutive patients operated on for gastric cancer. The specimens were stained with monoclonal antibody CAM 5.2 which reacts predominantly with cytokeratin filaments 8 and 19. Among 114 cases analysed, 33 cases (29%) had cytokeratine-positive cells in the bone marrow. There was no significant relationship between the presence of bone marrow micrometastases and site, depth of tumour invasion, lymph node metastases, presence of metastases. Patients with cytokeratine-positive cells had a trend towards a diffuse type histology (P=0.06). Among the 88 curatively resected patients, median survivals were 40 months and 36 months for cytokeratine-negative and cytokeratine-positive subsets respectively (P=0.9). Recurrence of the disease was observed in 39 cases (44.3%); 11 of 24 (45.8%) in the cytokeratine-positive subset and 28 of 64 (43.7%) in the cytokeratine-negative subset. In conclusion in our experience the presence of cytokeratine-positive cells in the bone marrow of curatively resected gastric cancer patients did not affect outcome and its independent prognostic significance remains to be proven before its official acceptance in the TNM classification.     

The prognostic value of positive peritoneal lavage cytology and the prevention of peritoneal dissemination after colorectal surgery

Peritoneal washing cytology during surgery was done in 745 patients with colorectal cancer. The positive washing cytology rate was 49/745 (6.6%). The peritoneal recurrence rates were 12/22 (54.5%) and 8/682 (1.3%) among patients with positive and negative peritoneal washing, respectively (p < 0.0001). The 5-year survival rate is 89.4% of the patients with positive cytology and 38.2% with negative cytology. The patients with positive cytology have a significantly lower survival rate than the negative one (p < 0.0001). Eleven patients of the positive cytology received intraperitoneal administration of MMC. Peritoneal dissemination occurred in 3/11 (27.3%) of the MMC treated group and 9/11 (81.8%) in the untreated group (p = 0.030). Our results indicated that intraperitoneal administration of MMC was an effective method of preventing peritoneal dissemination after resection of colorectal cancer.     

Evaluation of monoclonal antibodies for the detection of exfoliative nasopharyngeal carcinoma cells

Exfoliative cells were aspirated from 15 patients suspected of having nasopharyngeal carcinoma (NPC) and showing the presence of lesions or other abnormalities in the nasopharynx. They were tested for binding with a 125I monoclonal antibody (MAb) (MA6) which is selectively reactive against human B lymphocytes and a variety of carcinomas. A positive result was obtained from 6/9 patients with, and from 0/5 patients without, histologically confirmed disease. One patient with eskimoma also gave a negative binding result. Cytology was specific but less sensitive, tumour cells being detected in 3 of the patients with confirmed disease. Immunocytology using MA6 was limited, like cytology, by poor recovery of the tumour cells and the results were in complete concordance with cytology. The other MAbs used were raised against carcinoembryonic antigen (CEA) and a carcinoma cell line (Ca2), respectively. The latter was not reactive against the NPC tumour cells while the CEA antibody was not sufficiently selective to be useful.     

66例胃癌腹腔冲洗细胞学的临床研究

目的 探讨腹腔游离癌细胞形成的相关因素及其与胃癌预后的关系。方法 对66例胃癌患者进行术中腹腔冲洗液细胞学检测,分析其与浆膜受侵、淋巴结转移、分期等因素的相关性,并通过累积复发曲线分析预后。结果 66例胃癌腹腔冲洗液细胞学阳性率为36．4％(24／66),浆膜侵犯及淋巴结转移阳性组中,腹腔游离癌细胞检出率明显高于阴性组(P＜0．025)。相关因素分析显示,浆膜受侵、淋巴结转移及分期,与腹腔冲洗细胞学阳性显著相关;累积复发分析显示,腹腔游离癌细胞阳性者术后腹腔复发较阴性者显著增高(P＜0．01),提示预后不佳。结论 腹腔脱落癌细胞形成微转移灶,是胃癌术后腹腔复发转移及降低预后的主要危险因素之一,浆膜侵犯及腹腔淋巴结转移与腹腔脱落癌细胞呈正相关。术中检测腹腔游离癌细胞有助于评价手术效果、判断预后以及为辅助治疗提供依据。     

A case report of the combination therapy with S-1 plus CDDP intraperitoneal chemotherapy for CY positive cancer patient

A male patient in his 50s underwent distal gastrectomy for gastric cancer. In operation, there was no peritoneal dissemination. But peritoneal lavage cytology revealed positive peritoneal dissemination. Thus, we set an intraperitoneal infuser port to this patient. On specimen, a type-3 tumor was located in the gastric lesser of antrum to angle. Microscopic examination of specimens revealed a signet ring cell carcinoma and poorly differentiated adenocarcinoma under serosa, and positive of lymph node metastasis. The diagnosis was pT4N2M1P0CY1H0, Stage IV( Japanese classification of gastric carcinoma The 14 Edition). CDDP was administered through the infuser port (on day 7, a first dose of 60 mg/m2 and 30 mg/m2 for second) combined with oral administration of S-1 (100 mg/body) for two weeks, with one week of drug withdrawal. This chemotherapy was repeated for 11 courses. After that, peritoneal lavage cytology became negative. S-1 oral administration was continued for four years, and this patient has been well for five years and six months after the surgery. Therefore, it is suggested that intraperitoneal chemotherapy with cisplatin is an effective treatment for microscopical peritoneal dissemination.     

Disseminated tumor cells in pancreatic cancer patients detected by immunocytology: a new prognostic factor.

Using an immunocytological approach, we previously showed that disseminated cancer cells are frequently found in peritoneal cavity and bone marrow samples of gastrointestinal and pancreatic cancer patients. Recently, we demonstrated that the detection of isolated tumor cells could serve as a new prognostic factor in gastric and colorectal cancer. Thus far, no conclusive data concerning the clinical implication of minimal residual disease in pancreatic cancer exist. In this study, we investigated peritoneal lavage and bone marrow samples of 80 pancreatic cancer patients to determine the predictive value of immunocytologically detected disseminated tumor cells. Therefore, immunocytological findings were correlated with the clinical follow-up data (median observation time, 10.7 months; range, 2-61 months), and the findings in peritoneal cavity and bone marrow samples were compared. Fifty-two % of the patients showed minimal residual disease at least in one compartment (39% positive lavage and 38% positive bone marrow samples). The detection rate of isolated tumor cells increased in parallel to the tumor stage. The presence of tumor cells in the peritoneal cavity significantly correlated with the survival time of the patients (P = 0.0035). In bone marrow samples, a strong trend was seen (P = 0.06). The evaluation of both compartments increased the number of positive patients and resulted in a highly significant correlation: all patients who were positive in at least one compartment died within 18 months, whereas negative patients showed a 5-year survival rate of 30% (P<0.0001). We recommend immunocytological investigation of peritoneal cavity and bone marrow samples as a new prognostic marker in pancreatic cancer patients.     

High thymidine kinase 1 (TK1) expression is a predictor of poor survival in patients with pT1 of lung adenocarcinoma

In this study, we explore the association of thymidine kinase 1 (TK1) expression in tumour tissues with clinical pathological parameters and prognosis in patients with pathological T1 (pT1) lung adenocarcinoma. The expression of TK1 was studied by immunohistochemistry techniques in 80 patients with surgically resected pT1 lung adenocarcinoma, retrospectively and at >10-year follow-up. Compared to patients with low TK1 expression [labelling index (LI) <25.0%], patients with high TK1 expression (LI ≥25.0%) showed significantly increased lymphatic/vascular permeation and lymph node involvement and higher stromal invasion grade and pathological stage, and a greater number of patients had a tumour size of 2.1 to 3.0 cm. The 5-year survival and the mortality during follow-up for patients with high TK1 expression were significantly worse than that of patients with low TK1 expression. The prognoses of the cases with grade 0, grade 1 and grade 2 stromal invasions were similar and were better than those of cases with grade 3. In patients with stromal invasion grade 3, the 5-year survival and the mortality during follow-up were significantly worse for patients with high TK1 compared to patients with low TK1 expression. Univariate analyses showed that stromal invasion and TK1 expression were significant prognostic factors, while in the multivariate analysis, TK1 expression and tumour stage were found to be independent prognostic factors, but not stromal invasion. This is the first study showing that TK1 expression in combination with stromal invasion is a more reliable prognostic factor than stromal invasion classification itself in patients with pT1 lung adenocarcinoma. TK1 expression enables a further classification of the patients and opens opportunities for improved treatment outcome.     

Diagnostic p53 immunostaining of endobiliary brush cytology: preoperative cytology compared with the surgical specimen.

BACKGROUND: Endobiliary brush cytology is important in the distinction of malignant and benign causes of extrahepatic bile duct obstruction. The additional diagnostic value of p53 immunostaining on these cytology specimens was assessed. METHODS: All patients with extrahepatic bile duct obstruction who underwent endoscopic retrograde cholangiopancreatography (ERCP) with endobiliary brush cytology and subsequent surgery at the Academic Medical Center in Amsterdam during a 3-year period were studied. p53 Immunocytology was compared with the corresponding conventional light microscopic cytology and p53 immunostaining of the subsequent surgical specimen. RESULTS: Fifty-three patients with the following diagnoses were included: pancreatic carcinoma (23), bile duct carcinoma (15), ampullary carcinoma (5), lymph node metastases (2), carcinoma of unknown origin (4), chronic pancreatitis (3), and primary sclerosing cholangitis (1). Fifty-one percent of the carcinomas showed positive p53 immunostaining; all four surgical specimens without carcinoma were negative. The sensitivities of conventional light microscopic cytology, p53 immunocytology, and both tests combined were 29%, 24%, and 43%, respectively. These sensitivities were higher in cases of bile duct carcinoma (46%, 40%, and 66%) compared with cases of pancreatic carcinoma (13%, 9%, and 22%). Specificities of both tests were 100%. CONCLUSIONS: p53 Immunostaining on endobiliary brush cytology may be helpful in the diagnosis of malignant extrahepatic bile duct stenosis, especially in patients with bile duct carcinoma. Cancer (Cancer Cytopathol) Copyright 1999 American Cancer Society.