TUMOR DIAGNOSTIC LABORATORIES

The diagnostic services of the Department of Pathology consist of surgical pathology, immunohistochemistry, flow cytometry, cytopathology, hematopathology, clinical pathology, and autopsy pathology. An important part of the pathology program is the training of residents and fellows. We currently have two anatomic pathology fellowships. In addition, residents from MCP/Hahnemann and Thomas Jefferson University Schools of Medicine are trained in our department throughout the year. Members of the department are active participants in collaborative research activities both within and outside of the institution.

The role of the surgical pathology laboratory is to provide accurate diagnostic services to the clinicians so that patient care is best served. During the past year, the surgical pathology laboratory reviewed specimens from 7711 patients-3587 cases were from procedures performed at Fox Chase, and 4124 cases were second opinions for patients coming to the Center for either treatment or consultation.This number represents an overall increase of 7% over the calendar year 1997. We also performed 680 intraoperative surgical frozen section consultations. A correct and meaningful diagnosis of an individual's neoplasm is essential for proper clinical management. The members of the department actively participate in the Breast Evaluation Center and daily multidisciplinary clinics, and are also actively involved in helping procure tissue for the tumor bank.

Immunohistochemistry is an integral part of tumor diagnosis. It is also helpful in discriminating between benign and malignant lymphoid lesions, and in better characterizing lymphoid malignancies for more relevant therapy. The immunohistochemistry laboratory uses labeled antibodies to detect various epitopes employed in the diagnosis of neoplastic disorders. These tests are also adopted for prognostication (e.g., estrogen and progesterone receptors, and proliferation markers) and for identification of tumor sites (e.g., prostate specific antigen and thyroglobulin). During this past year, we have developed new tests and brought them into clinical use. Most notably is the test for Cerb B-2, which is used to determine if patients will respond to treatment with Herceptin.

As a clinical laboratory service, the facility performs immunophenotyping studies on peripheral blood, bone marrow, and biopsy specimens. Research projects that use flow cytometry continue to be an important function of the facility. Recently, two important flow cytometry developments have been emphasized. First, the minimal involvement of the bone marrow and peripheral blood by malignant lymphoma was recognized. Second, these lymphoma cells were immunophenotyped using panels of antibodies selected to complement the morphological and clinical findings. Newly recognized entities, especially of indolent lymphomas, can be diagnosed from flow cytometric immunophenotyping of peripheral blood.

Intracellular proteins, cytokines, and other gene products are currently evaluated for flow cytometry testing. At the present time, we are starting to test for terminal deoxynucleotidyl transferase (TdT) and myeloperoxidase, as well as intracellular immunoglobulins. Many of these are of proven or potential clinical importance. We also have the ability to analyze three different color signals, which enables us to examine intracellular antigens. This three color analysis is being used in clinical applications at the present time. The laboratory has also assumed responsibility for stem cell count; a specialized laboratory attached to the facility is being established for this purpose. In addition, the laboratory undertakes immunophenotypic analysis of fine needle aspirations (FNA). In cooperation with the cytology laboratory, this is an area of extensive undertaking, both in the diagnostic and research fields (see publications).

The cytopathology laboratory, which interacts with the surgical pathology, immunopathology, and flow cytometry laboratories, offers a full range of diagnostic cytology tests. Although the main object of cytologic testing is to diagnose cancer, some benign conditions such as those resulting from radiation or chemotherapy, infectious organisms and benign neoplasms are also diagnosed. The laboratory uses various concentration techniques and staining methods to prepare cytologic samples for microscopic study.

The molecular pathology laboratory develops and uses molecular assays to aid in the diagnosis of hematological malignancies, and possibly provide prognostic data that may be used to detect minimal levels of disease. Chromosomal translocations and antigen receptor gene rearrangements serve as specific markers for leukemia and lymphoma and, therefore, serve as molecular targets for disease identification. Molecular demonstration of disease complements morphologic, immunologic and cytogenetic data. In addition, it provides a greater level of sensitivity, allowing for detection of minimal levels of disease. This, then, allows the level of disease in individual patients to be quantified; over time, patients may be followed by these methods to determine whether they are in molecular remission or show evidence of relapse. For patients with persistent disease, we may detect whether their level of disease level is changing. These assays may also be applicable to stem cell products from patients undergoing autologous bone marrow transplantation, where units showing no evidence of disease at the molecular level would preferably be returned to the patient. Future directions of the laboratory include assay development for monitoring patients at high risk for solid tumors.

The outpatient/clinical pathology laboratory performs complete blood counts, differential counts, and chemistry profiles. The laboratory provides phlebotomy services, usually on the same day as the patient's clinic visit, making it more convenient to have blood work performed. The outpatient laboratory is accredited by the College of American Pathologists. In addition to providing services for our patients, the laboratory actively supports ongoing research protocols, as well as phlebotomy for genetic studies.

The anatomic pathology laboratory offers autopsy services for the institution. The autopsy increases our knowledge about the causes and course of an illness, and the effects of different types of treatment. The post mortem examination is an important aspect of hospital quality improvement, and findings are used for correlative clinicopathological teaching purposes.

RESEARCH PROJECTS

Harry S. Cooper, M.D. Dr. Cooper (in collaboration with CLAPPER, BELLACOSA) is investigating the early molecular events in multiple intestinal neoplasia. Recent generation of mouse strains with genetic deficiencies in the "colon cancer genes" has provided a novel opportunity to evaluate the functional relationship between the molecular and biochemical events associated with the formation of precancerous and cancerous colon lesions. The chemically induced mouse mutation called Multiple Intestinal Neoplasia (Min) produces a phenotype reminiscent of human familial adenomatous polyposis. Min mice develop a large number of polyps in the small and large intestine due to disruption of the adenomatous polyposis coli (APC) gene; the putative "gatekeeper" of human colorectal carcinogenesis. A colony of Min mice has been established at Fox Chase and a bank of intestinal tissues (normal and tumor) from heterozygous Min and wild type mice has been generated that currently includes over 1400 accessions. This novel tissue resource will support the comprehensive evaluation of the pathological and molecular events that accompany the progression of intestinal polyps to invasive carcinomas.

Colitis associated colorectal dysplasia and cancer is under investigation (in collaboration with CLAPPER, MURTHY^d). The Dextran Sodium Sulfate (DSS) murine colitis model has been developed and characterized; dysplasia and cancers have been induced in this model system. With time, chronic colitis shows depletion of glutathione S-transferase, a detoxification enzyme that may play a role in detoxifying carcinogenic agents. Studies have shown that this model may be ideal for chemoprevention studies of colitis related neoplasia as we have shown that treatment with oltipraz will reduce the incidence of dysplasia/cancer. Dr. Cooper (in collaboration with MURTHY^d) is also studying the expression of B-catenin and p53 in colitis associated neoplasia using the DSS colitis model.

Robin Edwards, M.D. The use of molecular methodology for detection of minimal disease and for prevention is under investigation. Specifically, the incidence of IgH-PCR positivity in acute myelogenous leukemia (AML) and myelodysplasia is of interest, as well as correlating molecular data with Fab subtype, immunophenotypic findings and cytogenetic data. In the future, these data may be used for evaluation of minimal disease in IgH-PCR+AML. Dr. Edwards is also studying morphologic features of Hogdkin's disease according to EBV status (in collaboration with AL-SALEEM). Finally, the early phases of collaborative efforts (MEROPOL) are underway to utilize molecular methods for early detection in patients at high risk for pancreatic or colorectal cancer.

Hormoz Ehya, M.D. Dr. Ehya is a co-investigator in a Phase II trial of oltipraz as a chemopreventive agent for lung dysplasia. He examines the bronchoscopically obtained samples from individuals at high risk for lung cancer and evaluates the cytologic changes in the bronchial mucosa of the participants before and after treatment with oltipraz. Dr. Ehya also collaborates in a study to assess the possible effect of difluoromethylornithine (DFMO) in preventing the progression of oral cavity dysplasia to invasive cancer.

Dr. Ehya (in collaboration with SAUTER) is investigating the cellular changes in nipple aspirate fluids. We have shown that the presence of abnormal cells in specimens obtained by this non-invasive method correlates with breast cancer risk. We are currently looking into the correlation of cytologic findings with other biomarkers such as DNA ploidy, proliferation index, PSA levels, etc. Our goal is to utilize this technique in future diagnostic and chemopreventive studies on the breast.

Nancy A. Young, M.D. Dr. Young's current research interest is in the cytodiagnosis of malignant lymphomas, and has published a new method to predict lymphoma grade based on the transformed lymphocyte count in fine-needle aspirates (in collaboration with AL-SALEEM, EHYA, SMITH). Dr. Young has also worked on studies using PCNA and p53 as ancillary techniques to determine lymphoma grade or biologic behavior. Dr. `Young is also studying proliferation markers to predict response to Gencytobine and radiation therapy for pancreatic cancer (in collaboration with COOPER, HOFFMAN).

Tahseen I. Al-Saleem, M.D. The role of tuberous sclerosis 2 (TSC2) in renal cancer is under investigation (in collaboration with HENSKE). Malignant tumors in TS children, renal and extra-renal were diagnosed and analyzed for the presence of TSC2 gene. As a member of the prostate cancer working groups, Dr. Al-Saleem contributes to various projects on prostate cancer (in collaboration with HANKS, TRICOLI). The group studies, among other things, the contribution of various pathologic findings in prostate biopsies to the patient's outcome following radiotherapy.

AL-SALEEM, T., WESSNER, L.L., SCHETHANER, B.W., PATTERSON, K., ROACH, E.S., DRYER, S.J., FAJIKAW, K., BJORNSSON, J., BERNSTEIN, J., HEINSKE, E.P. Malignant tumors of the kidney, brain, and soft tissues in children and young adults with the tuberous sclerosis complex. Cancer 83:2208-2216, 1998.

CLAPPER, M.L., ADRIAN, R.H., PFEIFFER, G.R., KILDO, K., EVERLY, L., COOPER, H.S., MURTHY, S. Depletion of colonic detoxification enzyme activity in mice with dextran sulfate sodium induced colitis. Aliment Pharmacol. Ther. (in press).

COOPER, H.S. Pathology of the gastrointestinal tract. In Benign Epithelial Polyps of the Intestines, edited by S.C. Ming and H. Goldman. Williams Wilkins, Baltimore, Chapter 33, pp. 819-853, 1998.

EHYA, H. Clinical cytology. In Pathology, Third Edition, edited by E. Rubin and J.L. Farber. J.B. Lippincott, Philadelphia, pp. 1566-1583, 1998.

GREEN, G.A., HANLON, A.L., AL-SALEEM, T., HANKS, G.E. A Gleason score of 7 predicts for a worse outcome in patients treated with radiotherapy for prostate cancer. Cancer 83:971-976, 1998.

GUNDUZ, K., SHIELDS, J.A., SHIELDS, C.L., EAGLE, R.C., EHYA, H., McLAUGHLIN, W. Lung adenocarcinoma metastatic to the vitreous cavity. Retina 18:285-286, 1998.

HOFFMAN, J.P., COOPER, H.S., YOUNG, N.A., PENDURTHI, T.K. Preoperative chemotherapy of chemoradiotherapy for the treatment of adenocarcinoma of the Pancreas and Ampulla of Vater. J. Hepatobiliary Pancreat. Surg. 5:251-254, 1998.

KATSETOS, C.D., STADNICKA, I., BOYD, J.C., EHYA, H., ZHENG, S., SOPRANO, C., COOPER, H.S., PATCHEFSKY, A.S., SOPRANO, D.R., SOPRANO, K.J. Cellular distribution of retinoic acid receptor-alpha protein in serous adenocarcinoma of ovarian, tubal and peritoneal origin: Comparison with estrogen receptor status. Am. J. Pathol. 153:469-480, 1998.

MOVSAS, B., HANLON, A.L., LANCIANO, R., SCHER, R.M., WEINER, L.M., SIGURDSON, E.R., HOFFMAN, J.P., EISENBERG, B.L., COOPER, H.S., PR0VINS, S., COIA, L.R. Phase I dose escalating trial of hyperfractionated pre-operative chemoradiation for locally advanced rectal cancer. Int. J. Radiat. Oncol. Biol. Phys. 42:43-50, 1998.

MURTHY, S., COOPER, H.S., YOSHITAKE, H., MEYER, C., MEYER, C.J., MURTHY, N.S. Combination therapy of pentoxifylline and TNF a monoclonal antibody in dextran sulfate-induced mouse colitis. Aliment Pharmacol. Ther. (in press).

TEDESCHI, M., YOUNG, N.A., LANGER. C. Difficult differentials in cancer: Unknown primary tumor vs extragonodal germ cell carcinoma. Primary Care & Cancer (in press).

WANG, Y.L., ADDYA, K., EDWARDS, R.H, RENNERT, H., DODSON, L., LEONARD, D.G.B., WILSON, R.B. Novel bcl-2 breakpoints in patients with follicular lymphoma. Diagn. Mol. Pathol. 7 (2):85-89, 1998.

WATSON, J.C., COOPER, H.S., BABB, J.S., SIGURDSON, E.R., KLEIN-SZANTO, A.J.P. Angiogenesis is an early event in the adenoma-carcinoma sequence in human colorectal cancer. Surgical Forum XLIX:440-442, 1998.

WURZER, J.C., AL-SALEEM, T., HANLON, A.L., FREEDMAN, G.M., PATCHEFSKY, A.S., HANKS, G.E. Histopathologic Review of prostate biopsies from patients referred to a comprehensive cancer center. Cancer 83: 753-759, 1998.

YOUNG, N.A., AL-SALEEM, T.I., EHYA, H., SMITH, M.R. Utilization of fine needle aspiration cytology and flow cytometry in the diagnosis and subclassification of primary and recurrent lymphoma. Cancer (Cancer Cytopathol.) 84:252-261, 1998.

COOPER, H.S., DEPPISCH, L.M., KAHN, E.I., LEV, R., MANLEY, P.N., PASCAL, R.R., QIZILBASH, A.H., RICKERT, R.R., SILVERMAN, J.F., WIRMAN, J.A. Pathology of the malignant colorectal polyp. Human Pathol. 29(1):15-26, 1998.

COPPOLA, D., HYACINTHE, M., FU, L., CANTOR, A.B., KARL, R., MARCET, J., COOPER, D.L., NICOSIA, S.V., COOPER, H.S. CD44V6 expression in human colorectal carcinoma. Human Pathol. 29:627-635, 1998.

KARKAVELAS, G. KATSETOS, C.D., GEDDES, J.F., HERMAN, M.M., VINORES, S.A., COOPER, H.S., PROVENCIO, J., FRANKFURTER, A. Class III b-tubulin isotype (bIII) in the adrenal medulla: II. Localization in primary human pheochromocytoma. Anat. Rec. 250(3):344-350, 1998.

SAUTER, E.R., BABB, J., DALY, M., ENGSTROM, P.F., EHYA, H., MALICK, J., DIAMANDIS, E. Prostate-specific antigen production in the female breast: Association with progesterone. Cancer Epidemiol. Biomark. Prev. 7:315-320, 1998.

SIEGELMANN-DANIELI, N., HANLON, A., RIDGE, J.A., PADMORE, R., FEIN, D.A., LANGER, C.J. Oral tongue cancer in patients less than 45 years old: institutional experience and comparison with older patients. J. Clin. Oncol. 16(2):745-753, 1998.

^a   R. Padmore: Present address--2481 Packard Road, Ann Arbor, MI 48104

^b   S. Bergman: Present address--Department of Pathology, Medical College of Virginia Hospital, Richmond, VA 23219

^c   S.J. Skarupa: Present address--Department of Pathology, Polyclinic Medical Center, Harrisburg, PA 17110

^d   S. Murthy: MCP/Hahnemann, Philadelphia, PA 19102

Illustrations or unpublished data in these reports should not be used without permission of the author.

Fox Chase Cancer Center

Scientific Report 1998