Prognostic value of histologic grade nuclear components of Scarff-Bloom-Richardson (SBR). An improved score modification based on a multivariate analysis of 1262 invasive ductal breast carcinomas

We did a multivariate analysis of 1262 patients with operable, invasive ductal breast carcinoma to assess the prognostic value of the Scarff-Bloom-Richardson (SBR) histologic grading system. Nodal metastasis and SBR were the two most important factors for metastasis-free survival (MFS), P = 10-9 and P = 10-5, respectively, for total study time. In patients who were node negative, the SBR and International Union Against Cancer (UICC) stages were the most important for MFS (P = 4 X 10-4 and P = 0.03). In order to try to improve the SBR prognostic value, we first studied the three components of the SBR separately: ductoglandular differentiation proved the least predictive and nuclear pleomorphism and mitotic index the most predictive. A rearrangement of the two nuclear scores alone produced higher risk values and better risk separation of patient subpopulations than SBR, and eliminated the SBR from the multivariate model. This rearrangement, modified SBR (MSBR), defined five new risk subgroups with statistically different risk ratios for MFS (P = 3 X 10-8). SBR grade II (55% of patients) was separated into three MSBR groups significantly different according to MFS (P = 0.008). In the patients who were node negative, MSBR replaced the SBR and was the most important factor for prediction of relapse of MFS (P less than 0.00001). The MSBR is more accurate and predictive than the standard SBR grade and is particularly useful when the nodal status of the patient is negative or unknown.

Nuclear characteristics as indicators of prognosis in node negative breast cancer patients

Nine clinical, biologic and histologic variables were evaluated for their significance in predicting the metastasis free survival (MFS) and the overall survival (OS) of 650 histologic node negative breast cancer patients. The variables studied were: menopausal status, UICC clinical stage of disease, Scarff-Bloom and Richardson (SBR) grade and its 3 components, estrogen and progesterone receptors, and anatomic tumor size. Multivariate Cox analyses revealed that histologic grade and clinical stage were the only significant prognostic factors for both MFS and OS. In the SBR grading system, grades I and III clearly have defined those patients with low and high risk for relapse, respectively. However, it is well known that more than 50% of the patients fall into the intermediate risk category, grade II, which provides essentially no useful prognostic information for those patients. To improve the assignment of patients to specific risk groups, a modified grade (MSBR), with five categories ordered according to the degree of malignancy, has been built from the nuclear pleomorphism and the mitotic index of the SBR grade. In combination with clinical stage, MSBR was found to be a prognostic indicator with high discriminatory power and caused the SBR grade to lose its significance. The first three categories of this MSBR may be gathered to designate low risk patients, whereas the last two categories, once combined, contain all the SBR grade III plus 57% of the SBR grade II tumors, and reliably identify high risk node negative patients. We suggest that a systemic adjuvant therapy should be discussed in this high risk group.

Non-Hodgkin's lymphoma of the urethra: a rare extranodal entity

We report a rare case of non-Hodgkin's lymphoma of the urethra in a female patient. A review of the literature showed that all such reported cases were described in females, were of varying histologic grade, and presented as a polyp or caruncle. Whether this entity is often localized and has the excellent prognosis of early carcinoma of the urethra will have to be determined by study of more cases.

Bypassing gutta-percha root fillings with an automated device

Endodontic retreatment using Canal Finder K files and chloroform was performed in 106 gutta-percha-obturated, curved root canals, 71 in vitro and 35 in vivo. The minimum time taken to bypass the obturation in a single root canal was 3 s and the maximum time 95 s. The mean times were 19 and 27 s in the two in vitro groups and 32 s in the in vivo group. Eighty-nine percent of the root canals which had been obturated short were bypassed apically in vivo. Root canal curvature was well maintained in all but two root canals. In these two cases apical transportation occurred. Breakage of files occurred three times in vitro, but this did not prevent the completion of bypassing with new files. These results are attributed to the mode of action of the Canal Finder system, which makes it an efficient root canal pathfinder. The advantages of the suggested technique are discussed in light of the clinical considerations of endodontic retreatment.

Imipramine and alprazolam treatment of lactate-induced acute endogenous distress in nonhuman primates

The authors studied the response of 10 macaque monkeys to administration of sodium lactate, a panicogenic agent used in human panic disorder research, after treatment with the tricyclic antidepressant imipramine, the triazolobenzodiazepine alprazolam, or placebo. Both drugs effectively blocked the lactate-induced acute endogenous distress responses that had been reliably observed in the monkeys before drug treatment. Only alprazolam significantly reduced the occurrence of conditioned situational anxiety responses observed in the home cage. The alprazolam monkeys appeared to be sedated compared to the imipramine and placebo groups, and tremor and temporary exacerbation of anxious behaviors were observed during alprazolam withdrawal.

Clear cell carcinoma arising in pleomorphic adenoma of the minor salivary gland

Malignant change arising in pleomorphic adenoma of the salivary glands is uncommon, with a reported incidence of 2-10 per cent. Only one case where a pleomorphic adenoma became a clear cell carcinoma appears to have been published in the English literature. An additional case of clear cell carcinoma arising in pleomorphic adenoma of a minor salivary gland is reported and the relevant literature discussed.

Infectious pneumoperitoneum as an uncommon presentation of endometrial carcinoma: report of two cases

Two patients with pneumoperitoneum are reported; in both cases, the cause was severe infection of the upper genital tract. Investigation led to the finding of an underlying endometrial carcinoma. Literature review of the etiology of pneumoperitoneum, nature of the usual infecting organisms, and therapeutic principles are presented. Endometrial carcinoma should be considered in the differential diagnosis of infectious pneumoperitoneum, especially where patient risk factors are present.

Child mental health in an HMO. A family systems approach

HMOs have been growing at a rapid rate with increasing numbers of people receiving mental health services within this system of care. Among those people are children who represent a significant proportion of HMO members. The goal of providing high quality, cost-efficient mental health services to children and families in a staff model HMO represents a challenge and opportunity for the mental health practitioner. A family systems model is described for providing mental health treatment for children's problems in the HMO. Clinical vignettes from the author's practice are presented illustrating time-efficient principles of systems psychotherapy in this setting.

Surgical-restorative treatment of bleaching-related external root resorption

Three teeth in 2 patients were treated after intracoronal bleaching with 30% hydrogen peroxide had resulted in external root resorption. An attempt to treat one tooth by placing an intracoronal dressing with calcium hydroxide had failed. The resorption defects were exposed surgically by reducing and re-contouring the alveolar crest. The restorations were made during the surgical procedure, with a light-cured composite in one case and with amalgam in the other, and were of compromised quality due to the difficulty of control. One year follow-up examinations revealed periodontal complications in both cases, in the form of a further resorption of the alveolar crest and gingival edema. These sequelae suggested that the restoration of bleaching-related resorption defects should have been a secondary stage, after the surgical exposure of the defects had been completed first. For the purpose of exposing the defects, the level of the alveolar crest should be reduced enough to secure a biological width from the restorations.

Human breast tumors: a comparison between the biochemical method of measuring estrogen and progesterone receptors and that of an immunohistochemical method

In a series of 94 human mammary carcinomas, the determination of total estrogen (ER) and progesterone (PR) receptors by a single saturating dose method (5 nM for ER, 10 nM for PR) using dextran-coated charcoal was compared to an immunohistochemical method utilizing ER monoclonal antibody (ER-ICA test). There was a good correlation expressed in positive terms between the ER-ICA test and the biochemical determination of ER (94% of concordance) with a statistical value of P less than 0.01 being found between the concentration of ER (biochemical) and the percentage of labeled cells (ER-ICA). The ER-ICA test complements the ER and PR (biochemical) and is particularly useful for ER determinations on small tumor specimens as no additional tissue other than that from the biopsy is required.

Primary breast sarcoma: a review of 33 cases with immunohistochemistry and prognostic factors

The clinical and pathological features of 33 previously untreated patients with primary breast sarcoma were retrospectively analysed to evaluate the prognostic significance of histologic variables on survival. The series comprised 17 cystosarcomas phyllodes and 16 stromal sarcomas (excluding angiosarcomas). All tumors were reviewed and classified in similar fashion to extramammary soft tissue sarcomas. In addition, immunohistochemical studies were performed on paraffin sections with a panel of several antibodies directed against cytoskeletal filaments and cellular enzymes; five cases were also examined by electron microscopy. Most tumors were malignant fibrous histiocytoma (21 cases) and fibrosarcoma (6 cases) types. Surgery was the main therapy. Metastasis-free survival rate was significantly correlated only with histological grade, consisting of tumor differentiation, tumor necrosis, and mitotic activity. Courses and survivals of the cystosarcoma and stromal groups were identical, questioning the clinical value of this pathologic distinction. All local recurrence, metastasis, or death occurred within 30 months, though follow-up was much longer. Immunohistochemistry was disappointing for identification of specific histologic sub-types.

Rhabdomyosarcoma in infants under one year of age: experience of the Institut Gustave-Roussy

Forty-three infants under 1 year of age (median 4 months) with rhabdomyosarcoma (RMS), representing 11% of all childhood RMS seen over the same period, were treated and followed between 1955 and 1984 at our institute. Compared to the 340 older children (1-16 years of age), there were no significant differences in male/female ratio, primary site, or clinical stage, but there was a higher frequency of alveolar and poorly differentiated histologic subtypes in infants aged under 1 year (P = 0.05 and P less than 0.001, respectively) and increased frequency of botryoid RMS in older children (P less than 0.02). Although children older than 1 year of age had a significantly higher complete remission rate (83% vs. 51%, P less than 0.001), their 5 year overall survival (43%) was no different from that of infants under 1 year of age (35%). In the older group there was no survival difference between alveolar (38%) and nonalveolar (44%) histologic subtypes, but in infants younger than 1 year, alveolar subtype had a significantly poorer prognosis (13% vs. 47%, P = 0.01). Management of patients at this age group is difficult and major advances are needed to increase survival rates with a minimum of morbidity.

Very late recurrence of childhood acute lymphoblastic leukemia treated with chemoimmunotherapy: a report of three cases occurring 19, 11, and 9 years after discontinuation of chemotherapy

Current therapeutic modalities for childhood acute lymphoblastic leukemia (ALL) are associated with a high cure rate, and recurrences more than 4 years after therapy cessation are very unusual. We report three cases of exceptionally late recurrences of childhood ALL after cessation of chemotherapy (CT) given for respective periods of 8, 7, and 24 months. CT was followed by maintenance immunotherapy (IMT) with Bacillus Calmette-Guérin (BCG) and allogeneic leukemic lymphoblasts pretreated with formaldehyde or irradiated in vitro. Leukemic recurrences were observed 19, 11, and 9 years after cessation of CT and appeared morphologically similar to the original blasts. A second complete remission was easily achieved in all three patients, but two went on to repeated relapse (one has died following the fourth recurrence). We speculate that some residual leukemic cells, remaining after the inadequate, short-term CT, were responsible for these unusual evolutions, and we question a possible delaying role of IMT in prolonging remission. Other possible etiologies are discussed.

Lymphoblastic lymphoma in adults: a clinicopathological study of 34 cases treated at the Institut Gustave-Roussy

We report a series of 34 adult patients with lymphoblastic lymphoma treated at our Institute between 1977 and 1986. At presentation, mediastinal involvement was seen in 76%, extranodal involvement (not including bone marrow) in 20%, stage IV in 53% and circulating blasts in 15%. In the 15 cases where immunological studies were performed, 12 proved to be of T type and the other three lacked both T and B markers. Chemotherapy with acute lymphocytic leukemia (ALL) protocols was given to 58% and lymphoma protocols to the other patients, with CNS prophylaxis given to a total of 28 patients. Although complete remission (CR) was observed overall in 74% of patients, 5 year survival was only 22% (42% in stages I-II and 8% stages III-IV) with improved results seen with recent aggressive anti-leukemic protocols. Five relapsed patients entered second CR and two were still in CR at this time. CNS relapse occurred in a total of eight patients (three without prophylaxis), and was isolated in two of six patients who achieved CR (despite CNS prophylaxis). In an analysis of prognostic factors, only the attainment of a CR was statistically significant (P less than 0.001). Thus we are unable to confirm other studies which demonstrated prognostic variations in this disease and believe that all such patients should receive aggressive chemotherapy with substantial CNS prophylaxis similar to those currently used for ALL.

Invasive apocrine carcinoma of the breast: a long term follow-up study of 34 cases

We have reviewed the morpho-functional criteria for infiltrating apocrine carcinomas of the breast and analysed long term follow-up of this entity. Thirty-four cases of pure apocrine carcinomas were retrieved from the files of the Dept. of Pathology, IGR, France, for the years 1955-1982. Each case was matched with two controls of other infiltrating ductal carcinomas according to the most important prognostic parameters: nodal status, histograde, anatomic tumor size, and patient age. No significant difference between the survival curves of the two groups was seen. Apocrine carcinoma, although possessing peculiar morphological, ultrastructural, biochemical, and immunohistochemical features to merit recognition as a separate histologic variant of breast cancer, by itself has no apparent clinical significance.

Markers in breast cancer: does CEA add to the detection by CA 15.3?

211 patients with various stages of breast cancer were studied by both the CA 15.3 and CEA markers to assess whether the latter may increase the screening sensitivity of the former. While both markers were equally specific, CA 15.3 was seen to be much more sensitive than CEA (p less than 0.0001). Also, the addition of the CEA did not add appreciably (7%) to positive detection by CA 15.3. There appears to be no advantage to including CEA in a marker panel to follow the course of breast carcinoma.

Medullary breast carcinoma. A reevaluation of 95 cases of breast cancer with inflammatory stroma

The hallmarks of diagnosis of medullary breast cancer (MedBC) used by the authors since 1977 have been that the tumor is well circumscribed, has syncytial architecture in greater than 75% of its surface, contains diffuse inflammatory infiltrate, has atypical nuclei, and forms no glandular pattern. In order to assess the clinical utility of these criteria, we studied a series of 95 previously untreated, surgically operable patients with breast carcinoma at the Institut Gustave-Roussy (IGR) between 1960 and 1979. A diagnosis of MedBC was initially made for these patients or suspected based on abundant inflammatory stroma observed in a histologic evaluation. Using these criteria, 26 cases were identified as typical medullary carcinoma (TMC), 23 cases as atypical medullary carcinoma (AMC), and 46 cases as nonmedullary carcinoma (NMC). The 26 cases of TMC represent a very small fraction of the total infiltrating operable breast carcinomas diagnosed at IGR during the same time period. The prognosis for these 26 patients was much more favorable than for the other groups. They had a 10-year disease-free survival of 92% compared with 53% for the AMC group and 51% for the NMC group. Neither distant metastasis nor secondary primaries of the same histology were seen. Therefore, it is possible with the use of strict histologic criteria to distinguish a group of patients with a much more favorable prognosis. This histologic diagnosis alone renders a most favorable prognosis for the patient even if other factors such as large tumor size and lymph node involvement are present and, by inference, the only therapy needed is the removal of all tumor. In contrast, atypical forms have a prognosis no different from other atypical types of breast carcinomas without inflammatory stroma, and adjuvant therapy appears to be justified if other factors warrant it.

Survival and mutagenic effects of 5-azacytidine in Escherichia coli

Survival and mutagenesis caused by 5-azacytidine was studied in Escherichia coli. Survival was partially lexA- and recA-dependent and was decreased by the presence of a DNA (cytosine-5)methyltransferase. The dcm, MspI, and EcoRII methyltransferase genes all decreased survival. There was no direct relationship between amount of methylase enzyme present and cell survival, but only plasmids containing a methylase gene sensitized cells to 5-azacytidine. Survival was not affected by uvrA, uvrB or umuCD mutations. Induction of sulA::lacZ fusions by 5-azacytidine was inhibited in strains containing elevated levels of DNA methylase. Cells resistant to 5-azacytidine when they contained a plasmid specifying the EcoRII methylase were sensitive if the plasmid specified the complete EcoRII restriction-modification system. The mechanism of cell death in these situations is therefore different. Mutation of the rpoB gene by 5-azacytidine was studied. The mutation rate was decreased by the presence of recA and lexA mutations. Mutation in umuCD had little effect on the mutation rate. The recA430 mutation, which does not support SOS-dependent mutagenesis induced by UV light, does support 5-azacytidine induced mutagenesis. The presence of DNA (cytosine-5)methyltransferase had no effect on the mutation rate caused by 5-azacytidine treatment. The mutagenic and lethal lesions caused by 5-azacytidine in the absence of methylase therefore differ from the lethal lesions that occur in the presence of methylase. The former could be due to the opening of the 5-azacytosine ring in DNA. Cell death in the presence of methylase could be due to tight binding of methylase to azacytosine containing DNA as well as inhibition of induction of the SOS response.