Identification of MYH mutation carriers in colorectal cancer: a multicenter, case-control, population-based study

BACKGROUND & AIMS

Whereas it has conclusively been demonstrated that biallelic MutY human homolog (MYH) mutations confer a significant risk for colorectal cancer (CRC), the influence of monoallelic mutations remains controversial. Characterization of MYH-associated CRC is critical to identify individuals who might benefit from preventive strategies. This prospective, multicenter, case-control, population-based study was aimed at (1) establishing the CRC risk associated with specific germline MYH mutations and (2) devising a set of clinical criteria to identify MYH carriers among newly diagnosed CRC.

METHODS

Genotyping for Y165C and G382D was performed by TaqMan technology. Single-stranded conformation polymorphism analysis was performed in heterozygotes to screen for mutations in the entire gene. All individuals were re-screened for any additional pathogenic variant.

RESULTS

Biallelic and monoallelic MYH mutations were found in 8 (0.7%) and 19 (1.7%) of 1116 CRC patients, respectively. None of the 934 control subjects carried biallelic mutations, whereas 22 (2.3%) of them were monoallelic carriers. In a meta-analysis including all previous case-control studies, monoallelic MYH carriers were not at increased risk for CRC (odds ratio, 1.11; 95% confidence interval, 0.90-1.37), although a significant association was found with the Y165C mutation in either homozygotes or heterozygotes (odds ratio, 1.67; 95% confidence interval, 1.17-2.40). Furthermore, presence of more than 15 synchronous colorectal adenomas or CRC diagnosed before the age of 50 years was the most effective set of criteria for the identification of biallelic MYH mutation carriers.

CONCLUSIONS

This study proposes the first set of clinical criteria designed to identify CRC patients with biallelic MYH mutations, and it argues against an increased risk for monoallelic carriers.

Detection of BRAF V600E mutation in colorectal cancer: comparison of automatic sequencing and real-time chemistry methodology

Mutation V600E of BRAF, a kinase-encoding gene from the RAS/RAF/MAPK pathway, in colorectal carcinoma (CRC) suggests a sporadic origin of the disease, providing an exclusion criterion for hereditary nonpolyposis colorectal cancer. Here we describe detection of this mutation by real-time chemistry TaqMan MGB probes, confirmed by direct DNA sequencing as the gold standard. DNA was extracted from paraffin-embedded tissue from 112 tumors obtained from the EPICOLON study. Seventy-two tumors were CRC with defective DNA mismatch repair (MMR; microsatellite instability and/or loss of protein expression by immunohistochemical analysis), and 40 were proficient MMR controls. BRAF mutation was detected in 20/72 (27.8%) CRC with defective MMR and in 3/40 (7.5%) proficient MMR controls (P = 0.011). BRAF mutation was detected in 19/51 (37.3%) tumors with loss of MLH1 expression and in none of the tumors with loss of MSH2 expression (0/13). BRAF mutation was not found in cases with germline mutation of MLH1 (4/112) or MSH2 (3/112) genes. The sensitivity and specificity of our real-time chemistry were both 100% for detecting the V600E mutation. Because real-time chemistry methodology has advantages in cost, time, and labor, we consider it a valuable alternative to automatic direct sequencing, particularly for serial measurements.

Cyclooxygenase 2 expression in colorectal cancer with DNA mismatch repair deficiency

BACKGROUND

Cyclooxygenase 2 (COX-2) overexpression is a frequent but not universal event in colorectal cancer. It has been suggested that COX-2 protein expression is reduced in colorectal cancer with a defective mismatch repair (MMR) system, a phenomenon commonly associated with hereditary nonpolyposis colorectal cancer (HNPCC) but also present in up to 15% of sporadic tumors.

AIM

To assess COX-2 expression in a large series of fully characterized colorectal cancer patients with respect to the MMR system and to dissect the mechanisms responsible for altered COX-2 expression in this setting.

PATIENTS AND METHODS

MMR-deficient colorectal cancer were identified in a nationwide, prospective, multicenter study (EPICOLON project). Control MMR-proficient colorectal cancer patients were randomly selected. COX-2 expression was evaluated by immunohistochemistry. Personal and familial characteristics, as well as MSH2/MLH1 expression and germ line mutations, were evaluated.

RESULTS

One hundred fifty-three patients, 46 with MMR deficiency and 107 with MMR proficiency, were included in the analysis. Overall, tumor COX-2 overexpression was observed in 107 patients (70%). COX-2 overexpression was observed in 85 patients (79%) with a MMR-proficient system, but only in 22 patients (48%) with a MMR-deficient colorectal cancer (P < 0.001). The lack of COX-2 overexpression was independently associated with a MMR-deficient system (odds ratio, 3.89; 95% confidence interval, 1.78-8.51; P = 0.001) and a poor degree of differentiation (OR, 3.83; 95% CI, 1.30-11.31; P = 0.015). In the subset of patients with a MMR-deficient colorectal cancer, lack of COX-2 overexpression correlated with a poor degree of differentiation, no fulfillment of Amsterdam II criteria, absence of MSH2/MLH1 germ line mutations, presence of tumor MSH2 expression, and lack of tumor MLH1 expression. CpG island promoter hypermethylation of COX2 was observed in 6 of 18 (33%) tumors lacking COX-2 expression in comparison with 2 of 28 (7%) tumors expressing this protein (P = 0.04).

CONCLUSIONS

Up to half of MMR-deficient colorectal cancer do not show COX-2 overexpression, a fact observed almost exclusively in patients with sporadic forms. COX2 hypermethylation seems to be responsible for gene silencing in one third of them. These results suggest the potential utility of nonsteroidal anti-inflammatory drugs in HNPCC chemoprevention and may explain the lack of response of this approach in some sporadic tumors.

Analysis of HER2 by chromogenic in situ hybridization and immunohistochemistry in lymph node-negative breast carcinoma: Prognostic relevance

In patients with lymph node-negative breast carcinoma (LNNBC), the prevalence of HER2 overexpression and gene amplification and their prognostic value have not been extensively evaluated. We examined 162 patients with LNNBC with complete follow-up. Immunohistochemistry (IHC) for HER2, Ki67, and p53 was performed. HER2 gene status was analyzed by chromogenic in situ hybridization (CISH) and discordant cases by fluorescence in situ hybridization. HER2 overexpression was seen in 24.7% of cases (40/162) and amplification by CISH in 17.6% (28/159). Agreement between IHC and CISH was achieved in 147 (92.5%) cases. Amplification was seen in 21 (100%) of 21 (3+), 6 (35.3%) of 17 (2+), and 1 (0.6%) of 121 (0-1+) tumors. Fluorescence in situ hybridization detected 3 (1.8%) additional cases. HER2 overexpression and amplification were present in tumors of high grade, with necrosis and lymph-vascular invasion (LVI) (all P < .027). In addition, amplified tumors showed Ki67 of more than 20% and p53 overexpression (P < .05). By univariate analysis, shorter disease-free survival (DFS) and overall survival (OS) were seen for patients with tumors showing HER2 amplification, LVI, and Ki67 of more than 20% (P < .05) (Kaplan-Meier). However, the multivariate analysis (Cox regression) demonstrated only Ki67 as an independent prognostic factor for both DFS (P = .017) and OS (P = .010), and as a trend for HER2 gene status (OS, P = .087) and LVI (DFS, P = .11; OS, P = .063). We conclude that IHC is a reliable method for detecting HER2 expression that can be complemented by CISH in nondefinitive cases (2+). Moreover, CISH is a valuable tool for the assessment of HER2 gene status with potential prognostic value and, therefore, in clinical decision making for treatment of high-risk LNNBC.

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) treated with 2-chlorodeoxyadenosine

Sinus histiocytosis with massive lymphadenopathy (SHML) or Rosai-Dorfman disease (RDD) is a rare but well-defined histiocytic proliferative disorder of unknown etiology that usually presents with cervical lymphadenopathy, fever, leukocytosis, and hypergammaglobulinemia in an otherwise healthy child. Although many patients undergo spontaneous remission, a subset of patients with systemic disease has a more serious course. For those patients with a poor outcome, steroids and chemotherapeutic agents such as etoposide or 6-mercaptopurine plus low dose methotrexate have been used. We present a child with a massive cervical lymphadenopathy treated with 2-chlorodeoxyadenosine (2-CdA, cladribine) after other approaches failed.

Mismatch repair status in the prediction of benefit from adjuvant fluorouracil chemotherapy in colorectal cancer

AIM

Some retrospective studies have shown a lack of benefit of 5-fluorouracil (5-FU) adjuvant chemotherapy in patients with mismatch repair (MMR) deficient colorectal cancer. Our aim was to assess if this molecular marker can predict benefit from 5-FU adjuvant chemotherapy. A second objective was to determine if MMR status influences short term survival.

METHODS

We included 754 patients with a median follow up of 728.5 days (range 1-1097). A total of 260 patients with stage II or III tumours received 5-FU adjuvant chemotherapy, according to standard clinical criteria and irrespective of their MMR status. A tumour was considered MMR deficient when either BAT-26 showed instability or there was loss of MLH1 or MSH2 protein expression.

RESULTS

At the end of the follow up period, 206 patients died and 120 presented with tumour recurrence. Sixty six (8.8%) patients had MMR deficient tumours. There were no significant differences in overall survival (MMR competent 72.1%; MMR deficient 78.8%; p = 0.3) or disease free survival (MMR competent 61.3%; MMR deficient 72.3%; p = 0.08). In patients with stage II and III tumours, benefit from 5-FU adjuvant chemotherapy was restricted to patients with MMR competent tumours (overall survival: chemotherapy 87.1%; non-chemotherapy 73.5%; log rank, p = 0.00001). Patients with MMR deficient tumours did not benefit from adjuvant chemotherapy (overall survival: chemotherapy 89.5%; non-chemotherapy 82.4%; log rank, p = 0.4).

CONCLUSIONS

Benefit from 5-FU adjuvant chemotherapy depends on the MMR status of tumours in patients with colorectal cancer. 5-FU adjuvant chemotherapy improves survival in patients with MMR competent tumours but this benefit from chemotherapy cannot be extended to patients with MMR deficient tumours.

Clinical performance of original and revised Bethesda guidelines for the identification of MSH2/MLH1 gene carriers in patients with newly diagnosed colorectal cancer: proposal of a new and simpler set of recommendations

Identification of individuals who should undergo hereditary nonpolyposis colorectal cancer (HNPCC) genetic testing is a critical and difficult issue. For this purpose, the National Cancer Institute outlined a set of recommendations, the Bethesda guidelines, which have recently been revised.

OBJECTIVE

To compare the clinical performance of original and revised Bethesda guidelines for the detection of MSH2/MLH1 gene carriers in patients with colorectal cancer.

METHODS

A total of 1,222 patients with newly diagnosed colorectal cancer were included in the EPICOLON study, a prospective, multicenter, nationwide epidemiology survey aimed at establishing the incidence of HNPCC in Spain (JAMA 2005; 293:1986-1994). Performance characteristics of the original and revised Bethesda guidelines were assessed with respect to the presence of MSH2/MLH1 germline mutations. Logistic regression analysis was performed to establish the most effective strategy.

RESULTS

Original or revised Bethesda guidelines were equivalent strategies in terms of sensitivity (100%vs 100%; ns), specificity (98.1%vs 97.9%; ns), and overall accuracy (98.1%vs 97.9%; ns), as well as positive (25.8%vs 24.2%) and negative predictive values (100%vs 100%). The most discriminating individual variables were criteria number 1 (i.e., fulfillment of the Amsterdam criteria; RR = 34.14; 95% CI = 6.85-170.16; p < 0.001) and number 2 (i.e., individuals with two HNPCC-related neoplasms; RR = 35.63; 95% CI = 4.83-262.6; p < 0.001) of the original guidelines, and criterion number 1 of the revised guidelines (i.e., colorectal cancer diagnosed under 50 yr of age; RR = 29.34; 95% CI = 3.81-225.96; p= 0.001). The aggregation of these three criteria was equivalent to both Bethesda guidelines in terms of sensitivity (100%) and negative predictive value (100%), but superior to the revised criteria regarding specificity (98.5%; p < 0.05), overall accuracy (98.5%; p < 0.05), and positive predictive value (30.8%).

CONCLUSIONS

Original and revised Bethesda guidelines are equivalent, highly effective criteria for the identification of MSH2/MLH1 gene mutation carriers in patients with newly diagnosed colorectal cancer. A new set of recommendations, based on a combination of some of their individual criteria, may provide additional advantages in terms of effectiveness.

Differential features of colorectal cancers fulfilling Amsterdam criteria without involvement of the mutator pathway

PURPOSE

Hereditary nonpolyposis colorectal cancer (HNPCC) is the commonest form of inherited colorectal cancer. Whereas it has been known that mismatch repair gene mutations are the underlying cause of HNPCC, an undetermined number of patients do not have these alterations. The main objectives of this study were to assess the relevance of clinically defined HNPCC patients without characteristic mutator pathway alterations and to identify their specific features.

EXPERIMENTAL DESIGN

This was a prospective, population-based, cohort that included 1,309 newly diagnosed colorectal cancer patients. Demographic, clinical, pathologic data and tumor DNA from probands as well as a detailed family history were collected. Microsatellite analysis and MLH1, MSH2, and MSH6 immunohistochemistry were done. Germ line MLH1 and MSH2 mutational analysis was done in all patients with evidence of MMR alterations.

RESULTS

Twenty-five patients (1.9%) fulfilled Amsterdam criteria of HNPCC but 15 (60%) of them did not have microsatellite instability and showed normal expression of MMR proteins. These patients presented mostly left-sided tumors without lymphocytic infiltrate; they were older, had fewer family members affected with colorectal or endometrial cancers, and more often fulfilled Amsterdam II criteria than HNPCC patients with microsatellite instability. Like unstable HNPCC patients, this group without mutator pathway alterations had a significant percentage of synchronous and metachronous adenomatous polyps and cancers.

CONCLUSIONS

We define an important group of HNPCC families with specific features, no evidence of mismatch repair deficiency, and an autosomal dominant trait with a lesser penetrance than HNPCC with deficiency.

[Perforation of the acalculous gallbladder in a renal transplant recipient with CMV infection]

We report the case of a renal transplant recipient who developed acute acalculous cholecyscitis resulting in gallbladder perforation. At admission CMV antigenemia was negative. Emergency laparatomy was performed and showed the gallbladder to be infarted with a perforation. The abdominal cavity contained two litres of sterile bilious fluid. The pathological report showed frequent endothelial cells contained intranuclear and intracitoplasmatic inclusion (fig. 1). Treatment with Ganciclovir iv was started after diagnosis, but a computerized tomography scan demonstrated severe acute pancreatitis (grade E. Baltazar). The patient developed multiorgan failure and died on 19th day after surgery. Necropsy showed cytomegalic inclusions in pancreas (fig. 2), gastrointerstinal tract, lung and graft. A necroticing pneumonia with Mycotic spores and hiphae was seen. Aspergillus was also observed in myocardium (fig. 3).

Accuracy of revised Bethesda guidelines, microsatellite instability, and immunohistochemistry for the identification of patients with hereditary nonpolyposis colorectal cancer

CONTEXT

The selection of individuals for hereditary nonpolyposis colorectal cancer (HNPCC) genetic testing is challenging. Recently, the National Cancer Institute outlined a new set of recommendations, the revised Bethesda guidelines, for the identification of individuals with HNPCC who should be tested for microsatellite instability.

OBJECTIVE

To establish the most effective and efficient strategy for the detection of MSH2/MLH1 gene carriers.

DESIGN, SETTING, AND PATIENTS

A prospective, multicenter, nationwide study (the EPICOLON study) in 20 hospitals in the general community in Spain of 1222 patients with newly diagnosed colorectal cancer between November 1, 2000, and October 31, 2001.

INTERVENTIONS

Microsatellite instability testing and MSH2/MLH1 immunostaining in all patients regardless of age, personal or family history, and tumor characteristics. Patients whose tumors exhibited microsatellite instability and/or lack of protein expression underwent MSH2/MLH1 germline testing.

MAIN OUTCOME MEASURES

Effectiveness and efficiency of both microsatellite instability testing and immunostaining, either directly or previous selection of patients according to the revised Bethesda guidelines, were evaluated with respect to the presence of MSH2/MLH1 germline mutations.

RESULTS

Two hundred eighty-seven patients (23.5%) fulfilled the revised Bethesda guidelines. Ninety-one patients (7.4%) had a mismatch repair deficiency, with tumors exhibiting either microsatellite instability (n = 83) or loss of protein expression (n = 81). Germline testing identified 11 mutations (0.9%) in either MSH2 (7 cases) or MLH1 (4 cases) genes. Strategies based on either microsatellite instability testing or immunostaining previous selection of patients according to the revised Bethesda guidelines were the most effective (sensitivity, 81.8% and 81.8%; specificity, 98.0% and 98.2%; positive predictive value, 27.3% and 29.0%, respectively) to identify MSH2/MLH1 gene carriers. Logistic regression analysis confirmed the revised Bethesda guidelines as the most discriminating set of clinical parameters (odds ratio, 33.3; 95% confidence interval, 4.3-250; P = .001).

CONCLUSION

The revised Bethesda guidelines constitute a useful approach to identify patients at risk for HNPCC. In patients fulfilling these criteria, both microsatellite instability testing and immunostaining are equivalent and highly effective strategies to further select those patients who should be tested for MSH2/MLH1 germline mutations.

Defective mismatch-repair colorectal cancer: clinicopathologic characteristics and usefulness of immunohistochemical analysis for diagnosis

The purpose of our study was to determine the usefulness of immunohistochemical analysis for the diagnosis of mismatch-repair (MMR) gene defective colorectal tumors and to describe their prevalence and clinicopathologic characteristics. We studied 172 cases. DNA was extracted from formalin-fixed, paraffin-embedded surgical samples, and microsatellite analysis was performed by polymerase chain reaction with BAT-26. The results were correlated with immunohistochemical analysis for hMLH1 and hMSH2. Microsatellite instability (MSI) was detected in 13 (7.6%) tumors, and all showed loss of protein expression of hMLH1 (11/13) or hMSH2 (2/13) (P < .000). Patients with MMR-defective tumors more frequently had poorly differentiated tumors (5/13 [38%] vs 18/159 [11.3%]; P = .02) located in the ascending colon (8/13 [62%] vs 30/159 [18.9%]; P < .0001) and a personal history of other neoplasms (4/13 [31%] vs 18/159 [11.3%]; P = .05). There were no differences in age, family history of cancer, or TNM stage. Immunohistochemical analysis seems to be a reliable method to detect most colorectal cancers with defective MMR genes.

Defective mismatch-repair colorectal cancer: clinicopathologic characteristics and usefulness of immunohistochemical analysis for diagnosis

The purpose of our study was to determine the usefulness of immunohistochemical analysis for the diagnosis of mismatch-repair (MMR) gene defective colorectal tumors and to describe their prevalence and clinicopathologic characteristics. We studied 172 cases. DNA was extracted from formalin-fixed, paraffin-embedded surgical samples, and microsatellite analysis was performed by polymerase chain reaction with BAT-26. The results were correlated with immunohistochemical analysis for hMLH1 and hMSH2. Microsatellite instability (MSI) was detected in 13 (7.6%) tumors, and all showed loss of protein expression of hMLH1 (11/13) or hMSH2 (2/13) (P < .000). Patients with MMR-defective tumors more frequently had poorly differentiated tumors (5/13 [38%] vs 18/159 [11.3%]; P = .02) located in the ascending colon (8/13 [62%] vs 30/159 [18.9%]; P < .0001) and a personal history of other neoplasms (4/13 [31%] vs 18/159 [11.3%]; P = .05). There were no differences in age, family history of cancer, or TNM stage. Immunohistochemical analysis seems to be a reliable method to detect most colorectal cancers with defective MMR genes.

Synchronous colorectal neoplasms in patients with colorectal cancer: predisposing individual and familial factors

PURPOSE

Patients with colorectal cancer have an increased risk for developing synchronous and metachronous neoplasms. However, besides those cases with inherited disorders predisposing to tumor multicentricity, it is unknown which patients are prone to this condition. This study was designed to identify individual and familial characteristics associated with the development of synchronous colorectal neoplasms in patients with colorectal cancer.

METHODS

During a one-year period, all patients with colorectal cancer attended in 25 Spanish hospitals were included. Exclusion criteria were colorectal cancer developed in the context of familial adenomatous polyposis or inflammatory bowel disease, refusal to participate in the study, incomplete family history, and inadequate examination of the colon and rectum. In addition to demographic, clinical, pathology, molecular (microsatellite instability status), and familial characteristics, presence of synchronous colorectal neoplasms (adenoma or carcinoma) were analyzed.

RESULTS

A total of 1,522 patients were included in the study. Synchronous colorectal neoplasms were documented in 505 patients (33.2 percent): adenoma (n = 411), carcinoma (n = 27), or both (n = 67). Development of these lesions was associated with male gender (odds ratio, 1.94; 95 percent confidence interval, 1.43-2.65), personal history of colorectal adenoma (odds ratio, 3.39; 95 percent confidence interval, 1.58-7.31), proximal location of primary tumor (odds ratio, 1.40; 95 percent confidence interval, 1.02-1.94), tumor TNM Stage II (odds ratio, 1.31; 95 percent confidence interval, 1.15-4.66), mucinous carcinoma (odds ratio, 1.89; 95 percent confidence interval, 1.19-2.99), and family history of gastric cancer (odds ratio, 2.03; 95 percent confidence interval, 1.17-3.52).

CONCLUSIONS

Based on individual and familial characteristics associated with synchronous colorectal neoplasms, it has been possible to identify a subgroup of patients with colorectal cancer prone to tumor multicentricity with potential implications on the delineation of preventive strategies.

Oncocytic Transformation in Pituitary Adenomas: Immunohistochemical Analyses of 65 Cases

Context.—Oncocytic change in pituitary adenomas has been evaluated by electron microscopy and more recently by immunohistochemistry. The clinical significance of this change is not well known, although some reports suggest a relationship with more aggressive behavior.

Objective.—To assess the frequency of oncocytic change in pituitary adenomas and to correlate this finding with clinicopathologic factors.

Design.—We studied oncocytic change in a series of 65 pituitary adenomas by immunohistochemistry. According to the percentage of oncocytic cells stained by antimitochondrial antibody, adenomas were classified in 3 groups: 50% or more, 10% to 49%, and 1% to 9% of oncocytic cells.

Results.—Eight cases (12.3%) showing at least 50% of oncocytic cells were classified as oncocytic adenomas: 6 were gonadotroph adenomas and 2 were null-cell adenomas. Among the remaining cases, 9 (14%; all gonadotroph adenomas) showed 10% to 49% oncocytic cells, and in 14 cases (21.5%; 5 gonadotroph adenomas, 6 somatotroph adenomas, 2 corticotroph adenomas, and 1 thyrotroph adenoma) between 1% and 9% were shown. Patients with adenomas that showed oncocytic change presented more frequently at a higher average age (P = .05), but no relationship with extrasellar extension or proliferative activity measured by Ki-67 was observed. In somatotroph adenomas, cases with oncocytic change showed higher percentages of Ki-67 (P = .05) but no correlation with extrasellar extension or cytokeratin staining (dot pattern versus perinuclear) was found.

Conclusion.—Adenomas with oncocytic change present more frequently in older patients, but they are not clinically more aggressive. In addition, somatotroph adenomas with oncocytic cells show similar cytokeratin pattern and higher proliferative activity, which is not correlated with local aggressiveness.

Tissue and tumor mosaicism of the myotonin protein kinase gene trinucleotide repeat in a patient with multiple basal cell carcinomas associated with myotonic dystrophy

We describe the third case (to our knowledge) of multiple basal cell carcinoma associated with myotonic dystrophy and carry out a genetic study of the tumor comparing it with healthy skin. We consider that our results show that this association might be not a purely random phenomenon and that the particular genetic characteristics of this disorder might have a role in the pathogenesis of the tumor.

Frequency of hereditary non-polyposis colorectal cancer and other colorectal cancer familial forms in Spain: a multicentre, prospective, nationwide study

BACKGROUND

Colorectal cancer is the third leading cause of cancer mortality in Western countries. Hereditary nonpolyposis colorectal cancer is the most common type of hereditary colorectal cancer, but its incidence remains controversial, ranging from 1 to 5%.

OBJECTIVE

This present prospective, multicentre, nationwide study was aimed at compiling prominent epidemiological and clinical data with respect to hereditary non-polyposis colorectal cancer and other familial colorectal cancer forms in Spain, where information is lacking.

METHODS

All patients with a de-novo diagnosis of colorectal cancer and who attended between November 2000 and October 2001 in 25 hospitals all over Spain were registered. Demographic, clinical and tumour-related characteristics of probands, and detailed family history, were obtained.

RESULTS

A total of 1872 colorectal cancer patients were included. Clinical diagnosis of hereditary non-polyposis colorectal cancer was established in 46 (2.5%) patients according to the Amsterdam II criteria. Comparison between patients fulfilling either the Amsterdam I or the Amsterdam II criteria revealed no differences with respect to demographic, clinical and tumour-related characteristics. A total of 504 (27.0%) patients had a family history of hereditary non-polyposis colorectal cancer-related neoplasm not fulfilling the Amsterdam criteria (familial colorectal cancer), while 360 (19.2%) patients fulfilled at least one of the Bethesda's criteria.

CONCLUSION

These clinicoepidemiological data provide a more accurate characterization of hereditary non-polyposis colorectal cancer and other familial colorectal cancer forms in Spain, with potential implications in preventive strategies.

Mesectodermal leiomyoma of ciliary body

A 37-year-old woman had a mass in her left ocular globe. Uveal melanoma was suspected and enucleation was performed. Microscopically, the lesion proved to be a typical case of mesectodermal leiomyoma of the ciliary body. According to some authors, the peculiar neural appearance of this tumor could be the reflection of its probable origin from mesectodermal smooth muscle. Immunohistochemical analysis showed reactivity for muscle-specific actin and negativity for desmin, S-100 protein, HMB-45, EMA, and GFAP. Our results do not support the proposed neuroectodermical origin of this tumor, since coexpression of muscular and neural markers was not observed.

[Toxic hepatitis associated with tamoxifen use. A case report and literature review]

Tamoxifen is an antiestrogenic drug that acts by binding to the estrogen receptor. The drug is used as a co-adjuvant treatment in advanced breast cancer expressing the oestrogen-receptor protein. Clinical trials of tamoxifen have shown its efficacy in reducing mortality and recurrence rates over a five-year treatment. Cases of tamoxifen-associated hepatotoxicity have been described, including cholestasis with or without cytolysis and steatohepatitis. We report the case of a female patient who developed hepatic alterations while undergoing continuous tamoxifen treatment. We also present an overview of similar cases published to date and comment on the advisability of continuing or suppressing this treatment in patients with hepatotoxicity or after a five-year treatment period.

Phyllodes tumor of the breast with actin inclusions in stromal cells: diagnosis by fine-needle aspiration cytology

The occurrence of hyaline inclusions in stromal cells in fibroepithelial tumors of the breast is very uncommon. These inclusions, characteristic of infantile digital fibromatosis, are comprised of actin filaments. This report illustrates a case of a benign phyllodes tumor of the breast with inclusion bodies, identified by fine-needle aspiration. Histologically, many of the stromal cells contained round intracytoplasmic inclusions, with positivity for smooth muscle actin.

Human immunodeficiency virus infection in pregnant women, transmission and zidovudine therapy

OBJECTIVE

To determine the rate of mother to child transmission of HIV infection in women treated with zidovudine (ZDV).

PATIENTS AND METHODS

A consecutive series of 52 HIV-positive pregnant women who either received antenatal care or delivered at our institution. Forty-three women were known to be HIV positive before delivery. Forty were treated with ZDV, 36 intravenously. Twelve had no antenatal care and one refused antenatal treatment. All neonates were treated with ZDV.

RESULTS

The HIV transmission rate in children born to mothers treated with ZDV was 6.6%. This compares with a transmission rate of 14% before we used ZDV. All three mothers who transmitted infection had low compliance, initiated therapy late in pregnancy or had advanced disease.

CONCLUSION

Our experience supports the idea that ZDV treatment has reduced HIV transmission rate.

[Validity of the declared tobacco consumption in pregnancy]

OBJECTIVES

To analyse the relationship between the stated consumption of tobacco by pregnant women who say they smoked before pregnancy and the levels of cotinine in their urine at the start and end of pregnancy.

DESIGN

Observational, longitudinal study.

PARTICIPANTS

During 1997.

STUDY GROUP

147 pregnant women at their first pre-natal visit to outclinics of the Hospital del Mar.

CONTROL GROUP

50 non-smoker pregnant women monitored during their pregnancy.

MEASUREMENTS AND MAIN RESULTS

The numbers of cigarettes per day that they said they smoked on their first monitoring visit to our centre and at the last attendance before giving birth were recorded. Cotinine levels in the urine samples taken on these visits were measured. Mean cotinine in pregnant women who said they had given up smoking was higher than in non-smokers. There was a statistically significant linear relationship between the number of cigarettes stated and cotinine levels at the first and last pregnancy monitoring visits, as well as between the variation in the number of cigarettes and cotinine levels at these two visits. The negative predictive value of what they said about their tobacco habit was 82.9%.

CONCLUSIONS

There was a certain under-declaration by pregnant smokers, although their statements of consumption and cotinine levels correlated closely. The under-declaration did not increase despite reiterated advice to stop smoking, which means that, despite its limitations, it could be a useful indicator for evaluating the effect of interventions aimed at stopping women smoking during pregnancy.