Is use of the pulmonary valve allograft justified as an aortic valve substitute?

Between January 1, 1990, and March 20, 1994, 56 patients had a homograft valve device placed in the aortic position. The mean age at operation was 53.3 years (range 5-77 years). Diagnosis included dominant aortic stenosis in 27 patients (48.2%) and aortic incompetence in 29 (51.8%). Thirteen patients (23.2%) had subacute bacterial endocarditis. Forty-three aortic homografts and 13 pulmonary homografts were placed. Concomitant procedures were performed in 12 patients (21.8%). The hospital mortality was 7.3% (four patients). On follow-up, three pulmonary valves have failed, two between 1 and 5 weeks post implantation. At reoperation a linear cusp fracture was found in all with no evidence of infection. All remaining patients have no, trivial, or mild, aortic regurgitation on echo and remain well. Pulmonary and aortic valves were compared for failure, P = 0.02 suggesting a significant difference between valve substitutes. In conclusion we advise caution in using pulmonary allografts in the aortic position.

Prognostic significance of microvessel density in lymph node negative breast carcinoma

We evaluated the prognostic value of tumor angiogenesis in node negative breast cancer (NNBC). Paraffin-embedded tissues from 87 patients with NNBC were immunostained for factor VIII-related antigen, using one tissue block representative of the invasive edge of the tumor. Sections were scanned at low power to identify "hotspots" of angiogenesis. Microvessel (MV) counts were performed at x200 magnification, using a grid eyepiece graticule. Within each hot spot, three fields (area of field = 0.22 mm2) were counted and averaged. The highest average for a hot spot and the highest single field value was recorded for each case. Patients were stratified into low and high MV groups and their survival compared. There were no differences in disease-free or overall survival between the two groups whether the highest average or the highest single value was used. Microvessel counts did not correlate with other prognostic features, ie, grade, size, estrogen receptor status, c-erb B-2 or accumulated P53 status. Because of the difficulty in assessing angiogenesis that is heterogenous throughout tumors, MV counting may not be suitable for clinical use as a prognostic factor in NNBC. This problem could be addressed in a prospective study involving more extensive tumor sampling.

Amplification of the MDM2 gene in human breast cancer and its association with MDM2 and p53 protein status

The present study reports on the frequency of MDM2 gene amplification and MDM2 protein expression in a series of 100 breast carcinomas and its association with accumulation of the p53 protein. Of the 100 cases, frozen samples for 82 cases were available for Southern blotting. Three of the 82 (4%) demonstrated MDM2 gene amplification of up to 6-fold. Immunohistochemical analysis of the formalin-fixed, paraffin-embedded tumours demonstrated that 7/97 (7%) had nuclear expression for MDM2 in 10-50% of the tumour cells (type 2 staining) and were denoted MDM2+. Two of the MDM2-amplified samples were MDM2+ with one of the two tumours also displaying type 2 p53 nuclear staining. Finally at the protein level, MDM2+ tumours were significantly associated with tumours having low levels of p53 staining (0-10% cells positive) (P = 0.03). We conclude that MDM2 gene amplification occurs at a lower frequency in breast cancer than in non-epithelial tumours. Alterations in MDM2 and p53 may represent alternative pathways in tumorigenesis, but they are not mutually exclusive in all cases.

Chromosome 1 aneusomy, identified by interphase cytogenetics, in mammographically detected ductal carcinoma in situ of the breast

Because of the relative rarity of ductal carcinoma in situ (DCIS) in the premammographic screening era, the unavailability of adequate fresh tissue for culture, and the lack of cytogenetic expertise in most pathology departments, there is little information on karyotypic abnormalities in DCIS. The purpose of this study was to investigate the frequency of chromosome 1 aneusomy in DCIS, using interphase cytogenetic techniques, and to correlate the findings with nuclear grade. Twenty-one cases of DCIS, identified in a mammographically screened population, were studied by in situ hybridization. Chromosome 1 numbers were identified in interphase nuclei in conventional histology sections, using a specific centromeric probe (pUC 1.77). In each case, 100 tumour nuclei were compared with 100 normal nuclei. Eighteen of 21 (86 per cent) cases were aneusomic for chromosome 2. This included 15 of 16 (94 per cent) pure comedo or predominantly comedo DCIS. Fifteen of 16 (94 per cent) DCIS with grade 3 nuclei and 3 of 5 (60 per cent) cases with grade 2 nuclei were aneusomic. One case with grade 3 nuclei (a comedo carcinoma) was negative. We conclude that chromosome 1 aneusomy precedes invasion and is a relatively consistent occurrence in those DCIS with high nuclear grade.

Proliferating cell nuclear antigen: a new prognostic indicator in renal cell carcinoma

Renal cell carcinoma is a tumor, the prognosis and behavior of which remain poorly understood. Proliferating cell nuclear antigen levels have been shown to act as an independent prognostic variable in a variety of malignancies. Proliferating cell nuclear antigen was evaluated in 59 cases of renal cell carcinoma, and the results were correlated with existing clinicopathological variables and survival. Proliferating cell nuclear antigen index (percentage of tumor cells positive for proliferating cell nuclear antigen) did not correlate with stage, grade or ploidy. To assess survival, tumors with proliferating cell nuclear antigen indexes of greater than and less than 60% were compared. The 24 patients with a high index (greater than 60%) had a significantly worse survival than did 35 with a low index (less than 60%, p < 0.001). Therefore, the prognostic potential of proliferating cell nuclear antigen in renal cell carcinoma is promising and may be of clinical value in the management of patients with renal cell carcinoma.

The diagnostic value of silver nucleolar organizer region assessment in breast cytology

Benign and malignant breast lesions in cytologic preparations can be difficult to distinguish. The authors applied the silver nucleolar organizer region (AgNOR) technique to cytologic preparations obtained from surgical specimens to evaluate its diagnostic usefulness in making this distinction. Sixty-two benign and 36 malignant lesions were examined. AgNORs were counted and evaluated using a subjective scoring technique to examine AgNOR size, shape, and clustering. The benign lesions had a mean count of 4.44 AgNORs/nucleus (95% CI, 2.4-6.5) and the malignant cases, 9.52 AgNORs/nucleus (95% confidence interval, 7.4-11.7; P < .0005). The median score for benign cases was 7 and for malignant cases, 13 (P < .0001). With a few exceptions, cases with high counts had high scores. The diagnostic accuracy of combined counting and pattern assessment was 90%. The likelihood ratio for correct diagnosis using AgNOR counting was 14:1 and for AgNOR scoring, 13:1.

Bcl-2 rearrangement in Hodgkin's disease and reactive lymph nodes

The chromosomal translocation t(14;18)(q32;q21), which involves the bcl-2 oncogene, occurs in most follicular lymphomas. Recent evidence suggests that this translocation occurs in Hodgkin's disease, linking its cellular origin and oncogenesis to follicular non-Hodgkin's lymphomas. Using polymerase chain reaction, the authors examined both Hodgkin's disease (n = 60) and reactive lymph nodes (n = 34) for the presence of bcl-2/JH breakpoint fragments, which are indicative of the t(14;18) chromosomal translocation in the major breakpoint region of the bcl-2 gene. The translocation was detected in approximately 10% of both Hodgkin's disease and nonmalignant reactive lymph node cases. These results suggest the possibility that the translocation may occur in the reactive component of Hodgkin's disease and not in the putative malignant cells, the Reed-Sternberg cells. Furthermore, the detection of the translocation in reactive lymph nodes suggests that it may not be the primary factor in the oncogenesis of follicular lymphoma.

Soft tissue and visceral sarcomas in Irish patients. Interim analysis of data obtained by the Dublin Soft Tissue Tumour Panel

The Dublin Soft Tissue Sarcoma Panel was established in 1989 with a view to achieving a unified approach to diagnosis and management of soft tissue and visceral sarcomas. This interim report presents data on 265 prospectively-evaluated patients and on a separate retrospective series of 126 patients. The patients in the prospective series were treated by 93 different surgical and medical specialists. Tumours presented in all anatomic sites and ranged in size from 0.2 to 60 cm. Leiomyosarcoma was the commonest tumour type. Eighty-nine tumours were inoperable at clinical presentation. There was a consensus panel diagnosis in over 90%, non-neoplastic reactive lesions and primitive round cell tumours being the most difficult cases diagnostically. Management, including onward referral for chemotherapy or radiation therapy, was inconsistent. The 2-year survival figures were: 43% (1989-91) and 37% (1980-88). These findings should provide a basis for the evaluation of coherent treatment strategies for Irish sarcoma patients.

Screening for breast cancer in Ireland: the Eccles Breast Screening Programme

The Eccles Breast Screening Programme is a population-based screening programme for breast cancer, based at the Mater Misericordiae Hospital, Dublin. It began in 1989 simultaneously with similar programmes in Belgium, France, Greece, Portugal and Spain. The objectives of the Eccles Programme are: (i) to evaluate the impact of mammographic screening on morbidity and mortality from breast cancer in Irish women; and (ii) to address the feasibility and potential value of a national breast cancer screening programme. The specific group targeted for screening is women born in 1925 to 1940 inclusive, in a defined geographical area comprising north Dublin City and County, and Counties Cavan and Monaghan. The areas combined comprise 16% of the country's population; just over 29,000 women were invited for screening. An analysis of the demographic and socioeconomic features of the target population reveals that it represents the total population remarkably well. Participants were invited from a population register to attend one of two screening units. Follow-up treatment for those with abnormalities takes place predominantly at the Mater Hospital where the facilities of the Departments of Pathology, Surgery and Oncology have been made available to the programme. Almost 18,000 women had a mammogram in the first round of screening, an overall response rate of 62%. A total of 129 cancers were detected, a prevalence of breast cancer of 7.2 per 1,000. Of those, 15 (11.6%) were entirely intraduct, and an additional 7 (5.4%) had minimal invasion. This is considerably higher than the proportion of intraduct cancers seen in referral practice populations.

Comparable prognostic factors and survival in elderly patients with aggressive non-Hodgkin's lymphoma treated with standard-dose adriamycin-based regimens

We retrospectively analysed the prognostic factors at diagnosis, clinical response, and survival of 192 patients with newly diagnosed aggressive NHL treated in a single institution between 1985 and 1991. Overall, 37.5% (72/192) of patients were 65 years or older (average age 71 years, range 65-85 years), and 62.5% (120/192) were under 65 years of age (average age 45, range 16-64 years). All patients were completely staged and had intermediate- or high-grade NHL. 127 patients were treated on similar regimens with the same chemotherapy dose intensity irrespective of age. Standard-dose m-BACOD (methotrexate, bleomycin, Adriamycin, cyclophosphamide, vincristine, prednisone) or CHOP were used to treat 60/72 (83%) elderly patients and 67/120 (56%) patients less than 65 years. The remaining younger patients were treated with more intensive regimens. There were no significant differences between the groups with regard to stage, histological grade, cell type, elevated LDH, number of extranodal sites, presence of B symptoms, or bulky disease. More elderly patients had a significantly (p < 0.02) poorer performance status (PS), with 42% (25/60) having a PS of 2 or more, compared to 22% (15/67) in those less than 65 years of age. Elderly patients had an inferior complete response rate, 65% versus 76%. However, overall response rates of 95% and 92% were similar. The disease-free survival at 3 years for complete responders in elderly patients was 74% compared to 82% in those under 65. The comparable 3-year overall survival was 59% and 62%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

A quantitative immunohistochemical evaluation of lentigo maligna and pigmented solar keratosis

Pigmented solar keratosis (PSK) is sometimes clinically indistinguishable from lentigo maligna, a form of malignant melanoma in situ. Occasionally histologic diagnosis is also difficult. Accurate diagnosis is essential, as the treatment and prognosis for each condition differs considerably. To determine whether there was a significant overlap in the number of melanocytes in these sun-damaged skin lesions, or whether immunohistochemistry might be helpful in the differential diagnosis, the authors examined skin biopsy specimens from 26 patients with obvious lentigo maligna and 15 patients with PSK using 3 monoclonal antibodies (HMB-45, NK1C3, and vimentin) and 1 polyclonal antibody (S-100 protein). Formalin-fixed paraffin sections were immunostained with each of the above antibodies, and immunopositive cells per mm2 of epidermis were counted. The difference between lentigo maligna and PSK counts was statistically significant at a level of P < .0001; furthermore, there was almost no overlap between the two groups. The sensitivity for the diagnosis of lentigo maligna was high with all antibodies. However, HMB-45 had the highest sensitivity and the lowest false-positive rate and was visually most pleasing. Using a cut-off count of 60 cells per mm2 of epidermis, HMB-45 had a sensitivity of 96% and a 0% false-positive rate. In this study, lentigo maligna was easily differentiated from PSK. The real value of immunohistochemistry in the differential diagnosis of these pigmented lesions should be tested in a prospective study using cases that are difficult to diagnose by routine light microscopy.

Pleomorphic rhabdomyosarcoma in adulthood. Analysis of 11 cases with definition of diagnostic criteria

Currently, pleomorphic rhabdomyosarcoma (RMS) in adults is considered to be extremely rare or nonexistent. The authors have identified 11 cases of pleomorphic RMS using the following criteria: pleomorphic sarcoma occurring within voluntary muscle, large polygonal or strap-like cells with copious eosinophilic cytoplasm, desmin and myoglobin immunoreactivity, or ultrastructural evidence of sarcomeric differentiation. Ten patients were male, the median age at presentation was 56 years (range, 27-84), and the thigh (seven cases) was the most common site. Of eight cases with clinical follow-up, one patient is alive at 20 months, and seven died 2 to 28 months following diagnosis. The tumors were generally patternless, but several had storiform areas. Cross-striations were not identified. Immunostaining for muscle-related antigens was positive as follows: desmin (in 10 of 11 cases), myoglobin (in 10 of 11 cases), actin HHF-35 (in all 11 cases), smooth-muscle actin (in six of eight cases), sarcomeric actin (in six of nine cases), and fast myosin (in five of five cases). Staining for S-100 protein was negative in all cases. On electron microscopy (six cases), two tumors had well-differentiated rhabdomyoblasts with sarcomeres, Z-disks, and hexagonal arrays of myofilaments; three were poorly differentiated; and one contained immature mesenchymal cells only. Pleomorphic RMS can be distinguished from other pleomorphic sarcomas provided that well-fixed tumor tissue is available for immunohistochemical staining and electron microscopy. We consider that this distinction is important in view of the poor prognosis associated with pleomorphic RMS in this series.

The detection of specific gene rearrangements in non-Hodgkin's lymphoma using the polymerase chain reaction

Characteristic gene rearrangements are present in most non-Hodgkin's lymphomas (NHL). These are usually detected by Southern blotting techniques. In this study, the ability of the polymerase chain reaction (PCR) to detect the t(14;18) chromosomal translocation and immunoglobulin heavy chain (IgH) gene rearrangement was evaluated. DNA from 14 follicular and 42 diffuse B-cell lymphomas was examined using oligonucleotide primers specific for opposing sides of the IgH gene rearrangement on chromosome 14 (towards conserved VH and JH sequences) and opposing sides of the t(14;18) chromosomal translocation (towards the major breakpoint region of the bcl-2 gene on chromosome 18 and conserved JH sequence on chromosome 14). The t(14;18) translocation was detected in 57% of follicular lymphomas and 21% of diffuse B-cell lymphomas. Clonal IgH gene rearrangements using PCR were detected in 50% follicular and 52% of the diffuse lymphomas. Either or both of these rearrangements were detected in 93% follicular and in 59% of diffuse lymphomas. PCR is a rapid and easy technique that can detect the abnormal rearrangement of the bcl-2 gene and clonal IgH rearrangement, indicating the presence of lymphoma. This may be of benefit in monitoring response to therapy and in predicting prognosis in this disease.

A study of regional distribution of renal blood flow using quantitative autoradiography

Quantitative autoradiography utilizing [14C]iodoantipyrine was used to measure regional renal blood flow in anesthetized rats. This technique allowed blood flow in any region of the kidney to be measured with a resolution of 100 microns. There was no significant difference between flow to polar and middle regions of the renal cortex [875 +/- 57 vs. 926 +/- 71 (SE) ml.100 g-1 x mm-1]. Areas of high optical density in renal cortex corresponded to peritubular capillaries. Mean cortical blood flow was three times greater than mean medullary blood flow. Outer medullary blood flow was uniform but significantly higher than inner medullary blood flow (272 +/- 16 vs. 45 +/- 7 ml.100 g-1 x mm-1; P < 0.001).

Tissue characterization and assessment of preoperative chemotherapeutic response in musculoskeletal tumors by in vivo 31P magnetic resonance spectroscopy

This study investigates the potential of in vivo 31P magnetic resonance spectroscopy (MRS) to characterize musculoskeletal tumors and to determine preoperative levels of histological necrosis, which is an important clinical indicator of patient response. Pretherapy MRS was performed on 28 patients with large musculoskeletal tumors: 13 with osteosarcoma, 3 with chondrosarcoma, 5 with malignant fibrous histiocytoma, 1 with desmoid tumor, 1 with Ewing's, 2 with hemangioendothelioma, 1 with myxoid liposarcoma, 1 with synovial cell sarcoma, and 1 with rhabdomyosarcoma. Fifteen patients had follow-up MRS examinations after commencement of chemotherapy (mean of five/patient), eight of whom have now had surgery. Elevated levels of PMEs (P < 0.01), P(i) (P < 0.01), and PDEs (P < 0.02) as well as elevated tumor pH (P < 0.05) were observed in all patients. The synovial cell sarcoma was characterized by high levels of PMEs (> 20%) and low pH (pH 6.76). This contrasted with the spectra obtained from the malignant fibrous histiocytomas which had high levels of PDEs (17 +/- 5%). Reductions in PDE levels postchemotherapy were associated with a high degree of necrosis (> 90%) at surgery, while an increase in PDE levels was associated with a low level of histological necrosis. Likewise, reductions in the ratios PDE/NTP and PDE/PCr and an increase in P(i)/PDE were also associated with a high level of necrosis.

31P MRS as an early prognostic indicator of patient response to chemotherapy

In this study 31P spectral changes were closely monitored following the initial administration of cytotoxic drugs and related to five parameters of patient response. Pre- and postchemotherapy 31P MRS examinations were performed on 16 patients with large, malignant tumors. These included four tumor types: (i) lymphoma (n = 7), (ii) breast carcinoma (n = 4), (iii) musculoskeletal tumors (n = 4), and (iv) adenocarcinoma (n = 1). A mean of 5 spectra/patient (range 2-10) was performed following the initial chemotherapy. The spectral trends exhibited by 14 of 16 patients reached "points of maximum change," after which they began to revert toward prechemotherapy values. In 2 of 16 patients that did not respond to the initial chemotherapy regimen, no spectral trends were observed. The degree of change of certain spectral parameters, namely, decreases in PME, PME/PDE, PME/PCr, PME/NTP, PDE/PCr, and tumor pH, as well as increases in the ratios Pi/PME and Pi/PDE, were associated with good patient response and separated responders from nonresponders. Pi/PME appears the most promising for discriminating partial from complete responders.

Proliferating cell nuclear antigen counts in formalin-fixed paraffin-embedded tissue correlate with Ki-67 in fresh tissue

Cell proliferation can be studied by a variety of techniques. However, most require fresh tissue. To evaluate cell proliferation in formalin-fixed paraffin-embedded sections, the authors immunohistochemically studied 35 tumors and 11 samples of normal/hyperplastic tissue with PC10, a monoclonal antibody directed against proliferating cell nuclear antigen. Results were compared with those obtained with Ki-67 on fresh tissues. There was no significant difference between proliferating cell nuclear antigen and Ki-67 counts, which were strongly correlated (r = 0.8). Proliferating cell nuclear antigen positivity was easier to evaluate because morphology was better preserved in formalin-fixed tissue. The authors conclude that PC10 is an alternative to Ki-67 in evaluating cell proliferation and has the advantage of reacting with formalin-fixed paraffin-embedded tissue.

Argyrophylic nucleolar organiser regions (AgNOR's) as a prognostic indicator in breast carcinoma

Silver staining nucleolar organiser regions (AgNOR's) were determined in archival histological specimens of breast carcinoma. Representative samples from forty-eight female patients were counted manually for AgNOR's--median 3.85 (range 1.1-10.2 AgNOR's per cell). Taking the median value of 3.85 as a cutoff, the patients were divided into two groups: A = Those with AgNOR counts > 3.85; B = Patients with AgNOR counts < or = 3.85. The 5 year survival was 21% in group A and 85% in group B (p < 0.001). There was no significant correlation between AgNOR's and tumour size, lymph node status, tumour grade, menopausal status and oestrogen receptors. We conclude that nucleolar organiser regions may be useful as a prognostic indicator in breast carcinoma especially in patients in whom other prognostic information is unavailable.

Myocardial collagen network in dilated cardiomyopathy. Morphometry and scanning electron microscopy study

Although some form of myocyte damage is probably the main abnormality responsible for heart failure in dilated cardiomyopathy, abnormalities of the supporting interstitial collagen meshwork also occur. To see if abnormal collagen could be detected in cardiomyopathic hearts, which did not have interstitial fibrosis by routine light microscopy, we examined interstitial collagen using scanning electron microscopy and a novel digestion technique. Cardiomyopathetic collagen fibrils were significantly thicker and more densely packed than normal. We conclude that an ultrastructural collagen abnormality occurs early in dilated cardiomyopathy, this abnormality may contribute to the pathophysiology of this disease.

Intermediate filament expression in carcinoid tumours

Twenty-eight carcinoid tumours were stained with monoclonal antibodies to epithelial and neural related intermediate filaments. All were found to express epithelial markers, and none expressed neural markers. These results support the theory that carcinoids are of epithelial, rather than neural crest origin.

Soft tissue and visceral sarcomas in Irish patients. A preliminary report from the Dublin Soft Tissue Tumour Panel

Sarcomas of the soft tissues and viscera are a diverse group of uncommon neoplasms that often present difficult diagnostic and management problems. The Dublin Soft Tissue Tumour Panel prospectively reviewed pathology material from 137 patients of four Dublin teaching hospitals between January 1989 and August 1990. The prevalence of sarcomas in Irish patients was found to be similar to that estimated for the United States. The most common sarcoma of soft tissues was malignant fibrous histiocytoma (14) and the most common visceral sarcoma was leiomyosarcoma (10). The most problematic diagnoses were 3 peripheral neuroepitheliomas (extraskeletal Ewing's sarcomas) which occurred in patients aged 19-27 years, distinctly younger than the typical adult sarcoma patient. Clinical follow-up is in progress and will be combined with the findings of a linked retrospective study, to facilitate evaluation of all aspects of management.