Sporadic CDKN2 (MTS1/p16ink4) gene alterations in human ovarian tumours

The cell cycle regulatory proteins p16 and p21 cause cell cycle arrest at the G1 checkpoint by inhibiting activity of cyclin D-CDK4 complexes. The TP53 gene, regulating the p21 protein, is mutated at high frequency in ovarian cancer. The CDKN2 gene, encoding the p16 protein, has been mapped to chromosome 9p21 and encompasses three exons. To establish the frequency of CDKN2 gene abnormalities in ovarian tumour specimens, we have studied this gene in five ovarian cancer cell lines and in 32 primary and five metastatic ovarian adenocarcinomas. Using polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) and sequencing techniques both exon 1 and 2 of the CDKN2 gene, encompassing 97% of the coding sequence, were analysed. In addition, the TP53 gene was studied for the presence of mutations. The cell line HOC-7 showed a 16 bp deletion in exon 2 of the CDKN2 gene, resulting in a stop codon, whereas in cell line SK-OV-3 this gene was found to be homozygously deleted. Nine primary tumour specimens showed a migration shift on SSCP. Sequencing revealed a common polymorphism (Ala148Thr) in seven of these ovarian tumour specimens. The two other tumour samples were found to contain silent mutations, one at codon 23 (GGT-->GGA) and the other at codon 67 (GGC-->GGT). Mutations in the TP53 gene were observed in 46% of the ovarian tumour specimens. We conclude that CDKN2 gene alterations are rare events in human ovarian cancer. The low prevalence of these alterations do not allow for analysis of an association of this gene with prognosis.

The clinical significance of androgen receptors in breast cancer and their relation to histological and cell biological parameters

To analyse the clinical significance of the presence of androgen receptors (AR) in breast carcinomas, clinical and histological parameters of 153 primary breast carcinomas (median follow-up 46 months) were examined. Oestrogen (ER) and progesterone receptor (PR) levels were determined in cytosol preparations using enzyme immunoassay assays and in cryostat sections by immunohistochemistry. AR and Ki-67 levels were only determined immunohistochemically. Data were analysed by uni- and multivariate models. 94/153 (61%) breast carcinomas were ER+ PR+ AR+, while 14 cases were only positive for AR. All grade III tumours (n = 17) were steroid receptor negative and 14 (76%) of these cases demonstrated high Ki-67 values suggestive of more aggressive behaviour. Strikingly, 14 ductal carcinomas negative for ER and PR were positive for AR. In univariate analysis, AR as well as ER, tumour size, lymph node status, grade and Ki-67 proved to be significant prognostic factors for disease-free survival (DFS). Multivariate analysis, however, showed lymph node status, tumour size and ER status to be the only independent prognostic factors for DFS within this model. We conclude that simple histological and cell biological parameters, including AR, can be used to select high- and low-risk patients at the time of primary surgery and can provide valuable information on treatment options.

Quality control of immunocytochemical staining of effusions using a standardized method of cell processing

OBJECTIVE

To improve the quality and reproducibility of immunocytochemical staining of effusions by using a standardized method of cell processing.

STUDY DESIGN

The study included the specimens of 108 effusions (44 benign, 56 adenocarcinoma metastases and 8 mesotheliomas). Hemorrhagic effusions were lysed using isotonic ammonium chloride. All pellets were fixed in 1% paraformaldehyde dissolved in phosphate-buffered saline (PBS), pH 7.4, and washed in PBS. A Burker counting chamber was used to adjust the pellets to a standard cell concentration. The panel of monoclonal antibodies (MAbs) included MOC-31, Ber-EP4 and anticarcinoembryonic antigen (anti-CEA). The alkaline phosphatase/anti-alkaline phosphatase technique was applied.

RESULTS

Standardized material processing resulted in reproducible specimens with good preservation of cell morphology, reduction of nonspecific interaction and good immunostain intensity. MAbs MOC-31 and Ber-EP4 gave similar results: both were positive in all adenocarcinomas. Anti-CEA was positive in 73%. Benign effusions showed no expression. In contrast to the literature, seven mesotheliomas showed variable membranous expression of MOC-31 and Ber-EP4.

CONCLUSION

High-quality immunostaining results were obtained by using a standardized method of cell processing. MAbs MOC-31 and Ber-EP4 cannot be used as differentiation markers between mesotheliomas and adenocarcinomas. Discrepancies in immunocytochemical staining results may be caused partly by differences in cell preparation.

The value of immunohistochemistry in patients with poorly differentiated adenocarcinomas and undifferentiated carcinomas of unknown primary

A subgroup of patients with metastatic carcinomas of unknown origin may benefit from combination chemotherapy. The relevance of immunohistochemistry in detecting such patients was investigated. Immunohistochemical studies with a panel of antibodies were performed on the tissue specimens of 41 patients having a light-microscopic diagnosis of poorly differentiated adenocarcinoma or undifferentiated carcinoma of unknown origin, who had been treated with cisplatin- containing chemotherapy. The study aimed to answer the following questions: (a) Can the tissue type of the tumor be verified? (b) Can a primary organ site be identified? (c) Can a prognostic immunohistochemical profile be recognized? The original diagnosis had to be changed in 2 of the 41 patients, who turned out to have a malignant lymphoma and neuroblastoma, respectively. The primary site was diagnosed in a patient with prostate cancer, whereas in one case the diagnosis could be narrowed down to a neuroendocrine tumor. No certain immunohistochemical profile with prognostic significance could be identified. It was concluded that immunohistochemistry should be routinely used in cases of undifferentiated carcinoma of unknown primary origin to verify the histological diagnosis and to select the appropriate therapy.

Regional metastasis in head and neck squamous cell carcinoma: revised value of US with US-guided FNAB

PURPOSE

To verify the acclaimed accuracy of ultrasound (US) combined with US-guided fine-needle aspiration biopsy (FNAB) in the detection of lymph node metastasis in the neck and to evaluate the interobserver variability.

MATERIALS AND METHODS

In a prospective, multicenter study of 185 patients with head and neck squamous cell carcinoma, US (n=238 neck sides) with US-guided FNAB (n=178 neck sides) was used for evaluation of the lymph node status of the neck. Findings were correlated with those of histopathologic examination in 238 neck sides.

RESULTS

US with US-guided FNAB had a sensitivity of 77% and a specificity of 100%. Nineteen of 178 aspirations were nondiagnostic. There were no significant differences between the four participating hospitals or the individual sonologists (P>.05).

CONCLUSION

Sensitivity of US with US-guided FNAB was slightly lower compared with previous reports. Specificity was similar to previous reports. Interobserver variability appeared to be low. The validity of US with US-guided FNAB is high and warrants widespread use of the procedure for evaluation of the neck.

Differential regulation of breast tumor cell proliferation by stromal fibroblasts of various breast tissue sources

A stromal fibroblast-mediated paracrine regulation of epithelial tumor cell proliferation and differentiation plays an important role in the development and progression of breast tumors. We have studied the paracrine growth regulation of various phenotypically different breast cancer cell lines using conditioned serum-free media (C-SFM) from primary breast fibroblasts. Fibroblast cultures were established from malignant primary tumors and adjacent normal breast tissue, benign fibroadenomas, cosmetic reduction mammoplasties and breast skin tissues. All fibroblast-conditioned media were shown to stimulate the proliferation of breast cancer cell lines. However, the C-SFM-induced MCF-7 proliferative response was shown to be significantly higher than the proliferative response observed with any of the other cell lines tested. More importantly, the MCF-7 proliferative response obtained with malignant tumor tissue fibroblast C-SFM was shown to be significantly higher than the response to C-SFM from paired (and unpaired) normal adjacent breast tissue fibroblasts. The MCF-7 proliferative response to fibroblast C-SFM from normal tissue (adjacent to the tumor) was further shown to be comparable to the MCF-7 response using benign or reduction mammoplastic tissue fibroblast C-SFM. In addition, we show that IGFs are only partly responsible for the observed proliferative effect of the C-SFMs, while EGF, TGF alpha and basic-FGF are shown not to be involved. We conclude that stromal fibroblasts can differentially regulate breast cancer cell proliferation. Both the fibroblast's tissue source as well as the target tumor cell's phenotype will determine the extent of the proliferative response.

Systemic and anti-neuronal auto-antibodies in patients with paraneoplastic neurological disease

Sera from 23 patients with paraneoplastic disease of the central nervous system (PNS) were examined for the presence of anti-neuronal (anti-Hu, anti-Yo/PCA) and anti-Ri) and systemic auto-antibodies, including antibodies against DNA, centromeres, nRNP, Sm antigen, Scl-70, Ro(SS-A), La(SS-B), mitochondria, thyroid antigens, parietal calls, brush border antigen and rheumatoid factor. As controls, sera from 33 patients with small cell lung cancer, 33 with ovarian cancer and 7 with breast cancer and from 107 aged-matched healthy persons were used. Systemic auto-antibodies were found in 52% of patients with paraneoplastic neurological syndromes compared with only 16% (P = 0.001) in the control group with cancer only and 15% in the group of healthy controls. The relatively high percentage of systemic auto-antibodies in patients with PNS indicates that there is a genetic susceptibility to the development of auto-immune phenomena. This may provide an explanation for the relatively rare occurrence of PNS in patients with cancer.

Expression of estrogen, progesterone and epidermal growth factor receptors in primary and metastatic breast cancer

The prognostic value of epidermal growth factor receptor (EGFR) expression and its biological role in estrogen receptor-positive (ER+) and ER-negative (ER-) primary breast cancer is controversial. In this study, distributions of ER, progesterone receptor and EGFR have been established using immunohistochemistry in both primary breast tumors and their matched axillary lymph node metastases of 26 patients or their matched distant metastases of 2 patients. In addition, 5 patients with bilateral breast cancer were studied. ER+ tumor cells were detected in 22 (69%) and EGFR+ tumor cells were detected in 11 (34%) primary breast carcinomas. Expression of ER and EGFR was inverse regarding the individual tumor cells in both primary tumors and metastases. Relationship of EGFR expression with poorly differentiated and large breast tumors was observed. Furthermore, primary tumors with a predominant lobular component were ER+ and, with one exception, EGFR-. Invasive ductal carcinomas were more frequently EGFR+. No apparent differences in receptor expression were observed between primary tumors and lymph node metastases or chronously or metachronously occurring bilateral breast cancers. Only one ER+ primary tumor showed a switch to EGFR expression in the involved lymph node. Our study shows that a shift in receptor phenotype between primary tumors and lymph node metastases is a rare event and, thus, additional analyses of involved lymph nodes will not likely serve as a better predictor for response to anti-estrogen therapy. We conclude that expression of EGFR is not a prerequisite for development of metastases.

Molecular genetic evidence for unifocal origin of advanced epithelial ovarian cancer and for minor clonal divergence

Detection of loss of heterozygosity (LOH) and DNA flow cytometry (FCM) were used to trace the origin of bilateral ovarian cancer from 16 patients. From each tumour the DNA index (DI) and LOH patterns for chromosomes 1, 3, 6, 11, 17, 18, 22 and X were determined with 36 microsatellite markers. Formalin-fixed, paraffin-embedded as well as frozen specimens were used. Flow cytometric cell sorting was used to enrich tumour cells for polymerase chain reaction (PCR)-driven LOH analysis. Analysis of the LOH data showed that in 12 of the 16 cases concordance was observed for all informative markers, namely retention of heterozygosity (ROH) or loss of identical alleles in both tumour samples. In four cases discordant LOH patterns were observed. In two cases the discordant LOH was found for one of the chromosomes tested while other LOH patterns clearly indicated a unifocal origin. This suggests limited clonal divergence. In the other two cases all LOH patterns were discordant, most likely indicating an independent origin. The number of chromosomes showing LOH ranged from 0 to 6. Comparison of DNA FCM and the LOH data showed that the latter technique has a higher sensitivity for the detection of a unifocal origin. In 14/16 cases evidence was found for a unifocal origin, while in two cases clonal divergence was found at LOH level and in two other cases clonal divergence at DNA ploidy level. In 12 cases the complete observed allelotype had developed before the formation of metastases, including the two cases showing a large DNA ploidy difference.

Expression of the gene encoding growth hormone in the human mammary gland

Progestins cause a syndrome of growth hormone (GH) excess and enhanced mammary tumorigenesis in the dog. This has been regarded as being specific for the dog. Recently we reported that progestin-induced GH excess originates from foci of hyperplastic ductular epithelium of the mammary gland in the dog. In the present report we demonstrate by reverse-transcriptase PCR and immunohistochemistry that a main factor involved in tissue growth, i.e. GH, is also expressed in normal and neoplastic human mammary glands. The gene expressed in the human mammary gland proved to be identical to the gene encoding GH in the pituitary gland. The role of progesterone in the GH expression of the human mammary gland needs, however, to be proven. It is hypothesized that this locally produced hGH may play a pathogenetic role in breast cancer.

Quantification of relative area of pS2 immunohistochemical staining and epithelial percentage in breast carcinomas: the effect of the latter on the interpretation of a cytosolic pS2 assay

In immunochemical assays of specific cell constituents in cytosols from tumors, the relationship between epithelial and stromal fractions is not taken into account. This may influence the outcome of the measurements and result in incorrect categorization as negative or positive. In a setting addressing pS2 (only detectable in epithelial cells) in breast carcinomas, we investigated three possibilities that may overcome this problem using histologic sections of breast carcinomas of 50 patients: (a) visual estimation of area percentage of immunohistochemical staining of the cell constituent of interest performed by three independent individuals, (b) quantification of area percentage of the immunohistochemical results by true color image analysis, and (c) quantification of the epithelial and stromal compartments of the tumors in Heidenhain's-azan-stained tissue sections, using the true color image analysis system, to assess the epithelial percentage in the tumors. This percentage was used as a correction factor for data on pS2 obtained by cytosolic determinations. Visual estimation appeared to be subject to interobserver variation and, subsequently, becomes less applicable in the absence of strict scoring rules. Based on tests for correlation, image analysis system quantification seemed reproducible in both quantification procedures. However, due to the high magnification necessary to visualize the immunohistochemical staining product, the effect of field selection caused systematic differences between repeat measurements (Friedman test). As a result of the contrasting colors of the azan staining, the calculation of the epithelia percentage could be performed at a low magnification. Consequently, here the effect of field selection was not present. Correction of cytosolic values for epithelial percentage resulted in 8% of the cases changing category.(ABSTRACT TRUNCATED AT 250 WORDS)

Transforming growth factor beta secretion from primary breast cancer fibroblasts

Transforming growth factor beta (TGF-beta) is a hormonally regulated growth inhibitor with autocrine and/or paracrine functions in human breast cancer. In vivo, enhanced immunohistochemical staining of extracellular TGF-beta 1 has been detected around stromal fibroblasts in response to the antiestrogen treatment. We have investigated the effects of tamoxifen on the production of TGF-beta by primary human breast fibroblast cultures in serum-free medium. Highly variable levels of mainly latent TGF-beta 1 were detected in conditioned media from both tumor and normal tissue derived fibroblasts. Hydroxy-tamoxifen was shown to increase latent TGF-beta 1 secretion in three of the eight tumor tissue-derived fibroblast cultures. Such effect of hydroxy-tamoxifen was not observed in fibroblast cultures established from normal adjacent breast tissue.

Cardiotoxicity as a dose-limiting factor in a schedule of high dose bolus therapy with interleukin-2 and alpha-interferon. An unexpectedly frequent complication

BACKGROUND

In a group of patients with metastatic melanoma treated with high dose immunotherapy, there was an unexpectedly high incidence of severe cardiac adverse effects.

METHODS

Sixteen patients with metastatic melanoma were treated with high dose interleukin-2 (IL-2) and alpha-interferon (alpha-IFN). Each treatment cycle consisted of IL-2 at a dose of 12 MIU/m2 and alpha-IFN at a dose of 3 MIU/m2, given as intravenous bolus injections every 8 hours on Days 1-5, every 3 weeks for a total of three cycles. Before treatment, careful cardiologic screening was performed, including electrocardiogram (ECG), stress test, cardiac multiple uptake-gated acquisition (MUGA) scan, and echocardiography. During therapy, patients were monitored with daily ECG and creatine phosphokinase measurements. Once cardiac damage was suspected, IL-2 and alpha-IFN were discontinued, and echocardiography, stress test and MUGA-scan were repeated. If indicated, cardiac catheterization with endomyocardial biopsies was performed.

RESULTS

Despite pretreatment cardiac screening, seven patients (44%) exhibited myocardial injury. Acute myocardial infarction occurred in one patient, cardiomyopathy developed in four, asymptomatic ECG changes appeared in one, and 1 patient died of acute cardiac arrest. Echocardiography showed hypokinesis and decreased left ventricular ejection fraction. These abnormalities disappeared within 6 months. Cardiac catheterization in four affected patients revealed normal coronary arteries, but endomyocardial biopsies showed interstitial edema, vacuolation, and degeneration of myocytes. Electron-microscopic examination showed fragmentation of myofibrils, swelling of mitochondria and loss of mitochondrial cristae.

CONCLUSIONS

This intensive treatment schedule of IL-2 and alpha-IFN is prohibited by severe and life-threatening cardiac toxicity.

Quantification of area percentage of immunohistochemical staining by true color image analysis with application of fixed thresholds

Most image analysis systems (IAS) use black-and-white cameras. However, true color IASs are considered to be useful for quantification of immunohistologically stained structures. Using a true color IAS, we evaluated two methods of segmentation for quantification of area percentage of staining: one using fixed, preset thresholds and one using thresholds interactively set per image. Furthermore, the effect of shading correction was evaluated, and measurements in both color and black-and-white mode were compared. The results of segmentation with fixed thresholds did not differ significantly from those of control percentages, established by interactive morphometry using a grid, which served as reference. Interactive segmentation was significantly different from the reference (t test, P = .0001). The effect of shading correction was negligible. Measurements with and without this procedure correlated highly (r = .99, P < .001). Comparison of the results obtained in color and black-and-white mode showed a significant difference in the latter from the reference (t test, P = .005). We conclude that it is possible to quantify, in a reliable way, area percentage of positive staining using a true color IAS with application of a segmentation method with fixed thresholds.

Leucocytoclastic vasculitis as presenting feature of primary Sjögren's syndrome

Described are two patients whose primary Sjögren's syndrome presented as leucocytoclastic vasculitis of the skin. One patient initially admitted complaints of dryness of the eyes and the mouth after direct questioning, and serologic testing revealed the presence of Ro/SS-A and La/SS-B antibodies. In the other patient the presence of antinuclear antibodies and rheumatoid factors in serum were the only suggestions of the presence of primary Sjögren's syndrome. Primary Sjögren's syndrome should be considered in patients presenting with leucocytoclastic vasculitis.

Differential expression of estrogen, progesterone, and epidermal growth factor receptors in normal, benign, and malignant human breast tissues using dual staining immunohistochemistry

Distribution of estrogen (ER), progesterone (PR) receptors, and epidermal growth factor (EGF) receptors was assayed by dual staining immunohistochemistry on 28 selected cytosolic ER-positive breast carcinomas and 22 nonmalignant breast tissues. ER-positive tumor cells were detected in 26 (93%) and EGF receptor positive tumor cells were detected in 7 (25%) carcinomas. In five tumors both ER and EGF receptors were detected but localized in distinct tumor cells. Only in one case of ductal carcinoma in situ co-expression was observed in a subset of tumor cells. In contrast, simultaneous expression of ER/PR and EGF receptors was observed in non-neoplastic ductal remnants in the majority of the carcinomas and the fibroadenomas. In addition, double-positive cells were occasionally detected in luminal epithelial cells of normal breast tissue and mastopathies. This study shows that ER/PR and EGF receptors in breast tumor cells are inversely related at the single cell level. However, demonstration of ER/PR and EGF receptors in individual normal luminal cells shows that expression is not mutually exclusive.

Ki-67 staining in benign, borderline, malignant primary and metastatic ovarian tumors: correlation with steroid receptors, epidermal-growth-factor receptor and cathepsin D

Ki-67 immunoreactivity was studied in relation to immunohistochemically assessed expression of epidermal-growth-factor receptor (EGFR), estrogen receptor (ER) progesterone receptor (PgR) and cytosolic levels of cathepsin D in advanced human ovarian adenocarcinomas, borderline and benign cystadenomas and normal ovaries. A significantly higher number of Ki-67-positive cells were found in metastatic tumors vs. primary adenocarcinomas and in the total group of adenocarcinomas vs. benign/borderline cystadenomas. Cathepsin-D levels were also significantly higher in metastatic tumors than in primary adenocarcinomas, which in turn presented higher levels than were found in normal ovaries. However, no significant difference was observed between cathepsin-D levels in malignant adenocarcinomas and borderline/benign cystadenomas. Immunohistochemically assessed expression of ER and PgR was detected in variable percentages of epithelial tumor cells, and stromal cells were occasionally positive as well. In the group of primary adenocarcinomas, 46% were ER-positive and 34% were PgR-positive, although there was no significant difference between primary and metastatic lesions with respect to ER or PgR expression. Concordance between immunohistochemically assessed ER or PgR data and cytosolic ER and PgR levels measured with enzyme immunoassay was relatively low. EGFR, immunohistochemically assessed with MAb-EGFRI, was positive in 76% of the primary and in 78% of the metastatic adenocarcinomas. A strong positive association was detected between ER and PgR, and EGFR was observed to present a weak positive correlation with Ki-67 and ER. Cathepsin-D levels were not found to be significantly correlated with the expression of ER, PgR, EGFR or Ki-67.

Antineuronal antibodies in patients with neurologic complications of primary Sjögren's syndrome

Neurologic complications of both the central and peripheral nervous systems occur frequently in patients with primary Sjögren's syndrome (primary SS), but the underlying cause of these complications is unknown. We studied the presence of antineuronal antibodies in relation to neurologic complications in a consecutive series of 45 patients with primary SS. Twenty-five patients had neurologic complications: 12 patients with polyneuropathy, three with psychiatric disorders, four with carpal tunnel syndrome, seven with migraine, seven with myalgia, and four with other complications (transverse myelitis, stroke, Bell's palsy, and pyramidal signs). Ten patients had more than one neurologic complication. Eleven patients had major and 14 had minor complications according to criteria used for rating neurologic complications in patients with systemic lupus erythematosus. Antineuronal antibodies were present in six of 11 (55%) patients with major neurologic complications and in four of 34 (11%) of patients without major neurologic complications (p = 0.001). This difference could be attributed mainly to the group of patients with polyneuropathy. Three of the 10 sera of patients with positive antineuronal antibodies had antibodies reacting with a 38-kd neuronal protein on immunoblotting, identical to the anti-Hu antibody reactivity in paraneoplastic neurologic disease associated with small-cell lung cancer.

Phase II study of oral administration of etoposide for patients with well- and moderately-differentiated adenocarcinomas of unknown primary site

BACKGROUND

The prognosis of patients with well- and moderately-differentiated adenocarcinomas of unknown primary is poor, as a consequence of chemotherapy resistance.

PATIENTS AND METHODS

We performed a phase II study with prolonged oral administration of etoposide in 25 chemotherapy-naive patients with well- and moderately-differentiated adenocarcinomas of unknown primary site. The treatment regimen was 50 mg/m2 for 21 days, every four weeks.

RESULTS

Of 24 evaluable patients, two achieved partial responses (8%) lasting 15+ and 17 months, 11 patients had stable disease, and 11 progressed during treatment. The major toxicity was myelosuppression. WHO grades 3 or 4 leukocytopenia was seen in six patients but confined to the first treatment cycle in five of them. Four of these latter five patients already had disease progression after one treatment cycle. A primary tumor site was later identified in four patients, three colon carcinomas and one carcinoma of the pancreas.

CONCLUSION

Etoposide given in this dose and schedule has only limited activity in patients with well- or moderately-differentiated adenocarcinomas of unknown primary site.

Axillary nodal metastases from an occult primary consistent with breast carcinoma

The records of 15 women presenting with axillary nodal metastases from an occult primary consistent with breast carcinoma were reviewed. Nine patients underwent complete axillary clearance and in six the clinical mass only was excised. Radiotherapy to the axilla was given to eight patients. One woman underwent mastectomy at the time of axillary surgery but no tumour was found in the excised breast; in the remaining 14 patients the breast was left untreated. One premenopausal woman received adjuvant systemic chemotherapy and one postmenopausal patient was given tamoxifen. Three patients died from recurrent disease at 16, 50 and 56 months after treatment of the axillary mass; one is alive at 42 months with systemic recurrence. In two of these patients the tumour in the breast became apparent before other metastases. Eleven patients survived for a median of 92 (range 18-144) months without evidence of disease. The prognosis of this patient group is better than that generally reported for stage II breast carcinoma.

[Endometriosis of the rectum]

Intestinal endometriosis is a diagnostic and therapeutic problem. In case the rectal wall is involved the physical signs of the endometriosis may mimic rectal carcinoma. Suspicion of the correct diagnosis can be aroused by a thorough history that will uncover the periodicity of symptoms e.g. cyclic bleeding. We present two patients with rectal endometriosis externa who were eventually treated successfully by surgery. Treatment may consist of hormonal therapy, although surgery will be necessary sooner or later in the majority of patients.

Angiosarcoma of the breast following lumpectomy, axillary lymph node dissection, and radiotherapy for primary breast cancer: three case reports and a review of the literature

INTRODUCTION

One of the risks of therapeutic irradiation is the development of secondary malignant tumors. In this paper three cases are reported of angiosarcoma of the breast following breast-conserving surgery and irradiation for primary breast cancer, and the literature is reviewed.

METHODS AND MATERIALS

Until now, 13 other cases of postirradiation angiosarcoma of the breast have been reported. The mean interval between treatment of primary breast cancer and the development of angiosarcoma in these 16 patients is 76 months. The clinical aspect is typical with multiple bluish or purple nodules of the skin, purple discolorations, erythematous maculas or areas, sometimes combined with ulceration, edema, or a palpable mass. Mammography does not necessarily raise suspicion and the interpretation of fine-needle aspiration or biopsy may be difficult.

RESULTS

In all patients mastectomy was performed, Follow-up data are available for 12 cases. Two patients died of extensive local recurrences and one of distant metastases.

CONCLUSION

Angiosarcoma of the previously irradiated breast is an extremely rare tumor and diagnosis may be difficult. The number of patients with long-term follow-up after breast-conserving therapy is growing fast. Therefore, the authors advise to pay special attention to uncommon skin changes of the treated breast, since clinical suspicion is the main clue to the diagnosis of postirradiation angiosarcoma. The primary therapy is (simple) mastectomy if wide tumor-free margins can be achieved. There is no indication for standard adjuvant chemotherapy or irradiation.