Histopathologic grading of squamous cell carcinoma of the uterine cervix. An evaluation of 70 stage Ib patients

The Expression of Cyclooxygenase-2 in Cervical Intraepithelial Neoplasia and Cervical Cancer

Aim To examine the relationship between tumor differentiation, parametrial, and lymphovascular invasion, as well as the differential expression pattern of cyclooxygenase-2 (COX-2) in cervical intraepithelial neoplasia and various forms of cervical cancer. Methods Histologically diagnosed cases of in-situ and malignant lesions of the cervix were included in the study. Two sections were cut from paraffin blocks. One section was stained with Haematoxylin and Eosin (H&E) for morphologic diagnosis, and the other sections were subjected to COX-2 immunohistochemical staining. Cases of colon carcinoma were taken as positive controls. Cytoplasmic and membrane staining of tumor cells were considered as positive staining, and grading was done. Results Out of the 62 patients, 40 cases (64.5%) showed positive expression of COX-2 in squamous cell carcinoma when compared to in-situ cervical intraepithelial neoplasia and adenocarcinoma. The results were statistically significant, with a p-value of 0.003. Conclusion COX-2 expression is directly proportional to the level of grading of the tumor. The higher the grading, the higher the expression of COX-2. Selective COX-2 inhibitors increase the efficacy of chemotherapy or radiotherapy.

Independent Validation of Tumor Budding Activity and Cell Nest Size as Determinants of Patient Outcome in Squamous Cell Carcinoma of the Uterine Cervix

A novel 3-tiered grading system that combines tumor budding activity and cell nest size has been found to be highly prognostic in squamous cell carcinomas (SCCs) of various sites, including lung, oral cavity, larynx, hypopharynx, and esophagus. A similar grading system has recently been proposed for SCC of the uterine cervix. In this study, we appraise this grading system in an institutional cohort of cervical SCC to assess its prognostic value in an independent dataset. Our study cohort consisted of 94 consecutive, surgically excised, neoadjuvant therapy-naive cases of SCC of the uterine cervix, stage pT1b or higher. Tumor budding activity and cell nest size were scored on each case, the sum of which formed the basis for assigning a grade in the 3-tiered grading system hereafter referred to as the "tumor budding/nest size" (TBNS) system. As individual variables, both high tumor budding and small nest size were each associated with reduced overall survival (OS), disease-specific survival, and disease-free survival. The full TBNS system was associated with decreased OS, disease-specific survival, and disease-free survival independent of patient age, pathologic stage, and regional lymph node status. TBNS grades 1, 2, and 3 subgroups were clearly distinguishable on multivariate analyses (hazard ratio for OS of 2.06 [95% confidence interval: 0.5-8.42] for grade 2 and 4.58 [95% confidence interval: 1.24-16.87] for grade 3 tumors, relative to their grade 1 counterparts [P=0.035]). Higher grade tumors in the TBNS system were significantly correlated with advanced pathologic stage and lymph node metastasis (P=0.044 and 0.04, respectively). Among the other, potentially prognostic factors, higher pathologic stage, and lymph node metastasis were associated with decreased OS (P<0.001 and 0.004, respectively), whereas keratinization, nuclear size, mitotic count, and World Health Organization (WHO) grade were not. In conclusion, the proposed TBNS grading system is an excellent prognostic indicator that may potentially provide information that is useful in clinical decision-making. Our findings validate the previous study that proposed this system for prognostically stratifying cervical SCC patients. If further confirmed, consideration should be given to routinely adding a TBNS grade to pathologic descriptions of cervical SCC.

Introducing a novel highly prognostic grading scheme based on tumour budding and cell nest size for squamous cell carcinoma of the uterine cervix

A novel histopathological grading system based on tumour budding and cell nest size has recently been shown to outperform conventional (WHO‐based) grading algorithms in several tumour entities such as lung, oral, and oesophageal squamous cell carcinoma (SCC) in terms of prognostic patient stratification. Here, we tested the prognostic value of this innovative grading approach in two completely independent cohorts of SCC of the uterine cervix. To improve morphology‐based grading, we investigated tumour budding activity and cell nest size as well as several other histomorphological factors (e.g., keratinization, nuclear size, mitotic activity) in a test cohort (n = 125) and an independent validation cohort (n = 122) of cervical SCC. All parameters were correlated with clinicopathological factors and patient outcome. Small cell nest size and high tumour budding activity were strongly associated with a dismal patient prognosis (p < 0.001 for overall survival [OS], disease‐specific survival, and disease‐free survival; test cohort) in both cohorts of cervical SCC. A novel grading algorithm combining these two parameters proved to be a highly effective, stage‐independent prognosticator in both cohorts (OS: p < 0.001, test cohort; p = 0.001, validation cohort). In the test cohort, multivariate statistical analysis of the novel grade revealed that the hazard ratio (HR) for OS was 2.3 for G2 and 5.1 for G3 tumours compared to G1 neoplasms (p = 0.010). In the validation cohort, HR for OS was 3.0 for G2 and 7.2 for G3 tumours (p = 0.012).

In conclusion, our novel grading algorithm incorporating cell nest size and tumour budding allows strongly prognostic histopathological grading of cervical SCC superior to WHO‐based grading. Therefore, our data can be regarded as a cross‐organ validation of previous results demonstrated for oesophageal, lung, and oral SCC. We suggest this grading algorithm as an additional morphology‐based parameter for the routine diagnostic assessment of this tumour entity.

Evaluation of the invasion front pattern of squamous cell cervical carcinoma by measuring classical and discrete compactness

The invasion front pattern of squamous cell carcinoma (SCC) is a conspicuous histological phenomenon, which is assessed without precise criteria. The current study was performed to introduce the classical (C(C)) and discrete compactness (C(D)) as new morphometric parameters for quantification of this pattern. A retrospective analysis of 76 surgically treated patients with cervical carcinoma was conducted and the pattern of invasion was qualitatively classified as closed, finger-like or diffuse, respectively, by two pathologists. After digitization of the histological slides with a field of view of 10.4 mm x 8.3mm, tumor areas were labeled and C(C) and C(D) were computed based on the drawings (binary images). Additionally, intraindividual variation of compactness was evaluated for 12 selected tumors. The qualitative pattern assessment by the pathologists was moderately reproducible with an interobserver agreement of 72% and a kappa coefficient of 0.44. The values of C(C) and C(D) referring to the invasion front patterns assigned by both pathologists were significantly different between the three classified groups (p< or =0.01 and p< or =0.0001), so that, both theoretically and in practice, compactness regards the same morphological feature. In due consideration of the analysis of the area under the ROC (receiver operating characteristic) curves and the variation coefficient of different tumor regions, C(D) is more suitable for practical use than C(C). Tumors with a microscopic invasion into the parametria and with lymph-vascular space invasion were found to have a lower value of C(D), which indicates a more diffuse pattern of invasion (p=0.028 and p=0.033). We conclude that the discrete compactness C(D) is a new and reproducible parameter for a computer assisted quantification of the invasion front pattern and, thus, defines a further phenotypic feature of SCC of the uterine cervix.

Cyclooxygenase-2 expression in cervical intraepithelial neoplasia III and squamous cell cervical carcinoma, and its correlation with clinicopathologic variables

The objective of the study was to compare cyclooxygenase-2 (COX-2) expression in cervical intraepithelial neoplasia III (CIN III) and squamous cell carcinoma (SCC) of the cervix, and its correlation with clinicopathologic factors of SCC with a review of the available literature. This study included 25 patients with CIN III and 67 patients with stage I-IIa SCC. All patients in the SCC group were treated with radical hysterectomy plus pelvic and para-aortic lymphadenectomy and postoperative chemoradiotherapy based on their histopathologic risk factors. Immunohistochemical analysis was performed on paraffin-embedded sections with COX-2 antibody. COX-2 expression in the SCC group was significantly higher than in the CIN III group (55.2% [37/67] vs 24% [6/25]; P= 0.008). Significantly higher expression of COX-2 was observed in patients with lymphovascular space invasion (LVSI) compared to patients without LVSI (61.9% [34/55] vs 33.3% [3/9]; P= 0.02). Additionally, patients with tumor sizes >4 cm had significantly higher COX-2 expression than patients with tumor sizes <4 cm (65.9% [27/41] vs 39% [10/26] P= 0.028). There was no significant relationship with respect to COX-2 expression and parametrial involvement, lymph node metastasis, recurrences, and survival. In multivariate analysis, LVSI was the only statistically significant determinant for COX-2 expression (P= 0.024; OR = 2.35; 95% CI = 1.1-4.9). Our results and a review of the literature both suggest that COX-2 expression may have a role in the development and progression of CIN III and it is related to some clinicopathologic variables of cervical carcinoma. Further studies are needed to clarify the role of COX-2 inhibitors in the management of CIN and SCC.

Clinicopathological Features Influencing Pelvic Lymph Node Metastasis and Vaginal and Parametrial Involvement in Patients with Carcinoma of the Cervix

PURPOSE

This study was undertaken to evaluate clinical and pathologic findings that predicted pelvic lymph node metastasis and parametrial and vaginal involvement in patients with stage IB carcinoma of the cervix.

METHODS

71 patients with diagnosis of stage IB (FIGO) cervical cancer were prospectively studied from December 1997 to August 2002. The patient's age, clinical stage (IB1 or IB2), histological classification, grade of differentiation, tumor volume, and lymphatic vascular space invasion (LVSI) were evaluated. Statistical methods included chi2 test and Fisher's exact test to evaluate significant differences between the groups. The level of significance was set at p < 0.05.

RESULTS

The clinical stage was IB1 in 51 patients (71.8%) and IB2 in 20 patients (28.2%). The histological classification identified squamous cell carcinoma in 60 patients (84.5%) and adenocarcinoma in 11 patients (15.5%). The average tumoral volume was 22.8 +/- 24.3 cm3 (0.3-140.0 cm3). The tumor was well differentiated (G1) in 8 (11.3%), moderately differentiated (G2) in 40 (56.3%) and poorly differentiated in 23 (32.4%) of the cases. The presence of LVSI was detected in 14 patients (19.7%) and was associated with pelvic lymph node metastasis and vaginal and parametrial involvement (p = 0.002, p = 0.001 and p < 0.001; respectively). The average number of positive pelvic lymph nodes was significantly higher in the patients with LVSI compared with patients without LVSI (2.47 +/- 2.8 vs. 0.33 +/- 0.74; p = 0.001). There was no association of age, clinical stage, histological classification, grade of differentiation or tumor volume with pelvic lymph node metastasis and vaginal and parametrial involvement.

CONCLUSION

The presence of LVSI is significantly associated with pelvic lymph node metastasis and vaginal and parametrial involvement in patients with stage IB cervical carcinoma.

Lymph node metastasis in lower lip squamous cell carcinoma in relation to tumour size, histologic variables and p27Kip1 protein expression

We studied a consecutive series of 95 patients undergoing radical surgical resection of lower lip squamous cell carcinoma (LLSCC) to assess the correlation between lymph node status and several prognostic variables, such as sex and age, tumour size, histologic grading, maximal microscopic tumour thickness, perineural infiltration and p27Kip1 protein status, to see which of these might be predictive of the development of lymph node metastases. Statistical analysis demonstrated a significant association between node status and tumour size, histological grading, maximal thickness, perineural invasion and p27Kip1 protein expression; additionally to node metastasis, low p27Kip1 protein expression was significant correlated with high microscopic thickness. These results indicate that lower lip squamous cell carcinomas of >2 cm, with G3-G4 histological grading, maximal thickness of >6 mm, perineural invasion and low p27Kip1 protein expression (LI<19.7%) are at high risk for the development of lymph node metastases.

[Caring for stage IB cancer of the cervix. Proposal for a protocol based on a review of the literature]

A review of the literarure indicates that there are two essential prognostic factors in stage Ib cancer of the cervix: the size of the tumour (determined by a physical examination and MRI) and invasion of the lymph nodes (determined by lymphadenectomy). Of the available means of treatment, many workers use surgery at stage Ib1 and a combination of chemotherapy and radiotherapy at stage Ib2. Hence, our pre-therapeutic assessment usually includes a physical examination under general anaesthesia, MRI of the abdomen and pelvis, and laparoscopic pelvic lymphadenectomy for stage Ib1 and laparoscopic lumbo-aortic lymphadenectomy for stage Ib2. For stage Ib1 < 2 cm, if extemporaneous examination of the pelvic lymph nodes is positive, we perform lymphadenectomy of the lumbo-aortic lymph nodes and initiate treatment with chemotherapy and radiotherapy. If pelvic lymphadenectomy gives negative results in a woman who does not wish to remain fertile, we carry out radical vaginal hysterectomy (Schauta-Stoeckel) rather than radical hysterectomy (Piver 2) by laparotomy or laparoscopy. If the margins are healthy and devoid of vascular or lymphatic involvement, no further treatment is given. If this is not the case, we suggest a postoperative radio-chemotherapy. For patients who wish to retain their fertility, we carry out radical cervicectomy. For tumours measuring between 2 and 4 cm, and if pelvic lymphadenectomy is positive, we propose radio-chemotherapy, or radical hysterectomy as for small tumours. For Ib2 tumours, and if no lumbar adenopathy is seen at MRI, we perform a lumbo-aortic lymphadenectomy, followed by a radio-chemotherapy. If invasion of lumbar lymph nodes is suspected at MRI, we perform a biopsy on the left scalenic lymph nodes; if invasion is present at this level, we give palliative treatment with simple pelvic radiotherapy. If lumbo-aortic lymphadenectomy reveals invasion, radiotherapy is directed at these nodes. If, at the end of combined chemotherapy and radiotherapy, some remaining tumour is discovered at the MRI assessment, we carry out extrafacial hysterectomy.

MIB-1 labeling index as a prognostic indicator for survival in patients with FIGO stage IB squamous cell carcinoma of the cervix

OBJECTIVE

The goal of this study was to assess whether the MIB-1 labeling index (LI) and conventional parameters could distinguish between a good and a poor prognosis in patients with squamous cell cervical carcinoma of the same FIGO stage.

METHODS

The study included 97 cases of stage IB squamous cell cervical carcinoma which were treated with radical hysterectomy between 1989 and 1991. The relation of the MIB-1 LI, conventional clinicopathologic parameters, and survival was evaluated.

RESULTS

The MIB-1 LI of the entire group of tumors was 57.1 +/- 15.9 (mean +/- SD). The MIB-1 LI was significantly different only in living and dead patients, while it was not related to conventional clinicopathologic prognostic parameters. The 5- and 10-year survival rates of patients with an MIB-1 LI </=55 were 90.0 and 88.6%, respectively, which were significantly better than the survival rates of patients with LI >55, which were 73.1 and 66%, respectively. Multivariate analyses showed that MIB-1 LI >55, lymph node metastasis, and tumor size >/=40 mm were powerful predictors of shorter survival.

CONCLUSIONS

Lymph node metastasis, tumor size, and MIB-1 LI were significant prognostic markers in patients with stage IB squamous cell cervical carcinoma.

Biology of cervical carcinoma

Cervical cancer is generally a locoregional disease. The endopelvic fascia envelops the cervix in anterior-posterior fashion and serves as a natural barrier. Thus, cervical cancer preferentially grows to the parametria and involves the ureters before it infiltrates the bladder or rectum. Disease stage, grade, cell type, tumor volume, depth of stromal invasion, vascular space invasion, and lymph node status are common prognostic indicators. Irregular vaginal bleeding and discharge are the two most frequent complaints. Although cervical cancer is still staged clinically, data continue to accumulate favoring a conversion to surgical staging to improve accuracy and treatment outcome.

Prognostic factors in surgically treated stage IB-IIB carcinoma of the cervix with negative lymph nodes

Comerci G, Bolger BS, Flannelly G, Maini M, de Barros Lopes A, Monaghan JM. Prognostic factors in surgically treated stage IB-IIB carcinoma of the cervix with negative lymph nodes. Int J Gynecol Cancer 1998; 8: 23-26. Two hundred and seventy-five females with stage IB-IIB negative lymph node cervical cancer, treated between January 1988 and December 1994 by radical hysterectomy and pelvic lymph node dissection, form the basis of this analysis. The clinical records were reviewed for all patients including histopathology, clinical features at presentation, and follow-up. Tumors were re-staged according to the 1995 FIGO classification. Median follow-up was 55 months and 85.8% were followed for longer than two years. There were 21 recurrences, 12 of which were true central recurrence (disease-free survival at 5 years: 91.66%). Fifteen of 25 deaths were due to cervical cancer (crude survival at 5 years: 93.27%). In univariate log-rank analysis, stage (P = 0.005), tumor size (P = 0.0002), and lymph-vascular space involvement (LVSI) (P = 0.01) appeared to be statistically significant factors for tumor recurrence. Other factors including age, histology type, differentiation, adjacent cervical intraepithelial neoplasia or cervical glandular intraepithelial neoplasia, and presence of intraepithelial disease at resection margin were not found to be statistically significant. In multivariate analysis (Cox regression) tumor size (P = 0.02) and LVSI (P = 0.03) were the only independent variables. In the presence of negative lymph nodes and complete surgical excision, tumor size and LVSI are important predictors of local recurrence.

Importance of the transitional zone between the cervical stroma and the parametrium in the treatment of cervical carcinoma

OBJECTIVES

Parametrial invasion is an important risk factor in cervical carcinoma. Because the vessels of the parametrium start in the zone between the cervical compact stromal layer and the parametrium, which we have defined as the parametrial initial zone (PIZ) or transitional zone, the invasion of a carcinoma into this part of the cervix is also important. Our objectives in this study were find a characteristic index of the transitional zone and to clarify the relationship between a transitional-zone invasion and the prognosis in a case.

METHODS

Thirty-three cases of carcinoma in situ were available to use for the morphological examination of the cervix. The cervix was divided into 8-12 sections. In each section, the outer diameters of the short axis of the arteries were measured with a light microscope and a micrometer. Using the arterial diameter as the characteristic index of the transitional zone, we performed epidemiological studies on 312 patients with clinical Stage Ib-III squamous-cell carcinoma of uterine cervix.

RESULTS

The arteries with an axis exceeding 300 microns were concentrated in the transitional zone at a rate of 94.6%. Therefore, arteries of this size are used as the characteristic index of the transitional zone. Patients with invasion to transitional zone only had lymph node metastasis at the rate of 28.1%, compared with 0% for patients who had no permeation to the zone (p < 0.001). The 5-year survival rate of patients with invasion to the transitional zone only was 87.3%, which is significantly lower than those without invasion (99.2%) (p < 0.01).

CONCLUSIONS

Measuring the short axis (300 microns < or = ) of the artery is the best method by which to pinpoint the transitional zone. The invasion of a carcinoma into the transitional zone in the cervix should be treated as a parametrial involvement.

Carcinoma of the cervix uteri: an assessment of the relationship of tumour proliferation to prognosis

The aim of this study was to ascertain whether assessing the growth fraction of cervical carcinoma of 28 patients, using antibody Ki-67, would be of value in clinical practice. The results showed no relationship between growth fraction and age, clinical stage, lymph node involvement or short term (3-5 years) survival.

Histopathologic predictors of the behavior of surgically treated stage IB squamous cell carcinoma of the cervix. A Gynecologic Oncology Group study

Disagreement persists about the superiority of Reagan and Ng's method over that of Broders' for the histologic grading of squamous carcinoma of the cervix. Uncertainty about the predictive value and reproducibility of any of the grading methods prompted a comparison of factors previously suggested as indicating the biologic behavior for cervical squamous carcinoma. One hundred ninety-five women, who were enrolled in a Gynecologic Oncology Group treatment protocol of Stage IB squamous carcinoma of the cervix and underwent radical hysterectomy with pelvic and paraaortic node sampling, formed the study population. The tumors were graded first by participating institutional pathologists, with submitted slides subjected to an independent review by two pathologists (R.J.Z. and S.W.). The histologic parameters examined included the presence and amount of keratinization, nuclear pleomorphism, mitotic rate, gestalt grading, pattern of invasion at the stromal interface, and inflammatory cell infiltrate. The depth of invasion and presence or absence of vascular invasion also were assessed. The probability of pelvic lymph node metastasis and the progression-free interval were determined for each parameter. Surprisingly, none of the grading methods was effective in predicting nodal spread or progression-free interval. However, an increasing depth of invasion strongly correlated with nodal spread and a diminished progression-free interval (P less than 0.0001). Vascular invasion was less effective in these predictions (0.05 less than P less than 0.10). Both measurements were reasonable reproducible. It was concluded that histologic grading of surgically treated cervical carcinoma is not useful but that the depth of invasion and vascular invasion are important predictors of behavior that should be reported routinely.

DNA level and stereologic estimates of nuclear volume in squamous cell carcinomas of the uterine cervix. A comparative study with analysis of prognostic impact

Grading of malignancy in squamous cell carcinomas of the uterine cervix is based on qualitative, morphologic examination and suffers from poor reproducibility. Using modern stereology, unbiased estimates of the three-dimensional, volume-weighted mean nuclear volume (nuclear vv), were obtained in pretreatment biopsies from 51 patients treated for cervical cancer in clinical Stages I through III (mean age of 56 years, follow-up period greater than 5 years). In addition, conventional, two-dimensional morphometric estimates of nuclear and mitotic features were obtained. DNA indices (DI) were estimated by flow cytometry. Finally, the semiquantitative malignancy grade score value (MGS) was determined according to previously published methods. Estimates of nuclear vv were on average increased in euploid lesions (2P = 0.01), but the overall relationship between nuclear vv and DI was poor. Different clinical stages of disease did not differ with regard to nuclear vv (2P = 0.99) and DI (2P = 0.56). No relationship was disclosed between MGS and nuclear vv (2P = 0.85). Single-factor analysis showed prognostic impact of clinical stage of disease (2P = 0.0001) and DI (2P = 0.04), whereas estimates of nuclear vv were only of marginal prognostic significance (2P = 0.07). However, Cox multivariate regression analysis showed independent prognostic value of patient age and nuclear vv along with clinical stage and DI. All other investigated variables were rejected from the model. A prognostic index with highly distinguishing capacity between prognostically poor and favorable cases was constructed (2P = 1.9 x 10(-7)). It is concluded that realistic estimates of nuclear volume are independent of nuclear DNA content and are of prognostic value for objective malignancy grading in patients with squamous cell carcinoma of the uterine cervix.

Age as a prognostic factor in patients with squamous cell carcinoma of the uterine cervix

Correlations between age and several prognostic factors, such as histologic cell type, depth of invasion, intravascular invasion, and lymph node metastases (LNM), were analyzed in squamous cell carcinoma of the cervix (SCC). A total of 380 patients with Stage IB or more advanced SCC underwent radical hysterectomy at the authors' institution from 1971 to 1987. The cases were divided into four age groups: 30 to 39 years, 40 to 49 years, 50 to 59 years, and 60 to 69 years. The depth of invasion was classified in four categories according to pathologic examination of surgical specimens. The only significant factor was the frequency of LNM with deeper invasion, which was less in the 60-to-69-year age group than in the younger age groups. The 5-year survival rates of the patients with LNM also were higher in the 60-to-69-year group. Thus, age 60 or older can be considered a prognostic factor correlating to LNM in squamous cell carcinoma of the cervix.

Histological grading and DNA content as predictors of distant metastases in squamous cell carcinoma of the uterine cervix

Squamous cell carcinoma of the uterine cervix with distant metastases can be treated by adjuvant chemotherapy. The at-risk patients are those with histologically proven metastases, the presence of tumour in paracervical tissue and parametrium, evidence of vascular invasion, a great depth of invasion, or poor tumour differentiation. Our studies lead us to believe that differentiation and DNA content are also important criteria.

The correlation of specific variables of tumor differentiation with response rate and survival in patients with advanced head and neck cancer treated with induction chemotherapy

The authors have reported previously that conventionally defined grades of tumor morphology do not correlate with tumor response or survival in advanced squamous cell cancers of the head and neck (SCCHN) treated with cisplatinum combination induction therapy. This lack of correlation may be the result of the imprecision and subjectiveness of the conventional grade determination. To examine this possibility, response and survival were correlated with individual parameters of morphologic differentiation in 136 patients with advanced, untreated SCCHN. A multi-variable analysis of degree of keratinization, number of mitotic figures per high powered field, degree of nuclear differentiation, presence of vascular invasion, intensity of inflammatory response, and invasion pattern of the cancer was performed. The grade of each variable was weighted by assigning a score from 1 to 4, with 1 representing the most differentiated and 4 the least. The cumulative score of each specimen was tallied and assigned to one of three groups, less than 12, 12 to 18, and greater than 18, analogous to the conventional grades of well, moderately, and poorly differentiated, respectively. No correlation between the grade of individual morphologic variables and response to chemotherapy was demonstrated, or between tumor response and cumulative score groups. There was no correlation of the grade of individual morphologic variables or cumulative score groups with survival. Only the survival of patients achieving a complete response to chemotherapy was correlated with the cumulative score groups: 2-year survivals of 84%, 70%, and 46% for less than 12, 12 to 18, and greater than 18, respectively. Multi-parameter analysis of individual features of tumor differentiation is not superior to conventional morphologic analysis in predicting response to chemotherapy or survival in patients with advanced SCCHN.

DNA viruses and human cancer

This review examines some of the evidence which aetiologically implicates various DNA viruses (primarily papillomavirus, hepatitis B virus and Epstein-Barr virus) in certain human cancers (cervical carcinoma, primary liver cell carcinoma, Burkitt's lymphoma and nasopharyngeal carcinoma, respectively). The evidence includes: presence of viral DNA, RNA and proteins in tumours (and cell lines derived from them); occurrence of viruses with apparently different oncogenic potential; their ability to transform cell lines in vitro or cause tumours in animals; epidemiological and serological data. Factors which affect the progression to cancer are briefly considered as they illustrate that there are several stages in tumorigenesis. These factors include the immune system, irradiation, presence of other viruses or carcinogens and treatment. The lack of a single unique characteristic which defines a transformed cell would be expected from the multistep hypothesis and is related to the possible virus-cell interactions that can occur. These form a continuous spectrum ranging from productive infection of a permissive cell, through infection of a non-permissive cell, to the inability of a virus to infect a cell. This spectrum may reflect the absence of increasing numbers of cellular functions necessary for productive virus infection, with cell transformation occurring as a rare type of abortive infection. The evidence, especially for human papillomavirus, indicates that it is quite probable that particular DNA viruses are the causative agents for certain human cancers. Even so other factors can play decisive roles in tumorigenesis. Final aetiological proof will only be obtained when an anti-virus vaccine eradicates one form of human cancer.

Carcinoma of the cervix uteri: an assessment of tumour proliferation using the monoclonal antibody Ki67

Thirty-one cervical biopsies of invasive carcinoma have been studied by immunohistochemical means using the monoclonal antibody Ki67 to determine tumour cell proliferation rates. A wide range (10-50%) in the extent of Ki67 staining (expressed as the percentage of labelled tumour cells) was observed indicating considerable variation on tumour growth rates. There was no significant relationship between the percentage of positive cells and conventional histological parameters such as cell type or tumour differentiation. Immunostaining with monoclonal antibody Ki67 therefore provides a new approach to the assessment of cervical tumour biopsies which will require long term clinical follow-up to establish its prognostic significance.

Thickness of uninvolved fibromuscular stroma and extrauterine spread of carcinoma of the uterine cervix

The minimum thickness of cervical fibromuscular stroma remaining uninvolved with invasive cervical carcinoma was examined in relation to pelvic node metastases and 5-year cancer death rate, using specimens from Stage IB, IIA, and IIB patients who underwent radical hysterectomy and pelvic lymphadenectomy. The nodal metastasis and 5-year cancer death rates were 7% and 8%, respectively, in patients with the uninvolved fibromuscular stroma thickness above 3 mm, and 37% and 26%, respectively, in patients with the thickness below 3 mm. The thickness of cancer-unaffected cervical fibromuscular stroma seemed to be closely related to and to be a more useful parameter of the biological behavior of invasive cervical carcinoma than the depth of the cancer invasion. A threshold value of the minimum thickness of the tissue as a barrier against extrauterine spread of cervical cancer could not be identified in this study.

Cervical carcinoma DNA content, S-fraction, and malignancy grading. II. Comparison with clinical staging

In an attempt to achieve more biologically meaningful subclassification of squamous cell cervical cancers and ultimately more reliable prediction of tumor behavior, we have studied the tumor pretreatment DNA content (i.e., DNA index), cell-cycle S-fraction, and histomorphologic malignancy grading properties for tumors having similar and different clinical staging. The tumor DNA index, %S-phase cells, and average malignancy grades were statistically tested against known clinical predictive variables for 90 primary squamous cell carcinomas of the uterine cervix studied prior to radiotherapy. We observed that the biological and morphological tumor properties of cervical cancers broadly overlapped between different stages of disease and for other clinical criteria including the gross morphology, lymph node status, and intravenous positivity. No significant differences were detected in the DNA indices, %S, or malignancy grades between the stages of disease or the other clinical criteria. It was concluded that: the gross clinical staging criteria inadequately reflected the tumor biological properties; and that the possibility exists for refining prognosis by use of the biological and morphological noncodependent tumor parameters to supplement staging criteria; and the use of cell-cycle cytokinetic and malignancy grading criteria in addition to tumor DNA index is superior to DNA index (or DNA content) alone for identifying biologically different cervical cancers.

Cervical carcinoma DNA content, S-fraction, and malignancy grading. I. Interrelationships

The flow cytometric measured DNA content (i.e., DNA index), S-fractions, and histopathologic malignancy grades were studied for ninety uterine cervical squamous cell carcinomas using tissue biopsies taken prior to radiotherapy. The DNA aneuploidy frequency for low S-phase tumors (%S less than 14) was only 9/29 (31%) compared to 22/30 (73%) for intermediate (%S 15-23) and 30/31 (97%) for high (%S greater than 24) tumors. An overall mean %S of 20 +/- 7 (range 2-45%) was observed for these cervical cancers, with the S-fraction significantly increasing (P = less than 0.01) from 12 +/- 5, to 18 +/- 8, and 26 +/- 7 for diploid/near diploid, low-degree DNA aneuploidy, and high-degree DNA aneuploidy tumors, respectively. Broad heterogeneity was observed for the microscopic scored malignancy grades within DNA index and the cell-cycle S-fraction subgroups. Generally, multifactorial histopathology scoring was not significantly correlated with either the tumor DNA index or %S variables. Based on statistical analysis, the malignancy grades more closely reflected the tumor proliferative activity than the DNA index, with nuclear polymorphism, mitotic frequency, and the invasion pattern showing the lowest P values (which were not significant at P = 0.05). High tumor S-fraction was associated with high malignancy grade, as evidenced by 19/25 (75%) of high S-fraction, high degree DNA aneuploidy tumors having greater than average malignancy grade compared to only 2/14 (14%) low to moderate S-fraction tumors having similar DNA index. The results indicate that more reliable identification of biologically different cervical cancers can be achieved by evaluating the tumor DNA index in relationship to the cell-cycle %S and malignancy grading.

The quiet revolution. Techniques of cell biology applied to tissue diagnosis

In the past decade many of the techniques of cell biology developed in the research laboratory have been applied to tissue diagnosis. Increasing use of electron microscopy has allowed ready differentiation of many neoplasms with an identical appearance under the light microscope. The identification of highly specific antigenic substances in individual cells using monoclonal antibodies in the immunoperoxidase technique has allowed a degree of diagnostic accuracy not previously available in tissue diagnosis. Recent efforts have been directed at more accurately predicting biological behavior on the basis of cellular characteristics. Techniques being introduced include morphometry (computer-assisted image analysis), cytophotometry (measurement of cellular DNA content), flow cytometry (analysis of cells in suspension for DNA content and other physical and chemical properties), scanning electron microscopy, and cytogenetics (the study of cellular chromosomes).

Morphometric grading of squamous cell carcinoma

Histological grading of squamous cell carcinoma is subjective and suffers from poor observer reproducibility. We investigated the feasibility of quantifying histological differentiation via point counting, using both the degree of keratinization and a novel definition of differentiation that was based on architectural features of the tumour. Multiple recounts of 20 cases of human oral squamous cell carcinoma were performed at several magnifications (X100, X160 and X250). Six lines of human squamous cell carcinoma tumour lines were examined for changes in differentiation following transplantation to athymic nude mice. Observer reproducibility was extremely high for all recounts except at the highest magnification, where the tumour architecture may have been obscured. Of the human squamous cell carcinomas transplanted to nude mice, five of six tumour lines showed significant histological changes, most commonly toward decreased differentiation. The changes were usually present in the initial transplant and were similar to those we have reported for transplants of adenocarcinomas. We conclude that histological differentiation can be quantified in squamous cell carcinomas with a high degree of observer reproducibility, even in the absence of keratinization; the method employed is sufficiently sensitive to be applied to practical problems of biological significance.

Prognostic factors in squamous cell carcinoma of the lower lip

One hundred eighty-seven squamous cell carcinomas of the lower lip were examined microscopically to identify parameters that might predict metastasis and patient outcome. Excision specimens of 157 nonmetastasizing carcinomas (group I) were compared with specimens from 30 tumors that had metastasized (group II). The following features were recorded: architectural pattern; microscopic thickness (mm); cytologic grade; presence of muscle, nerve, or vessel invasion; inflammatory response; and mitotic rate. The mean thickness was 2.5 mm for group I tumors and 7.5 mm for group II tumors. Seventy-six per cent of the group I tumors were 3 mm thick or less, whereas only one group II lesion (3 per cent) was less than 3 mm thick. Five per cent of the group I neoplasms, compared with 77 per cent of the group II tumors, were at least 6 mm thick. Perineural invasion was seen in 5 per cent of the group I and 41 per cent of the group II lesions. Three per cent of the group I carcinomas had a dispersed pattern, compared with 57 per cent of those in group II. One group I lesion (0.6 per cent) and 37 per cent of the group II tumors were grade 4. Each of these differences was statistically significant (P less than 0.0001). For all lesions studied, metastases had occurred in 60 per cent with perineural invasion, 74 per cent measuring 6 mm or more, 77 per cent with a dispersed pattern, and 92 per cent that were grade 4. These important prognostic variables were best evaluated in the deeper portions of the lesions.