Clinical significance of abnormal nuclear DNA content in serous ovarian tumors

Gross genomic alterations differ between serous borderline tumors and serous adenocarcinomas--an image cytometric DNA ploidy analysis of 307 cases with histogenetic implications

Our objective was to study the gross genomic alterations in serous borderline tumors and serous adenocarcinomas of the ovary. A retrospective analysis of 245 serous borderline tumors and 62 serous adenocarcinomas from 249 patients was performed using high-resolution image cytometric DNA ploidy analysis. DNA ploidy status, S-phase fraction, and DNA index were evaluated. The majority of serous borderline tumors were diploid (225/245 cases, 92%). The remaining 8% showed an aneuploid peak predominantly with DNA index of less than 1.4. Grades 2 and 3 serous adenocarcinomas were more often (80%) nondiploid, mostly with DNA index exceeding 1.4. Grade 1 serous adenocarcinomas were an intermediate group, more similar to serous borderline tumors. The S-phase fraction increased from serous borderline tumors (mean = 0.6%) through grade 1 serous adenocarcinomas (mean = 2.8%), being highest in grades 2 and 3 adenocarcinomas (mean = 6.8%). Our findings support the hypothesis that serous borderline tumors and grades 2 and 3 serous adenocarcinomas are genomically different lesions, with grade 1 serous adenocarcinomas being an intermediate group more close to borderline tumors.

Deoxyribonucleic acid content as an indicator of progression of squamous cell carcinogenesis in the esophagus: Comparative analysis on imprint-cytospin and tissue section preparation

BACKGROUND

The purpose of this study was to explore the potential use of image analysis on tissue sections preparation as a predictive marker of early malignant changes during squamous cell (SC) carcinogenesis in the esophagus. Results of DNA ploidy quantification on formalin-fixed, paraffin-embedded tissue using two different techniques were compared: imprint-cytospin and 6 microm thick tissue sections preparation.

METHODS

This retrospective study included 26 surgical specimens of squamous cell carcinoma (SCC) from patients who underwent surgery alone at the Department of Surgery in CHUV Hospital in Lausanne between January 1993 and December 2000. We analyzed 53 samples of healthy tissue, 43 tumors and 7 lymph node metastases.

RESULTS

Diploid DNA histogram patterns were observed in all histologically healthy tissues, either distant or proximal to the lesion. Aneuploidy was observed in 34 (79%) of 43 carcinomas, namely 24 (75%) of 32 early squamous cell carcinomas and 10 (91%) of 11 advanced carcinomas. DNA content was similar in the different tumor stages, whether patients presented with single or multiple synchronous tumors. All lymph node metastases had similar DNA content as their primary tumor.

CONCLUSIONS

Early malignant changes in the esophagus are associated with alteration in DNA content, and aneuploidy tends to correlate with progression of invasive SCC. A very good correlation between imprint-cytospin and tissue section analysis was observed. Although each method used here showed advantages and disadvantages; tissue sections preparation provided useful information on aberrant cell-cycle regulation and helped select the optimal treatment for the individual patient along with consideration of other clinical parameters.

Serous and mucinous borderline (low malignant potential) tumors of the ovary

The prognosis for stage I serous borderline ovarian tumors (SBOTs) is thought to be excellent, despite rare, late recurrences. The behavior of advanced-stage SBOTs primarily depends on the invasiveness vs noninvasiveness of associated extraovarian implants. Pelvic and abdominal lymph node involvement and foci of microinvasion do not seem to adversely affect prognosis. Serous tumors with a micropapillary and/or cribriform growth pattern seem to be more frequently bilateral and exophytic and manifest at an advanced stage with a higher incidence of invasive implants than typical SBOTs. Molecular data suggest that such tumors may represent an intermediate stage in the typical SBOT-invasive low-grade serous carcinoma progression. Limited experience with endocervical (müllerian)-type mucinous borderline tumors shows a possible relation to SBOTs in clinicopathologic features and biologic behavior Intestinal-type mucinous borderline ovarian tumors (I-MBOTs) and well-differentiated mucinous carcinomas manifest at stage I in most cases; the prognosis is excellent. Mucinous tumors associated with pseudomyxoma peritonei are almost always secondary to similar tumors of the appendix or other gastrointestinal sites and should not be diagnosed as high-stage I-MBOTs. Rare primary ovarian mucinous tumors associated with pseudomyxoma peritonei are those arising in mature cystic teratomas. Advanced-stage ovarian mucinous carcinomas typically show frank, infiltrative-type invasion; the prognosis is poor.

Clinical management potential tumours of low malignancy

Approximately 3000 American women are diagnosed with borderline ovarian tumours annually. Common signs and symptoms include abdominal/pelvic pain and a palpable adnexal mass. Pelvic sonography may be helpful, although not specific, in the diagnosis. Serum CA 125 is abnormal in only about 50% of patients. Primary surgery is the principal treatment; it consists of resection of the primary tumour(s) (frequently in the form of fertility-sparing surgery), frozen-section analysis and consideration of comprehensive surgical staging. The role of surgical staging remains unclear; further research is necessary. For patients with stage I disease, surgery alone is the standard. For patients with stage II-IV disease (with non-invasive or invasive peritoneal implants), the role of post-operative therapy remains unclear. Approximately 20-30% of the latter will relapse, frequently after several years. Most so-called recurrences are low-grade carcinomas. Potential predictive or prognostic factors include age, FIGO stage, residual disease and the micropapillary pattern. After fertility-sparing surgery, most patients retain normal reproductive function.

Cell Proliferation in Ovarian Carcinoma: Superior Accuracy of S-Phase Fraction (SPF) by DNA Labeling Index versus Flow Cytometric SPF, Lack of Independent Prognostic Power for SPF and DNA Ploidy, and Limited Effect of SPF on Tumor Growth Rate

OBJECTIVES

The goal of this work was to test the hypotheses that S-phase fraction (SPF) by DNA labeling index (SPF-LI) would predict the course of the disease for ovarian/peritoneal carcinomas and that SPF-LI would correlate better with pathologic classification and outcome than SPF by DNA flow cytometry (SPF-F).

METHODS

Tritiated thymidine (1985-1988) and bromodeoxyuridine (1988-1999) DNA labeling (SPF-LI) was evaluated in vitro on 178 tumors. Cellular DNA and SPF-F were measured flow cytometrically. During this time, 90% of ovarian/peritoneal tumors accessioned in surgical pathology were studied.

RESULTS

Tumors of low malignant potential (LMP, "borderline") had low SPF-LI (median = 1.2%). High-grade invasive carcinomas of various types and carcinosarcomas all had high SPF-LI (medians = 11.2-23.4%). Serous low-grade invasive carcinomas (median = 1.05) resembled LMP tumors. SPF-LI of ovarian carcinomas other than LMP tumors increased slightly as FIGO stage increased (P = 0.07). Survival of patients with high-grade ovarian carcinomas was not predicted by SPF-LI or SPF-F, nor was DNA ploidy predictive. SPF-LI produced tighter distributions for various tumor types than did SPF-F. Neither SPF nor DNA ploidy contributed to prediction of outcome when tumor type and stage were included in multivariate models. We calculated the mean cell loss rate of high-grade carcinomas to be 94%.

CONCLUSIONS

LMP ovarian/peritoneal tumors have low proliferation rates in contrast to high-grade carcinomas. Proliferation correlated with tumor type and stage, but neither it nor DNA ploidy predicted survival independently. Proliferation rate is growth limiting only when low. At higher levels cell loss limits growth. SPF-LI measures proliferation more accurately than SPF-F; SPF-F is not sufficiently reliable for clinical use.

Ovarian serous borderline tumors: a critical review of the literature with emphasis on prognostic indicators

BACKGROUND

The behavior of ovarian serous borderline tumors (SBTs) and significance of various prognostic factors are unclear and difficult to evaluate because of inconsistencies and confusion in the literature. Recent studies have suggested that the morphological features of the primary tumor (presence or absence of micropapillary features) and the peritoneal "implants" (presence or absence of invasive features) can reliably subclassify SBTs into benign and malignant types. The aim of the current review was to test two hypotheses. First, that the alleged malignant behavior of SBTs is poorly documented, and second, that the morphological features of the primary ovarian tumors and the associated peritoneal implants are sufficient to separate SBTs into benign and malignant types, thereby obviating the need for the category.

METHODS

245 studies reporting approximately 18,000 patients with borderline ovarian tumors were reviewed. After excluding series that lacked clinical follow-up or were not analyzable for other reasons, there remained 97 reports that included 4,129 patients. In addition to recurrences and survival, we evaluated the type of peritoneal implants, microinvasion, lymph node involvement, late recurrences, and progression to carcinoma, as these features have served as the underpinning of the concept of "borderline malignancy" or "low malignant potential."

RESULTS

Among 4,129 patients with SBTs reviewed, the recurrence rate after a mean follow-up of 6.7 years was 0.27% per year for stage I tumors, the disease-free survival was 98.2%, and the overall disease-specific survival rate was 99.5%. For patients with advanced-stage tumors, the recurrence rate was 2.4% per year. However, the majority (69%) of reported recurrences were not pathologically documented, and only 26 cases (8.4% of all recurrences) were documented to have recurred from an adequately sampled ovarian tumor. The most reliable prognostic indicator for advanced stage tumors was the type of peritoneal implant. After 7.4 years of follow-up, the survival of patients with noninvasive peritoneal inplants was 95.3%, as compared with 66% for invasive implants (P < .0001). Microinvasion in the primary ovarian tumor was associated with a 100% survival rate at 6.7 years, and lymph node involvement was associated with a 98% survival rate at 6.5 years. The few reported cases of stage IV disease, progression to invasive carcinoma, and very late (>20 years) recurrences were poorly documented. The survival for all stages among approximately 373 patients in 6 prospective randomized trials followed for a mean of 6.7 years was 100%.

CONCLUSION

Surgical pathological stage and subclassification of extraovarian disease into invasive and noninvasive implants are the most important prognostic indicators for SBTs. Survival for stage I tumors is virtually 100%. Survival for advanced stage tumors with noninvasive implants is 95.3%, whereas survival for tumors with invasive implants is 66%. Invasive implants behave as carcinomas and are most likely metastatic. The precise nature of so-called noninvasive implants is not clear, but they behave in a benign fashion. The presence of a micropapillary architecture in the primary ovarian tumor is a strong predictor of invasive implants. These data support the recommendation that ovarian tumors with a micropapillary architecture be designated "micropapillary serous carcinomas," and those lacking these features, "atypical proliferative serous tumors."

Retrospective evaluation of DNA ploidy of hepatocarcinoma on cytologic samples

DNA ploidy was evaluated by image cytometry in a series of 84 hepatocellular carcinomas diagnosed by fine-needle aspiration biopsy. In the series were included eight cases originally diagnosed as suspect and reclassified as well-differentiated hepatocarcinoma. The study was retrospectively performed on Papanicolaou-destained, Feulgen-restained smears. The 5c exceeding rate and the visual interpretation of the corresponding histograms were evaluated and compared with size of the tumors, serum alpha-fetoprotein values, hepatic functional staging, and patient survival. Sixty-eight cases were aneuploid and 16 euploid (9 diploid and 7 polyploid). Four of the eight cytologically suspect cases were aneuploid. Statistical analysis showed an association between size and cytologic grading, 5c exceeding rate and cytologic grading, and between aneuploidy and multiple tumors; in a Cox multivariate DNA content analysis, aneuploidy and multiple tumors were the two prognostically significant variables. DNA ploidy evaluation by static cytometry of hepatic tumors may be useful in the diagnosis on cytologic samples and could represent an independent prognostic parameter in predicting the survival outcome of patients with hepatocellular carcinoma.

Ki 67 expression in 35 borderline ovarian tumours: relations with clinicopathologic parameters and ploidy

OBJECTIVE

To test the diagnostic and prognostic interest of Ki 67 expression and DNA ploidy in ovarian tumours.

METHODS

The reactivity of tumour cells with the monoclonal antibody MIB 1 against Ki 67, was assessed by an indirect immunoperoxidase staining technique applied to 25 benign, 35 borderline and 20 malignant tumours of the ovary. In each cases, ploidy was analyzed by DNA flow cytometry.

RESULTS

Ki 67 immunopositivity was detected in three benign tumours (12%), 14 borderline tumours (40%) and 14 ovarian carcinomas (70%). The mean and standard deviation of Ki 67 positive cells in benign, borderline and malignant tumours were: 1% +/- 8, 5% +/- 9.6 and 44.5% +/- 31 respectively. A difference in Ki 67 immunostaining was found between carcinomas and benign tumours (P < 0.0001), and between borderline and carcinomas (P = 0.001) but not between benign and borderline tumours. Evaluable DNA histograms from flow cytometry were generated in 77 cases (96.2%) of ovarian tumours. All 25 benign, 97.1% of 35 borderline and 44.5% of 20 malignant ovarian tumours were diploid. A difference was found between borderline and carcinomas (P = 0.001), but not between borderline and benign tumours.

CONCLUSION

Ki 67 labelling was correlated with neither histologic and prognostic parameters, nor with survival, nor with DNA ploidy in borderline ovarian tumours.

Immunohistochemically detected p53 and HER-2/neu expression and nuclear DNA content in familial epithelial ovarian carcinomas

BACKGROUND

Some epithelial ovarian carcinomas tend to occur more frequently in certain families. This clustering may be due to a genetic predisposition, but the role of inherited susceptibility in all families with multiple cases of ovarian carcinoma is currently unresolved. Studies characterizing familial ovarian carcinomas are few.

METHODS

From a population-based study of 559 patients with epithelial ovarian carcinoma, 27 families with 2 or more ovarian carcinoma cases occurring in first-degree relatives were identified. Histopathology, ploidy, and immunohistochemically detected p53 and HER-2/neu expression in these tumors were examined.

RESULTS

The mean age of the patients with familial ovarian carcinoma was 56.7 years. Approximately 67% of the tumors were either serous or undifferentiated adenocarcinomas. The percentage of aneuploid tumors was 46%, that of p53 positive tumors was 51%, and that of HER-2/neu positive tumors was 69%. When the families were divided into families with cases of breast carcinoma in addition to ovarian carcinoma cases and/or ovarian carcinoma in 2 consecutive generations (12 families) and families with ovarian carcinoma occurring in sisters only without cases of breast carcinoma (15 families), no differences were noted in the frequency of any of the studied variables.

CONCLUSIONS

Familial ovarian carcinomas do not appear to differ from sporadic ovarian carcinomas with regard to patient age at presentation, histopathology, ploidy, and immunohistochemically detected p53 expression. Immunohistochemically detected HER-2/neu expression was found to occur more frequently in familial ovarian carcinomas than has been reported in sporadic ovarian carcinomas.

Malignant tumors arising in endometriosis: clinical-pathological study and flow cytometry analysis

BACKGROUND

Malignant transformation to endometriosis is a well documented phenomenon that occurs most commonly in the ovaries with cancer arising in extra-ovarian endometriosis being a rare event.

METHODS

A retrospective clinical-pathological evaluation of eleven cases with malignant tumors arising in endometriosis was performed to evaluate the prognostic impact of various factors. Nuclear DNA content (ploidy) was assessed through flow cytometric study.

RESULTS

Ovarian origin was identified in eight cases and three were associated with extra-ovarian endometriosis. Histologic type was endometrioid carcinoma in ten patients. The eleventh case had high grade endometrial stromal sarcoma. All tumors were diploid with no relation to stage, grade, or clinical outcome. The S-phase fraction (SPF) was analyzed in nine patients and no correlation could be demonstrated with any histologic parameters or clinical outcome.

CONCLUSIONS

The DNA content seems to have no association with the classical prognostic parameters in these cases.

Flow-cytometric analysis of deoxyribonucleic acid content in advanced ovarian carcinoma: its importance in long-term survival

OBJECTIVE

Our purpose was to evaluate the importance of deoxyribonucleic acid content to long-term survival from advanced epithelial ovarian carcinoma.

STUDY DESIGN

Clinical and pathologic prognostic factors, including deoxyribonucleic acid content measured by means of flow cytometry, were analyzed for 282 patients.

RESULTS

In 80% of the patients, the deoxyribonucleic acid patterns were nondiploid. In univariate analysis stage (p < 0.0001), residual disease (p < 0.0001), deoxyribonucleic acid index (p = 0.01), and deoxyribonucleic acid ploidy (p = 0.02) significantly predicted progression-free survival. In multivariate analysis stage (p < 0.001), residual tumor (p = 0.001), deoxyribonucleic acid ploidy (p = 0.02), and deoxyribonucleic acid index (p = 0.02) retained independent prognostic value. Residual disease and deoxyribonucleic acid content retained independent prognostic value for stage III tumors but not for stage IV tumors.

CONCLUSION

Deoxyribonucleic acid analysis with flow cytometry provides prognostic information about long-term progression-free survival from advanced ovarian carcinoma and should be considered in the stratification processes of patients in future clinical trials. This prognostic information appears to be inversely related to tumor burden.

Ovarian tumors of low malignant potential. Correlation of DNA index and S-phase fraction with histopathologic grade and clinical outcome

BACKGROUND

DNA ploidy and/or S-phase fraction have been used as biologic predictors of aggressive behavior in a variety of solid tumors, including ovarian carcinomas. Recently, attention has focused on borderline lesions to determine if flow cytometry plays a role in separating potentially aggressive tumors from those which will pursue a more innocuous course.

METHODS

Paraffin-embedded tissue from 42 tumors with low malignant potential (LMP) were analyzed by flow cytometry (FC) to determine the DNA index (DI) and S-phase fraction (SPF). These result were then correlated with conventional pathologic parameters (size, nuclear grade, architecture, and mitotic index) and with clinical parameters (stage and age). Statistical analysis was carried out using the Fisher's Exact and Kruskal-Wallis tests.

RESULTS

Thirty-five cases (83.3%) were diploid, while 7 cases (16.7%) showed aneuploid stemlines, with a mean DI of 1.2 (range: 1.1-1.4). The mean SPF was 3.5% for the diploid tumors and 4.5% for the aneuploid tumors. Serous tumors comprised 74% of our cases; the remainder were either mucinous or endometrioid tumors. Complex solid architectural patterns were found in 29 tumors whereas high nuclear grade was seen in 24. A mitotic rate (MR) of 0-3/10 high power fields was seen in 29 tumors (69%), with only 5 having 10 or more mitotic figures. Aneuploidy statistically correlated with higher stage (P < 0.009). Marginal correlation was seen with a larger tumor size (P = 0.06). SPF showed a direct linear correlation with MR (P < 0.001). Also, smaller SPF's were seen in the serous tumors versus the mucinous and endometroid group (P < 0.05). Two patients with diploid and one patient with aneuploid stemlines had recurrent disease during the follow-up period.

CONCLUSIONS

DI and SPF correlated with some of the histologic parameters we evaluated. DI and SPF, however, could not predict which tumor(s) would behave in a more aggressive fashion.

An evaluation of prognostic factors in advanced ovarian cancer

A summary is presented of currently available prognostic factors in advanced ovarian cancer of the common epithelial types. The emphasis is on the most promising clinical, classical pathological, biochemical, immunohistochemical, molecular biological and quantitative pathological factors.

p53 protein detected by immunohistochemistry as a prognostic factor in patients with epithelial ovarian carcinoma

BACKGROUND

The clinical significance of p53 suppressor gene nucleoprotein immunostaining in ovarian epithelial cancer has not been determined.

METHODS

p53 protein expression was studied by immunohistochemistry from paraffin embedded tissue in a series of 136 patients with malignant ovarian epithelial tumors. The median follow-up time of the patients still alive was 10 years.

RESULTS

Sixty (44%) carcinomas stained clearly positive for p53 protein. Positive staining for p53 protein was associated with the serous histologic type (P = 0.0006), a higher than the median S-phase fraction size determined by DNA flow cytometry (P = 0.02), and poor histologic grade of differentiation (P = 0.04), but not with the International Federation of Gynecology and Obstetrics (FIGO) stage, age at diagnosis, or DNA ploidy. Cancers with positive staining had only 17% 5-year and 9% 15-year survival rates compared with 42% 5-year and 36% 15-year survival rates corrected for intercurrent deaths among the rest of patients (P = 0.002). In a multivariate analysis, positive p53 staining was associated with poor survival (relative risk of death, 1.8, 95% confidence interval [CI], 1.2-2.9) together with less than radical surgery (nonradical vs. radical: RR, 5.5; 95% CI, 2.2-13.6), and advanced FIGO stage (RR, 1.4; 95% CI, 1.0-2.0).

CONCLUSION

Although p53 protein immunostaining is associated with several other prognostic factors in epithelial ovarian cancer, it may also have independent prognostic value in this disease.

DNA ploidy and PCNA index in pancreatic lesions producing hyperinsulinemic hypoglycemia

DNA nuclear content and PCNA index (proportion of PCNA reactive cells) have been studied by flow cytometry in eight pancreatic lesions producing hyperinsulinemic hypoglycemia to assess DNA ploidy and tumoral growth fraction. Adult nesidioblastosis had a diploid DNA index, two adenomas were near diploid, and four of the adenomas and the carcinoma were aneuploid. The median value of PCNA index (6.056% +/- 6.76) was significantly correlated (P < 0.05) with the mean tumor diameter (2.43 cm +/- 1.96). Tumors with a PCNA index < 6.056% showed a diameter less than the mean tumoral diameter and a benign clinical course. Tumors with PCNA index > 6.056% generally displayed a diameter bigger than the mean tumoral diameter, being associated with lymph node metastases in one case. The authors conclude that nuclear DNA and PCNA index cytometric studies are useful parameters to assess the biological behavior of pancreatic lesions producing hyperinsulinemic hypoglycemia.

Computerized image analysis and flow cytometric evaluation of ovarian borderline tumors: a study of 24 cases

DNA content evaluation in the study of ovarian borderline tumors has been shown to be a useful adjunct to histopathologic diagnosis. This study compares flow cytometry and computerized image analysis (CIA) in evaluating the DNA content of these lesions. Twenty-four cases of ovarian borderline tumors (15 serous, 9 mucinous) were studied utilizing formalin-fixed paraffin-embedded tissue. Flow cytometry of cell suspensions and CIA of cell suspensions and paraffin sections were compared in the evaluation of DNA content. Twenty-three tumors (96%) were diploid and only 1 (4%) was aneuploid. There was 100% correlation between flow cytometry and CIA of cell suspensions. Image analysis of Feulgen-stained paraffin sections was found to be unreliable when compared with the use of cell suspensions in the evaluation of DNA content. Clinical follow-up in 17 patients showed recurrent disease in two patients with diploid tumors and no evidence of disease in the patient with an aneuploid tumor. The reported rate of aneuploidy in borderline tumors varies depending on the diagnostic method employed in evaluating DNA content. This study shows good correlation between flow cytometry and image analysis of cell suspensions and supports the low rate of aneuploidy found in these lesions by other authors utilizing these methods. The majority of borderline ovarian tumors have been shown to have a diploid DNA content; however, the finding of aneuploidy in histologically classified borderline tumors warrants close clinical follow-up since aneuploidy in these tumors has been associated with an adverse prognosis.

Cellular DNA content and survival in advanced ovarian carcinoma

BACKGROUND

The prognosis of patients with advanced ovarian cancer is generally poor. To date, no satisfactory methods for predicting individual prognosis have been reported, especially in patients with little or no residual tumor after debulking.

METHODS

The authors investigated in a retrospective study the prognostic significance of nuclear DNA content as measured by flow cytometry of the tumor specimens from 184 women with nonpretreated International Federation of Gynecology and Obstetrics Stage III and IV ovarian cancer. Clearly defined inclusion criteria for the study population were used.

RESULTS

Seventy-one (39%) cancers were diploid, whereas 113 (61%) were aneuploid. Ploidy showed a significant correlation with clinical and morphologic features such as age, histologic grade, serous histologic type, and residual tumor after debulking. No significant correlation was found between ploidy and ascites, estrogen- and progesterone receptor levels, and elevated pretreatment CA-125 levels. Univariate analysis showed significant correlations between overall survival and histologic grade (P = 0.003), patient age (P = 0.001), residual tumor after primary surgery (P < 0.001), stage (P = 0.019) and ploidy (P = 0.009). Multivariate analysis revealed residual tumor (P < 0.001) and age (P = 0.051) to be associated independently with survival. Ploidy was not established as an independent prognostic factor.

CONCLUSIONS

These results suggest that abnormalities of the nuclear DNA content in advanced ovarian carcinomas are associated with various clinical and morphologic prognosticators, but that ploidy is not an independent prognostic factor for survival.

Dysplasia and aneuploidy as markers of malignant degeneration in Barrett's oesophagus. The Rotterdam Oesophageal Tumour Study Group

The role of dysplasia and aneuploidy as markers in columnar epithelium for malignant degeneration in Barrett's oesophagus was compared in a case control study comprising 38 patients with benign Barrett's oesophagus and 50 patients with Barrett's oesophagus associated with adenocarcinoma. Tissue specimens of columnar epithelium were reviewed for the presence of specialised columnar epithelium and the grade of dysplasia. Ploidy was determined using the method for formalin fixed paraffin wax embedded tissue described by Hedley. There was no significant difference in the frequency of specialised columnar epithelium between both groups. Dysplasia was found more often in columnar epithelium associated with adenocarcinoma compared with benign Barrett's oesophagus (p < 0.001). Multivariate analysis using logistic regression showed an increased risk of malignancy in Barrett's oesophagus in case of dysplasia (odds ratio 9.4, p = 0.003 for mild dysplasia and 33.1, p < 0.001 for moderate or severe dysplasia). Ploidy was not statistically significantly correlated with dysplasia. Aneuploidy or increased G2/tetraploidy proved to be an independent risk factor for younger patients (age < 65 years: odds ratio 44.7, p = 0.003). In conclusion, dysplasia and aneuploidy or increased G2/tetraploidy in columnar epithelium are independent risk factors for malignant degeneration. Patients with these risk factors should be offered a more intensive screening programme.

Morphologic and morphometric features of low grade serous tumours of the ovary

Peritoneal washings from twelve patients with serous tumours of the ovary were studied. Six patients had borderline serous tumours (BSTs), and six had grade one adenocarcinomas. Papanicolaou stained slides were assessed for nine morphologic parameters; background, single cells, size of papillary fragments, contour of papillary fragments, psamomma bodies, cytoplasmic vacuoles, nuclear pleomorphism, nuclear membrane contour, and nucleoli. The slides were destained and restained by the Feulgen method for assessment, with a computer based image analysis system (CAS100, Cell Analysis Systems, Inc., Elmhurst, IL), of DNA content, nuclear size, and nuclear roundness. The contour of the papillary fragments (P = 0.004) and the presence of nuclear pleomorphism (0.019) were distinguishing characteristics. All six BSTs were diploid while three of the six adenocarcinomas had aneuploidy. Two exhibited polyploid DNA distribution and one exhibited diploid DNA distribution. The pooled data for the nuclear size and roundness showed little difference in the modal values, although the nuclei of the adenocarcinoma cells were slightly larger than those of the borderline cells (54 sq. microns vs. 46 sw. microns). However, the coefficients of variation (CVs) for each of these parameters were larger in the adenocarcinoma group than in the borderline group (59.7 vs. 36.4% for size and 33.5 vs. 17.8% for roundness). Although the sample size is small, the data suggest that aneuploidy is rare in borderline tumours. In addition, the presence of papillary groups with irregular contours and nuclear pleomorphism (reflected in higher CVs for nuclear size and roundness) both occur more commonly in adenocarcinomas than in borderline tumours and may be of predictive value in distinguishing the two groups.

Tumor DNA ploidy and prognosis of patients with serous cystadenocarcinoma of the ovary

BACKGROUND

Although it is important to determine any relationship between tumor DNA ploidy and its biologic behavior, the correlation between DNA ploidy and the prognosis of patients with ovarian cancer is not conclusive. Accordingly, the authors evaluated the clinical application of DNA ploidy in ovarian cancer.

METHODS

Flow cytometric measurements were performed in 45 selected patients with well-differentiated serous cystadenocarcinoma of the ovary, Stages Ic-IV. All of them had the same surgical procedure, with retroperitoneal lymphadenectomy including paraaortic nodes, followed by the same postoperative chemotherapeutic regimen.

RESULTS

Of the 45 ovarian cancers, 28 were diploid and 17 were aneuploid. The 2-year survival rate and the estimated 5-year survival rate for patients with diploid tumors were significantly greater than those for patients with aneuploid tumors (73.2% versus 46.7% and 29.1% versus 22.4%, respectively). The 2-year survival rate in patients with advanced disease (Stage III or IV) was also significantly higher for those with diploid tumors (53.3% versus 37.4%, respectively), but the estimated 5-year survival rate was similar in both groups (8.9% versus 9.1%, respectively). Patients with advanced disease had aneuploid tumors more frequently than those with early-stage disease. A significantly higher incidence of retroperitoneal lymph node metastasis was observed in aneuploid tumors than in diploid tumors (43.8% in diploid tumors versus 86.7% in aneuploid tumors). The authors found no difference in the response to chemotherapy between diploid and aneuploid tumors.

CONCLUSIONS

Although tumor DNA ploidy was not as reliable as conventional parameters such as surgical stage in establishing prognosis, it may provide an indicator of lymph node involvement.

The prognostic value of clinical, pathologic, and biologic parameters in ovarian cancer

BACKGROUND

The prognosis in ovarian cancer remains poor, and there is a need to identify patients who are less likely to respond to treatment.

METHODS

In a study of 133 unselected patients with ovarian adenocarcinoma treated by a standard protocol, variables such as age, tumor type, International Federation of Gynecology and Obstetrics stage, cellular differentiation, amount of residual disease after surgery, and results from flow cytometry were correlated with survival and relapse at 24 months.

RESULTS

Although stage and cellular differentiation were found to be significant associations with survival and relapse, multivariate analyses identified only residual disease and ploidy status (and the related DNA index and percentage of aneuploid cells) as independent prognostic variables. The magnitude of the effect of ploidy depended on the amount of residual disease; among patients with less disease (< 2 cm), the mortality rate was nearly fourfold higher for those with aneuploid tumors than for those with diploid tumors.

CONCLUSIONS

Routine use of ploidy determination in ovarian cancer is an important prognostic indicator, especially for a subgroup of patients with minimal residual disease.

DNA flow cytometric analysis of serous ovarian tumors of low malignant potential

BACKGROUND

Ovarian serous tumors of low malignant potential (STLMP) occasionally progress; a small percentage of patients die of the tumor. There is no known way to predict which tumors will progress.

METHODS

Forty STLMP were analyzed by DNA flow cytometry and compared with 26 serous carcinomas.

RESULTS

Forty percent of Stage I STLMP and 40% of Stage III STLMP were DNA aneuploid as compared to 54% of serous carcinomas. Aneuploidy was found in 50% of STLMP that progressed and in 38% of neoplasms that did not progress. Four of the 30 Stage I STLMP progressed, and 3 of the 4 were aneuploid; whereas, of the 26 Stage I STLMP that did not progress, 9 were DNA aneuploid. Stage III STLMP were aneuploid in 4 out of 10 instances (40%). Aneuploidy was not related to progression as three of four DNA diploid tumors progressed, and three of six that did not progress were aneuploid. Thirteen of 16 aneuploid STLMP had peridiploid aneuploid populations. The mean follow-up periods were 14.3 years for Stage I STLMP and 8.3 years for Stage III STLMP:

CONCLUSIONS

DNA aneuploidy in Stages I and III STLMP does not identify neoplasms likely to relapse with sufficient frequency to be useful in identifying those patients at high risk for relapse.

Intratesticular serous cystadenoma of borderline malignancy. A pathological, histochemical and DNA content study of a case with long-term follow-up

A 61-year-old man presented with a painless right testicular swelling of 6 months duration. A right orchiectomy was performed and pathological examination showed an intratesticular serous borderline tumour (SBT). Immunohistochemical staining was positive for carcinoembryonic antigen, LeuM1, B72.3, S100-protein, Ca125, cytokeratins AE1/AE3 and vimentin, suggesting a Müllerian origin or differentiation. DNA image analysis revealed an aneuploid histogram. The favorable outcome of the patient confirms that testicular SBTs behave as non-aggressive tumours, even when characterized by aneuploid DNA content.

Prognostic factors in well-differentiated early-stage epithelial ovarian cancer

BACKGROUND

The prognosis of patients with early ovarian cancer is good as compared with that of patients with advanced disease. However, there are no methods for predicting prognosis of early ovarian cancer, on which treatment decisions can be based.

METHODS

The prognostic significance of DNA flow cytometric and morphometric analysis was evaluated in 64 surgically treated patients with well-differentiated early-stage (International Federation of Gynecology and Obstetrics [FIGO] Stage IA, IB, IC, and IIA) epithelial ovarian cancer. The extent of the well-defined staging procedure was assessed strictly in every patient.

RESULTS

Only five patients died of recurrent ovarian cancer; all of these patients belonged to the inaccurately staged group. No significant relationship was found between clinicopathologic characteristics, such as menopausal status, FIGO stage, histologic cell type, and 5-year disease-free survival rate. Forty-two of the tumors had a mitotic activity index (MAI) of less than 30, and 43 of the tumors showed a volume percentage epithelium (VPE) of less than 65. Neither as a single parameter nor in combination did MAI and VPE correlate significantly with disease-free survival. Thirty-two tumors (50%) were DNA diploid, 15 were considered wide-CV-diploid, and 17 were aneuploid. Nearly 90% of the tumors showed DNA indices (DI) of 1.40 or less. The 5-year disease-free survival rate was significantly lower (61%) for patients with DI greater than 1.40 than for those with DI of 1.40 or less (96%) (P < 0.005). From the total number of five patients who died of their disease, three had tumors with DI in the tetraploid range.

Proliferating cell nuclear antigen in epithelial ovarian cancer: relation to results at second-look laparotomy and survival

We determined the proliferative index (PI) of 92 previously untreated advanced epithelial ovarian cancers using PCNA/cyclin immunostaining and image analysis quantitation. In this retrospective study, there was a relationship between tumor PI and 5-year survival. For patients with a tumor PI greater than the median, the estimated 5-year survival was 44%; for patients with a tumor PI below the median, the estimated 5-year survival was 15% (P = 0.003). This may partly reflect sensitivity to chemotherapy, as those patients with more rapidly proliferating tumors were more likely to achieve a pathologic complete response to platinum-based therapy.

Molecular and biological factors in the pathogenesis of ovarian cancer

BACKGROUND

The classic prognostic parameters are insufficient for predicting the prognosis of the individual patient. Knowledge of molecular and biological factors which are responsible for the development and progression of ovarian cancer may improve the prediction of prognosis.

MATERIALS AND METHODS

Recent data both on factors associated with the development and control of ovarian cancer cells and on DNA ploidy have been reviewed.

RESULTS

Observations suggest that steroid and peptide hormones have a role in disease etiology and progression, and that peptide growth factors and cytokines, oncogenes and tumor suppressor genes, by their impact on mitosis and cell number may influence the rate of mutations, which could confer malignant transformation. DNA ploidy is an objective independent prognostic factor. DNA aneuploidy indicates high risk, diploidy low risk. Only tumours shown to be DNA diploid by flow-cytometry and image cytometry are considered diploid. S-phase fraction is currently not reliable.

CONCLUSION

Understanding the mechanisms involved in ovarian cancer development and growth will allow opportunities for the rational design of effective anti-tumour treatment modalities. More objective and reproducible prognostic variables will improve the predictiveness of prognosis.

Serous borderline tumors of the ovary. A clinicopathologic, immunohistochemical, and quantitative study of 44 cases

The clinicopathologic features of 44 serous borderline tumors (SBT) of the ovary were evaluated. Nineteen were Stages II and III, and 9 had invasive peritoneal implants. All 19 patients received chemotherapy and 4, who had invasive implants, died of disease after 3, 4.3, 8, and 9 years. The other 25 patients were free of tumor 1-14 years (mean, 5.3 years) after surgery. Coexpression of low molecular weight keratins (AE1, CAM 5.2) and vimentin was found in all tumors and their implants. No significant differences were found between SBT with different volume-corrected mitotic indices (M/Vi) with respect to gross features, presence or absence of implants, stage, and survival. Cytometric DNA analysis also was performed on the primary ovarian tumors and the implants. Twenty-one primary tumors had diploid or tetraploid histograms, and 23 had aneuploid histograms. DNA ploidy of the primary ovarian tumors did not correlate with gross features, the presence or absence of implants, M/Vi, stage, and survival. The data from this study confirm that most SBT are clinically benign, but SBT with invasive implants may behave aggressively. Expression of intermediate filaments, M/Vi, and DNA ploidy evaluation of the primary ovarian tumors seem to be of no value in predicting prognosis. However, four of seven patients with aneuploid DNA implants died of tumor.

Diagnostic significance of nuclear DNA content and nuclear area in oral hyperplasia, dysplasia, and carcinoma

The nuclear DNA content and the nuclear area in hyperplasia, dysplasia, and carcinoma of the oral cavity were quantitatively analyzed by microspectrophotometry. In carcinoma, marked variability of the nuclear DNA content and the nuclear area was found. The mean nuclear DNA content, the variance of the nuclear DNA content, the frequency of cells above tetraploid (4 C), the mean nuclear area, and the variance of nuclear area in hyperplasia and dysplasia were significantly different from these values with carcinoma. In some cases of leukoplakia and verrucous hyperplasia with subsequent malignant formation, the values were beyond the lower limit of carcinoma. The results suggest that the nuclear DNA and the nuclear area are important objective indices for predicting malignant potential of precancerous lesions.

Flow cytometric analysis of nuclear DNA content in ovarian tumors. Association of ploidy with tumor type, histologic grade, and clinical stage

The authors undertook a prospective, flow cytometric study of nuclear DNA ploidy in 140 fresh ovarian tumors. There were 43 benign tumors, 27 borderline tumors, and 70 malignant tumors. Results of DNA ploidy analysis were compared to age at diagnosis, menopausal status, tumor size, histologic type, grade, and International Federation of Gynecology and Obstetrics (FIGO) stage. Although the majority of benign tumors were diploid, 19% were aneuploid. Among the benign tumors, DNA ploidy was significantly associated with tumor type and tumor size. All borderline tumors were diploid. Of the 70 malignant tumors, 64% were aneuploid. In the malignant tumors, DNA aneuploidy had significant univariate associations with histologic type, grade, and FIGO stage. By multivariate analysis, DNA aneuploidy remained significantly associated with stage and grade, both known predictors of survival in ovarian cancer. These results indicate that DNA ploidy varies with the aggressive potential of an ovarian cancer and may, at the time of initial diagnosis, provide additional information about tumor prognosis.

Prognostic impact of chromosome aberrations in ovarian cancer

Clinico-cytogenetic correlations were assessed in 88 patients with malignant ovarian tumours. Cytogenetic analysis of the primary tumours yielded normal karyotype (N) in 33 patients and abnormal karyotypes (A) in 55 patients. Within the A group, seven tumours had simple abnormalities (AS), i.e., numerical changes only or a single structural aberration, and 48 had karyotypes with complex aberrations (AC). A correlation analysis between groups N and A revealed that cytogenetic abnormalities were more often found among seropapillary tumours, and that cases with abnormal karyotypes on average were of higher stage and more often had residual tumour mass after initial surgery (P less than 0.05 for all variables). When the three groups N, AS, and AC were compared, they were found to be significantly different with regard not only to the three parameters mentioned above, but now tumour grade also appeared to correlate with karyotypic pattern (P = 0.001), with poorly differentiated tumours having the most complex karyotypes. In a correlation analysis between karyotypic pattern and survival, group A patients had shorter survival than group N (P = 0.049). In the corresponding analysis between groups N, AS, and AC, the differences were also significant (P = 0.039), with shorter survival in group AC than in groups N and AS. Stage, grade, residual tumour after primary surgery, and performance status also correlated with survival time. A multivariate analysis identified abnormal karyotype as being independently associated with short survival in advanced clinical stages (P = 0.030) of ovarian carcinoma. We conclude that cytogenetic analysis of tumour cells may be of clinical value in the assessment of prognosis in patients with malignant ovarian tumours.

Uptake of 2-fluoro-2-deoxy-D-[U-14C]-glucose during chemotherapy in murine Lewis lung tumor

Mice bearing intramuscular Lewis lung tumor were treated with BCNU and doxorubicin (ADM) to study chemotherapy-induced changes in the uptake of 2-fluoro-2-deoxy-[U-14C]glucose (FDG). A decreased FDG uptake, tumor regression and a diminished proportion of aneuploid versus diploid cells as evaluated by DNA flow cytometry were seen after treatment with BCNU but not with ADM; HPLC indicated that most of the 14C activity in tumors was from FDG6-phosphate. The results suggest that changes in FDG uptake reflect the effectiveness of antitumor therapy. FDG may be valuable in follow-up studies of cancer treatment.

Comparison of S-phase fraction, working formulation, and Kiel classification in non-Hodgkin's lymphoma

The prognostic value of S-phase fraction (SPF), determined by flow cytometric study from paraffin-embedded tissue, and grading by Working Formulation (WF) and Kiel classification were compared among 245 patients with non-Hodgkin's lymphoma followed for the median of 89 months or until death. Histologic reclassification and SPF determinations were done without knowledge on clinical data. SPF (P equals 0.0001), WF (P equals 0.0003), and Kiel classification (P equals 0.0008) were associated with mortality in lymphoma in a univariate analysis, and WF and SPF were independent prognostic factors in Cox's multivariate analysis. Although SPF correlated strongly both with WF and Kiel grades (P less than 0.0001), low-grade and high-grade malignant lymphomas according to Kiel classification, and high-grade lymphomas according to WF could be divided into groups with significantly different outcome by SPF. The results suggests a role for SPF in therapeutic decision-making.

Multiparameter flow-cytometric quantitation of epidermal growth factor receptor and c-erbB-2 oncoprotein in normal and neoplastic tissues of the female genital tract

A novel multiparameter flow-cytometric method was used to quantify the expression of epidermal growth factor receptor (EGFR) and c-erbB-2 oncoprotein on 85 cryopreserved normal tissues (30 ovary, 29 endometrium, 16 cervix) and 67 carcinomas (31 ovarian, 18 cervical, 15 endometrial, 3 vulvar). Overexpression of the EGFR and c-erbB-2 oncoproteins was found in respectively 3/31 (9%) and 10/31 (32%) ovarian carcinomas, 13/18 (72%) and 7/18 (38%) cervical carcinomas, and 2/15 (13%) and 2/15 (13%) endometrial carcinomas. Oncoprotein expression was significantly higher in the malignant tumors (for all tumor sites) than in the corresponding normal tissues (P less than 0.034 for all combinations). Aneuploid tumors expressed levels of EGFR and c-erbB-2 oncoprotein significantly higher than those of DNA diploid tumors (P = 0.042 and P = 0.048, respectively). Oncoprotein could be detected in nearly all normal tissues: expression was higher in premenopausal than in postmenopausal patients (EGFR, P = 0.07; c-erbB-2, P less than 0.001). The present study supports the idea that EGFR and c-erbB-2 may play an important role in the autocrine, paracrine, and/or endocrine growth control and differentiation of normal tissues. Alteration in the expression of these oncoproteins is probably involved in malignant transformation and tumorigenesis.

Multi-parameter flow cytometric quantitation of the expression of the tumor-associated antigen SM3 in normal and neoplastic ovarian tissues. A comparison with HMFG1 and HMFG2

SM3 is a monoclonal antibody that reacts with a peptide epitope in the core protein of polymorphic epithelial mucin. Multi-parameter flow cytometry was used to characterize the expression of SM3 and compare it with two related tumor-associated antigens, HMFG1 and HMFG2, in cell suspensions of 44 malignant ovarian tumors, 15 benign ovarian tumors, and 16 normal ovaries. Tumor-associated antigen expression was significantly higher in malignant ovarian neoplasms than in benign neoplasms (P less than 0.001 for all three antigens). SM3 was expressed more specifically in malignant than benign tumors but had a lower affinity than HMFG1 and HMFG2. Multi-parameter flow cytometric evaluation of a panel of monoclonal antibodies can be used to help in choosing the best antibody for immunohistochemistry, imaging, and eventually treatment of ovarian tumors.

The prognostic value of image analysis in ovarian cancer

Histologic grading is very important for treatment decisions in ovarian cancer. All grading systems contain a significant subjective component, which could be reduced by including objective measurements into the diagnostic decision. Image analysis was used to determine nuclear area and ploidy distributions in 42 patients with epithelial ovarian cancer, and the results were related to tumor grade and clinical outcome. The mean nuclear area, mean optical density, number of hyperploid cells, and the standard deviation between measurements were significantly higher in Grade 2 and 3 tumors compared with Grade 1 tumors, in rapidly progressive tumors compared with less aggressive malignancies, and in recurrent tumors compared with primary lesions. The number of nuclei with very high DNA content was found to be of prognostic importance. Image analysis thus provides additional prognostic information in epithelial ovarian cancer.

Flow cytometric DNA analysis of hepatocellular carcinoma

The prognostic value of nuclear DNA content was studied retrospectively using flow cytometry in 203 cases of resected hepatocellular carcinoma. The occurrence of DNA aneuploidy, which was detected in 50% of patients, correlated significantly with tumor size and the presence of vascular invasion or intrahepatic metastasis. Overall, patients with DNA aneuploid tumors had a significantly worse prognosis than those with DNA diploid tumors (P less than 0.001) and, also in subdivided groups by tumor size (P less than 0.01). Among DNA aneuploid patients, the survival times were significantly shorter for patients with a low DNA index (less than 1.5) than for those with a high DNA index (greater than or equal to 1.5) (P less than 0.05). In a Cox multivariate analysis, nuclear DNA content provided significant prognostic value (P = 0.008), as did vascular invasion (P = 0.001) and intrahepatic metastasis (P = 0.005). These results indicated that nuclear DNA content has an important prognostic value in hepatocellular carcinoma.

DNA ploidy and cell-cycle analysis: tools for assessment of cancer prognosis

DNA ploidy and cell cycle analysis as measured by flow cytometry (FC) and image analysis (IA) have moved out of the realm of the research laboratory to become valid clinical tests used in the assessment of prognosis of the cancer patient. Although much information on the relationship of DNA ploidy/%S-phase analysis to patient prognosis is available in the literature, the data are not presented in such a way as to be helpful in clinical decision making. Because predictive values and confidence intervals, which measure the likelihood that a given clinical test will rule in or rule out a clinical outcome, were not calculated in previous reviews, conclusions about the clinical utility of these analyses were not possible. Using the available raw data on DNA ploidy and %S-phase analysis from previously published papers, predictive values and confidence limits were calculated for specific clinical presentations. In several such clinical situations (tumor type, stage, etc.), predictive value of greater than 90% was derived. We conclude that in these situations DNA ploidy and %S-phase analysis can be used to predict clinical outcome, to design treatment, and to guide patient management. The evaluation of the clinical utility of these tests must ultimately rest on prospective trials which show that randomized arms respond to treatment regimens dependent upon the DNA ploidy and %S-phase status.

Flow cytometric evaluation of epithelial ovarian cancer

We investigated the prognostic significance of deoxyribonucleic acid content and proliferative activity of tumor cell populations as measured by flow cytometry of the tumor specimens from 115 women with epithelial ovarian cancer. Deoxyribonucleic acid aneuploidy was found in 87 of 115 (76%) of these cancers with a mean deoxyribonucleic acid index of 1.6 and S-phase fraction of 14.7%. The S-phase fraction of the 28 (24%) diploid tumors was 7.0%. Deoxyribonucleic acid ploidy was significantly correlated with survival. S-phase fraction was significantly correlated with ploidy, residual tumor, histology, grade, ascites, time to recurrence, and survival. Diploidy versus aneuploidy were the best discriminating values for deoxyribonucleic acid index and an S-phase fraction of greater or less than 18% for that parameter. Multivariate analysis revealed stage, S-phase fraction, residual tumor, and grade to be independently associated with time to recurrence, and stage, age, S-phase fraction, and largest metastases were factors associated with survival. Deoxyribonucleic acid ploidy did not significantly improve either model. These results suggest that abnormalities of deoxyribonucleic acid content and the proliferative activity of tumor cell populations are reflective of their biologic activity.

Clinical significance of nuclear DNA content in pancreatic carcinoma

The nuclear DNA content of 62 pancreatic adenocarcinomas was analysed by flow cytometry from paraffin-embedded material. Radical surgery could be performed in 12 of the 24 cases with diploid carcinoma, but only in 3 of the 38 cases with a non-diploid tumour (P = 0.0002); the radically resected carcinomas also had a lower fraction of cells in the S-phase (P = 0.009). Non-diploid nuclear DNA content (38 cases, 61 per cent) was associated with advanced stage (P = 0.002), poor histological differentiation (grade II or III, P = 0.004), and primary tumour site in the body or the tail as compared with the head (P = 0.01). The median survival time of the patients with diploid carcinoma was 13 +/- 3 (SE) months, and that of the patients with non-diploid carcinoma 3 +/- 1 months (P = 0.0001). The DNA index with the cutoff value 1.4 was a slightly more powerful prognostic factor than DNA ploidy, and it was the most important independent prognostic factor in Cox's multivariate analysis (P less than 0.001) followed by histological grade (P less than 0.03). We conclude that diploid pancreatic carcinomas are associated with a longer survival than the non-diploid ones, and that radically operable carcinomas form a special subgroup with frequent diploidy and less aggressive biological behaviour.

Prognostic value of flow cytometric DNA content analysis in granulosa cell tumor of the ovary

The nuclear DNA content and S-phase fraction of 23 ovarian granulosa cell tumors were measured from paraffin-embedded tissue with flow cytometry. Crude survival of the patients with a euploid tumor (17 diploid, one tetraploid) was more favorable than that of the patients with an aneuploid tumor (n = 5, P = 0.02). The percentage of S-phase cells was a good predictor of survival. If more than 6% S-phase cells were present in the DNA histogram, both crude survival (P = 0.0001) and survival corrected for intercurrent deaths (P = 0.0001) were clearly inferior as compared with tumors with less than 6% S-phase cells. The results indicate that DNA flow cytometric study may provide a rapid and valuable method to predict the biological behavior of granulosa cell tumors of the ovary.

Relationship of DNA ploidy to chemoresistance of tumors as measured by in vitro tests

To examine whether patients with aneuploid tumors might derive more benefit from chemotherapy than would patients with diploid tumors, predictive tests for determining resistance in human tumors were carried out and the test results compared with the DNA ploidy of the corresponding tumors. Multidrug-resistance in 15 kidney carcinomas grown as primary cultures was determined by immunofluorescence by Mab C219, which is specific for the plasma membrane glyco-protein P-170, and by the use of tritiated nucleotide incorporation after addition of doxorubicin. Aneuploid tumors had a higher tendency to be more sensitive than diploid tumors, but the correlation was not significant. This was confirmed by reanalyzing our earlier data on ovarian and lung cancers. In conclusion, DNA measurement using flow cytometry does not appear to be a suitable tool for prediction of resistance of human tumors to chemotherapy.

The prognostic significance of nuclear DNA content in invasive breast cancer--a study with long-term follow-up

The nuclear DNA content of 351 breast carcinomas was determined by flow cytometry from paraffin-embedded tissue to assess the prognostic significance of DNA ploidy, the DNA index (DI) and the S-phase fraction (SPF). The minimum follow-up of the patients was 22 years, and they were all from a defined urban population. DNA ploidy correlated with histological type and grade, mitotic count and nuclear pleomorphism (P less than 0.0001), and also with axillary nodal status (P = 0.0005), tumour necrosis (P = 0.001), primary tumour size (P = 0.03), menopausal status (P = 0.004) and the presence of distant metastases at the time of the diagnosis (P = 0.04). Survival corrected for intercurrent deaths of the patients with a diploid tumour was better than that of the patients with a non-diploid tumour (P = 0.0001, 48% vs 28% at 25 years). SPF had prognostic significance in both axillary node positive and negative patients, but ploidy and DI only in the node negative group, and their significance was greater in post-menopausal than in premenopausal patients. Axillary nodal status, primary tumour size, histological grade and the type of tumour margin circumscription were the most important independent prognostic factors in Cox's multivariate analysis, and SPF had independent prognostic value, whereas ploidy and DI did not. It is concluded that DNA ploidy, DI and SPF have long-term prognostic significance in breast cancer.