Vascularized Bone Grafts from the Lateral Femoral Condyle for the Treatment of Avascular Lunate Necrosis (Kienböck's)

Background

Avascular necrosis of the lunate (Kienböck's disease) is rare and one of the main causes of progressive painful arthritis, requiring surgical intervention. Various approaches have shown benefits in treating Kienbock's disease but with limitations. The article aims to analyze the functional outcome using lateral femoral condyle free vascularized bone grafts (VBGs) as the first choice of treatment for Kienböck`s.

Materials and methods

This was a retrospective analysis of 31 patients with Kienbock's who had microsurgical revascularization or reconstruction of the lunate between 2016 and 2021 using either corticocancellous or osteochondral VBGs from the lateral femoral condyle. The characteristics of lunate necrosis, choice of VBG and postoperative functional outcome were reviewed.

Results

Corticocancellous VBGs were used in 20 patients (64.5%), while osteochondral VBGs in 11 patients (35.4%). The lunate was reconstructed in 11 patients, revascularized in 19 patients, and one patient received augmentation of a luno-capitate arthrodesis with a corticocancellous graft. We noted postoperative irritation of the median nerve (n = 3) and screw loosening requiring removal (n = 1) as minor complications. All patients had complete graft healing at eight-month follow-up and acceptable functional outcomes.

Conclusions

Free VBG from the lateral femoral condyle represent a reliable method of lunate revascularisation or reconstruction in advanced Kienböck's. Their main advantages are the constant vascular anatomy, straightforward graft harvesting technique and possibility to harvest several graft types according to the requirements at the donor site. Postoperatively, the patients become pain-free and have an acceptable functional outcome.

[Hematogenous osteomyelitis due to clavicular fracture : A rare complication after conservative treatment]

We present a case of a nondislocated clavicular fracture that was conservatively treated for 4 weeks with a sling. The patient was a smoker and suffered from type 2 diabetes mellitus. After 2 months a suppurative infection occurred due to an escalation based on a clavicular osteomyelitis. Through antibiotic treatment and an aggressive surgical approach the infection was cured but ended up with a painful malunion of the clavicle. The bone reconstruction was achieved with a long locking plate with an additional vascularized medial femoral condyle free flap. After 18 months the patient was subjectively very satisfied with the outcome, had no pain and excellent functional results in the Constant Murley and DASH (Disabilities of Arm, Shoulder and Hand) scores. The X‑ray assessment showed full bone union.

Modulation of EGFR Gene Transcription by a Polymorphic Repetitive Sequence – a Link between Genetics and Epigenetics

The epidermal growth factor receptor (EGFR) plays a crucial role in growth, differentiation and motility of normal as well as tumor cells. The transduction of extracellular signals to the cytoplasm via the receptor not only depends on ligand binding, but is also determined by the receptor density on the cell surface. Therefore, with regard to cancer diagnosis and therapeutic approaches targeting EGFR it is important to know how the expression level of EGFR is controlled. We found that transcription activity declines with increasing numbers of CA dinucleotides of a highly polymorphic CA repeat in the first intron of the epidermal growth factor receptor gene. In vivo data from cultured cell lines support these findings, although other regulation mechanisms can compensate this effect. In addition, we showed that RNA elongation terminates at a site closely downstream of the simple sequence repeat (SSR) and that there are two separate major transcription start sites. Model calculations for the helical DNA conformation revealed a high bendability in the EGFR polymorphic region, especially if the CA stretch is extended. These data suggest that the CA-SSR can act like a joint, bringing the promoter in proximity to a putative repressor protein bound downstream of the CA-SSR. The data indicate that this polymorphism may be a marker for cancer, linking genetic and epigenetic risk factors. Furthermore, in breast cancer, heterozygous tumors with short CA-SSR showed an elevated EGFR-expression in contrast to tumours with longer CA-SSR. Tumours with loss of heterozygosity in intron 1 of egfr revealed an increased EGFR expression if the longer allele was lost. Moreover, decreased EGFR gene levels were significantly correlated with poor prognosis in breast cancer.

One-stage reconstruction of isolated and combined tendon defects with the vascularized adductor magnus tendon graft: Surgical technique and preliminary results

INTRODUCTION

Secondary reconstructions of isolated and combined tendon defects are still a challenge for plastic surgeons. Due to its reliable anatomy, reconstructive potential and low donor-site morbidity, the medial femoral condyle is an ideal area for harvesting isolated and combined tendon flaps. This study evaluates our preliminary results with the vascularized adductor magnus tendon flap.

PATIENT AND METHODS

The study included six patients who received a vascularized tendon flap (upper extremity: three patients; lower extremity: three patients) from 2011 to 2015. For three patients, the adductor magnus tendon was used as a single flap; for the other three patients, the tendon was included in a composite flap. A retrospective chart review provided the patients' demographic data, surgical details and the post-operative course. The further objective and patient-reported outcome was evaluated with a long-term follow-up.

RESULTS

All of the free vascularized flaps healed without complications and with good vascularization upon duplex ultrasonography. One patient did, however, require revision surgery in the late post-operative course. At the end point, all patients showed good functional results without any donor-site morbidity.

CONCLUSION

For carefully selected isolated and combined tendon defects on the upper and lower extremities, the vascularized adductor magnus tendon flap provides a reliable and versatile method for microsurgical reconstruction.

Fourier Transform IR Spectra and Rovibrational Investigation of Monoisotopic H3 116Sn35Cl, H3 116Sn79Br and H3 116SnI in the υ6 Region

Fourier transform infrared spectra in the υ6 region of the unstable monoisotopic species H3 116Sn35Cl, H3 116Sn79Br and H3 116SnI have been recorded with a solution of 0.04 cm-1 (0.12 cm-1 for H3SnI). Rotational J and K structure of the υ6 fundamental has been resolved for H3SnCl and H3SnBr, while Q branches were measured for H3SnI. The hot bands (υ3 + υ6) - υ3 and 2υ6 ±2 - υ6 ±1 have been identified. A rovibrational analysis has been performed, and the following band centers (for given A0 values) have been determined: H3 116Sn35Cl 488.786(2), H3 116Sn79Br 473.493(2) and H3 116SnI 453.680(9) cm-1.

A Diazenidoborate: Formation and Structure of Cs[(CF3)3BN=NCF3]

Cs[(CF3)3BNH2] reacts with CF3NO to form cesium trans-trifluoromethyldiazenido-tris(trifluoromethyl) borate Cs[(CF3)3BN=NCF3] (2), the structure of which has been investigated by single-crystal X-ray diffraction. The diazene nature of the anion is confirmed by the length of the N=N bond, 1.231(6) Å, and the size of the N-N-B angle, 115.5(4)° - the B-N bond length being 1.559(7) A. Compound 2 is hitherto the first diazenidoborate which has been fully characterized

The Fourier Transform IR Spectra of CIF and BrF

Fourier transform infrared spectra of C1F and BrF have been measured with a resolution of 0.04 cm-1 in the region of the fundamental and First overtone with an accuracy of 2 and 4 x 10-3 cm-1, respectively. The rotational structure was resolved up to J" = 58/62 (ClF/BrF), and υo values have been obtained from rotational analyses o f the υ 1 ← 0, 2 ← 1, 2 ← 0 and. in part, 3 ← 1 and 3 ← 0 vibrational bands. These have been employed to obtain the hitherto most accurate ωe, ωeχe and (for C1F) ωeγe values. From the rotational analyses, Be, αe, γe, De and ße have been derived.

The υ5 and υ6 Fundamental Bands of HCCCN1

The bending fundamental bands of HCCCN, υ5 and υ6, have been recorded in the region from 470 to 700 cm-1 with a resolution of 0.04 cm "' using an FT spectrometer. The band centers have been determined precisely; υ5 = 663.2220(10) and υ6 = 498.8022(10) cm-1 . From the obtained effective rotational constants, the sign o f the /-type doubling constants has been determined to be positive for the υ5 = 1 and υ6 = 1 vibrational states.

Abstract P3-05-09: Interlaboratory variability of Ki67 labeling index in breast cancer tissue microarrays

Objective: Assessment of tumor proliferation using the Ki67 labeling index (Ki67-LI) is increasingly recommended for prognostication and adjuvant chemotherapy decisions in breast cancer. Our aim was to investigate interlaboratory variance of Ki67-LI results using TMA and centralised assessment to exclude preanalytic influences and postanalytic variance, respectively.

Methods: Nine pathology laboratories (8 German and 1 Dutch) performed Ki67 staining of a TMA slide according to their routine in house protocol (including internal and external quality assurance). 40 samples per lab were centrally analyzed. The Ki67-LI was calculated after counting first all tumor cells and subsequently all Ki67 positive tumor cells of each sample regardless of staining intensity. For each tissue sample we evaluated the range of Ki67-LIs between different labs. Further 20 labs of the German Breast Screening Pathology Initiative will participate in 2013.

Results: The range of Ki67-LIs between the labs was: 1-5% in 4 (10%), 6-10% in 6 (15%), 11-15% in 7 (17,5%), 16-20% in 2 (5%), 21-25% in 7 (17%), 26-30% in 4 (10%), 31-35% in 1 (1%), 36-40% in 4 (10%), 41-45% in 2 (5%), 46-50 in 0 (0%) and >50% in 3 samples (7%), respectively. Thus, in 35% of results of the 9 labs (26 of the 40 TMA specimens) the Ki67-LI differed by more than 25%. The analysis of variance (ANOVA) came out with F = 4.24 which is much larger than the critical F value of 1.97 for these study results (p = 7.74902E-05). This means that the observed interlaboratory variance of 4.24 is systematic and not due to sampling error. The respective standard deviation is 33.4%.

Conclusion: In a setting strictly standardised in terms of preanalytic influences by using TMA and postanalytic variance by centralised quantification, Ki67-LI seems to be heavily influenced by laboratory-specific analytic variables. Taking this into consideration, there may be a risk of prognostic or predictive misclassification in some breast cancer patients in daily practice.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-05-09.

[Arthropathia ochronotica: a rare cause of early joint degeneration]

HISTORY AND ADMISSION FINDINGS

A 70-year-old deaf-mute women suffered from progressive chronic pain of the right hip joint caused by destructive osteoarthritis of the hip.

INVESTIGATIONS

In addition to painfully restricted range of motion of the right hip joint the clinical examination showed a bluish-black pigmentation of the ear-cartilage and the sclera.

TREATMENT AND COURSE

A total endoprosthetic replacement of the right hip joint was performed. During surgery, blackening of the hip joint capsule and cartilage was found. Histological, the diagnosis of an ochronosis was confirmed. Discoloration after exposure of urine to air supported the diagnosis. Based on extensive internal medical examination relevant cardiac changes were excluded.

CONCLUSION

Ochronosis (arthropathia ochronotica) is a rare entity which can be identified by a visual diagnosis. Early diagnosis can provide crucial information for the prognosis. Additionally, an interdisciplinary treatment concept should be established because of the early onset of degenerative changes at the skeletal system and pathological changes at internal organs. With suspicion on an ochronosis extended internal examinations are recommended in order to avoid complications.

Reconstruction of the nose with a new double flap technique: microvascular osteocutaneous femur and microvascular chondrocutaneous ear flap--first clinical results

This study describes a new microvascular flap combination from the medial femur and ear to reconstruct the nose after subtotal resection and presents the first clinical results. In four patients a squamous cell carcinoma of the nose was registered. In three patients this was diagnosed for the first time while in the fourth patient it was the second relapse after two resections and local flap surgery. In every case, tumour resection ended up in an extended defect of the nose, cheek and upper lip region. For skeletal reconstruction and the inner lining of the nose, a microvascular osteocutaneous femur flap was used. After reconstructing the nasal skeleton, the remaining defect was covered by a microvascular composite flap from the left ear and preauricular region. Both flap pedicles were anastomosed to the facial vein and artery. In every case, the flaps healed without complications. There was no tumour relapse. 12 months after reconstruction, minor surgical corrections were made. The patients showed a satisfying functional and aesthetic result. The combination of a microvascular osteocutaneous femur flap and a microvascular ear flap can be used successfully for reconstructing the nose after subtotal resection.

[Gorham-Stout syndrome (GSS) with fulminant aseptic osteonecrosis of the shoulder]

We report here a case of the rare Gorham-Stout syndrome (GSS) of the humerus. GSS is a disease in the course of which spontaneous idiopathic osteolysis occurs. We describe a case of a 46-year-old business economist who suffered an inadequate trauma and within 3 weeks developed self-limited idiopathic osteolysis of the left humerus head, also affecting the rotator cuff. This could be diagnosed especially on the basis of histopathological findings. Hereupon we indicated operative repair by means of inverted shoulder joint endoprosthesis.

A combined anterolateral thigh flap and vascularized iliac crest flap in the reconstruction of extended composite defects of the anterior mandible

The technique of lower anterior facial reconstruction using a combination of an anterolateral thigh flap (ALTF) and a microvascular iliac crest flap is described and the results of 18 cases are reported. Eleven patients suffered recurrence after surgery and radiotherapy of oral squamous cell carcinoma of the lower face. These patients underwent a second surgery and reconstruction. In seven patients reconstruction was performed during primary surgical therapy, followed by postoperative radiotherapy. The pedicle of the ALTF was used for elongation of the iliac crest pedicle. There were no problems with the pedicle length and anastomoses even in patients who had received previous surgery and irradiation of the neck. There was no flap loss. There were no severe postoperative complications. One patient had distant metastases 18 months postoperatively. In all other patients there was no tumour recurrence or metastasis within 10-43 months of follow-up. The ALTF and vascularized iliac bone flap combination is useful in reconstruction of the lower face. The main advantage is the elongation of the iliac flap pedicle by the ALTF pedicle in patients with previous surgery in the neck.

Whole genome expression analysis for biologic rational pathway modeling: application in cancer prognosis and therapy prediction

Using semi-quantitative microarray technology, almost every one of the approximately 30 000 human genes can be analyzed simultaneously with a low rate of false-positives, a high specificity, and a high quantification accuracy. This is supported by data from comparative studies of microarrays and reverse-transcription PCR for established cancer genes including those for epidermal growth factor receptor (EGFR), human epidermal growth factor receptor-2 (HER2/ERBB2), estrogen receptor (ESR1), progesterone receptor (PGR), urokinase-type plasminogen activator (PLAU), and plasminogen activator inhibitor-1 (SERPINE1). As such, semi-quantitative expression data provide an almost completely comprehensive background of biological knowledge that can be applied to cancer diagnostics. In clinical terms, expression profiling may be able to provide significant information regarding (i) the identification of high-risk patients requiring aggressive chemotherapy; (ii) the pathway control of therapy predictive parameters (e.g. ESR1 and HER2); (iii) the discovery of targets for biologically rational therapeutics (e.g. capecitabine and trastuzumab); (iv) additional support for decisions about switching therapy; (v) target discovery; and (vi) the prediction of the course of new therapies in clinical trials. In conclusion, whole genome expression analysis might be able to determine important genes related to cancer progression and adjuvant chemotherapy resistance, especially in the context of new approaches involving primary systemic chemotherapy. In this review, we will survey the current progress in whole genome expression analyses for cancer prognosis and prediction. Special emphasis is given to the approach of combining biostatistical analysis of expression data with knowledge of biochemical and genetic pathways.

Papilläre Tumoren der Mamma

The term papilloma applies to benign proliferative epithelial breast lesions with a papillary architecture. The papillae in such lesions contain an arborizing fibrovascular core, glandular surface epithelium and a basal myoepithelial layer. A basement membrane encloses these structures. Papilloma may occur at any site in the ductal lobular system and according to its localization is subdivided into two types: solitary (central) papilloma which are located in the major nipple/subareolar ducts or large segmental ducts and multiple (peripheral) papillomas in cystically dilated terminal ductal lobular units (TDLU). Stromal changes, epithelial metaplasia and/or proliferations and neoplasia may alter the prototypical architecture. In a significant number of papillomas atypia can be identified which have to be classified as atypical proliferates of the ductal type. These lesions must be distinguished from the papillary type of ductal carcinoma in situ. Some 17% of all papilloma are associated with (synchronous) intraductal or invasive carcinoma, but these also act as an indicator for subsequent (metachronous) carcinoma. As a consequence, in minimally invasive biopsy papilloma has to be classified as B3 and usually has to be followed by surgical excision.

[The significance of "normal tissue" in the development of breast cancer: new concepts of early carcinogenesis]

Only little information on the primary molecularbiological events involved in early breast is available. In particular, the definition of postulated precursor lesions of invasive breast cancer, such as ductal hyperplasia or ductal carcinoma in situ, is under an intense, controversial discussion in terms of pathogenesis and tumor biology. The most recent research on biological regulation mechanisms and genetic alterations in morphologically normally appearing breast tissue give rise for a reinterpretation for the most common progression models of breast cancer. The detection of genetic alterations within normal breast tissue in particular challenges the commonly postulated relationship between invasive and in situ breast carcinomas on the one hand, and benign, proliferative breast lesions on the other. The concerns about these relationship are further supported by the description of different cellular compartments within the normal female breast, including a "progenitor cell compartment" with different cytokeratin expression patterns, which can be transferred towards well known or suspected precursor lesions of invasive and in situ breast cancer. The aim of this manuscript is to provide an overview of the most recent results and developments in breast pathology, and to describe the consequences of our changing understanding of breast carcinogenesis.

Die avaskuläre Kapitatumnekrose bei Sportlern

The possibility of osteonecrosis of the carpal bones should always be considered when athletes present with pain of unknown origin in the hand and wrist, in particular, if they are participating in sports such as gymnastics or weight-lifting that involve extreme loading of the wrist with axial compression and microtrauma. This sort of extreme loading of the wrist combined with a constitutionally "weak" blood supply to the individual carpal bones may lead to the formation of osteo-necrotic zones. A treatment method that can produce excellent results, depending on the pathomorphology, is available in the form of vascularized bone grafting.

Expression of MAGE-A cancer/testis antigens in esophageal squamous cell carcinomas

BACKGROUND

Although the diagnosis and therapy of esophageal cancer have improved over the past decade, the prognosis remains dismal. Since MAGE-A cancer/testis antigens (CTA) are potential targets for immunotherapy, this study was aimed at evaluating their expression in these patients and its prognostic value.

MATERIALS AND METHODS

Using 57B monoclonal antibody, MAGE-A CTA expression was analyzed in paraffin-embedded tumor specimens of 98 patients with esophageal squamous cell carcinoma or adenocarcinomas who had undergone surgical resection. For all patients, a postoperative follow-up of at least 4 years was available. The expression was quantified using a scoring system considering intensity and homogeneity of the immunostaining. The prognostic relevance of MAGE-A expression was analyzed in univariate analyses as well as Cox proportional hazard regression analysis.

RESULTS

57B positivity could be detected in 38 tumors (38.8%). Positive staining was observed in five out of 32 adenocarcinomas (15.2%) and in 33 out of 66 (50%) squamous cell carcinomas. MAGE-A expression did not correlate with the TNM classification, grading or age of the patients. Both univariate (p=0.88) and multivariate analyses (p = 0.82) revealed that MAGE-A expression lacked prognostic significance in esophageal carcinomas.

CONCLUSION

MAGE-A was expressed in half of the squamous cell carcinomas of the esophagus, but rarely in adenocarcinomas. Although its immunodetection was insufficient for prognostic evaluation, the high expression rate suggests MAGE-A as a potential target for immunotherapy in the first group with the ability for pretherapeutic testing.

High resolution infrared spectra and rovibrational analysis of the coupled nu2/nu5 bands of D3Si35Cl. Equilibrium rotational constants

The Fourier transform infrared spectrum of monoisotopic D3Si35Cl in the region of the nu2/nu5 band system was recorded with a resolution of 2.4x10(-3) cm-1. More than 9000 lines of the strongly Coriolis x,y-coupled bands, (nu2)0=701.936, and (nu5)0=688.898 cm-1, have been assigned, among them 276 forbidden but perturbation allowed transitions around avoided crossings according to Delta(k-l)=+/-3 mechanisms. Three different models taking into account redundancies in the framework of unitary equivalent reductions of the rovibrational Hamiltonian have been employed to fit the data. All three models reproduced consistently the full data set employing 28 refined parameters with an rms deviation of 0.31x10(-3) cm-1. The equivalence of the parameter sets was established by the agreement of parameter sums obtained with the different models. The analysis of the avoided crossings, together with the fit of the forbidden lines, allowed an independent determination of the ground state parameters A0 and D(K)0. Combined with existing data for nu1, nu3, nu4, and nu6, the present results allowed the determination of experimental values, Ae=1.4371895(94) and Be=0.19823049(59) cm-1. The experimental results are compared with those of previous ab initio calculations of the anharmonic force field.

[Bootstrapping algorithm approach reveals inherent regulatory pattern in 550 invasive breast cancer cases: CK5/6/CK14 and CK8/18/CK19 builds an antagonistic set]

All the preliminary observations on a lot of marker sets defining different stages in the tumor development are building a framework of work hypothesis which can be verified in characterising large pools of histological uniform rated paraffin probes. We developed a bootstrapping algorithm based on correlation measures to uncover regulatory patterns of immunohistochemical characterized tissue arrays with 550 invasive breast cancer cases. The algorithm is implemented in 'S' a computer language used to model mathematical solutions. Focussing on the Cytokeratins versus a set of prominent markers in breast cancer differentiation it will be obvious that markers which are known to appear in early (progenitor) forms conform to CK5/6 and CK14 while others associated with late stages conform to CK8/18 and CK19. Markers examined are among others EGFR, EMA, erb-B2, Vimentin, p53, ER and PR. The developed approach is an elegant and complete procedure to reveal the real regulatory patterns which are enclosed in a certain experimental design. The statistical significance of the results calculated by our algorithm is generally high and in the presented experimental design smaller than 0.6 * 10E-6.

[Expression of early placenta insulin-like growth factor (EPIL) in breast cancer cells provides an autocrine loop with enhancement of predominantly HER-2-related invasivity]

AIMS

Recently, we were able to show that the expression of early placenta insulin like growth factor (EPIL) is expressed by highly motile HER-2-positive breast cancer cells in vitro (Brandt et al., Cancer Res. 2002) in Paget cells in vivo and indicates a poor clinical prognosis, irrespectively of other prognostic factors.

METHODS

In order to demonstrate the interplay between HER-2 and Epil we established a cellular model for high simultaneous Epil and HER-2 expression. The HER-2-positive breast cancer cell line SKBR3 was modified with an EPIL expression vector. In addition, an assay for the knockdown of EPIL-expression via siRNA was established. Erk1/2 expression was measured via Western Blot. The phenotype of the viable cells was determined by laser scan microscopy.

RESULTS

Epil overexpression in SKBR3 cells resulted in fast and frequent protrusion formation of the cells shown by laser scan microscopy. The cells were further characterized by a significantly increased invasiveness, which could be reversed by Epil specific siRNA treatment. Increased invasiveness and morphological changes were associated with a decreased erk1/2 phosphorylation.

CONCLUSIONS

These data further supports the assumption that EPIL might provide an autocrine loop in HER-2-positive breast cancer cells that enforce metastasis, conceivably escape from adjuvant therapy and in consequence poor clinical outcome. A tight interaction between HER-2 and EPIL in invasive breast cancer cells is therefore likely. The exact mechanims remain to be elucidated.

Ck5-positive cells are precursor cells of glandular and myoepithelial cell lineages in the human breast epithelium. A new cell concept as a basis for a better understanding of proliferative breast disease?

The question of whether stem cells exist in the human breast has never been satisfactorily resolved. Using a double immunofluorescence technique for simultaneous demonstration of cytokeratin subgroups 5, 8/18/19 and the differentiation marker smooth muscle actin, we provided direct evidence of the existence of a Ck5-positive cells that differentiate to either the glandular or myoepithelial cell lineage via intermediary cells. We postulate that the Ck5-positive cells are phenotypically and behaviourally committed adult stem cells. We further provide evidence that benign proliferative breast disease lesions resemble normal breast epithelium, whereas most breast carcinomas phenotypically consist of glandularly differentiated cells. The results were corroborated biochemically by Western blotting techniques. This cell biological model provides a new tool which helps to distinguish benign and malignant breast lesions. Furthermore this model provides a basis to unravel the regulatory mechanisms that govern normal and pathological cell growth.

Deciphering a subgroup of breast carcinomas with putative progression of grade during carcinogenesis revealed by comparative genomic hybridisation (CGH) and immunohistochemistry

Distinct parallel cytogenetic pathways in breast carcinogenesis could be identified in recent years. Nevertheless, it remained unclear as to which tumours may have progressed in grade or which patterns of cytogenetic alteration may define the switch from an in situ towards an invasive lesion. In order to gain more detailed insights into cytogenetic mechanisms of the pathogenesis of breast cancer, the chromosomal imbalances of 206 invasive breast cancer cases were characterised by means of comparative genomic hybridisation (CGH). CGH data were subjected to hierarchical cluster analysis and the results were further compared with immunohistochemical findings on tissue arrays from the same breast cancer cases. The combined analysis of immunohistochemical and cytogenetic data provided evidence that carcinomas with gains of 7p, and to a lesser extent losses of 9q and gains of 5p, are a distinct subgroup within the spectrum of ductal invasive grade 3 breast carcinomas. These aberrations were associated with a high degree of cytogenetic instability (16.6 alterations per case on average), 16q-losses in over 70% of these cases, strong oestrogen receptor expression and absence of strong expression of p53, c-erbB2 and Ck 5. These characteristics provide strong support for the hypothesis that these tumours may develop through stages of well- and perhaps intermediately differentiated breast cancers. Our results therefore underline the existence of several parallel and also stepwise progression pathways towards breast cancer.