Characterization of a family with rare deletions in CNTNAP5 and DOCK4 suggests novel risk loci for autism and dyslexia

BACKGROUND

Autism spectrum disorders (ASDs) are characterized by social, communication, and behavioral deficits and complex genetic etiology. A recent study of 517 ASD families implicated DOCK4 by single nucleotide polymorphism (SNP) association and a microdeletion in an affected sibling pair.

METHODS

The DOCK4 microdeletion on 7q31.1 was further characterized in this family using QuantiSNP analysis of 1M SNP array data and reverse transcription polymerase chain reaction. Extended family members were tested by polymerase chain reaction amplification of junction fragments. DOCK4 dosage was measured in additional samples using SNP arrays. Since QuantiSNP analysis identified a novel CNTNAP5 microdeletion in the same affected sibling pair, this gene was sequenced in 143 additional ASD families. Further polymerase chain reaction-restriction fragment length polymorphism analysis included 380 ASD cases and suitable control subjects.

RESULTS

The maternally inherited microdeletion encompassed chr7:110,663,978-111,257,682 and led to a DOCK4-IMMP2L fusion transcript. It was also detected in five extended family members with no ASD. However, six of nine individuals with this microdeletion had poor reading ability, which prompted us to screen 606 other dyslexia cases. This led to the identification of a second DOCK4 microdeletion co-segregating with dyslexia. Assessment of genomic background in the original ASD family detected a paternal 2q14.3 microdeletion disrupting CNTNAP5 that was also transmitted to both affected siblings. Analysis of other ASD cohorts revealed four additional rare missense changes in CNTNAP5. No exonic deletions of DOCK4 or CNTNAP5 were seen in 2091 control subjects.

CONCLUSIONS

This study highlights two new risk factors for ASD and dyslexia and demonstrates the importance of performing a high-resolution assessment of genomic background, even after detection of a rare and likely damaging microdeletion using a targeted approach.

Retrograde fixation of fractures of the neck and shaft of the humerus with the 'Halder humeral nail'

The Halder humeral nail is a new intramedullary device designed for displaced two part humeral neck and shaft fractures. It is inserted retrograde from the olecranon fossa and a unique trio wire is inserted through the nail to provide good proximal fixation. This avoids the use of proximal screws and damage to the rotator cuff thereby ensuring good rotator cuff function. The results of 100 cases are presented. At 6 weeks, 95 patients could perform the majority of daily tasks. There were four non-unions, one following a deep infection.

A randomized, double blind, Phase III trial using oral beta-carotene supplementation for women with high-grade cervical intraepithelial neoplasia

To evaluate the effect of daily beta-carotene (30 mg) versus placebo over a 2-year period on cervical intraepithelial neoplasia (CIN) 2 and 3 lesions. Human papillomavirus (HPV) typing was done to determine whether lesion regression was related to HPV. Micronutrient levels were measured to determine whether levels were predictive of regression. Variables that influence the risk of HPV infection and CIN, such as cigarette smoking and sexual behavior, were evaluated. Women were randomized to beta-carotene or placebo, with cytology and colposcopy every 3 months. Cervical biopsies were performed before treatment and after 6 and 24 months to evaluate response. Persistence of or progression to CIN 3 resulted in removal from the study, whereas treatment continued for 2 years on all others. The presence and type of HPV was determined by PCR. Response was defined as an improvement in CIN by 2 grades. Mantel-Haenszel chi(2) test was used to analyze response to treatment. Fisher's exact test was used to determine the effect of HPV and CIN grade on response Wilcoxon's rank-sum tests were used to compare micronutrient levels between groups. Twenty-one of 124 enrolled women were not randomized because they either moved, became pregnant, voluntarily withdrew, or the pathological review of their initial cervical biopsies did not confirm CIN 2 or 3. Of the remaining 103 women, 33 experienced lesion regression, 45 had persistent or progressive disease, and 25 women did not complete the study and were considered nonresponders in the final analysis. The overall regression rate (32%) was similar between treatment arms and when stratified for CIN grade. Data on 99 women with HPV typing showed that 77% were HPV-positive and 23% HPV-negative at enrollment. HPV-positive lesions were subdivided into indeterminate-, low-, and high-risk categories; the response rate was highest for women with no HPV detected (61%), lower for indeterminate/low-risk (30%), and lowest for high-risk (18%; P =.001). CIN regression was negatively correlated with retinol levels. In conclusion, beta-carotene does not enhance the regression of high-grade CIN, especially in HPV-positive subjects.

In situ duct carcinoma of the breast: clinical and histopathologic factors and association with recurrent carcinoma

There has been a recent increase in the diagnosis of in situ duct carcinoma of the breast (DCIS) as a result of mammographic screening. DCIS is heterogeneous in appearance and likely in prognosis. There is no generally accepted model to predict progression to invasive carcinoma. We investigated the prognostic effect of clinical presentation and pathologic factors for women diagnosed with primary DCIS. A cohort of 124 patients was accrued between 1979 and 1994 and was followed to 1997; 78 had DCIS detected mammographically, and 88 underwent lumpectomy alone. In this article, we provide details about characteristics affecting the choice of primary therapeutic modality, and we examine the effects of factors on progression for the two patient subgroups. Presentation with bloody nipple discharge was associated with a significant increase in DCIS recurrence (p=0.07). The pattern of duct distribution was important: DCIS in which the involved ducts were more widely separated had a significantly greater recurrence of DCIS than when the involved ducts were more concentrated (p=0.08 for mammographically detected DCIS, p=0.07 for patients who underwent lumpectomy alone). For mammographically detected DCIS, younger patients had more DCIS recurrence (p=0.07). We found considerable heterogeneity in nuclear grade; 50% of patients exhibited more than one grade. Nuclear grade, necrosis, and architecture were not significantly associated with either recurrence of DCIS or development of invasive carcinoma. Longer follow-up will allow further evaluation of the prognostic relevance of the factors assessed.

Phase II trial of oral altretamine for consolidation of clinical complete remission in women with stage III epithelial ovarian cancer: a Southwest Oncology Group trial (SWOG-9326)

OBJECTIVE

The aim of this study was to evaluate the 2-year survival rate in a group of women in complete clinical remission (cCR) from Stage III ovarian cancer following front-line therapy who were then treated with a 6-month course of altretamine.

METHODS

Patients were documented to be in cCR by physical examination, computed tomography or magnetic resonance imaging scan, and serum CA-125. Treatment consisted of altretamine (Hexalen) 260 mg/m(2)/day po divided into four doses taken after meals and at bedtime for 14 of 28 days for six cycles. Based on previous experience in the Southwest Oncology Group, the treatment would be considered promising if the 2-year survival rate was > or = 65% as measured from study registration.

RESULTS

From 9/1/93 and 7/1/97, 112 patients were registered and 97 were fully evaluable. The majority of patients had optimally debulked (< or = 1 cm: 63%), high-grade (Grade 3: 82%) tumors. The 2-year survival rate in this study was 75% (95% CI: 66-84%). For those patients with optimal disease, the 2-year survival rate was 82% (95% CI: 72-92%) and for those with suboptimal disease it was 64% (95% CI: 48-79%). Four patients (4%) experienced Grade 4 and 21 patients (22%) experienced Grade 3 toxicities consisting primarily of nausea/vomiting, neutropenia, fatigue, anxiety, and paresthesias.

CONCLUSIONS

The 2-year survival rate in this study warrants further evaluation of consolidation therapy for women in clinical complete remission following front-line chemotherapy for Stage III ovarian cancer. Caution is advised in the interpretation of these data, however, because of the nonrandomized nature of the trial and the unknown contribution of front-line use of paclitaxel to the durability of clinical complete response.

Metamorphic development of the bronchial columella of the larval bullfrog (Rana catesbeiana)

Histological and immunohistochemical analyses of head and respiratory structures in bullfrog (Rana catesbeiana) tadpoles were undertaken to address the hypothesis that the bronchial columella (BC) is the primary sound conduction pathway in these larval anurans. In postembryonic tadpoles, the BC is composed of fibroblasts surrounded by a Type I collagen matrix, with Type II collagen located in basement membranes at the distal ends. It provides a highly flexible tendon-like attachment between the round window and the membranous sac of the primary bronchus of the ipsilateral lung. As the animals approach metamorphic climax stages, the fibroblasts decrease in number and the BC becomes almost exclusively collagenous. During metamorphic climax, the BC degenerates and is completely resorbed by the time the animal becomes a postmetamorphic froglet. At all larval stages examined, the BC is structurally and immunohistochemically different from both the opercularis muscle of tadpoles and the tympanic columella (stapes homolog) of postmetamorphic animals. These observations suggest that the BC may not be rigid enough to provide an effective coupling between the lungs and the round window. An alternative hypothesis for the function of the BC, based on its structure, is presented.

Heightened expression of cyclooxygenase-2 and peroxisome proliferator-activated receptor-delta in human endometrial adenocarcinoma

Epidemiological studies indicate that nonsteroidal anti-inflammatory drugs (NSAIDs) significantly reduce the risk and mortality from colorectal cancer, in part by inhibiting prostaglandin (PG) synthesis. Cyclooxygenase (COX), the rate-limiting enzyme in PG biosynthesis, exists in two isoforms, COX-1 and COX-2. Genetic and pharmacological evidence suggest that COX-2 is involved in the development of colorectal cancer. We have previously shown that COX-2-derived prostacyclin participates in blastocyst implantation through activation of peroxisome proliferator activated receptor delta (PPARdelta), a member of the nuclear hormone receptor family. Furthermore, our recent studies suggest that a similar pathway is operative during colorectal carcinogenesis. These observations prompted us to examine whether the COX-2-PPARdelta signaling pathway is also involved during development of uterine adenocarcinoma. Here we describe for the first time the heightened expression of COX-2 and PPARdelta, but not COX-1, in uterine endometrial adenocarcinoma.

Factors associated with local breast cancer recurrence after lumpectomy alone: postmenopausal patients

BACKGROUND

We have been following a cohort of patients who underwent a lumpectomy without receiving adjuvant radiotherapy or adjuvant systemic therapy. We now report the experience of a postmenopausal subgroup.

METHODS

The postmenopausal subgroup included 244 patients accrued between 1977 and 1986 and followed up. The end point was ipsilateral local breast cancer recurrence. The factors studied were the patient's age in years; tumor size (in mm); nodal status (N-, Nx, N+); estrogen and progesterone receptor status (< 10, - 10 fmol/mg protein); presence or absence of lymphovascular/perineural invasion; presence or absence, and type, of DCIS (none, non-comedo, comedo); percentage of DCIS; histological grade (1,2,3); and nuclear grade (1,2,3). Univariate analyses consisted of Kaplan-Meier plots and the Wilcoxon (Peto-Prentice) test statistic; the multivariate analyses were step-wise Cox and log-normal regressions.

RESULTS

The median follow-up of those patients still alive was 9.1 years, and the overall relapse rate was 24% (59/244). The univariate results indicated that the characteristics of smaller tumor size, negative nodes, positive ER status, and no lymphovascular or perineural invasion were associated with significantly (P <.05) lower relapse. From the multivariate analyses, the factors lymphovascular or perineural invasion, age, and amount of DCIS were all significantly associated with local relapse with both Cox and log-normal regressions. Additionally, there was weak evidence of an association between ER (P = .08 in the Cox regression and in the log-normal) and nodal status (P = .09 in the log-normal regression) with local relapse. We also are able to define a low-risk subgroup (N-, age -65, no comedo, ER positive, no emboli) with a crude 10-year local recurrence rate of 9%.

CONCLUSION

With longer follow-up, and for postmenopausal patients, there continues to be support for the theory that local relapse is affected by the factors lymphovascular or perineural invasion, age, amount of DCIS, ER, and nodal status. A low risk subgroup has been identified.

Factors affecting distant disease-free survival for primary invasive breast cancer: use of a log-normal survival model

BACKGROUND

Invasive breast cancer is a frequently diagnosed disease that now comes with an ever expanding array of therapeutic management options. We assessed the effects of 20 prognostic factors in a multivariate context.

METHODS

We accrued clinical data for 156 consecutive patients with stage 1-3 primary invasive breast cancer who were diagnosed in 1989-1990 at the Henrietta Banting Breast Center, and followed to 1995. There is complete follow-up for 91% of patients (median follow-up of 4.9 years). The event of interest was distant recurrence (for distant disease-free survival, DFS). We used Cox and log-normal step-wise regression to assess the multivariate effects of the following factors on DFS: age, tumor size, nodal status, histology, tumor and nuclear grade, lymphovascular and perineural invasion (LVPI), ductal carcinoma-in-situ (DCIS) type, DCIS extent, DCIS at edge of tumor, ER and PgR, ERICA, adjuvant systemic therapy, ki67, S-phase, DNA index, neu oncogene, and pRb.

RESULTS

There was strong evidence against the Cox assumption of proportional hazards for nodal status, and nodal status was not in the Cox step-wise model. With step-wise log-normal regression, a large tumor size (P < .001), positive nodes (P = .002), high nuclear grade (P = .01), presence of LVPI (P = .03), and infiltrating duct carcinoma not otherwise specified (P = .05) were associated with a reduction in DFS.

CONCLUSIONS

For nodal status, there was strong evidence against the Cox assumption of proportional hazards, and it was not included in the Cox model although it was in the log-normal model. Only traditional factors were included in the step-wise models. Thus, this statistical management of prognostic markers in breast cancer appears to be very important.

Interspecific variation of zona pellucida glycoconjugates in several species of marsupial

The zona pellucida glycoconjugate content of several marsupial species was investigated using differential lectin histochemistry. Ovaries from fat-tailed dunnarts, a southern brown bandicoot, grey short-tailed opossums, brushtail possums, ringtail possums, koalas and eastern grey kangaroos were fixed, embedded in paraffin wax, sectioned and stained with ten fluorescein isothiocyanate-conjugated lectins. Sections were also incubated with either neuraminidase or saponified, respectively, before incubation with the lectins to identify saccharide residues masked by sialic acids or O-acetyl groups on sialic acids. The zonae pellucidae surrounding the oocytes of the marsupials demonstrated interspecific variation in glycoconjugate content, with mannose-containing glycoconjugates exhibiting the greatest variation. Some of the zona pellucida glycoconjugates of all species, except those of the opossums, were masked by sialic acid with an increase in fluorescence with lectins from Arachis hypogea (PNA), and Glycine max (SBA), after desialylation. The disaccharide beta-galactose(1-4)N-acetyl-D-glucosamine appeared to be conformationally masked by O-acetyl groups of sialic acids in the zonae pellucidae of all species, with an increase in fluorescence with the lectin from Erythrina cristagalli (ECA), after saponification. Similar intensity and localization of beta-(1-4)-N-acetyl-D-glucosamine, as shown by staining of the lectin from Triticum vulgaris (WGA), to the inner and outer regions of the zona pellucida, were found to those reported in eutherian species. WGA fluorescence became uniform throughout the zonae pellucidae after saponification, indicating differential O-acetylation of sialic acids on the internal compartment of the zonae pellucidae.

Interspecific variation of zona pellucida glycoconjugates in several species of marsupial

The zona pellucida glycoconjugate content of several marsupial species was investigated using differential lectin histochemistry. Ovaries from fat-tailed dunnarts, a southern brown bandicoot, grey short-tailed opossums, brushtail possums, ringtail possums, koalas and eastern grey kangaroos were fixed, embedded in paraffin wax, sectioned and stained with ten fluorescein isothiocyanate-conjugated lectins. Sections were also incubated with either neuraminidase or saponified, respectively, before incubation with the lectins to identify saccharide residues masked by sialic acids or O-acetyl groups on sialic acids. The zonae pellucidae surrounding the oocytes of the marsupials demonstrated interspecific variation in glycoconjugate content, with mannose-containing glycoconjugates exhibiting the greatest variation. Some of the zona pellucida glycoconjugates of all species, except those of the opossums, were masked by sialic acid with an increase in fluorescence with lectins from Arachis hypogea (PNA), and Glycine max (SBA), after desialylation. The disaccharide beta-galactose(1-4)N-acetyl-D-glucosamine appeared to be conformationally masked by O-acetyl groups of sialic acids in the zonae pellucidae of all species, with an increase in fluorescence with the lectin from Erythrina cristagalli (ECA), after saponification. Similar intensity and localization of beta-(1-4)-N-acetyl-D-glucosamine, as shown by staining of the lectin from Triticum vulgaris (WGA), to the inner and outer regions of the zona pellucida, were found to those reported in eutherian species. WGA fluorescence became uniform throughout the zonae pellucidae after saponification, indicating differential O-acetylation of sialic acids on the internal compartment of the zonae pellucidae.

Update on airborne mold and mold allergy

In considering the clinical aspects of fungal sensitivity, assessing exposure potential and clinical testing are essential. Valid prevalence data are difficult to secure. For ambient air, the Burkard Volumetric Spore Traps, or equal, capture spores best. For in-home analysis for fungi, the history and personal inspection of the house remains the most available method of assessment. Allergy skin test material is unavailable for most airborne fungi. Those that are available are not standardized. Yet the practicing allergist/clinical immunologist must select what fungal extract are available based on air sampling data and personal exposure of the patient. A major management approach with patients with proven sensitivity to fungal antigens and a clear correlation with clinical illness is avoidance of fungal sources. Immunotherapy should be considered when avoidance and well tolerated pharmacotherapy are ineffective in controlling the patient's symptoms.

Growth of sea cucumber collagen fibrils occurs at the tips and centers in a coordinated manner

Collagen fibrils are the principle source of mechanical strength in the mutable dermis of the sea cucumber Cucumaria frondosa. To obtain information about the mechanism by which collagen molecules self-assemble into fibrils, we have isolated single intact fibrils with lengths in the range 14-444 microm. These fibrils have been studied by scanning transmission electron microscopy, yielding data that show how cross-sectional mass, and hence the number of molecules in the cross-section, depend on axial location. In an individual fibril, the two ends always display similar mass distributions. The two tips of each fibril must therefore maintain identity in shape and size throughout growth. The linear relationship between cross-sectional mass and distance from the adjacent end shows that a growing tip is (like the tip of a vertebrate collagen fibril) paraboloidal in shape. Comparison of data from many different fibrils, over a wide range of lengths, however, revealed that the paraboloidal tip becomes blunter as the fibril grows in length. In contrast to vertebrate fibrils, those from C. frondosa do not have a central shaft region of constant cross-sectional mass. Rather, the cross-sectional mass increases to a maximum in the center of each fibril. The maximum cross-sectional mass of the fibrils increases exponentially with increasing fibril length. The centrosymmetry, the paraboloidal shape of the tips, and the hyperbolic increase in maximum cross-sectional mass with fibril length, is evidence for a co-ordinated regulation of length and diameter, which differs from the kind of regulation that gives rise to collagen fibrils in vertebrates (chickens and mice).

Assessment of treatment for patients with primary ductal carcinoma in situ in the breast

BACKGROUND

Current mammographic technology has resulted in increased detection of ductal carcinoma in situ (DCIS). It is necessary to assess which patients presenting with DCIS are good candidates for breast conservation and which of these patients should receive adjuvant radiation.

METHODS

We accrued clinical data for 124 patients with a primary diagnosis of DCIS from 1979 through 1994. Primary therapy was a mastectomy for 18 patients, and a lumpectomy for 106 patients. Only 18 of the latter group of patients received adjuvant radiotherapy. For the 88 lumpectomy-alone patients (median follow-up, 5.2 years), we evaluated the effects of clinical (age and initial presentation) and pathologic (nuclear grade, architecture, parenchymal involvement, calcifications, and measured margins) factors on recurrence of DCIS or the development of invasive breast cancer.

RESULTS

Patients who underwent lumpectomy with or without adjuvant radiotherapy (median follow-up, 5.0 years) were significantly more likely to have recurrence of DCIS (P=.05) than those who underwent mastectomy (median follow-up, 6.7 years): 18% (19/106) versus 0% (0/18), respectively; lumpectomy-alone patients experienced a 19% (17/88) rate of DCIS recurrence. All recurrent DCIS was ipsilateral. For lumpectomy-alone patients, the factors associated with ipsilateral recurrence of DCIS were extent of involvement of the parenchyma (P=.01, for univariate; P=.07, for multivariate) and initial presentation (P=.05, for univariate; P=.07, for multivariate). Eleven lumpectomy-alone patients developed invasive breast cancer (6 ipsilateral, 5 contralateral); none of the 18 lumpectomy patients who received adjuvant radiation developed invasive disease. None of the factors investigated, including primary surgery and adjuvant radiotherapy, were associated with a significant effect on the development of invasive disease.

CONCLUSIONS

Longer follow-up is required to determine if the benefits of either mastectomy or radiotherapy following lumpectomy persist. There is a suggestion that patients under 40 years of age or women who present with nipple discharge might be considered for either adjuvant radiotherapy following lumpectomy or a simple mastectomy.

Assessment of tumor size for multifocal primary breast cancer

BACKGROUND

Tumor size affects the choice of surgical procedure and patient prognosis. It is standardly assessed as the largest unidimensional measurement and, for multifocal disease, as the largest size of the largest focus. We examine some different methods of assessing tumor size: the standard method; the sum of the largest sizes for all foci; surface area; and volume.

METHODS

Data for a cohort of 678 primary invasive breast cancer patients accrued from 1971 to 1990 were updated to 1996; there were 571 patients with unifocal disease and 107 patients with multifocal disease. We used step-wise Cox regression to investigate the effects on time to death of the prognostic factors tumor size (estimated in one of the four ways), age, nodal status, ER, PgR, adjuvant radiotherapy, adjuvant hormonal therapy, and adjuvant chemotherapy. We also examined the association between tumor focality and nodal status.

RESULTS

For all patients, tumor size was included in the multivariate model, regardless of estimation method. For patients with multifocal disease, tumor size was included in the final model only when it was estimated as the total surface area (P = .03) or volume (P = .01) of the foci. More multifocal patients were N+ (P = .056).

CONCLUSIONS

For patients with multifocal disease, the significance association with mortality for total surface area or volume may imply a biologic relevance or mode of tumor activity for the foci.

Competing causes of death for primary breast cancer

BACKGROUND

A patient's likelihood of dying from breast cancer or another cause can be assessed with competing risks analyses.

METHODS

Data for a cohort of 678 patients with primary invasive breast cancer accrued from 1971 to 1990, updated to 1995, included cause of death (e.g., breast cancer vs. other cause). We investigated the effects of age, tumor size, nodal status, ER, PgR, and adjuvant therapy (hormones, chemotherapy, radiotherapy) on type of death and time to death for patients of all ages and for those over the age of 65 years.

RESULTS

Although there were no significant univariate differences in breast cancer death rates by age group (P=0.94), more patients over the age of 65 years died from other causes (41/207 [20%] of those older than 65 years vs. 16/471 [3%] of those younger than 65 years; P <.001). In competing risks analyses, older age was associated with non-breast cancer death, whereas larger tumor size was associated with breast cancer death. PgR was positively, and nodal status negatively, associated with survival, regardless of type. In the older patient group, the competing risks analyses identified similar effects for age and tumor size; in addition, higher ER assay values were less likely to be associated with breast cancer death.

CONCLUSIONS

With increased lifespan, there will be more breast cancer cases in women older than 65 years; we have shown that women in this group have more non-breast cancer deaths. It becomes important, then, to delineate differential effects of prognostic factors on competing causes of death.

Child sexual abuse in KwaZulu-Natal, South Africa

This paper discusses child sexual abuse in a hospital serving a largely rural population in Eshowe, KwaZulu-Natal, South Africa during a period of 9 years and 2 months. Child sexual abuse was a significant problem. The incidence of sexually transmitted diseases at presentation was high (65.9%). The abuser, when identified, was more commonly an acquaintance or stranger than a family member. The shortage of resources in 'third world' countries means that medical personnel must take the lead in identifying and managing children with sexual abuse. Frequently they must assume additional roles, such as that of social worker, if management is to be successful. However, high patient case loads in these situations make this difficult and therefore child sexual abuse may not be adequately dealt with. A possible solution to this problem is the use of outside agencies to research the problem and the establishment of regional special units to manage child abuse.

Vascular injuries in total knee arthroplasty. A review of the problem with special reference to the possible effects of the tourniquet

Considering the proximity of the major vascular structures to the back of the knee, vascular complications of total knee arthroplasty are relatively rare. A patient who developed acute vascular insufficiency immediately following a total knee arthroplasty is reported. This stimulated a survey of arterial complications encountered by members of the British Association for the Surgery of the Knee. The majority of surgeons still use a tourniquet but will modify their practice if there is anxiety about vascular status. The mechanism of injury to the vascular system is either direct trauma or thrombosis. The outcome following treatment after direct injury is extremely good. The outcome after thrombosis is extremely poor. There is no recorded case of thrombosis occurring when a tourniquet was not used. Whether all knee arthroplasties should be done without a tourniquet is discussed. Early intervention is vital if a vascular injury is suspected.

Assessing genetic markers of tumour progression in the context of intratumour heterogeneity

This is a report from the Kananaskis working group on quantitative methods in tumour heterogeneity. Tumour progression is currently believed to result from genetic instability and consequent acquisition of new genetic properties in some of the tumour cells. Cross-sectional assessment of genetic markers for human tumours requires quantifiable measures of intratumour heterogeneity for each parameter or characteristic observed; the relevance of heterogeneity to tumour progression can best be ascertained by repeated assessment along a tumour progressional time line. This paper outlines experimental and analytic considerations that, with repeated use, should lead to a better understanding of tumour heterogeneity, and hence, to improvements in patient diagnosis and therapy. Four general principles were agreed upon at the Symposium: (1) the concept of heterogeneity requires a quantifiable definition so that it can be assessed repeatably; (2) the quantification of heterogeneity is necessary so that testable hypotheses may be formulated and checked to determine the degree of support from observed data; (3) it is necessary to consider (a) what is being measured, (b) what is currently measurable, and (c) what should be measured; and (4) the proposal of working models is a useful step that will assist our understanding of the origins and significance of heterogeneity in tumours. The properties of these models should then be studied so that hypotheses may be refined and validated.

Promotion of breast cancer screening in communities: a research agenda

This paper used the National Cancer Institute of Canada (NCIC) cancer control framework to review research on participation in breast cancer screening programs and identify areas for further study. Cancer Lit, MEDLINE, CINAHL, Sociofile, Health and the Public Affairs Information Service databases were searched for literature published from 1990 to 1995. Information was also obtained from provincial breast cancer screening programs and Health Canada. Interventions designed to promote participation in screening programs have not been effective. Involvement of the target community, however, increased success and sustainability. Barriers to initial participation within screening programs include alternative sources of screening and the lack of funds to screen all eligible women. Studies show that participation decreases with successive screening rounds. The priorities for study are development of: a theoretical framework for recruitment strategies, a method to capture all Canadian screening results including those performed through provincial health insurance plans and a mechanism to deliver screening to all eligible Canadian women.

The effect of non-polar liquids and non-ionic detergents on the ultrastructure and assembly of rat tail tendon collagen fibrils in vitro

Non-ionic detergents or emulsions of non-polar liquids when added to solutions of rat tail tendon collagen (RTTC) or to the dispersed fibrils produced similar conspicuous ultrastructural modifications in the form of a D-periodic lesion between bands c2 and d in the 'gap region' of the fibril close to the start of the overlap region. The size and extent of the lesion in some fibrils indicates that at least some of the collagen molecules rupture. In an attempt to detect peptide fragments produced in this way we ran SDS-PAGE gels of collagen fibrils treated with the non-ionic detergent Triton X-100. These contained two peptides (44 and 32 kDa) not seen in controls. The lesions are thought to result from interactions between the hydrophobic part of non-polar liquids or detergents with an anomalous part of the fibril's D-period. The anomalous region has a high concentration of hydrophobic and alanyl residues but exceptionally few charged and hydroxyproline ones. We suggest that the anomalous region may play a part in storing and dissipating strain energy and permitting cross-link formation. Similar collagen-lipid interactions may occur under pathological conditions.

The Iowa Articulation Story. Collaboration works

Historically, Iowa has had a majority of diploma and associate degree nursing graduates. Although educational mobility for registered nurses to obtain baccalaureate nursing degrees was available in Iowa before 1991, direct nursing education articulation did not exist. The impetus for developing a statewide nursing articulation plan to facilitate the entry of registered nurses to baccalaureate nursing programs was the result of a recommendation from the Iowa Board of Nursing's 1988 Statewide Plan for Nursing. The Iowa Articulation Plan for Nursing Education: RN to Baccalaureate, implemented in 1991, resulted from collaboration among nurse educators from all levels of nursing and nursing service representatives. The plan consists of four separate options and can be adapted for use in other parts of the country. The Iowa articulation story describes the process used and outcomes achieved when nurses collaborate to advance nursing education.

Posterior dislocation of the shoulder with ipsilateral humeral shaft fracture: a very rare injury

A third case of a posterior dislocation of the shoulder with ipsilateral humeral shaft fracture is described. It is recommended that this difficult management problem requires internal fixation of the humeral shaft fracture to allow control of the shoulder.

Estrogen replacement in surgical stage I and II endometrial cancer survivors

OBJECTIVE

Our purpose was to evaluate our experience with estrogen replacement in women with a history of early-stage endometrial cancer and to determine whether it increased the risk for recurrence or death.

STUDY DESIGN

A retrospective review was performed of 123 women with surgical stage I and II endometrial adenocarcinoma treated between 1984 and 1994; 62 had received estrogen replacement therapy after cancer therapy. Sixty-one women received no estrogen. Variables analyzed included age parity, surgical stage, grade, depth of myometrial invasion, presence of intercurrent illnesses, duration of follow-up, and duration of estrogen replacement, if applicable. Outcome variables assessed included recurrence rate, time to recurrence, and disease-free interval.

RESULTS

The estrogen replacement therapy group had earlier stage disease (p = 0.04) and less severe depth of invasion (p = 0.003); however, the total number of deaths in each group was not significantly different. The disease-free survival in the estrogen replacement therapy group did not differ significantly compared with those not receiving estrogen replacement therapy. The data are suggestive of improved disease-free survival in the estrogen replacement therapy group, which may be related to differences in age, stage, grade, and depth of invasion. The overall recurrence rate was 6.5%, with an overall death rate of 1.6%.

CONCLUSIONS

There is no evidence to suggest that estrogen decreased the disease-free interval or increased the risk for recurrence in early-stage disease.

Enzymic control of collagen fibril shape

The shape of collagen fibrils growing in vitro in a cell-free enzyme/substrate system is shown to be dependent on the enzyme/substrate (E/S) ratio. Long fibrils with tapered ends were generated by exposing pCcollagen (procollagen from which the N-propeptides had been removed) to procollagen C-proteinase (which acts by cleaving the C-propeptides from the pCcollagen, converting it to insoluble fibril-forming collagen). Tip shape profiles, established quantitatively by scanning transmission electron microscopy, depended critically on the C-proteinase/pCcollagen ratio. The finest tips occurred at low ratios, the coarsest at high ratios. All fibrils had molecules oriented with amino termini closest to the pointed ends, i.e. N,N-bipolar fibrils in which molecules change orientation abruptly at one location along the fibril. Fibrils had maximal diameter at this molecular switch region. Shape asymmetric fibrils occurred at low E/S ratios, near-shape symmetric fibrils occurred at high ratios. Fibrils generated at low E/S ratios bore the closest resemblance to those formed in vivo except that the central shaft regions of fibrils formed in vitro showed no tendency to be limited to a uniform diameter.

Combined fine-needle aspiration, physical examination and mammography in the diagnosis of palpable breast masses: their relation to outcome for women with primary breast cancer

OBJECTIVE

To examine the combined and individual predictive values of fine-needle aspiration (FNA), physical examination (PE) of the breast and mammography (the "triple test") in diagnosing breast cancer in relation to the results of open surgical biopsy.

DESIGN

A study of the records of patients who received both FNA and open surgical biopsy for the same palpable breast lump. The results of diagnostic assessment and open surgical biopsy were categorized as positive or negative. Concordance (percentage of tests found to be correct at biopsy), sensitivity, specificity (percentage of patients without breast cancer for whom the diagnostic test was negative) and positive predictive value (percentage of patients with a positive test found to have breast cancer) were determined for the triple test for each diagnostic modality. In addition, prognostic variables (tumour size, node positivity, estrogen and progesterone receptor status) and outcomes were assessed in patients with a diagnosis of breast cancer.

SETTING

A university-affiliated general hospital with a special focus on women's health.

PATIENTS

Of 290 patients who had both FNA and open surgical biopsy, 191 underwent all three diagnostic procedures.

MAIN OUTCOME MEASURES

The diagnostic accuracy of FNA, PE and mammography to permit preoperative definitive therapy or to allow observation without mandating open surgical biopsy.

RESULTS

In 81 patients all three diagnostic modalities were in agreement for a diagnosis of either benign or malignant disease; the concordance for the triple test was 98.8% specificity was 100% and sensitivity was 95.5%. Nodal status, tumour size and outcome were similar whether or not the triple test was positive, but, interestingly, when the triple-test results were positive, estrogen (p < 0.05) and progesterone (p < 0.03) receptor values were more likely to be negative.

CONCLUSIONS

When all three diagnostic modalities were in agreement for a diagnosis of malignant disease, the combination of FNA, PE and mammography had excellent concordance with the results of open surgical biopsy, and in this situation definitive treatment may be carried out. If all three modalities are in agreement for a diagnosis of benign disease, a period of close observation with repetition of FNA may be safely entertained. Lack of concordance of the three diagnostic modalities mandates biopsy. Triple-test positively does not predict a worse outcome.

Factors associated with local breast cancer recurrence after lumpectomy alone

BACKGROUND

The purpose was to determine the rate of local breast relapse in patients with breast cancer uniformly treated with partial mastectomy but without postoperative radiotherapy and without systemic adjuvant therapy. We also systematically examined the factors associated with local recurrence to determine whether a low-risk subgroup existed.

METHODS

A retrospective review of a prospectively followed (median, 8 years) cohort of 293 patients was performed. The end-point was ipsilateral local breast cancer recurrence. The patient's age, tumor size, nodal status, estrogen and progesterone receptor status, histology, and tumor and nuclear grade were studied, as were the presence and amount of carcinoma in situ and the presence of tumor emboli using univariate Kaplan-Meier and Cox step-wise multivariate analyses.

RESULTS

The overall local relapse rate was 26% (77 recurrences). Univariate factors significantly associated with decreased local relapse included older age, negative nodes, small tumor size, positive estrogen receptor status, and absence of tumor emboli. Significant multivariate variables were age, nodal status, estrogen receptor status, absence of comedo carcinoma in situ, and tumor emboli. A low-risk subgroup of 66 patients was defined with a 6% 10-year local recurrence rate.

CONCLUSION

Important patient and tumor variables associated with local breast cancer relapse after breast-conserving surgery can define a low-risk subgroup.

Collagen fibril formation

Collagen is most abundant in animal tissues as very long fibrils with a characteristic axial periodic structure. The fibrils provide the major biomechanical scaffold for cell attachment and anchorage of macromolecules, allowing the shape and form of tissues to be defined and maintained. How the fibrils are formed from their monomeric precursors is the primary concern of this review. Collagen fibril formation is basically a self-assembly process (i.e. one which is to a large extent determined by the intrinsic properties of the collagen molecules themselves) but it is also sensitive to cell-mediated regulation, particularly in young or healing tissues. Recent attention has been focused on "early fibrils' or "fibril segments' of approximately 10 microns in length which appear to be intermediates in the formation of mature fibrils that can grow to be hundreds of micrometers in length. Data from several laboratories indicate that these early fibrils can be unipolar (with all molecules pointing in the same direction) or bipolar (in which the orientation of collagen molecules reverses at a single location along the fibril). The occurrence of such early fibrils has major implications for tissue morphogenesis and repair. In this article we review the current understanding of the origin of unipolar and bipolar fibrils, and how mature fibrils are assembled from early fibrils. We include preliminary evidence from invertebrates which suggests that the principles for bipolar fibril assembly were established at least 500 million years ago.

Clinical behavior of untreated axillary nodes after local treatment for primary breast cancer

BACKGROUND

The purpose of this study was to examine the rate of axillary failure in patients with primary breast cancer treated without axillary dissection or radiation and to determine what factors may be associated with axillary failure.

METHODS

We studied 112 patients with invasive breast cancer treated for primary disease with breast-conserving surgery without axillary dissection or radiation to the breast or axilla, accrued between 1977 and 1986. Data for these patients were prospectively gathered for a research database and reviewed retrospectively to determine axillary failure. The effects of age, tumor size, estrogen receptor (ER) status, progesterone receptor (PgR) status, histologic grade, nuclear grade, and tumor emboli on time to axillary failure were examined.

RESULTS

The median follow-up was 9.6 years. There were 26 axillary recurrences, resulting in a 10-year actuarial nodal control rate of 72%. Patients with nodal failure proceeded to axillary dissection with minimal morbidity. In both univariate and multivariate analyses, only tumor size was significantly associated with axillary failure (p = 0.04 and p = 0.06, respectively).

CONCLUSIONS

This study demonstrates a significant effect of tumor size on axillary failure and a reasonable rate of local control in small tumors. Further research should examine the utility of axillary dissection in women with small breast cancers.

The Henrietta Banting Breast Centre database: a model for clinical research utilizing a hospital-based inception cohort

The cohort study design has been used successfully in clinical cancer research. Cohorts, however, are valuable only if they produce results which are valid and generalizable. Some hospital-based inception cohorts satisfy both these requirements and may thus be useful research tools. The development of one such hospital-based cohort, the Henrietta Banting Breast Centre database, is described. This cohort is composed of 1097 women diagnosed with primary breast cancer at Women's College Hospital, Toronto, from January 1977 through December 1986. Details of diagnostic procedures, pathology, treatment, dates and sites of recurrence, and date of death are available on 96% of women. By comparison with published series and with the Ontario Cancer Registry, we have demonstrated validity and generalizability. A major advantage is the ready availability of paraffin tissue blocks on virtually all cases, facilitating analyses of the prognostic importance of specific biologic variables and immunocytochemical hormone assays. Other completed studies and future uses of the cohort are described.

Correlation of C-myc and HER-2/neu amplification and expression with histopathologic variables in uterine corpus cancer

OBJECTIVE

Initial studies of protooncogenes in uterine corpus cancer have focused on a single aspect of the gene in question (deoxyribonucleic acid, ribonucleic acid, protein) or have studied a small number of patients. Therefore we evaluated c-myc and HER-2/neu gene amplification and ribonucleic acid overexpression in such malignancies and correlated these molecular changes with known pathologic risk factors.

STUDY DESIGN

Quantitative Southern blot analysis for oncogene deoxyribonucleic acid was used to examine 37 tumors from patients with primary untreated uterine corpus cancer referred to the City of Hope National Medical Center. Six normal endometrial specimens were controls. Seventeen tumors were also examined by Northern blotting to assess increased ribonucleic expression.

RESULTS

Histologic types included adenocarcinoma (n = 30), papillary serous adenocarcinoma (n = 2), adenosquamous carcinoma (n = 2), mixed mullerian sarcoma (n = 2), and leiomyosarcoma (n = 1). Carcinomas were stage I (n = 10), II (n = 18), or III (n = 6). Twenty-three had myometrial invasion of less than one third, six one third to two thirds, and eight deeper invasion (greater than two thirds). According to the criteria of the International Federation of Gynecology and Obstetrics stage was as follows: I (n = 22), II (n = 3), III (n = 7), and IV (n = 5). Ten (27%) and four (11%) tumors showed gene amplification of c-myc and HER-2/neu, respectively. Six demonstrated overexpression of either the c-myc or HER-2/neu gene. HER-2/neu gene amplification was associated more closely with overexpression. Stepwise logistic analysis demonstrated c-myc amplification to be associated with higher grade (p = 0.01).

CONCLUSION

In this referral population, c-myc activation is more common than HER-2/neu activation in uterine corpus cancer and is associated with tumors of higher grade.

Vertebrate (chick) collagen fibrils formed in vivo can exhibit a reversal in molecular polarity

A reversal in molecular polarity can occur in vertebrate collagen fibrils. This has been demonstrated using a method for isolating, from chick embryo tendon, entire collagen fibrils 2 to 14 microns in length and suitable for electron-optical examination. A polarity reversal is present in some, but not all, of these fibrils. Such fibrils have two N-ends. The transition region, occupying several D-periods in which the reversal occurs, is not restricted to a central location in a fibril. Analysis of the fibril banding pattern through the transition region shows that the relative axial alignment of antiparallel molecules brings oppositely-directed C-telopeptides into axial register. This could allow antiparallel molecules to be covalently linked via polymeric cross-links involving these C-telopeptides.

Characteristics of local recurrence following lumpectomy for breast cancer

We report the clinical characteristics and treatment of local breast relapse in our breast cancer patients who were initially managed with breast conservation surgery (lumpectomy) alone. A retrospective study was conducted of 366 patients who were treated since 1977. The clinical, pathological, and treatment data regarding the primary tumor and the recurrences (91) were reviewed. The actuarial rate of local breast relapse in this group was 31% at 10 years. Breast relapse was significantly less in those patients 65 years old or greater. Acceptable treatment of the breast relapse included total mastectomy or repeat lumpectomy plus radiotherapy. Most relapses were small and occurred in the same area as the original tumor and had similar histology and estrogen and progesterone receptor values. About one-third of patients will have isolated relapses after conservation surgery alone, but in the older age group, isolated breast relapse occurs less frequently. The recurrences are usually surgically resectable, and acceptable results can be achieved with salvage surgery.

Word meaningfulness and event-related potentials during phrase processing

Evoked Potentials (EP) were recorded to visual presentation of words in phrases. Three EP components, P250, N400, P560, and their dependence on the role that each word plays in the phrase were studied. Subjects were requested to perform a congruity/incongruity task after the presentation of short phrases of two-types that differed in the position of meaningful keywords. We show how these keywords contribute substantially to N400 and possibly to P560 but do not reliably affect P250.

The standardization of estrogen receptors

Tumour estrogen receptor (ER) status may determine the medical treatment of a patient with breast cancer; yet inter-laboratory results can vary markedly, particularly when absolute cut-offs in fmol/mg cytosol protein are used. The use of standardized log units is proposed to permit greater inter-laboratory comparability. We have assessed the biochemical ER values using the dextran-coated charcoal method with three data sets, two quality control (QC) sets for Ontario laboratories and a data set with values for 184 primary breast cancer patients seen at Women's College Hospital (WCH) between 1985 and 1986. The distributions for all the raw data were skewed toward the lower end of the range; a log transformation improved the symmetry of the distributions. There was marked inter-laboratory variation in the QC data, and standardized log units greatly reduced this variability. The WCH data had similar differentiation by tumour size and nodal status with both the raw data and standardized log units. However, standardized log units provided more consistent evidence of an association between ER and immunohistochemical ERICA. The standardized log units provide quantitative receptor values suitable for multi-centre research, for future work with clinical outcomes, and for the daily management of patients.

Effect of administration route and estrogen manipulation on endometrial uptake of Photofrin porfimer sodium

OBJECTIVE

Our purpose was to evaluate the influence of the route of drug administration and target tissue vascularity on the distribution of a photosensitizer, Photofrin porfimer sodium, in the uterus.

STUDY DESIGN

The study was divided in two phases. In phase I 80 mature female rats were hormonally suppressed and then stimulated with estrogen. They were randomized to receive intravenous, intraperitoneal, or intrauterine Photofrin and killed 3, 6, 24, or 48 hours later. Drug distribution and levels were then determined. In phase II 40 female rats were randomized to receive hormonal stimulation, suppression, both, or neither. All received intrauterine Photofrin and were killed 24 hours later. Statistical analysis was performed with the unpaired t test and the two-way analysis of variance.

RESULTS

Intrauterine administration was determined to be the simplest and most effective method of delivery because it provided for optimal uptake and distribution (p = 0.05) within the uterus, at lower doses.

CONCLUSIONS

Selective localization of photosensitizer within the target tissue suggests that highly selective photodynamic destruction of endometrial tissue can be achieved. Furthermore, the combination of intrauterine administration of photosensitizer with estrogen adjuvant may minimize the most debilitating side effect of Photofrin, cutaneous phototoxicity.

Evidence for bimodal distribution of breast carcinoma ER and PgR values quantitated by enzyme immunoassay

Breast carcinoma oestrogen receptor (ER) and progesterone receptor (PgR) values obtained by radioligand binding assays have commonly been observed to have approximate log-normal distributions. We examined the distribution of log-transformed receptor values obtained by enzyme immunoassay for 5468 primary breast carcinomas in five Ontario laboratories. In each laboratory, it was found that the frequency histograms for the log transformed receptor values were not unimodal, and generally were suggestive of bimodality. This was not affected by stratification by age or inferred menopausal status (< or = 49, > or = 50 years), and could not be explained by kit characteristics. However, the low point in the distribution varied from 5 to 63 fmol/mg cytosol protein, depending on the receptor, patient age and laboratory. The tendency towards biomodality was more distinct for ER than for PgR. It remains to be determined whether the low points on the frequency histograms have clinical relevance for discriminating between hormone-sensitive and hormone-insensitive tumours.

The structured oral self-directed learning evaluation: one method of evaluating the clinical reasoning skills of occupational therapy and physiotherapy students

The Structured Oral Self-directed Learning Examination (SOSLE) is used to evaluate the clinical reasoning skills of occupational therapy (OT) and physiotherapy (PT) students. It is an oral examination which evaluates a student's problem-solving ability, self-directed learning skills, knowledge level and self-assessment ability. The three parts of the examination are conducted over a 24-hour period. Validation of this instrument was carried out in two groups of OT and PT undergraduate students over two consecutive years (Year 1--n = 20) (Year 2--n = 18). Inter-rater reliability correlations varied from 0.61 to 0.78 the first year to 0.85 to 0.99 in the second year. The results obtained from the SOSLE were also compared to written and tutorial marks obtained in the same course. Pearson Correlation Coefficients (PCC) among mean SOSLE and two written paper scores ranged from 0.0-0.05 (Year 1) to 0.0-0.1 (Year 2). The PCC among the mean SOSLE and tutorial performance scores were 0.57 (Year 1) and 0.0 (Year 2). The results show that good agreement between raters can be reached using this evaluation method. However, the poor correlations between the SOSLE and the other methods of evaluation may show that different skills are being evaluated. Further validity testing needs to be carried out to confirm that this tool is measuring process oriented skills.

Surgical treatment of unexpected invasive cervical cancer found at total hysterectomy

OBJECTIVE

To determine the proper management of patients found to have invasive cancer of the cervix on pathologic examination of a uterus removed for benign indications.

METHODS

We report 18 patients undergoing hysterectomy who were found to have cervical cancer with invasion deeper than 3 mm and/or lymph-vascular space involvement. None had gross residual tumor following simple hysterectomy. All patients underwent a second operation. Seventeen women underwent a radical parametrectomy, upper vaginectomy, and pelvic lymphadenectomy; one had pelvic and periaortic lymphadenectomy alone because of bilateral grossly positive obturator nodes.

RESULTS

Median follow-up was 72 months. One of the 15 women without residual disease or nodal involvement at second operation had pelvic recurrence 66 months after therapy. Three patients with disease identified at radical surgery underwent tailored postoperative pelvic radiation, and two of these had pelvic recurrence. The overall actuarial 5-year survival for the 18 patients was 89%. Operative morbidity was comparable to that of patients undergoing primary radical hysterectomy.

CONCLUSION

This study confirms that patients with unexpected invasive cervical cancer found at total hysterectomy can undergo radical re-operation with low morbidity and excellent cure rates.