Service screening mammography reduces breast cancer mortality among elderly women in Turku

OBJECTIVES

The aim of this study was to assess the effects of service screening mammography on breast carcinoma incidence and refined mortality among women aged 55-69 at entry in three cities employing different screening policies.

METHODS

Since 1987, the city of Turku, Finland, has provided service screening mammography for women aged 55-69 at entry (in 1987), and Tampere provided screening for women aged 55-59 at entry, whereas Helsinki did not screen any of these age groups. The incidence of breast carcinoma during the screening period 1987-97 in women born in 1918-32 (1918-22, 1923-27, 1928-32) was compared with incidence during the pre-screening period 1976-86 in women born in 1907-21 (1907-11, 1912-16, 1917-21) in each city. The follow-up for mortality was four years longer.

RESULTS

Breast carcinoma incidence was 31-38% higher in the screening period in all three cities irrespective of screening. In breast carcinoma mortality, no significant changes were seen in Helsinki or Tampere. In Turku, a 36% mortality reduction (relative risk [RR] 0.64; 95% confidence interval [CI] 0.47-0.88; P=0.007) in the whole study population and a 47% reduction in women aged 65-69 at entry (RR 0.53; 95% CI 0.28-0.99; P=0.047) were seen.

CONCLUSIONS

The incidence of breast carcinoma increased in all study cities irrespective of screening. The comprehensive screening programme in Turku including women aged 55-69 at entry was associated with a significant reduction in breast carcinoma mortality. The pronounced decrease in mortality in the oldest age group (65-69 years at entry) also indicated that women of this age group greatly benefit from mammography screening.

A missense mutation in the BRCA2 gene in three siblings with ovarian cancer

Inherited susceptibility to ovarian cancer has been associated with germline defects at several loci. The major known ovarian cancer susceptibility gene is BRCA1 on chromosome 17q, which confers a risk of approximately 60% by the age of 70 years. Truncating mutations in BRCA2 on chromosome 13q also predispose to ovarian cancer, although they confer a lower risk than mutations in BRCA1. We have studied the molecular basis of ovarian cancer predisposition in a Finnish family with three affected sisters. Analysis of polymorphic markers provided evidence against linkage to BRCA1, but the sibship was consistent with linkage to BRCA2. Conformation-sensitive gel electrophoresis was used to screen the entire coding sequence of BRCA2. A G to A transition at nucleotide 8702 was observed, which is predicted to convert glycine 2901 to aspartate in the encoded protein. This sequence variant was not detected in 220 cancer-free Finnish control individuals, or in several hundred cancer families of many nationalities previously screened for BRCA2 mutations. Taken together with the fact that this amino acid residue and the surrounding region of BRCA2 is identical in mouse and chicken, the data suggest that this alteration is a disease-causing BRCA2 missense mutation. Previously published data indicate that the risks of breast and ovarian cancer conferred by BRCA2-truncating mutations varies with the position of the mutation in the gene. The missense mutation reported here suggests that the BRCA2 domain including and surrounding glycine 2901 may be more important in preventing neoplastic transformation in ovarian epithelium than in breast epithelium.

Prediction of survival with fluorine-18-fluoro-deoxyglucose and PET in head and neck cancer

The aim of this prospective study was to investigate if high uptake of 18F-fluoro-2-deoxy-D-glucose (FDG) is associated with aggressiveness in head and neck cancer and low probability of survival.

METHODS

Thirty-seven patients with squamous-cell carcinoma of the head and neck underwent FDG-PET in the fasting state before cancer treatment. FDG uptake in primary tumor was quantitated as the standardized uptake value of FDG normalized to the predicted lean body mass (SUVlean, n = 37) and as the graphically determined metabolic rate for FDG (rMR[FDG], n = 34). Paraffin-embedded tumor samples were used for histologic evaluation, and expression of cytokeratin and Ki-67 antigen were assessed by immunohistochemistry.

RESULTS

Interobserver agreement for the determination of quantitative uptake of FDG in tumors was excellent (r2 = 0.996, p < 0.00001), and all 37 primary tumors were visualized. A high uptake of FDG as assessed by SUVlean was associated with a higher than the median mitotic count (p = 0.01), absence of keratinization (p = 0.03), low or moderate histological grade of differentiation (p = 0.046) and advanced stage (p = 0.03), but not with Ki-67 expression (p = 0.11). The overall survival of patients with a SUVlean lower than or equal to the median value (9.0) was clearly better in univariate analysis than that of patients with a SUVlean higher than the median (3-yr survival 73% versus 22%, relative risk of death (RR) 4.2, 1.6-11.0). However, in a multivariate analysis the only independent predictors of survival were the mitotic count (RR 4.0, 1.4-11.7) and stage (3.8, 1.2-12.2).

CONCLUSION

High uptake of FDG in untreated head and neck cancer is associated with advanced disease, and may portend poor survival. Aggressive treatment approaches should be considered for patients presenting with a tumor with high uptake of FDG.

Assessment of cervical lymph node status in head and neck cancer patients: palpation, computed tomography and low field magnetic resonance imaging compared with ultrasound-guided fine-needle aspiration cytology

OBJECTIVE

Since the assessment of lymph node metastases in head and neck cancer patients remains a major problem, the findings of different imaging methods and the role of these methods in the clinical management are compared.

MATERIAL AND METHODS

Palpation, computed tomography (CT) and low field magnetic resonance imaging (MRI; 0.1 T) are evaluated and compared with ultrasound-guided fine-needle aspiration cytology (US-guided FNAC) prospectively in 105 consecutive patients with a primary cancer in the head and neck region.

RESULTS

In the subgroup of 86 patients with palpable normal necks, CT showed lymph nodes fulfilling the radiologic criteria for malignancy in 27% (23/86), MRI in 17% (10/60) and US in 14% (12/86) of the patients US guided FNAC usually showed malignancy in necks containing lymph nodes with central necrosis on CT, but the enlarged lymph nodes that were also common on the contralateral side were often benign on cytology. In 5 patients, FNAC under US-guidance showed malignancy although none of them had lymph nodes fulfilling the radiologic criteria for malignancy. In the other subgroup of 19 patients with palpable metastatic necks, 2 patients had bilateral metastases detected by all imaging methods but not by palpation.

CONCLUSION

CT is superior to low field MRI in depicting small pathologic lymph nodes. Unlike lymph node structure, lymph node size is not a highly reliable criterion for malignancy. The findings must be correlated in relation to the primary disease. Since FNAC under US-guidance offers additional information about enlarged lymph nodes and since it can show malignancy in small lymph nodes not found by other methods, it can be recommended for most head and neck cancer patients irrespective of the use of CT or MRI.

PAP smear after radiation therapy for cervical carcinoma

Vaginal PAP smear is frequently used for the follow-up of cervical carcinoma after primary therapy. Irradiation induced atypia can interfere with cytological analysis and thus detection of a local recurrence, or simulate malignant atypia and cause unnecessary suspicion of recurrence. In this retrospective study we evaluated the reliability of cytological analysis and the reported frequency of irradiation induced atypia after radiotherapy. Eighty-nine patients treated for cervical carcinoma at Turku University Central Hospital during the years 1970-88 were included in the study. During the median follow-up of 34 months a total of 697 PAP smears were taken with a median of 7.8 samples per patient. During the follow-up 44 (50%) patients had a recurrent disease, which was local in 17 (39%) cases. Nine out of 12 PAP smears taken 0-60 days before detection of a local recurrence showed class III-V cellular atypia. However, three PAP smears showed class I-II, and were therefore false negative. The rate of false positive samples was only 3%. In 567 PAP smears irradiation induced atypia was indicated as present/not present (+/-) and it was positive in 89 (16%) samples. The detection rate was considerably higher (75%) in class II samples than in rest of the material. Irradiation induced atypia was detected in 28% of the PAP smears taken during the first four months after radiotherapy and the rate decreased thereafter. Cytological analysis of vaginal PAP smear was a reliable indicator of recurrence in most cases and is a valuable tool for the detection of local recurrence of cervical carcinoma after primary radiotherapy.

Mammography screening interval and the frequency of interval cancers in a population-based screening

In a population-based mammography screening, 129,731 examinations were carried out among 36,000 women aged 40-74 in the city of Turku, Finland, in the period 1987-94. Women older than 50 were screened at 2-year intervals, and those younger than 50 at either 1-year or 3-year intervals, depending on their year of birth. Screen-detected breast cancers numbered 385 and, during the same time period, 154 women were diagnosed with breast cancer outside screening in the same age group in the same city, and 100 interval cancers were detected. Two hundred and fifty (67%) of the screen-detected cancers were of post-surgical stage I compared with 45 (45%) of the interval cancers and 52 (34%) of the cancers found outside screening (P<0.0001). However, among women aged 40-49 the frequency of stage I cancers did not differ significantly among screen-detected cancers, interval cancers and cancers found outside screening (50%, 42% and 44% respectively; P=0.73). Invasive interval cancers were more frequent among women aged 40-49 if screening was done at either 1-year (27%) or 3-year intervals (39%) than in older women screened at 2-year intervals (18%; P=0.08 and P=0.0009 respectively). Even if adjusted for the primary tumour size, screen-detected cancers had smaller S-phase fractions than interval cancers or control cancers (P=0.01), but no difference in the S-phase fraction size was found between cancers of women younger than 50 and those older than this (P=0.13). We conclude that more interval cancers were found among women younger than 50 than among those older than 50 and that this could not be explained by the rate of cancer cell proliferation.

Palpation, ultrasound, and ultrasound-guided fine-needle aspiration cytology in the assessment of cervical lymph node status in head and neck cancer patients

BACKGROUND

Lymph node status of the neck is the most important prognostic factor in head and neck cancer patients. Assessment of the lymph nodes status is still often based on palpation only, although the low accuracy of palpation is known.

METHODS

Altogether 105 consecutive head and neck cancer patients were examined using ultrasound (US) and ultrasound-guided fine-needle aspiration cytology (FNAC) to evaluate the additional information obtained by these methods.

RESULTS

Of the 86 patients with palpable normal necks, FNAC taken under US-guidance showed malignancy in 13. The US size criteria for malignancy were fulfilled in 7 of these patients, whereas the lymph nodes were of normal size in 6 of them. In the whole patient material, US-guided FNAC showed bilateral metastasis in 3 patients although only unilateral or no metastasis was found by palpation.

CONCLUSION

US combined with US-guided FNAC can be recommended as a method for evaluating for regional metastases in head and neck cancer patients, both for those with and those without palpable metastasis.

Fine-needle aspiration biopsy in the diagnosis of parotid gland lesions: evaluation of 438 biopsies

The usefulness of fine-needle aspiration biopsy (FNAB) in the diagnosis and treatment of salivary gland lesions is still controversial. The 438 FNABs taken at the Turku University Central Hospital between 1984-1991 were reviewed. Of these FNABs, 218 had been confirmed histologically. Within this subset, 136 FNABs were taken from benign neoplasms, and of these, 103 were correct (sensitivity 76%, specificity 83%). Only 26 of the 47 FNABs from malignant lesions were cytologically considered to be malignant (sensitivity 55%) and 11 samples raised a false suspicion of malignancy (specificity 92%). Out of 35 FNABs from non-neoplastic lesions, 27 were correct (sensitivity 77%, specificity 80%). There were 175 patients (217 FNABs), who had not been operated on: the follow-up of these patients showed that false malignant and false benign findings were rare. FNAB was safe and no serious complications occurred. However, there was a delay in the treatment of six patients probably because of the physicians' limited understanding of the diagnostic role of FNAB. FNAB offers valuable information about the type of parotid lesion, but the clinician must know how to interpret the cytologic statement, and the decision to use operative and other treatment should not be based solely on the result of FNAB. Diagn Cytopathol 1996; 15:185-190.

Aneuploidy in salivary gland adenomas

The occurrence of abnormal nuclear DNA content in major salivary gland adenomas is not well known and its correlation with tumor recurrence has not been documented previously. From 1987 to 1991, 119 consecutive major salivary gland adenomas were operated on at Turku University Central Hospital. These tumors were analyzed by flow cytometry and 100 (84%) were found to be diploid, 12 (10%) near-diploid and 7 (6%) aneuploid with DNA indexes > 1.15. The mean proliferation rate measured as a percentage of cells in the S-phase fraction was 2.5 +/- 1.6%. The histological slides were then blindly reclassified according to current World Health Organization classification. As a result histological classification was changed in 3 tumors: malignant cells were found in 2 aneuploid tumors and 1 diploid neoplasm. Preoperative cytological fine-needle aspiration biopsy had been considered as possibly malignant in 2 of these cases. Among all case material 10 specimens were recurrent tumors; although the tendency to recur depended on the extent and adequacy of the surgery performed, multiple recurrences were associated with non-diploid tumors.

Increased glucose metabolism in untreated non-Hodgkin's lymphoma: a study with positron emission tomography and fluorine-18-fluorodeoxyglucose

Glucose metabolism has been shown to be increased in neoplastic tissue. It has been suggested that high activity of glucose metabolism is associated with a high grade of malignancy of human cancer. We studied in vivo glucose metabolism in 22 patients with untreated non-Hodgkin's lymphoma with fluorine-18-fluorodeoxyglucose (FDG) and positron emission tomography (PET). FDG uptake in lymphoma deposits was measured blinded to clinical data, and compared with histologic classification and proliferative activity. Tracer uptake was measured by using two indices of FDG accumulation: the standardized uptake value (SUV) and the regional metabolic rate (rMR) for the tracer. The median SUV of the lymphomas was 8.5 (range, 3.5 to 31.0), and the median rMR 22.7 mumol/100 g/min (range, 9.0 to 124.3 mumol/100 g/min). A high FDG uptake in tumors was associated with high histologic degree of malignancy as defined by the Working Formulation (P = .005 for the SUV, and P = .04 for the rMR) or by the Kiel classification (P = .003 for the SUV, and P = .02 for the rMR). A high FDG accumulation was also associated with a high S-phase fraction (r = .786 for the SUV, P = .0002; and r = .774 for the rMR, P = .02). We conclude that in untreated non-Hodgkin's lymphomas high FDG uptake is associated with high histologic grade of malignancy and a high proliferation rate. This minimally invasive method may find application in assessing lymphoma lesions in patients who are poor candidates for surgery, and it may provide further information in cases where the grade of aggressiveness of lymphoma is not settled based on clinical or histologic data.

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.

Fine-needle aspiration cytology of submandibular gland lesions

The usefulness of fine-needle aspiration cytology (FNAC) in the diagnosis and treatment of submandibular gland lesions is not well known. The 210 FNACs taken from submandibular gland lesions at Turku University Central Hospital between 1984 and 1991 were reviewed. Of these FNACs, 78 samples from primary lesions were confirmed histologically. Within this subset 10 FNACs were taken from benign neoplasms, all of which were correctly classified (sensitivity 100 per cent; specificity 88 per cent). Only four of the 14 FNACs from malignant lesions were cytologically considered malignant (sensitivity 29 per cent). On the other hand, four FNACs raised a false suspicion of malignancy (specificity 6 per cent). Out of 54 FNACs from non-neoplastic lesions 43 were correct (sensitivity 80 per cent; specificity 63 per cent). There were 104 patients (123 FNACs), who had not been operated on: the follow-up of these patients shows that in this subset of FNACs there were no false malignant but probably one false benign finding (1 per cent). We conclude that FNAC can offer valuable information about the type of the submandibular gland lesion, but the decision of operative and other treatment should not be based solely on the result of FNAC.

The subrenal capsule assay in selecting chemotherapy for ovarian cancer: a prospective randomized trial

In order to find out whether the response rate and survival in epithelial ovarian cancer can be improved by aid of sensitivity testing with the subrenal capsule assay (SRCA), 196 patients with FIGO Stage II-IV epithelial ovarian cancer were randomized to be treated with either cyclophosphamide-doxorubicin-cisplatin (CAP) or SRCA-guided chemotherapy. The drug combinations tested with the SRCA were (1) cyclophosphamide-doxorubicin-carboplatin (CACAR), (2) CAP, (3) carboquone-methotrexate-tegafur (CQ-MTX-TEG), (4) cisplatin-etoposide-hexamethyl-melamine (P-VP-HXM), and (5) bleomycin-epirubicin-cisplatin (BEP). A total of 132 patients (CAP, 69; SRCA, 63) were eligible for efficacy analysis based on relaparotomy findings. The overall response rate was 59% in the CAP arm and 62% in the SRCA arm. In the SRCA arm, 16 patients were treated with CACAR, 24 with CAP, 10 with CQ-MTX-TEG, 11 with P-VP-HXM, and 2 with BEP. The response rate to CACAR was 63% and to SRCA-CAP was 75%. The number of complete responses was higher when CAP was given as guided by the assay than when given at random (14/24 vs 23/69; P = 0.03, Pearson chi 2). Survival curves as estimated by Kaplan-Meier method gave a median survival of 24 (SE = 4) months to the SRCA arm and 28 (SE = 5) for the CAP arm (P = 0.7; log-rank test). Because no survival benefit was achieved, the SRCA obviously needs further development before it can be routinely recommended in the choice of first-line chemotherapy for patients with ovarian cancer.

The role of cul-de-sac aspiration cytology in the follow-up of ovarian cancer

The methods most often used for follow-up of ovarian cancer are physical examination, CA-125 measurement and ultrasonography or computed tomography. In the present study the role of cul-de-sac aspiration cytology as a supplementary method was evaluated. We analyzed the records of 110 stage I-IV ovarian cancer patients who had undergone cul-de-sac aspiration as a part of their follow-up schedule after the primary treatment. During the median follow-up of 5 years altogether 577 cul-de-sac aspirations were performed with a median interval of 9 months. Only in 2 cases the obtained sample was insufficient for evaluation. Twenty patients had cul-de-sac cytology > or = class III at some point during the follow-up. In 12 cases the preceding or subsequent CA-125 values taken within 3 months were < 35 U/l. In 7 cases CA-125 values increased later, but in 5 cases the tumour marker values remained within normal range during the entire follow-up. Nine out of these 12 patients had a clinical recurrence later on, but 3 patients had no evidence of the disease. Twenty-seven recurrences were detected during the follow-up. Cul-de-sac aspiration cytology was the first or the only indication of recurrence in 9 cases (33%) and is a useful supplementary method in the follow-up of ovarian cancer.

p53 protein, PCNA staining, and DNA content in follicular neoplasms of the thyroid gland

Forty-nine follicular adenomas and 11 follicular carcinomas of the thyroid were investigated by immunohistochemistry for the expression of p53 protein and proliferating cell nuclear antigen (PCNA). The DNA ploidy and the S-phase fraction (SPF) of the neoplasms were analysed by flow cytometry. Twelve adenomas (24 per cent) and six carcinomas (55 per cent) were DNA non-diploid (P = 0.07). The carcinomas had a higher proliferation rate than the adenomas when assessed either by SPF size (median 9.9 per cent vs. 2.9 per cent, P = 0.0003) or by PCNA staining intensity (P < 0.0001). Some scattered nuclei in two (4 per cent) adenomas and in three (27 per cent) carcinomas stained positively for p53 (P = 0.04). The two adenomas with positive staining for p53 were subserially sectioned, but no signs of invasion were found; both patients are alive and well 6 and 7 years after surgery. One of the two adenomas showing positive p53 nuclear staining was DNA aneuploid, and both were positive in PCNA staining, but their SPFs were low (2.1 and 3.3 per cent). We conclude that p53 protein expression is not confined to follicular carcinomas; scattered p53-positive cells may also be present in histologically and clinically benign follicular adenomas. Because both follicular adenomas and carcinomas may be DNA aneuploid and their SPF and PCNA staining distributions overlap, the distinction between follicular adenoma and carcinoma should still be based on histological criteria.

Immunohistochemical detection of p53 protein in borderline and malignant serous ovarian tumors

The p53 suppressor gene protein expression was studied with immunoperoxidase staining in 61 serous tumors of the ovary. Twenty four (53%) of the 45 histologically malignant tumors were positive for p53, whereas neither the six benign nor the 10 tumors of borderline malignancy showed positive staining, except for one borderline tumor with atypia and increased mitotic activity. Therefore, p53 immunostaining may have diagnostic value in discriminating between borderline and malignant serous ovarian tumors. Malignant ovarian tumors with negative staining for p53 were associated with a 67% 3-year crude survival rate as compared with only an 18% 3-year survival rate if p53 staining was positive (p = 0.002). In a multivariate analysis, the p53 staining was the most important prognostic factor, with a relative risk of 4.2 (95% confidence interval, 1.8-9.9) followed by the FIGO stage (2.1, 1.3-3.5). We conclude that immunohistochemical p53 suppressor gene protein expression analysis has both diagnostic and prognostic value.

Glycoprotein CD44 expression and its association with survival in breast cancer

To investigate the clinical significance of CD44 expression (lymphocyte-homing receptor) in adenocarcinoma, deparaffinized sections from 198 female breast carcinomas were stained with Hermes-3 MoAb for CD44 glycoprotein. In 16% of the cancers most (> or = 90%) of the cancer cells stained positively for CD44, whereas the rest of the cancers were either heterogenous (46%) or negative (38%) in CD44 staining. Cancers with > 50% CD44 positive cells were more often poorly differentiated (grade 3) than those with < or = 50% positive cells (38 vs. 19%, P = 0.006), they had higher mitotic counts (P = 0.04), and were more often estrogen receptor negative (52 vs. 31%, P = 0.01). Among ductal not otherwise specified cancers and node-positive cancers strong CD44 expression was associated with poor outcome (P = 0.05 and 0.02, respectively). However, CD44 expression was not an independent prognostic factor in these subgroups in a multivariate analysis. Unlike in lymphomas the unfavorable prognosis associated with CD44 expression may not be explained by the greater metastatic potential of CD44-positive cells, because the difference in mortality between the groups appeared to diminish with time, and CD44 positivity was associated with aggressive histological features.

Basal cell adenocarcinoma of the parotid gland: a case report and review of the literature

Basal cell adenocarcinoma is a rare salivary gland tumour. A DNA diploid parotid gland basal cell adenocarcinoma, with a low mitotic rate, in a 78-year-old female patient is described. Total removal of the affected salivary gland without sacrificing the facial nerve gave a good therapeutic result.

DNA content analysis of fine needle aspirates obtained from lymphatic tissue

DNA ploidy and S-phase fraction (SPF) of 69 lymphomas and 50 samples from benign lymphatic tissue were determined by flow cytometry from cells obtained by fine needle aspiration biopsy. An aneuploid histogram with a DNA index (DI) > 1.05 was obtained from 15 (22%) lymphomas. However, six (12%) benign lymph nodes also showed a bimodal DNA histogram, with the DI ranging from 1.06 to 1.15. The benign nature of these lymph nodes was confirmed by histology, follow-up of > 5 years or both. The median size of the SPF was 3.2%, 3.6%, 4.2%, 12.1% and 15.5% in benign lymph nodes, Hodgkin's disease and in low, intermediate and high grade non-Hodgkin's lymphomas, respectively. Only 8 (18%) of the benign tumors had an SPF > 5% as compared with 39 (62%) of the lymphomas (P < .0001). An SPF of > 12% was never obtained from benign tissue. The size of the SPF as determined from a fine needle aspirate correlates with lymphoma histology, and a bimodal DNA histogram with a small DI obtained from lymphatic tissue does not necessarily indicate the presence of lymphatic malignancy.

Lymphocyte homing receptor (CD44) expression is associated with poor prognosis in gastrointestinal lymphoma

Lymphocyte homing receptor (CD44) is involved in lymphocyte adhesion to endothelial cells of high endothelial venules (HEVs) and lymphocyte exit from the blood circulation, and it may be involved also in hematogenous dissemination of malignant lymphoma. Prognostic significance of lymphocyte homing receptor expression defined by Hermes-3 antibody was studied among 27 gastrointestinal lymphomas followed up for 8 to 20 years after the diagnosis. Lymphomas lacking or with very weak homing receptor expression (n = 14, 52%) were associated with 57% 10-year survival rate as compared with only 15% among lymphomas that expressed CD44 more strongly (P = 0.02). We conclude that lack of lymphocyte homing receptor expression is common in gastrointestinal lymphoma, and that CD44 expression is associated with unfavourable prognosis.

Staging of uterine endometrial carcinoma with ultra-low field (0.02 T) MRI: a comparative study with CT

OBJECTIVE

The purpose of this investigation was to evaluate the capability of ultra-low field MRI for staging endometrial carcinoma.

MATERIALS AND METHODS

Computed tomography and MRI were performed on 47 patients with uterine endometrial carcinoma. The results were compared with those from clinical examination and with histopathological results after operation in 43 cases. The local extension of the endometrial carcinoma was correctly staged in 77% with clinical examination in 58% with CT, and in 88% with MRI.

RESULTS

Tumor growth was overestimated by clinical examination in 21%, by CT in 35%, and by MRI in only 5%. Magnetic resonance imaging was most accurate in detecting cervical extension and was better than CT in detecting tumor invasion to the outer half of the myometrium. The sensitivities of CT and MRI in the assessment of deep myometrial invasion were 67 and 83%, respectively, the corresponding specificities being 67 and 79%. Magnetic resonance imaging at 0.02 T was not able to differentiate tumors with superficial myometrial invasion from those confined entirely to the endometrium. The detection of metastatic lymphadenopathy was difficult with all examination methods.

CONCLUSION

Our results indicate that MRI at 0.02 T is a convenient, inexpensive, and accurate imaging method for the preoperative staging of endometrial carcinoma.

Complications of Teflon injection for stress urinary incontinence

Four significant complications of Teflon injections for stress urinary incontinence are reported in 22 women and eight men. Three of the complications included periurethral abscess, urethral diverticulum, and periurethral Teflon granuloma with urethral wall prolapse occurred in women. These complications needed surgical excision and further surgery for stress incontinence, in two patients the outcome was good. Among the female patients the cure rate for stress incontinence with Teflon injection was only 18% in the 5-year follow-up. One other complication, a Teflon cyst, occurred in a male who had previously undergone radical retropubic prostatectomy. Only two of the eight men (25%) who received Teflon injections had maintained improvement after 1 year.

Prognosis of lymphoma from a fine-needle aspirate

The prognostic value of S-phase fraction (SPF) determined by flow cytometry from a fine-needle aspirate was investigated in a prospective series of 52 non-Hodgkin lymphomas. The aspirates were drawn either at diagnosis (n = 16) or at lymphoma recurrence (n = 36). Patients with lymphoma with a large SPF (> 10%, n = 24) had only a 21% 3-year survival rate corrected for intercurrent deaths as calculated from the date of aspiration, whereas a smaller SPF was associated with a 71% 3-year survival rate (n = 28, P = 0.0009). SPF size also correlated with Working Formulation grading (P = 0.002). In a multivariate analysis the relative risk of death from lymphomas with a large SPF was 4.01 (1.60-10.1), whereas histological grading, age, and sex had no additional independent prognostic value. SPF determined from a fine needle aspirate had unexpectedly good prognostic value, and the result suggests that the method is of clinical importance.

Proliferating cell nuclear antigen (PCNA) as a prognostic factor in non-Hodgkin's lymphoma

The prognostic value of immunoperoxidase staining for proliferating cell nuclear antigen (PCNA) was studied in a series of 140 non-Hodgkin's lymphomas with median follow-up of 9 years. Lymphomas where > 50% of cells showed positive staining for PCNA had inferior 5-year survival as compared with those with less than 50% of positive cells (57% vs 41%, P = 0.008). The presence of > 50% of positively staining cells for PCNA was strongly associated with a larger than the median size of the SPF (median, 8.3%), and high histological grade of malignancy (P < 0.0001 for both). Lymphomas with both a large percentage (> 50%) of PCNA positive cells and a larger than the median SPF had inferior outcome as compared with lymphomas where either one or both of these factors were small. Although PCNA staining was not an independent prognostic factor in a multivariate analysis, it appears to be supplementary to the SPF even if determined from old paraffin-embedded tissue material.

DNA ploidy, S-phase fraction and mitotic indices as prognostic predictors of female breast cancer

DNA ploidy, S-phase fraction (SPF), mitotic index (MI), volume corrected mitotic index (M/V index) and standard prognostic factors were related to disease outcome in a series of 363 women with breast cancer followed-up for over 10 years in our clinic. DNA ploidy and SPF were significantly related to histological type, tumour grade and mitotic indices (p < 0.001). In univariate survival analysis, pN status (p < 0.0001), tumour diameter (p < 0.0001), MI (p = 0.001), M/V index (p = 0.0003) and SPF (p = 0.015) predicted survival. In pN(-) tumours. MI (p = 0.059) was related to survival. In pN(+) tumours, tumour diameter (p = 0.0004), M/V index (p = 0.023) and SPF (p = 0.045) predicted survival. In multivariate survival analysis, tumour diameter (p < 0.001). M/V index (p < 0.007), pN status (p = 0.014) and patient age (p = 0.09) were independently related to survival. In pN(-) tumours, tumour diameter independently predicted survival (p = 0.033). In pN(+) tumours, tumour diameter (p < 0.001), M/V index (p = 0.006) and the year of treatment (p = 0.08) were independent predictors. The results show that tumour diameter, pN status and proliferative activity of cancer cells are important prognostic factors in breast cancer. Of the proliferation indices, M/V index and SPF are equally powerful predictors, and the use of M/V index is advocated due to simplicity of the assessment.

Sex steroid receptors, S-phase fraction and DNA ploidy as determinants of the risk of relapse and death of female breast cancer

S phase fraction (SPF) and DNA ploidy were related to disease outcome by a separate analysis of sex steroid receptor positive and negative tumours in a series of 232 patients with breast carcinoma followed-up for over 8 years in our clinic. SPF was significantly higher in receptor-negative tumours than in receptor-positive ones (p = 0.037). SPF predicted recurrence only in ER+ or PR+ patients (p = 0.02-0.003). Recurrence-free survival (RFS) was significantly related to SPF only in ER+ (p = 0.001) and PR+ (p less than 0.001) tumours. In survival analysis, ER+ (p = 0.002) and PR+ (p less than 0.001) patients were efficiently divided into prognostic groups by SPF, whereas in ER- and in PR- tumours SPF had only suggestive predictive value. In N- tumours, SPF predicted recurrence-free survival and disease-related survival in ER+ (p = 0.003) (p = 0.039) and in PR+ (p = 0.003) (p = 0.012) tumours, respectively, whereas in ER-, PR-, tumours, SPF had no predictive value. In pN+ tumours, SPF also predicted survival in ER+ (p = 0.03) and in PR+ (p = 0.024) tumours. Thus the prognosis of ER+ or PR+ tumours with an SPF less than 9% is favourable with a risk of death of about 20%, in contrast to that of about 70% in tumours with an SPF greater than 9% during the follow-up period. To conclude, the proliferation rate as measured by S phase fraction by FCM is a highly significant prognostic factor in breast cancer. The prognostic value of S phase fraction is confined to steroid receptor-positive tumours, whereas in receptor-negative tumours SPF has no predictive value. The results thus suggest that all women with steroid receptor-negative breast tumours and those receptor-positive tumours with an SPF higher than 9% should be subjected to postoperative adjuvant chemotherapy immediately.

Flow and image cytometric study of pancreatic neuroendocrine tumours: frequent DNA aneuploidy and an association with the clinical outcome

Eighteen pancreatic neuroendocrine (NE) tumours were analysed for nuclear DNA content by image cytometry (ICM) and flow cytometry (FCM). The DNA indices (DIs) obtained by ICM were somewhat higher than those obtained by FCM, but a major disagreement was present only in 1 case. Thirteen patients had been followed up at least for 6 years after the diagnosis or until death. At 6 years of follow-up all 4 patients with a tumour with a DI greater than or equal to 1.8 by ICM had died from their NE tumour or had metastatic disease, whereas all 9 patients with a smaller DI had no evidence of the disease (P = 0.001). The DIs calculated from the FCM data also correlated well with the final outcome (P = 0.01). A high incidence of DNA aneuploidy was found by both methods in histologically and clinically benign NE tumours; 12 (67%) were DNA aneuploid by FCM and 16 (89%) by ICM. It is concluded that pancreatic NE tumours are frequently DNA aneuploid, and both cytometric DNA methods give prognostic information in these tumours. The presence of DNA aneuploidy should not be considered as a sign of malignant behaviour in pancreatic NE tumours, whereas a large DI is associated with poor prognosis.

Aggressiveness of breast cancers found with and without screening

OBJECTIVE

To examine how breast cancers found by mammographic screening differ from those found outside screening.

DESIGN

Comparative cohort study.

SETTING

Turku, southwestern Finland.

PATIENTS

126 women aged 40-74 years with breast cancer detected during the first round of mammographic screening in 1987-90 and 125 women within the same age range with breast cancer detected outside screening during the same period.

MAIN OUTCOME MEASURES

Primary tumour size, axillary nodal status, histological features, oestrogen and progesterone receptor concentrations, ploidy, and S phase fraction.

RESULTS

Compared with the controls women with cancers detected by screening had a smaller primary tumour (57 (46%) screened v 11 (10%) controls had tumours less than or equal to 11 mm in diameter, p less than 0.0001), and less often had axillary nodal metastases (104 (83%) screened v 71 (57%) controls node negative, p less than 0.0001). After adjustment for the smaller size of the primary tumour compared with control cancers, those cancers detected by screening were less likely to have axillary nodal metastases (odds ratio 0.44, 95% confidence interval 0.23 to 0.84), poor histological differentiation (0.20, 0.08 to 0.49), high mitotic counts (0.38, 0.15 to 0.97), tumour necrosis (0.45, 0.22 to 0.93) or to be of the ductal histological type (0.46, 0.22 to 0.95). They had low oestrogen receptor (0.29, 0.12 to 0.70) and progesterone receptor (0.35, 0.17 to 0.92) concentrations less often and had smaller S phase fractions (0.72, 0.55 to 0.96) than control cancers.

CONCLUSIONS

Even after adjustment for the smaller size of screen detected breast cancers, their histological and cytometric features suggest low malignant potential. They may also be less likely to metastasise to axillary lymph nodes than cancers found outside screening.

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.

Histological features, DNA content and prognosis of breast carcinoma found incidentally or in screening

Histology features, the nuclear DNA content and prognosis of 42 female breast carcinomas found in a physical examination based screening, 54 breast cancers found incidentally by medical personnel, and 274 breast cancers first suspected by the patient were compared. There was no significant difference in the distribution by primary tumour size (P = 0.08) or histological type (P = 0.87) of breast cancer between the screen-detected and 139 self-suspected cancers of women with similar mean age and living at the same time in the same city, but the screen-detected carcinomas were better differentiated (P = 0.0002), and had less mitoses (P = 0.008), less tumour necrosis (P = 0.004) and DNA aneuploidy (P = 0.01), smaller S-phase fractions (P = 0.009), less axillary metastases (P = 0.04), and had better outcome (P = 0.005) than self-suspected carcinomas. These parameters did not differ significantly between the screen-detected and incidentally found cancers, but incidental cancers had more often axillary metastases (P = 0.02). The results indicate that screen-detected breast carcinomas have favourable biological features suggesting low degree of malignant potential.

Fine needle aspiration biopsy in the diagnosis of thyroid nodules

The fine needle aspiration (FNA) biopsies performed on thyroid nodules at Turku University Central Hospital from 1983 to 1988 were reviewed. Of the 1,054 total aspirated nodules, 194 were investigated histologically after thyroid surgery (191 cases) or at autopsy (3 cases). Two cases with an insufficient FNA sample, 4 with an incidental occult papillary carcinoma and 2 cases with carcinoma outside the nodule investigated by FNA biopsy were excluded from the series, leaving 186 histologically confirmed nodules in the final analysis. Three (3%) of the 107 cases with an FNA biopsy diagnosis of benign, 4 (8%) of the 52 with an FNA diagnosis of equivocal, 3 (20%) of the 15 with an FNA diagnosis of suspicious and all 12 (100%) with an FNA diagnosis of malignant were histologically malignant. If only an unequivocally malignant cytologic finding is considered positive, FNA biopsy had a diagnostic specificity of 100%, a sensitivity of 55% and an accuracy of 95% among the histologically confirmed cases. Follow-up revealed no cases of cancer among the 863 thyroids that were not explored surgically. It is concluded that FNA biopsy is a practical method with considerable diagnostic value in the evaluation of thyroid nodules.

Effects of the antiestrogen toremifene on growth of the human mammary carcinoma cell line MCF-7

The effects of toremifene, a new antiestrogenic drug, were investigated in vitro on the exponentially growing human mammary carcinoma cell line MCF-7. The drug effects were monitored by serial cell counts and DNA flow cytometry. The inhibitory effect of toremifene on MCF-7 became greater as the drug concentration was increased from 1 microM to 10 microM. At 5 microM toremifene induced a large decrease in the relative percentages of S- and G2/M-phase cells, and an increase in the amount of cell debris, indicating increased cell death. After withdrawal of the drug the mammary cancer cells resumed logarithmic growth similar to that of control cells. The effects caused by toremifene were similar to those caused by tamoxifen both in quality and quantity.

DNA index and S-phase fraction and their combination as prognostic factors in operable ductal breast carcinoma

The prognostic significance of DNA ploidy, DNA index (DI), and S-phase fraction (SPF) and their various combinations were studied together with 16 other clinicopathologic factors in 222 patients with operable invasive ductal breast carcinoma. The patients have been followed for a minimum of 22 years after the diagnosis or until death. Nuclear DNA content was determined by flow cytometry from paraffin-embedded tissue. Patients with DNA diploid cancer (n = 57, 26%) had better survival rate corrected for intercurrent deaths than patients with nondiploid cancer (P = 0.002), and also, a small SPF (less than or equal to 14%, calculated in 134 cases) was associated with a favorable outcome in a univariate analysis (P = 0.01). The prognostic value of the DI and SPF was increased if they were combined. The most effective combination was obtained if diploid cancers were grouped together with DNA aneuploid cancers with a DI less than 2.1 and an SPF less than 14%. This combination had considerable prognostic value in a univariate analysis (P = 0.0002) and had independent prognostic value (P = 0.04) in Cox's multivariate analysis together with the primary tumor size (P less than 0.001) in axillary node negative patients but not in axillary node positive patients. In the whole series the presence of axillary nodal metastases (P less than 0.001), high mitotic count (P less than 0.001), a large primary tumor size (P = 0.001), poorly circumscribed tumor margin (P = 0.005), and slight or absent tubule formation (P = 0.05) were the only independent prognostic factors in a multivariate analysis.

DNA ploidy in pancreatic neuroendocrine tumors

The nuclear DNA content of 17 pancreatic neuroendocrine tumors was measured from paraffin-embedded tissue with flow cytometry. The tumors were classified by immunostaining with antisera for synaptophysin, insulin, gastrin, glucagon, pancreatic polypeptide, somatostatin, and vasoactive intestinal polypeptide. Eight (47%) of the 17 tumors were aneuploid, and two (12%) were multiploid (had two aneuploid stemlines of cells). Seven of the eight insulinomas, one of the four gastrinomas, and two of the four nonspecified neuroendocrine tumors had an abnormal nuclear DNA content. The DNA indices of the aneuploid and multiploid cases ranged from 1.13 to 1.93, and three cases had a DNA index greater than 1.50. During the follow-up for up to 16 years (mean, 7 years), one patient with diploid nonspecified tumor died of the disease, another patient with a multiploid gastrinoma had metastatic disease develop, and a third patient with a multiploid nonspecified tumor was alive with the disease. The authors conclude that many neuroendocrine tumors of the pancreas have an abnormal nuclear DNA content as measured by DNA flow cytometry. DNA multiploid pancreatic neuroendocrine tumors may be associated with a less favorable clinical course, but this needs to be confirmed in additional studies.

Biologic progression in non-Hodgkin's lymphoma. A flow cytometric study

The nuclear DNA content of 37 primary non-Hodgkin's lymphomas both at presentation and at relapse was determined by flow cytometric analysis from paraffin-embedded tissue to investigate changes in DNA ploidy and S-phase fraction (SPF) during the course of the disease, and their association with survival. The repeat biopsies were done from 5 months to 15 years after the diagnosis. Four low-grade lymphomas according to the Working Formulation transformed into intermediate-grade lymphomas (four of 11, 36%), and four intermediate-grade lymphomas into high-grade lymphomas during the follow-up (four of 16, 25%), and five of these eight transformed lymphomas were fatal within 18 months after relapse. The SPF correlated strongly with poor prognosis if measured either from the primary biopsy (P = 0.008), the first (P = 0.009), or the latest repeat biopsy (P = 0.006). If SPF was greater than or equal to 6% larger in a repeat biopsy than at presentation prognosis was poor; six of nine such patients died from lymphoma within 11 months from recurrence. An increase of greater than or equal to 6% in the SPF was more common in high-grade (four of nine, 44%) and intermediate-grade (four of 16, 25%) lymphomas than in low-grade lymphomas (one of 11, 9%), and it was occasionally (three of nine) associated with a morphologic change. In a few cases a repeat biopsy was diploid despite DNA aneuploidy at presentation. In conclusion, the study provides evidence that not only may low-grade lymphomas transform into higher grade lymphomas, but high-grade lymphomas may also frequently transform into more malignant forms during the course of the disease. The SPF is useful in monitoring the biological behavior of non-Hodgkin's lymphoma, and it appears to give information not obtained by histologic study alone.

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.

Evidence for false aneuploid peaks in flow cytometric analysis of paraffin-embedded tissue

It has recently been shown that bimodal histograms with false aneuploid peaks may be obtained by DNA flow cytometry from histologically normal tissue allowed to autolyze. To investigate if such peaks can be generated from surgically excised archival tissue, 198 paraffin blocks from 179 patients containing histologically normal spleen (n = 65), liver (n = 26), thyroid (n = 32), pancreas (n = 19), salivary gland (n = 49), or lymph node tissue (n = 7), obtained from the archives of two university pathology departments, were analyzed for nuclear DNA content. The great majority (n = 160, 83.8%) of the 191 interpretable histograms had a single symmetrical G1 peak; and 8 histograms, all produced from liver tissue had a tetraploid pattern. A slight or a prominent repeatable deviation in the G1 peak outline was present in 14 (7.3%) cases. A peak resembling an aneuploid G1 peak with a DNA index (DI) ranging from 1.14 to 1.38 was repeatedly produced from 9 (4.7%) blocks containing histologically normal or inflamed splenic (n = 3), pancreatic (n = 3), liver (n = 1), thyroid (n = 1), or lymph node (n = 1) tissue. The three abnormal peaks produced from pancreatic tissue were rounded in shape and resembled closely the ones that can be obtained from autolytic pancreatic tissue, and the six remaining extra peaks were all fused with the "diploid" peak. In conclusion, false peaks, probably caused by degradation of the nuclear contents during formalin fixation or before it, may rarely be obtained from surgical paraffin-embedded samples.

Influence of cellular DNA content on survival in ovarian carcinoma

Flow cytometric analysis of nuclear DNA content was performed on paraffin-embedded tissue from 153 ovarian epithelial carcinomas. The DNA ploidy, DNA index, and S phase fraction were determined without knowing the final outcome of the patients. Fifty-one (38%) of the 134 classifiable histograms were considered to be diploid, 70 (52%) aneuploid, and 13 (10%) multiploid. The DNA index was a better prognostic factor for survival than DNA ploidy; 48% of the patients with a small DNA index (less than 1.3) survived for 5 years after the diagnosis, in contrast to 14% of the patients with a large DNA index (greater than 1.3) (P less than .0001). Carcinomas with a small S phase fraction (less than 11%) were associated with favorable survival (P = .0002). In multivariate analysis, the size of the residual tumor at surgery (P less than .001), the DNA index (P = .001), and the S phase fraction (P = .05) were the only significant independent prognostic factors. The results indicate that flow cytometric nuclear DNA content analysis provides important additional information for the estimation of survival in ovarian carcinoma.

Autolysis is a potential source of false aneuploid peaks in flow cytometric DNA histograms

Serial flow cytometric nuclear DNA content analyses were performed from normal human spleen, thyroid, liver, and pancreas removed from ten patients at autopsy and stored for up to 8 d without any preservative to study the effect of autolysis on DNA histograms. Fine needle aspiration biopsy (FNAB) samples were taken in diluted ethanol and tissue biopsies from the same area in formalin for embedding into paraffin at the time of autopsy and serially thereafter. Histograms obtained from samples taken within 10 h after death had a symmetrical G1 peak with a small coefficient of variance (CV) except histograms produced from paraffin-embedded pancreatic tissue, but bimodal distributions similar to those seen in aneuploid tumors were obtained from many samples stored longer than for 20 h. The DNA indices of the bimodal histograms were usually less than 1.3. The false peaks were more prominent in FNAB samples than in paraffin-embedded samples. The time of appearance of the false aneuploid peaks varied individually, and they were usually first seen in samples taken from the pancreas, followed by the liver, the thyroid and the spleen. Because neoplasms may become necrotic in vivo and fixation of fresh surgical samples may be slow and incomplete, increased DNA staining caused by autolysis may be a source of false aneuploid peaks in DNA content analysis.

Association of DNA aneuploidy with human papillomavirus-induced malignant transformation of sinonasal transitional papillomas

The nuclear DNA content of 19 transitional papillomas of the sinonasal region and 9 maxillary squamous cell carcinomas was studied by flow cytometry; the presence of human papillomavirus (HPV) DNA types 11 and 16 was determined by the in situ hybridization technique from paraffin-embedded tissue. Thirteen (68%) of the papillomas and none of the carcinomas contained HPV genome. Six (32%) of the papillomas and 4 (44%) of the carcinomas had an aneuploid DNA content. The relative DNA content (DNA index) of the aneuploid maxillary carcinomas was larger than that of aneuploid papillomas (p = 0.004). Three of the papillomas underwent malignant transformation, all three of which contained HPV type 16 DNA; two were also aneuploid. Data indicate that papillomas containing HPV type 16 DNA have a tendency (p = 0.06) to undergo malignant transformation, and that this tendency is greater if DNA aneuploidy or HPV type 11 DNA is also present (p = 0.02).

Co-existence of two aneuploid stemlines in benign adenomas. A report of three cases with stemline heterogeneity

The co-existence of 2 or more aneuploid stemlines (DNA multiploidy) has been described in malignant human neoplasms and such cancers have often been found to be associated with a poor prognosis. Here 3 benign human adenomas with 2 co-existing aneuploid stemlines are described. Despite DNA stemline heterogeneity and large DNA indices up to 2.8 none of the adenomas recurred or gave rise to metastases after a simple excision during the follow-up of 8, 10 and 11 years. Two adenomas were hormonally active. Marked cellular atypia and frequent mitoses were seen in 1 of the adenomas but the other 2 tumours had little atypia. The present cases indicate that DNA stemline heterogeneity may occur in benign adenomas, and not even the presence of 2 aneuploid stemlines with greatly increased nuclear DNA content can be regarded as a conclusive sign of malignancy.

A simple preservative for flow cytometric DNA analysis

A solution containing citric acid buffered saline (CABS) and 99% ethanol (E) 1:1 was used for preserving cells for flow cytometric DNA analysis. DNA histograms obtained from fine needle biopsy aspirates and preserved in CABS+E had a similar mean coefficient of variation (CV) as was obtained from aspirates taken in CABS (3.3 vs. 3.4%) and a clearly smaller mean CV than was obtained from aspirates preserved in 50% ethanol (mean 4.8%, P less than .0001). Aspirates taken in CABS more often contained a small (less than 3,000) number of cells as compared with aspirates preserved either in CABS+E or ethanol (P less than .0001). Since preservation of cells in CABS+E allows long-term storage of samples and results in a decreased number of insufficient samples as compared with buffered saline and in an enhanced resolution as compared with 50% ethanol, CABS+E is recommended for preservation of cytological samples to be analyzed for DNA content with flow cytometry.

Comparison of fresh, ethanol-preserved, and paraffin-embedded samples in DNA flow cytometry

Fresh, ethanol-preserved, and formalin-fixed and paraffin-embedded samples taken from the same part of 15 human tumors, and from one normal spleen and one pancreas were analyzed for nuclear DNA content by flow cytometry. The coefficient of variation (CV) values of the G1 peaks were smaller in the fresh than in the other samples (P less than 0.001). The DNA ploidy of the tumors was the same in all types of samples. The DNA indices (DIs) measured from either ethanol-preserved or formalin-fixed tissue correlated strongly with those obtained from fresh tissue (P less than 0.001), although they tended to be somewhat smaller in the fresh samples. The S-phase fractions measured from all types of samples were of the same order of magnitude in most cases (P less than 0.001). Uninterpretable histograms were most often obtained from fresh samples. Identical DI values and rather constant S-phase fractions were obtained from ethanol-preserved samples stored at 4 degrees C for up to 5 months. It is concluded that all three types of samples are suitable for the determination of DNA ploidy, DI, and S-phase fraction and that 50% ethanol is suitable for long-term preservation of flow cytometric samples.

Endobrush sampling for endometrial cancer

The two intra-uterine cytological sampling methods Endobrush and Pistolet were compared for clinical applicability in 66 premenopausal and 47 postmenopausal women. The taking of the specimens succeeded in 94% of the cases with the Endobrush method and in 99% with the Pistolet method. The two intra-uterine sampling methods were both almost painless. The Endobrush and the Pistolet specimens were filtered and stained by the Papanicolaou method. The Endobrush specimens were also used to make smears, which were also stained by the Pap method. According to the separate evaluations of two cytologists the Endobrush smear yielded specimens with a large or moderate number of cells in 59.0 to 71.4%, the Endobrush filter method in 73.6 to 76.5% and the Pistolet filter method in 71.4 to 76.8%. Specimens with good or moderate quality were found in 83.3%, 86.8 to 89.6% and 93.7 to 99.1%, respectively. Unsatisfactory specimens accounted for only 2.8-0.9% of the cases. All four endometrial carcinomas were placed in Pap classes 3 to 5 on the basis of the Endobrush and Pistolet filter specimens. The diagnostic quality of the smears was inferior to that of the filter specimens. The results suggest that the Endobrush filter method yields cytological endometrial samples which are similar in cell number, quality and diagnostic value to those obtained by the Pistolet method. Endobrush method is also simple, quick and painless, and therefore well acceptable to patients and suitable for clinical use.

Prognostic value of DNA ploidy and proliferative activity in Hodgkin's disease

To investigate the occurrence and the prognostic significance of DNA aneuploidy in Hodgkin's disease, the nuclear DNA content of 70 patients with Hodgkin's disease was determined from paraffin-embedded tissue by flow cytometry. DNA aneuploidy was found in eight (11%) cases. None of the five lymphomas of the lymphocytic depletion type was aneuploid, and DNA aneuploidy was not associated with any of the histologic subtypes. DNA ploidy did not have significant association with prognosis, but the two patients with aneuploid lymphoma who died had the largest DNA indices measured (1.63 and 2.03). Patients with lymphoma with greater than 10% S phase cells had poorer crude survival rate (P = 0.01) and survival rate corrected for known intercurrent deaths (P = 0.002) than patients with lymphoma with less than 10% S phase cells. In multivariate analysis, age at diagnosis, sex, histologic subtype, and S phase fraction had independent prognostic value.

Clinical significance of abnormal nuclear DNA content in serous ovarian tumors

The nuclear DNA content of 160 serous ovarian neoplasms was determined by flow cytometry from paraffin-embedded tissue. Three (11%) of the 27 histologically benign, seven (16%) of the 43 borderline malignant, and 59 (66%) of the 90 malignant neoplasms were aneuploid (P less than 0.0001). None of the patients with an aneuploid benign or borderline malignant tumor died from cancer, but in carcinomas the DNA index (DI) was a more important prognostic factor in a multivariate analysis than age at diagnosis, stage, histologic grade or ploidy (diploid versus aneuploid). A DI of 1.3 was the most effective value in predicting prognosis; patients with carcinoma with the DI more than 1.3 had inferior survival compared with those with the DI less than 1.3 (P = 0.002). Carcinomas with the DI more than 1.3 were more common in patients older than 60 years at diagnosis (P = 0.0002), and were associated with a low grade of differentiation (P = 0.008) but not with stage. It is concluded that DNA aneuploidy may occur in benign and borderline malignant serous ovarian tumors and that the DI is a highly valuable and objective prognostic parameter in serous ovarian carcinomas.