Detecting microcalcifications in atherosclerotic plaques by a simple trichromic staining method for epoxy embedded carotid endarterectomies

Atherosclerotic plaques have a high probability of undergoing rapid progression to stenosis, becoming responsible of acute coronary syndrome or stroke. Microcalcifications may act as enhancers of atherosclerotic plaque vulnerability. Considering that calcifications with a diameter smalller than 10 µm in paraffin embedded tissue are rather difficult to detect, our aim was to analyze microcalcifications on semithin sections from epoxy resin embedded samples of carotid endarterectomies using an original trichromic stain (methylene blue-azur B - basic fuchsine - alizarin red). We have compared samples stained either with our method, methylene blue-azur B alone or with Von Kossa staining, and methylene blue-azur B -basic fuchsine alone or with Von Kossa staining.

Our method resulted to be simple and fast (ca. 2 min), it gives a sharp general contrast for all structures and allows to easy identify collagen and elastin. In addition, gray-green colour associated to intracellular lipid droplets evidences foam cells, which are particularly abundant in endarterectomies samples. Mast cells and their metachromatic granules are also well recognized. Calcifications over 0,5 µm are clearly recognizable. In conclusion, microcalcifications are clearly distinguished from the extracellular matrix in spite of their reduced dimensions. Methylene blue-azur B-basic fuchsine-alizarin red method is easy to use, reproducible, and is particularly suitable for the identification of microcalcifications in the morphological analysis of atherosclerotic plaques.

Microplicae-like structures of the fallopian tube in postmenopausal women as shown by electron microscopy

Female reproductive aging is associated with several morphological changes of the genital tract with a subsequent decline in fertility; however, ultrastructural changes occurring after menopause have still not been well illustrated. Our aim was to characterize the three-dimensional microanatomy of the luminal surface of the human fallopian tube in perimenopause and postmenopause. Twenty bioptic samples of fallopian tubes were obtained after surgery under the informed consent of the patients. Samples were processed for transmission electron microscopy (TEM) and field-emission scanning electron microscopy (FE-SEM). As age increases the surface epithelium of the fallopian tube appeared somewhat flattened. Correlated TEM/FE-SEM observations showed gradual shortening of microvilli and deciliation. The most interesting finding was the gradual formation of microplicae-like structures on the surface epithelium, particularly from late perimenopause to postmenopause. Microplicae-like structures, associated with other regressive changes, represent an important adaptation of the epithelium of the fallopian tube; these are likely induced by the physiological process of aging, thus better withstanding hormonal changes associated with the advent of the menopause.

A singular pancreatico-colic artery: anatomical report and clinical implications

After dissection of the abdominal cavity of a 59-year-old male, a long artery, extending from the hepatic artery to the transverse colon, and comprised proximally within the neck of the pancreas and distally within the transverse mesocolon, has been detected. This "pancreato-colic" artery (P-C A) was 13 cm in length and 4 mm in diameter at the origin. Its mesocolic part (2.5 mm in diameter) contributed to the formation of the marginal arcade. No middle colic artery from the superior mesenteric was observed. Thus, the transverse colon was supplied by the distal part of the P-C A. Considering both the P-C A caliber and topography, attention should be paid during pancreatic resections and in the interposition of the transverse colon for esophageal replacement in order to avoid serious bleeding and necrosis. Embryologically, the proximal part of the P-C A might be regarded as an intrapancreatic variant of the tract of the longitudinal anastomosis between the ventral segmental arteries, persisting in the adult as dorsal pancreatic artery. Different from its usual retropancreatic location, this part might be entrapped inside the gland by the developing primitive pancreatic anlages. The distal, mesocolic, part of the P-C A might be regarded as a replacing middle colic artery into the dorsal mesentery during midgut rotation.

Pietro Motta's latest studies on the microanatomy of menopause: revised concepts on the beauty of aging

Menopause signs a hallmark in women's life. When compared to traditional two-dimensional techniques, scanning electron microscopy (SEM) allows to discover the impressive microcosm of the human body and offers original views of the real three-dimensional ultrastructure of reproduction. On the basis of Prof. Motta's last and original book, herein we show a selection of microscopic images that characterize the 3D changes taking place on the surface epithelia of the aging woman's reproductive tract. Biopsies of ovaries, tubes, uteruses, cervices and vaginas were obtained from women (45-72 years old) during surgical or endoscopical procedures and after the informed consent of the patients. Samples were processed for SEM as reported elsewhere. Reproductive aging is associated to epithelial flatness, higher stromal density, absence of ovarian follicles, thickening of vascular walls and lack of glandular secretion. The uterus and the tube show a morphodynamic sequence of gradual microvilli shortening, patchy to complete deciliation and formation of microplicae like structures. The formation of microplicae like structures is interpreted as an adaptive mechanical response of the genital epithelia to the new microenvironment. We can propose that these structures may represent the initial stage of a physiologic metaplasia. In conclusion, imaging of menopause through the use of SEM allows a better understanding of the morphological and physiopathological bases of female aging and represents a perfect blend of art and aesthetics: a further confirmation of the endless beauty of our inner microscopic anatomy.

Cumulus oophorus extracellular matrix in the human oocyte: a role for adhesive proteins

A viscous elastic matrix secreted by the cumulus oophorus cells represent the "extracellular matrix" surrounding the human mature oocyte obtained from assisted reproductive technology (ART). The cumulus matrix is involved in several reproductive processes, including the pick-up of the oocyte-cumulus complex by the oviduct, the final maturation of the ovum and sperm-egg interaction. As showed by some Authors, the cumulus matrix is rich in hyaluronan, as well as in other proteins including inter-alpha-trypsin inhibitor, a dermatan sulfate proteoglycan, and a pentraxin-3. Proteins and hyaluronan are linked together to form a meshwork comprised of granules and filaments. We found in human cumulus oocyte complexes the presence of specialized cells still capable of producing fibronectin and tenascin-c in the post-ovulatory period. Moreover, fibronectin and tenascin-c are present within the hyaluronan matrix at fertilization during the tubal sojourn of the ovum and the embryo. Since pentraxin3 is important in matrix stabilization and gamete interactions, a possible role for fibronectin and tenascin-c may be postulated in the final maturation of the ovum, in the tubal pick-up and in the complex dialogue with the tubal epithelium.

Ultrastructural morphodynamics of human Sertoli cells during testicular differentiation

Our study reviews and ultrastructurally characterises human pre-Sertoli cells between the 6th and the 20th week of gestation by means of integrated light microscopy, transmission electron microscopy and high resolution scanning electron microscopy (standard or following ODO maceration). The morphofunctional differentiation of Sertoli cells defines testicular differentiation. These somatic cells are mostly of mesonephric origin and can be first morphologically recognised in 7 week-old embryos altogether with the formation of testicular cords. The latter organise as primordial germ cells surrounded by pre-Sertoli cells. Due to the great synthetic activity of pre-Sertoli cells the rough endoplasmic reticulum develops. The basal lamina of the cords becomes distinguishable at 7 to 8 weeks of gestation. Both prespermatogonia and pre-Sertoli cells actively proliferate but the latter greatly outnumber prespermatogonia. Many interdigitations and cytoplasmic processes are observed between neighbouring pre-Sertoli cells. Due to cell proliferation a sort of compartmentalisation is established inside the cords in which pre-Sertoli cells tend to localise closer to the basal membrane embracing prespermatogonia with long and thin cytoplasmic processes. One of the main typical features of differentiating pre-Sertoli cells is the irregular nucleus and the prominent nucleolus. When the embryo is 14 to 20 weeks-old pre-Sertoli cells maintain their general morphology whereas the most significant change is the maximum development of Leydig cells. Testicular cords do not show any lumen at all so they cannot be termed "tubules".

Ultrastructure of human Leydig cells at early gonadal embryogenesis

The ultrastructure of human Leydig cells at different stages of the testicular prenatal development is described by means of transmission and scanning electron microscopy. Between 5 and 7 weeks of gestation (w.g.) the interstitial tissue of the gonad is filled with small undifferentiated mesenchymal cells, migrating primordial germ cells and blood vessels. When the embryo is 7 to 8 weeks-old Leydig cells (LC) appear in basically two morphological patterns, light and dark cells. Their most significative feature is the development of the smooth endoplasmic reticulum (SER) as a dense tubulo-vesicular network and the presence of numerous pleomorphic mitochondria with mainly lamellar cristae. At 14 and 16 w.g. the testicular interstitium reaches the maximum development; the cytoplasm of the LC shows a widespread network of anastomosing tubules of the SER and mitochondria with tubular cristae. Fetal LC show a partial cell coat, lack the crystals of Reinke, have few lipid droplets and show no signs of massive cell degeneration, at least until 16 w.g. These ultrastructural modifications in fetal LC are in accordance with the changes in both steroidogenic activity and hCG levels reported by the literature to occur at this stage of development. Junctional complexes were often observed among LC from 7 to 8 w.g. onwards.

The collagen fibrils arrangement in the Wharton's jelly of full-term human umbilical cord

In the present study, a cell maceration/scanning electron microscopy method is employed in order to reveal the three-dimensional organization of the collagen fibrils in the Wharton's jelly of the human umbilical cord at term. By this method the jelly appears as a three-dimensional network of collagen fibrils that runs continuously from the amniotic membrane to the umbilical vessels. A diverse architecture of the collagen fibrillar network in the inner and outer region of the cord is observed suggesting an anatomical as well as a functional compartmentalization. In fact, the network is soft in the inner part and it is characterized by canalicular structures whereas in the outer region the collagen is dense and the network is characteristically composed by a sponge-like system of cavernous spaces. It is suggested that these cavities might store the ground substance and allow its diffusion during twisting or compression of the cord. Furthermore they may facilitate the flow of metabolites throughout the jelly from and to the umbilical vessels and the amniotic cavity.

Scanning electron microscopy study of the palatine salivary glands of rabbits

The structure of the palatine salivary glands of rabbits was studied employing scanning electron microscopic methods. The fractured surface of the palatine salivary glands revealed that they were formed of small lobuli separated by interlobular spaces containing numerous bundles of collagen fibers. The NaOH treated specimens showed the organization of the collagen fibrils in their original location. In the interstitial stroma compartment, the collagen fibrils revealed a complex three-dimensional arrangement forming channel-like structures for supporting nerve fibers, small vessels and capillaries. Single groups of acinar cells were clearly demonstrated, and each acinus was enveloped by a characteristic basal lamina showing a sponge-like structure made up of several interconnected meshes of collagen fibrils. Furthermore, taking advantage of the ODO method and field emission scanning electron microscopy, within the cytoplasm of secretory acinar cells numerous organelles were clearly observed in a three-dimensional way such as Golgi complex lamellae, rough endoplasmic reticulum, mitochondria and secretory granules. All these cytoplasmic components revealed their real and microtopographical arrangement in some areas of the acinar cytoplasm clearly suggesting their direct involvement in energetic as well as secretory activities.

Ultrastructural dynamics of human testicular cords from 6 to 16 weeks of embryonic development. Study by transmission and high resolution scanning electron microscopy

When the embryo is 6-week-old the gonad is composed mostly of migrating primordial germ cells, surface coelomic mesothelium and mesenchymal cells. At 7 weeks of gestation (wg) testicular cords consist of prespermatogonia, larger, with a more regular outline and higher mitotic activity than primordial germ cells, embraced by somatic pre-Sertoli cells. The morphofunctional development of Sertoli cells defines testicular differentiation. Towards 7.5 wg the gonad is finally in its differentiated stage; the basal lamina of the cords becomes distinguishable, testicular cords radially branch and elongate, and Leydig cells are clearly recognized. Primordial germ cells are large and spherical, with rounded and eosinophilic nuclei and large nucleoli. Pre-Sertoli cells, in turn, show round or columnar nuclei and rough endopasmic reticulum. Prespermatogonia and mostly pre-Sertoli cells actively proliferate. Many interdigitations and cytoplasmic processes are observed between neighboring pre-Sertoli cells and between pre-Sertoli cells and prespermatogonia. A sort of com partmentalization is established inside the cords in which pre-Sertoli cells tend to localize closer to the basal membrane embracing the prespermatogonia with long and thin cytoplasmic processes. Between 14 and 16 wg the most significant changes besides maximum development of Leydig cells are differentiation of mesenchymal cells around the cords into future peritubular cells and maturational changes of pre-Sertoli cells. These likely reveal a peak coinciding in time with reported increases in either testosterone production and Müllerian Inhibiting Substance secretion. During the period herein considered testicular cords show no lumen neither any sign of canalization so they cannot be termed "tubules".

The extracellular matrix of normal human placental villi at term: a scanning electron microscopy study

The three-dimensional organisation of the extracellular fibrillar matrix in normal human placental villi at term is investigated by scanning electron microscopic after 2N-NaOH-maceration technique. The latter method consists of a chemical digestion of cellular components of the villi that allows the visualisation of the extracellular fibrillar network in a real three-dimensional fashion by scanning electron microscope. By this approach, the extracellular fibrillar matrix, mainly composed by collagen fibrils, forms a continuous skeleton within the whole villous system of the placenta. This sort of collagenous fibrillar skeleton forms the axis of chorionic villi and connects them with the basal plates. Significant differences in quantity and arrangement of the extracellular matrix are observed at the various levels of the villous ramification. In fact, in the stem villi, the fibrillar extracellular matrix is considerable and the fibres are arranged longitudinally at the villous surface (outer fibrils) and circularly in the inner core of the villous around the wall of the fetal vessels (inner fibrils). On the contrary, in mature intermediate and terminal vili, the extracellular fibrillar matrix is significantly reduced and the fibrils are mainly arranged in a thin circular layer around the capillaries and sinusoids. The present study confirms morphologically the existence of a diverse organization of the extracellular matrix specific for the various levels of the villous ramification as suggested by previous immunohistochemical studies. Moreover, the presence of a highly organized collagenous fibrillar skeleton as observed in our study, stress the important mechanical role of the extracellular matrix in sustaining the chorionic fetal vessels and the trophoblastic layer. Furthermore, the fine reticular-meshed network of this skeleton observed in the terminal villi suggests an additional role of the extracellular matrix to ensure a favorable milieu for active feto-maternal exchanges at this level of the villous tree.

Extracellular fibrillar matrix architecture of human placental villi at term

The spatial organisation of the extracellular fibrillar matrix of normal human placental villi at term can be directly visualised by scanning electron microscopy after 2N-NaOH maceration technique. By these methods, the extracellular fibrillar matrix of placental villi appears as a continuous network of isolated collagen fibrils and/or small fibrillar bundles interwoven each other. This sort of "collagenous fibrillar skeleton" forms the axis of chorionic villi and connects them with the basal plates running through the whole villous system of the placenta. Significant variations in the spatial arrangement as well as in the quantity of the extracellular matrix is observed at different levels of the villous ramification. Within the stem villi, the fibrillar extracellular matrix are abundant and, whereas the fibrils near the villous surface run parallel to the longitudinal axis of the villous (outer fibrils), those located in the inner core of the villous are arranged circularly around the wall of the fetal vessels (inner fibrils). In mature intermediate and terminal villi, viceversa, the extracellular fibrillar matrix is significandy reduced and the fibrils are mainly organised in a thin circular layer around the capillaries and sinusoids. The present study demonstrated the existence of a diverse spatial architecture of the extracellular matrix that results to be peculiar to the various levels of the ramification of the villous tree. Therefore, these morphological data strongly suggest a "compartmentalisation" of the villous tree as suggested by previous immunohistochemical study. Such a highly organised "collagenous fibrillar skeleton" stresses the important mechanical role of the extracellular matrix in sustaining the chorionic fetal vessels and the trophoblastic layer. Furthermore, the fine reticular-meshed network observed within the terminal villi suggests that at this level an additional role ensuring a favourable milieu for active feto-maternal exchanges may exist.

Mitochondrial morphology in human fetal and adult female germ cells

The aim of this study has been to observe, by electron microscopy, the morphological changes affecting mitochondria and associated organelles in the human female germ cell during oogenesis, maturation and fertilization. In the primordial germ cell (PGC), rounded mitochondria with a pale matrix and small vesicular cristae are disposed near the nucleus and significantly increase in number during PGC migration and settlement in the gonadal ridge, where they differentiate into oogonia. In these early stages of mammalian oogenesis, aggregates of mitochondria are typically clustered around or in close relationship with the nuage. In oocytes at early prophase stage, mitochondria proliferate while aligned along the outer surface of the nuclear membrane, contain a more dense matrix than before, and have lamellar cristae. Oocytes of primordial and primary follicles mostly contain round or irregular mitochondria whose matrix has become very light. These mitochondria show typical parallel, arched cristae, and are clustered near the nucleus with other organelles forming the Balbiani's vitelline body. When follicles grow, the mitochondria of the oocytes become even more numerous and are dispersed in the ooplasm. Both paranuclear accumulation and subsequent dispersion of mitochondria in the cytoplasm are likely to be regulated by microtubules. By ovulation, mitochondria are the most prominent organelles in the ooplasm. They form voluminous aggregates with smooth endoplasmic reticulum (SER) tubules and vesicles. These mitochondrial-SER aggregates (M-SER) and the mitochondrial-vesicle complexes (MV) could be involved in the production of a reservoir of substances or membranes anticipating subsequent fertilization and early embryogenesis. Just after fertilization, the mitochondria of the oocyte undergo a further substantial change in size, shape, and microtopography. In the pronuclear zygote, mitochondria concentrate around the pronuclei. During the first embryonic cleavage divisions, round or oval mitochondria with a dense matrix and few arched cristae are gradually replaced by elongated ones with a less dense matrix and numerous transverse cristae. A progressive reduction in size and number of M-SER aggregates and MV complexes also occurs. In summary, oocyte mitochondria show dynamic morphological changes as they increase in number and populate different cell domains within the oocyte. They form complex relationships with other cell organelles, according to the different energetic -metabolic needs of the cell during differentiation, maturation, and fertilization, and are ultimately inherited by the developing embryo, where they eventually assume a more typical somatic cell form.

Late effects of therapy in 94 patients with localized rhabdomyosarcoma of the orbit: Report from the Intergroup Rhabdomyosarcoma Study (IRS)-III, 1984-1991

BACKGROUND

We reviewed the late complications of therapy in 94 patients with localized, primary rhabdomyosarcoma of the orbit treated on the Intergroup Rhabdomyosarcoma Study (IRS)-III protocol (1984-1991).

PROCEDURE

A questionnaire was sent to the institutions that had registered 106 patients with orbital RMS on the IRS-III protocol, seeking information about vision, periocular structures, and growth and development of the 102 survivors.

RESULTS

Ninety-four questionnaires were returned. The median follow-up interval was 7.6 years. The affected eye was removed from 13 patients because of local recurrence (N = 10) or other causes (N = 3). Seventy-nine of the eighty-one remaining patients had received radiation therapy. Sixty-five of these seventy-nine patients (82%) developed a cataract, and 43 of them (66%) underwent cataract surgery. Fifty-five patients (70%) had decreased visual acuity. Twenty-four patients had a dry eye, and 22 had chronic keratitis, conjunctivitis, or corneal changes. Strabismus, diplopia, retinopathy, and uveitis were uncommon. The orbit was hypoplastic in 48 of 82 patients assessed (59%). Ptosis and enophthalmos were reported in 22 patients. Decreased statural growth was noted in 13 of the 53 irradiated patients aged 3-14 years at diagnosis with sufficient data (24%).

CONCLUSIONS

The overall survival rate was 96% (102/106). The eye was preserved in 86% of the patients, but vision was impaired in 70% of them. Other frequent complications were cataract, orbital hypoplasia, keratoconjunctivitis, and ptosis/enophthalmos. The current IRS-V study recommends decreasing the dose of irradiation and using conformal techniques in an attempt to minimize these complications.

Late complications of therapy in 213 children with localized, nonorbital soft-tissue sarcoma of the head and neck: A descriptive report from the Intergroup Rhabdomyosarcoma Studies (IRS)-II and - III. IRS Group of the Children's Cancer Group and the Pediatric Oncology Group

BACKGROUND

This review of children and adolescents with nonorbital soft-tissue sarcoma of the head and neck was undertaken to describe late sequelae of treatment, as manifested primarily by problems with statural growth, facial and nuchal symmetry, dentition, vision and hearing, and school performance.

PROCEDURE

Four hundred sixty-nine patients entered the IRS-II and -III protocols with localized, nonorbital soft-tissue sarcomas of the head and neck from 1978 through 1987. Their overall survival rate was 53% (250/469) at 5 years. Two hundred thirteen patients were surviving relapse-free 5 or more years after diagnosis, for whom there were serial height measurements at 2 or more years after initiation of therapy. Their median age at diagnosis was 5 years; the median length of follow-up was 7 years. All received multiple-agent chemotherapy, and all but 3 received irradiation to the primary tumor volume. Sixty-eight percent of the tumors arose in cranial parameningeal sites, 22% in nonparameningeal sites, and 10% in the neck. We reviewed flow sheets submitted to the IRS Group Statistical Office to ascertain which late sequelae were recorded.

RESULTS

One hundred sixty-four patients (77%) had one or more problems recorded. One hundred ninety of the two hundred thirteen patients (89%) were under 15 years of age at study entry, and at follow-up 92 (48%) had failed to maintain their initial height velocity, which had decreased by more than 25 percentile points from the original value. Thirty-six of the one hundred ninety patients (19%) were receiving growth hormone injections. Hypoplasia or asymmetry of tissues in the primary tumor site was reported in 74 patients, and 13 underwent reconstructive surgery. Poor dentition or malformed teeth were noted in 61 patients. Impaired vision developed in 37 patients, owing primarily to cataracts, corneal changes, and optic atrophy. Thirty-six patients had decreased hearing acuity, and 9 were fitted with hearing aids; 5 of these 9 had received cisplatin. Thirty-five patients were noted to have problems learning in school. Four patients developed a second malignancy (two sarcomas, one carcinoma, one leukemia).

CONCLUSIONS

Late sequelae affected the majority of these patients treated for soft-tissue sarcoma of the head and neck on IRS-II and -III. The potential impact of certain sequelae could be reduced by specific measures, such as surgical reconstruction and hormonal therapy. Late sequelae must be taken into account in designing future curative treatments.

Secondary leukemia or myelodysplastic syndrome after treatment with epipodophyllotoxins

PURPOSE

The incidence of secondary leukemia after epipodophyllotoxin treatment and the relationship between epipodophyllotoxin cumulative dose and risk are not well characterized. The Cancer Therapy Evaluation Program (CTEP) of the National Cancer Institute (NCI) has developed a monitoring plan to obtain reliable estimates of the risk of secondary leukemia after epipodophyllotoxin treatment.

METHODS

Twelve NCI-supported cooperative group clinical trials were identified that use epipodophyllotoxins at low (<1.5 g/m2 etoposide), moderate (1.5 to 2.99 g/m2 etoposide), or higher (> or =3.0 g/m2 etoposide) cumulative doses. Cases of secondary leukemia (including treatment-related myelodysplastic syndrome) occurring on these trials have been reported to CTEP, as has duration of follow-up for all patients, thereby allowing calculation of cumulative 6-year incidence rates of secondary leukemia for each etoposide dose group.

RESULTS

The calculated cumulative 6-year risks for development of secondary leukemia for the low, moderate, and higher cumulative dose groups were 3.3%, (95% upper confidence bound of 5.9%), 0.7% (95% upper confidence bound of 1.6%), and 2.2%, (95% upper confidence bound of 4.6%), respectively.

CONCLUSION

Within the context of the epipodophyllotoxin cumulative dose range and schedules of administration encompassed by the monitoring plan regimens, and within the context of multiagent chemotherapy regimens that include alkylating agents, doxorubicin, and other agents, factors other than epipodophyllotoxin cumulative dose seem to be of primary importance in determining the risk of secondary leukemia. Data obtained by the CTEP secondary leukemia monitoring plan support the relative safety of using epipodophyllotoxins according to the therapeutic plans outlined in the monitored protocols.

Microarchitecture of the cat testis with special reference to Leydig cells: a three-dimensional study by alkali maceration method and scanning electron microscopy

Testes from adult cats were studied by means of parallel transmission and scanning electron microscopy (SEM) after NaOH digestion technique, which selectively removed connective tissues or cells. The testis is covered by a dense fibroconnective tunica albuginea that partially divides the organ in lobules by sending septa into the parenchyma. The lamina propria of the seminiferous tubules consisted of one or two rows of cells. The interstitium was made up of randomly arranged collagen bundles. The most significant feature was the numerous Leydig cells rich in lipid droplets and displaying epithelioid features. Following alkali digestion and SEM these cells showed a cord-like arrangement. The cords were formed by one or two closely apposed cells, in between which some labyrinthine or canalicular-like spaces were left that in some areas opened in wide perivascular spaces. This particular arrangement of Leydig cells and the labyrinthine intercellular spaces is very likely designed to improve cell secretion of hormones, facilitating their transport into the blood, as well as the traffic of fluids and metabolites. The present techniques allowed the visualization of a real three-dimensional testicular microarchitecture and microtopography, not detectable with other methods. Such a study may help to better highlight the testicular morphophysiology.

Preservation of the bladder in patients with rhabdomyosarcoma

PURPOSE

To review the pathologic findings from children with gross residual rhabdomyosarcoma (RMS) of the bladder and compare the treatment outcome of those who underwent cystectomy with those who did not.

PATIENTS AND METHODS

Primary and follow-up records and pathology specimens for 28 patients with gross residual disease entered onto the intergroup Rhabdomyosarcoma Study (IRS) III were reviewed. These patients were assigned to receive 20 weeks of multiagent induction chemotherapy and 4 weeks of radiotherapy. Future therapy decisions were based on clinical and histologic evaluation at 20 weeks.

RESULTS

All patients had a clinical and histologic response. Thirteen patients underwent cystectomy at intervals that ranged from 1.5 to 38 months after the start of therapy. All but one patient are alive and well without recurrence. Reasons for cystectomy included presumed evidence of tumor growth from imaging studies, findings at cystoscopy, or histologic interpretation of biopsies. In 12 of 14 specimens from 15 patients who retained their bladder, no tumor cells were seen at first or second evaluation. In cystectomy specimens, tumor cellularity was markedly reduced and all tumor cells were in varying degrees of cellular maturation. Review of primary tumor specimens showed a greater degree of cellular maturation in patients with retained bladders than in those who underwent cystectomy.

CONCLUSION

Bladder RMS is responsive to chemotherapy and radiotherapy. Twelve of 26 patients showed complete loss of tumor cells after induction therapy. Cystectomy specimens showed diminished tumor cells with varying degrees of cellular maturation. It is hypothesized that these tumors may have shown further maturation and ultimate loss of matured cells with continuing therapy.

Development of mouse submandibular gland studied by field emission scanning electron microscopy

The ultrastructural organization of mouse submandibular gland from 15 days gestation to 180 days of age was studied by field emission scanning electron microscopy. At 15 days of gestation several groups of acini, intercalated and striated ducts were present. They consisted of numerous pyramidal and/or polyhedral cells with spherical or elongated nuclei and short microvilli. At 3 days after birth different shapes of acinar structures covered by a network of fine collagen bundles were observed. The acinar portions corresponded to the terminal tubules and showed the acinar cells containing immature secretory granules. Fractured specimens of ducts revealed a flat surface with large central nuclei. At 14 days after birth acinar terminal portions possessed a round shape; branches of either intercalated and striated ducts were also observed. Gap junctions and interdigitations were numerous at the base of acinar cells. At 30 days after birth the acinar terminal portions and striated ducts revealed a large number of secretory granules. Acinar cells showed a pyramidal shape and basal nuclei. Freeze-cracked surfaces of the striated ductal cells evidenced also a pyramidal shape. Secretory granules ranged from 0.3 to 1.2 microns in size and were clearly observed by infoldings of the basement membranes. At 90 days after birth the ultrastructural features were more differentiated when compared with the previous ages. The freeze-cracked specimens showed very numerous secretory granules in all acinar and striated ductal cells. The granules occupied almost all the apical region of the cells. The outer surface of the basement membrane of acinar and myoepithelial cells was constituted by a spongy-like material covered by fine collagen fibrils. At 180 days after birth numerous secretory granules were seen either in acinar and ductal cells. A morphofunctional polarization of the cell was finally clearly observed in that the cytoplasmic organelles were concentrated in the basal portion whereas the secretory granules were located in the apical region of the cells.

The argument for conservative, delayed surgery in the management of prostatic rhabdomyosarcoma

Exenteration is no longer required for most patients who have rhabdomyosarcoma (RMS) of the prostate. This site comprised only about 5% of newly diagnosed cases in the IRS-III (1984-1991). The mean age at the time of diagnosis was 5.3 yrs (range, 0 to 19 years). Most tumors were relatively large, had embryonal histology, and were clinically localized but unresectable without major loss of organ function. The 44 patients with group III tumors (gross residual disease) were treated according to the IRS-III protocol. Forty-three of them underwent biopsy only, and one patient had subtotal resection as the initial procedure. The average number of surgical procedures per patient was two (range, one to five). Six of the 44 patients had no additional surgery. The second-look procedures performed in the other 38 patients included exenteration (14), prostatectomy (7), cystoscopic/perineal needle biopsy (8), laparotomy with biopsy (6), and subtotal excision with bladder salvage (3). Additional surgery was required for four patients, for evaluation of a residual mass, postoperative fistula, ureteral stricture, or small bowel obstruction. Six patients with relapse or residual disease underwent additional chemotherapy and late exenteration (3), prostatectomy (1), or biopsy (2). Four of the six have been cured, one is in treatment for a second malignancy, and the other has residual disease after exenteration. Thirty-six of the 44 patients with group III tumors have been cured (minimum follow-up period, 6 years; range, 6 to 11 years), compared with 23 of the 47 in IRS-II (1978-1984) (P = .001). Two of the six deaths in this group were caused by infection. The bladder salvage rate for those cured of their disease also was better (64% v 57% for IRS-II). The two patients with group IIA tumors were cured by gross primary excision, local radiotherapy, and vincristine and actinomycin therapy. By contrast, all patients with metastatic disease (group IV) died of the tumor. Conservative, delayed surgery, performed after intensive chemotherapy with or without radiotherapy, yields a better cure rate while maintaining a high rate of bladder salvage in children with group III prostatic RMS.

The collagen skeleton of the cat testis. A scanning electron microscopy study after 2N-NaOH maceration

Testes from adult cats were studied by means of scanning electron microscopy (SEM) after 2N-NaOH maceration method which selectively digests cells and tissue compounds. As seen by this technique, the testis appears covered by a dense fibroconnective tunica albuginea that divides partially the organ by sending septa into the parenchyma. The interstitium is made up by a rich connective tissue composed by randomly-arranged fine collagen bundles that clearly outline the spaces occupied by the seminiferous tubules. The basement membrane of the seminiferous tubules consists in two rough layers of collagen fibers that in some places leave small fenestrations. The three-dimensional arrangement of collagen fibers in the interstitium outlines a system of cavities likely to be lacunar spaces for Leydig cells and vascular imprints. Especially, the above chemical technique followed by deep observations under the SEM allowed a clear and complete view of the real three-dimensional microarchitecture of the connective tissue of the testis. Therefore, the collagen component was revealed to actually form a unique and complex skeleton for the whole organ. This three-dimensional figure closely follows indeed the classical histological compartmentalization of the testis with a better insight of its spatial microtopographical features. Moreover, this structural pattern is also likely to give rise to very fine morphofunctional subcompartmentalization, especially regarding the basement membrane of the seminiferous tubules and the lacunar spaces for Leydig cells including satellite vessels.

The p53 gene in pediatric therapy-related leukemia and myelodysplasia

We investigated the frequency of p53 mutations in 19 pediatric cases of therapy-related leukemia or myelodysplastic syndrome. Eleven children presented with acute myeloid leukemia, one with mixed-lineage leukemia, two with acute lymphoblastic leukemia, and five with myelodysplasia at times ranging from 11 months to 9 years after a primary cancer diagnosis. The primary cancers, which included 11 solid tumors and eight leukemias, were treated with various combinations of DNA topoisomerase II inhibitors, alkylating agents, or irradiation. Leukemic or myelodysplastic marrows were screened for possible mutations by single-strand conformation polymorphism (SSCP) analysis of p53 exons 4 to 8. The only observed mutation was an inherited 2-basepair deletion at codon 209 in exon 6 that would shift the open reading frame, create a premature termination codon, and foreshorten the resultant protein. Prior therapy in this patient included DNA topoisomerase II inhibitors, alkylating agents, and irradiation. The secondary leukemia presented as myelodysplasia with monosomies of chromosomes 5 and 7 and abnormalities of chromosome 17. Although the primary cancer was an embryonal rhabdomyosarcoma and there was a family history of cancer, the case did not fulfill the clinical criteria for Li-Fraumeni syndrome. This study suggests that germline p53 mutations may predispose some children to therapy-related leukemia and myelodysplasia, but that p53 mutations otherwise are infrequent in this setting.

Collagen fibrillar skeleton in pregnant rabbit endometrium at term: a SEM study after NaOH maceration

This paper describes the spatial organization of the collagen fibrillar skeleton in pregnant rabbit endometrium at term, employing an alkali/low temperature/maceration technique followed by scanning electron microscopic (SEM) observations. Parallel light microscopic (LM) and transmission electron microscopic (TEM) investigations were made to identify the location and possible changes in the endometrial collagen network. Two different types of NaOH maceration were applied, demonstrating separately: 1) the collagen structures (2N-NaOH maceration removes the cells and basal laminae); and 2) the cellular elements (6N-NaOH maceration removes the collagen fibrils). After 2N-NaOH maceration, the collagen network of the endometrium is seen in a superficial compartment around the glands and a deep compartment situated near the endometrial-myometrial junction. Significant changes are observed only in the superficial compartment. The luminal mucosal surface is characterized by numerous thin projections reducing the uterine cavity which, as a consequence, further appears very irregular and highly convoluted. The subepithelial collagen network is composed of densely packed fibrils with a woven course. It contains many tubular or channel-like invaginations (100-150 microns in width and 200-300 microns in length) where endometrial glands are located. These invaginations, corresponding to the glandular impressions, are extremely dilated, enlarged and variable in shape. The collagen fibrils are arranged concentrically around the glandular orifices without forming bundles. At the bottom of the spaces between the mucosal projections, small fenestrations (4-8 microns in diameter each) are present. They form small groups of about 10-20 in number and are due to the endometrial blood capillaries. The deep compartment of the endometrial collagen network is little altered, preserving its general lamellar arrangement. The changes in the endometrial collagen skeleton are due to a variety of complex mechanical and hormonal stimuli affecting the uterus during pregnancy. These may be significant for correct implantation, placentation and delivery.

Pleuropulmonary blastoma: a marker for familial disease

OBJECTIVE

To catalog and evaluate patterns of disease in families of children with pleuropulmonary blastoma (PPB).

METHODS

Data have been collected since 1988 on 45 children with PPB and their families. All pathologic materials were centrally reviewed. Preliminary molecular genetic analyses were performed when possible.

RESULTS

In 12 of 45 patients, an association was found between PPB and other dysplasias, neoplasias, or malignancies in the patients with or in their young relatives. The diseases found to be associated with PPB include other cases of PPB, pulmonary cysts, cystic nephromas, sarcomas, medulloblastomas, thyroid dysplasias and neoplasias, malignant germ cell tumors, Hodgkin disease, leukemia, and Langerhans cell histiocytosis. Abnormalities of the p53 tumor suppressor gene, Wilms tumor suppressor gene (WT1), and the putative second genetic locus for Wilms tumor (WT2) were not found in preliminary investigations.

CONCLUSIONS

The occurrence of PPB appears to herald a constitutional and heritable predisposition to dysplastic or neoplastic disease in approximately 25% of cases. All patients with PPB and their families should be investigated carefully. Further research of this new family cancer syndrome may provide insight into the genetic basis of these diseases.

The collagen skeleton of the human umbilical cord at term. A scanning electron microscopy study after 2N-NaOH maceration

The organization of the collagen fibrils in the human umbilical cord at term is directly visualized by means of a scanning electron microscopy cell maceration method. This technique clearly reveals that there is a much more extensive collagen fibrillar architecture within the umbilical cord than that reported in the classical histological descriptions. The Wharton's jelly, in fact, appears as a spongy network of interlacing collagen fibres and small woven bundles apparently arranged at random and forming a continuous soft skeleton that encases the umbilical vessels. The collagen fibrillar network shows the presence of a wide system of interconnected cavities consisting of canalicular-like structures as well as cavernous and perivascular spaces. This system of cavities might play a mechanical role allowing the storing of the ground substance of the jelly and its diffusion during twisting or compression. Furthermore, it may have an important role facilitating the diffusion throughout the jelly of diffused materials (i.e. water and trophic metabolites) either from or to the umbilical vessels and the amniotic cavity, thus overcoming the lace of a proper vasculature with the jelly.

The Third Intergroup Rhabdomyosarcoma Study

PURPOSE

The ultimate goal of the Third Intergroup Rhabdomyosarcoma Study (IRS-III, 1984 to 1991) was to improve treatment outcome in children with rhabdomyosarcoma through clinical trials comparing risk-based protocols of surgery and multiagent chemotherapy, with or without irradiation.

PATIENTS AND METHODS

One thousand sixty-two previously untreated, eligible patients who were entered onto the study after surgery were randomized or assigned to treatment by clinical group (I through IV), histology (unfavorable or favorable), and site of the primary tumor. Initial responses, progression-free survival (PFS), and survival (S) were the end points used in comparisons between randomized groups and between patients treated in IRS-III and IRS-II (1978 to 1984).

RESULTS

The overall outcome of therapy in IRS-III was significantly better than in IRS-II (5-year PFS, 65% +/- 2% v 55% +/- 2%; P < .001 by stratified testing). Patients with group I favorable-histology tumors fared as well on a 1-year regimen of vincristine and dactinomycin (VA), as did a comparable group treated with VA plus cyclophosphamide (C) (5-year PFS, 83% +/- 3% v 76% +/- 4%; P = .18). Results for patients with group II favorable-histology tumors, excluding orbit, head, and paratesticular sites, were inconclusive regarding the benefit from addition of doxorubicin (ADR) to VA. Patients with group III tumors, excluding those in special pelvic, orbit, and other selected nonparameningeal head sites, fared much better on the more intensive regimens of IRS-III than on pulsed VAC or VAC-VADRC in IRS-II (5-year PFS estimates, 62% +/- 3% v 52% +/- 3%; P < .01); however, there were no significant differences in outcome among the groups treated in IRS-III. Patients with metastatic disease at diagnosis (clinical group IV) did not benefit significantly from the more complex therapies evaluated in IRS-III.

CONCLUSION

Intensification of therapy for most patients in IRS-III, using a risk-based study design, significantly improved treatment outcome overall. The largest gain from this strategy was realized in patients with gross residual tumor after biopsy (clinical group III). It was also possible to decrease therapy for selected patient subsets without compromising survival.

Acute myeloid leukemia in patients treated for rhabdomyosarcoma with cyclophosphamide and low-dose etoposide on Intergroup Rhabdomyosarcoma Study III: an interim report

The early occurrence of five cases of acute myeloid leukemia (AML) in children treated for primary rhabdomyosarcoma on the Intergroup Rhabdomyosarcoma Study III (IRS III) has prompted this report. These patients received cyclophosphamide and four received etoposide in addition to other agents. There were 1,062 eligible patients entered on IRS III between 1984 and 1991. Following surgery, treatment consisted of multiagent chemotherapy and radiotherapy in select clinical groups. Median follow-up time is 3.7 years (range 0-7.4 years). Incidence densities and odds ratios for AML were calculated for various treatment groups. Five cases of secondary AML have been reported through August 1992. A single case of osteogenic sarcoma was reported in the same period and a patient with myelodysplastic syndrome has occurred since that time. Median time to development of AML was 39 months. Incidence density of AML for patients receiving neither cyclophosphamide nor etoposide was 0, for those receiving cyclophosphamide but no etoposide it was 7.6, and when both agents were given, it was 51.6. The odds ratios of AML for the latter two groups indicated a risk of AML which was seven times higher in the patients who received both agents. A history of breast cancer was present in all five families of patients with AML and several other cancers had occurred in three families. Preliminary analysis suggests a possible causal role for low-dose etoposide in addition to that assumed for cyclophosphamide in the early development of AML among pediatric patients treated for rhabdomyosarcoma.

Report of the Cancer Therapy Evaluation Program monitoring plan for secondary acute myeloid leukemia following treatment with epipodophyllotoxins

BACKGROUND

Recent reports have documented the occurrence of treatment-related acute myeloid leukemia (AML) following therapy with epipodophyllotoxins. These reports have led to growing concern among oncologists, which could lead to premature abandonment of these agents at a time when the relationship between cumulative dose of epipodophyllotoxin and risk of treatment-related AML has not been determined.

PURPOSE

Because of the increasingly important role of epipodophyllotoxins in the treatment of several types of adult and pediatric tumors, the Cancer Therapy Evaluation Program (CTEP) of the National Cancer Institute (NCI) has developed a monitoring plan to obtain reliable estimates of the risk of treatment-related AML following epipodophyllotoxin treatment.

METHODS

We identified 12 NCI-supported Cooperative Group clinical trials in which patients with solid tumors are being treated with epipodophyllotoxins at different cumulative doses. One trial is using a moderate dose of teniposide (900 mg/m2), and 11 trials are using etoposide at a low dose (< 1500 mg/m2), a moderate dose (1500-3999 mg/m2), or a high dose (> or = 4000 mg/m2). Cases of treatment-related AML and treatment-related myelodysplastic syndrome (MDS) (hereafter referred to as treatment-related AML/MDS) occurring in these trials are reported to CTEP, with initial analysis for each cumulative dose group triggered by the reporting of four cases of treatment-related AML/MDS in that group. For each analysis, total patient follow-up for the group is determined and cumulative 6-year incidence rate is calculated.

RESULTS

Three cases of treatment-related AML and one case of treatment-related MDS (with documented monosomy 7) were reported in a group of 207 patients who received etoposide at a low cumulative dose. The calculated 6-year rate of development of treatment-related AML/MDS was 3.2% (95% upper confidence interval bounded by 7.2%).

CONCLUSIONS

The 6-year cumulative rate of treatment-related AML/MDS (3.2%) is within the range previously reported for alkylator-based regimens that did not include epipodophyllotoxins.

IMPLICATIONS

Previous reports have suggested that higher cumulative doses of alkylators are associated with increased risk of treatment-related AML, and a critical goal of the monitoring plan is to determine whether a similar relationship exists for the epipodophyllotoxins. Estimates will be developed for leukemogenic risk for the moderate- and high-cumulative-dose groups when four cases of treatment-related AML/MDS have been identified within each group.

Sequelae of treatment in 109 patients followed for 5 to 15 years after diagnosis of sarcoma of the bladder and prostate. A report from the Intergroup Rhabdomyosarcoma Study Committee

BACKGROUND

As increasing numbers of young patients with cancer survive, interest in the late effects of therapy is rising.

METHODS

The sequelae of treatment were reviewed after a minimum of 5 years of observation in 109 surviving patients with sarcoma of the bladder or prostate who were enrolled in the Intergroup Rhabdomyosarcoma Studies I and II (1972-1984). The 82 male and 27 female patients were 3 weeks to 19 years of age when the diagnosis was made (median, 2 years) and were 5-29 years of age at last contact (median, 11 years). Treatment consisted of chemotherapy with vincristine, dactinomycin, and cyclophosphamide and bladder irradiation in nearly all patients.

RESULTS

Fifty-four patients underwent total cystectomy, and 10 had a partial cystectomy. Of the 55 patients with bladder preservation, 1 had a urinary conduit with a nonfunctioning bladder. Thus, 54 bladders (50% of the total) remained in place as part of the urinary tract. There was no information regarding bladder function in two patients. Satisfactory bladder function was found in 38 patients (73%), 9 were incontinent, and 5 had urinary frequency with or without nocturia. Posttherapy hematuria was detected in 29% of patients. Nine of the 31 patients (29%) with follow-up renal imaging studies had a structural abnormality, chiefly hydronephrosis, which was more frequent in those with urinary diversion. Positive urine cultures were found mainly among those with enteric urinary conduits, but only two cases of pyelonephritis were documented. Abnormalities of irradiated bone and bowel were observed infrequently. Only one patient had a significantly elevated blood urea nitrogen or serum creatinine value, and only one patient was hypertensive. Most patients were still prepubertal at last follow-up. Of 24 patients who were intrapubertal or postpubertal, 7 (29%) were receiving sex hormone replacement because of delayed pubertal development. Height was decreased by 25% or more in 11 patients, as confirmed by growth chart analysis. Secondary surgical procedures other than repeat biopsy or cystectomy consisted primarily of urinary conduit revisions and repair of bowel adhesions or fistulous tracts. Information about psychosocial status was limited.

CONCLUSIONS

Overall, 50% of the patients retained their bladders, and 73% of them had satisfactory bladder function. Renal function was preserved in nearly every patient.

Second malignant neoplasms in children treated for rhabdomyosarcoma. Intergroup Rhabdomyosarcoma Study Committee

PURPOSE

This study was performed to determine the incidence and risk factors involved in the development of a second malignant neoplasm (SMN) after treatment of primary rhabdomyosarcoma (RMS) in patients enrolled onto Intergroup Rhabdomyosarcoma Studies I and II (IRS I and II).

PATIENTS AND METHODS

There were 1,770 patients with primary RMS entered onto IRS I and II between 1972 and 1984. They were treated with chemotherapy and, in most instances, radiotherapy according to randomized or assigned regimens based on clinical grouping. Median follow-up time for these patients was 8.4 years. Incidence density (ID) was calculated for each study and for treatment and age groups. The 10-year cumulative incidence was estimated for each study.

RESULTS

Twenty-two SMNs have been reported through 1991. The most common tumor type was a bone sarcoma followed by acute nonlymphoblastic leukemia (ANLL). The median time to the development of an SMN was 7 years (range, 1 11/12 to 15 9/12 years). The 10-year cumulative incidence rate was 1.7% for both studies. ID and cumulative incidence estimates were highest for patients who received both an alkylating agent and radiotherapy. The majority of patients for whom family histories were available had either neurofibromatosis themselves or a family history that suggested the Li-Fraumeni syndrome (LFS).

CONCLUSION

The results of this study suggest that genetic abnormalities play a prominent role in the development of an SMN after therapy for a primary RMS. Chemotherapy with an alkylating agent and radiotherapy play significant roles in the development of an SMN compared with patients who received only one of these therapeutic modalities.

Late effects of therapy in patients with paratesticular rhabdomyosarcoma. Intergroup Rhabdomyosarcoma Study Committee

PURPOSE

We report on long-term health-related problems determined from extended follow-up of 86 children and adolescents who were treated for paratesticular rhabdomyosarcoma on the Intergroup Rhabdomyosarcoma Studies I and II (IRS I-II).

PATIENTS AND METHODS

Patients were treated between 1972 and 1984, and ages at diagnosis ranged from 10 months to 19 years. The majority of these patients had initial retroperitoneal lymph node dissection (RLND) or sampling performed.

RESULTS

Problems related to surgical procedures included bowel obstruction in nine patients, loss of normal ejaculatory function in eight, development of a hydrocele in five, and lymphedema of the leg in five. Sequelae related to radiotherapy were difficult to assess with the exception of three patients whose remaining testes were in the field of radiotherapy. In general, kidney and bladder function were normal in patients who received radiotherapy to the paraaortic lymph nodes and/or bladder. Four patients who had abdominal radiotherapy had chronic diarrhea. Two patients had urethral strictures and urethritis. Four patients had bone or soft tissue hypoplasia in the field of radiotherapy. Chemotherapy-related late effects were primarily hemorrhagic cystitis or gonadal dysfunction after cyclophosphamide. A third of the patients who received cyclophosphamide developed hemorrhagic cystitis, and half of these had extended periods of gross hematuria after therapy was discontinued. The testicular size was small in children whose testes were irradiated and in some who received cyclophosphamide. Tanner staging was normal in 45 patients for whom it was recorded. Elevated follicle-stimulating hormone (FSH) values or known azoospermia occurred in more than half the patients for whom data were available.

CONCLUSIONS

A variety of sequelae related to therapy were determined in this patient population. These findings suggest that some aspects of therapy warrant reevaluation and that improved plans for follow-up care need to be provided.

Ascending myelitis after intensive chemotherapy and radiation therapy in children with cranial parameningeal sarcoma

In 1977, a program of early, wide-field radiation therapy (RT) to the central nervous system and repeated lumbar intrathecal (IT) medications along with systemic chemotherapy was begun by the Intergroup Rhabdomyosarcoma Study (IRS) for patients younger than 21 years of age with cranial parameningeal sarcoma and a high risk of meningeal extension. From 1977 until 1987, 149 eligible patients with high-risk cranial parameningeal sarcoma were enrolled in IRS trials. None had evidence of lower extremity or sphincter impairment at diagnosis. Five of the 149 (3.4%) had ascending myelitis at 5.5 to 9 months after the initiation of therapy, with loss of sphincter control and inability to walk; this progressed to severe flaccid quadriparesis and necessitated long-term ventilatory support in 4. All five had received vincristine, dactinomycin, cyclophosphamide, and doxorubicin; four also had received cisplatin and three also had received etoposide. All patients received 4770 to 5500 cGy to the primary tumor, and four patients received 3000 cGy of cranial RT. Three patients received cervical RT and two received spinal RT. The patients also received four to seven courses of IT methotrexate, hydrocortisone, and cytosine arabinoside. Three patients died: one after local tumor recurrence with central nervous system extension and two without known recurrence. In one of the latter patients, the results of an autopsy showed necrosis of the cervical spinal cord and caudal medulla. Although the exact cause of this complication is unclear, no additional cases have been reported to the IRS since the protocol was revised in 1987 to reduce the doses of the IT drugs and to limit them to four courses each.

Influence of age, sex, and concurrent intrathecal methotrexate therapy on intellectual function after cranial irradiation during childhood: a report from the Children's Cancer Study Group

Standard IQ tests were performed in 70 children and adolescents 3.5-10 years (median 5 yrs) after 24 Gy cranial irradiation, with or without concurrent intrathecal methotrexate, for central nervous system prophylaxis of acute lymphoblastic leukemia. Lower IQ scores correlated with younger age, female gender, and concomitant intrathecal methotrexate therapy. Multivariate analysis identified age as the most important determinant of the three factors. The lowest IQ scores were observed in girls who were less than 5 years old at the time of irradiation and who received concurrent intrathecal methotrexate. The observed adverse contribution of simultaneous intrathecal methotrexate therapy on IQ outcome may have significant implications for school performance, peer relationships, and occupational expectations.

Results of intensive therapy in children with localized alveolar extremity rhabdomyosarcoma: a report from the Intergroup Rhabdomyosarcoma Study

Preliminary analyses of treatment results and prognostic factors from the first Intergroup Rhabdomyosarcoma Study (IRS I) suggested that alveolar histology and extremity site were among factors associated with an adverse outcome in clinical group I patients whose tumors had been completely resected. A high incidence of alveolar histology among the extremity tumors compounded the problem. These findings prompted an amendment to IRS II shortly after the study opened. Therapy for patients with alveolar extremity tumors in groups I and II was changed to more intensive repetitive pulse vincristine, dactinomycin, and cyclophosphamide (VAC) for 2 years. The outcome of 44 patients who received intensive therapy on IRS II is compared with a control series of 30 patients who were treated on IRS I. The control patients received standard VAC therapy for 2 years or VA for 1 year. Half of group I control patients received local radiotherapy, whereas none was given to group I intensive therapy patients. In both studies group II patients received radiotherapy to the primary tumor site and to identified positive regional lymph nodes. Compared with the control group, patients given more intensive therapy had a longer disease-free survival (DFS) (69% v 43% at 3 years), but this was of marginal significance (P = .06). The overall survival difference (77% v 57% at 3 years) was not significant (P = .23). Despite the limited statistical evidence, there is some indication that intensive therapy improved the prognosis of children with localized alveolar rhabdomyosarcoma (RMS).

No involvement of bovine leukemia virus in childhood acute lymphoblastic leukemia and non-Hodgkin's lymphoma

Bovine leukemia virus (BLV) is the causative agent of enzootic bovine lymphosarcoma. Much speculation continues to be directed at the role of BLV in human leukemia. To test this hypothesis rigorously, a case-control study of childhood acute lymphoblastic leukemia and non-Hodgkin's lymphoma was conducted between December 1983 and February 1986. Cases (less than or equal to 16 years at diagnosis) derived from patients diagnosed at the primary institutions and affiliated hospitals were matched (age, sex, and race) with regional population controls. DNA samples from bone marrow or peripheral blood from 157 cases (131 acute lymphoblastic leukemia, 26 non-Hodgkin's lymphoma) and peripheral blood from 136 controls were analyzed by Southern blot technique, under highly stringent conditions, using cloned BLV DNA as a probe. None of the 157 case or 136 control DNA samples hybridized with the probe. The high statistical power and specificity of this study provide the best evidence to date that genomic integration of BLV is not a factor in childhood acute lymphoblastic leukemia/non-Hodgkin's lymphoma.

The Intergroup Rhabdomyosarcoma Study-I. A final report

The results of treatment of 686, previously untreated patients younger than 21 years with rhabdomyosarcoma or undifferentiated sarcoma, who were entered on Intergroup Rhabdomyosarcoma Study-I (IRS-I) were analyzed after a minimum potential follow-up time of 7 years. Patients in Clinical Group I (localized disease, completely resected) were randomized to receive either vincristine, dactinomycin, and cyclophosphamide (VAC) or VAC + radiation. At 5 years, approximately 80% of patients given either treatment were still disease-free and there was no significant difference between treatments in the overall percentages of patients surviving of 93% and 81%, respectively (P = 0.67). Patients in Clinical Group II (regional disease, grossly resected) were randomized to receive either vincristine and dactinomycin (VA) + radiation or VAC + radiation. At 5 years, 72% and 65% of the patients, respectively, were disease-free and there was no evidence of a difference between treatments (P = 0.46). The overall survival percentage at 5 years was approximately 72% for both treatments. Patients in Clinical Groups III (gross residual disease after surgery) and IV (metastatic disease) were randomized to receive either "pulse" VAC + radiation or "pulse" VAC + Adriamycin (doxorubicin) + radiation. The complete remission (CR) rate was 69% in Clinical Group III and 50% in IV, with no statistically significant difference in CR rates between treatments in either group. Those who achieved a CR had a nearly 60% chance of staying in remission for 5 years in Clinical Group III compared with approximately 30% in Clinical Group IV. The overall survival percentage at 5 years was 52% in Clinical Group III compared to 20% in Clinical Group IV (P less than 0.0001). The 5-year survival percentage for the entire cohort of 686 patients was 55%. Survival after relapse was poor, being 32% at 1 year and 17% at 2 years. The risk of distant metastasis was much greater than the risk of local recurrence within each clinical group, and there was no evidence of differing types of relapses between treatments. Primary tumors of the orbit and genitourinary tract carried the best prognosis, whereas tumors of the retroperitoneum had the worst prognosis. The authors conclude that for the therapeutic regimens evaluated there was no therapeutic advantage to including radiation in the treatment of Clinical Group I disease, or cyclophosphamide given as a daily low-dose oral regimen in the treatment of Clinical Group II disease or Adriamycin in the treatment of Clinical Groups III and IV diseases.

The Intergroup Rhabdomyosarcoma Study-I. A final report

The results of treatment of 686, previously untreated patients younger than 21 years with rhabdomyosarcoma or undifferentiated sarcoma, who were entered on Intergroup Rhabdomyosarcoma Study-I (IRS-I) were analyzed after a minimum potential follow-up time of 7 years. Patients in Clinical Group I (localized disease, completely resected) were randomized to receive either vincristine, dactinomycin, and cyclophosphamide (VAC) or VAC + radiation. At 5 years, approximately 80% of patients given either treatment were still disease-free and there was no significant difference between treatments in the overall percentages of patients surviving of 93% and 81%, respectively (P = 0.67). Patients in Clinical Group II (regional disease, grossly resected) were randomized to receive either vincristine and dactinomycin (VA) + radiation or VAC + radiation. At 5 years, 72% and 65% of the patients, respectively, were disease-free and there was no evidence of a difference between treatments (P = 0.46). The overall survival percentage at 5 years was approximately 72% for both treatments. Patients in Clinical Groups III (gross residual disease after surgery) and IV (metastatic disease) were randomized to receive either "pulse" VAC + radiation or "pulse" VAC + Adriamycin (doxorubicin) + radiation. The complete remission (CR) rate was 69% in Clinical Group III and 50% in IV, with no statistically significant difference in CR rates between treatments in either group. Those who achieved a CR had a nearly 60% chance of staying in remission for 5 years in Clinical Group III compared with approximately 30% in Clinical Group IV. The overall survival percentage at 5 years was 52% in Clinical Group III compared to 20% in Clinical Group IV (P less than 0.0001). The 5-year survival percentage for the entire cohort of 686 patients was 55%. Survival after relapse was poor, being 32% at 1 year and 17% at 2 years. The risk of distant metastasis was much greater than the risk of local recurrence within each clinical group, and there was no evidence of differing types of relapses between treatments. Primary tumors of the orbit and genitourinary tract carried the best prognosis, whereas tumors of the retroperitoneum had the worst prognosis. The authors conclude that for the therapeutic regimens evaluated there was no therapeutic advantage to including radiation in the treatment of Clinical Group I disease, or cyclophosphamide given as a daily low-dose oral regimen in the treatment of Clinical Group II disease or Adriamycin in the treatment of Clinical Groups III and IV diseases.

Lymphatic metastases with childhood rhabdomyosarcoma. A report from the Intergroup Rhabdomyosarcoma Study

A review of 1415 patients without distant metastasis from the Intergroup Rhabdomyosarcoma Study (IRS) I and II revealed an overall 10% incidence of identified lymphatic spread at diagnosis, whereas 81 of 592 children with localized rhabdomyosarcoma who had grossly complete resection (and therefore with more complete pathologic data) had histologically proven lymphatic spread (14%). The percentage of patients in this latter group with nodal metastases was highest for the prostate (41%), paratesticular sites (26%), and genitourinary sites overall (24%). Sites with a small percentage of proven lymphatic involvement were the orbit (0%), nonorbital head and neck sites (7%), and truncal sites (3%), whereas the percentage of patients with nodal metastases from extremity lesions was 12%. The primary tumor mean diameter was significantly larger in the group with nodal metastases, but there was no evidence of a relationship between lymphatic spread and age, sex, or histologic subtype. Patients with lymph node metastases who had resection had a poorer survival rate (logrank P value = 0.001), with a 3-year survival estimate of 54%, compared with 78% for patients without lymphatic metastases. Patients with extremity lesions and positive lymph nodes also did poorly when compared with patients with normal nodes (P = 0.006), and a similar observation was made for patients with paratesticular sarcoma (P = 0.06).

Localized orbital rhabdomyosarcoma. An interim report of the Intergroup Rhabdomyosarcoma Study Committee

Children with rhabdomyosarcoma (RMS) (1461 total cases) were included in two prospective, randomized protocols conducted by the Intergroup Rhabdomyosarcoma Study (IRS) Committee from November 1972 to June 1983. Treatment assignment was determined by extent of tumor at diagnosis (clinicopathologic group) and not by primary site. Accordingly, 127 patients with RMS confined to the region of the eyelid and orbit were treated by a variety of regimens characterized by initial partial tumor resection followed by concurrent multiagent chemotherapy and orbital radiation therapy. Recurrent tumor developed in ten patients. Seven relapsed initially in the orbit (of whom 4 were salvaged) and three in regional nodes. In addition to the six patients who died of tumor, three died of other causes for a 93% 3-year actuarial survival rate. In 89 children who had subtotal resection or biopsy only, the local control rate with radiotherapy and chemotherapy was 94%.

Intensive chemotherapy including cisplatin with or without etoposide for children with soft-tissue sarcomas

Forty-two children, 6 months to 17 years of age with newly diagnosed soft-tissue sarcomas (gross residual or metastatic), were treated according to either of two pilot protocols that included intensive chemotherapy before irradiation. Vincristine, actinomycin D, cyclophosphamide, and doxorubicin were used in various combinations with cisplatin alone (regimen 35) or with cisplatin plus etoposide (regimen 36) in a 20-week induction treatment; irradiation (4,000 cGy) was delayed until week 6. Fourteen (82%) of the 17 patients on regimen 35 and 15 (60%) of the 25 on regimen 36 had a complete response. Although severe leukopenia was frequent in both groups (88% and 84% of patients), there were only two fatal infections and no early deaths. Other potentially serious toxicity included a greater than 10% weight loss in 52% of the patients and hypomagnesemia in 74%. An average of 75-100% of the prescribed drug doses were administered during the induction phase of therapy. We conclude that this intensified treatment is toxic but feasible to deliver. The higher overall response rate compared to that in the preceding Intergroup Rhabdomyosarcoma Study (69% vs 53%) suggests improved therapeutic efficacy that warrants further evaluation of both regimens.

Infants younger than 1 year of age with rhabdomyosarcoma

Of a total of 1561 patients registered in the Intergroup Rhabdomyosarcoma Study (IRS) as of May 1983, 78 patients (5%) were younger than 1 year of age. These infants did not differ from the older children (1-20 years of age) in male/female ratio, clinical grouping, or survival rates. Infants younger than 1 year of age had a significantly greater frequency of undifferentiated sarcoma, 18% versus 7% in older children (P less than 0.005). Infants also had a significantly greater proportion of cancers with botryoid pathology, 10% versus 4% in older children (P less than 0.005). When reviewed by the newly proposed IRS cytopathologic classification, there was no difference in pathologic types between the two age groups. Infants younger than 1 year of age had a higher rate of bladder-prostate-vagina primary tumor sites than older children, 24% versus 10% (P less than 0.05). In addition, infants tended to receive less of the prescribed doses of chemotherapy and radiation therapy than older children, and to develop more toxicity to treatment than older children. Despite these differences, the overall survival curve for the two age groups appears to be similar. In contrast to Wilms' tumor and neuroblastoma, in which age (less than 1 year) is a favorable prognostic factor, age does not appear to be an important prognostic factor in rhabdomyosarcoma.

Late effects of therapy in orbital rhabdomyosarcoma in children. A report from the Intergroup Rhabdomyosarcoma Study

Late effects of therapy were evaluated in 50 children surviving orbital rhabdomyosarcoma following treatment on Intergroup Rhabdomyosarcoma Study I. All patients had microscopic or gross tumor present following surgery and subsequently received radiotherapy and various combinations of chemotherapeutic agents. Problems in the eye included infections and functional and structural changes. Decreased vision in the treated eye was the most common functional problem and in most patients related to cataract formation, which occurred in 90% of eyes. Changes in the cornea and retina were also seen. Bony hypoplasia of the orbit and facial asymmetry were present in one half of the children. Gonadal development was normal. Statural growth was retarded in 61% of the patients. All children were in school, with five having learning or behavioral problems. One child developed acute myeloblastic leukemia. The excellent survival in patients with orbital rhabdomyosarcoma provides support for treatment programs that use multiple-agent chemotherapy and radiotherapy and do not include orbital exenteration initially.

Soft tissue sarcomas arising in the retroperitoneal space in children. A report from the Intergroup Rhabdomyosarcoma Study (IRS) Committee

One hundred one eligible children with soft-tissue sarcomas arising within the retroperitoneal space have been registered on Intergroup Rhabdomyosarcoma Study Committee (IRS) studies I and II and followed for at least 2 years or until death. The most common presenting symptoms and signs were pain in the abdomen or lower extremities, and/or an abdominal mass, usually noted by a parent or a physician seeing the child for other complaints. The median age at diagnosis was 6.5 years and the sex ratio (M/F) 1.7:1. Histologic types were embryonal or botryoid rhabdomyosarcoma (RMS) in 58 patients, alveolar RMS in 8, pleomorphic RMS in 2, undifferentiated sarcoma in 20, extraosseous Ewing's sarcoma in 4 and unspecified sarcoma in 9. Median tumor size was 10 cm, significantly larger than the 7.5 cm noted in the IRS studies as a whole (P less than 0.05). One patient had complete tumor removal (Group I); 12 had grossly complete removal with microscopic residual tumor (Group II). Fifty-one patients had residual local tumor after biopsy or partial resection (Group III) and 37 patients had distant metastases at diagnosis (Group IV). Treatment included surgery, radiation therapy (RT) and combination chemotherapy with vincristine and actinomycin D with or without cyclophosphamide and Adriamycin (doxorubicin) according to protocol. Thirty-nine of 99 patients (39%) had major difficulties in the delivery of specified RT. Seventy patients received sufficient therapy to be evaluable for treatment response. Forty-one (58%) achieved a complete remission and 16 (23%) achieved partial remission. Twenty-four of 41 children (59%) achieving a CR have relapsed. The proportion of children who remained relapse-free at 2 and 3 years of follow-up was 44% or 42%, respectively. Overall, 40 children have developed recurrent sarcoma and the median disease-free interval and overall survival times were 54 and 88 weeks, respectively. Most children experienced severe myelosuppression; there were three early deaths from infection which occurred during granulocytopenic periods. One third of the patients experienced cystitis. Children with soft-tissue sarcomas arising in the retroperitoneal space have a poor prognosis associated with large tumors which, because of location and/or extent (Groups III or IV), are unresectable and difficult to treat.

Necrotizing lymphoid vasculitis in X-linked lymphoproliferative syndrome

An 8-year-old maternally related relative of three boys who had developed agammaglobulinemia associated with Epstein-Barr virus (EBV)-induced infectious mononucleosis was studied for X-linked lymphoproliferative syndrome (XLP) in 1979. At that time, he demonstrated no striking immunologic aberrations and was seronegative for EBV. Subsequently, immunologic abnormalities including failure to switch from IgM to IgG antibody synthesis after secondary immunization with bacteriophage phi X174 were detected. In 1983, he experienced episodic intracerebral hemorrhages, with the second being fatal. At autopsy, necrotizing vasculitis and aneurysms involving arteries of the central nervous system were observed. Studies of blood obtained immediately before and after death failed to show antibodies to EBV. However, EBV genome was demonstrated in tissues obtained at autopsy by DNA hybridization studies. Fatal lymphoid vasculitis in this patient is unique among boys with XLP in the registry. These findings probably extend the phenotypic expressions of XLP.

Significance of X granules in histiocytosis X: an ultrastructural study

Histiocytosis X is characterized by the presence of cytoplasmic rod structures called Langerhans' cell granules or X granules (XG). It has been speculated that histiocytosis X is a Langerhans' cell disorder. This ultrastructural study was performed to quantitate the number of XG containing histiocytes in the histiocytosis X lesions. Twenty-four specimens from 22 patients with histiocytosis X were studied: 4 from skin, 5 from lymph node, 11 from bone, 2 from lung, 1 from gingiva, and 1 from cheek. The majority of the histiocytes in histiocytosis X lesions do not contain X granules. The majority of the histiocytes in histiocytosis X lesions do not contain X granules. The percentage of histiocytes with XG in a lesion has no relation to the age of the patient or the organ from which it was obtained, except for skin, where they were quite numerous. The relative percent-age of histiocytes with granules does not correlate significantly with the prognosis of these patients.