Abstract P4-03-04: Computer extracted image measurements of nuclear shape and texture from H&E images appear to stratify low and high risk ER+ breast cancers assessed via oncotype DX

Background: In this study we investigate the ability of computer extracted image features (nuclear morphology and texture) from digitized H&E tissue slides to stratify women with lymph node negative (LN-), estrogen receptor positive (ER+) breast cancer (BCa) as low or high risk as determined by Oncotype DX (ODX), a 21 gene-expression assay. Each year, over 120,000 women in the United States (1 million worldwide) are diagnosed with ER+ BCa. Treatment guidelines recommend hormone therapy (HT) plus chemotherapy (CT); however, up to 85% of ER+ BCa patients will not benefit from CT, yet will still suffer its side effects. ODX yields a numeric risk score (RS) ranging from 1-100; RS<18 suggests patients will respond to HT alone while RS>30 indicates need for adjuvant CT. Unfortunately, this test is expensive (>$4000), time-consuming, and involves destructive tissue testing. The goal of this study is to show that quantitative features calculated from H&E images can accurately predict risk stratification as determined by ODX in women with LN-, ER+ BCa, suggesting a histologic image based classifier could serve as a low-cost alternative.

Methods: Digitized H&E-stained ER+ BCa tissue sampled from 111 patients (34 high and 77 low-risk as determined by ODX) were obtained from the University of Pennsylvania, the University of Medicine and Dentistry of NJ, and Case Western Reserve University. Regions of cancer were annotated manually by an expert pathologist, and representative fields of view (FOV) were chosen at 20x magnification (2000 by 2000 pixels) for each patient. A selection of nuclear boundaries was annotated manually in each FOV. For each nucleus, a set of 2343 features was extracted, including 21 morphological (size, shape, and boundary) and 2322 texture (Gabor, Local Binary Pattern, Greylevel, and Laws filter features). Using Minimum Redundancy Maximum Relevance (mRMR) feature selection, the 3 features best able to separate low and high ODX risk categories were identified and used to build a supervised Bayesian classifier. Classifier training employed a randomized 3-fold cross-validation scheme; in each trial, two-thirds of the dataset were randomly selected for training, and the remaining one-third employed for independent testing. Classifier performance was evaluated using area under the receiver operating characteristic curve (AUC), positive predictive value (PPV), and negative predictive value (NPV) with respect to low and high ODX risk categorization. Performance metrics were averaged over 100 trials of 3-fold cross-validation (see table).

Results: The mRMR method selected one morphological feature (nuclear area) and two Laws-based texture features as being highly discriminating between risk categories. The Bayesian classifier trained with these 3 features yielded high AUC, PPV, and NPV measures with low variance in distinguishing ODX risk categories. The supervised classification results indicate that quantitative image features from H&E-stained histopathology are able to accurately discriminate between low and high risk patients as determined by ODX.

Classification PerformancePerformance MetricAverage (100 Trials)Standard DeviationAUC0.870.018PPV0.810.039NPV0.880.017

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-03-04.

Abstract P2-02-04: Kinetic heterogeneity features on breast DCE-MRI as prognostic markers of breast cancer recurrence

PURPOSE

Breast tumors have been shown to be heterogeneous lesions, and tumor heterogeneity is one of the major difficulties in the way of an effective cancer diagnosis and successful treatment. We evaluate the predictive capacity of DCE-MRI kinetic heterogeneity features for assessing the risk of breast cancer recurrence as determined by a validated tumor gene expression assay.

METHOD AND MATERIALS

Bilateral Breast DCE-MRI scans were retrospectively analyzed from 57 women with estrogen receptor positive/node negative invasive breast cancer. The ages of the women at the time of the imaging ranged from 37 to 74 years with a mean age of 55.5 years. The women were imaged prone in a 1.5T scanner (GE LX echo, GE Healthcare, or Siemens Sonata, Siemens); matrix size: 512 × 512; slice thickness: 2.4-4.4 mm; flip angle: 25° or 30°. The images were collected before and after the administration of gadodiamide (Omniscan) or gadobenate dimeglumine (MultiHance) contrast agents. Dynamic contrast enhanced images were acquired at 90 second intervals for 3 post contrast time points. The women had previously undergone Oncotype Dx (Genomic Health Inc.) profiling of their tumor. The Oncotype DX assay provides the likelihood of 10-year breast cancer recurrence, using a score stratified into 3 risk categories (risk: low ≤17, medium = 18-30, high ≥ 31). Pixel-wise relative enhancement curves were computed using three post-contrast time points. Fuzzy C-means clustering was applied to partition the tumor pixels according to the variance of their relative enhancement. To capture kinetic heterogeneity, wavelet features were extracted within each tumor partition as a measure of spatial variation. Mean and variance of these features were further estimated within each region. Using these features, multivariable logistic regression was performed with leave-one-out cross-validation and feature selection to classify the tumors as high or low/medium risk. We compared our kinetic heterogeneity features against standard kinetics and texture features. Area under the curve (AUC) of the receiver operating characteristic (ROC) was used to evaluate classification performance.

RESULTS

Feature selection indicated an optimal set of 7 kinetic heterogeneity features (out of 54). The classifier based on these features had an AUC = 0.82 in classifying high versus low/medium risk tumors. Classifiers based on standard kinetics and texture features performed with AUCs of 0.69 and 0.64 respectively.

CONCLUSION

Wavelet kinetic features from breast DCE-MRI could be used to capture the spatial pattern of kinetic heterogeneity of and potentially serve as prognostic markers for the risk of recurrence. In addition, breast DCE-MRI kinetic heterogeneity features could be used to assess likelihood of recurrence and ultimately help guide therapeutic decisions. Larger studies are needed to validate these findings.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-02-04.

P1-03-09: Significance of FAP, SMA and CD31 Expression in the Stroma of Breast Cancer

Breast cancer stroma heterogeneity has been demonstrated in various gene expression profile analyses. Whether there is any association between stroma heterogeneity and the molecular phenotype of breast cancer has yet to be established. Therefore, we performed immunohistochemical analyses (IHC) to evaluate the expression of the following stromal cell markers (fibroblast activation protein (FAP), smooth muscle actin (SMA), and CD31, an endothelial cell marker) in tumor tissues from a contemporary cohort of 52 patients comprising of all four molecular subtypes (luminal A (n=25); luminal B (n=2); Her2-neu (+) (n=5); and basal (n=20)). We hypothesize that stroma heterogeneity as reflected by the proportion of stromal cells staining (+) for FAP and SMA may correlate with their molecular epithelial phenotype. Furthermore, studying the distribution of these stromal cell markers in IHC sections may evaluate their spatial relationship with tumor cells, immune cells, and tumor microvasculature which may have strategic significance within the tumor/microenvironment.

P1-06-11: Comparison of Community and Central Her2 Assessment on Outcome of Neoadjuvant Chemotherapy in the I-SPY Trial

Background: Her-2/neu overexpression, by immunohistochemistry (IHC) or fluorescence in-situ hybridization (FISH), is highly correlated with response to trastuzumab and these are currently the gold-standard, FDA-cleared testing methods for assigning treatment to Her-2-directed therapies. However, substantial variability has been documented between community and central laboratory IHC and FISH testing. Biologically, Her-2 overexpression may reflect increased gene copy number, gene expression and/or protein production, and these can be measured by other platforms, including comparative genomic hybridization (CGH), expression arrays and quantitative protein assays, respectively. We sought to determine the degree to which community IHC/FISH results differed from centrally-assessed IHC, FISH, and other assessment platforms within the I-SPY Trial and whether response to neoadjuvant chemotherapy (NAC) differed by platform.

Methods: The I-SPY Trial enrolled 237 women 2002–06 with invasive breast tumors at least 3 cm in clinical/radiographic size who subsequently underwent anthracycline/taxane NAC, serial core biopsies and imaging. Pathologic complete response (pCR) was determined at time of surgery and 3-year follow up has been reached. Trastuzumab was given to Her2+ patients at physician discretion, based upon community IHC/FISH results, and became more widespread after 2005. Central I-SPY laboratories determined Her2 copy number by MIP array, gene expression by Affymetrix and Agilent arrays, and Her2 protein by reverse-phase protein array (RPMA). Unsupervised clustering algorithms were used to evaluate expression patterns. Composite variables were constructed for DNA, RNA and protein positivity as well as for community and central IHC/FISH. Platforms were compared and Kaplan-Meier curves were constructed to compare outcomes by platform.

Results: 222 women were evaluable, though not all patients had results for all platforms. Community composite IHC/FISH was positive in 64/214 (30%) but only 41 of these (64%) were confirmed by central IHC/FISH and 4 additional cases were centrally positive despite negative community testing. Concordance was high among centrally-assessed Her2 platforms, but was lower between community IHC/protein and central RNA (90%), DNA (91%) and protein (91%). Among patients receiving trastuzumab (n=36), the pCR rate was ∼50% regardless of Her2-assessment platform; in contrast, those not receiving trastuzumab had pCR rates below 30%. Among the 64 patients deemed Her2+ by community IHC/FISH, 30 (48%) had pCR and 15 (25%) have had distant relapse. Five distant relapses have occurred despite pCR; all received trastuzumab, all were Her2 positive by multiple central platforms and 3/5 were ER-positive. Sites of distant relapse included brain, bone and viscera; only 1 of 5 had isolated brain relapse.

Conclusions: Community IHC/FISH testing for Her2 expression in the I-SPY Trial overcalled Her2 positivity compared to central testing while central results were highly concordant among DNA, RNA and protein platforms. Despite the high rate of community “false positives”, relapse after pCR occurred only in central Her2 “true positives,” exclusively among those receiving trastuzumab, and was rarely isolated to CNS sanctuary sites.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-06-11.

Abstract P5-14-03: The Impact of Routine Cavity Margins on Reducing the Need for Re-Excision in Women Undergoing Breast-Conserving Surgery for Invasive or Non-Invasive Breast Cancer

Background: The goal of breast conserving surgery (BCS) in women with invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS) is to remove all malignant cells from the breast or to reduce the residual tumor burden to a level that is likely to be eradicated by adjuvant radiation therapy and/or systemic therapy. Theoretical concerns exist that radiography of lumpectomy specimens and subsequent pathologic processing may lead to artifactually positive lumpectomy margins (LM), and the need for subsequent re-excision. To improve the chances of obtaining negative final margins (FM) (generally defined as 2 mm or greater), a number of surgeons in the US and abroad have adopted a technique in which 4-6 additional margins surrounding the main lumpectomy specimen, so-called “cavity margins” (CM), are routinely obtained. The purpose of this study was to assess the clinical utility of the routine use of CM in reducing the need for re-excision.

Methods: The surgical pathology records at our institution were searched for all cases of BCS with additional complete routine CM sampling performed by a single surgeon between May 2008 and April 2010. Patients in whom additional CM were obtained based on intraoperative findings of grossly close margins were excluded from the analysis. The demographic characteristics of the patients and the histological features of the tumor were recorded. We then tabulated the number of patients who had positive LM, CM, and FM, defined as either DCIS or invasive carcinoma at or less than 2 mm from inked specimen margin. The number needed to treat (NNT) to prevent one re-excision was calculated.

Results: We identified 97 women (74 with IBC and 33 with DCIS-only) who had undergone BCS with routine CM sampling during the study period. Mean patient age was 62. Median specimen volume was 178 cc3. 90% of the IBCs were ductal subtype. Mean IBC size was 1.5 cm. 63% of tumors were ER+, 58% PR+, and 7% HER2+. Of the 97 patients in this study, 64 had +LM and 33 had -LM. Of the 64 with +LM, 38 did not have tumor in the CM and 26 had tumor in the CM. Of these 26, 18 had +FM (re-excision needed) and 8 had -FM (no re-excision needed). The proportion of patients with actual tumor at ink (not just close margins) in the lumpectomy specimen was significantly higher among the group with tumor present in the CM than it was in the group with no tumor present in the CM (14/26 versus 7/38, p = 0.006). The NNT with routine CM compared with standard BCS to prevent one re-excision was 2.0 (95% CI, 1.5 — 2.1).

Discussion: In this study the routine use of CM reduced the need for reexcision in women undergoing BCS for IBC or DCIS; one re-excision was avoided for every two patients treated with this surgical approach. The absence of tumor in the CM in the majority of patients with positive LM suggests that specimen radiography and/or pathologic processing techniques may result in artifactually positive LM. Our results indicate that improved specimen imaging and pathological processing techniques are needed to increase the fidelity of margin assessment. In the meantime, the routine use of cavity margins may reduce the need for re-excision in women undergoing BCS.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-14-03.

Massive hemorrhage and infarction complicating focal nodular hyperplasia of the liver

BACKGROUND

Spontaneous infarction or hemorrhage of focal nodular hyperplasia (FNH) has rarely been reported in the literature.

CASE OUTLINE

A 43-year-old woman presented with upper abdominal pain and anemia. CT scan showed an enormous perihepatic hematoma. Trisegmentectomy successfully dealt with the problem.

CONCLUSION

Although conservative management of FNH is often adopted, this case illustrates that these lesions can undergo massive bleeding.

The Cooperative Breast Cancer Tissue Resource: archival tissue for the investigation of tumor markers

Investigators continue to search for reliable markers of prognosis of breast cancer. For many analyses, laboratory techniques permit the use of archival paraffin-embedded tissue collected years previously and readily linked to clinical and follow-up information. Laboratory investigators have often expressed the need for such a tissue resource. We have developed a publicly available resource of archival breast cancer specimens. The pathological material has been collected and reviewed by investigators at four institutions and currently includes breast cancer specimens from more than 9300 cases. Institutional pathologists reviewed slides and blocks using a common protocol and coding scheme. Clinical information and details of follow-up came from data routinely collected by the institutions' cancer registries. Coded data are maintained centrally in a single database. A subset of the data may be searched on the World Wide Web to determine the availability of cases with specified characteristics. The material collected by this Cooperative Breast Cancer Tissue Resource is generally representative of breast cancer diagnosed in community hospital settings in the United States. Seventy-two percent of the living cases have been followed for at least 5 years, and follow-up status is updated regularly. Interested laboratory investigators may apply to the Resource for the use of these tissues. This Resource is proving valuable to laboratory investigators who require large numbers of specimens for validation studies of prognostic markers of breast cancer.

Genitourinary tuberculosis after renal transplantation: report of 3 cases and review

Mycobacterium tuberculosis infection of the genitourinary tract is an uncommon disease in renal transplant recipients and presentation is atypical. Genitourinary tuberculosis is associated with graft rejection, and this diagnosis should be considered for renal transplant recipients with unexplained fever and constitutional symptoms.

Detection of "occult" lymph node metastasis in breast cancer: should pathologists go the extra mile?

Approximately 25% of patients with stage I (node negative) breast cancer relapse at a rate similar to those with stage II disease. Inadvertent pathologic "understaging" of lymph node status is one plausible explanation for this phenomenon. While many studies have shown that additional sectioning +/- immunohistochemical staining for epithelial markers increases the rate of detection of small deposits of metastatic carcinoma, few have had sufficient statistical power to examine the impact of "occult" metastasis on clinical outcome. This provocative update by the International Ludwig Breast Cancer Study Group provides support for considering going "the extra mile" to detect lymph node metastasis in postmenopausal patients and those with the lobular subtype of invasive breast cancer.

The importance of postoperative radiation therapy in multimodality management of locally advanced breast cancer: a phase II trial of neoadjuvant MVAC, surgery, and radiation

PURPOSE

To determine the impact of postoperative radiation on locoregional relapse and overall survival rate in a multimodality protocol for locally advanced breast cancer (LABC).

MATERIAL AND METHODS

Of the patients entered in the protocol, 55 were evaluable. Treatment consisted of: neoadjuvant MVAC (methotrexate, vinblastine, adriamycin, and cisplatin) until a maximum response had been achieved; modified radical mastectomy; 6 courses of postoperative adjuvant MVAC chemotherapy, and chest wall irradiation (CWXRT). Multivariate analysis of locoregional response and overall survival was done.

RESULTS

Of the total, 42 patients received chest wall radiation; 28 of these also received radiation to regional lymph nodes. Chest wall doses ranged from 45 Gy to 50.4 Gy to the whole chest wall, with 31 patients receiving an additional chest-wall boost. The incidence of locoregional relapse with and without radiation was 7% vs. 31%, respectively (p = 0.026). An overall survival benefit was seen in those receiving radiation, with a mean overall survival of 50 months vs. 20 months, and a 3-year overall survival of 88% vs. 46% with and without radiation, respectively (p = 0.003). Multivariate analysis showed that overall survival was affected by the presence of pathological CR (p = .047), the number of pre-operative chemotherapy cycles (p = .036) and whether or not they received radiation (p = 0.003). Neither the interval between surgery and radiation, technique of radiation, nor radiation modality significantly affected local control.

CONCLUSION

The significant improvement in local regional control and overall survival with the addition of radiation suggests that radiation should be an integral part of multimodality management of locally advanced breast cancer.

A Phase II trial of neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin in the treatment of patients with locally advanced breast carcinoma

BACKGROUND

Traditionally, primary surgical therapy is considered unsuitable for the treatment of patients with locally advanced breast carcinoma (LABC). Multiple reports have documented the efficacy of primary chemotherapy in this group of patients. The purpose of this study was to investigate the efficacy of a multimodality treatment program in reducing distant and local disease relapses in patients with LABC.

METHODS

Fifty-five patients with large operable or inoperable Stage III breast carcinoma, median tumor greatest dimension 7 x 8 cm, were treated with neoadjuvant MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) to achieve maximum clinical response, followed by modified radical mastectomy, adjuvant MVAC for six courses, and chest wall radiation. Of these patients, 37 had Stage IIIA disease and 18 had Stage IIIB or inflammatory breast carcinoma.

RESULTS

Forty-nine patients achieved overall responses to the neoadjuvant chemotherapy, including 16 complete clinical remissions. Histopathologic evaluation was performed for all patients; nine were pathologically free of disease and six had residual intraductal carcinoma only. After a median follow-up of 47 months (range, 8-76 months), 24 patients had relapsed: 6 locoregional and distant, and 18 distant only. The median disease free and overall survival have not been reached; the 5-year disease free and overall survival rates are 51% and 63%, respectively. The number of lymph nodes with metastases was found to be an independent predictor of relapse in univariate and multivariate analyses.

CONCLUSIONS

This multidisciplinary approach produced an excellent local control rate and a respectable 5-year distant relapse free rate. Axillary lymphadenectomy after primary chemotherapy provides crucial prognostic information, which can be important in planning multimodality treatment of patients with LABC.

Discrimination of late apoptotic/necrotic cells (type III) by flow cytometry in solid tumors

A method is described for the discrimination of Type III, late apoptotic, and necrotic cells, to improve the accuracy of proliferation and ploidy determinations of breast tumors. We selected an immunological probe, antitubulin antibody, and a DNA specific stain, propidium iodide (PI), both capable of crossing the permeable membranes of Type III, late apoptotic, and necrotic cells. This study utilized MDA-MB-175-VII breast carcinoma cells deprived of oxygen for up to 11 d to simulate intratumoral hypoxia, and 10 human breast tumors and mouse-human breast tumor xenografts disassociated by mechanical or enzymatic means. After 24 h under hypoxic conditions, the MDA cells displayed characteristics associated with both apoptosis and necrosis. Approximately 50% of day 1 cells showed membrane permeability by trypan blue and absence of DNA laddering; however, by day 3-4 characteristic apoptotic DNA laddering by gel electrophoresis was evident. Substantial DNA content loss, further evidenced by a reduction in PI staining and fluorescent microscopy, was obvious by day 5. By day 10, 98% of cells showed no propidium iodide staining by conventional PI live/dead cell gating, but were positive for antitubulin antibody staining. When the study was extended to the analysis of ten tumors, antitubulin antibody showed a range of 78%-96% staining with a median value of 87.5%, while PI staining showed a range of 8%-74% with a median value of 11.5%. This study demonstrates that a large percentage of cells in tumors and hypoxic cell populations have significantly reduced DNA content, such that conventional live/dead cell gating using PI may include many Type III cells as live cells, thus significantly altering data involving multicolor investigations.

Sequence analysis of the DNA binding domain of the estrogen receptor gene in ER (+)/PR (-) breast cancer

Estrogen stimulates the proliferation of breast cancer cells and regulates the expression of other proteins, including the progesterone receptor (PR), via interaction with a unique estrogen receptor (ER), a ligand-inducible transcription factor that binds to regulatory DNA sequences associated with target genes. The best indirect evidence of an intact ER gene signaling system in a tumor is the demonstration of both ER and PR cytosol protein. The molecular basis of the ER (+)/PR (-) phenotype is unknown and may reflect either defective PR gene expression or alterations in the ER-specifically, inability of the ligand-receptor complex to effectively bind to regulatory sequences in DNA. To test the latter possibility, we evaluated 10 ER (+)/PR (-) resected human breast cancers for small deletions and point mutations in the DNA binding domain of the ER gene. Exons 2 and 3 and their flanking intron sequences were selectively amplified using the polymerase chain reaction and then directly sequenced using the Sanger dideoxynucleotide method. A normal gene sequence was found in all cases studied. We conclude that sequence aberrations in the DNA binding domain of the ER are not a common cause of absent PR expression in ER (+)/PR (-) breast carcinomas.

Sucrase-isomaltase is an independent prognostic marker for colorectal carcinoma

PURPOSE

Expression of disaccharidase sucrase-isomaltase (SI) is significantly enhanced during neoplastic transformation of colonic epithelium. Our study was designed to determine whether expression of SI within primary tumors was significantly associated with survival in patients with colorectal carcinoma (CRC).

METHODS

SI expression was analyzed by immunohistochemistry in paraffin sections from 182 Stage I to III CRC that had been resected for cure at the New England Deaconess Hospital between 1965 and 1977. Expression was scored as absent or present in 1 to 50 percent or more than 50 percent of tumor cells. Associations were explored among SI expression, other clinical or pathologic variables, and overall survival. The data set is mature, with 91 (56 percent) patients who had died of CRC at a median follow-up of 96 months.

RESULTS

Fifty-five percent of primary CRC expressed SI. When the multivariate Cox analysis was performed, nodal status, T stage, primary site, grade, and SI expression were independent covariates. SI expression was not associated with the expression of other clinicopathologic variables but increased the risk of death from colorectal carcinoma by 1.83-fold.

DISCUSSION

These results indicate that SI is a prognostic marker for CRC that is independent of stage-related variables in patients who have undergone potentially curative resections.

Molecular biological analysis of paraffin-embedded tissues

Molecular biology techniques have been adapted to the analysis of paraffin-embedded tissues (PETs), expanding their clinical utility. In vitro amplification with the polymerase chain reaction (PCR) promises to be the most useful means of retrospective analysis because it can be performed successfully on nucleic acids that have been partially degraded during fixation, paraffin embedding, and the extraction process. Five clinical situations in which DNA analysis of PETs can be helpful are: (1) confirmatory molecular diagnosis of lymphoma in which fresh tissue has not been obtained at the time of surgery, (2) identification of infectious agents, (3) genetic characterization of a putative inherited disease in which the affected individual has died, (4) confirmation of donor cell malignancy in transplant recipients, and (5) specimen identification. The role of the pathologist in molecular diagnosis will grow because of the feasibility of using PETs, a venue unique to our profession.

A simple, rapid method for isolating RNA from paraffin-embedded tissues for reverse transcription-polymerase chain reaction (RT-PCR)

Described here is a simple, rapid technique for isolating RNA from archived formalin-fixed, paraffin-embedded tissues (PETs). Using this modified acid guanidinium thiocyanate method, RNA sufficient as a template for the reverse transcription-polymerase chain reaction (RT-PCR) can be isolated in 2 hr from a single 20-microns-thick section of tissue. Spliced mRNA corresponding to portions of the estrogen receptor (ER) gene was successfully amplified from fixed, embedded human breast cancers containing increased amounts of ER protein. This method makes it feasible to safely and efficiently isolate RNA from large numbers of routinely processed paraffin blocks for retrospective studies of endogenous proteins such as hormone receptors, oncogenes, and viruses.

Recurrent secretory carcinoma in residual mammary tissue after mastectomy

A case of secretory carcinoma recurrent in residual breast parenchyma 8 years after modified radical mastectomy is described. The patient, 27 years old at the time of initial diagnosis, was disease free until two chest wall nodules appeared. The recurrent and primary carcinomas were identical and exhibited the mixed solid, papillary, and microacinar growth patterns characteristic of secretory carcinoma. Intraductal and invasive carcinoma involved fibrous tissue and mammary lobules remaining at the site of previous mastectomy. Immunohistochemical staining for alpha-lactalbumin was strongly positive; the carcinoma did not express estrogen or progesterone receptor proteins. Flow cytometric DNA analysis showed a diploid tumor with a synthetic phase of 10%. No further evidence of recurrent carcinoma developed during the ensuing 11 months of follow-up, without adjuvant chemotherapy or radiation. It is important to recognize the morphologic features of this unique form of invasive carcinoma because of its exceptionally good prognosis. Long-term follow-up is mandatory because of the potential for late locoregional recurrence, even after mastectomy.

Adenocarcinoma arising within a gastric duplication cyst

A rare case of carcinoma arising within a gastric duplication cyst in a 72 year old woman is presented. This is the oldest patient in whom neoplastic transformation of this usually benign developmental abnormality has been reported. The clinical and pathologic features of this patient are demonstrated and reviewed in the context of prior reported cases.

Abnormalities of 2q: a common genetic link between rhabdomyosarcoma and hepatoblastoma?

Cytogenetic and restriction fragment length polymorphism (RFLP) analyses were performed on a mediastinal germ cell tumor comprising distinct teratoma and embryonal rhabdomyosarcoma components in a 31-year-old male and a hepatoblastoma in a 2 month-old male child. Clonal relationship between the teratoma and rhabdomyosarcoma of the germ cell tumor was established by the presence in both of i(12p), the characteristic marker of germ cell tumors. Both the rhabdomyosarcoma component of the mediastinal germ cell tumor and the hepatoblastoma exhibited rearrangements of 2q. These data suggest that malignant differentiation of a teratoma is accompanied by the development of chromosome abnormalities specific for the transformed histology and further suggest that 2q abnormalities may be the common genetic link in the development of the two histologically unrelated tumor types, embryonal rhabdomyosarcoma and hepatoblastoma.

Sphincter preservation in rectal cancer by local excision and postoperative radiation therapy

The authors report the preliminary results of 14 patients with localized, mobile, resectable rectal cancer treated with local excision and postoperative radiation therapy (RT). All had negative surgical resection margins and two received 5-fluorouracil (5-FU). The median follow-up was 29 months (4-43 months). The 3-year actuarial survival was 88%. The incidence of local failure was 7% (only site of failure) and 21% (component of failure). The incidence of local failure increased with T stage (T1, 0/3 [0%]; T2, 1/7 [14%]; and T3, 2/4 [50%]) and tumor size (greater than 3 cm, 33%, versus less than or equal to 3 cm, 0%). Three patients developed local failure at 6, 15, and 21 months. Three underwent a salvage abdominoperineal resection and were locally controlled at 2 and 28 months following salvage surgery. One patient underwent an abdominoperineal resection for a clinically presumed local failure; however, no tumor was found in the specimen. Therefore, the 13 patients who either were initially locally controlled or underwent salvage or nonsalvage surgery had no evidence of disease in the pelvis at the time of last follow-up. Local excision and postoperative RT may be an alternative to standard surgery in selected cases. However, additional follow-up and more experience are needed in order to determine if this approach will ultimately have local control and survival rates similar to those of a low anterior resection or an abdominoperineal resection.

The clinical significance of vascular invasion in colorectal cancer

A number of investigators have examined the influence of vascular invasion by tumor in colon, rectal, and colorectal cancer. Some consider the presence of vascular invasion an unfavorable prognostic feature and propose treatment recommendations based on its presence. Vascular invasion has two distinct components: blood vessel invasion and lymphatic vessel invasion. The use of elastic tissue stains enhance both the detection of blood vessel invasion and its differentiation from lymphatic vessel invasion. Almost all series report an increased incidence of blood vessel invasion with increasing stage and grade. Although the influence of blood vessel invasion and lymphatic vessel invasion on patterns of failure is variable, both are associated with a decrease in survival; however, treatment recommendations based solely on the presence of blood vessel invasion or lymphatic vessel invasion should be made with caution.

Lymphatic vessel invasion is an independent prognostic factor for survival in colorectal cancer

To assess whether lymphatic vessel invasion (LVI) is an independent prognostic factor in colorectal cancer, we retrospectively reviewed the records of 462 patients who underwent potentially curative surgery for carcinoma of the colon and rectosigmoid/rectum (rs/rectum) at the New England Deaconess Hospital from 1965-1978. Sixty-one patients were identified as having tumors with lymphatic vessel invasion (LVI+), and they were compared with the remaining group of 401 patients who had tumors without lymphatic vessel invasion (LVI-). The incidence of lymphatic vessel invasion was significantly increased in tumors with blood vessel invasion (24% vs. 5%, p = 0.000001). Patients with LVI+ tumors also had a significantly increased incidence of positive nodes (59% vs. 25%, p = 0.0004), the average number of positive nodes (4.8 vs. 2.2, p = 0.0003), and a lower 5-year survival rate (colon: 57% vs. 84%, p = 0.0001; rs/rectum: 38% vs. 71%, p = 0.004). There was a significant (p less than or equal to 0.05) increase in local (16% vs. 7%), abdominal (33% vs. 9%), and distant (13% vs. 4%) failure as a component of component of failure in patients with LVI+ colon cancer and a significant increase in abdominal (33% vs. 11%) and distant (13% vs. 8%) failure as a component of failure in patients with LVI+ rectosigmoid/rectal cancer. Proportional hazards analysis demonstrated that lymphatic vessel invasion was an independent prognostic factor for survival.

Selection criteria for local excision with or without adjuvant radiation therapy for rectal cancer

As an alternative to radical surgery, local excision with or without adjuvant pelvic radiation therapy has been used in selected patients with rectal cancer. To determine which clinical and pathologic features can predict the presence of positive lymph nodes (LN+), a retrospective review of 168 patients who underwent potentially curative surgery for rectosigmoid and rectal cancer was performed. By univariate analysis, tumor penetration, grade, and histology were significant predictive features. This was confirmed by logistic regression analysis. The incidence of LN+ increased with increasing tumor penetration (T1, 0%; T2, 28%; T3, 36%; T4, 53%; P = 0.04), grade of adenocarcinoma (well-differentiated, 0%; moderately differentiated, 30%; poorly differentiated, 50%; P = 0.07, [borderline significance]), and the presence of any colloid histology (pure adenocarcinoma, 30%; total colloid, 52%; P = 0.04). Using 2 X 2 contingency tables, the presence of blood vessel invasion (BVI), lymphatic vessel invasion (LVI), vascular invasion (VI), total colloid histology, and high grade further increased the incidence of LN+ with increasing tumor penetration. Regardless of tumor size, grade, histology, BVI, LVI, or VI, none of the nine patients with Stage T1 tumors or the seven with well-differentiated adenocarcinomas had LN+. For this group, local excision alone is recommended. The incidence of LN+ was greater than or equal to 19% in all other categories. For this group of patients, if there is no evidence of gross tumor in the pelvis, then a local excision plus adjuvant pelvic radiation may be an alternative to radical surgery.

Resectable adenocarcinoma of the rectosigmoid and rectum. II. The influence of blood vessel invasion

Several series have examined the influence of blood vessel invasion (BVI) by tumor on survival of patients with colorectal cancer; however, little data are available regarding its influence on patterns of failure. In an effort to determine the influence of BVI on the patterns of failure and survival in rectosigmoid and rectal cancer, a retrospective review of 168 patients who underwent potentially curative surgery at the New England Deaconess Hospital was performed. In patients who had tumors with extramural BVI, there was a significant decrease in five-year actuarial survival compared with patients who had tumors with intramural BVI or were BVI-negative (BVI-). When the intramural and extramural types of BVI were combined, no significant impact was noted on the patterns of failure or survival in patients with BVI+ versus those with BVI- tumors. In contrast, the presence of lymphatic vessel invasion was found to significantly decrease survival. By using a proportional hazards analysis, it was found that BVI was not an independent prognostic variable. Therefore, the use of BVI alone is not recommended for selecting patients with rectosigmoid and rectal cancer who may benefit from adjuvant therapy.

Resectable adenocarcinoma of the rectosigmoid and rectum. I. Patterns of failure and survival

In an effort to determine the patterns of failure and survival of rectosigmoid and rectal cancer, a retrospective review of 168 patients who underwent potentially curative surgery at the New England Deaconess Hospital was performed. The 5-year actuarial survival for the entire group was 67%. Survival rates decreased with increasing penetration of the bowel wall by tumor and the presence of lymph node metastasis, but only the latter reached statistical significance. Those patients who underwent an abdominoperineal resection also experienced a significant decrease in survival compared to a low anterior resection. Patterns of failure, expressed as the actuarial incidence of first failure at 5 years, were examined by stage. With the exception of stages B3 and C3, there was a trend towards increased abdominal, distant, and total failure with increasing bowel wall penetration by tumor. A similar trend was seen in local failure in those patients with positive nodes. Knowledge of these data may help identify those patients who may benefit most from adjuvant therapy.

Resectable adenocarcinoma of the rectosigmoid and rectum. I. Patterns of failure and survival

In an effort to determine the patterns of failure and survival of rectosigmoid and rectal cancer, a retrospective review of 168 patients who underwent potentially curative surgery at the New England Deaconess Hospital was performed. The 5-year actuarial survival for the entire group was 67%. Survival rates decreased with increasing penetration of the bowel wall by tumor and the presence of lymph node metastasis, but only the latter reached statistical significance. Those patients who underwent an abdominoperineal resection also experienced a significant decrease in survival compared to a low anterior resection. Patterns of failure, expressed as the actuarial incidence of first failure at 5 years, were examined by stage. With the exception of stages B3 and C3, there was a trend towards increased abdominal, distant, and total failure with increasing bowel wall penetration by tumor. A similar trend was seen in local failure in those patients with positive nodes. Knowledge of these data may help identify those patients who may benefit most from adjuvant therapy.

Resectable adenocarcinoma of the rectosigmoid and rectum. II. The influence of blood vessel invasion

Several series have examined the influence of blood vessel invasion (BVI) by tumor on survival of patients with colorectal cancer; however, little data are available regarding its influence on patterns of failure. In an effort to determine the influence of BVI on the patterns of failure and survival in rectosigmoid and rectal cancer, a retrospective review of 168 patients who underwent potentially curative surgery at the New England Deaconess Hospital was performed. In patients who had tumors with extramural BVI, there was a significant decrease in five-year actuarial survival compared with patients who had tumors with intramural BVI or were BVI-negative (BVI-). When the intramural and extramural types of BVI were combined, no significant impact was noted on the patterns of failure or survival in patients with BVI+ versus those with BVI- tumors. In contrast, the presence of lymphatic vessel invasion was found to significantly decrease survival. By using a proportional hazards analysis, it was found that BVI was not an independent prognostic variable. Therefore, the use of BVI alone is not recommended for selecting patients with rectosigmoid and rectal cancer who may benefit from adjuvant therapy.

Resectable adenocarcinoma of the rectosigmoid and rectum. I. Patterns of failure and survival

In an effort to determine the patterns of failure and survival of rectosigmoid and rectal cancer, a retrospective review of 168 patients who underwent potentially curative surgery at the New England Deaconess Hospital was performed. The 5-year actuarial survival for the entire group was 67%. Survival rates decreased with increasing penetration of the bowel wall by tumor and the presence of lymph node metastasis, but only the latter reached statistical significance. Those patients who underwent an abdominoperineal resection also experienced a significant decrease in survival compared to a low anterior resection. Patterns of failure, expressed as the actuarial incidence of first failure at 5 years, were examined by stage. With the exception of stages B3 and C3, there was a trend towards increased abdominal, distant, and total failure with increasing bowel wall penetration by tumor. A similar trend was seen in local failure in those patients with positive nodes. Knowledge of these data may help identify those patients who may benefit most from adjuvant therapy.

Potentially curative surgery of colon cancer: the influence of blood vessel invasion

A number of series have examined the influence of blood vessel invasion (BVI) by tumor on survival of patients with colorectal cancer; however, there are little data available regarding its influence on patterns of failure. In an effort to determine the influence of BVI on the patterns of failure and survival in colon cancer, a retrospective review of 294 patients who underwent potentially curative surgery at the New England Deaconess Hospital (NEDH) was performed. Patients whose tumors had BVI experienced a significant decrease in the 5-year actuarial survival rate. BVI had little impact on the patterns of failure in stage B2 disease, but a significant increase in total failure and local failure (as a component of failure) occurred in stage C2. However, when examined by proportional hazards analysis, BVI was found not to be an independent prognostic variable. For patients with stage C2 tumors, which are also BVI+, radiation therapy to the tumor bed might play a contributory role in overall management.

Potentially curative surgery of colon cancer: patterns of failure and survival

In an effort to determine the patterns of failure and survival of colon cancer, a retrospective review of 294 patients who underwent potentially curative surgery at the New England Deaconess Hospital (NEDH) was performed. For the entire group, the 5-year crude survival rate was 68% and the actuarial rate was 80%. Survival decreased with increasing bowel wall penetration by tumor and the presence of lymph node metastasis. Although survival varied with the tumor site, none of the differences was statistically significant. Other variables, including the grade of adenocarcinoma, size, and the type of surgery had a significant impact on survival. Patterns of failure, expressed as the actuarial incidence of first diagnosed failure at 5 years, were examined by stage and site. There was a trend toward increased failure with increasing bowel wall penetration by tumor and the presence of lymph node metastasis. Abdominal failure, either as the only site or as a component of failure, was the most common type of failure. When compared by site, patients with cecal carcinoma had a significantly lower incidence of local and distant failure than patients with disease in other selected sites. No differences in patterns of failure were seen in patients with carcinomas in the mobile sections of the colon compared with those who had disease arising in the nonmobile sections of the colon. These data may be useful in identifying those patients who might benefit most from adjuvant therapy.

Colloid carcinoma of the colon and rectum

To determine the clinicopathologic significance of colloid carcinoma in carcinoma of the colon and rectosigmoid/rectum, a retrospective review of 462 patients who underwent potentially curative surgery at the New England Deaconess Hospital was performed. Seventy-seven patients (17%) were identified who had tumors with some component of colloid present. Colloid carcinoma occurred in 49 (11%). The remaining 28 (6%) had adenocarcinoma with colloid features. Compared to patients with pure adenocarcinoma, the 5-year actuarial survival of patients with colloid carcinoma was lower in the colon, rectosigmoid/rectum, and colorectum. Patterns of failure, expressed as the actuarial incidence of failure at 5 years, were examined by histologic condition and stage. Patients with Dukes' Stage B colloid carcinoma had a higher incidence of total failure, and patients with Dukes' Stage C colloid carcinoma had a higher incidence of local, abdominal, and total failure. None of the differences reached statistical significance. The presence of colloid carcinoma may have a real but small impact on the patterns of failure and survival in colorectal cancer.

Juvenile fibroadenoma with atypical epithelial hyperplasia

We studied 49 patients with fibroadenomas with severe atypical epithelial hyperplasia, sometimes suggestive of in situ carcinoma. The term "juvenile fibroadenoma" (JFA) is recommended for these lesions, which occur mainly in adolescent and young women. Twenty-six cases (2%) were obtained through a review of 1,321 consecutive fibroadenomas and 23 were seen in consultation. The 49 patients ranged in age from 10-72 years (average 26 years); 50% were younger than 21 years. This age distribution was significantly lower than that of patients with adult FA (p less than 0.001). Four patterns of atypical epithelial hyperplasia were observed: ductal-laciform, ductal-solid, cystic-papillary and lobular-terminal ductal. Forty-six patients were treated by excision only. Eight years was the average follow-up and 7 years the median follow-up for 28 (57%) patients followed for more than a year (range 1-19 years). Two patients, aged 47 and 59 years at the time of diagnosis of JFA, subsequently developed carcinoma in the contralateral and ipsilateral breast, respectively; all others have remained well. Atypical epithelial proliferation in this setting should be interpreted conservatively. Long-term follow-up is recommended after excision of JFA.

[Affective disorders in general hospitals: the organic affective syndrome]

After a survey of the literature on secondary depression and mania caused by physical illness or drugs, a retrospective study on 77 inpatients (seen in the hospital psychiatric consultation service) is reported. Forty per cent of patients presented a diagnosis of depression; 58% of depressed patients had at least one of the "risk factors" for secondary depression (physical illness and drugs known to cause affective disturbances) compared to 24% and 16% of patients with other or no mental disorders (p less than 0.05).

Histopathologic and ultrastructural correlates of tumor growth suppression by high energy shock waves

High energy shock waves (HESW) are cytotoxic to tumor cells as determined by vital staining and impaired ability of viable cells to form colonies in a clonogenic assay. In addition, direct exposure of tumor nodules to HESW results in suppression of tumor growth rate. In order to identify histopathologic and ultrastructural correlates of these observations, R3327AT-3 prostatic tumor cells were exposed to HESW in vitro and in vivo. Damage to cells in suspension was manifested by fragmentation of cells to form debris. At the ultrastructural level, mitochondria were swollen and contained distorted cristae following exposure of tumor cells to HESW. In vivo exposure of tumor nodules to HESW did not cause a distinct histopathologic or ultrastructural effect that could be qualitatively distinguished from spontaneously occurring cell death. Hemorrhage and necrosis were observed in muscle and fibroadipose tissue adjacent to tumor. The mechanism of HESW-induced cytotoxicity is not clear from our studies. Evidence of damage of normal tissues exposed in vivo and tumor cells in vitro is reflected in histomorphological changes.

Leiomyosarcoma of the anus treated with sphincter-preserving surgery and radiation therapy

The sixth published case of a leiomyosarcoma of the anus is reported and the previous literature reviewed. Treatment with successful preservation of anal sphincter function is described. Local excision of the tumor was followed by external beam radiation therapy and an Iridium-192 implant. The details and rationale for this mode of therapy for resectable anal tumors are discussed.

High energy shock waves suppress tumor growth in vitro and in vivo

Exposure of the Dunning R3327AT-3 rat prostatic carcinoma and SK-Mel-28 human melanoma, in vitro, to high energy shock waves resulted in a reduction in cell viability as determined by trypan blue exclusion and a decrease in the number of colonies formed in a clonogenic assay. Flow cytometric determination of DNA content in R3327AT-3 cells treated in vitro indicated a selective diminution of cells in the G2 and M phases of the cell cycle. When R3327AT-3 cells exposed to high energy shock waves were subsequently injected into rats, or tumor bearing animals were treated by high energy shock waves targeted at the tumor, a delay in tumor growth was observed. These observations indicate that high energy shock waves are cytotoxic to tumor cells in vitro and in vivo. Additional research into the possible use of high energy shock waves in the non-invasive destruction of animal and human tumors is warranted.

Sphincter preservation in patients with low rectal cancer treated with radiation therapy with or without local excision or fulguration

Twenty-six patients with small cancers limited to the lower two-thirds of the rectum were treated with conservative surgery and radiation therapy (XRT). The selection factors for this approach were age, refusal of a permanent colostomy, or the high risk of local recurrence because of inadequate surgical margin or palpable residual tumor after local surgical treatment alone. In patients treated with local excision or fulguration followed by XRT, there was a 6% local failure rate (one in 17); in 16 of 17 patients receiving radiation doses above 4,500 cGy, the local control was complete for follow-up periods of 6 months to 7 years. In nine patients treated with XRT for residual tumor, local failure occurred in five (56%). The disease-free survival for those without residual tumor versus those with residual tumor was 88% and 44%, with median follow-up periods of 20 and 23 months, respectively. Serious late complications occurred only if total doses were greater than 6,300 cGy. Local excision combined with XRT proved to be a safe alternative to radical surgery in selected patients and resulted in excellent local control while allowing preservation of anal sphincter function.

Beauvaria bassiana keratitis

The cornea of a 64-year-old white male underwent progressive thinning following removal of a foreign body and after treatment with topical antibiotics and corticosteroid. Initial attempts at laboratory identification of an infectious agent were negative. The process progressed to corneal perforation. After a penetrating keratoplaty, histopathological examination of host button tissue showed a fungus, identified as Beauvaria bassiana on culture.

Palisading prostate granulomas following surgery

Fifteen cases of palisading granulomas of the prostate occurring in patients with a history of previous prostate surgery are described and illustrated. This distinctive histologic lesion strongly resembles a rheumatoid nodule, but is not associated with connective tissue disease or infection and is probably related to prior transurethral prostatectomy or needle biopsy.

Prognostic value of infranodal conduction time in patients with chronic bundle branch block

His bundle recordings were obtained in 121 patients with chronic bundle branch block and the patients were followed for a mean period of 18 months. Seventy-nine patients had an infranodal conduction time (H-Q) less than 70 msec while 42 had H-Q greater than or equal to 70 msec. There was no significant difference in mean age, smoking history, diabetes, syncope, dizziness, blood pressure, and serum cholesterol or triglyceride levels between the two groups. There was a significantly greater incidence of progresssion to second degree or third degree atrioventricular block (9/42, 21%), and of severe congestive heart failure (16/42, 38%) in patients with H-Q greater than or equal to 70 compared with those with H-Q less than 70 (1/79, 1.3%; and 13/79, 16%, respectively). The risk of sudden death was significantly greater only in the group with H-Q greater than or equal to 70 and severe congestive heart failure. There was no correlation between the presence of first degree atrioventricular block and/or any particular type of bundle branch block pattern with sudden death and/or progression to second degree or third degree atrioventricular block. Analysis of the surface electrocardiogram is only of limited value in predicting high risk patients with chronic bundle branch block. Electrophysiologic studies are of greatest value in patients with bundle branch block with transient neurologic symptoms in whom no cause for the symptoms is evident.