Petechial hemorrhages, ethanol, and opioids in victims from intoxication

Petechial hemorrhages are of interest to forensic pathologists because of their association with pressure on the neck. This study shows the associations between ethanol, opioids in blood and the risk of petechiae in conjunctivae and eye lids of 865 medico-legally examined victims from intoxication, 112 (12.9 %) with petechiae. Livor mortis on the front, face down body position, higher body weight, and younger age of the victims were independently associated with higher risk of petechiae. These variables were used for adjustment in the logistic regression analyzes. We found associations between ethanol, opioids, and the risk of petechiae when analyzed simultaneously. The association between ethanol and the risk of petechiae differed in opioid negative and positive victims (interaction, p = 0.028). In the opioid negative group, the association was J-formed, victims with low to medium level ethanol having lower risk (OR = 0.77) than those without ethanol or opioids, whereas high ethanol level gave a 4-fold higher risk (OR = 3.97). In the opioid positive group, the J-formed pattern was reversed. Victims with low to medium level ethanol had more than 4 times higher risk (OR = 4.65), whereas high level ethanol gave a slightly elevated risk (OR = 1.34) only compared to no ethanol or opioids. The results suggest that ethanol and opioids have a complex association with the risk of petechiae independent of livor mortis, initial body position, body weight, and age in victims from intoxication. Of practical value for the post-mortem examination is that the pathologist must consider both the ethanol level and the presence of opioids when judging the significance of petechiae in the eye regions.

Asphyxiation death caused by oxygen-depleting cargo on a ship

The extreme danger associated with entering enclosed spaces loaded with oxygen-depleting organic cargo in ships and tanks is obviously underestimated, both among crew and management. We present a case report to highlight this occupational hazard and to increase the knowledge about the imperative precautions, in order to prevent future accidents. An experienced customs officer was found lifeless at the bottom of the unattended cargo hold on a ship loaded with woodchips. The oxygen content in the cargo atmosphere was below 2%, which is incompatible with life. Forensic autopsy revealed injuries related to the fall, and there were no positive toxicological findings in blood, lung or urine. Management and workers must be taught about the extreme rapidity of developing unconsciousness and asphyxiant death when entering enclosed spaces loaded with oxygen-depleting cargo. Even a single inhalation can result in unconsciousness and death. Dozens of annual deaths and severe injuries can easily be prevented if simple precautions are followed.

Genomic Evolution of Breast Cancer Metastasis and Relapse

Patterns of genomic evolution between primary and metastatic breast cancer have not been studied in large numbers, despite patients with metastatic breast cancer having dismal survival. We sequenced whole genomes or a panel of 365 genes on 299 samples from 170 patients with locally relapsed or metastatic breast cancer. Several lines of analysis indicate that clones seeding metastasis or relapse disseminate late from primary tumors, but continue to acquire mutations, mostly accessing the same mutational processes active in the primary tumor. Most distant metastases acquired driver mutations not seen in the primary tumor, drawing from a wider repertoire of cancer genes than early drivers. These include a number of clinically actionable alterations and mutations inactivating SWI-SNF and JAK2-STAT3 pathways.

Subclonal diversification of primary breast cancer revealed by multiregion sequencing

The sequencing of cancer genomes may enable tailoring of therapeutics to the underlying biological abnormalities driving a particular patient's tumor. However, sequencing-based strategies rely heavily on representative sampling of tumors. To understand the subclonal structure of primary breast cancer, we applied whole-genome and targeted sequencing to multiple samples from each of 50 patients' tumors (303 samples in total). The extent of subclonal diversification varied among cases and followed spatial patterns. No strict temporal order was evident, with point mutations and rearrangements affecting the most common breast cancer genes, including PIK3CA, TP53, PTEN, BRCA2 and MYC, occurring early in some tumors and late in others. In 13 out of 50 cancers, potentially targetable mutations were subclonal. Landmarks of disease progression, such as resistance to chemotherapy and the acquisition of invasive or metastatic potential, arose within detectable subclones of antecedent lesions. These findings highlight the importance of including analyses of subclonal structure and tumor evolution in clinical trials of primary breast cancer.

Efferent vascular invasion in the axillary nodes in breast carcinoma: a potent prognostic factor

Tumour cells in the efferent vessels of the axillary nodes in breast cancer (EV status) have been associated with poor prognosis since 1979. A prospective study (1980-1989) of all the nodes from 1037 consecutive female patients with unilateral breast cancer whose treatment included axillary node dissection yielded 471 node-positive cases. Tumour cells were found in the efferent nodal vessels of 210 patients, while 252 were negative. In the remaining 9 patients efferent nodal vessels could not be identified. At follow-up, 62% of the node-positive patients had died of breast carcinoma, in contrast to 32% of node-negative patients. The prognosis in cases with 1-3 versus 4+ tumour-bearing nodes was highly significant, 36% and 64%, respectively having died of breast carcinoma,. Prognosis was not dependent on the number of EV+ nodes in those cases showing efferent vascular invasion, one positive node was enough. Differentiation between these nodal growth forms thus provides a strong prognostic indicator, available to all with access to routine surgical pathology. We confirmed the significance of both variables using Cox's regression analysis and showed that the number of positive nodes adds significant prognostic information to that of EV status, which is the stronger of the two prognostic indicators. EV+ patients with more than three positive nodes have more than a three times higher risk of dying than EV- patients with three or fewer positive nodes.

'Missed' micrometastases--the extent of the problem

The value of detecting micrometastases in patients with breast cancer has been debated for many years. The aim of this study was to determine whether and why such tumour deposits are missed at the time of reporting. The series comprised 272 patients treated surgically for breast carcinoma. For node-negative cases, the haematoxylin and eosin stained slides were re-examined. Those still remaining negative were stained with epithelial membrane antigen marker (EMA). Hilar sections were used in 76% of cases. Micrometastases were found in 35 cases reported as node-negative: 15 being identified on re-examination and 20 after staining with EMA, a gain of 44%, including 20 of embolic type. All were found in hilar sections of the nodes. The patients in whom micrometastases were found on further examination had significantly smaller tumour deposits than those reported as node-positive. In cases with infiltrating ductal carcinoma these presented as embolic growth, while those with infiltrating lobular carcinoma, for example, tended to colonize the nodal parenchyma, giving nodal growth. Differentiation between these growth patterns enables pathologists to distinguish between the dangerous embolic type and the less important nodal growth. In conclusion, many of these micrometastases can be detected if the slides reported as node-negative on first reading are re-examined. In those remaining negative, immunohistochemical staining is recommended.

Staging nodal growth in breast cancer on a histological basis

This study describes the axillary tumour-load in 484 women with breast carcinoma with spread to one or more nodes. The aim was to relate tumour-load to nodal histology. The tumour area and that of residual lymphoid tissue was measured from standardised nodal sections. The presence/absence of tumor cells in the efferent vessels (EV) defined their nodal status as EV+ or EV-. The former has a poor prognosis. While the number of EV+ cases increased with the total tumour-load, the number of EV- cases decreased. In the EV+ there was high positive correlation between tumour-load and number of deaths from breast cancer, with a corresponding negative correlation in the EV-. Twice as many patients with EV+ nodes died of breast cancer compared to the EV- group. Investigation of 164 consecutive tumour-bearing nodes showed a similar pattern. Irrespective of EV status the area of residual lymphoid tissue remained constant. Although the lymphoid area was similar the tumour-load was twice as high in the EV+ cases. These findings stress basic biological differences in the growth of breast carcinoma in the nodes. Patients with the smallest micrometastases that are found in the afferent lymphatics of the node and the EV+ patients in which tumour cells are present in the efferent nodal vessels have a poor short-term prognosis. The patients with larger micrometastases in the nodal lymphoid tissue and also EV- patients with the next highest tumour-load are both of low prognostic risk, with the exception of the few EV- with an exceptionally high tumour-load.

The size of a micrometastasis in the axilla in breast cancer: a study of nodal tumour-load related to prognosis

Much has been written on micrometastases to the axilla in breast cancer but there is no consensus as to their size. In this study three levels of nodal tumour-load are defined following measurement of nodal tumour area on histology. The two cut-points described are both of clinical interest. The smallest deposits, up to 0.0001 cm2, include embolic growth on the afferent side of the node, which is, as reported previously, of poor prognosis. In such cases post-operative prognosis approaches that in the "node-positive", here defined as cases with an axillary tumour-load of 0.5 cm2 or more. Between these two groups is a collection of cases, 40% of the total series, with a prognosis similar to the node-negative. It is suggested that the deposits in this intermediate group should be termed micrometastases, the high risk cases with embolic growth reported as such and those with larger deposits as node-positive.

Fibrosarcoma in children--a rare tumour with long-term survival even with advanced disease--a report of 3 cases

Fibrosarcoma is a rare tumour in children. The potential of malignancy has been questioned. We present three cases of fibrosarcoma in children . The follow-up periods range from 10 to 37 years. The first patient had pulmonary metastases at the time of diagnosis in 1958. The primary tumour in fossa ischio-rectalis was resected in 1960. Lung metastases were resected in 1960 and 1989. Radiotherapy was given in 1992. He is still alive with metastases 37 years after the first manifestation of disease. The second patient had a primary tumour and several local recurrences in the mandible. He is alive without evidence of disease 4 years after resection of pulmonary metastases and 21 years after resection of the primary tumour. The third patient has no signs of recurrence or metastatic spread 10 years after a wide excision of subcutaneous tumours of the left upper arm. The cases demonstrate a special tumour-entity of low-grade malignancy, which show a good prognosis and a wide spectrum of biological behaviour.

Breast cancer: two micrometastatic variants in the axilla that differ in prognosis

Measurement of the area of the tumour deposits present in routine sections from the axillary nodes from a series of 1069 breast cancer patients showed that 138 cases had a single micrometastasis (0.2 cm2 or less), while in 29 a similar load was spread over two or more nodes. These 167 cases represent 15% of the patients in the series. Twentyfive of them had died of breast cancer within a mean follow-up of 6 years. They had smaller micrometastases than those surviving (P < 0.0025). Histological examination in the 138 with single micrometastases showed that two variants were present. In one, tumour growth was confined to the capsular lymphatics and/or the subcapsular sinus. In the other, tumour growth was present in the nodal lymphoid tissue, and, on occasion, at the other sites as well. Those with growth in the lymphoid tissue had a better prognosis than those without (P < 0.0035). Prognosis in the former was comparable to that in the node-negative cases, while in those lacking such growth it was similar to that in the node-positive. The presence of these two variants could explain divergent reports in the literature on prognosis in cases with micrometastases. While the mechanisms behind this apparent paradox remain speculative, the observation can be of diagnostic interest in routine surgical pathology.