Calculi and intracellular ochronosis in the submandibular tissues from a patient with alkaptonuria

Alkaptonuria (AKU) is a rare autosomal recessive condition caused by deficiency of the enzyme homogentisate 1,2 dioxygenase, resulting in widespread deposition of oxidised homogentisic acid (HGA) polymer, primarily in joint tissues but also in other connective tissues. Macroscopic pigmentation of connective tissues in AKU is well documented and is the end point of a process that is not understood. Deposition in less common regions may provide clues to the pigment formation process. This is the first report of detection of ochronotic pigment in acinar cells and lumina in the submandibular gland of a patient with AKU. Deposition was noted in the apical region of the cells. A lobar duct presented a large calculus with unusual deposits possibly associated with calcium salts. This report highlights the effect that local and intracellular factors may have on converting HGA into polymeric derivatives in the absence of an extracellular matrix.

Alkaptonuria--a review of surgical and autopsy pathology

Alkaptonuria is a rare, inherited defect of homogentisic acid 1,2-dioxygenase that leads to the widespread deposition of polymeric homogentisic acid, and clinical symptoms from degeneration of joints and the aortic valve. Pathological descriptions are few and mainly those of late-stage changes related to joint or valve failure. In this review, the macroscopic and histopathological changes in the tissues in alkaptonuria are illustrated by the detailed autopsy study of a 74-year-old female who died from disseminated ovarian carcinoma. The pathology is discussed in the context of the literature and in relation to potential pathogenic mechanisms of tissue damage. This review highlights the heterogeneity of some of the manifestations. In symptomatic patients, degenerative changes in synovial and intervertebral joints are usually well advanced, while early changes include diffuse cartilage pigmentation and chondrocyte necrosis. The initial stage of pigment deposition in the cardiovascular system may be influenced by intravascular pressure and flow disturbances, whereas more intense pigmentation affects fibrolipid components of atheromatous plaques. Pigmentation of the aortic and mitral valve cusps and valve rings is a result of intracellular and extracellular pigment deposition and is associated with calcification and clinically significant aortic stenosis.

Hibernoma--correlation of histopathology and magnetic-resonance-imaging features in 10 cases

OBJECTIVE, DESIGN AND PATIENTS: Hibernoma is an uncommon, slow-growing, benign soft-tissue tumour resembling brown adipose tissue. The histological appearances are well-documented, but there are relatively few descriptions of the magnetic resonance (MR) imaging features. We report a retrospective comparison of the histological and MR appearances of ten hibernomas of the extremities, classified histologically into lipoma-like [<70% multivacuolated adipocytes (MVAs)] and non-lipoma-like hibernomas (>70% MVAs).

RESULTS

The lipoma-like hibernomas measured 4-27 cm in maximum size. All were well-defined on MR imaging and histology except for one subcutaneous lesion that blended in with surrounding fat histologically. All lesions were isointense with subcutaneous fat on T1- and T2-weighting apart from one lesion that was predominantly slightly hypointense on T1-weighting and predominantly slightly hyperintense on T2-weighting and STIR. Two slightly inhomogeneous lesions contained thin (<5 mm thickness) tortuous vessels. One patient received intravenous contrast, but the lesion did not enhance. The six non-lipoma-like hibernomas measured 2.5-15.5 cm in maximum size and all were unencapsulated. Three were well-defined and three partly ill-defined on MR imaging. There were no significant differences in the MR characteristics of the non-lipoma-like variants. On T1-weighting, the non-lipoma-like hibernomas that contained >90% MVAs were predominantly slightly hypointense to subcutaneous fat. One lesion was isointense with subcutaneous fat, but this lesion only contained from 80-90% MVAs. All non-lipoma-like lesions were slightly hyperintense on STIR but so too were two of the four lipoma-like lesions. Four of the six non-lipoma-like lesions showed marked or moderate inhomogeneity due to thick septa and prominent vessels. Of the two cases that received intravenous contrast, both showed enhancement corresponding to regions of >90% MVAs or prominent vessels within fibrous septa.

CONCLUSIONS

MR imaging has shown some distinguishing features between lipoma-like and non-lipoma-like hibernomas. Lipoma-like hibernomas are usually isointense with subcutaneous fat on T1-weighting, are either homogeneous or slightly inhomogeneous and may contain thin tortuous vascular structures. Non-lipoma-like hibernomas are pre-dominantly slightly hypointense to subcutaneous fat on T1-weighting, often display marked or moderate inhomogeneity with prominent septa and vessels and enhancement is typical. The appearances of non-lipoma-like hibernomas are not diagnostic and may be mimicked by lipoma variants and by well-differentiated liposarcoma or atypical lipoma.

Marsh stars in Liverpool

INTRODUCTION/METHODS

After the recognition of contaminating algae on histopathological sections stained by periodic acid Schiff (PAS) and Grocott methods, a detailed audit was undertaken to assess the extent of contamination and its possible source.

RESULTS

The contaminating organism was a member of the staurastrum genus of Chlorophyta, star shaped organisms commonly found in fresh water marshes. The organisms were seen on sections stained by the diastase-PAS, PAS, or Grocott methods and on cytological preparations between July 2003 and May 2004. It is unlikely that contamination of water baths or concentrated staining solutions was to blame, and a more general contamination of the laboratory water supply is the most likely source.

CONCLUSIONS

Contaminating organisms may appear on histological and cytological material and their nature and source should be investigated. Although in this instance, confusion with pathologically important organisms was minimal, algae may occasionally cause significant disease.

acp Best Practice No 169. Evidence based pathology: squamous carcinoma of the hypopharynx

This best practice article reviews the published evidence on the pathology and patterns of spread of carcinomas of the hypopharynx, and the relevance of pathological features to prognosis. Medline (1966-2001) was searched using a combination of head and neck neoplasms and prognosis, focusing on hypopharynx and pathology. Other relevant publications were identified from the bibliographies of these papers, and from those obtained opportunistically. There is relatively little pathological literature devoted specifically to squamous carcinomas of the hypopharynx and most information comes from large series of patients with head and neck cancers at a range at sites. Lack of consistency in reporting and shifts in terminology make comparisons between series difficult. The most important features determining prognosis are size and extent of local spread of the primary carcinoma and extent of involvement of regional lymph nodes. There is evidence to support the use of the minimum dataset criteria for head and neck carcinomas at this site. Within the hypopharynx, subsite related differences in aetiology and biology may become important.

Ischaemic preconditioning of skeletal muscle

Ischaemic preconditioning is a process by which exposure of a tissue to a short period of non-damaging ischaemic stress leads to resistance to the deleterious effects of a subsequent prolonged ischaemic stress. It has been extensively described in the heart, but few studies have examined the possibility that it can occur in skeletal muscle. We have used a rat model of ischaemia of one limb to examine this possibility. Exposure of the hind limb to a period of ischaemia of five minutes and reperfusion for five minutes significantly protected the tibialis anterior muscle against the structural damage induced by a subsequent period of limb ischaemia for four hours and reperfusion for one hour. This protection was evident on examination of the muscle by both light and electron microscopy. Longer or shorter times of prior ischaemia had no effect.

Molecular markers of metastasis in squamous carcinomas

The prognosis for patients with squamous carcinomas of the head and neck region is strongly influenced by the presence or absence of cervical lymph node metastases. Biological markers that indicated a high risk of metastasis would have a major role in determining the optimal therapeutic strategy for these patients. This editorial discusses recent studies of molecular and genetic markers of squamous carcinomas in relation to metastatic potential and highlights some of the issues that limit current progress in this field of study.

The management of retroperitoneal soft tissue sarcoma: a single institution experience with a review of the literature

AIM

Ten percent of soft tissue sarcomas (STS) arise in the retroperitoneal tissues. The prognosis for patients with retroperitoneal sarcoma is poor with a 5-year survival rate between 12% and 70%. Stage at presentation, high histological grade, unresectable primary tumour and incomplete resection are associated with a less favourable outcome.

METHODS

Complete follow-up data were available on 22 patients who underwent surgery for retroperitoneal STS in our institution between 1990 and 2000. Patient, tumour and treatment variables were analysed including use of adjuvant therapy and survival status.

RESULTS

Eighteen patients underwent surgery for primary disease, four patients were treated for recurrent disease or metastases. Ten patients presented with pain, seven with an abdominal mass, other presentation included weight loss and haematuria. Thirteen patients presented with tumours larger than 10 cm. The tumours were seven liposarcomas, six leiomyosarcomas, three malignant fibrous histiocytomas, two rhabdomyosarcomas, two malignant schwannomas and two undifferentiated sarcomas. Six primary tumours were completely excised, five patients received radiotherapy and five received chemotherapy. Local recurrence rate was 45% and recurrence-free interval for 10 patients with recurrence was 11 months. Five patients received radiotherapy and five received chemotherapy. The median survival for patients with primary tumours was 36 months, and 5-year survival was 44%. Adjuvant therapy was not associated with higher survival rates.

CONCLUSION

This study re-emphasizes the poor outcome of patients with retroperitoneal STS. Adjuvant radiotherapy and chemotherapy do not appear to be any proven benefit and the single most important prognostic factor is aggressive successful en bloc resection of the primary tumour. Our resection rate and 5-year survival rates are comparable with previous reported UK series although lower than large reports from North American centres. This might partly be explained by difficulty in data collection in a retrospective analysis, but may reflect inadequate subspecialization in UK centres.

Molecular markers of metastasis in squamous carcinomas

The prognosis for patients with squamous carcinomas of the head and neck region is strongly influenced by the presence or absence of cervical lymph node metastases. Biological markers that indicated a high risk of metastasis would have a major role in determining the optimal therapeutic strategy for these patients. This editorial discusses recent studies of molecular and genetic markers of squamous carcinomas in relation to metastatic potential and highlights some of the issues that limit current progress in this field of study.

Bizarre parosteal osteochondromatous proliferation with cortical invasion

A 15-year-old male presented with an 18-month history of increasing swelling on the radial aspect of his left forearm. Radiographs and MR images showed a partly calcified mass on the lateral border of the radius with erosion of the underlying cortex. Following a CT-guided needle biopsy, the mass was excised by segmental resection of the radial shaft with replacement by a vascularised fibular graft. Histological examination of the resected specimen showed many features typical of a bizarre parosteal osteochondromatous proliferation (BPOP) but with destruction of the underlying cortical bone by cellular spindle cell tissue. Although there were no cytological signs of malignancy, we believe that this unusual disease should be regarded as a particularly aggressive form of BPOP and treated by wide excision. Clinical follow-up of our patient at 2 years shows no sign of local recurrence or metastasis.

Basic fibroblast growth factor and angiogenesis in squamous carcinoma of the tongue

The relationship between basic fibroblast growth factor (bFGF), receptors for bFGF and neoangiogenesis was investigated in 51 patients with squamous cell carcinoma of the tongue, 26 of whom had metastatic disease in cervical lymph nodes. Vessels were demonstrated by immunocytochemical labelling for CD34 and expressed as raw counts and volume-weighted counts. bFGF protein and its receptors FGFR1(flg) and FGFR2(bek), were demonstrated using immunocytochemical labelling. In situ hybridisation for bFGF mRNA was performed using a 250-bp digoxigenin-labelled RNA probe. In normal epithelium, the expression of bFGF protein and mRNA was more intense in the basal layer, while receptors for bFGF were expressed more strongly in the superficial parts. In carcinomas, expression of bFGF was greater in the more poorly-differentiated cells, but showed no relation to the overall tumour differentiation. There was strong bFGF expression in tumour-infiltrating lymphocytes. The expression of bFGF receptors was variable, with FGFR2 being particularly high in areas of keratinisation. There were no consistent changes in bFGF or receptor expression between primary carcinomas and their lymph node metastases, and there was no correlation with measures of vascularity or tumour growth pattern. bFGF is synthesised by all squamous carcinomas and has the potential to modulate angiogenesis. However, these data suggest that changes in the expression of bFGF and its receptors are not related to the intensity of neoangiogenesis in lingual carcinomas or their nodal metastases.

Dermatomyositis and Whipple's disease

A 14-year-old boy presented with a 3-year history of a skin rash typical of juvenile dermatomyositis, and a 2-month history of mild proximal weakness, myalgia, and weight loss. A quadriceps biopsy showed perifascicular fibre atrophy, focal necrosis and regeneration, immunohistochemical labelling for HLA-1 on the surface of the fibres, and focal C5-9 deposition in capillaries. Macrophages with diastase-resistant, PAS-positive cytoplasm were present. Ultrastructural studies showed electron dense and membranous debris. The patient's symptoms responded to intravenous immunoglobulin and oral prednisolone. Four months after discontinuing prednisolone, the patient developed cardiac failure, ventricular tachycardia, and a recurrence of his rash. The 16S ribosomal RNA specific for Tropheryma whippelii was identified by polymerase chain reaction (PCR) analysis in skeletal and cardiac muscle. The myalgia and skin rash responded to prednisolone and oral co-trimoxazole, and the tachycardia is controlled by oral verapamil. This patient appears to have a novel association of juvenile dermatomyositis and Whipple's disease.

Neoangiogenesis and squamous cell carcinoma of the tongue

The relationship between neoangiogenesis and prognosis was investigated in 51 patients with surgically resected squamous carcinomas of the tongue. Twenty-six patients had lymph node metastases treated by radical neck dissection. Potential methodological sources of variation in vascular counts were examined. Vessels were immunolabeled for CD34, and the vessel counts (VC)--as well as the vessel counts adjusted for tumor area (VV)--were obtained in the most vascular parts of the carcinomas. Vascular hot spots were distributed throughout the carcinomas. The VC per hot spot increased with increasing size of carcinoma, and was higher in the resected carcinoma than in the diagnostic biopsy in four of eight cases. VC was not related to the growth pattern of the carcinoma or to metastasis, but patients with nodal metastases tended to have a lower VV than those with no metastases (p = 0.049). The tumor-specific survival of the whole group was 59%, and patients with nodal metastases had a shorter survival than those without metastases (p = 0.008). Cox's proportional hazards model demonstrated that carcinomas with a low VC tended to have a good prognosis (p = 0.023). The results from this relatively small series of cases support the hypothesis that some measures of neoangiogenesis are independent predictors of the spread and prognosis of lingual carcinomas. The variations in methodology among different studies currently preclude an accurate assessment of the prognostic significance of neoangiogenesis.

Muscle fibre atrophy in critically ill patients is associated with the loss of myosin filaments and the presence of lysosomal enzymes and ubiquitin

Muscle wasting and weakness are common features of patients with critical illnesses, and may impair their recovery. This study examines whether cytoskeletal and contractile proteins are damaged, and which proteolytic mechanisms might be involved, in the muscle fibre atrophy or necrosis associated with the acute myopathy of critically ill patients. Ninety-eight muscle biopsies were obtained by the conchotome method from 57 critically ill patients and examined morphometrically and by immunohistochemical labelling. Sequential biopsies showed a mean reduction in fibre cross-sectional areas of 3-4% per day. More intense immunolabelling for desmin was seen in the smaller fibres of 52% of the biopsies, while immunolabelling for dystrophin, actin and myosin heavy chains was maintained. Myosin ATPase activity was weak in the smaller fibres in some biopsies, and electron microscopy showed the loss of myosin filaments in atrophic fibres. These changes suggest that loss of the filamentous structure of myosin, without degradation of the immunolabelled epitopes, leads to the collapse of the intermyofibrillar desmin network. Fibres with abnormal desmin labelling showed increased cathepsin B, lysozyme and ubiquitin immunolabelling. Nine cases showed increased immunolabelling for heat shock protein 72. The changes in desmin immunolabelling were more prevalent in patients with higher APACHE II scores on admission, but were not related to other clinical features. The results indicate that fibre atrophy is associated with myosin filament depolymerization and the presence of several proteolytic enzymes. In our study, these changes occurred in patients who were critically ill but who did not receive large doses of steroids or neuromuscular blocking agents.

Effect of propylthiouracil-induced hypothyroidism on the onset of skeletal muscle necrosis in dystrophin-deficient mdx mice

1. Duchenne and Becker muscular dystrophies are X-linked disorders caused by defects in muscle dystrophin. The mdx mouse is an animal model for Duchenne muscular dystrophy which has a point mutation in the dystrophin gene, resulting in little (<3%) or no expression of dystrophin in muscle. Mdx mice show a characteristic pattern of muscle necrosis and regeneration. Muscles are normal until the third postnatal week when widespread necrosis commences. This is followed by muscle regeneration, with the persistence of centrally nucleated fibres. 2. This work has examined the hypothesis that the onset of this muscle necrosis is associated with postnatal maturation of the thyroid endocrine system and that pharmacological inhibition of thyroid hormone synthesis delays the onset of muscle necrosis. 3. Serum T4 and T3 concentrations of mice were found to rise immediately before the onset of muscle necrosis in the mdx mouse, and induction of hypothyroidism by treatment of animals with propylthiouracil was found to delay the onset of muscle necrosis. 4. The results provide the first demonstration of experimental delay of muscle necrosis by manipulation of the endocrine system in muscle lacking dystrophin, and provide a novel insight into the way in which a lack of dystrophin interacts with postnatal development to precipitate muscle necrosis in the mdx mouse.

Myotubular myopathy: morphological, immunohistochemical and clinical variation

Myotubular myopathy frequently presents in male infants with severe generalised muscular hypotonia and weakness associated with ventilatory insufficiency, and is diagnosed on biopsy by the presence of many fibres with central nuclei and mitochondrial aggregation. In a 6-year period, we have investigated five unrelated patients with clinical and pathological features suggesting an X-linked myotubular myopathy, including one female patient. In one male infant, a biopsy of vastus lateralis showed less than 2% centrally-nucleated fibres, while biceps brachii showed up to 15% centrally-nucleated fibres. Immunohistochemical expression of the neural cell adhesion molecule (CD56) was more intense in the biceps muscle than in vastus lateralis, while expression of desmin and vimentin was similar. Morphometric evaluation of tissue from each of the patients revealed a wide spread of values for the number of centrally-nucleated fibres per microscopic field, and variation in the extent of immunohistochemical expression of NCAM, utrophin, laminin alpha 5 chain, vimentin and HLA1 antigen. These variations in the manifestations of myotubular myopathy have not been previously described, and will need to be correlated with the increasing knowledge of the mutations in the MTM1 gene coding for myotubularin.

Mucosal melanoma of the head and neck

Two hundred and fifty-nine patients with mucosal melanoma of the head and neck were reviewed. The data of these patients were obtained from the records of the Department of Head and Neck Oncology at the University of Liverpool and from the Merseyside and Cheshire Cancer Registry. Survival curves were constructed using the life table method and differences were investigated by the Log Rank Test. Prognostic factors were further analysed by Cox's proportional hazards model. Melanomas of the nasal cavities and sinuses accounted for 69%; 22% occurred in the oral cavity and 9% in the pharynx, larynx and upper oesophagus. In 49% treatment was by wide local resection and in 8% by irradiation. Thirty-six per cent had combined modalities of treatment. Primary site recurrence occurred in 52% and 36% developed nodal recurrence. The tumour specific survival at 5 years was 45% at 10 years 28%, at 20 years 17% and closely resembled the observed survival. Young male patients tended to have a favourable prognosis as did those treated surgically. Radiotherapy on its own was ineffective. Amelanotic melanoma had a particularly poor survival. Whereas site had no effect on survival. The study confirms the poor prognosis of mucosal melanoma of the head and neck. Young patients should be offered radical surgical treatment combined with radical radiotherapy if feasible as this offers the best chance of cure.

Tumours of the minor salivary glands

One hundred and forty-five patients were identified with minor salivary gland tumours. General information and tumour-specific information on stage, grade of tumour, resection margins, recurrence and survival were collected. Data was analysed by both univariate and multivariate methods. Indices predicting tumour recurrence and survival were analysed. Forty-two benign lesions, mostly pleomorphic adenomas were identified, one recurred, all survived. One hundred and three malignant lesions were identified, mostly adenoid cystic carcinomas (70%) or mucoepidermoid carcinomas (19%). Late stage disease and the presence of neck node metastases predicted both early recurrence and high eventual mortality. Survival was favoured by the histological type (mucoepidermoid > adenoid cystic), site of primary (oral cavity and oropharynx > nose, sinuses and larynx) and good general condition. Many tumours recurred after 5 years of disease-free survival and late mortality was a feature (80% survival at 5 years, 20% at 20 years). Many patients survive some time with either local recurrence or distant metastases. Long-term follow-up is advocated as local or distant recurrence may be treatable. The value of super radical treatment of the primary is questionable given the likelihood of recurrence at distant sites.

p53 protein expression in tumours from head and neck subsites, larynx and hypopharynx, and differences in relationship to survival

The present study involves an immunohistochemical analysis of p53 protein expression in head and neck tumours located at two separate subsites, the larynx and hypopharynx. It attempts to relate differences in expression to differences in the behaviour of these tumours. Detection of the p53 protein was performed using immunohistochemistry on 32 specimens of hypopharyngeal squamous cell carcinoma and 35 specimens of laryngeal squamous cell carcinoma. p53 overexpression was found in 66% of the hypopharyngeal tumours and in 51% of the laryngeal specimens analysed. Some differences between the two tumour types were noted in the pattern staining. p53 staining in those with hypopharyngeal tumours was associated with a statistically significant increased survival. For laryngeal carcinoma the converse was true but did not reach statistical significance. Differences in the behaviour of different head and neck tumour types may be reflected in differences in expression of the p53 protein. While p53 protein expression does not appear to be a useful prognostic indicator in laryngeal carcinoma it might be a useful prognostic indicator in tumours of the hypopharynx. Moreover, it may help predict those tumours which are radioresistant, thus suggesting other modes of treatment for these tumours. Of particular importance is the molecular basis for the observed differences in survival associated with p53 expression in the two tumour sites. This is under further investigation.

Microvascular endothelial activation in the skeletal muscles of patients with multiple organ failure

The relationship between microvascular damage and the presence of muscle fibre atrophy and necrosis has been investigated in skeletal muscle biopsies taken from 57 patients with multiple organ failure. Immunohistochemical studies showed no loss of capillaries and no luminal thrombosis, while neutrophil leucocytes were more prevalent in the patients' biopsies than in controls. Deposition of the complement membrane attack complex (C5-9MAC) in capillaries was observed in 41% of cases. Endothelial activation was suggested by an increased intensity of expression of ICAM-1, and by an increased proportion of capillaries expressing P selectin and E selectin, although this was not directly associated with neutrophil accumulation. Endothelial swelling was present in many biopsies with 38% of the biopsies having larger capillary profiles on immunohistochemical labelling for von Willebrand factor (vWF), thrombomodulin and CD34, and on Ulex europaeus agglutinin 1 binding. Endothelial swelling was confirmed by image analysis and morphometric evaluation of capillary ultrastructure, however, the capillary luminal area was not reduced as the capillaries were dilated. Increased vWF labelling was associated with C5-9MAC deposition and with fibre necrosis, but the vascular changes were not related to fibre atrophy nor to clinical indices of the severity of the patients' illness. The results suggest that microvascular damage and ischaemia may not be major factors in the pathogenesis of muscle fibre damage in multiple organ failure, but that endothelial activation is a common occurrence. The variability in the patterns of markers of endothelial activation, and the small proportion of capillaries affected, may reflect the complexity of the endothelial response to circulating or locally produced cytokines.

p53 expression and p53 gene mutation in oral cancer and dysplasia

BACKGROUND

The aim of the current study was to examine the possible association of the p53 tumor suppressor gene with the development of oral cancer. We examined biopsy material from patients with oral squamous cell carcinoma for p53 protein expression and p53 mutations.

METHODS

Eighteen samples were analyzed. These comprised oral squamous cell carcinoma biopsy samples and oral dysplastic biopsy material taken from nine patients. An immunohistochemical technique was used to determine p53 protein expression. A direct sequencing technique was used to detect mutations in the p53 gene itself.

RESULTS

Overall seven of nine (77%) oral squamous cell carcinomas and seven of nine (77%) oral dysplastic lesions analyzed showed evidence of p53 protein over-expression. Mutations in exons 5 and 6 of the p53 gene were detected in five of nine (55%) oral squamous cell carcinomas and four of nine (44%) dysplastic lesions analyzed.

CONCLUSIONS

Both p53 protein over-expression and p53 mutations were noted in dysplastic oral lesions. Over-expression of the p53 protein and p53 gene mutations were not always coexistent, however, suggesting that gene mutation may be only one of the mechanisms responsible for stabilization of the p53 protein.

Adenoid cystic carcinoma of the head and neck

Adenoid cystic carcinoma has a long natural history but frequently proves fatal. The present study describes 108 patients with an adenoid cystic carcinoma of the head and neck seen over a 30-year period. Analysis of the data utilized both univariate and multivariate methods. Forty per cent of patients had tumours arising from the oral cavity and half of these were in the hard palate; 29% occurred in the major salivary glands; 41% of tumours were locally advanced at presentation and 11% had lymph node metastases at this time. The histological pattern was solid in 25%, cribriform in 40% and tubular in 20%. In addition, 15% of patients had a polymorphous low-grade adenocarcinoma and these were analysed separately. Primary site recurrence was more common in the presence of locally advanced tumours at presentation (T3-4) (P = 0.0093). Only six patients had surgery with adjuvant radiotherapy. Six patients had no curative treatment, 21 had primary radiotherapy, 39 had local excision and 42 radical excision. The actuarial primary site recurrence rate was 100% at 30 years. The neck node recurrence rate was 23% at 15 years. Tumour specific survival was 40% at 20 years. Solid histology had a worse prognosis than other histological types (P = 0.0429) but those patients with polymorphous low-grade adenocarcinomas fared very well. Patients with tumours of the hard palate fared better than those patients with tumours at other sites (P = 0.0301). Early disease at the primary site (T1-2) was a good prognostic sign (P = 0.0013). Patients with neck node metastases at presentation tended to do badly (P = 0.009).

Mandibular invasion in patients with oral and oropharyngeal squamous carcinoma

Invasion of the mandible in squamous carcinoma of the oral cavity and oropharynx has always proved a problem for head and neck oncologists. We studied 82 patients who had mandibulectomies as part of their primary surgical treatment for cancer of these sites. In 40 patients, the tumour appeared to be invading the mandible on clinical grounds and 33 patients had tumours invading the mandible when the latter was examined histopathologically. Multivariate analysis showed that tumour was more likely to be fixed to and clinically invading the mandible in the presence of cancer of the oral cavity, compared with oropharyngeal cancer (P < 0.0001). There was a high degree of correlation between clinical invasion of the mandible and histopathological invasion of the mandible (P = 0.0059). In addition, clinical invasion of the mandible correlated with radiological findings (P = 0.0284). The 5-year survival of those patients with tumour that appeared not to be invading the mandible was 53% compared with 25% for those where tumour did appear to be invading the mandible (P < 0.02). The sensitivity and specificity of clinical evidence of mandibular invasion was calculated with the final arbiter of invasion being the histopathological findings. The sensitivity of clinical examination was 91% and the specificity 80%. The positive predictive value was 75% and the negative predictive value 93%. Mandibular invasion is a poor prognostic sign in cancer of the oropharynx and oral cavity. Detection of invasion prior to operation is obviously extremely important and it appears that clinical findings are an accurate method of predicting invasion.

An immunohistochemical analysis of p53 protein expression in pre-malignant and malignant tissues of the oral cavity

This study looks at p53 protein expression in dysplastic and malignant lesions of the oral cavity using an immunohistochemical staining technique. Archival biopsy specimens of oral dysplasia of squamous cell carcinoma from 64 patients were analysed immunohistochemically. Sections from 90 oral biopsy specimens were examined in all. Positive immunohistochemical detection of the p53 protein, demonstrated by brown nuclear staining, was detectable in over 80% of mild, moderate and severe dysplastic tissues as well as carcinoma-in-situ and squamous carcinoma specimens. We concluded that p53 protein expression occurs frequently in both malignant and dysplastic lesions of the oral cavity, suggesting that abnormally detectable p53 protein is present at the very early stages of development of oral squamous carcinoma. Oral cancer may provide a good model for the study of multistage tumorigenesis in head and neck cancer as the lesions are frequently detected at the pre-invasive stage and are accessible to biopsy.

Expression of the E-cadherin-catenin cell adhesion complex in primary squamous cell carcinomas of the head and neck and their nodal metastases

Reductions in cell-cell adhesion and stromal and vascular invasion are essential steps in the progression from localized malignancy to metastatic disease. In this study, changes in the expression of the components of the E-cadherin-catenin cell adhesion complex have been investigated using immunohistochemical techniques in primary tumours and nodal metastases from 36 patients with squamous cell carcinoma of the head and neck. For 14 patients the corresponding primary and nodal metastases samples were available. None of the 51 samples showed normal E-cadherin expression when compared with either the adjacent normal squamous epithelium or with normal colonic epithelium that was used as positive control material. In 88% of primary tumours fewer than 50% of cells exhibited normal membranous E-cadherin expression. Loss of membranous E-cadherin expression was more extensive in poorly differentiated carcinomas while, in individual carcinomas, membranous E-cadherin expression was stronger in those parts of the neoplasm that expressed the differentiation marker involucrin. Expression of beta-catenin generally paralleled that of E-cadherin, but in 12 cases there was strong membranous beta-catenin expression in samples that exhibited predominantly cytoplasmic E-cadherin labelling. Expression of alpha-catenin was generally weak and did not correlate with the expression of either beta-catenin or E-cadherin. Marked intratumoral heterogeneity for protein expression was evident for all antibodies, and the abnormal expression of the catenins is a novel finding. E-cadherin is expressed more intensely in cells with greater squamous differentiation, but there was no correlation between the decreased expression of any of the adhesion molecules of the E-cadherin complex tested and local recurrence, metastasis or survival. The loss of expression of components of the E-cadherin complex is a common abnormality in squamous carcinomas and, while it may be permissive for metastasis, it does not appear to be the only determinant of this process.

Do positive resection margins after ablative surgery for head and neck cancer adversely affect prognosis? A study of 352 patients with recurrent carcinoma following radiotherapy treated by salvage surgery

It is generally accepted by surgeons that failure to eradicate malignant disease at the primary site has an adverse effect on survival. The present study investigates 352 patients with squamous carcinoma of the head and neck treated by primary radical radiotherapy and who subsequently underwent surgical ablation for a recurrent carcinoma. A total of 303 (86%) patients had a negative resection margin and 49 (14%) had a positive resection margin. Oral carcinoma was 1.7 times more likely to be associated with a positive margin than other tumours (P = 0.0292). Actuarial calculations demonstrated that 47% of patients with negative margins and 66% of patients with positive margins developed a primary site recurrence (P = 0.0286). Neck node recurrence occurred in 10% of those patients with negative margins and 12% of patients with positive margins. Patients with positive margins had a significantly poorer survival than those with negative margins (P = 0.022). Multivariate analysis failed to confirm any independent adverse effect from a positive margin. The 5 year tumour-specific survival of patients with a positive margin was poorer by 12% than for those patients with a negative margin. The pattern of failure differed between the two groups, with patients having positive margins tending to die of local recurrence.

Fasting increases the extent of muscle necrosis in the mdx mouse

1. The effects of fasting for 48 h were investigated in C57BL/10 (wild type) and age-matched C57BL/10 dystrophin-deficient (mdx) mice. 2. Fasting resulted in an increased percentage of necrotic fibres in muscles from the hindlimb and lumbar regions of mdx mice. The percentage of necrotic fibres of forelimb and chest muscles of mdx mice was unaltered by fasting. In wild-type mice, very few necrotic fibres were observed after fasting. 3. The necrotic changes in fasted mdx muscle were not accompanied by altered energy status as evaluated by muscle ATP and phosphocreatine concentrations. 4. A significantly decreased rectal temperature was observed in mdx but not in wild-type mice after fasting. 5. Fasting would normally be expected to cause a reduction in muscle fibre size. The high prevalence of necrosis in fasted mdx mice is therefore an unusual response that may be related to disturbance of the mechanisms which, in the fed state, compensate for the dystrophin deficiency in these animals.

Objective quantification of muscle and fat in human dystrophic muscle by magnetic resonance image analysis

Information about changes in muscle composition has to date been primarily restricted to histological examination of biopsy samples or qualitative assessment of images obtained using a variety of techniques (e.g., ultrasound, CT, and MRI). We describe the development of a quantitative method for the analysis of muscle composition using MR T2 relaxation time mapping and image analysis. This approach provides an objective means of studying muscle and, when used in conjunction with force production measurements, may provide an accurate measure of response to muscle therapy.

Elemental analysis of femoral bone from patients with fractured neck of femur or osteoarthrosis

The elemental composition of bone has been determined by inductively coupled atomic emission and mass spectrometry to test the hypothesis that changes in major or minor elemental concentrations may contribute to the risk of fracture. Femoral bone was obtained from patients at operation for the treatment of fracture and compared with that of patients with osteoarthrosis and a necropsy control group. The data suggest that there are no major differences in bone elemental composition in patients with fractures compared with the control group. Bone adjacent to joints with osteoarthrosis tends to be less mineralized (per unit trabecular bone volume) than control bone and bone from fracture patients, and has significantly lower concentrations of boron, lead and, zinc. These observations may reflect the more rapid turnover of bone close to the arthritic joint.

Energy and nitrogen balance and changes in midupper-arm circumference with multiple organ failure

Energy intake and energy expenditure, nitrogen intake, and urinary nitrogen excretion (or urea production rates) were measured in 35 intravenously fed patients with multiple organ failure over the course of their illness to determine to what extent nutrient requirements were met despite fluid retention. Energy and nitrogen balance were related to serial measurements of midupper-arm circumference (MAC). The target feeding regimen of 176 kJ (42 kcal)/kg fat-free mass (FFM) was achieved in only three patients and the target of 0.24 g N/kg FFM in only four. Two patterns of change in MAC were noted: a steady decrease with time and no change with time. Serial muscle biopsy data indicated that all the patients were wasting away; the maintenance of MAC in the group with no change over time was due to fluid retention. Abnormal losses were not measured, but energy and nitrogen balance in the group in which arm circumference decreased had no apparent effect on the rate of wasting.

Biphasic synovial sarcoma in the small intestinal mesentery

BACKGROUND

A 46-year-old man presented with recurrent anemia and polyarthralgia. Investigations revealed a mass in the ileal mesentery, which was resected. Results of routine histologic examination suggested a diagnosis of synovial sarcoma, a rare malignancy usually not reported at this site.

METHODS

Tissue was examined immunohistochemically, ultrastructurally, and by fluorescent in situ hybridization to confirm the diagnosis.

RESULTS

Immunohistochemical studies revealed widespread labeling for cytokeratins and focal labeling for desmin and vimentin in the epithelial component, with labeling for epithelial membrane antigen in the epithelial and spindle-cell components. Fluorescent in situ hybridization analysis showed the characteristic t(X;18) translocation of synovial sarcoma.

CONCLUSIONS

This is a unique case of synovial sarcoma in the small intestinal mesentery. Immunohistochemical labeling confirmed the diagnosis, although, to the authors' knowledge, the pattern of desmin labeling has not been described previously. The clinical association with polyarthralgia, which resolved after removal of the neoplasm, also has not been described previously.

Preserved merosin M-chain (or laminin-alpha 2) expression in skeletal muscle distinguishes Walker-Warburg syndrome from Fukuyama muscular dystrophy and merosin-deficient congenital muscular dystrophy

The merosin M-chain (or laminin-alpha 2) is one of three subunits of laminin-2 which is highly expressed in striated muscle and peripheral nerve. Complete lack of laminin-alpha 2 expression in skeletal muscle is the hallmark of one form of congenital muscular dystrophy which is characterized by dysmyelination of the central nervous system (CNS), links to chromosome 6q2 and is common among Caucasians. Laminin-alpha 2 expression was also found to be significantly reduced in Fukuyama congenital muscular dystrophy which links to chromosome 9q3. We report consistently preserved laminin-2 expression, including laminin-alpha 2, as detected by immunofluorescence in skeletal muscle from five patients with Walker-Warburg syndrome which is characterized by congenital muscular dystrophy and, in addition, type II lissencephaly or pachygyria, defective CNS myelination, and ocular dysgenesis. These findings show that in spite of partial phenotypic overlap between Fukuyama CMD and Walker-Warburg syndrome the two disorders are nosologically separate disease entities. They also exclude that Walker-Warburg syndrome is allelic to the common form of congenital muscular dystrophy with laminin-alpha 2 deficiency.

Second primary tumors in patients with head and neck squamous cell carcinoma

BACKGROUND

The concept that a patient could develop cancer twice was first put forward by Billroth. Second primary neoplasms are a particular feature of head and neck cancer.

METHODS

This study examines the records of 3436 patients with squamous cell carcinoma of the head and neck, of whom 274 subsequently developed a second neoplasm.

RESULTS

The actuarial second primary rate was 9.1% at 372 months, and median time to presentation for the second tumor was 36 months. Second tumors were more likely to occur in male patients younger than 60 years at the time of their index tumor, and who had laryngeal and oral cavity index tumors. Patients whose index tumor was small at diagnosis had a greater chance of developing a second tumor as did those with no cervical lymph node metastases to the neck. Radiotherapy to the index tumor was not associated with an increased risk of developing a second tumor. The commonest sites for second tumors were the head and neck (50%) and the lung (34%), and 86% were squamous cell carcinomas. The tumor-specific mortality for those who developed a second primary tumor was 20% after 15 years compared with 44% for patients who did not develop a second primary tumor. The 5-year survival for patients who developed a secondary tumor from the time of its diagnosis was 26%.

CONCLUSIONS

Second primary tumors in the head and neck of patients with cancer are not uncommon. If the second tumor occurs in the head and neck region, the prognosis is reasonably good.

Lymphoma presenting to a head and neck clinic

Lymphomas generally have a good prognosis compared with squamous carcinomas. The present study investigates a series of 185 lymphomas of the head and neck seen over a 30-year-period. The records of 236 patients were examined and the histology slides reviewed. The lymphomas were classified according to the working formulation method and staged using the Ann Arbor system. A total of 185 patients had a non-Hodgkin's lymphoma, of those 43 were low grade, nine intermediate and 103 high grade. The histology slides of 30 patients were not available for review. In addition, 51 patients had Hodgkin's disease. One hundred and fifty patients were stage 1 or 2 and 74 stage 3 or 4. In 12 patients insufficient data was available for staging; 152 were extranodal and 84 nodal. The 5-year survival of those patients with Hodgkin's disease was 73%. For the patients with non-Hodgkin's lymphoma the 5-year survival was 43% for low grade and 48% for high grade lesions. The survival of patients with Hodgkin's disease was significantly better than for non-Hodgkin's lymphoma (P < 0.01). The 5-year survival of patients with extranodal disease was 54% and for patients with nodal disease 65% (P = NS). Treatment was by irradiation for localized lesions and by chemotherapy or a combination for more advanced lesions. Lymphomas have a relatively good prognosis in the head and neck as elsewhere in the body and every effort should be made to provide adequate diagnosis and treatment in combined clinics.

Second primary tumors in patients with head and neck squamous cell carcinoma

BACKGROUND

The concept that a patient could develop cancer twice was first put forward by Billroth. Second primary neoplasms are a particular feature of head and neck cancer.

METHODS

This study examines the records of 3436 patients with squamous cell carcinoma of the head and neck, of whom 274 subsequently developed a second neoplasm.

RESULTS

The actuarial second primary rate was 9.1% at 372 months, and median time to presentation for the second tumor was 36 months. Second tumors were more likely to occur in male patients younger than 60 years at the time of their index tumor, and who had laryngeal and oral cavity index tumors. Patients whose index tumor was small at diagnosis had a greater chance of developing a second tumor as did those with no cervical lymph node metastases to the neck. Radiotherapy to the index tumor was not associated with an increased risk of developing a second tumor. The commonest sites for second tumors were the head and neck (50%) and the lung (34%), and 86% were squamous cell carcinomas. The tumor-specific mortality for those who developed a second primary tumor was 20% after 15 years compared with 44% for patients who did not develop a second primary tumor. The 5-year survival for patients who developed a secondary tumor from the time of its diagnosis was 26%.

CONCLUSIONS

Second primary tumors in the head and neck of patients with cancer are not uncommon. If the second tumor occurs in the head and neck region, the prognosis is reasonably good.

Characterization of revertant muscle fibers in Duchenne muscular dystrophy, using exon-specific monoclonal antibodies against dystrophin

Most Duchenne muscular dystrophy (DMD) patients have genetic deletions or point mutations in the dystrophin gene that alter the reading frame of dystrophin mRNA. This causes early termination of translation, and no dystrophin (or, less commonly, a truncated N-terminal dystrophin fragment) is produced. In many DMD patients, however, a small proportion of muscle fibers show strong dystrophin staining, and these "revertant fibers" are thought to arise by a mechanism that restores the reading frame. Exon-specific monoclonal antibodies (mAbs) have now been used to determine, for the first time, which exons are removed, in order to correct the reading frame in individual muscle fibers. Thus, 15 revertant fibers in a DMD patient with a frameshift deletion of exon 45 were shown to correct the frameshift by the additional deletion of exon 44 (or perhaps exon 46 in some fibers) from the dystrophin mRNA, but not by larger deletions. This result was consistent with reverse transcription (RT)-PCR and sequencing of a minor dystrophin mRNA with an exon 43/46 junction in this biopsy. In a DMD patient with a frameshift deletion of exons 42 and 43, however, larger deletions than the minimum necessary were used to correct the frameshift. In this patient, who produces a half-size N-terminal dystrophin fragment in all fibers, we were able to show that the revertant dystrophin replaces the truncated dystrophin in revertant-fiber sarcolemma. The results are consistent with somatic mutations in revertant-fiber nuclei, which result in removal of additional exons from dystrophin mRNA.(ABSTRACT TRUNCATED AT 250 WORDS)

Full-length and short forms of utrophin, the dystrophin-related protein

All previous studies of the localization of utrophin (the dystrophin-related protein) in muscle and other tissues have been performed only with antibodies against the C-terminal region of the protein. Since several short forms of dystrophin, the apo-dystrophins, are produced from the 3' end of the dystrophin gene, there is a possibility that similar short forms of utrophin exist and that these could be responsible for some of the many different localizations of 'utrophin' in muscle. We have produced a new panel of 15 mAbs against the N-terminal region of utrophin and we have used it together with mAbs against the C-terminal region to show that full-length utrophin is present at neuromuscular junctions, in nerves, blood vessels and capillaries in normal muscle and in the sarcolemma of patients with muscular dystrophy and dermatomyositis. However, two of the 15 mAbs also recognised rat/mouse utrophin and both of these detected an additional 62 kDa protein on Western blots of rat C6 glioma cells. This potential 62 kDa 'apo-utrophin' was not detected in human cerebral cortex, in rat Schwannoma cells nor in any of the non-nerve cells and tissues tested.

The pathology of the lower leg muscles in pure forefoot pes cavus

Enlargement of the peroneus longus muscle is a common occurrence in patients with forefoot pes cavus, and may contribute to the cavus deformity. The present study compares the morphology of up to five lower leg muscles from 17 patients with forefoot pes cavus with those of normal muscles. Eight cases had an identifiable neurogenic cause for the cavus. In four cases of hereditary motor-sensory neuropathy, the tibialis anterior showed more severe damage than the peroneus longus. In two cases of cerebral palsy, fibre atrophy and increased oxidative enzyme activity were observed. In nine clinically idiopathic cases, the histological appearances ranged from normal to generalised fibre atrophy or hypertrophy in individual muscles. There was a trend for the mean fibre area to be greater in peroneus longus than in tibialis anterior in six of the idiopathic group of patients. The muscle cross-sectional area on magnetic resonance imaging was correlated closely with the mean fibre area measured on tissue sections. In idiopathic forefoot pes cavus, fibre hypertrophy in peroneus longus (relative to tibialis anterior) may contribute to the cavus deformity. Muscle fibre hyperplasia may contribute to the peroneal muscle enlargement in Friedreich's ataxia. In none of the cases was peroneus longus enlargement due to fat or fibrous tissue replacement.

Soft tissue cervical metastases of squamous carcinoma of the head and neck

Some 497 of 3085 patients with squamous cell carcinoma of the head and neck treated between 1963 and 1990 had a later radical neck dissection at some time after initial treatment. The histological slides were all reviewed, firstly to confirm the presence of squamous cell carcinoma within the neck, and secondly to ascertain whether the metastasis was to soft tissue, to a lymph node or to both. The presence of extracapsular rupture in lymph node deposits was also assessed. Of the 497 patients, 138 had soft tissue deposits only, and 359 had nodal deposits only. Of the patients with nodal deposits 165 had extracapsular rupture and 194 did not. The 5-year survival of the 138 patients with soft tissue metastases was 27% compared with 33% for patients with extracapsular rupture and 50% for patients with no extracapsular rupture. Weighted logistic regression showed that soft tissue deposits were significantly more common in patients in poor general condition, plus poorly differentiated squamous cell carcinoma plus T4 tumours (P < 0.005), and in patients with poorly differentiated squamous cell carcinoma plus T4 tumours (P < 0.025). Cox's multivariate analysis with backward elimination showed that gender, histological differentiation, site of primary tumour and age of patient had no statistically significant effect on survival. The number of nodes (P < 0.0001), the presence of extracapsular rupture (P < 0.0001) and the presence of soft tissue free metastases (P < 0.001) were all highly significant. The N-status at recurrence also reached statistical significance (P < 0.0001).

Immunohistochemical and biochemical indicators of muscle damage in vitro: the stability of control muscle and the effects of dinitrophenol and calcium ionophore

The biochemical, histological and ultrastructural effects of 2,4-dinitrophenol and the calcium ionophore, A23187, on rat soleus muscle incubated in vitro have been examined to test the hypothesis that immunohistochemical techniques can be used to recognize early structural features of fibre damage. In control muscles, despite mild glycogen depletion and a mild reduction in protein synthetic rate in the central portion of the muscle, fibres throughout the muscle appear to be viable with normal cytoskeletal and contractile protein architecture, normal concentrations of high energy phosphates and no creatine kinase efflux. Dinitrophenol causes rapid creatine kinase efflux, extensive loss of immunolabelling for desmin and dystrophin, and abnormal myosin immunolabelling. Creatine kinase efflux and the changes in desmin and dystrophin are reduced by the exclusion of calcium. A23187 causes more gradual creatine kinase efflux associated with changes in myosin immunolabelling, but loss of desmin and dystrophin immunolabelling is restricted to a few of the most peripheral fibres. The results suggest that immunohistochemical methods can be used to reveal differences in the intracellular mechanisms of muscle damage. Although both dinitrophenol and A23187 may act, in part, through calcium-mediated processes, their effects on cytoskeletal proteins differ. Creatine kinase efflux after A23187 may not be due to gross sarcolemmal damage.

Hereditary distal myopathy with granulo-filamentous cytoplasmic inclusions containing desmin, dystrophin and vimentin

A 56-year-old female and her 34-year-old daughter presented with a predominantly distal myopathy affecting the peroneal and calf muscles, neck flexors and hand muscles. Both patients and two other daughters had cardiac arrhythmias, three requiring the insertion of cardiac pacemakers. Skeletal muscle biopsies revealed a complex myopathic process with granular degeneration, rimmed vacuoles and eosinophilic cytoplasmic inclusions. Ultrastructurally, the inclusions were composed of electron dense granular material and filaments forming linear masses beneath the sarcolemma and rounded masses within the cytoplasm of the fibres. Immunohistochemistry revealed labelling of the inclusions for desmin, dystrophin and vimentin, but not for alpha-actinin, spectrin, utrophin or myosin heavy chains. This family shows a hereditary distal myopathy with some features in common with previously-reported cases in which biopsies showed cytoplasmic inclusion bodies containing desmin. This group of diseases is clinically and pathologically heterogeneous. In the present cases, the accumulation of cytoplasmic filaments may reflect a generalised disturbance of filamentous protein metabolism rather than a specific disorder of desmin.

Expression of the 43 kDa dystrophin-associated glycoprotein in human neuromuscular disease

The expression of the 43 kDa dystrophin-associated glycoprotein (43DAG) has been studied using immunohistochemical labelling with a monoclonal antibody, MANDAG-1, and compared with immunolabelling for dystrophin and the dystrophin-related protein, utrophin, in normal muscle and in muscle from 50 patients with neuromuscular disease. 43DAG and dystrophin were expressed in vascular smooth muscle and at the sarcolemma of normal muscle fibres, with increased labelling at neuromuscular and myotendinous junctions. 43DAG expression was reduced in Duchenne and Becker dystrophies with patchy labelling, more intense around presumptive satellite cells. In Duchenne dystrophy, there was increased 43DAG expression in "revertant" fibres. In Becker dystrophy, 43DAG expression was more extensive around individual fibres, showed more interfibre variation and was more closely related to the intensity of immunolabelling for both dystrophin and utrophin than in Duchenne dystrophy. In other neuromuscular diseases, including congenital muscular dystrophy, no abnormalities of 43DAG expression were identified. The results suggest that in the absence of dystrophin, 43DAG is synthesized but is not stabilized in the sarcolemma. Stability is greater in Becker dystrophy but a normal dystrophin molecule appears to be required for the complete and stable membrane integration of 43DAG. Utrophin may confer some additional stability to the membrane integration of 43DAG but this is incomplete where dystrophin is absent or abnormal.

Occult node metastases in head and neck squamous carcinoma

The present study examined the Liverpool database in an attempt to determine what proportion of N0 necks for various head and neck primary sites harbored subclinical squamous cell carcinoma and whether empiric treatment of occult disease improved survival over and above a "wait-and-watch policy" (treatment when metastasis becomes manifest). One hundred seventeen neck dissections were carried out for N0 necks, with 32% of specimens found to contain squamous cell carcinoma. The risk of carcinoma was highest in the hypopharynx, with 50% of specimens associated with a pyriform fossa primary cancer. Twenty-nine percent of neck dissection specimens for oral cavity cancer contained carcinoma and this was commonly associated with lateral border of tongue or anterior floor of mouth carcinomas. Twenty-five percent of specimens when primary tumor was in the oropharynx contained carcinoma and were due to tonsillar carcinoma. Twenty-one percent of laryngeal cancers produced histologically positive nodes and were mostly associated with posterior epiglottic tumors. Two hundred forty-six patients had a pyriform fossa cancer and of these only 37 had N0 disease and surgical treatment. Of these, 23 patients had radical neck dissections, whereas in 14 the necks were not treated. There was no difference in survival between the two groups (chi 1(2) = 0.787, P = NS). The Liverpool database also contained 1631 previously untreated patients with no clinical evidence of neck node metastases. Of these only 107 had a neck dissection. There was no difference in survival (chi 1(2) = 2.79, P = NS).(ABSTRACT TRUNCATED AT 250 WORDS)