Microscopic histopathology of chronic refractory lateral epicondylitis

The histopathologic features from 11 patients who were treated surgically for lateral epicondylitis were graded and compared to similar tissue from 12 cadaveric specimens. All studies were done by a single pathologist who had no knowledge of the origin of the specimen. The surgical specimens were interpreted as abnormal in all 11 specimens, and all 12 of the control specimens were reported as being without histologic abnormality. Vascular proliferation was present in 10 of 11 and focal hyaline degeneration was recorded in all 11 of the surgical specimens. Neither feature was present in any of the control material (P < 0.001). These data suggest that chronic refractory lateral epicondylitis requiring surgery is a degenerative rather than inflammatory process. This may account for the lack of response to rest and antiinflammatory medication.

Phyllodes tumor: clinicopathologic review of 60 patients and flow cytometric analysis in 30 patients

We reviewed 66 phyllodes tumors of the breast from 60 patients. Our patients included 59 women and one man ranging in age from 16 to 72 years. Fifty patients presented for primary treatment of newly diagnosed breast masses, nine presented with recurrent tumors, and one presented with soft tissue metastases 9 years after bilateral subcutaneous mastectomies and multiple chest wall recurrences of phyllodes tumor. After 0.3 to 53.2 years (mean, 15.5 years) of follow-up, 26 (43.3%) patients are free of disease without recurrence, 26 (43.3%) patients are dead of other (17 patients) or unknown (nine patients) causes, four (6.7%) patients had locally recurrent tumor 0.7 to 2.9 years after lumpectomy and are free of disease 3 months to 12 years after re-excision or simple mastectomy, two (3.3%) patients are lost to follow-up, and two (3.3%) patients died with metastatic disease 1.8 and 7 years after diagnosis. Histologic features and flow cytometric analysis showed no correlation with outcome. Fifty-six breast tumors were biphasic and nine were purely stromal tumors. Twenty-six (47%) biphasic tumors showed stromal overgrowth. Tumor margins were pushing in 20 (39%) and infiltrative in 29 (61%) of 49 evaluable cases. Twenty-one tumors were highly cellular and 17 showed cytologic atypia. Necrosis was identified in 16 tumors. Mitotic rates ranged from 0/10 high-power fields to 48/10 high-power fields. Twenty-four diploid, six aneuploid, three tetraploid, and one polyploid tumor were identified by flow cytometry. S-phase fractions tended to be higher in nondiploid tumors. Neither DNA content nor S-phase fraction correlated with outcome. Our results indicate that most mammary phyllodes tumors, including purely stromal tumors, behave as low-grade, nonmetastasizing neoplasms. Neither histologic evaluation nor DNA content provides reliable clues concerning the natural history of an individual tumor.

Pattern of p53 gene mutations in breast cancers of women of the midwestern United States

BACKGROUND

Mutation in the p53 gene is the most common genetic lesion in human cancers. The pattern of mutation in the p53 gene differs among cancers and may be a useful epidemiological tool for identification of factors contributing to carcinogenesis.

PURPOSE

Our purpose was to determine if the pattern of p53 mutation in breast carcinomas in our population of women residing in the midwestern region of the United States is similar to the pattern of p53 mutation in breast cancers in patients from other regions of the United States and Europe and in other epithelial tumors.

METHODS

With a technique we recently developed for the analysis of p53 mutations in genomic DNA from tumor cell clusters in touch preparations of solid tumors, we sequenced exons 5-9 and adjacent splice junctions of the gene in 44 breast cancers. Cells from each tumor were also stained with three monoclonal antibodies which recognize different epitopes of the p53 protein.

RESULTS

We detected p53 mutations in 14 (32.6%) of 44 breast carcinomas. Only half of the mutations were missense changes. The other half included five microdeletions (three producing frame-shifts), one single-base substitution generating a stop codon, and one single-base substitution generating a splice junction abnormality. Nuclear expression of p53 antigen was present in eight of 44 cancers, including six with hemizygous missense mutations in the p53 gene.

CONCLUSIONS

The pattern of p53 mutations in our breast cancer population differs from that reported in breast cancer populations by other investigators in which most p53 mutations were missense. Among 14 mutations in our population, at least five drastically altered the structure of p53, suggesting that a recessive mechanism of inactivation of the p53 gene may be more common than in other populations.

IMPLICATIONS

Differences in the pattern of p53 mutation in breast cancers in Midwestern women and in breast cancers in other populations may reflect selection bias or small sample sizes currently available. However, our data are compatible with the possibility that an endogenous or exogenous factor influences p53 carcinogenesis in some women with breast cancer in the Midwest to a greater extent than in other regions of the United States and Europe.

DNA content flow cytometry as a prognostic factor for node-positive breast cancer. The role of multiparameter ploidy analysis and specimen sonication

The DNA content was analyzed in paraffin-embedded material from 167 patients with node-positive breast cancer to learn whether specimen sonication and multiparameter ploidy analysis (MPPA) (using DNA content and light scatter) could improve the strength of ploidy as a prognostic variable. Sonicated specimens were found to have fewer aggregates, a lower percentage of cells in S-phase (%S) and G2M phase than the corresponding nonsonicated specimens. The results using MPPA predicted the prognosis better because they allowed detection of small aneuploid peaks in histograms classified as diploid or tetraploid using DNA content alone. Ploidy was a significant univariate factor, and patients with tetraploid tumors had the best survival. In the multivariate analysis, if other routine factors were examined preferentially, ploidy and %S did not provide additional prognostic information for survival. This study of paraffin-embedded breast cancers suggested that sonication and MPPA may improve the ploidy analysis in certain cases and that tetraploidy may be a favorable ploidy pattern in this group.

Survival and management considerations in postirradiation osteosarcoma and Paget's osteosarcoma

Postirradiation and Paget's osteosarcomas are high-grade malignancies. The five-year survival was only 10% in recent experience at the author's institution. Progressive pain is an important clinical feature in both conditions. Careful roentgenographic studies demonstrate cortical destruction and a soft-tissue mass in virtually all patients. Metastasis was present in 25% of both groups of patients at presentation. In contrast to previous series, more than 80% of the patients with postirradiation osteosarcoma had had irradiation for malignant entities and more than 70% had been treated with modern radiotherapy regimens (cobalt-60 or linear accelerator). Twice as many patients with postirradiation osteosarcoma were evaluated and treated in the 1980s than in the previous decade. The initial indication for irradiation often was carcinoma of the breast, uterus, or cervix, or lymphoma. Two-thirds of the patients had progressive disease that was not controllable within six months after diagnosis. Early detection may be the only effective means of improving survival with postirradiation or Paget's osteosarcoma. These patients require lifelong follow-up evaluations.

Direct sequencing from touch preparations of human carcinomas: analysis of p53 mutations in breast carcinomas

A new technique for characterizing somatic mutations in very small samples of cellularly heterogeneous human cancer tissue was developed and tested using mutations in the p53 gene in breast carcinomas as a model system. The technique combines touch preparation of specimens to obtain homogeneous clusters of carcinoma cells free of normal cells with a nested pair of polymerase chain reaction (PCR) amplifications of DNA to increase the amount of target gene sequence sufficiently to permit direct sequencing of the p53 gene. Touch preparations of fresh or previously frozen tissue from human adenocarcinomas derived from several organs were stained, and clusters of 10-50 malignant cells were transferred by pipette into microfuge tubes for PCR amplification. Exons 5-9 of the p53 gene, which contain the major mutational hot spots associated with most human cancers, were sequenced by the following steps: 1) two rounds of PCR amplification using DNA Taq polymerase and two sets of oligonucleotide primers, the second set being nested within the segment amplified by the first set and having attached T7 and SP6 phage promoter sequences, 2) transcription of the amplified DNA sequences with T7 and SP6 RNA polymerases, and 3) dideoxy sequencing of single-stranded RNA transcripts with reverse transcriptase and with additional oligonucleotide primers to achieve specificity for this unique region of the genome. The utility of this approach is illustrated by our success in detecting and analyzing point mutations in cell clusters from four of 11 primary adenocarcinomas of the human breast.

Metabolic and neurologic effects of an intravenous medium-chain triglyceride emulsion

These studies were undertaken to investigate the relationship between medium-chain fatty acid availability, medium-chain fatty acid oxidation, and central nervous system toxicity during infusion of medium-chain triglycerides in dogs. Six dogs received a sequential, stepwise infusion of trioctanoin at three different rates for 80 min each, providing calories below and equal to resting energy expenditure in the species. Ketone body production rates (using a 14C beta-hydroxybutyrate tracer) and plasma concentrations of lactate and octanoate were monitored. Three animals were infused with saline to serve as controls. Blood-brain barrier integrity was assessed with Evans blue dye, and brain samples were taken at the end of the study to quantify brain water. Three animals were studied under anesthesia to obtain good quality EEG and intracranial pressure measurements. Results were (1) plasma octanoate increased to 0.37 +/- 0.13, 0.78 +/- 0.2, and 1.44 +/- 0.41 mmol/liter during the three infusion intervals; (2) emesis, somnolence, and coma were observed at the two highest trioctanoin rates; (3) ketone body concentrations and production increased from 102 +/- 15 to 859 +/- 54 mumol/liter and 3.6 +/- 0.43 to 18.5 +/- 1.7 mumol/kg/min, respectively, at the highest trioctanoin infusion rate; and (4) plasma lactate also increased from 1.3 +/- 0.1 to 4.3 +/- 0.9 mmol/liter at the highest infusion rate. EEG changes were also observed, consisting of high amplitude slowing and reduction in amplitude of faster components. There was no extravasation of Evans blue dye, nor change in brain water or intracranial pressure. The conclusion--medium-chain triglycerides have significant dose-related central nervous system toxicity in dogs. Therefore, caution should be exercised in clinical studies with MCTs, including careful measurement of medium-chain fatty acid concentrations.

Primary malignant bone tumors of the hand

Malignant bone tumors of the hand are rare and few centers have extensive experience in the care of patients with these lesions. Eighteen patients with 22 lesions were evaluated at our institution. There were nine chondrosarcomas, four hemangioendothelial sarcomas, two cases each of osteosarcoma and fibrosarcoma, and a single case of Ewing's tumor. The average age of the patients was 39 years. Ten lesions each were located in the metacarpals and phalanges, with two lesions in the carpus. There were nine local recurrences, which appeared at an average of 24.5 months (range, 3 to 74 months). Curettage procedures resulted in the highest rate of local recurrence (85%). Three patients died of metastatic disease. Surgical control of these lesions requires careful preoperative planning and wide surgical margins. Regular oncologic follow-up is necessary.

Lymphokine-activated killer (LAK) cell activity in tumor-infiltrating lymphocytes from non-small cell lung cancer

Tumor-infiltrating lymphocytes (TILs) are often seen in non-small cell lung cancers (NSCCs). Their functional role in the pathogenesis of lung cancer is unknown. The authors studied TILs in 27 patients with NSCC and determined the following: (1) the immunologic phenotype as defined by monoclonal antibodies against various surface markers, (2) activation state as indicated by interleukin-2 (IL-2) receptor expression and the kinetics of proliferation response to IL-2, and (3) the ability to develop lymphokine-activated killer (LAK) type cytotoxicity against both natural killer (NK)-resistant tumor cell targets (M14) and fresh autologous tumor cells. The authors' results show TILs from NSCCs to be a heterogeneous population composed of T-cells, B-cells, monocytes, and NK cells in frequencies similar to those found in peripheral blood lymphocytes (PBLs). TILs demonstrated increased IL-2 receptor expression and a more rapid proliferative response to IL-2 than PBLs, implying activation of TILs by the tumor milieu. Finally, TILs generated cytotoxicity against NK-sensitive (K562) and NK-resistant (M14) cell line targets consistently after in vitro treatment with IL-2 but were less consistent in their ability to lyse fresh autologous tumor cells and less effective than PBL LAK cells in lysing all targets. Comparison with LAK cells generated from normal volunteers suggests that decreased killing of autologous tumor cells only partially results from an inherent resistance to lysis by fresh NSCC targets. It appears, therefore, that tumor cells taken from NSCCs are not readily killed by the immune cells that infiltrate the tumor stroma and that this failure does not result from nonspecific immune deficiency in TILs.

Endoscopic gastric vagotomy: a feasibility study using laser in dogs

The aim of this study was to explore the feasibility of an endoscopic approach to gastric vagotomy using the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in dogs. Based on gross and histologic measurements, target zones for endoscopic vagotomy were defined with reference to mucosal side landmarks. Target zones containing the unbranched segments of the major intramural vagal branches were linear and symmetrically located anterior and posterior to the midline of the lesser curvature extending from the level of the esophagogastric junction to the proximal antral border. Because of minimal variability between dogs, this zone could be accessed endoscopically and reliably injured. Unfortunately, it was necessary to produce a nearly full thickness burn to interrupt the deep intramural vagal branches. Despite efforts to control dosimetry, delayed perforations occurred in three of four dogs. We conclude that endoscopic gastric vagotomy using the Nd:YAG laser is not feasible in the dog model because of difficulty controlling the depth of thermal injury. An endoscopic approach to vagotomy remains conceptually appealing because of the predictable location of and accessibility to a target zone.

Interlaboratory variability of immunohistochemical stains. Results of the cell markers survey of the College of American Pathologists

Immunohistochemical techniques have become commonplace adjunctive aids in anatomic pathology. Although much has been written describing modifications of the basic techniques, sensitivity, and specificity of reagents, little has been published regarding the interlaboratory variability in immunostain results on a given test sample. The Cell Markers Survey of the College of American Pathologists was organized to address this question of interlaboratory variability and to disseminate information on the techniques and reagents currently available.

Dedifferentiated chondrosarcoma of bone

Dedifferentiated chondrosarcoma is a highly malignant variant of chondrosarcoma. Approximately 11% of chondrosarcomas can be expected to dedifferentiate into more anaplastic lesions. Radiographic evidence of a benign-appearing cartilage lesion adjacent to a lytic, highly aggressive lesion suggests dedifferentiation. Despite radical surgical treatment, the prognosis is unfavorable, with a 5 year survival rate of 10%.

Randomized trial to evaluate the addition of tamoxifen to cyclophosphamide, 5-fluorouracil, prednisone adjuvant therapy in premenopausal women with node-positive breast cancer

A randomized clinical trial was performed to determine if the addition of hormonal therapy with tamoxifen to a combination chemotherapy regimen was superior to the chemotherapy alone for adjuvant treatment of premenopausal women after mastectomy for node-positive breast cancer. The chemotherapy regimen utilized consisted of cyclophosphamide (C), 5-fluorouracil (F), and prednisone (P), and the doses employed were: C, 150 mg/m2 IV days 1 to 5; F, 300 mg/m2 IV days 1 to 5; and P, 10 mg orally three times daily on days 1 to 7. A total of ten courses of therapy, given every 6 weeks, was planned. Tamoxifen (T) was given at a dose of 10 mg twice daily and was stopped 6 weeks after the last course of CFP. Four hundred patients are fully eligible and evaluable. With a median observation time of 5.3 years, the proportion of recurrences on each arm were: CFP, 95 of 202 (47%); CFPT, 77 of 198 (39%). The relapse-free survival distribution for CFPT was superior to that for CFP, at a borderline level of significance (two-sided P = 0.06). When significant prognostic factors were considered in covariate analysis, CFPT was not significantly better than CFP (P = 0.43). This marked change in level was due to imbalance in several factors not considered in stratification. Currently, 31% of CFP and 25% of CFPT patients have died, and although there is a slight separation of the survival curves in favor of CFPT, the difference is not significant (P = 0.21). Analysis within receptor subsets also showed no significant advantage for the addition of tamoxifen. This study does not establish a significant advantage for the concurrent administration of tamoxifen with the CFP regimen. It does, however, clearly demonstrate the importance of examination of clinically important prognostic factors, even those not utilized in stratification, and consideration of these factors in covariate analysis if imbalances are present.

Steroid receptors and giant cell tumor of bone

The cell of origin and giant cell tumor remains unknown, but on the basis of most experimental evidence it is probably a mesenchymal cell showing some macrophage characteristics. The clinical features which have led people to suggest that this tumor may be a steroid receptor positive lesion are tenuous at best. Early histochemical data suggesting a presence of estrogen and progesterone receptors in giant cell tumor have not been substantiated by further studies. Immunohistochemical techniques have not identified estrogen receptors in giant cell tumor. Multiple biochemical techniques have failed to identify clinically significant levels of estrogen or progesterone receptors in giant cell tumor.

Aneurysmal bone cyst: clinicopathologic features and treatment of ten cases involving the hand

Ten cases of aneurysmal bone cyst in the hand were identified among 208 such lesions in our institutional files. The patients (six women and four men) had a mean age of 27.3 years. Two patients had open physes. Seven lesions were in the metacarpals. Radiographic examination showed that in all cases the lesion was both expansile and completely lucent. There were no recurrences in the three patients treated by complete excision and bone grafting. Curettage and bone grafting in seven cases was associated with four recurrences. Three of these four local recurrences were treated successfully with curettage procedures. Treatment of aneurysmal bone cysts of the small bones of the hand requires either thorough exteriorization, curettage, and bone grafting or excision and bone grafting.

Randomized trial of observation versus adjuvant therapy with cyclophosphamide, fluorouracil, prednisone with or without tamoxifen following mastectomy in postmenopausal women with node-positive breast cancer

Following mastectomy for node-positive breast cancer, 261 postmenopausal women were randomized to observation or adjuvant treatment with cyclophosphamide, fluorouracil, prednisone (CFP) alone or combined with tamoxifen (T). Doses used were: C, 150 mg/m2 intravenously (IV) days 1 to 5; F, 300 mg/m2 IV days 1 to 5; P, 10 mg by mouth 3 times daily on days 1 to 7; and T, 10 mg by mouth 2 times daily. A total of ten courses of treatment, administered every 6 weeks, was planned and T was stopped 6 weeks after the last course of CFP. Two hundred thirty-four patients were fully eligible and evaluable. With a median observation time slightly in excess of 5 years, the proportion of recurrences on each arm were: CFP, 29 of 75 (39%); CFPT, 29 of 71 (41%); and observation, 50 of 88 (57%). Relapse-free survival distributions for both CFP and CFPT were superior to observation (both two-sided P = .01). Considering prognostic factors in covariate analysis revealed two-sided P = .0006 for CFP v observation and P = .0003 for CFPT v observation. No substantial difference was identified between CFP and CFPT. Survival data are not yet mature with 31% dead; and, although slight separations of the curves exist in favor of the treatment arms, no significant differences in survival have been seen. Both adjuvant therapy programs are well tolerated and there were no treatment-related deaths. Further maturation of the data is required to determine if the advantages in relapse-free survival will be translated into any overall survival benefit which must be considered the goal of primary interest.

Absence of intratubular germ cell neoplasia in testicular yolk sac tumors in children. A histochemical and immunohistochemical study

The majority of testicular germ cell tumors in adults are accompanied by neoplastic intratubular germ cells; these cells were uniformly absent in ten pure yolk sac tumors (endodermal sinus tumors) of the testicle in children studied morphologically and immunohistochemically. These differences may reflect divergent pathogenetic mechanisms that in turn may explain the tendency for different histologic types of testicular germ cell tumors to occur at different ages and the discordant biologic behavior between germ cell tumors of similar morphologic type in children and adults.

Primary leiomyosarcoma of bone

Adequate treatment of primary leiomyosarcoma of bone requires surgical ablation with the goals being those for any malignant tumor of bone--eradication of the lesion and preservation of as much function as possible. Careful preoperative staging will determine whether amputation is necessary or whether successful limb-saving resection is possible.

Prostaglandin synthesis by osteoid osteoma and osteoblastoma

Osteoid osteomas are characterized clinically by a pattern of nocturnal pain which is exquisitely sensitive to salicylates. Etiology for the pain has been ascribed by previous investigators to the presence of nonmyelinated nerve fibers or to the effect of prostaglandins. In an effort to corroborate the potential role of prostaglandins in mediating the pain associated with this tumor, we have determined the concentration of prostaglandins E2, F2 alpha, 6-keto-F1 alpha, and thromboxane B2 utilizing radioimmunoassay of extracts of homogenated tumor tissue. Results were compared with similar extracts of normal bone and a variety of other osseous tumors. The increased concentrations of prostaglandin E2 found in cases of osteoid osteoma and osteoblastoma confirm studies of explants of these tumors previously recorded in the literature.