Quantitation of borderline and malignant mucinous ovarian tumours

Morphometry and digital AgNOR analysis in cytological imprints of benign, borderline and malignant serous ovarian tumours

AIM

The aim of the study was to determine values of a quantitative morphometry analysis of nuclear characteristics and argyrophilic nucleolar organizer regions (AgNORs) in differential cytodiagnosis of benign, atypically proliferating (borderline) and malignant serous ovarian tumours.

METHODS

Cytological imprints of benign (n = 20), borderline (n = 19) and malignant (n = 20) ovarian serous tumours were analysed. A computerized, digital analysis was used to determine morphometric nuclear features, the number and characteristics of single AgNORs, cluster AgNORs, total AgNOR and AgNOR area/nucleus (relative area) ratio. According to their size AgNORs were classified in three categories. A one-way variance analysis and post hoc test (Scheffé) were used for statistical analysis.

RESULTS

The morphometric nuclear analysis showed that benign, borderline and malignant serous ovarian tumours are statistically different (P < 0.001) according to the area and outline, the values being highest in malignant tumours and lowest in the borderline group. Digital analysis of AgNORs in benign, borderline and malignant groups showed that the total AgNOR number increases with progression of the lesion (meaning tumour malignancy) significantly (P < 0.001) between benign and malignant as well as between borderline and malignant serous ovarian tumours (P < 0.001). The progression of the lesion malignancy was accompanied by a significant (P < 0.001) progressive increase of the total and relative AgNOR area per nucleus. The AgNOR size increases from benign to malignant tumours and a statistically significant difference (P < 0.001) was observed in all three groups regarding small and large AgNORs.

CONCLUSION

Combining different markers of morphometric nuclear characteristics and AgNOR values could improve differential cytodiagnosis of benign, borderline and malignant serous ovarian tumours.

Evaluation of diagnostic efficiency of computerized image analysis based quantitative nuclear parameters in papillary and follicular thyroid tumors using paraffin-embedded tissue sections

Computerized image analysis (IA) system has emerged in recent years as a very powerful tool for objective and reproducible quantification of histological features. It has shown considerable potential for diagnostic application in diverse histological situations. The objectives of the present study were to evaluate the discriminatory diagnostic efficiency of computerized image analysis based quantitative subvisual nuclear parameters in papillary and follicular neoplasms of thyroid. A total of 60 cases were studied. Forty-four cases belonged to training set and 16 cases belonged to a test set. A minimum of 100 nuclei was analyzed in each case using uniform 5 m mm thick hematoxylin stained sections. The IA workstation comprised of an Olympus microscope, a 10 bit digital video camera, an image grabber card and a pentium 120 MHz computer. Optimas 5.2 software was utilized for data collection on 8 morphometric and 8 densitometric parameters. Multivariate stepwise discriminant statistical analysis of data was done with the help of BMDP statistical software release 7.0. Results from a training set revealed correct classification rates of 98.0%, 84.5% and 61.2% for the histological groups of hyperplastic papillae versus papillae of papillary carcinoma (group I), follicular variant of papillary carcinoma versus the broad category of follicular neoplasms consisting of both follicular adenoma and follicular carcinoma (group II) and follicular adenoma versus follicular carcinoma (group III), respectively. Results of test set revealed correct classification rates of 100%, 80% and 50% for groups I, II and III respectively. It was concluded that computerized nuclear IA parameters have potential usefulness for discriminating benign versus malignant papillary lesions of thyroid, follicular variant of papillary carcinoma versus follicular adenoma and/or follicular carcinoma but are of no value in discriminating between follicular adenoma and follicular carcinoma.

The management of borderline epithelial tumors of the ovary

The histopathological diagnosis and treatment of borderline epithelial tumors of the ovary (BTO) still pose problems to both pathologists and gynecologists. BTO is a disease of younger, fertile females and generally has an excellent prognosis. A minority of patients, however, succumb to this disease. A review of the literature is given addressing aspects of epidemiology, histology, treatment and prognosis, resulting in a proposal for the management of serous and mucinous borderline tumors of the ovary.

The prognostic value of morphometry in advanced epithelial ovarian cancers

The relationship between morphometric and clinical data was assessed in a series of 60 advanced ovarian carcinomas. Morphometric parameters included nuclear area, nuclear perimeter, shortest and longest nuclear axis, roundness coefficient, volume percentage of epithelium (VPE) and mitotic index. All patients had at least 5 years of follow-up. Univariate survival analysis showed that FIGO stage (P < 0.001), VPE (P < 0.001), mean nuclear area (P < 0.001) and size of residual tumour (P < 0.001) are significantly associated with survival. When the response rate of these patients to cisplatin combination chemotherapy was evaluated, variables with good prognostic outcome were residual tumour size (P = 0.01), mean nuclear area (P = 0.0006) and s.d. of nuclear area (P = 0.0019). We conclude that morphometric parameters are able to support diagnostic and therapeutic decisions.

Absence of correlation between nuclear morphometry and survival in stage I non-small cell lung carcinoma

To evaluate the utility of nuclear morphometry as a prognostic indicator in lung cancer, 5-year follow-up information was obtained in 46 cases of surgically resected Stage I non-small cell lung cancer (NSCLC). Nuclear area, perimeter, major diameter, minor diameter, and nuclear shape factor were determined from representative histologic sections of the tumors with a computer-assisted digitizing system. The morphometric parameters were compared between patients with favorable outcome (Group I: alive with no evidence of disease, n = 17) and those with poor outcome (Group II: dead of disease or with recurrence of disease, n = 29). No significant differences in any of the morphometric parameters were found between tumors in Groups I and II for individual tumor cell types or the combined cases. Failure to demonstrate a correlation between morphometric parameters and prognosis in Stage I NSCLC indicates that future efforts to determine objective prognostic factors should concentrate on other variables, such as specific genetic abnormalities.

Nuclear morphometry in prognosis of renal adenocarcinoma

Nuclear morphometry was carried out on 95 parenchymatous adenocarcinomas of the kidney treated by radical nephrectomy and hilar lymphadenectomy and followed up for at least five years. The study assessed nuclear area, nuclear perimeter, major diameter, nucleolar area, nuclear shape factor, and nuclear size. There was a significant statistical correlation between survival and the morphometric parameters and between the parameters themselves except for nuclear shape factor. The multiple regression proved that nuclear area is the factor which shows the greatest statistical significance for prognosis. Taking a mean nuclear area of 35 microns 2 allowed two prognostic groups to be established regardless of stage, with those below the threshold having a good prognosis and those above it having a poor prognosis: 96.7 percent of patients with a good prognosis survived after five years (60 months) compared with 17.2 percent of those with a poor prognosis.

A combination of cytological and architectural morphometry in assessing regenerative hyperplasia and dysplasia in ulcerative colitis

Morphometry and stereology were used to assess the cytological and architectural characteristics of regenerative and dysplastic colorectal mucosal abnormalities in ulcerative colitis. Reproducibility of measurements was assessed and found to be good, confirming the objective and reproducible nature of morphometric analysis. Discriminant analysis between the morphometric features of regenerative mucosal change and low-grade dysplasia revealed the significant cytological and architectural variables from which a cytological and architectural score were derived. The architectural score was capable of classifying all of the cases into their correct diagnostic category, although a combination of the two scores provided better separation of cases. Probability density analysis was carried out so that probabilities of group membership could be allocated to cases, given their cytological and architectural scores. Discriminant analysis was also applied to low- and high-grade dysplasia. Important cytological and architectural variables were identified and used separately to derive scoring systems. In combination, the dual scoring of lesions was capable of separating low- from high-grade dysplasia, although overlap was still evident. Again, probability density analysis allowed the allocation of cases into one or other category, although a closer examination showed that such a rule could not successfully classify a new set of low- and high-grade dysplasia cases. Quantitative histological analysis of mucosal abnormalities is shown to be of use in the objective diagnosis of reactive and dysplastic change in patients with ulcerative colitis. The use of simple scoring systems and probability based allocation of cases promotes the future role of morphometric techniques in the diagnostic laboratory.

Morphometric analysis, ploidy and response to chemotherapy in squamous carcinomas of the head and neck

The histopathology of 54 squamous carcinomas of the head and neck was evaluated by qualitative grading and morphometry in order to identify those features which predicted a good response to cisplatinum chemotherapy. The histopathology of 66 cases was correlated with tumour ploidy, determined by flow cytometry of paraffin-embedded material, since a separate study has shown that aneuploid carcinomas respond better to chemotherapy. The degree of differentiation was a poor predictor of ploidy, although diploid carcinomas did show more keratin and less nuclear pleomorphism than aneuploid carcinomas. The prominence of nucleoli in tumour cells and the surface area to volume (s/v) ratio of the tumour islands were the variables most strongly correlated with ploidy, with diploid carcinomas having prominent nucleoli and a low s/v ratio. A good response to chemotherapy was related partly to the architecture of the carcinoma (pushing border and low s/v ratio), and partly to the tumour cells (well differentiated) and the percentage of necrotic tumour. A lack of inflammatory reaction or desmoplasia was associated with a poor response. The results indicate that both subjective and objective histopathological criteria may be used to predict ploidy and the response to cisplatinum chemotherapy of squamous carcinoma of the head and neck. A combination of s/v ratio and the percentage of necrotic tumour can be used to identify a group of patients with a relatively good survival.

Quantitative nuclear morphology in the diagnosis of ovarian tumors of low malignant potential (borderline)

Ovarian tumors of low malignant potential or of borderline malignancy are characterized histologically by the association of malignant type of epithelial proliferation with a noninvasive pattern of growth. Because epithelial proliferation relates to features of nuclear morphology and chromatin structure and because of the difficulties to distinguish nuclear atypism seen in borderline malignancy from that in frankly invasive tumors by usual microscopic study, the authors concentrated their studies exclusively on computerized analysis of cell nuclei images. Using specially developed methods of analysis the authors described geometrical, optical, and structural differences among the epithelial and stromal cell nuclei of benign, borderline, and malignant ovarian tumors. The structural differences concern the pattern of chromatin condensation and suggest that the cytokinetic properties of the borderline tumors are intermediate to those of benign and malignant. The results demonstrate that the quantitative evaluations provide objective and reproducible data useful in the differential diagnostic of the borderline malignancy.

Prognosis of ovarian carcinomas: prediction by histoquantitative methods

Prediction of prognosis of ovarian carcinomas by morphometric, histopathological and clinical indices was estimated in 105 tumours. Morphometric parameters included mitotic activity index, volume-corrected mitotic index (M/V index), volume fraction of neoplastic epithelium, nuclear area, nuclear perimeter, shortest and longest nuclear axis and form factor of nucleus. Cox's multivariate regression model showed that the clinical stage was the best predictor of prognosis followed by the M/V index, which expresses the mitotic activity as the number of mitotic figures per square millimeter of neoplastic epithelium in the microscope field. In all tumour subgroups studied the M/V index was the best prognostic factor and for stage I tumours it was the only parameter selected by the Cox's model as a significant and independent prognostic predictor. We conclude that the M/V index can be used as a significant prognostic factor in ovarian carcinomas.

The role of morphometry in predicting prognosis in pancreatic islet cell tumors

Morphometry of 31 pancreatic islet cell tumors was examined to determine the value of this technique in assessing tumor behavior. Patients were followed for a mean period of 5.1 years (range, 1 month-14 years) after diagnosis. Initially 17 localized and nine metastatic tumors were studied. Discriminant analysis was carried out on these cases and identified nuclear/cytoplasmic ratio and number of nuclei/mm2 as the significant discriminatory features. These were combined to derive a classification rule which was capable of correctly identifying localized and metastatic tumors in 92% of cases. The classification rule was applied subsequently to an additional five test cases, all of which were classified successfully. The failure of increased nuclear size and pleomorphism to correlate with malignancy in these tumors was confirmed. Tumors which metastasized had significantly greater gross diameters than localized lesions, but overlap existed. Mitotic counts were not a helpful discriminatory feature. Morphometry may be useful in improving histologic assessment of pancreatic islet cell tumor behavior.

A morphometric assessment of transitional mucosa in the colon

Quantitative morphometric analysis was used in 10 resection specimens to assess so-called transitional mucosa immediately adjacent to colorectal carcinoma. Eleven nuclear and cellular variables were measured from the malignant epithelial area and from zones of increasing distance (1 cm) from the lesion. In addition, mean mucosal height was assessed for each zone. Morphometrical differences between the mucosa immediately adjacent to the malignant epithelium and that taken at some distance from it were determined by Mann-Whitney U tests. Transitional mucosa showed increased mucosal height but no nuclear differences from normal mucosa. Other work has shown that there are nuclear morphometric differences associated with premalignant conditions in the colon. Thus, the suggestion that transitional mucosa represents early neoplastic change cannot be supported.

Architectural morphometry in ulcerative colitis with dysplasia

Semi-automatic image analysis was used to assess the architectural features of normal colorectal mucosa and ulcerative colitis with and without dysplasia. Eight measured and derived morphometric variables were compared with the histological grading. The main data-set variation was due to: (1) the area of mucosa and epithelium per unit length of muscularis mucosae; (2) mean mucosal and epithelial height; and (3) the percentage epithelium and number of crypts per unit length of muscularis mucosae. Discriminant analysis using the variables mean epithelial height and mean lamina propria area per unit length of muscularis mucosae separated normals (n = 10) from high-grade dysplasia (8). The classification rule allocated low-grade dysplasia (8) to the high-grade category and 60% of regeneration cases (10) to the normal mucosa group. Scatter plots of the two discriminating variables separated normal and regenerative mucosa from dysplasia. Histological review of overlapping cases allowed redesignation of a high-grade dysplasia lesion as low grade. Architectural morphometry may be of use in assessing premalignant mucosal changes in ulcerative colitis as a guide to patient surveillance and therapy.

The prognostic value of morphometrical features and cellular DNA content in cis-platin treated late ovarian cancer patients

In 73 CAP-1 treated stage III and IV ovarian cancers, the prognostic significance of morphometric features and cellular DNA content has been evaluated in comparison with histologic type, grade of differentiation and a number of clinical characteristics. Borderline tumours were excluded from the study. Median follow-up was 44 months, median survival time 36 months. Single features associated with prognosis were (in order of decreasing significance according to single variate analysis): FIGO stage (P = 0.0002), bulky disease (P = 0.004), standard deviation and mean of nuclear area (P = 0.0006 and P = 0.01), cellular DNA content (P = 0.01), mitotic activity index (P = 0.08) and volume percentage epithelium (P = 0.13, not quite significant). Tumours with a mean nuclear area greater than 70 micron2 (which occurred in 35% of the cases) were nearly all aneuploid. Multivariate analysis showed that the statistically most significant prognostic combination of features consisted of mean nuclear area, presence or absence of bulky disease and FIGO stage (in order of decreasing importance) (Mantel-Cox = 23.07, P less than 0.00001). A low value for the multivariate function of this combination of features was associated with a poor prognosis within 24 months, a high value with a favourable outcome. Another favourable combination of features appeared to be diploid cellular DNA content and a low mitotic activity index (11 patients, one died). However, even with the prognostically most favourable combination of these features, several patients died. Of all combinations of features investigated, only two were associated with an excellent prognosis (low mitotic activity index and low volume percentage epithelium). Cancers of 7 patients (10%) displayed such features, and none of them died during the follow-up period (minimally 20 and maximally 54 months). It is concluded that morphometric and flow cytometric analysis can provide significant and objective information to predict the prognosis of cis-platin-treated advanced ovarian cancer patients.

DNA flow cytometry and morphometry as prognostic indicators in advanced ovarian cancer: a step forward in predicting the clinical outcome

In 74 patients with advanced ovarian cancer, the value of DNA flow cytometry and morphometry was evaluated and compared with histological grading and clinical outcome. By means of both DNA flow cytometry and morphometry a clear distinction was found between a favorable group of 15 patients, with a median survival of more than 60 months, and the remaining patients, of whom the majority died during the same follow-up period. The levels of significance for DNA flow cytometry (P = 0.0002) and morphometry (P = 0.0001) with respect to survival of the favorable and unfavorable groups of patients were higher than for histological grading (P = 0.02). In a multivariate analysis it was demonstrated that morphometry proved to be the factor of most relevance for survival, although the effect of DNA flow cytometry was almost as good. Data such as presence of ascites, the size of the residual tumor mass, choice of chemotherapy, FIGO stage, and histological grade were not of additional prognostic relevance in this analysis. It is concluded that both morphometry and DNA flow cytometry are a step forward in identifying favorable and unfavorable groups of patients with advanced ovarian cancer. For the daily practice of management of ovarian cancer patients, morphometry may be an attractive support of visual grading.

Prognostic factors in borderline and invasive ovarian tumors of the common epithelial type

Present reports show that surgical factors, response to therapy and histological criteria are important for predicting the prognosis of patients with common epithelial types of ovarian tumors. Newer techniques such as morphometry, DNA cytometry, immunological and immunopathological techniques may help to define prognostic factors even more accurately. As a result, these recently developed methods may enhance the value of well-established classical predictors of the outcome in case of borderline or invasive ovarian tumour.

The significance of nuclear diameter in the biologic behavior of thyroid carcinomas: a retrospective study of 127 cases

The relationship between nuclear diameter and biologic behavior was studied in 127 cases of thyroid carcinoma. Using a sonic digitizer coupled to a minicomputer, nuclear diameters of 200 randomly selected cancer cells from each case (hematoxylineosin-stained paraffin sections) projected at X 400 magnification were traced and averaged. A total of 25,400 measurements were made. The nuclear diameters varied from 4.7 to 13.1 micron. By analysis of variance, the nuclear diameters were significantly different (p = 0.0007) among the four types of thyroid cancers, being largest in the undifferentiated cancers (8.7 +/- 0.8 micron) and smallest in the medullary cancers (6.6 +/- 0.1 micron). Nuclear diameter was also significantly correlated with degree of tumor differentiation (p = 0.002), maximal tumor diameter (p = 0.03), mitotic rate (p = 0.002), and 5-year survival (p less than 0.05) for all types of tumors. The correlation between nuclear diameter and disease stage was significant only for undifferentiated cancers (p = 0.04). No significant correlations were seen between nuclear diameter and duration of disease, sex, or age of the patient.

Observer variability in microcomputer-assisted morphometric study of nuclear parameters

To evaluate observer variability during microcomputer-assisted planimetry, nuclear features (area, perimeter, and form factor) were studied in a case of malignant lymphoma. Tissue fixed in glutaraldehyde, embedded in plastic and sectioned at 1 micron was studied using a Zeiss Kontron IBAS 2000 image analysis system. Manual tracing of nuclear outline was performed to obtain the parameters. Both interindividual and intraindividual reproducibilities were evaluated, the former among 8 observers and the latter by the observers repeating the measurements. With the present technique, intraindividual reproducibility was high and correlation was excellent for area, perimeter and form factor measurements. A high degree of interindividual inconsistency was demonstrated for all parameters. Interindividual correlation was poor for form factor. It is concluded that poor interindividual reproducibility even when the objective method of morphometry is used may be a significant problem in tissue investigations, especially when results from different laboratories are being compared.

Classification of normal colorectal mucosa and adenocarcinoma by morphometry

Semi-automatic image analysis was used to make a morphometrical assessment of 15 nuclear and cellular variables in normal (n = 20) and malignant (n = 30) colorectal epithelium. Principal components analysis on the matrix of correlations between variables identified four main sources of variation within the dataset. These were, in decreasing order of importance: (1) nuclear size, nuclear cytoplasmic ratio and nuclear position within the cell; (2) the variability of nuclear size; (3) nuclear elongation and polarity; (4) nuclear shape and its variation. Discriminant analysis was conducted between histologically normal mucosa (n = 10) and adenocarcinoma in ulcerative colitis (n = 20). Using stepwise variable selection, the mean nuclear cytoplasmic ratio (normal, mean 20.4 (s.d. +/- 2.0); tumour, mean 39.7 (s.d. +/- 7.0)) and the coefficient of variation of nucleus to cell apex distance (normal, mean 19.2 (s.d. +/- 7.5); tumour, mean 47.8 (s.d. +/- 9.1)) were chosen as discriminating features. They were used to derive a discriminant function which gave perfect discrimination between the two groups. Scatter plots of these two variables confirmed complete separation of normal mucosa from adenocarcinoma and provided a simple method of applying the discriminant function. Discriminatory performance did not deteriorate when the function was applied to further normals (n = 10) and adenocarcinoma (n = 10). This study highlights the descriptive differences between normal and malignant colorectal epithelium and shows that case allocation may be made to these two lesion categories using a morphometrically-derived classification rule.

Morphometrical analysis in ulcerative colitis with dysplasia and carcinoma

Semi-automatic image analysis was used to assess the epithelium in ulcerative colitis with dysplasia and carcinoma. There were three main sources of variation within the dataset: (1) nuclear size, nuclear cytoplasmic ratio and nuclear stratification; (2) the variation of nuclear size; and (3) nuclear shape and polarity. Discriminant analysis chose the mean nuclear cytoplasmic ratio % and the coefficient of variation of nucleus to cell apex distance to derive a scoring system which completely separated normal mucosa (n = 20) and carcinoma (n = 30). The classification rule allocated all high grade dysplasia to the tumour category. Scores for regeneration and low grade dysplasia overlapped with each other and the normal and tumour groups. Scatter plots of the two discriminating variables showed good separation of regeneration and high grade dysplasia, and a degree of overlap with low grade dysplasia. The scatter plots allowed identification of overlapping and misallocated cases, requiring review of their histology and redesignation of the diagnosis in five cases. This study confirms quantitatively the visual criteria used in grading mucosal changes and their trend from regeneration through dysplasia to carcinoma. It underlines the necessity of assessing not only cytological but also architectural and inflammatory components when diagnosing regeneration and low grade dysplasia. Mucosal morphometry may be of use in confirming high grade dysplasia which is an indication for colectomy.

Quantification of epithelial volume by image processing applied to ovarian tumors

This paper describes an image analysis technique for automated estimation of the percentages of epithelium and stroma in (tumor) tissue. The program is evaluated on ovarian tumors of the serous, mucinous, and endometrioid type. From standard paraffin sections, stained with pararosanilin Feulgen and naphthol yellow, a blue-yellow image pair was recorded. The blue image was used for the determination of the total tissue area and the yellow image for the epithelial area. For the latter the image processing method is based on the fact that epithelial nuclei are generally more tightly packed than stromal nuclei. A structural approach was applied, in which the segmentation of the nuclei was based on the image contrast range in the density domain. The method has been tested with 78 image pairs from 19 ovarian tumors with varying degrees of malignancy. The area percentages, as assessed with image processing, were strongly correlated to control percentages, established by interactive morphometry (r = 0.98).

Computerized interactive morphometry in pathology: current instrumentation and methods

This review is concerned with the current applications of interactive computerized morphometry for diagnostic applications. "Interactive" differs from fully automatic procedures in that the essential function of cell recognition is performed by a trained observer, assisted by a computerized instrument that performs all desirable measurement and processing tasks. This article describes the instrumental needs (video systems, computer, and specialized hardware) and interactive peripherals, in particular, high-resolution touch screens for most common and currently useful video analysis tasks. The authors describe a number of general instrumental procedures with widespread applications (point counting, tracing of contours, graphic standards of size and length, shape analysis, automatic edge detection). Diagnostic procedures are based on the generation of multiple data followed by either multivariate statistical analysis that allows diagnosis of individual cases or hierarchical algorithms. The best current application is the objective study of controversial or difficult cases; there is a possibility that in the future interactive computerized morphometry may become useful for the mass screening of cytologic specimens.

Morphometric data to FIGO stage and histological type and grade for prognosis of ovarian tumours

The prognostic value of using histological typing, grading, and morphology, in addition to clinical staging, was assessed in 98 cases of invasive ovarian cancer of the common epithelial types (serous, mucinous, and endometrial). All of these cases had at least five years of follow up. When regression analysis was used, the International Federation of Gynaecology and Obstetrics' (FIGO) staging system was the best indicator for prognosis. Analysis of a combination of morphometric features was the second best indicator, being especially useful for the those patients with stage I disease. Variables that indicated a relatively poor prognostic outcome were mitotic index above 30; volume percentage epithelium above 65%; shortest nuclear axis above a mean of 1 X 1 micrometers. Histological typing of ovarian tumours was of limited value; mucinous tumours have a somewhat better prognosis than serous tumours, but the prognostic value of typing alone was found to be limited. Qualitative histological grading was useful, but the prognostic value of morphometric grading was better. Measurement of morphological features with an interactive computer program is simple and can be done by a pathologist or a technician: in future it is likely that such automated systems of measurement will improve the objectivity of tissue analysis.

Ovarian epithelial tumors of borderline malignancy. A clinical and pathologic study of 109 cases

One hundred nine cases of ovarian tumors of low malignant potential (borderline tumors) diagnosed at Stanford University Medical Center from 1958 to 1982 were reviewed. The patients ranged in age from 10 to 79 years (mean, 40.5 years). The histologic types and corresponding stages of these neoplasms were 73 serous (Stage IA: 35 patients; Stage IB+C: 16 patients; stage II: 8 patients; Stage III: 14 patients), 30 mucinous (Stage IA: 27 patients; Stage IB+C: 3 patients), and 6 mixed seromucinous (all Stage IA). Borderline endometrioid, clear cell, and Brenner tumors were excluded. Follow-up information from 3 to 27 years from the time of initial diagnosis (mean, 7.6 years; median, 7.1 years) revealed that 89 patients are alive without further evidence of neoplasm, and three patients died of unrelated disease without recurrent tumor. Seventeen patients have developed persistent or recurrent neoplasms in the contralateral ovary (six patients) and/or elsewhere within the peritoneal cavity (15 patients) at 5 to 226 months (mean, 61 months) after the initial excision. All of the second neoplasms were borderline serous or seromucinous tumors histologically identical to the original tumor; none of the borderline mucinous tumors recurred. Patients who initially had Stage III borderline serous tumors developed persistent or recurrent neoplasms more commonly (64%) than did patients with lower stage tumors (12%). No correlation was found between the development of a subsequent serous neoplasm and patient age, the primary tumor size, or any single histologic feature. Following treatment of the subsequent neoplasms, 13 patients are free of neoplasm, one patient is alive with tumor, one patient has died of intercurrent disease with tumor, and two patients have died with widespread abdominal tumor 53 and 232 months after their initial diagnosis. These findings confirm the excellent prognosis for patients with borderline serous tumors, despite involvement of the peritoneal cavity and the development of recrudescent tumor, although long-term follow-up is indicated. Mucinous borderline tumors, as defined by published criteria, almost invariably present as localized (low-stage) tumors and, in our experience, do not recur when confined to the ovary.

Morphometric grading of squamous cell carcinoma

Histological grading of squamous cell carcinoma is subjective and suffers from poor observer reproducibility. We investigated the feasibility of quantifying histological differentiation via point counting, using both the degree of keratinization and a novel definition of differentiation that was based on architectural features of the tumour. Multiple recounts of 20 cases of human oral squamous cell carcinoma were performed at several magnifications (X100, X160 and X250). Six lines of human squamous cell carcinoma tumour lines were examined for changes in differentiation following transplantation to athymic nude mice. Observer reproducibility was extremely high for all recounts except at the highest magnification, where the tumour architecture may have been obscured. Of the human squamous cell carcinomas transplanted to nude mice, five of six tumour lines showed significant histological changes, most commonly toward decreased differentiation. The changes were usually present in the initial transplant and were similar to those we have reported for transplants of adenocarcinomas. We conclude that histological differentiation can be quantified in squamous cell carcinomas with a high degree of observer reproducibility, even in the absence of keratinization; the method employed is sufficiently sensitive to be applied to practical problems of biological significance.

Mucosubstances in classification of serous and mucinous ovarian tumors: a morphometrical study

108 serous and 106 mucinous ovarian cystadenomas of varying malignancy were studied with the saliva-periodic acid-Schiff (SPAS) reaction and with the Alcian blue (AB) pH 2.7 method, which stain neutral and acid mucosubstances, respectively. Positively stained mucin was quantitated morphometrically and the measured parameters were tested by discriminant analysis. As expected, the mucinous tumors were more positive for mucin than the serous ones. Also the borderline tumors contained more mucin than their benign or malignant counterparts. The best discriminating capacity for mucin was obtained in serous tumors with the AB stain and in mucinous tumors with the SPAS reaction. The ratio of neutral to acid mucosubstances decreased in mucinous cystadenomas with increasing malignancy.

The outlook for women with borderline epithelial tumours of the ovary

Seventy-two women with borderline epithelial tumours of the ovary have been followed up for between 3 and 9 years. Patients with disease confined to one or both ovaries had a good prognosis, irrespective of histological type. When extra-ovarian spread was present at the time of diagnosis, neither the histological type nor the amount of residual tumour predicted the long-term outcome in individual patients.

The value of morphometry to classic prognosticators in breast cancer

In 271 breast cancer patients with adequate follow-up for at least 5.5 and maximally 12 years, the value of morphometry to classic prognosticators of breast cancer (tumor size and axillary lymph node status) was assessed. Previous studies had indicated the value of this quantitative microscopic technique. Apart from quantitative microscopic features, subjective qualitative features such as nuclear and histologic grade were assessed as well. Univariate life-table analysis showed the significance (p less than 0.001) of several features such as lymph node status, tumor size, nuclear and histologic grade, and several morphometric variables (mitotic activity index, mean and standard deviation of nuclear area). Cellularity index was also significant (p = 0.02). Survival analysis with Cox's regression model, using a stepwise selection as well as backwards elimination, pointed to three features: mitotic activity index, tumor size, and lymph node status. Mitotic activity was the most important prognostic feature, but the combination of these three features in a multivariate prognostic index had even more prognostic significance. Kaplan-Meier curves showed that the 5-year survival of lymph node-negative patients (n = 146) is 85%, versus 93% in patients with a "good prognosis index" (n = 150). For lymph node-positive patients (n = 125), 5-year survival was 55%, compared with 47% in the "high index" (poor prognosis) patients (n = 121). Logistic discriminant analysis with 5.5-year follow-up as a fixed endpoint (191 survivors and 80 nonsurvivors) essentially gave the same results. Application of two instead of one decision threshold (e.g., numerical classification probability 0.60 and 0.40) decrease the number of false-negative and false-positive outcomes, however, with a number of patients falling in the class "uncertain." Thus, in agreement with other studies, morphometry significantly adds to the prognosis prediction of lymph node status and tumor size. Mitotic activity index is the best single predictor of the prognosis. An additional index advantage is that the multivariate model results in a continuous index variable that can be subdivided in many classes with an increasing risk of recurrence, so that more refined clinical therapeutic decision making is possible in individual patient care. The morphometric techniques are inexpensive and fairly simple and therefore can be applied in most pathology laboratories.

The reproducibility of a quantitative grading system of bladder tumours

In order to test the reproducibility of a histomorphometrical grading system of bladder tumours, 15 tumours were twice measured independently by three pathologists. The data obtained were then analysed and compared with that of histological grading only. The way in which these morphometrical results are presented to the clinician in a computerized report is described. The need for a satisfactory reliable reproducibility test of every histomorphometrical grading system before introduction in diagnostic pathology is discussed.

Mucinous tumors of the ovary. A clinicopathologic study of 70 cases

Seventy cases of mucinous ovarian tumor were reviewed. All patients were followed for a minimum of 5 years. Clinicopathologically, three groups were defined: (1) mucinous cystadenoma, which demonstrated no nuclear stratification and no stromal invasion (15 cases); (2) mucinous tumor of uncertain malignant potential, which was characterized by nuclear stratification of two to three layers and no stromal invasion (21 cases); and (3) mucinous carcinoma, which showed stromal invasion and/or nuclear stratification in excess of three layers (34 cases; 15 with invasion, 19 without). All patients with mucinous cystadenomas remained tumor-free after initial surgery. Two patients with mucinous tumors of uncertain malignant potential died of tumor at 55 and 72 months, respectively, whereas 18 with mucinous carcinomas died after intervals ranging from 2 to 71 months. All mucinous tumors of uncertain malignant potential were Stage I at presentation. Twenty-one mucinous carcinomas were Stage I (six tumor deaths), one was Stage II (tumor death), ten were Stage III (nine tumor deaths), one was Stage IV (tumor death), and one was of uncertain stage (tumor death). Patients with mucinous carcinomas having stromal invasion demonstrated poorer survival (10 of 15 dead) than those with mucinous carcinomas lacking this finding (8 of 19 dead); however, stromal invasion was related to higher stage (5 with invasion Stage I; 16 without invasion Stage I).

Observer reproducibility during computer-assisted planimetric measurements of nuclear features

To evaluate observer variance during microprocessor-assisted planimetry, nuclear features (area, perimeter, and form factor) were studied in a series of mammary ductal carcinomas. Fragments of formalin-fixed, paraffin-embedded tissue were re-embedded in plastic, sectioned at 1 micron, stained with methylene blue, and studied with a Zeiss-Kontron MOP-3 microprocessor-assisted planimeter. Both interobserver and intraobserver reproducibility were evaluated, the former among three different observers and the latter by two observers repeating their own measurements. Reproducibility was good for measurement of area, but deteriorated progressively for measurement of perimeter and form factor. Not only was observer correlation poor (identified via linear regression), but paired t-tests also showed consistent variation among observers. The major difficulty was in following the irregular nuclear contours that are characteristic of cancer cells. It is concluded that adequate demonstration of observer reproducibility remains an essential part of tissue investigation, even when the objective methods typical of morphometry are used.

Quantitative morphology. A study of the trophoblast

It is difficult to predict the possible development of a malignant trophoblastic tumor after the evacuation of a hydatidiform mole. In order to help resolve this difficulty, a morphometric study has been carried out. The mean nuclear area of the trophoblast in a group of hydatidiform moles, followed by a trophoblastic malignancy, was found to be statistically significantly larger than that of the trophoblast in a group of hydatidiform moles which were not followed by malignant trophoblastic disease. However, the mean trophoblast/nontrophoblast ratio in villi demonstrated no statistically significant difference between those 2 groups of hydatidiform moles. Therefore it is not advisable to grade hydatidiform moles on the basis of trophoblastic proliferation alone. It is suggested that the trophoblastic lining of hydropic villi in the placental tissue of hydatidiform moles has malignant features already, but these are more pronounced in those hydatidiform moles which are subsequently followed by a choriocarcinoma.

Borderline or malignant ovarian tumour? A case report of decision making with morphometry

A young woman presented with bilateral ovarian tumours. Multiple sections of each tumour were shown to many pathologists for consultation; some considered the tumours to be borderline, whereas others thought that one or both of them was malignant. Morphometry showed that the numerical classification probabilities for borderline tumour were 0.78 for the left ovarian tumour and 0.85 in the right. The lesions were therefore regarded as borderline tumours and no additional chemotherapy was given. Three years after the second operation the patient is alive and well without clinical or biochemical evidence of recurrence. Most patients with borderline tumours who die from the disease do so in the first two years after the operation. This young patient was prevented from severe overtreatment by the application of morphometry, illustrating its use in this area of diagnostic gynaecopathology.

In search for the best qualitative microscopical or morphometrical predictor of oestrogen receptor in breast cancer

The correlation between oestrogen receptor (OR), qualitative and quantitative microscopical features has been studied in 198 breast cancers, 60 patients were younger than 50 years of age, 138 were older than 50. This age distinction was made because of the obvious age dependency of the OR-content, with 50 years as the cut-off point. Compared with elastosis grade, the morphometric features have a much lower percentage of doubtful cases (22.2 vs. 40.4%) with a higher percentage overall correct classifications (55.6 vs. 45.4%). In terms of sensitivity and specificity, selection of the best single predictor depends on the age of the patient. Mean nuclear area has the highest combination of sensitivity and specificity (88.9 and 80.0%) in woman younger than 51, while elastosis grade is the best single predictor in patients older than 50 (sensitivity: 91.2%; specificity: 70.6%). Using multivariate analysis, a combination of mean and standard deviation of the nuclear area results in 83.3% correct classifications with only 5% doubtfuls in the younger age group. With more features in the analysis, no false negatives and only 13.3% false positives is the most optimal result. In the older age group, a decision tree consisting of elastosis grade and mean nuclear area gives the best results. Subsequent investigation of mean nuclear area in elastosis grade 0 cancers gives a considerable reduction of the false negatives, thus increasing the specificity to 94.6% and the correct negative predictions to 72.7%. It is concluded that selective morphometry gives a considerable enhancement of the histopathological prediction capacities of oestrogen receptor in breast cancer.

Prognostic indicators in breast cancer--morphometric methods

Morphometric methods were applied to predict the clinical course of individual patients with breast cancer. Measurement of tumour diameter, assessment of mitotic and cellular indices, and quantitative microscopy of nuclear features were assessed together with nuclear features and histological grades. Of the tumours from 78 patients investigated, 42 had died from metastases within 6.5 years ('non-survivors'), while the other 36 were alive and well without evidence of metastases at the end of the follow-up period (minimum 6.5 years) ('survivors'). If the tumours of the 42 non-survivors are compared with those of 36 survivors, there are many reproducible significant differences, the most important being cellularity index and mitotic activity index, followed by quantitative microscopical nuclear parameters and nuclear and histological grade. Discriminant analysis, of the quantitative microscopical data alone showed 82% of all patients to be correctly classified as survivor or non-survivor. By contrast with the axillary lymph node invasion status alone, or the tumour diameter and axillary lymph node status together, 59% and 64% of the patients were predicted correctly as survivor or non-survivor. With a more realistic statistical approach of discriminant analysis, 78% of the patients were classified correctly with quantitative microscopy, in place of 54% with the axillary lymph node status, 56% with the TNM-system and 64% with a combination of TNM system and nuclear and histological grade. Morphometry thus seems possible to predict the outcome of individual patients more accurately than with the usual staging/grading methods. This technique might therefore prove to be useful in the selection of patients for adjuvant chemotherapy.

Disagreement of histopathological diagnosis of different pathologists in ovarian tumors-with some theoretical considerations

Microscopical sections of forty-nine ovarian tumors have been assessed as benign, borderline or malignant by four different pathologists, who were unaware of the FIGO stage and clinical follow-up of each patient and each others' diagnosis. There was absolute agreement in 37 cases (75.5%), and disagreement in 12 cases (24.5%). The majority of the disagreements involved borderline-malignant differences. If one of the pathologists did disagree with the other three (in 9 cases, or 18%), there is no correlation between disagreement and histopathological experience. In three cases (6.5%) two pathologists did disagree with the other two. It is concluded that in pathology, objective reproducible and if possible, quantitative techniques should be used instead of subjective grading methods. The probability of the diagnosis should be expressed in a numerical way.

Estrogen receptors in human breast cancer. II. Correlation between the histochemical method and biochemical assay

The present study defines criteria for determining the presence of estrogen-receptors in human breast carcinomas demonstrated by a histochemical assay using 17 beta-estradiol-carboxy-methyl-oxim-bovine serum albumen-FITC. The criteria were: 1) the percentage of cells showing fluorescence; 2) the intensity of the fluorescence observed, and 3) the percentage of epithelial structures in tissue specimens. Using these predefined criteria in 132 human breast carcinomas as 91.6% agreement was found between the results of the histochemical assay and those of the biochemical Charcoal method. The main causes of disagreement (7 of the 11 cases) were sampling errors between the tissue specimens used for the histochemical and biochemical assay, and an insufficient percentage of epithelial structures (less than 15%) to allow biochemical identification of estrogen receptor activity. In the hands of pathologists with experience of the field of histochemistry this histochemical assay may be the method of choice for the assessment of estrogen receptors.