Identification of Glandular (Acinar)/Tubule Formation in Invasive Carcinoma of the Breast: A Study to Determine Concordance Using the World Health Organization Definition

CONTEXT.—

The Nottingham Grading System (NGS) developed by Elston and Ellis is used to grade invasive breast cancer (IBC). Glandular (acinar)/tubule formation is a component of NGS.

OBJECTIVE.—

To investigate the ability of pathologists to identify individual structures that should be classified as glandular (acinar)/tubule formation.

DESIGN.—

A total of 58 hematoxylin-eosin photographic images of IBC with 1 structure circled were classified as tubules (41 cases) or nontubules (17 cases) by Professor Ellis. Images were sent as a PowerPoint (Microsoft) file to breast pathologists, who were provided with the World Health Organization definition of a tubule and asked to determine if a circled structure represented a tubule.

RESULTS.—

Among 35 pathologists, the κ statistic for assessing agreement in evaluating the 58 images was 0.324 (95% CI, 0.314-0.335). The median concordance rate between a participating pathologist and Professor Ellis was 94.1% for evaluating 17 nontubule cases and 53.7% for 41 tubule cases. A total of 41% of the tubule cases were classified correctly by less than 50% of pathologists. Structures classified as tubules by Professor Ellis but often not recognized as tubules by pathologists included glands with complex architecture, mucinous carcinoma, and the "inverted tubule" pattern of micropapillary carcinoma. A total of 80% of participants reported that they did not have clarity on what represented a tubule.

CONCLUSIONS.—

We identified structures that should be included as tubules but that were not readily identified by pathologists. Greater concordance for identification of tubules might be obtained by providing more detailed images and descriptions of the types of structures included as tubules.

Abstract P1-07-02: Using clinical characteristics and molecular markers to predict the risk of subsequent ipsilateral breast events after excision of DCIS

PURPOSE To examine incremental values of estrogen receptor (ER) status, body mass index (BMI), menopausal status, and a previously reported multi-gene classifier over commonly used clinical factors (i.e. age, tumor grade, comedonecrosis, surgical margins, and treatment) in predicting risk of any ipsilateral recurrence (IR) event within five years after DCIS diagnosis.

METHODS A derivation cohort consisted of participants in the Translational Breast Cancer Research Consortium (TBCRC) 038, a retrospective multicenter cohort study in women undergoing surgical resection for DCIS between 01/01/1998 and 02/29/2016 (n=216). The validation cohort, the Repository of Archival Human Breast Tissue (RAHBT) at Washington University School of Medicine, provided cases meeting the same eligibility criteria as TBCRC038 (n=97). Participants in both cohorts had RNA-seq data and either developed IR 1-5y after initial DCIS diagnosis or were free from subsequent breast events for at least five years. The previously reported 812-gene classifier had been developed from a subset of the TBCRC038 samples using a negative-binomial regression model to identify differentially expressed genes in the primary tumor associated with subsequent recurrence events. This classifier has been shown to be highly correlated with 5-year invasive, DCIS, and all breast cancer events, and validated in the RAHBT cohort. Cox proportional hazards regression was used to estimate hazard ratios (HRs) of IR in the TBCRC038 cohort (76 with IR). The clinical score was developed using clinical predictors (aforementioned clinical factors and ER) and their regression coefficients from the model with the maximum predictive accuracy (e.g. c-index) and the minimum number of predictors; the summary score integrated the clinical score and multi-gene classifier. Predictive performance of both clinical and summary scores was validated in the RAHBT cohort (20 with IR).

RESULTS In the TBCRC cohort derivation set, we used a multivariable model based on clinical factors alone (clinical score) and found that ER status, but not BMI or menopausal status, was independently associated with a higher IR risk (HR=2.06, 95% CI 1.18-3.58). Adding the multi-gene classifier to the clinical factors-based model (summary score) in the TBCRC038 test set increased predictive accuracy (c-index 0.68 to 0.70), with the genomic classifier-adjusted HR of 14.96 (95% CI 8.64-25.91). The summary score had higher predictive performance for IR risk than clinical score alone (c-index 0.82 vs. 0.70). In the RAHBT validation samples, model performance was similarly improved using summary scores clinical factors-based model plus multigene classifier as compared to clinical scores along (c-index 0.74 vs. 0.58).

CONCLUSION Combining clinical factors and a multigene classifier provided more accurate risk estimates of IR within five years after excision of DCIS than clinical factors alone.

Figure 1. Observed and predicted recurrence-free survival in the first five years after initial DCIS diagnosis in the RAHBT validation cohort, by risk groups defined by clinical scores (left) and clinical score plus multigene classifier (right).

Citation Format: Ying Liu, Siri H. Strand, Lorraine King, Bryan Harmon, Fergus J. Couch, Kristalyn Gallagher, Mark Kilgore, Shi Wei, Angela DeMichele, Tari King, Priscilla F. McAuliffe, Jeffrey Marks, Carlo Maley, Robert West, E Shelley Hwang, Graham A. Colditz. Using clinical characteristics and molecular markers to predict the risk of subsequent ipsilateral breast events after excision of DCIS [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-07-02.

Molecular classification and biomarkers of clinical outcome in breast ductal carcinoma in situ: Analysis of TBCRC 038 and RAHBT cohorts

Ductal carcinoma in situ (DCIS) is the most common precursor of invasive breast cancer (IBC), with variable propensity for progression. We perform multiscale, integrated molecular profiling of DCIS with clinical outcomes by analyzing 774 DCIS samples from 542 patients with 7.3 years median follow-up from the Translational Breast Cancer Research Consortium 038 study and the Resource of Archival Breast Tissue cohorts. We identify 812 genes associated with ipsilateral recurrence within 5 years from treatment and develop a classifier that predicts DCIS or IBC recurrence in both cohorts. Pathways associated with recurrence include proliferation, immune response, and metabolism. Distinct stromal expression patterns and immune cell compositions are identified. Our multiscale approach employed in situ methods to generate a spatially resolved atlas of breast precancers, where complementary modalities can be directly compared and correlated with conventional pathology findings, disease states, and clinical outcome.

Abstract PD5-08: The human tumor atlas network (HTAN) breast pre cancer atlas: A multi-omic integrative analysis of ductal carcinoma in situ (DCIS) and correlation with clinical outcomes

Introduction. As nonobligate precursors of invasive disease, pre-cancers provide a unique vantage point from which to study the molecular pathways and evolutionary dynamics that lead to the development of life-threatening cancers. Ductal carcinoma in situ (DCIS) is the most commonly diagnosed precursor of breast cancer, with variable propensity for invasive progression. In order to address the problems of over- and under-treatment, we performed a multimodal, integrated profile of DCIS with clinical outcomes with which to develop and validate predictors of invasive progression. Methods. We present observations on DNA, RNA, and protein expression on two independent patient cohorts of DCIS, diagnosed from 1981 to 2014, from the Translational Breast Cancer Research Consortium (TBCRC 038) and the Washington University Repository of Archival Human Breast Tissue (RAHBT). Patients initially diagnosed with DCIS, with either DCIS or invasive recurrence (cases; mean follow up 5.8 years) were matched to those without recurrence (controls; mean follow up 10.3 years), based upon age at diagnosis and year of diagnosis. Results. We present genomic and cellular changes that correlate with both disease states and patient outcomes in DCIS. DCIS can be clustered by classification systems developed for IBC. Specific immune cell types and pathways correlate with longitudinal outcome. Luminal cell adhesion and metabolism pathways are upregulated in controls and cases, respectively. Highly multiplexed ion beam imaging (MIBI) was used to validate RNA seq findings, and to provide single cell-level spatial context for molecular alterations.Conclusion. We have performed an integrated multi-omic analysis of DCIS and associated tumor micorenvironment. Our multi-scale approach employs in situ methods to generate a spatially resolved atlas of breast precancers where different modalities can be directly compared to each other, and correlated with conventional pathology findings and clinical outcome. The PreCancer Atlas represents a complex multi-modal database for DCIS study, whose design allows for future discovery and hypothesis generation.

Table 1. Breast Pre-cancer Atlas Multi-scale Characterization AssaysAssayScaleType of DataIntegration and validation with other assaysRNA-seq (Single duct, single cell, TME)Cell, duct, organ, normal tissue1. Whole transcriptome gene expression profiling per single duct (also enabling CNV and cell type prediction)2. Whole transcriptome gene expression profiling per single duct1. Prediction of CNV confirmed by DNA-seq (single duct) and FISH (single cell)2. Prediction of cell type composition (Cibersort) confirmed by multiplex IHC and multicolor flow cytometryLow-pass whole genome DNA-seqDuct and adjacent normalCNV profiling per single ductAnalysis of CNV supported by RNA-seq (single duct) and MIBI (single cell)Whole genome sequencingDuct and adjacent normalMutation status per single ductMutational analysis confirmed by RNA-seqMultiplex IHC (MIBI & Cyclic multicolor)Cell1. Cell type2. Proteomic analysisAnalysis of cell type supported by RNA-seq of ducts (Cibersort) and single cellsH&E MorphometricsCell, duct, organSpatial location of cell types, organization of ductsAnalysis of H&E images correlated with FISH data

Citation Format: Shelley Hwang, Siri H Strand, Belen Rivero, Lorraine King, Tyler Risom, Bryan Harmon, Fergus Couch, Kristalyn Gallagher, Mark Kilgore, Shi Wei, Angela DeMichele, Tari King, Priscilla McAuliffe, Julie Nangia, Ana Maria Storniolo, Alastair Thompson, Gaorav Gupta, Joanna Lee, Jennifer Tseng, Robyn Burns, ChunFang Zhu, Magda Matusiak, Shirley X Zhu, Jason Wang, Jose Seoane, Jen Tappenden, Daisy Ding, Dadong Zhang, Jingqin Luo, Sujay Vennam, Sushama Varma, Lunden Simpson, Luis Cisneros, Timmothy Hardman, Lauren Anderson, Cody Straub, Sucheta Srivastava, Deb J Veis, Christina Curtis, Rob Tibshirani, Robert Michael Angelo, Allison Hall, Kouros Owzar, Kornelia Polyak, Carlo Maley, Jeff Marks, Graham Colditz, Robert B West. The human tumor atlas network (HTAN) breast pre cancer atlas: A multi-omic integrative analysis of ductal carcinoma in situ (DCIS) and correlation with clinical outcomes [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD5-08.

Tumour-infiltrating lymphocytes in ductal carcinoma in situ (DCIS)-assessment with three different methodologies and correlation with Oncotype DX DCIS Score

AIMS

Tumour-infiltrating lymphocytes (TILs) are prognostic in invasive breast cancer; however, their prognostic significance in ductal carcinoma in situ (DCIS) has not been established. The Oncotype DX (ODX) Breast DCIS Score test is a genomic assay used to predict the local recurrence risk. The aims of this study were to quantify TILs in DCIS by the use of three methodologies, and correlate them with the ODX DCIS Score.

METHODS AND RESULTS

We studied 97 DCIS cases, all with an ODX DCIS Score. Cases with a low ODX DCIS Score were considered as one group, and those with an intermediate/high ODX Score were considered together. TILs were quantified on haematoxylin and eosin-stained slides. The methodologies used to quantify TILS included assessment of stromal TILs, assessment of touching TILs, and assessment of circumferential TILS. In cases with >5% stromal TILS, the percentage of stromal TILS was considered to be high. In cases with a mean number of more than five touching TILs per DCIS duct, TILs were considered to be present. The ODX DCIS Score was intermediate/high in 27 (28%) cases and low in 70 (72%) cases. There were >5% stromal TILs in 33 (34%) cases, and more than five touching TILs per DCIS duct in 15 (15%) cases; circumferential TILs were present in nine (9%) cases. In univariate analysis, a low ODX DCIS Score showed significant associations with absent touching TILS (P = 0.027), stromal TILs < 5% (P = 0.031), and absent circumferential TILs (P = 0.002). In logistic regression analysis adjusted for necrosis and nuclear grade, touching TILs and circumferential TILs showed significant associations with the ODX DCIS Score, whereas stromal TILs did not.

CONCLUSIONS

Our results suggest that both the presence of TILs and the spatial arrangement of TILs or close proximity of TILs to DCIS, and TILs touching or encircling DCIS, may be predictive of recurrence.

Insertional oncogenesis by HPV70 revealed by multiple genomic analyses in a clinically HPV-negative cervical cancer

Cervical carcinogenesis, the second leading cause of cancer death in women worldwide, is caused by multiple types of human papillomaviruses (HPVs). To investigate a possible role for HPV in a cervical carcinoma that was HPV-negative by PCR testing, we performed HPV DNA hybridization capture plus massively parallel sequencing. This detected a subgenomic, URR-E6-E7-E1 segment of HPV70 DNA, a type not generally associated with cervical cancer, inserted in an intron of the B-cell lymphoma/leukemia 11B (BCL11B) gene in the human genome. Long range DNA sequencing confirmed the virus and flanking BCL11B DNA structures including both insertion junctions. Global transcriptomic analysis detected multiple, alternatively spliced, HPV70-BCL11B, fusion transcripts with fused open reading frames. The insertion and fusion transcripts were present in an intraepithelial precursor phase of tumorigenesis. These results suggest oncogenicity of HPV70, identify novel BCL11B variants with potential oncogenic implications, and underscore the advantages of thorough genomic analyses to elucidate insights into HPV-associated tumorigenesis.

Comparison of Local Recurrence Risk Estimates After Breast-Conserving Surgery for DCIS: DCIS Nomogram Versus Refined Oncotype DX Breast DCIS Score

BACKGROUND

A ductal carcinoma in situ (DCIS) Nomogram integrating 10 clinicopathologic/treatment factors and a Refined DCIS Score (RDS) that incorporates a genomic assay and three clinicopathologic factors (Oncotype DX DCIS Score) are available to estimate DCIS 10-year local recurrence risk (LRR). This study compared these estimates.

METHODS

Patients 50 years of age or older with DCIS size 2.5 cm or smaller and a genomic assay available were identified. An RDS within 1-2% of the range of Nomogram LRR estimates obtained by assuming use and non-use of endocrine therapy (Nomogram ± ET) was defined as concordant. Assuming a 10-year risk threshold of 10% for recommending radiation, Nomogram ± ET and RDS estimates were compared, and threshold concordance was determined.

RESULTS

For 54 (92%) of 59 patients, the RDS and Nomogram ± ET LRR estimates were concordant. For the remaining 5 (8%) of the 59 patients, the RDS LRR estimates were lower than the Nomogram + ET estimates, with an absolute difference of 3-8%, and thus were discordant. For these five patients, the RDS estimates of 10-year LRR were lower than 10% (range 5-8%) and the Nomogram + ET estimates were 10% or higher (range 11-14%). These five patients with both discordant and threshold-discordant estimates all had close margins (≤ 2 mm).

CONCLUSIONS

Among 92% of women 50 years of age or older with DCIS size 2.5 cm or smaller, free-of-charge online Nomogram 10-year LRR estimates were concordant with those obtained using the commercially available RDS (> $4600). Among the 8% with discordant risk estimates, the RDS appeared to underestimate the LRR and may lead to inappropriate omission of radiotherapy. Unless other data show a clinically significant advantage of the RDS (Oncotype DX DCIS Score), the study data suggest that for women 50 years of age or older with DCIS size 2.5 cm or smaller, its use is not warranted.

One percent sodium carboxymethylcellulose prevents experimentally induced abdominal adhesions in horses

OBJECTIVE

To evaluate the efficacy of 1% sodium carboxymethylcellulose (SCMC) for prevention of experimentally induced abdominal adhesions in horses.

STUDY DESIGN

Prospective, controlled, experimental study.

ANIMAL POPULATION

Twelve healthy adult horses.

METHODS

The effect of 1% SCMC on adhesion formation was evaluated in 12 healthy horses by using an established model of serosal trauma to induce intraabdominal adhesions. After ventral median celiotomy, 2 separate areas of the jejunum were abraded, and three 2-0 chromic gut sutures were placed in each abraded area. Jejunal resection and end-to-end anastomosis was performed at 2 sites distant to the abrasion sites. In treated horses (n = 6), 2 L of 1% SCMC was applied to the intestine before and after intestinal manipulation. In control horses (n = 6), 2 L of saline solution were applied to the intestine before and after surgical manipulation. All horses were euthanatized 10 days after surgery, and the abdominal cavity was evaluated for adhesion formation. The frequency of intraabdominal adhesions between groups was compared with a chi-square test. Statistical significance was set at P <.05.

RESULTS

All control horses had intraabdominal adhesions. Fibrous adhesions were associated with both jejunal abrasion sites in 5 control horses. Fibrous adhesions were also associated with 1 or both jejunal anastomotic sites in 5 control horses. Only 1 treated horse developed adhesions at the jejunal abrasion sites, and no adhesions were present at the anastomotic sites in the treated horses. There were significantly fewer adhesions in the SCMC treatment group compared with the control group (P <.05).

CONCLUSION

In this experimental model, application of 1% SCMC reduced the frequency of intraabdominal adhesions at areas of serosal abrasion and at jejunal anastomotic sites.

CLINICAL RELEVANCE

In horses at an increased risk for developing intraabdominal adhesions after intestinal surgery, the use of 1% SCMC during celiotomy may decrease the frequency of adhesion formation.

Early transcription and silencing of cytokine genes underlie polarization of T helper cell subsets

Naive CD4+ T cells activated through TCR/CD28 under Th1 or Th2 conditions expressed canonical cytokine patterns irrespective of cell division. Only cells that had divided fewer than four times were capable of reexpressing alternative cytokines when restimulated under opposing conditions. Although T cells transcribed both IFN-gamma and IL-4 within hours in a Stat4-/Stat6-independent manner, neither T-bet nor GATA-3 was induced optimally without Stat signals, and polarized cytokine expression was not sustained. Cytokine genes were positioned apart from heterochromatin in resting T cell nuclei, consistent with rapid expression. After polarization, the majority of silenced cytokine alleles were repositioned to heterochromatin. Naive T cells transit through sequential stages of cytokine activation, commitment, silencing, and physical stabilization during polarization into differentiated effector subsets.

Safety and efficacy of mangafodipir trisodium (MnDPDP) injection for hepatic MRI in adults: results of the U.S. multicenter phase III clinical trials (safety)

The short-term safety of mangafodipir trisodium (MnDPDP) injection was studied in 546 adults with known or suspected focal liver lesions. An initial contrast-enhanced computed tomography examination was followed by unenhanced magnetic resonance imaging (MRI), injection of MnDPDP (5 micromol/kg), and enhanced MRI. Adverse events were reported for 23% of the patients; most were mild to moderate in intensity, did not require treatment, and were not drug related. The most commonly reported adverse events were nausea (7%) and headache (4%). The incidence of serious adverse events was low (nine events in six patients) and not drug related. Injection-associated discomfort was reported for 69% of the patients, and the most commonly reported discomforts included heat (49%) and flushing (33%). Changes in laboratory values and vital signs were generally transient, were not clinically significant, and did not require treatment. There were no clinically significant short-term risks from exposure to MnDPDP.

Evaluation of a bioresorbable hyaluronate-carboxymethylcellulose membrane for prevention of experimentally induced abdominal adhesions in horses

OBJECTIVE

To evaluate the efficacy of a bioresorbable hyaluronate-carboxymethylcellulose membrane (HA-membrane) for prevention of experimentally induced abdominal adhesions in horses.

STUDY DESIGN

Experimental study.

ANIMAL POPULATION

Twelve healthy adult horses.

METHODS

The effect of an HA-membrane on adhesion formation was evaluated in 12 healthy horses using an established model of serosal trauma to induce adhesions. A ventral median celiotomy and two jejunal resections and end-to-end anastomoses were performed. Two separate jejunal areas were abraded, and three 2-0 chromic gut sutures placed in the abraded areas. In treated horses (n = 6), HA-membranes were applied to the jejunum to completely cover the anastomoses and abraded areas of jejunum. Nontreated horses (n = 6) served as controls. All horses were killed 10 days after surgery. The abdominal cavity was evaluated for adhesion formation. The frequency of intra-abdominal adhesions between groups was compared with a chi2 test with statistical significance set at P < .05.

RESULTS

All control horses had intra-abdominal adhesions; fibrous adhesions were associated with both jejunal abrasion sites in 5 horses. One treated horse developed adhesions. There were significantly fewer adhesions in the HA-membrane-treated group (P < .0034).

CONCLUSIONS

In this experimental model, application of an HA-membrane to a localized area of serosal trauma reduced the frequency of intra-abdominal adhesion formation.

CLINICAL RELEVANCE

Application of an HA membrane may decrease the frequency of adhesions in horses at an increased risk of postoperative adhesion formation.

Radiation-induced apoptosis and gene expression in neonatal kidney and testis with and without protein synthesis inhibition

PURPOSE

To analyse the incidence of radiation-induced apoptosis, expression of two apoptosis-related genes, Bcl-2 and p53, and post-radiation levels of cell proliferation in the neonatal rat (4-5 days old) kidney and testis.

MATERIALS AND METHODS

Apoptosis was quantified in control or treated kidney or testis at 2, 4, 6, 8 and 24h after 5 Gy of whole body X-irradiation (n=4 per group). Morphology (light and electron microscopy) and DNA gel electrophoresis were used to assess apoptosis. Temporal and spatial expression of Bcl-2 or p53 were analysed using immunohistochemistry. Administration of cycloheximide (1.5mg/kg) was used to determine whether new protein synthesis had a role in induction of apoptosis. Tritiated thymidine uptake and autoradiography were used to indicate alterations in cell proliferation (radiolabel administered 1 h prior to tissue collection) or S-phase cells undergoing radiation-induced apoptosis (radiolabel administered 1 h prior to irradiation).

RESULTS

Apoptosis peaked at 4 h in the testis and 6 h in the kidney and was significantly higher in the renal nephrogenic zone than in the testis (p<0.05). Mitosis was almost completely negated after irradiation in both tissues. A higher proportion (almost fivefold) of the apoptotic cells died in S phase in the kidney than in the testis. Cycloheximide negated induction of apoptosis in the kidney, and markedly decreased apoptosis in the testis. Bcl-2 expression was highest in the differentiated zone of control kidneys and increased after irradiation in the nephrogenic zone, particularly near foci of apoptosis in developing nephrons. In the control testis, Sertoli cells had moderate expression of Bcl-2. After irradiation, there was complete absence of Bcl-2 expression in apoptotic Sertoli cells, with surviving cells increasing Bcl-2 expression. Irradiated kidney had more intense nuclear p53 expression compared with controls. In the testis, p53 that was present in controls continued to be expressed in surviving cells but not apoptotic cells in radiation-treated animals.

CONCLUSIONS

Unique differences can be identified between the incidence and biomolecular control of radiation-induced apoptosis in the normal neonatal kidney and testis. These results may find application for minimizing damage to these normal neonatal tissues in the development of, for example, cancer treatment regimens.

Transition metals as protease inhibitors

An alternative approach to the development of clinically useful protease inhibitors was investigated. The approach utilized coordination chemistry of transition metal ions rather than substrate analogs to block active sites of these enzymes. In the case of serine proteases it was found that aqueous Ti(IV) is a potent inhibitor of the trypsin subclass, but not the chymotrypsin subclass. The direct binding of Ti(IV) to trypsin was made possible by the presence of a free carboxyl group at the bottom of the substrate binding pocket of the enzyme, and the five-coordinate geometry of TiO(SO4)(H2O). Although initial binding of Ti(IV) was reversible, it was followed in time by irreversible inhibition. Direct binding of octahedral or tetrahedral metal ion complexes was prevented by the inability of the enzyme active sites to promote formation of a five-coordinate transition state of the metal ion required for reaction. These studies demonstrate the ability of direct metal ion binding as a way to enhance blocking of enzyme active sites as compared with that of traditional organic inhibitors. Application of these findings was investigated by measuring the affect Ti(IV) had on growth of Escherichia coli, Salmonella typhimurium, and Pseudomonas aeruginosa. Five-coordinate titanyl sulfate completely inhibited the growth of these organisms. This suggests that five-coordinate titanyl sulfate, which is easier and less expensive to manufacture than conventional antibiotics, may be useful in controlling endemic infections of E. coli and S. typhimurium.

Cognitive and behavioral predictors of sexually transmitted disease risk behavior among sexually active adolescents

OBJECTIVE

To identify important cognitive and behavioral predictors of sexually transmitted disease (STD) risk behavior among a sexually active adolescent cohort.

DESIGN

One-year longitudinal study of health beliefs, sexual behaviors, and STD acquisition among 549 adolescents, 14 to 21 years of age.

SETTING

School- and community-based health clinics in a large metropolitan area.

PARTICIPANTS

Data from 410 sexually active adolescents completing surveys at baseline and 1-year follow-up.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Sexually transmitted disease risk behavior--a composite measure of condom use consistency with most recent sexual partner(s), number of vaginal sex partners, and frequency of intercourse with most recent sexual partner(s).

RESULTS

For girls (n = 335), a model including baseline STD risk behavior, condom use self-efficacy, oral contraceptive use, communication with sexual partners about STD prevention, and alcohol use in connection with sexual activity explained 21.1% of the variance in STD risk behavior at 1-year follow-up. For boys (n = 75), the strongest predictors of STD risk behavior at follow-up included baseline STD risk behavior, perceived susceptibility to STD, condom use self-efficacy, negative outcome expectations associated with condom use, and perceived barriers to STD prevention.

CONCLUSIONS

Efforts targeting reduction in STD risk behavior must begin before the onset of somewhat stable patterns of sexual risk behavior. Among adolescents who are sexually active, interventions should include components that increase condom use self-efficacy, build skills to communicate with sexual partners about STD prevention, and address behaviors associated with STD risk behavior including oral contraceptive use.

Apoptosis and mitosis in oral and oropharyngeal epithelia: evidence for a topographical switch in premalignant lesions

Apoptosis (programmed cell death) may play a part in carcinogenesis. The mucosa of the oral cavity, a common site for the development of dysplasia and squamous cell carcinoma, is ideal for the study of carcinogenesis in vivo. Earlier work suggested that apoptosis falls with the development of carcinoma, and that carcinogenesis is preceded by topographical changes in apoptosis. To explore these hypotheses, 72 paraffin sections were obtained: 15 normal (N), nine mild dysplasia (D), 15 severe dysplasia/carcinoma in situ (CIS), 30 squamous cell carcinoma (SCC: power analysis suggested 15 per group). Apoptotic (AI) and mitotic (MI) indices and AI/MI ratio were calculated (1000 cells/slide). These, with age, sex, alcohol and smoking habits, and anatomical subsite, were entered into a regression model with histological group as dependent. Vertical cell position (cp) was plotted, and resultant frequency curves were compared. MI significantly increased (mean N 0.39, 95% confidence interval 0-0.35; D 0.63, 0.23-0.98; SCC 0.86, 0.51-1.21, P < 0.0001) and AI/MI significantly decreased (D 0.54, 0.20-0.86; SCC 0.28, 0.05-0.61, P < 0.05) progressing from D, through CIS, to SCC. However, after inclusion of all variables, only MI remained significant (P < 0.0001). Peak incidence of mitosis shifted downwards in CIS relative to N and D, whilst peak apoptosis shifted upwards. Thus, programmed cell death remains static as mitosis increases in carcinogenesis of the oral cavity. However, there is an alteration in the topographical relationship of these events in CIS which may make homeostatic mechanisms involving apoptosis less efficient.

Specific interactions of chromatin with the nuclear envelope: positional determination within the nucleus in Drosophila melanogaster

Specific interactions of chromatin with the nuclear envelope (NE) in early embryos of Drosophila melanogaster have been mapped and analyzed. Using fluorescence in situ hybridization, the three-dimensional positions of 42 DNA probes, primarily to chromosome 2L, have been mapped in nuclei of intact Drosophila embryos, revealing five euchromatic and two heterochromatic regions associated with the NE. These results predict that there are approximately 15 NE contacts per chromosome arm, which delimit large chromatin loops of approximately 1-2 Mb. These NE association sites do not strictly correlate with scaffold-attachment regions, heterochromatin, or binding sites of known chromatin proteins. Pairs of neighboring probes surrounding one NE association site were used to delimit the NE association site more precisely, suggesting that peripheral localization of a large stretch of chromatin is likely to result from NE association at a single discrete site. These NE interactions are not established until after telophase, by which time the nuclear envelope has reassembled around the chromosomes, and they are thus unlikely to be involved in binding of NE vesicles to chromosomes following mitosis. Analysis of positions of these probes also reveals that the interphase nucleus is strongly polarized in a Rabl configuration which, together with specific targeting to the NE or to the nuclear interior, results in each locus occupying a highly determined position within the nucleus.

American Indian--Alaska Native youth health

OBJECTIVE

To assess risk behaviors, health problems, worries and concerns, and resiliency-promoting factors among American Indian-Alaska Native adolescents.

DESIGN

Survey.

SETTING

Nonurban schools from eight Indian Health Service areas.

PARTICIPANTS

A total of 13,454 seventh- through 12th-grade American Indian-Alaska Native youths.

MAIN OUTCOME MEASURES

revised version of the Adolescent Health Survey, a comprehensive, anonymous, self-report questionnaire with 162 items addressing 10 dimensions of health.

RESULTS

Poor physical health was reported by 2% of the study sample and was significantly correlated with social risk factors of physical and/or sexual abuse, suicide attempts, substance abuse, poor school performance, and nutritional inadequacies. Injury risk behaviors included never wearing seatbelts (44%), drinking and driving (37.9% of driving 10th through 12th graders), and riding with a driver who had been drinking (21.8%). Physical and sexual abuse prevalence was 10% and 13%, respectively, with 23.9% of females reporting physical abuse and 21.6% of females reporting sexual abuse by the 12th grade. Almost 6% of the entire sample endorsed signs of severe emotional distress. Eleven percent of the teens surveyed knew someone who had killed himself or herself, and 17% had attempted suicide themselves. Sixty-five percent of males and 56.8% of females reported having had intercourse by the 12th grade. Weekly or more frequent alcohol use rose from 8.2% of seventh graders to 14.1% by the 12th grade; for males, the survey noted an increase in regular alcohol use of 3% to 5% a year to 27.3% by the 12th grade. For each variable measured, rates are much higher for American Indian adolescents than those for rural white Minnesota youth, except for age at first intercourse and alcohol use.

CONCLUSIONS

American Indian-Alaska Native adolescents reported high rates of health-compromising behaviors and risk factors related to unintentional injury, substance use, poor self-assessed health status, emotional distress, and suicide. Interventions must be culturally sensitive, acknowledge the heterogeneity of Indian populations, be grounded in cultural traditions that promote health, and be developed with full participation of the involved communities.

Deep vein thrombosis: a perspective on anatomy and venographic analysis

Pulmonary thromboembolism affects 750,000 Americans annually. DVT is the primary origin of PE, which results in approximately 150,000 patient deaths annually. Normal variants affect the incidence of DVT. Patients with duplicated or fenestrated superficial femoral veins and patients with five or more valves are at increased risk for development of DVT. Positive contrast venography performed in the radiology department under fluoroscopic control remains the "gold standard" for the diagnosis of DVT, despite the development of other modalities. Low-osmolar contrast agents, either nonionic or dilute ionic, and postprocedure infusion of 2,500 U of heparin mixed in 150 mL of physiologic saline should be used to reduce the incidence of postphlebography DVT. Positive venographic signs of DVT include filling defect, cutoff, nonvisualization, and collateralization.

An ultrastructural study on the "meconium corpuscles" in rat foetal intestinal epithelium with particular reference to apoptosis

During the embryonic development of the intestine, programmed deletion of epithelial cells plays a vital role in the formation of secondary lumina and of villi. Electron microscopy shows that this deletion is effected by apoptosis, a distinctive mode of cellular death recently recognised as being implicated in normal tissue involution in the adult, as well as during intrauterine development. The process involves cellular condensation and budding to form membrane-bounded apoptotic bodies containing well-preserved organelles. These are then either engulfed by neighbouring principal cells or sloughed off into the intestinal lumen. Engulfed apoptotic bodies that show various degrees of lysosomal degradation have previously been referred to as "meconium corpuscles".

Innervation of arteriovenous anastomoses in the web of the foot of the domestic duck, Anas platyrhynchos: structural evidence for the presence of non-adrenergic non-cholinergic nerves

An analysis of the innervation of arteriovenous anastomoses in the web of the foot of the Pekin Duck (Anas platyrhynchos) was compared with the innervation of the right atrium of the duck heart using histochemical, ultrastructural and morphometric techniques, before and after 6OHDA. The presence of intense catecholamine fluorescence and nerve terminals containing typical noradrenergic small dense-cored vesicles, together with the absence of fluorescence and degeneration of noradrenergic terminals after 6OHDA, indicated the presence of a dense adrenergic innervation at the periphery of the anastomoses. Ultrastructural and histochemical data gave support to the presence of a cholinergic innervation. There was evidence that arteriovenous anastomoses were innervated by non-adrenergic, non-cholinergic nerves, viz. after 6OHDA, the mean diameter, mean percentage and mean density of granular vesicles in axon profiles associated with anastomoses (107 . 25 nm, 22 . 34% and 12 . 73 vesicles micron-2, respectively) were significantly higher (P less than 0 . 001) than values in the atrium (87 . 13 nm, 9 . 92% and 5 . 51 vesicles micron-2, respectively) and axons associated with anastomoses contained large granular vesicles ranging up to 210 nm in diameter. This non-adrenergic non-cholinergic innervation may represent the non-adrenergic non-cholinergic vasodilatory nerves shown by pharmacological methods to be present in the foot of the Pekin Duck.

Pressure standardized lumbar discography

The basic procedure for carrying out clinical lumbar discography has been examined. As a consequence, a pressure-standardized injection technique has been established. It is shown that monitoring the flow of contrast medium into the disc can, in the case of a true nuclear injection, improve the diagnostic efficiency. Additionally, knowledge of this flow can help to avoid a commonly occurring, but not often recognized, artefact described in detail elsewhere (Quinnell and Stockdale, 1980).

An electron-microscope study of the mode of cell death induced by cancer-chemotherapeutic agents in populations of proliferating normal and neoplastic cells

Deletion of scattered single cells by ultrastructurally typical apoptosis was observed to take place continuously in the lining of the small intestinal crypts of normal mice, and in untreated Crocker mouse ascites tumours. Injection of the cancer-chemotherapeutic agents actinomycin D, mitomycin C, cytosine arabinoside and cycloheximide massively enhanced the rate of apoptosis in each situation, the morphology of cell death induced by these drugs being fundamentally different from that of coagulative necrosis, which developed without treatment in the centres of solid nodules that grew after subcutaneous inoculation of the tumour. In the crypt lining, where the predominant cell type affected appeared to be epithelial, the apoptotic bodies were either extruded into the lumen or rapidly phagocytosed and degraded by adjacent viable cells. But bodies in the ascites tumour were rarely ingested by uninvolved cells, presumably because of their wide dispersal in a fluid medium, and the stages in their development were seen more clearly than has been possible in solid tissues, where phagocytosis is ususlly rapid: they eventually underwent a change resembling coagulative necrosis or in-vitro autolysis. Reports suggesting that cancer-chemotherapeutic agents enhance autophagy in solid malignant neoplasms require confirmation, for secondary lysosomes of any sort were found to be uncommon in the treated ascites tumours, and there is little doubt that phagocytosed apoptotic bodies have been mistaken for autophagic vacuoles in the past. The significance of the fact that cancer-chemotherapeutic agents induce a type of cell death that is found in normal tissues is at present unknown.

An Electron-Microscope Study of Cell Deletion in the Anuran Tadpole Tail During Spontaneous Metamorphosis with Special Reference to Apoptosis of Striated Muscle Fibres

The mechanism of cell deletion responsible for involution of the anuran tadpole tail during spontaneous metamorphosis was studied by light and electron microscopy, attention being focused on epidermis and striated muscle.

The earliest indication of pending dissolution of epidermal cells was found to be aggregation of condensed chromatin beneath the nuclear envelope. This is followed by breaking up of the nucleus, and cytoplasmic condensation and budding with the production of a number of compact, membrane-bounded cell fragments with relatively well preserved organelles. These are then ingested and degraded by nearby viable cells, the majority by distinctive macrophage-like cells, which are scattered throughout the epidermis, and a few by epithelial cells. The morphological changes observed in the dying epidermal cells are the same as those described both in the ‘programmed cell death’ that plays an important role in the normal development of vertebrate embryos and in the type of cell death that has been shown to be involved in regulating the size of tissues in adult mammals under normal as well as pathological conditions; it has been suggested elsewhere that apoptosis might be a suitable name for the phenomenon.

Deletion of striated muscle fibres in the tadpole tail is accomplished by a process that appears to be a modification of classical apoptosis, in which dilatation and confluence of elements of the sarcoplasmic reticulum lead to internal fragmentation, the usual surface budding presumably being precluded by the large volume and specialized structure of these cells. The early and late nuclear changes, and the apparent ultrastructural integrity of organelles in the membrane-bounded muscle fragments are typical of apoptosis, and subsequent degradation within macrophages follows the standard stereotyped pattern. An essentially similar process has been described by others in the muscles of metamorphosing insect larvae, but whether striated muscle cells in adult higher vertebrates can undergo apoptosis is still uncertain.