Intravaskuläres Lymphom unter dem klinischen Bild einer therapieresistenten Thrombophlebitis

Wir berichten über eine 63-jährige Patientin, die nach einmonatiger erfolgloser antibiotischer Therapie aufgrund eines Erysipels rechts mit der Verdachtsdiagnose einer therapieresistenten Thrombophlebitis in einer phlebologischen Praxis vorgestellt wurde. Klinisch imponierte ein derbes rotes, schmerzhaftes und brennendes Areal im Bereich der rechten Wade sowie mehrere bis 3 cm große derbe, leicht druckschmerzhafte Areale des linken Beines mit Betonung des Unterschenkels. Hinweise für eine tiefe Beinvenenthrombose oder eine Thrombophlebitis fanden sich nicht. Histologie: In der konventionellen histologischen Untersuchung fand sich zunächst das Bild eines hochmalignen, intravaskulären Tumorgeschehens. Mit Hilfe immunhistochemischer Färbungen wurde ein intravaskuläres (angiotropes) T-Zell-Lymphom (maligne Angioendotheliomatose) gesichert. Schlussfolgerung: Der Fall unterstreicht die Notwendigkeit der frühzeitigen histologischen Untersuchung auch vermeintlich harmloser Hautveränderungen.

Activity and Distribution of Methane-Oxidizing Bacteria in Flooded Rice Soil Microcosms and in Rice Plants (Oryza sativa)

The activity and distribution of CH(inf4)-oxidizing bacteria (MOB) in flooded rice (Oryza sativa) soil microcosms was investigated. CH(inf4) oxidation was shown to occur in undisturbed microcosms by using (sup14)CH(inf4), and model calculations indicated that almost 90% of the oxidation measured had taken place at a depth where only roots could provide the O(inf2) necessary. Slurry from soil planted with rice had an apparent K(infm) for CH(inf4) of 4 (mu)M and a V(infmax) of 0.1 (mu)mol g (dry weight)(sup-1) h(sup-1). At a depth of 1 to 2 cm, there was no significant difference (P > 0.05) in numbers of MOB between soil from planted and nonplanted microcosms (mean, 7.7 x 10(sup5) g [fresh weight](sup-1)). Thus, the densely rooted soil at 1 to 2 cm deep did not represent rhizospheric soil with respect to the number of MOB. A significantly increased number of MOB was found only in soil immediately around the roots (1.2 x 10(sup6) g [fresh weight](sup-1)), corresponding to a layer of 0.1 to 0.2 mm. Plant-associated CH(inf4) oxidation was shown in a double chamber with carefully washed intact rice plants. Up to 90% of the CH(inf4) supplied to the root compartment was oxidized in the plants. CH(inf4) oxidation on isolated roots was higher and had a larger variability than that in soil slurries. Roots had an apparent K(infm) for CH(inf4) of 6 (mu)M and a V(infmax) of 5 (mu)mol g (dry weight)(sup-1) h(sup-1). The average number of MOB in homogenized roots was larger than on the rhizoplane and increased with plant age. MOB also were found in surface-sterilized roots and basal culms, indicating the ability of these bacteria to colonize the interior of roots and culms.

Prediction of Metastasis in Node-Negative, Hormone Receptor Positive, Tamoxifen Adjuvant Treated Primary Breast Cancer Patients Using Ki-67 (IHC) and RT-PCR Based 14-Gene Prognostic Signature

Background: Risk estimation based on the recommendations of St. Gallen Consensus commonly decides for additional cytostatic therapy in node-negative (N-), hormone receptor positive (HR+) primary breast cancer patients. High proliferative activity in the HR+ subtype confers a 19-fold relative risk of relapse compared with HR+ tumors of low proliferative activity. Furthermore immunohistochemically determined Ki-67 is characterized as a Luminal B marker that identifies a high risk subgroup in HR+, N- breast cancer patients.Aim of this investigation was to compare risk estimation using Ki-67 (%) with the results of a RT-PCR based multi-gene prognostic signature. Methods: Tumor tissues of totally 321 unselected primary breast cancer patients were formalin fixed and routinely processed for immunohistochemical determination and scored for protein expression of ER, PgR and Ki-67. HER2 was determined using dd-PCR. Content of both hormone receptors and proliferation activity were evaluated counting positively coloured nuclei from at least 100 tumor cells. The median follow up was 61 months. To calculate the cut off for high proliferation Ki-67 values were subjected to a log rank CART analysis. High proliferation was defined by Ki-67 of 19% and more. With this cut off it was possible to distinguish significantly various patient cohorts (N-, pT1, postmenopausal) into two different risk groups regarding metastasis free survival. The definition of low risk was low proliferation and HER2 negativity, of high risk high proliferation or HER2 positivity. The risk for metastasis of 16 new primary breast cancer patients was estimated based on two surrogate risk groups and the multi-gene prognostic signature. Results: Tamoxifen adjuvant treated HR+, HER2-, low proliferating (Ki-67 <19%), N- low risk patients (N= 68) and HR+, HER2-, high proliferating/HR+, HER2+, N- high risk patients (N= 84) showed a recurrence rate of 2.94% and 27.4%, respectively (P< .000). In the ongoing observation study all 5 low proliferating HER2- tumors had a low risk gene prognostic signature. From 11 high proliferating HER2- patients one patient had a low risk gene signature (9%), 3 patients a moderate risk gene signature (27%) and 7 patients a high risk gene signature (64%). Conclusion: Despite the small number of patients investigated up to now (N= 16) the preliminary results appear to show that low proliferative activity is associated with a low risk gene prognostic signature, whereas high proliferation means only in part a high risk gene prognostic signature.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6025.

Gene Expression Profiling for Therapy Prediction in a Breast Cancer Neoadjuvant Therapy Study Applying Docetaxel/Epirubicin/Cyclophosphamide

Background: Gene expression profiling is a powerful tool to identify markers associated with clinical and therapy outcome of cancer patients. Prediction of the response to neoadjuvant regimens remains a persistent challenge. Aim of this ongoing study is the development of a gene set predicting the response of the tumor to a taxane- anthracycline based neoadjuvant chemotherapy.Material and Methods: Microarray expression profiling was performed on biopsy samples from patients before treatment using Human Genome Survey microarrays (HGSM). The protocol for a phase II study was elaborated for the treatment of breast cancer patients suffering from a primary tumor 1.5 cm or inflammatory breast cancer with Docetaxel/Epirubicin/Cyclophosphamide (TEC) prior to surgical treatment. The study was approved by the local ethical committee and all patients signed an informed consent.Results: Overall 80 patients have been enrolled in the presented study. High quality gene expression data were available from 58 patients. Of these patients 21 responded to the TEC regimen (pCR or MIB1 expressing cells in the residual tumor <= 5% and decrease of Mib1-expression >= 20%). Based on the gene-expression profile we were able to identify a preliminary gene set of 150 genes which allows us to separate responding tumors from the non responding ones based on their gene expression profile. A comparable separation of the groups could not achieved by established tumor markers, e.g. ER, PgR, HER2, uPA etc. which are measured simultaneously on the HGSM. Among the genes distinguishing the two groups several genes normally expressed in mononuclear blood cells were identified, pointing to the presence of tumor infiltrating leukocytes, predominantly in the tumors responding the TEC regimen. The presence of these cells has already been verified in a subset of the samples.Conclusion: We identified a gene set which allows to select patients who will benefit from neoadjuvant chemotherapy. Furthermore at least in the so far investigated samples tumor infiltrating leukocytes are significantly more often found in tumors which respond to a taxane- anthracycline based neoadjuvant chemotherapy.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2039.

Semi-quantitative gene expression profiling for therapy prediction in a breast cancer neoadjuvant therapy study applying docetaxel/epirubicin/cyclophosphamide

21144

Background: More than 28000 curated human genes can be analyzed semi-quantitatively using a chemiluminescent detection technology and 60mer oligonucleotides on a Human Genome Survey Microarray (HGSM, Applied Biosytems). Methods: HGSM expression profiling was performed on biopsy samplesfrom a setting of patients under neoadjuvant treatment. The protocol for a phase II study was elaborated for the treatment of breast cancer patients suffering from a primary tumor > 1,5 cm or inflammatory breast cancer with Docetaxel / Epirubicin/Cyclophosphamide (TEC) prior to surgical treatment. The study was approved by the local ethical committee and 80 patients will be included into the study after written informed consent. 40 patients have been already included in the ongoing study. In this prospective study a biopsy from the tumor is taken before chemotherapy. Therefore, success of treatment is detectable directly at the operated residual tumor. Our results demonstrate a low rate of false-positives (1.2%), a high specificity and quantification accuracy of HGSM system. Comparison of data from HGSM and RT-PCR obtained on mRNA from fresh frozen tissue resulted a Pearson-correlation of 0.92 to 0.63 for the breast cancer genes. Results: Tumour response (pCR, pPR) of more than 70 % can be achieved using neoadjuvant TEC- regimen. 25 % of pCR in this study is comparable with data of other published neoadjuvant trails. First expression profiling results are obtainable showing that a subset of 148 genes indicates patients with complete remission (pCR, no detectable tumor at end of chemotherapy), partial remission (pPR) and progressive disease (pPD). Remarkable, that the expression profile clearly separated pCR and pPD tumors whereas pPR tumors presented with a closer relationship to pPD tumors than to pCR tumors but displayed small specific subprofiles. A comparable separation of the groups could not achieved by established tumor markers, e.g. ER, PgR, HER2, uPA etc. which are measured simultaneously on the HGSM. Conclusions: HGSM expression profiling is promising to have the potential to figure out genes that are related to cancer progression and chemotherapy resistance, especially in PST.

No significant financial relationships to disclose.

Therapy prediction in a breast cancer primary systemic chemotherapy (PST) study applying docetaxel/epirubicin/cyclophosphamide (TEC) by gene expression profiling

10049

Background: Currently there are no tests to assist in selecting the optimal PST regimen for breast cancer patients. Primary study goals of this prospective, single-armed multicentric investigation are pathologically confirmed tumor response and the rate of breast conserving therapy (BCT). Secondary goals are to find histopathologic and gene profiling patterns best correlating with tumor remission in a taxane- anthracycline based neoadjuvant setting as well as to evaluate cytostatic toxicity and quality of life. Methods: In this phase II study of totally 40 eligible patients with invasive breast cancer Human Genome Survey Microarray (HGSM) expression profiling is performed on jet-biopsy sample basis. The protocol was elaborated for the treatment of patients suffering from a primary tumor with 6 cycles of TEC (3-weekly) prior to the surgical treatment. The selection of predictor genes was done with BRB-ArrayTools Version 3.3 using a model based on the Compound Covariate Predictor, Diagonal Linear Discriminant Analysis, Nearest Neighbor Classification, and Support Vector Machines with linear kernel.We estimated the prediction error of each model using leave-one-out cross-validation (LOOCV) as described by Simon R. 2000 random permutations were used. Clustering was done using Cluster 3.0 and Java TreeView 1.0.12. Results: Tumor response (pCR, pPR) of more than 70% can be achieved using neoadjuvant TEC-regimen. 22% pCR (ypT0; ypN0) and 90% BCT in this study are comparable with data of other published PST trials. Preliminary expression profiling results reveal a subset of 148 genes that classifies all patients with a complete remission (pCR), in one cluster with a very closely related gene expression pattern (n=5; PPV = 100%). Furthermore 10 patients defined as responders due to selected MIB1-expression based criteria (expressing cells in the residual tumor ≤ 5% and a Δ MIB1-expression ≥ 20%) can be correctly classified in 9 of 10 cases. Comparable separation of the groups could not be achieved by established tumor factors. Conclusions: HGSM expression profiling is promising to have the potential to figure out genes that are related to chemotherapy response, especially in PST.

No significant financial relationships to disclose.

Zellul�re Ver�nderungen nicht-kleinzelliger Lungenkarzinome nach neoadjuvanter Therapie

Microscopic analysis of resection specimens of non-small cell lung cancer after neoadjuvant therapy evokes the subjective impression of cytologic changes, especially enlargement of the individual tumor cells and their nuclei. Therefore, objectivization of these changes was tested morphometrically. Corresponding investigations could be carried out in 24 patients who had each received identical neoadjuvant therapy. The diameters and areas of the tumor cells and their nuclei as well as the nucleocytoplasmic ratio were assessed. The adenocarcinomas investigated revealed a significant cellular enlargement after treatment. Moreover, in 18 resection specimens (75%), cytomorphological changes could be shown in comparison to untreated tumor tissue. The cellular and nuclear parameters analysed as well as the cytomorphological changes assessed showed no significant correlation to the grade of therapy-induced tumor regression and thus do not allow an assessment of therapy success. Based on these results, grading of non-small cell lung cancer is not recommended after neoadjuvant therapy and the diagnosis of "large cell anaplastic" carcinoma should be made with reservation.

[Impact of DNA image cytometry (ICM) parameter and established prognostic factors on disease free survival (DFS) and overall survival (OS) of node-negative breast cancer (NNBC) patients]

OBJECTIVE

DNA ICM allows measurement of nuclear DNA content and genotypical grading of malignancy. The aim of this study was to prove the prognostic value of DNA parameter in comparison to established prognostic factors for DFS and OS.

PATIENTS AND METHODS

Cytological imprints of 177 unselected primary NNBC patients were subjected to ICM. ICM parameter 2cDI, 5cEE, 9cEE, DNA mean value, proliferation fraction (SG2M) and ploidy were investigated together with established parameter like pT-stages, histology, grading, hormone receptor status and patient age regarding DFS and OS. Univariate and multivariate analysis were performed.

RESULTS

Univariate analysis revealed that except ploidy all ICM parameter and pT-stages, histology as well as grading were significant prognostic factors for DFS. However, only 2cDI and pT-stages were proved independent prognostic factors in multivariate analysis. Regarding OS 9cEE, histology and pT-stages were significant factors in univariate analysis. However, only 9cEE and pT-stages were found to be independent prognostic factors in multivariate analysis.

CONCLUSIONS

DNA - ICM parameter 2cDI and 9cEE together with pT-stages were proved independent prognostic factors in NNBC patients.

[Remission rate of mediastinal lymph nodes after multimodal therapy of lung cancer--is it a prognostic factor?]

OBJECTIVE

General acceptance in the oncologic community has been gained for combined modality treatment of non-small cell lung (NSCLC) cancer in locally advanced stage IIIA and IIIB disease. However, no optimal regimen has been established. This study (chemotherapy and radiochemotherapy followed by operation) assesses feasibility, response, resectability, and survival in patients with stage IIIA and IIIB lung cancer. Currently, only little data is available about the prognostic significance of tumor clearance of mediastinal nodes. Thus, an important aim of our study was to evaluate the prognostic significance of the extent of tumor reduction in mediastinal nodes by a neoadjuvant multimodality protocol.

PATIENTS

In a phase II protocol, 26 patients underwent neoadjuvant radiochemotherapy. Subsequently, a radical lymphadenectomy was performed during surgery. The extent of tumor regression was determined according to the methodology initially described by Salzer-Kuntschik for osteosarcoma: Grade I: no vital tumor cells, grade II: some tumor cells, grade III: less than 10 % vital tumor cells, grade IV: 10-50 % vital tumor cells, grade V: more than 50 % vital tumor cells, grade VI: no effect of chemotherapy.

RESULTS

Complete pathologic response was seen in 30.7 % of primary tumors, in 38.5 % of mediastinal lymph nodes, and in 23 % of corresponding specimens simultaneously. Median survival was 34.7 months for those patients with grade I, 12.6 months with grade II, and 8.9 months for patients showing a grade III/IV regression in mediastinal nodes. Response rate to neoadjuvant chemotherapy in mediastinal nodes proved to be the only statistically significant parameter for long-term survival: In cases with no vital tumor cells in the operation specimen, median survival was 34.7 months in comparison to those with vital cells showing a median survival of only 11.4 months (P = 0.01).

CONCLUSION

Patients with locally advanced NSCLCs can enjoy long-term survival after multimodal therapy. However, the complications related to therapy are considerably. Especially, clearance of tumor cells from mediastinal lymph nodes is an important independent prognostic factor.

[Apoptosis and tumor regression in locally advanced non-small cell lung cancer with neoadjuvant therapy]

Dysregulation of apoptosis is closely associated with malignant cell transformation. On the other hand, apoptosis is induced by chemotherapy or irradiation. Therefore, in 54 patients with locally advanced non-small cell lung cancer (NSCLC, 36 squamous cell carcinomas, 18 adenocarcinomas, stage IIIA/IIIB), apoptotic indices were comparatively analysed before onset and after termination of neoadjuvant therapy. The results were compared with the response to neoadjuvant therapy (extent of therapy-induced tumour regression) as well as the survival times. A statistically significant difference could not be established between pre-therapeutically and post-surgically established apoptotic indices (mean values: 0.93% vs. 1.1%). Neither before therapy nor after surgery did the apoptotic indices show a significant predictive value concerning different overall survival times. These results suggest that neoadjuvant therapy does not modify the extent of apoptosis in lung cancer in the long term. Only a few weeks after the completion of the neoadjuvant chemoradiotherapy this contributes to a net proliferation of the residual tumour tissue which is largely equivalent to that of the untreated tumour.

[Neoadjuvant therapy in non-small cell lung cancer. Prognostic impact of "mediastinal downstaging"]

In the course of a prospective multicenter study, 40 (26 squamous cell and 14 adenocarcinomas) patients with stage IIIA and IIIB non-small cell lung cancer (NSCLC) were submitted to surgery after neoadjuvant radiochemotherapy. Pretherapeutic clinical lymph node status was compared to the lymph node involvement established in the resection specimens. Therapy-induced tumor regression was classified according to a three-step tumor regression grading system. In 29 patients (72.5%) a downward shift in lymph node involvement could be established,whereas in 27.5% ( n=11) pretherapeutic lymph node status was maintained. Of 26 patients with post-therapeutic N0 or N1 status, 21 revealed less than 10% vital tumor tissue in the resection specimens (regression grades IIb or III). Patients with post-therapeutic N0 or N1 lymph node status were found to have a survival benefit compared to patients with N2 lymph node involvement, though this difference was not statistically significant (p=0.27). On the other hand, tumor regression showed a significant correlation to the overall survival period (p=0.02). Thus, therapy-induced tumor regression grading seems to be a more precise method to predict the outcome of the disease.

Grading of tumor regression in non-small cell lung cancer : morphology and prognosis

OBJECTIVE

Different types of multimodality therapy, including chemoradiotherapy and surgery, increasingly are being used for the treatment of patients with locally advanced non-small cell lung cancer (NSCLC; stages IIIA and IIIB). In this context, the applicability of a morphologic regression grading and its prognostic value were investigated.

PATIENTS AND METHODS

In a multicenter phase II trial, 54 patients with locally advanced NSCLC received neoadjuvant bimodality treatment (ie, two cycles of ifosfamide, carboplatin, and etoposide, followed by twice-daily radiation up to 45 Gy with simultaneous administration of carboplatin and vindesine). Forty patients underwent resections. Using the corresponding resection specimens of the primary and regional lymph nodes, the following regression grading was established: grade I, no regression or only spontaneous tumor regression; grade II, morphologic evidence of therapy-induced tumor regression with at least 10% (grade IIa) or < 10% (grade IIb) vital tumor tissue; and grade III, complete tumor regression with no evidence of vital tumor tissue. Regression grading then was correlated with the survival time.

RESULTS

Three tumors were classified as regression grade I, 10 were classified as regression grade IIa, 20 were classified as regression grade IIb, and 7 were classified as regression grade III. Patients with tumors of regression grades IIb or III showed significantly longer survival times than those with tumors of regression grades I or IIa (median survival time, 36 vs 14 months, respectively; 3-year survival rate, 52% vs 9%, respectively; p = 0.02). These survival times were also compared for patients who had undergone complete resection (median survival time, not reached vs 23 months, respectively; 3-year survival rate, 56% vs 11%, respectively; p = 0.03). The presurgical clinical response after patients had received neoadjuvant multimodality therapy had no predictive value in assessing the extent of therapy-induced tumor regression in the resection specimen.

CONCLUSIONS

After neoadjuvant therapy of patients with NSCLC, the proposed tumor regression grading was of predictive value for long-term survival. Beyond the achievement of complete tumor resection (R0), a therapy-induced tumor regression of < 10% of vital tumor tissue is pivotal for superior long-term outcomes.

Relationship of c-myc and erbB oncogene family gene aberrations and other selected factors to ex vivo chemosensitivity of ovarian cancer in the modified ATP-chemosensitivity assay

A pilot study on relationships of selected molecular factors [erbB-1, erbB-2, erbB-3, and c-myc oncogene average gene copy numbers (AGCN); steroid receptors and pS2 gene expression; tumor cells' DNA values] to the ex vivo chemosensitivity of ovarian cancer in a modified adenosine triphosphate cell viability chemosensitivity assay (ATP-CVA), was performed. Despite the relatively small number of patients, numerous correlations among the factors tested were found. Nevertheless, only c-myc gene dosage positively affected ex vivo chemosensitivity of tumors tested.

c-myc oncogene gene dosage, serum CEA and CA-15.3 antigen levels, and cellular DNA values in relation to ex vivo chemosensitivity of primary human breast cancer

A pilot study on relationships of selected molecular factors (c-myc oncogene average gene copy numbers (AGCN); serum CEA and CA 15.3 antigen levels; tumor cells' DNA values), to the ex vivo chemosensitivity of primary female human breast cancer in a modified adenosine triphosphate cell viability chemosensitivity assay (ATP-CVA), was performed. Four drug combinations were tested. A group of 75 cases of female primary breast cancer was assessed. Numerous correlations were found among molecular factors tested but none, with the exception of tumor grading, of these reflected ex vivo chemosensitivity of tumors tested. The results suggest that the parameters tested may not be important factors related to adjuvant chemoresponsiveness of primary human breast cancer to tested drug combinations.

Human papillomavirus genotypes in cervical cancer with different histological features

We report the case of a 32-year-old woman having developed two cervical cancers synchronously, an adenocarcinoma and a squamous cell carcinoma. Polymerase chain reaction with the general primers GP5/GP6 and a subsequent enzyme-linked immunosorbent assay to detect human papillomaviruses (HPV) resulted in isolation of HPV 33 in the squamous cell carcinoma and HPV 18 in the adenocarcinoma. This is the first reported case of two histologically different synchronous cervical cancers with this distinct HPV expression pattern, and further confirms the association of certain 'high-risk' HPV genotypes to different histological features of carcinoma. Furthermore, the important role of microdissection for gaining tumor tissue of different areas in molecular diagnostics is supported.

Relationship of c-myc and erbB oncogene family gene aberrations and other selected factors to ex vivo chemosensitivity of ovarian cancer in the modified ATP-chemosensitivity assay

A pilot study on relationships of selected molecular factors [erbB-1, erbB-2, erbB-3, and c-myc oncogene average gene copy numbers (AGCN); steroid receptors and pS2 gene expression; tumor cells' DNA values] to the ex vivo chemosensitivity of ovarian cancer in a modified adenosine triphosphate cell viability chemosensitivity assay (ATP-CVA), was performed. Despite the relatively small number of patients, numerous correlations among the factors tested were found. Nevertheless, only c-myc gene dosage positively affected ex vivo chemosensitivity of tumors tested.

c-myc oncogene gene dosage, serum CEA and CA-15.3 antigen levels, and cellular DNA values in relation to ex vivo chemosensitivity of primary human breast cancer

A pilot study on relationships of selected molecular factors (c-myc oncogene average gene copy numbers (AGCN); serum CEA and CA 15.3 antigen levels; tumor cells' DNA values), to the ex vivo chemosensitivity of primary female human breast cancer in a modified adenosine triphosphate cell viability chemosensitivity assay (ATP-CVA), was performed. Four drug combinations were tested. A group of 75 cases of female primary breast cancer was assessed. Numerous correlations were found among molecular factors tested but none, with the exception of tumor grading, of these reflected ex vivo chemosensitivity of tumors tested. The results suggest that the parameters tested may not be important factors related to adjuvant chemoresponsiveness of primary human breast cancer to tested drug combinations.

Lack of squamous cell lung carcinoma in vitro chemosensitivity to various drug regimens in the adenosine triphosphate cell viability chemosensitivity assay

A pilot study on squamous cell lung carcinoma (LC) chemosensitivity in adenosine triphosphate cell viability chemosensitivity assay (ATP-CVA) was performed. Besides the histological investigation, a modified ATP-CVA was used for the analysis of cancer cell chemosensitivity to four drug regimens, including topotecan, a promising agent for non-small-cell lung cancer (NSCLC) chemotherapy. Results of in vitro chemosensitivity testing showed chemoresistance or only weak response in the predominant amount of tumors.

Multicentric metachronous central carcinoid of the lung: a case report

A 51-year-old female patient with metachronous multiple central typical carcinoid represents the subject of the case discussed. The patient underwent bronchoplastic surgery in order to remove the first carcinoid tumor twelve years ago. She was readmitted to the hospital following a long tumor-free period of disease when two new central carcinoids were diagnosed. The carcinoids were first treated by rigid bronchoscopical removal of the tumors followed by laser coagulation of the bases. Bronchoscopic follow-up one year after the treatment did not reveal any pathological findings.

[Clinical importance of histology, grading and ploidies in primary breast cancer]

OBJECTIVE

In order to characterise carcinoma of the breast the determination of ploidy can be used in addition to established prognostic factors such as histology and grading. The aim of the investigation was to establish the association between histology, grading and ploidy and to indicate the prognostic and predictive value of these parameters in relation to disease free survival (DFS) and overall survival (OS).

MATERIAL AND METHODS

125 consecutive cases of primary breast carcinoma occurring between the years 1992-1995 were surveyed. The median follow up time lasted 45 months. Correlation analyses were carried out using the Chi-square test, Kaplan-Meier (univariate) and Cox (multivariate) methods.

RESULTS

Histology and grading showed no correlation to ploidy but seems to be of importance for DFS in node-negative breast carcinoma. Ploidy did not influence neither DFS nor OS. Ductal histology appeared to be a useful factor in predicting the response of cases treated with an anti-oestrogen (Tamoxifen) since in this group a higher relapse rate of 25% occurred.

CONCLUSIONS

Ploidy appears not to be of clinical importance.

Lack of squamous cell lung carcinoma in vitro chemosensitivity to various drug regimens in the adenosine triphosphate cell viability chemosensitivity assay

A pilot study on squamous cell lung carcinoma (LC) chemosensitivity in adenosine triphosphate cell viability chemosensitivity assay (ATP-CVA) was performed. Besides the histological investigation, a modified ATP-CVA was used for the analysis of cancer cell chemosensitivity to four drug regimens, including topotecan, a promising agent for non-small-cell lung cancer (NSCLC) chemotherapy. Results of in vitro chemosensitivity testing showed chemoresistance or only weak response in the predominant amount of tumors.

Amplification of erbB-4 oncogene occurs less frequently than that of erbB-2 in primary human breast cancer

ErbB-4 protein is a recently discovered member of the ErbB family. The role of ErbB-4 protein in mammary-gland tissue has not been definitively established. To date, the expression of erbB-4 in breast tissue has been determined in only a few cases and, to the best of our knowledge, its amplification has not been examined. We therefore used the double differential polymerase chain reaction (ddPCR) for determination of the amplification profile of erbB-4 and erbB-2, another gene from the ErbB family, in human primary breast cancer specimens. We examined the amplification of the genes in 20 normal breasts and 176 invasive breast cancer samples. Amplification of erbB-2 was detected in 19% and erbB-4 in 13% of the samples studied. Co-amplification of the two oncogenes was found in only five out of 176 samples. Human breast cancer-derived cell lines in most cases overexpress both erbB-2 and erbB-4 (Beerli et al., 1995. Mol. Cell Biol. 15, 6496-6505; Han et al., 1995. Proc. Natl. Acad. Sci. USA 92, 9747-9751), but data on separate erbB-2 overexpression, without overexpression of erbB-4, were also reported (Wosikowski et al., 1997. Clin. Cancer Res. 3, 2405-2414). At the gene level, we found that co-amplification of the genes in the case of human breast cancer is rare. Moreover, an inverse association of the erbB-4 amplification with estrogen receptor activity and direct correlation with the tumor size were found. Due to these correlations, erbB-4 oncogene amplification can be assumed to be of prognostic or predictive value in the diagnosis of breast cancer.

Analysis of long-term survival in patients with locally advanced non-small cell lung cancer

Neoadjuvant combined radiochemotherapy followed by definitive tumor resection improved survival in patients with locally advanced non-small cell lung cancer (NSCLC). Fifty-four patients (NSCLC IIIa + IIIb) were treated with combined radiochemotherapy within a phase I/II study. Twenty-six patients had been resected after combined neoadjuvant treatment and this group was evaluated concerning long-term survival. The median survival for patients with stage IIIa tumor was calculated to be 26 months and 13 months for patients with IIIb status. Patients with no viable tumor cells in the mediastinal lymph nodes had a significantly better survival probability than patients with residual microscopic lymph node disease (p=0.038). Patients with no viable tumor cells had a 1-year (2-year) survival rate of 100% (60%) versus 58% (42%) for patients with residual microscopic tumor in the mediastinal nodes. No significant difference between the N1- and the N2-status was seen. Hence, response to neo-adjuvant radiochemotherapy seems to be an additional important prognostic factor in patients with advanced NSCLC.

Tumour regression in non-small-cell lung cancer following neoadjuvant therapy. Histological assessment

In the scope of a prospective multi-centre study after neoadjuvant combined chemotherapy (carboplatin, ifosfamide, etoposide, vindesine) and radiotherapy (45 Gy) 40 resection specimens of locally advanced non-small-cell lung cancer were analysed in order to establish reproducible pathological/anatomical results of tumour regression. Resection specimens of 28 squamous cell carcinomas and 12 adenocarcinomas were investigated using serial sections of the primary lesion. The mean age of the patients was 57 years. The results were compared to spontaneous regressive changes in a control group of 50 untreated non-small-cell lung cancers. Marked scarry fibrosis in the region of the former primary tumour, concentric foci of fresh tumour necroses and surrounding foam cell clusters with transition into vascular granulation tissue could be established as characteristic features of therapy-induced tumour regression, whereas untreated carcinomas revealed necroses with adjoining vital tumour tissue. Using a three-step regression system, 3 tumours could be classified as grade I (no or only slight tumour regression), 10 tumours as grade IIA (marked but incomplete tumour regression, more than 10% vital tumour tissue), 20 tumours as grade IIB (less than 10% vital tumour tissue) and 7 tumours as grade III (complete tumour regression without vital tumour tissue). After a median follow-up period of 32.3 months in patients with grade IIB or III tumour regression ("responders") the median survival time of 27.9 months was found to be significantly longer than in patients with grade I or IIA tumour regression ("non-responders") with a median survival period of 13.7 months (log-rank test, P = 0.020). The resection specimens analysed, which were obtained 7 weeks (on average) after the end of radiochemotherapy, did not show specific changes due to preoperative therapy, but quite characteristic histological alterations in the former tumour area were registered, which had been induced by combined neoadjuvant radiation and chemotherapy. The grade of therapy-induced tumour regression could be shown to be a significant prognostic factor in non-small-cell lung cancer.

[Regression grading of neoadjuvant non-small-cell lung carcinoma treatment]

In the scope of a multi-center-study 35 resection specimens from patients with locally advanced non-small cell lung cancer after neoadjuvant chemotherapy and radiation were processed histologically and graded according to the following regression grading system: grade I: no or only slight, in general spontaneous tumor regression, grade IIa: incomplete tumor regression with more than 10% and grade IIb less than 10% vital tumor tissue as well as grade III: complete tumor regression. In 15 patients with grade II a to III tumor regression roughly concentric foci of various size with a sequence of central tumor necrosis, narrow foam cell rim, vascular granulation tissue and peripheral scar formation were demonstrated as characteristic feature of response to neoadjuvant therapy. In patients with grade IIb to III tumor regression ("responders") median survival time of 27.9 months was significantly longer than in patients with grade I to II a tumor regression ("non-responders") with a median survival time of 12.7 months.

[Chlorinated carbohydrate content of fetal and pediatric organs and tissues]

Organic halogens are used as pesticides and in chemical industries. They are secreted with breast milk and accumulated in fat tissue of infants. Organic halogens can be found already in newborns. We analysed polychlorinated biphenyl (PCB), DDT, hexachlorocyclohexane (HCH), and heptachlor in subcutaneous fat tissue and other tissues (placenta, liver, kidney, lung, brain, thymus, muscle, heart) of 34 fetuses and dead children. These substances were found regularly in placenta, in fetal subcutaneous fat tissue and in fetal organs. They therefore can influence possibly early and sensitive stages of intrauterine development. The average concentrations found in fetal fat tissue were: PCB 0.7 mg/kg fat tissue, DDT 0.7 mg/kg, HCH 0.14 mg/kg, and heptachlor 0.03 mg/kg.

[Prolactin producing hypophyseal carcinoma. Case report of an extremely rare metastatic tumor]

A 59-year-old male patient was transnasally operated on because of a pituitary adenoma with hypopituitarism. A second operation and X-ray therapy followed a half year later due to recurrent tumor. Both neoplasmas were classified as sparsely granulated prolactin cell adenomas. Immunohistochemical studies revealed strong immunoreactivity for prolactin and FSH in the tumor cells of both the pituitary adenoma and the recurrent tumor. Two years later the prolactin plasma levels were extremely elevated. A tumor in the liver was identified. Biopsy revealed a solid endocrine tumor containing prolactin by immunohistology. Due to structural and immunohistological similarities this tumor could be identified as a metastasis of the pituitary tumor. After 5 months of therapy the patient died from thrombembolism. Post-mortem studies confirmed the diagnosis of a metastasizing prolactin-secreting pituitary carcinoma. Only six similar cases have been reported in the literature. Our case report confirms the experience with 35 definite pituitary carcinomas reparted in the current literature: malignant pituitary tumors develop after pituitary surgery and can be identified not from the pituitary tumor, but only from its metastases.

Prognostic relevance of aberrations in the erbB oncogenes from breast, ovarian, oral and lung cancers: double-differential polymerase chain reaction (ddPCR) for clinical diagnosis

We have determined the average gene copy numbers (AGCN) of the erbB-1 gene, encoding the epidermal growth factor receptor (EGF-R), the erbB-2 and the erbB-3 genes in breast, ovarian, oral, and lung cancer tissue by using double-differential PCR (ddPCR). The ddPCR method comprises the co-amplification of the single-copy gene HBB, the erbB-1, erbB-2 and erbB-3 oncogenes and the second single-copy reference gene SOD2 under equal reaction conditions. In a retrospective study the AGCN of the erbB genes and the time up to the appearance of metastases were subjected to life-table analysis in 128 women with primary breast cancer. Patients whose breast cancer tissue showed an AGCN for erbB-1 of less than 0.4 and greater then 1.6, as expected from the literature, for erbB-2 of greater than 2.0 and for erbB-3 of less than 1.75 had decreased disease-free survival (DFS). The quotient of erbB-1 and erbB-2 AGCN was the most significant in multivariate Cox analysis followed by nodal status and progesterone receptor status. In extensive studies a similar association between erbB AGCN and metastasis was seen in ovarian cancer and oral cancer, though erbB oncogene aberrations in those entities were not as frequent as in breast cancer. The AGCN of erbB oncogenes may not be of prognostic value in untreated lung cancer patients.

Double-differential PCR for gene dosage estimation of erbB oncogenes in benign and cancer tissues and comparison to cellular DNA content

Competitive and differential quantitative PCR methods circumvent the limiting factors of PCR which cause poor reproducibility. We describe the development and performance evaluation of another quantitative PCR method, double-differential PCR (ddPCR). The ddPCR method comprises the co-amplification of the single-copy gene HBB, the erbB-1, erbB-2 and erbB-3 oncogenes and the second single-copy reference gene SOD2 under equal reaction conditions. The ratio of band intensities of the PCR products in silver-stained polyacrylamide gels expresses the average gene copy number (AGCN) per cell of the erbB oncogenes. The coefficient of variability (CV) was less than 25% for an AGCN of 1. The PCR data were in correlation to the results from dot blotting. DNA image analysis did not reveal any correlation between DNA content and gene dosage deviation of the erbB oncogenes. The method was applied to normal breast tissue, benign breast diseases, breast cancer tissue and lymph node metastases. We suggest this method as being reproducible, low cost and rapid, and therefore suitable for clinical studies on erbB oncogene dosage estimation.

[Necrotizing enterocolitis in the newborn infant. Pathogenetic risk factors in a 3 year analysis]

In a clinical study possible risk factors causing necrotizing enterocolitis (NEC) were studied in 17 preterm infants with NEC and compared with a control group of 17 healthy preterm infants. We found a more frequent rate of blood exchange transfusions and a lower rate of breast milk feeding in patients who later developed NEC than in the control group. But there were no differences between both groups concerning factors promoting hypoxia of the gut, the number of infections, antibiotic treatment, or hyperosmolar enteral feeding. The preterm infants with NEC did not show any characteristics in history, physical examination and clinical course. These children could not be distinguished as a risk group for this illness from the newborn infant control group. Therefore, with the exception of breast milk feeding, no special prevention of the necrotizing enterocolitis can be recommended.

[Multifocal bronchial cancer]

Since the entire surface of the bronchial mucosa is exposed to carcinogenic stimuli, the possibility of developing multiple primary lung carcinomas must be discussed. Multiple primary lung carcinomas do not necessarily occur simultaneously (synchronous), they can also develop successively (metachronous). They can be localized ipsilateral as well as contralateral, and histologically they have an identical or different character. In our study of 612 patients with bronchogenic carcinoma we found 18 patients (2.9%) to have a synchronous multiple primary carcinoma. The growing clinical relevance of the diagnosis of the multiple primary bronchogenic carcinoma--which is certainly diagnosed to rarely--and the distinction from metastases will be discussed.

[Social indication for hospitalization. Annual analysis of the pediatric department of the Magdeburg district hospital]

The patients' data of 156 children hospitalized on account of social indication were analysed at the Clinic for Pediatrics of Magdeburg District Hospital. Reasons for socially indicated hospitalization were: proved or imminent neglecting of children (49%), insufficient nursing of sick children (31%), suspected ill-treatment (8%), serious family troubles temporarily preventing nursing and safety of children (12%). Neglected hygienic condition of the body, improper nutrition of malnutrition, physical and mental lagging behind might be evidence for the social sufferings of children. Mothers of children obtaining in-patient treatment as a result of social indication predominantly lack lasting partnerships. They are Less qualified concerning vocational training or gave birth to their first child at a comparatively early age. There is an urgent necessity of closely cooperating between the Clinic for Pediatrics, the Maternity Advisory Centre, the Youth Well-Fare Service and the Department of Youth-Well-Fare in order to detect the children concerned in time to be able to find the best possible solution for the future life of the children without delay.

[The tumorlet carcinoid in bronchiectasis-changed lungs. An example of a multifocal, endocrine tumor]

Tumorlets of the lungs are multifocal hyperplasias of endocrine cells which may develop via nodular hyperplasia into peripheral, occasionally also metastatic, carcinoids. They are observed with a particular frequency in bronchiectasis. Resected material obtained from patients with bronchiectasis (4 women, 3 men, mean age 43.5 years, range 19-66 years) were submitted to conventional histological studies employing HE, PAS and van Gieson staining, and also to an immunohistological analysis. Conventional staining sufficed to identify endocrine cell proliferations in the scarred lung tissue in 3 preparations. An assignment to bronchioles and alveoli with conventional histology was, in view of the extensive scarring of the lung parenchyma, very difficult, but was accomplished with the aid of immunohistological investigation. As a multifocal tumour, the tumourlet suggests itself as a model, employing immunohistochemistry, for studying the formal genesis of neuroendocrine tumours of the lung, since it shows the earliest intra-epithelial neoplastic transformations through in situ tumour to carcinoid.

[The acardius amorphus]

We report on an acardius in a 47-year old tenthgravida. The postnatally detected acardius did not cause any obstetrical problems. The following theory seems to be the most suitable explanation for the development of an acardius: in a twin (multiple) pregnancy with blood vessel anastomoses between both twins, a twin with a haemodynamic advantage supplies the other one with oxygen-deprived blood; the latter thus becomes an acardius.

[Immunohistochemical diagnosis of occult breast cancer]

The techniques associated with immunohistochemistry are of major interest in modern tumour diagnosis. Their simple application provides a wider scope for diagnosis by increasing the possibilities of characterising tumour cells. In particular, the combination of various tumour markers has led to a better understanding of tumour histogenesis. If the primary tumour is unknown and only metastases are available for diagnosis, further important information can be gained allowing a correlation with the origin of the metastases. In three own cases an occult carcinoma of the female breast could be diagnosed pre-operatively via immunohistochemistry techniques. Since no marker is available that reacts specifically with cells of metastasizing mammary cancer, lymph node metastases have been examined with several different markers. For that purpose, the epithelial membrane antigen (EMA), Thomsen-Friedenreich-antigen (T-Ag) and alpha-lactalbumin (ALA) have been used to point out several pathways of cell metabolism. It could be demonstrated that the prospective use of the three markers is of the highest value to make diagnosis easier and safer than by interpreting the morphological appearance. The diagnostic value of tumour markers is an important step forward, especially in the interpretation of tumour cell embolism, macrometastases and micrometastases in regional lymph nodes.

[Intramural gas collection in the small bowel (author's transl)]

Intramural gas collection in a bowel segment is an important roentgenological sign, consistent with necrosis of the bowel wall. This is demonstrated by an example of jejunal volvulus and an inflammatory conglomeration of intestine. The diagnostic interpretation must be completed by the clinical picture and other signs of intestinal ischemia.