Clinical and histopathologic factors related to prognosis in primary squamous cell carcinoma of the vagina

The goal of this retrospective study concerning primary carcinoma of the vagina (PCV) was to analyze clinical and histopathologic prognostic factors in one of the largest known material, which comprised 314 patients. PCV is a rare disease, and the majority of published studies are based on small materials; therefore, the established knowledge concerning prognostic factors is insufficient. Routine treatment is based on irradiation with risk for undertreatment or overtreatment, which leads to unnecessary complications in the absence of prognostic factors. The overall 5-year disease-specific survival rate in this study was 45% and in stage I 75%. In the univariate statistical analysis, several factors correlated significantly with disease-specific survival. However, in the multivariate analysis, there were only three factors that independently could predict poor survival-high age at diagnosis, large tumors (> or =4 cm), and advanced stage. Common background factors with no prognostic significance were prior hysterectomy, other gynecological malignancies, and pelvic irradiation. In conclusion, this study has elucidated three strong prognostic factors that might be considered in the choice of therapy and also for modification of the FIGO guidelines. Increased knowledge concerning complementary biologic markers to discriminate between low- and high malignant tumors is however of great importance.

Clinical and histopathologic factors related to prognosis in primary squamous cell carcinoma of the vagina

The goal of this retrospective study concerning primary carcinoma of the vagina (PCV) was to analyze clinical and histopathologic prognostic factors in one of the largest known material, which comprised 314 patients. PCV is a rare disease, and the majority of published studies are based on small materials; therefore, the established knowledge concerning prognostic factors is insufficient. Routine treatment is based on irradiation with risk for undertreatment or overtreatment, which leads to unnecessary complications in the absence of prognostic factors. The overall 5-year disease-specific survival rate in this study was 45% and in stage I 75%. In the univariate statistical analysis, several factors correlated significantly with disease-specific survival. However, in the multivariate analysis, there were only three factors that independently could predict poor survival—high age at diagnosis, large tumors (≥4 cm), and advanced stage. Common background factors with no prognostic significance were prior hysterectomy, other gynecological malignancies, and pelvic irradiation. In conclusion, this study has elucidated three strong prognostic factors that might be considered in the choice of therapy and also for modification of the FIGO guidelines. Increased knowledge concerning complementary biologic markers to discriminate between low- and high malignant tumors is however of great importance.

Gain of chromosome 3q is an early and consistent genetic aberration in carcinomas of the vulva

The aim was to determine whether specific gains of chromosome 3q and laminin-5gamma2-chain expression can improve early detection of invasive capacity in precancerous and squamous cell carcinoma of the vulva (VSCC). Six VSCC and three precancerous lesions were studied. Multicolor fluorescence in situ hybridization (FISH) probe sets were applied to nuclei suspensions prepared from archival material using the Hedley method. The probe panel consists of the centromers of chromosome 7, chromosome 3, and the TERC gene residing on the long arm of chromosome 3. Laminin-5gamma2-chain immunohistochemical analysis was performed on corresponding specimens and was expressed only in the VSCC. The genome-specific FISH analysis revealed 3q amplification in 43% of the nuclei analyzed for the VSCC and 22% of the nuclei for the precancerous lesions. Low-level 3q amplifications were found in precancerous lesions with an average fold increase of 1.15 for 3q. The invasive lesions showed higher average fold increases for 3q, averaging 1.32. Laminin-5gamma2-chain protein was expressed only in VSCC, whereas 3q gains were observed both in precancerous lesions and in VSCC, indicating that gain of chromosome 3q is an early and consistent event during carcinogenesis of VSCC.

Gain of chromosome 3q is an early and consistent genetic aberration in carcinomas of the vulva

The aim was to determine whether specific gains of chromosome 3q and laminin-5γ2-chain expression can improve early detection of invasive capacity in precancerous and squamous cell carcinoma of the vulva (VSCC). Six VSCC and three precancerous lesions were studied. Multicolor fluorescence in situ hybridization (FISH) probe sets were applied to nuclei suspensions prepared from archival material using the Hedley method. The probe panel consists of the centromers of chromosome 7, chromosome 3, and the TERC gene residing on the long arm of chromosome 3. Laminin-5γ2-chain immunohistochemical analysis was performed on corresponding specimens and was expressed only in the VSCC. The genome-specific FISH analysis revealed 3q amplification in 43% of the nuclei analyzed for the VSCC and 22% of the nuclei for the precancerous lesions. Low-level 3q amplifications were found in precancerous lesions with an average fold increase of 1.15 for 3q. The invasive lesions showed higher average fold increases for 3q, averaging 1.32. Laminin-5γ2-chain protein was expressed only in VSCC, whereas 3q gains were observed both in precancerous lesions and in VSCC, indicating that gain of chromosome 3q is an early and consistent event during carcinogenesis of VSCC.

Primary carcinoma of the vagina: factors influencing the age at diagnosis. The Radiumhemmet series 1956-96

The objective to this retrospective study of 341 cases of primary carcinoma of vagina (PCV) diagnosed between 1956 and 1996 was to find whether epidemiological, clinical, and histopathological variables were related to the age at diagnosis of patients with PCV. The univariate statistical analysis showed that younger age at diagnosis significantly correlated with a history of cervical dysplasia, hysterectomy, gynecological infections, and tumors located in the upper part of the vagina, whereas older age at diagnosis significantly correlated with late menarche and exophytically growing tumors. In the multivariate regression analysis, the remaining independent predictors were a history of cervical dysplasia and age at menarche. Further, parity >/=4 as well as nulliparity, smoking, and unstable marital status were more common among patients with PCV than among those in the general Swedish female population. This study indicates that the etiology of vaginal carcinoma may be age related. In young patients, the disease seems to be etiologically related to cervical neoplasia and thus human papillomavirus (HPV) dependent. However, in the most common age group, the older patients, there might be another (probably non-HPV-related) etiology associated with hormonal factors and trauma to the vagina.

Laminin-5 gamma2-chain expression and DNA ploidy as predictors of prognosis in endometrial carcinoma

Expression of the laminin-5 gamma2-chain in carcinoma cells has been implicated in tumor invasion. The aim was to investigate the expression and prognostic significance of the ln-5 gamma2-chain compared with clinicopathological factors and tumor cell DNA ploidy in endometrial carcinoma. Histological specimens from 80 endometrial carcinomas were examined with respect to immunohistochemical ln-5 gamma2-chain expression and correlated to the clinicopathological characteristics, DNA ploidy, and survival. Sixty-eight of 80 investigated cases were judged to be positive for the ln-5 gamma2-chain. Ln-5 gamma2-chain did not show any correlation to stage, histopathological subtype, grade, and DNA ploidy. In univariate analyses, advanced stage (p < 0.001), nonendometrioid carcinoma (p = 0.030), low grade (p < 0.001), aneuploid tumors (p < 0.001), and ln-5 gamma2-chain expression (p = 0.017) were highly associated with poor survival. Aneuploid tumors in combination with strong ln-5 gamma2-chain expression were significant predictors (p < 0.001) of poor prognosis. In multivariate analyses including stage, histopathological subgroup, grade, DNA ploidy, and ln-5 gamma2-chain expression, all lost their significant prognostic information except for stage (p < 0.001) and grade (p < 0.05). Ln-5 gamma2-chain expression and DNA ploidy both as a single parameter and in combination were demonstrated to be signifi- cant prognostic factors in univariate analysis. However, stage and grade provided more useful clinical information beyond histopathological subgroup, DNA ploidy, and ln-5 gamma2-chain expression. The results also indicate that ln-5 gamma2-chain expression is upregulated during the progression of endometrial carcinoma.

Laminin-5 gamma 2 chain as an invasivity marker for uni- and multifocal lesions in the lower anogenital tract

During recent decades it has become apparent that there are two types of vulvar disease: the classic type found in elderly women with unicentric and unifocal lesions, and the type found in younger women, in which precancerous and invasive changes develop in the anogenital lower tract in a multicentric and multifocal fashion, often over a long period of observation. The laminin-5 gamma 2 chain is an extracellular protein that is a component of the basement membrane. Recently its expression has been recognized as a marker in cervical cancer that permits identification of invasive capacity. The aim of our study was to determine if laminin-5 gamma 2 chain antibody can act as a sensitivity marker of invasive capacity in precancerous and invasive carcinoma in women with uni- and multifocal changes in the anogenital tract. The result showed that all patients in the older group of women with invasive carcinoma of the vulva had moderate to high positive expression of the laminin-5 gamma 2 chain. In the group of younger patients with multifocal precancerous changes observed over long periods, most of the patients with vulva intraepithelial neoplasia (VIN) 3 showed laminin-5 gamma 2 chain positivity already in the precancerous changes, and all of them developed invasivity during the period of observation. Normal epithelium without atypia was mostly negative or of low immunoreactivity of laminin-5. In conclusion, positive laminin-5 gamma 2 chain expression seems to indicate the invasiveness potential of precancerous lesions and is also expressed in all investigated invasive carcinomas of the anogenital tract.

Laminin-5 γ 2 chain as an invasivity marker for uni- and multifocal lesions in the lower anogenital tract

Abstract.

Nordström B, Einhorn N, Silfverswärd C, Sjövall K, Tryggvason K, Auer G. Laminin-5 γ 2 chain as an invasivity marker for uni- and multifocal lesions in the lower anogenital tract.

During recent decades it has become apparent that there are two types of vulvar disease: the classic type found in elderly women with unicentric and unifocal lesions, and the type found in younger women, in which precancerous and invasive changes develop in the anogenital lower tract in a multicentric and multifocal fashion, often over a long period of observation.

The laminin-5 γ 2 chain is an extracellular protein that is a component of the basement membrane. Recently its expression has been recognized as a marker in cervical cancer that permits identification of invasive capacity.

The aim of our study was to determine if laminin-5 γ 2 chain antibody can act as a sensitivity marker of invasive capacity in precancerous and invasive carcinoma in women with uni- and multifocal changes in the anogenital tract. The result showed that all patients in the older group of women with invasive carcinoma of the vulva had moderate to high positive expression of the laminin-5 γ 2 chain. In the group of younger patients with multifocal precancerous changes observed over long periods, most of the patients with vulva intraepithelial neoplasia (VIN) 3 showed laminin-5 γ 2 chain positivity already in the precancerous changes, and all of them developed invasivity during the period of observation. Normal epithelium without atypia was mostly negative or of low immunoreactivity of laminin-5. In conclusion, positive laminin-5 γ 2 chain expression seems to indicate the invasiveness potential of precancerous lesions and is also expressed in all investigated invasive carcinomas of the anogenital tract.

Cancer of the vagina: Laminin-5gamma2 chain expression and prognosis

The purpose of this experiment was to investigate the expression and the prognostic impact of the gamma2 subchain of laminin-5 in vaginal malignancies. The outcome of the rare disease primary carcinoma of the vagina is poor and little is known about prognostic markers. The gamma2 chain of laminin-5, an epithelial basement membrane protein, is thought to play a crucial role in tumor cell adhesion, migration, and proliferation, and may thus be an additive potential marker. Archival, paraffin-embedded sections were stained immunohistochemically with an antibody against the gamma2 chain of human laminin-5 protein. The material consisted of 59 cases of primary vaginal malignancies, subdivided into short- and long-time survivors. All invasive malignancies of epithelial origin were positively stained with the antibody against the gamma2 chain. High expression of the gamma2 chain correlated significantly in an univariate analysis with short-time survival (P = 0.041), but in the multivariate analysis only age and tumor size were independent prognostic factors. A significant intercorrelation between large tumors and high gamma2 chain immunoreactivity was found (P = 0.003). These results indicate that laminin-5gamma2 subchain expression in primary vaginal carcinomas is of prognostic impact. However, in a multivariate analysis only patient age and tumor size had independent prognostic value.

Classification of human ovarian tumors using multivariate data analysis of polypeptide expression patterns

Large amounts of data on quantitative gene expression are generated by procedures such as 2-DE analysis of proteins or cDNA microarrays. Quantitative molecular variation may potentially be used for the development of methods for the classification of tumors. We used here the statistical concepts of principal components analysis (PCA) and partial least square analysis (PLS) in an attempt to type ovarian tumors. Using a set of 170 polypeptides, 22 tumors were used to establish a model ("learning set") for classification into 3 groups (benign/borderline/malignant). Eighteen tumors were then used to test the model. Six of 8 carcinomas and 3 of 4 borderline tumors were correctly classified. Two of 6 benign lesions were correctly classified, 3 were classified as borderline and 1 as carcinoma. We conclude that it may be possible to classify tumors according to their constitutive protein expression profile using multivariate analysis, thus making classification by artificial intelligence a future possibility.

Recurrent fallopian tube carcinoma: TP53 mutation and clinical course

Primary fallopian tube carcinoma is a rare, aggressive gynecological cancer; little is known about its cause. Previous studies have indicated that p53 immunopositivity is correlated with short-term survival in primary fallopian tube carcinoma. We examined p53 and p21/WAF1 immunostaining and TP53 mutation in exons 5 to 8 by single-stranded conformation polymorphism and constant denaturant gel electrophoresis in nine cases of primary fallopian tube carcinoma and their metastases/recurrences from patients who survived for between a few months and more than 20 years after diagnosis. We found that 1.) p53 immunopositivity without detectable p21/WAF1 immunostaining did not correlate with TP53 mutations in the conserved domains; 2.) mutations in TP53 occurred in two metastases/recurrences but not in their corresponding primary tumors; 3.) in two cancers, a TP53 mutation was observed in the primary tumor but not in the metastases/recurrences; 4.) constant denaturant gel electrophoresis seems to be more sensitive than single-stranded conformation polymorphism in detecting TP53 mutations; and 5.) in the nine cases studied, p53 immunoreactivity and/or TP53 mutation analysis did not correlate with tumor progression, survival, or response to treatment.

Overestimated risk of second primary malignancies in ovarian cancer patients

Registry-based cohort studies have established an increased risk of developing second primary malignancies (SPM) in patients with a primary ovarian cancer. In order to examine the accuracy of cancer registration with emphasis on registration of SPM, 344 women with ovarian cancer and 379 subsequent SPM, registered between 1958 and 1992 in the Stockholm-Gotland Cancer Registry (SGCR), a division of the Swedish Cancer Registry (SCR), were investigated. Complete records including pathology reports were examined and an additional histopathological evaluation was conducted for a sample of the group. The results revealed that 28 diagnoses of SPM were incorrectly registered (14 cases were misdiagnosed SPM of the gastrointestinal tract, mainly colon and rectum) and 34 women (with 38 SPM) were incorrectly registered with ovarian cancer. Recalculations of the risk of a subsequent cancer were performed on the basis of these findings and the results suggest an overestimation of the risk of developing SPM. Inferences of these findings to other primary sites of multiple malignancies should be made with caution and further studies are needed.

Malignant mixed müllerian tumors of the ovary: histopathologic and clinical review of 36 cases

Among 2,895 malignant ovarian tumor cases referred to Radiumhemmet, Stockholm from 1975 through 1995, 36 were certified to be malignant mixed müllerian tumors. The overall prognosis was poor with only 18% five-year actuarial survival (median survival 16.6 months). Five patients are still surviving after 75, 68, 117, 121, and 168 months, respectively. Fifteen women treated with melphelan, doxorubicin (adriamycin) and cisplatin (MAP) had a five-year actuarial survival of 33.3% and a median survival of 19.8 months. In a multivariate analysis taking into account stage, age, radiation, type of chemotherapy, histopathologic type and completeness of surgery, the most important predictors for survival were stage (stages I-II vs stages III-IV, P < 0.05), histopathologic type (homologous vs heterologous, P < 0.05), and type of chemotherapy (MAP or CAP vs other types, P < 0.05). We concluded that homologous tumor and chemotherapy containing cisplatin, doxorubicin, and melphalan, as well as early stage of the tumor, provided the optimal survival rate.

Two-dimensional gel analysis of protein expression in ovarian tumors shows a low degree of intratumoral heterogeneity

The process of tumor progression leads to the emergence of multiple clones, and to the development of tumor heterogeneity. One approach to the study of the extent of such heterogeneity is to examine the expression of marker proteins in different tumor areas. Two-dimensional gel electrophoresis (2-DE) is a powerful tool for such studies, since the expression of a large number of polypeptide markers can be evaluated. In the present study, tumor cells were prepared from human ovarian tumors and analyzed by 2-DE and PDQUEST. As judged from the analysis of two different areas in each of nine ovarian tumors, the intratumoral variation in protein expression was low. In contrast, large differences were observed when the protein profiles of different tumors were compared. The differences in gene expression between pairs of malignant carcinomas were slightly larger than the differences observed between pairs of benign tumors. We conclude that 2-DE analysis of intratumoral heterogeneity in ovarian cancer tissue indicates a low degree of heterogeneity.

Primary carcinoma of the fallopian tube: comparative genomic hybridization reveals high genetic instability and a specific, recurring pattern of chromosomal aberrations

Primary fallopian tube carcinoma (PFTC) is a rare and highly aggressive tumor. Twelve cases of PFTC (stages IA to IV) were analyzed by comparative genomic hybridization. The most consistent DNA gain was mapped to chromosome arm 3q in 11 of 12 cases. In six cases, the gain of 3q was present as a high level copy number increase (amplification) with a consensus region mapped to 3q26.2-qter. In the 12 cases, other frequent gains were located on chromosome arms 1q (in 11 cases), 2q (in 10), 7q (in 9), 8q (in 9), 5p (in 8), 6p (in 7), 12p (in 7), and 14q (in 6). Frequent copy number losses occurred on chromosome arms 16q (in 8 cases), 22q (in7), 6q (in 6). 8p (in 6), 18q (in 6), Xq (in 6), 1p (in 5), and 17p (in 5). All chromosomes were involved in chromosomal aberrations and the average number of copy alterations per case was 19.7. None of the 12 carcinomas revealed the presence of human papillomavirus (HPV) genomes. All of the cases exhibited crude aneuploidy. Strong p53 immunoreactivity could be observed in 10 of 12 cases while p21/WAF1 expression was low or undetectable. These results indicate that PFTC is a genomically highly unstable cancer, an observation that is in agreement with the poor prognosis associated with this tumor. A high frequency of 3q-gains has also been observed in HPV-related carcinomas of the uterine cervix. However, none of the PFTC was HPV related, suggesting that the 3q-gain is independent from HPV DNA.

Recurrent primary pleomorphic adenomas of salivary gland origin: intrasurgical rupture, histopathologic features, and pseudopodia

BACKGROUND

The rate of tumor recurrence after surgery for benign salivary gland pleomorphic adenoma varies considerably in different clinical settings and seems to depend to a great extent on the surgical technique used. The importance of tumor spillage for subsequent recurrence has recently been questioned. The current follow-up study was undertaken to ascertain whether intrasurgical rupture, tumor spillage, or any histopathologic feature might have had an impact on the rate of recurrence.

METHODS

The medical records of all 255 patients operated on for benign salivary gland pleomorphic adenoma between the years 1974 and 1993 at the Department of Otorhinolaryngology, Huddinge University Hospital, were reviewed. All patients alive in April 1995 (n = 230) were sent a simple questionnaire. Two hundred thirteen of these patients received follow-up. All cases of tumor recurrence after surgery or intrasurgical rupture of the tumor capsule were reviewed histopathologically.

RESULTS

Two (7.1%) of the 28 patients who had macroscopic capsule rupture during surgery experienced recurrence at a later stage. This was not a statistically higher rate than the 4.1% recurrence rate for the rest of the material. As many as 5 of the 9 primary tumors that subsequently recurred (56%) sent fingerlike tumor extensions or pseudopodia outside the pseudocapsule. The rate of occurrence of such structures was statistically higher than that of the tumors that ruptured during surgery (25%) and the examined uncomplicated cases (8%).

CONCLUSIONS

Occurrence of pseudopodia--microscopic fingerlike formations of tumor tissue that extend beyond the main lump of the tumor--is a significant risk factor for local recurrence.

The impact of tumour angiogenesis, p53 overexpression and proliferative activity (MIB-1) on survival in squamous cervical carcinoma

Tumour angiogenesis (antifactor VIII-related antigen antibody), p53 overexpression (DO-1) and proliferative activity (MIB-1) were immunohistochemically analysed for the prediction of long-term survival in 113 patients with squamous cervical carcinoma. The median follow-up time was 82 months (range 72-99). In early stages (IB-IIA), neovascularisation was significantly related to tumour size. Significantly more patients in stage IIA had high tumour vascularity compared to stage IB (P < 0.01) but no significant difference was found between early and advanced stages (IIB-IVB) of cervical carcinoma. p53 overexpression was correlated to the stage of disease (P < 0.01). No relationship was found between tumour angiogenesis, p53 overexpression or MIB-1 and pelvic lymph node metastases, histological subtype or differentiation. Tumours with more than 50% p53 overexpression was significantly correlated with survival in the univariate analysis, but no independent predictive value was found. It is concluded that immunohistochemically detectable p53 overexpression as measured by DO-1 and proliferative activity as measured by MIB-1 seems of no clinical value for the prediction of long-term survival in squamous cervical carcinoma. The predictive value of tumour angiogenesis for survival outcome has still to be determined in squamous cervical carcinoma.

Aggressive endometrial cancer in a young patient

An unusually aggressive case of endometrial cancer in a 30 year old woman is presented. The patient experienced abnormal uterine bleeding, at times requiring blood transfusions, for almost half a year before the diagnosis was revealed. For obvious reasons there is a reluctancy to perform invasive examinations in young women. The diagnostic options are discussed.

HPV-types, cytological and histopathological findings in three groups of women with possible HPV-related disease

OBJECTIVE

The aim of this investigation was to study three groups of women presenting with possible HPV-infection with regard to HPV-types and cervical dysplasia.

METHODS

Eighty women were included. Eighteen of them were present partners to men with condylomas, 20 had clinical vulvar HPV-lesions and 42 were referred due to an abnormal PAP-smear. Samples for HPV-analysis by PCR-technique were taken from the vulva, the portio and the cervical canal. A universal HPV-primer as well as specific primers for HPV 6/11, 16, 18, 31, and 33 were utilized. PAP-smears were taken as well as biopsies from cervix/portio.

RESULTS

Seventy-eight percent had HPV-DNA identified. Sixty-seven percent of those with HPV 16 and/or 18 had dysplasia verified by histopathology and 50% of those with 31 and/or 33. Twenty of 21 women with dysplasia had HPV 16, 18, 31 and/or 33 identified. One woman with dysplasia was HPV-negative. Histopathologically verified CIN were diagnosed in all groups investigated. Women referred for suspicion of CIN significantly more often had HPV detected at the cervix/portio. HPV 6/11 was mostly found in women with condylomas. Apart from this the occurrence of the different HPV types were alike in the three groups.

CONCLUSION

Infection with HPV is a process and the usefulness of different diagnostic methods seems to depend on when during the course of the disease they are used. HPV-findings in women with dysplasia were all associated with oncogenic virus-types. High-risk virus was often found simultaneously with low-risk virus indicating a covariation in the acquisition of the different HPV-types.

Biological malignancy grading in early-stage ovarian carcinoma

The usefulness of adjuvant therapy in early ovarian cancer is a matter of controversy and there is a need for predictive methods to distinguish between low and high risk patients. Specimens from 95 early-stage ovarian cancer patients have been analysed for conventional clinical variables as well as for the biological markers--DNA content, MIB-1, p53, WAF-1--and correlated to survival. Prognostic significance achieved in univariate analysis could be improved by using a score based on several biological markers. Using a score based on DNA content, MIB-1, p53 and WAF-1, a significant predictor could be achieved with the aim of determining the postsurgical therapy. By using this tool, it is hoped that adjuvant therapy can be avoided for one-third of the patients with early-stage ovarian cancer.

Prognostic value of amplification of c-erb-B2 in bladder carcinoma

Amplification of c-erb-B2 is examined in patients with transitional cell bladder carcinoma. In a pilot study we found that the amplification correlated with high tumor grade. Tumor grade is a known prognostic factor. Therefore, we next examined the prognostic value of c-erb-B2 amplification in patients with >16 years of clinical follow-up. The gene copy number was determined, using semiquantitative PCR, in archival formalin-fixed tissues. Twenty-three percent (37/163 patients) showed the amplification. The amplification correlated with grade and stage. Moreover, we found that tumor grade (P < 0.001) and c-erb-B2 amplification (P < 0.001) showed prognostic information for survival. Patients with grade 3 tumors and concomitant c-erb-B2 amplification showed the worst prognosis. Multivariate analysis indicates that grade and c-erb-B2 amplification are independent prognostic factors.

Decreased expression of Ras GTPase activating protein in human trophoblastic tumors

The normally developing placenta undergoes extensive but regulated noninvasive cellular proliferation. Various proto-oncogenes and growth factors have been associated with the regulation of trophoblastic placental growth. Activation of some oncogenes and altered expression of growth factors have been demonstrated in trophoblastic tumors (hydatidiform mole and choriocarcinoma). The ras proto-oncogene plays a key role in the signal transduction cascade of activated growth factors, and is known to be activated or overexpressed in multiple tumor types. Ras GTPase activating protein (RasGAP), a major down-regulator of ras activity, is present at high levels in placenta. To assess the role that Ras-GAP plays in the development of trophoblastic tumors, we performed immunohistochemical analyses with anti RasGAP antibodies of normal placentas, hydatidiform moles, invasive moles, and malignant choriocarcinomas. Normal placentas and noninvasive hydatidiform mole displayed intense positive staining confined to trophoblasts, whereas no staining was observed in the trophoblasts of invasive moles or choriocarcinomas. Thus, there was an inverse correlation between expression levels of RasGAP protein and the invasive potential and malignant phenotype in human trophoblastic tumors. The data indicate that RasGAP may play a regulatory role in trophoblast proliferation and that abolishing its activity may be associated with malignant transformation of these cells.

Long-term adjuvant interferon treatment of human osteosarcoma. A pilot study

During the period from 1971 to 1990 all osteosarcoma patients referred to the Karolinska Hospital without signs of metastases received human leukocyte interferon (IFN) as adjuvant treatment. Patients referred between 1985 and 1990 were given more intensive human leukocyte IFN treatment, i.e. a standard dose of 3 MU s.c. daily for 3-5 years. These 19 patients, all followed for 5 years, were included in a pilot study which entailed patients with central localization where radical surgery was not feasible. Metastases developed in 9 patients, of whom 3 had local recurrences. Sixty-three percent are free of disease at 5 years. Side-effects were negligible and long-term toxicity practically non-existent. It is suggested that a randomized multicenter IFN trial should be instituted on patients with poor prognosis receiving chemotherapy and/or that IFN treatment should be combined with other therapeutic modalities--irradiation, chemotherapy or anti-angiogenic substances--in osteosarcoma.

DNA-ploidy and mutant p53 overexpression in primary fallopian tube cancer

Nuclear DNA content and p53 immunoreactivity were determined in 53 cases of primary fallopian tube cancer (PFTC). All tumors showed a distinctly aneuploid DNA distribution pattern, whereas p53 immunoreactivity was observed in 51% of the cases. If the patients were divided into two groups according to survival time, p53 immunoreactivity was present in 40% of the tumors from patients surviving for more than 8 years and in 65% of tumors from patients who died within 2 years. This difference was not statistically significant (P = 0.438). Patient survival was significantly correlated to the clinical stage (FIGO) (P = 0.0009).

Carcinoma of the fallopian tube. A clinical and histopathologic review. The Radiumhemmet series

A histopathologic and clinical review of the Radiumhemmet series of primary fallopian tube carcinoma (PFTC) treated from 1923 to 1991 revealed that 128 cases fulfilled the diagnostic criteria for PFTC. These cases were staged according to the new FIGO staging rules for PFTC. Survival was studied with respect to prognostic factors such as age, stage, histologic subgroups, degree of differentiation and mode of treatment. The mean age at diagnosis was 56 years. Seventy-four per cent were found to be in stage Ia-IIa and 26 % in stage III-IV. Forty-five per cent were nulliparous and 22 % had evidence of previous pelvic inflammatory disease. Treatment modalities changed during the studied period. Thirty-three per cent of patients underwent surgery with total abdominal hysterectomy and bilateral salpingo-oophorectomy while 67 % were incompletely operated. A trend towards improvement in results was noticed-however, it was not statistically significant. Among the 14 prognostic variables tested in the multivariate analysis the first in rank were stage (P = 0.001) and degree of differentiation of the tumors (P = 0.070). Patients receiving chemotherapy had superior survival rates compared with those without chemotherapy (P = 0.0006) and patients with cisplatinum-containing chemotherapy did better than those without cisplatin.

Combination of granulosa cell tumour and carcinoid in an imitation of appendix vermicularis within a mature teratoma--a unique case

A case of primary carcinoid of the ovary in association with an imitation of appendix vermicularis is presented. These elements were thus parts of a mature teratoma. In the other ovary a granulosa cell tumour with a similar morphology was found. Following surgery no additional treatment was administered and the patient is well 13 years after the diagnosis.

Paget's disease of the vulva: the Radiumhemmet series 1975-1990

Twenty-eight patients with a diagnosis of 'extramammary Paget's disease of the vulva' were referred to the Radiumhemmet, Karolinska Sjukhuset, Stockholm, during the period 1975-1990. A clinical and histopathologic retrospective review was undertaken. Six patients had associated malignancies (21.4%). The disease was considered primary invasive in three cases, whereas three patients later developed an invasive cancer. Surgery-local resection, hemivulvectomy or vulvectomy-was performed in 24 cases. Twelve patients, in which surgery was supposed to be radical with respect to free margins, had a significantly longer recurrence-free survival than 12 patients in which the surgical margins were dubious.

Demonstration of gene-amplification by PCR in archival paraffin-embedded breast cancer tissue

The polymerase chain reaction (PCR) is a powerful tool to examine genetic alterations in tumor samples. We describe a simple, rapid, nonisotopic PCR method to semi-quantitatively determine the number of gene copies in human formalin-fixed paraffin-embedded tissue. The procedure is exemplified by analysis of 15 years old breast cancer samples to determine the presence of amplification of c-erb-B2. The samples were obtained from routine specimens kept in pathological archives. Patients with amplified samples showed a poor prognosis, both for recurrences and death in breast cancer.

Symptoms and diagnostic difficulties in ovarian epithelial cancer

OBJECTIVE

To investigate and analyze symptoms in patients with different types of ovarian cancer.

METHOD

Records of 160 women with ovarian cancer were studied in detail following the patients from first consultation to operation and diagnosis at Sodersjukhuset, Stockholm.

RESULT

No specific group of symptoms could be linked to type or stage of ovarian cancer. Gastrointestinal symptoms were more common in patients with class 1C tumors. Only 21% complained of gynecological symptoms. Women with class 1C cancer had significantly more advanced disease than those with 2C-5C cancer as 77% had a stage III-IV tumor compared with 40% of class 2C-5C patients.

CONCLUSION

Diagnosis of ovarian cancer is difficult due to the multitude of symptoms often appearing late in the disease. The majority of women did not experience symptoms in the genital organs. Methods to encourage early consultation should be investigated.

Adjuvant interferon treatment in human osteosarcoma

An update of the adjuvant trial on osteosarcoma in Sweden comparing patients receiving natural interferon (IFN) alpha with a high-dose chemotherapy group and a nonadjuvant group is presented. The overall survival for the IFN group is 49%, for the chemotherapy group 54%, and for the nonadjuvant group 35%. Trial evaluation was complicated by group differences with respect to various clinicopathologic features of prognostic significance. The role of IFN in the treatment of osteosarcoma can still not be established.

Immunoreactivity with monoclonal antibody A-80 and nuclear DNA content in benign and malignant human breast disease

Immunohistochemical analysis with the monoclonal antibody (MoAb) A-80, recognizing a tumor-associated cytoplasmic mucin-type glycoprotein, and cytometric nuclear DNA assessment were performed on 314 surgical specimens of the human mammary gland. The series included 36 benign conditions, 34 epithelial hyperplasias, 40 carcinomas in situ, and 204 primary invasive carcinomas. Normal breast parenchyma, benign tumors, and other nonmalignant lesions were all of DNA diploid (euploid) type and rarely expressed the A-80 glycoprotein. Differences in MoAb A-80 immunoreactivity and nuclear DNA content were noted among subtypes of epithelial hyperplasias. Fifteen of 34 epithelial hyperplasias were of DNA aneuploid type and the majority were A-80 immunoreactive. Of these 15 immunoreactive aneuploid epithelial hyperplasias, atypical intraductal hyperplasia was the most common subgroup. None of the 19 epithelial hyperplasias of DNA euploid type immunoreacted. Most of the intraductal (33 of 40) and invasive (180 of 204) carcinomas immunostained with MoAb A-80. The majority of the A-80 immunoreactive malignant tumors were of DNA aneuploid type (26 of 33 carcinomas in situ and 108 of 180 invasive mammary carcinomas). The results suggest that expression of the A-80 glycoprotein occurs at an early stage of malignant transformation. Genetically stable (euploid) mammary tumors seem to immunoreact with MoAb A-80 less frequently than genetically unstable (aneuploid) tumor variants. Combined analysis with MoAb A-80 and of nuclear DNA content in premalignant and malignant mammary lesions could be a useful tool of differential diagnostic and prognostic value.

Benign mixed Müllerian tumor of the ovary

A case of benign Müllerian tumor of the ovary in a 53-year old woman is reported. The stromal element consisted of rhabdomyoblasts which clearly indicate that this tumor belongs to the Müllerian family. She remains free of disease 12 months following an abdominal hysterectomy and bilateral salpingo-oophorectomy.

Prognostic factors in cystosarcoma phyllodes. A clinicopathologic study of 77 patients

The authors studied prognostic factors in 77 patients with primary cystosarcoma phyllodes (CSP) of the breast. Median patient age was 50 years of age, and the median follow-up time was 8 years. Sixteen patients (21%) had distant metastases and subsequently died of CSP. Clinical variables such as age, symptom duration, clinical tumor size, and type of surgery were not of prognostic value. Local recurrence was more common among patients treated with breast-conserving surgery than among those treated with mastectomy. However, there was no significant difference between these two subgroups in terms of distant metastasis-free survival or overall survival. The prognostic significance of several histopathologic parameters was also assessed, e.g., stromal cellularity, stromal cellular atypism, mitotic activity, atypic mitoses, stromal overgrowth, tumor contour, tumor necrosis, and heterologous stromal elements. In a multivariate Cox analysis, the only features that were found to be independent prognostic factors were tumor necrosis (P less than 0.05) and presence of stromal elements other than fibromyxoid tissue (P less than 0.01). In summary, additional studies of prognostic factors in CSP are warranted because of the conflicting results in published reports.

Paragangliomas: neuroendocrine features and cytometric DNA distribution patterns. A clinico-pathological study of 22 cases

Paragangliomas from 22 patients with extraadrenal tumours of this type were studied. Neuroendocrine features were examined using immunohistochemical techniques. Twenty-two antisera raised against neuroendocrine "markers", regulatory peptides, serotonin and intermediate filament proteins were studied in this group and cytometric DNA assessments were made by means of image cytometry. One normal and 5 hyperplastic carotid bodies were used as controls in the DNA cytometric investigations. Clinical and/or histopathological evidence of "malignancy" was present in 5 cases. The tumour cells showed heterogeneity with regard to their expression of different peptides, and the immunohistochemical analyses did not permit differentiation between benign and malignant paragangliomas. An euploid nuclear DNA distribution pattern was found in all controls and in 17 of the tumours; all except 1 were clinico-pathologically benign. An aneuploid DNA pattern was observed in 5 of the cases and some malignant features were present in 4 of these cases. DNA data may give further information apart from that obtained from the histopathological findings which may be of value in predicting the biological behaviour of this tumour type.

Prognostic factors in invasive squamous cell carcinoma of the vulva

Histological malignancy grading and its correlation to prognosis were retrospectively investigated in 303 cases of squamous cell carcinoma of the vulva. A scoring system based on several variables is suggested. The scores and the individual histological variables were tested along with clinical factors with a view to predicting survival. Various histological variables including mode of invasion, depth of invasion and nuclear polymorphism, as well as the sum of the scores were good predictors of survival. The study revealed a significantly better survival rate in stage III if no metastases were suspected. An age factor was also found showing that cancer of the vulva has a worse prognosis in older women.

Grading of human urothelial carcinoma based on nuclear atypia and mitotic frequency. I. Histological description

The World Health Organization (WHO) grade II bladder tumors constitute a clinically and histologically heterogeneous group due to imprecise histological definitions. In an attempt to improve this problem 124 transitional cell carcinomas of the bladder were histologically reviewed using a modified Bergkvist system. The grade II tumors were divided into 2 groups, grades IIa and IIb, mainly with reference to the degree of nuclear atypia and number of mitoses. Using definitions possible to express by numerical means, the separation was easy and reproducible. Due to great histological resemblance between certain close grades we propose a new grading system with 3 grades combining I and IIa (grade A), IIb and III (grade B), and a third group (grade C) for the anaplastic tumors.

Grading of human urothelial carcinoma based on nuclear atypia and mitotic frequency. II. Prognostic importance

A grading system was applied in a retrospective study of 124 patients with transitional cell carcinoma of the bladder using a modified Bergkvist system. The intermediate World Health Organization (WHO) grade II tumors were divided into supposedly benign and malignant forms of grades IIa and IIb, respectively. The 5-year survival was 92% for patients with grade IIa urothelial carcinoma, compared to 43% for patients with grade IIb tumors. The corresponding figures for grades I and III tumors were 100 and 44%, respectively. When excluding carcinoma in situ (5-year survival 50%) no patient with a noninvasive tumor (stage Ta) died of bladder carcinoma within 5 years, compared to 50% of those with invasive cancers (stages T1 to T4). We propose a new grading system in which grades I and IIa are embraced as grade A, grades IIb and III as grade B, and grade IV as grade C. The 5-year survival rate in the 3 grades was 94, 44 and 27%, respectively. Grade A seems to represent a type of tumor with universally favorable prognosis, in contrast to grades B and C. This offers practical advantages, since the former can be treated conservatively, whereas the latter need more urgent radical intervention, especially in patients in whom invasive growth is recorded.

Vascular tumours in occlusive disease of the iliac-femoral vessels

Two cases of intraluminal tumours of the iliac-femoral vessels are presented. One was a benign haemangioendothelioma of the common femoral vein and the other a leiomyosarcoma of the iliac artery. Their clinical features were similar to those of patients having venous thrombosis and atherosclerotic occlusive disease respectively. Consequently every physician specialized in vascular disease should be aware of intraluminal tumours as an uncommon explanation of these common clinical pictures.

Endometrial stromal sarcoma of the uterus. A clinical and histopathological study. The Radiumhemmet series 1936-1981

Twenty-eight cases of endometrial stromal sarcoma treated from 1936 to 1981 at Radiumhemmet were reviewed. Histopathologically, 16 were classified as high-grade stromal sarcomas and 12 were of a low grade. A significant relation between mitotic count and relative survival within 10 years of the diagnosis was found (p less than 0.05) showing a more favorable outcome for patients with low counts compared with patients with higher counts. Primary treatment included surgery and radiotherapy in 21 cases. Two advanced cases were only irradiated and five cases were treated with surgery alone. Adjuvant radiotherapy seems to be of benefit in high-grade tumors, demonstrated in a 5-year survival rate of 73%, which exceeds most reported results. Five out of seven women dying of low-grade tumors were diagnosed in an advanced stage.

Mixed müllerian tumours of the uterus--prognostic factors: a clinical and histopathologic study of 147 cases

One hundred and forty-seven women with uterine mixed Müllerian tumours (UMMT) treated at Radiumhemmet from 1936 through 1981 were reviewed. The prognostic value of clinical and histopathologic data was analysed with bivariate and multivariate techniques. Stage, age and abdominal pain were found to be significant predictors of survival. Surgery and combined radiotherapy (intracavitary + external irradiation) gave in stage I, a lower local failure rate (p = 0.006) and better overall survival (p = 0.001) than surgery in combination with either intracavitary or external irradiation.

Reappraisal of uterine sarcoma diagnosis in the Swedish Cancer Registry

An investigation of over- and under-registration of uterine sarcomas in the Swedish Cancer Registry during the period 1958-1980 was carried out. A histopathologic review of a 10% sample (159 cases) revealed that 18% of the cases, the majority of which were benign leiomyomas, could not be reclassified as sarcomas. All 186 cases of uterine sarcoma treated at Radiumhemmet during the period 1958-1980 were found in the Cancer Registry, but only 90% as sarcomas. As a consequence of over- and under-registration of the sarcoma tumors, the estimated incidences will be affected. In this study, however, we could not find any time trend in the erroneous registration, which implies that comparisons in incidence over time would still be valid.

Dysgerminoma. The Radiumhemmet series 1927-1984

Dysgerminoma is a rare, highly radiosensitive, malignant germ cell tumor occurring in young females. At Radiumhemmet, Stockholm, Sweden, from 1927 to 1984, 60 patients with histologically confirmed pure dysgerminoma were treated. Primary treatment was surgery followed by radiotherapy. Recurrences were irradiated. The mean age was 23.2 years. Sixty-seven percent were in International Federation of Gynecology and Obstetrics (FIGO) Stage I, 6% Stage II, 22% Stage III, 3% Stage IV, and 2% were not staged. The median follow-up time was 19 years (range, 1-53). Generally, women with Stage IA disease had unilateral oophorectomy and unilateral external irradiation. Fourteen have borne 22 children after treatment. Seventeen women in the series have died, 11 from dysgerminoma. Actuarial survival, only counting deaths from dysgerminoma, was 83% at 5 years. No patient has died of dysgerminoma since 1963 when radiotherapy with megavoltage x-rays was introduced. The authors consider external irradiation to be an effective treatment as a complement to surgery in dysgerminoma of the ovary.

Prognostic factors in uterine leiomyosarcoma. A clinical and histopathological study of 143 cases. The Radiumhemmet series 1936-1981

One hundred and forty-three patients with uterine leiomyosarcomas treated at Radiumhemmet from 1936 through 1981 were reviewed. Clinical and histopathological findings were analysed by bivariate and multivariate analyses to assign prognostic factors. Mitotic count, menopausal status and stage showed to be significant predictors of survival. The series was divided into two periods of time and a significantly higher survival rate in the second period was noted for patients with stage I disease. Thirty-seven patients with tumors showing less than 10 mitotic figures per 10 high power fields had a 5-year survival rate of 65% compared with 17% for 106 patients with 10 or more mitotic figures per 10 high power field. No significant predictor of a bad outcome for these low mitotic count tumors was found.

The age of osteosarcoma patients is increasing. An epidemiological study of osteosarcoma in Sweden 1971 to 1984

We conducted an epidemiological study of osteosarcoma in Sweden from 1971 to 1984 to investigate whether the typical features of the disease had changed. Of 294 osteosarcoma patients reviewed, 249 had primary skeletal tumours, and for these the mean annual incidence was 2.1 per million, without any clear trend over time. The mean male/female ratio for the period was 1.6 again with no consistent pattern over time; nor was there any significant change in the distribution of tumours according to location. The only feature which showed a significant change over the 14-year period was the mean age of the patients, being at its lowest (19 years) in 1972 and at its highest (40 years) in 1981. Excluding the 22 patients with craniofacial tumours, the remaining 227 also showed a significant increase in mean age. Analysis of the annual age distribution disclosed an increasing fraction of patients older than those in the classical age peak between 10 and 29 years. A large number of trials have shown improved survival in osteosarcoma over the last 15 years, which has been attributed mainly to adjuvant chemotherapy. The change we have observed in age distribution should also be taken into account in the evaluation of the results of treatment; it may be that older patients have a better prognosis.

Choriocarcinoma of the fallopian tube associated with induced superovulation in an IVF program; a case report

The authors present a case of choriocarcinoma of the fallopian tube. The patient was enrolled in an IVF program and to our knowledge this is the first report of a choriocarcinoma following treatment with clomiphene citrate and hMG. The possible role of superovulation in inducing the tumour is discussed. The patient was treated by conservative surgery only and is in remission 1.5 years after the event.

Radiation therapy in early glottic cancer. Analysis of 177 consecutive cases

Early vocal cord carcinomas (TiS or T1) in a consecutive series of 177 patients treated by primary radiotherapy over a 10-year period 1970-79 at the Department of General Oncology, Radiumhemmet, Karolinska Sjukhuset, were analysed regarding treatment results. In 137 cases the tumours were invasive (T1N0M0) and in 40 cases carcinoma of in situ type (TiS). Patient were treated with cobalt 60 gamma irradiation in fractions of 2 Gy up to a total dose of 64 Gy delivered as split course (CRE=17.8). Minimum follow-up time was 5 years. Tumour recurred in 21 cases (12%). All but 4 patients were rescued by subsequent surgery, giving 98% total survival. Treatment failures after primary radiotherapy were analysed in detail. Failures could not be attributed to treatment irregularities. No difference in pretreatment tumour size was detected when cured patients were compared with patients who relapsed. Biological factors that cause a relative radioresistance are considered to be the main reason for radiotherapy failures in early glottic cancer.