BRCA mutated pancreatic cancer: A change is coming

Pancreatic cancer remains a leading cause of cancer-related death with few available therapies for advanced disease. Recently, patients with germline BRCA mutations have received increased attention due to advances in the management of BRCA mutated ovarian and breast tumors. Germline BRCA mutations significantly increase risk of developing pancreatic cancer and can be found in up to 8% of patients with sporadic pancreatic cancer. In patients with germline BRCA mutations, platinum-based chemotherapies and poly (ADP-ribose) polymerase inhibitors are effective treatment options which may offer survival benefits. This review will focus on the molecular biology, epidemiology, and management of BRCA-mutated pancreatic cancer. Furthermore, we will discuss future directions for this area of research and promising active areas of research.

Phosphorylated transducer and activator of transcription-3 (pSTAT3) immunohistochemical expression in paired primary and metastatic colorectal cancer

BACKGROUND

Signal Transducer and Activator of Transcription-3 (STAT3) mediates cellular functions. We assessed the IHC expression of phosphorylated STAT3 (pSTAT3) in paired primary tumors and liver metastases in patients with advanced stage colorectal cancer (CRC).

METHODS

We included patients with tissue blocks available from both the primary CRC and a surgically resected liver metastasis. The IHC pSTAT3 expression agreement was measured using Cohen's kappa statistic.

RESULTS

The study included 103 patients, 55% male, median age was 64. 43% tumors originated in rectum, and 63% of the primary tumors were synchronous. Expression of pSTAT3 was 76% in liver metastases and 71% in primary tumors. A difference in pSTAT3 staining between the primary tumor and liver metastases was noted in 64%. There was lost expression of pSTAT3 in the liver metastases in 28% and gained expression in 36% of cases compared to the primary. The kappa statistic comparing agreement between staining patterns of the primary tumors and liver metastases was a "less-than-chance", at -0.02. Median survival was 4.9 years, with no difference in survival outcomes by pSTAT3 expression in the primary tumor or liver metastases.

DISCUSSION

STAT3 is not a prognostic marker in the selective setting of metastatic CRC to liver, but it may remain a potential therapeutic target given most liver metastases expressed pSTAT3. Discordant pSTAT3 expression in between primary tumors and paired liver metastases suggests that use of this class of drug to treat liver predominant metastatic colorectal cancer in a biomarker-driven approach may require confirmatory liver tumor biopsy.

ctDNA applications and integration in colorectal cancer: an NCI Colon and Rectal-Anal Task Forces whitepaper

An increasing number of studies are describing potential uses of circulating tumour DNA (ctDNA) in the care of patients with colorectal cancer. Owing to this rapidly developing area of research, the Colon and Rectal-Anal Task Forces of the United States National Cancer Institute convened a panel of multidisciplinary experts to summarize current data on the utility of ctDNA in the management of colorectal cancer and to provide guidance in promoting the efficient development and integration of this technology into clinical care. The panel focused on four key areas in which ctDNA has the potential to change clinical practice, including the detection of minimal residual disease, the management of patients with rectal cancer, monitoring responses to therapy, and tracking clonal dynamics in response to targeted therapies and other systemic treatments. The panel also provides general guidelines with relevance for ctDNA-related research efforts, irrespective of indication.

Delving into Early-onset Pancreatic Ductal Adenocarcinoma: How Does Age Fit In?

PURPOSE

With the rising incidence of early-onset pancreatic cancer (EOPC), molecular characteristics that distinguish early-onset pancreatic ductal adenocarcinoma (PDAC) tumors from those arising at a later age are not well understood.

EXPERIMENTAL DESIGN

We performed bioinformatic analysis of genomic and transcriptomic data generated from 269 advanced (metastatic or locally advanced) and 277 resectable PDAC tumor samples. Patient samples were stratified into EOPC (age of onset ≤55 years; n = 117), intermediate (age of onset 55-70 years; n = 264), and average (age of onset ≥70 years; n = 165) groups. Frequency of somatic mutations affecting genes commonly implicated in PDAC, as well as gene expression patterns, were compared between EOPC and all other groups.

RESULTS

EOPC tumors showed significantly lower frequency of somatic single-nucleotide variant (SNV)/insertions/deletions (indel) in CDKN2A (P = 0.0017), and were more likely to achieve biallelic mutation of CDKN2A through homozygous copy loss as opposed to heterozygous copy loss coupled with a loss-of-function SNV/indel mutation, the latter of which was more common for tumors with later ages of onset (P = 1.5e-4). Transcription factor forkhead box protein C2 (FOXC2) was significantly upregulated in EOPC tumors (P = 0.032). Genes significantly correlated with FOXC2 in PDAC samples were enriched for gene sets related to epithelial-to-mesenchymal transition (EMT) and included VIM (P = 1.8e-8), CDH11 (P = 6.5e-5), and CDH2 (P = 2.4e-2).

CONCLUSIONS

Our comprehensive analysis of sequencing data generated from a large cohort of PDAC patient samples highlights a distinctive pattern of biallelic CDKN2A mutation in EOPC tumors. Increased expression of FOXC2 in EOPC, with the correlation between FOXC2 and EMT pathways, represents novel molecular characteristics of EOPC.See related commentary by Lou, p. 8.

Adenosine 2A Receptor Blockade as an Immunotherapy for Treatment-Refractory Renal Cell Cancer

Adenosine mediates immunosuppression within the tumor microenvironment through triggering adenosine 2A receptors (A2AR) on immune cells. To determine whether this pathway could be targeted as an immunotherapy, we performed a phase I clinical trial with a small-molecule A2AR antagonist. We find that this molecule can safely block adenosine signaling in vivo. In a cohort of 68 patients with renal cell cancer (RCC), we also observe clinical responses alone and in combination with an anti-PD-L1 antibody, including subjects who had progressed on PD-1/PD-L1 inhibitors. Durable clinical benefit is associated with increased recruitment of CD8⁺ T cells into the tumor. Treatment can also broaden the circulating T-cell repertoire. Clinical responses are associated with an adenosine-regulated gene-expression signature in pretreatment tumor biopsies. A2AR signaling, therefore, represents a targetable immune checkpoint distinct from PD-1/PD-L1 that restricts antitumor immunity. SIGNIFICANCE: This first-in-human study of an A2AR antagonist for cancer treatment establishes the safety and feasibility of targeting this pathway by demonstrating antitumor activity with single-agent and anti-PD-L1 combination therapy in patients with refractory RCC. Responding patients possess an adenosine-regulated gene-expression signature in pretreatment tumor biopsies.See related commentary by Sitkovsky, p. 16.This article is highlighted in the In This Issue feature, p. 1.

Neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios as predictive and prognostic markers in patients with locally advanced rectal cancer treated with neoadjuvant chemoradiation

Background

A standard therapy for locally advanced rectal cancer (LARC) includes fluoropyrimidine (FP)-based neoadjuvant chemoradiation (nCRT). Previous studies have inconsistently demonstrated that baseline neutrophil- and platelet-to-lymphocyte ratios (NLR and PLR) are predictive of response to nCRT or prognostic of outcomes in LARC.

Methods

We reviewed patients with LARC undergoing nCRT followed by surgery from 2005 to 2013 across 8 Canadian cancer centres. Outcome measures of interest were pathological complete response (pCR), disease-free survival (DFS) and overall survival (OS). Logistic regression and Cox proportional hazard models were used to assess for associations between baseline hematologic variables and outcomes.

Results

Of 1527 identified patients, 1237 (81%) were included in the DFS/OS analysis. Median age was 62 (range 23–88), 69% were male, and 80% had performance status (PS) 0–1. Twenty-six percent had elevated NLR (≥ 4), and 66% had elevated PLR (≥ 150). Ninety-seven percent of patients received FP-based nCRT, with 96% receiving ≥44 Gy. 81% completed neoadjuvant chemotherapy and 95% completed neoadjuvant radiotherapy, with a pCR rate of 18%. After a median follow-up time of 71 months, 8% developed local recurrence, 22% developed distant recurrence and 24% died. 5-year DFS and OS were 69% (95% CI 66–72%) and 79% (95% CI 77–82%), respectively. In multivariate analyses, elevated baseline NLR and PLR were neither prognostic for DFS and OS nor predictive of pCR.

Conclusions

NLR and PLR were not found to be independently prognostic for DFS or OS and did not predict for pCR in patients with LARC undergoing nCRT followed by surgery.

Epidermal growth factor receptor inhibitor-induced hypomagnesemia: a survey of practice patterns among Canadian gastrointestinal medical oncologists

Background

The optimal management of hypomagnesemia (hMg) induced by epidermal growth factor receptor inhibitors (egfris) for advanced colorectal cancer is unclear. We surveyed gastrointestinal medical oncologists in Canada to determine practice patterns for the management of egfri-induced hMg.

Methods

Based on distribution lists from the Eastern Canadian Colorectal Cancer Consensus Conference and the Western Canadian Gastrointestinal Cancer Consensus Conference, medical oncologists were invited to participate in an online questionnaire between November 2013 and February 2014.

Results

From the 104 eligible physicians, 40 responses were obtained (38.5%). Panitumumab was more commonly prescribed than cetuximab by 70% of respondents, with 25% prescribing cetuximab and panitumumab equally. Most respondents obtain a serum magnesium level before initiating a patient on an egfri (92.5%) and before every treatment (90%). Most use a reactive strategy for magnesium supplementation (90%) and, when using supplementation, favour intravenous (iv) alone (40%) or iv and oral (45%) dosing. Magnesium sulfate was used for iv replacement, and the most common oral strategies were magnesium oxide (36.4%) and magnesium rougier (18.2%). Under the reactive strategy, intervention occurred at hMg grade 1 (70.3%) or grade 2 (27%). Of the survey respondents, 45% felt that 1-5 of their patients have ever developed symptoms attributable to hMg, and 35% have had to interrupt egfri therapy because of this toxicity, most commonly at grade 3 (30%) or grade 4 (45%) hMg. The most important question about egfri-induced hMg was its relevance to clinical outcomes (45%) and its symptoms (37.5%).

Conclusions

In Canada, various strategies are used in the management of egfri-induced hMg, including prophylactic and reactive approaches that incorporate iv, oral, or a combination of iv and oral supplementation. Clinicians are concerned about the effect of hMg on clinical outcomes and about the symptoms that patients experience as a result of this toxicity.

Evaluation of NeuroPage as a memory aid for people with multiple sclerosis: A randomised controlled trial

Memory problems are reported in 40%-60% of people with multiple sclerosis (MS). These problems affect independence and may limit the ability to benefit from rehabilitation. Our aim was to evaluate the effectiveness of NeuroPage for people with MS living in the community. A multicentre, single-blind, randomised controlled crossover trial was conducted. The intervention comprised the NeuroPage service, which sends reminder messages to mobile phones at pre-arranged times. In the control condition participants received "non-memory texts", that is, messages not aimed at providing a reminder; for example, supplying news headlines or sport updates. Outcome measures were completed using postal questionnaires after each condition. There were 38 participants aged 28 to 72 (mean 48, SD 11) and 10 (26%) were men. There were no significant differences between NeuroPage and control conditions on the Everyday Memory Questionnaire (p = 0.41, d = 0.02). The number of daily diary items forgotten in the NeuroPage condition was significantly less than in the control (9% vs. 31%, p = 0.01, d = -0.64). Psychological distress was less in the NeuroPage condition than control (p = 0.001, d = -0.84). Further evaluation of the effect on everyday memory is required.

Dysexecutive symptoms and carer strain following acquired brain injury: Changes measured before and after holistic neuropsychological rehabilitation

BACKGROUND

Following acquired brain injury (ABI), deficits in executive functioning (EF) are common. As a result many brain-injured patients encounter problems in every-day functioning, and their families experience significant strain. Previous research has documented the benefits of cognitive rehabilitation for executive dysfunction, and rehabilitation programmes designed to ameliorate functional problems associated with ABI.

OBJECTIVES

This study primarily aims to evaluate whether a neuropsychological rehabilitation programme reduces reported symptoms of everyday dysexecutive behaviour and carer strain.

METHODS

In this study 66 ABI outpatients attended comprehensive holistic neuropsychological rehabilitation programme. A repeated-measures design was employed to determine the effect of rehabilitation on EF and carer strain, as part of a service evaluation. Outcome measures comprised the dysexecutive questionnaire (DEX/DEX-I) and carer strain index (CSI), applied pre- and post-rehabilitation.

RESULTS

Results indicate rehabilitation benefited clients and carers in 5 of 6 DEX/DEX-I subscales, and 2 of 3 CSI subscales, (p < 0.05). An effect of aetiology on rehabilitation was found on the metacognitive scale of the DEX-I.

CONCLUSIONS

Therefore, this study supports a comprehensive holistic neuropsychological rehabilitation programme as effective in reducing reported symptoms of dysexecutive behaviour and carer strain following ABI.

Prognostic and predictive effects of diabetes, hypertension, and coronary artery disease among women on extended adjuvant letrozole: NCIC CTG MA.17

BACKGROUND

Women with breast cancer and diabetes mellitus (DM) have poorer survival. Mechanisms include insulin dysregulation and/or DM related co-morbidities (CM). In MA.17 adjuvant letrozole (LET) after 5 years of tamoxifen (TAM) reduced the risk of recurrence and improved survival. We evaluated DM, hypertension (HTN), and coronary artery disease (CAD) as prognostic and predictive factors in MA.17.

PATIENTS AND METHODS

Disease free survival, distant disease free survival (DDFS) and overall survival (OS) were compared using Cox regression model adjusting for other prognostic factors: in women treated by placebo (PLAC) based on the presence or absence of baseline DM (n = 462), HTN (n = 1627), CAD (n = 604) or any one of these CM (n = 2049), and between LET and PLAC groups in each CM. Analyses based on nodal status were performed.

RESULTS

DM was neither prognostic nor predictive for women on extended LET. Women with one CM had similar outcomes on LET compared to women free of CM. For node positive women, the difference between LET and PLAC in DDFS was greater among women with one CM (hazard ratio [HR] = 0.30 [0.15-0.60], p = 0.001) compared to those without CM (HR = 0.72 [0.45-1.16], p = 0.17, p interaction = 0.04). Women on PLAC with HTN trended towards lower DDFS (HR = 1.50 [0.98-2.3], p = 0.06) and OS (HR = 1.61 [0.95-2.72], p = 0.08) than non-HTN women. HTN women had better DDFS on LET than non-HTN women. Women with one CM on PLAC had lower OS (HR = 2.10 [1.26-3.51], p = 0.004) than those free of CM.

CONCLUSIONS

DM was not prognostic or predictive of outcomes. Women with CM who remain disease free after 5 years of TAM should be offered LET. HTN trended towards a negative prognosticator and outcomes among this group were improved on LET. More studies are needed to assess impact of adrenergic stimulation as a possible link to poorer breast cancer outcomes.

Location of colon cancer (right-sided versus left-sided) as a prognostic factor and a predictor of benefit from cetuximab in NCIC CO.17

BACKGROUND

Right- and left-sided colon cancers (RC, LC) differ with respect to biology, pathology and epidemiology. Previous data suggest a mortality difference between RC and LC. We examined if primary tumour side also predicts for outcome in chemotherapy refractory, metastatic colon cancer (MCC). We also compared RC versus LC as a predictor of efficacy of epidermal growth factor receptor (EGFR) inhibition with cetuximab.

METHODS

Reanalyzing NCIC CO.17 trial (cetuximab versus best supportive care [BSC]), we coded the primary tumour side as RC (caecum to transverse colon) or LC (splenic flexure to rectosigmoid). The association between tumour side and baseline characteristics was assessed. Cox regression models determined factors affecting overall survival (OS) and progression free survival (PFS).

RESULTS

Patients with RC (150/399) had more poorly differentiated, mutant KRAS, mutated PIK3CA and wild-type BRAF tumours, fewer liver and lung metastases, and shorter interval between diagnosis and study entry. Among BSC patients, tumour side was not prognostic for PFS (hazard ratios (HR) 1.07 [0.79-1.44], p = 0.67) or OS (HR 0.96 [0.70-1.31], p = 0.78). Among wild-type KRAS patients, those with LC had significantly improved PFS when treated with cetuximab compared to BSC (median 5.4 versus 1.8 months, HR 0.28 [0.18-0.45], p < 0.0001), whereas those with RC did not (median 1.9 versus 1.9 months, HR 0.73 [0.42-1.27], p = 0.26), [interaction p = 0.002].

CONCLUSION

In refractory MCC, tumour location within the colon is not prognostic, but is strongly predictive of PFS benefit from cetuximab therapy. Additional research is needed to understand the molecular differences between RC and LC and their interaction with EGFR inhibition.

Performance of multinomial designs in comparison with response-based designs in non-randomized phase II trials of targeted cancer agents

BACKGROUND

In phase II trials of cytotoxic agents, a multinomial phase II design incorporating early progression and response end points was shown to perform more efficiently than designs based only on response. We undertook a study to evaluate the performance of these designs in trials of targeted agents using the actual phase II data.

PATIENTS AND METHODS

Using best response data from sequentially enrolled patients in 15 NCIC Clinical Trials Group and 7 European Organization for Research and Treatment of Cancer trials of targeted agents, we determined that trials would have been stopped at the end of stage I of accrual by applying rules generated by the multinomial and Fleming designs. Two variants of the multinomial design were studied: to stop accrual after stage I of enrolment, Variant A required either response or progression criteria to be met, whereas Variant B required that both response and progression criteria to be met.

RESULTS

Using early progression, null/alternate hypotheses of 60% and 40% (60/40), the multinomial A variant recommended early stopping more often than the Fleming design. In most of the cases, this recommendation was correct given the final trial outcome. In contrast, the multinomial B variant never led to recommendations for early stopping and changing progression hypotheses did not improve the performance of this design.

CONCLUSIONS

The multinomial A design using 60/40 hypotheses carried out better than the Fleming design in appropriately stopping trials of inactive targeted agents early. The multinomial B design was not useful for early stopping decisions. The multinomial A design may be favored over response-based designs in phase II trials of targeted agents.

Motion-guided attention promotes adaptive communications during social navigation

Animals are capable of enhanced decision making through cooperation, whereby accurate decisions can occur quickly through decentralized consensus. These interactions often depend upon reliable social cues, which can result in highly coordinated activities in uncertain environments. Yet information within a crowd may be lost in translation, generating confusion and enhancing individual risk. As quantitative data detailing animal social interactions accumulate, the mechanisms enabling individuals to rapidly and accurately process competing social cues remain unresolved. Here, we model how motion-guided attention influences the exchange of visual information during social navigation. We also compare the performance of this mechanism to the hypothesis that robust social coordination requires individuals to numerically limit their attention to a set of n-nearest neighbours. While we find that such numerically limited attention does not generate robust social navigation across ecological contexts, several notable qualities arise from selective attention to motion cues. First, individuals can instantly become a local information hub when startled into action, without requiring changes in neighbour attention level. Second, individuals can circumvent speed-accuracy trade-offs by tuning their motion thresholds. In turn, these properties enable groups to collectively dampen or amplify social information. Lastly, the minority required to sway a group's short-term directional decisions can change substantially with social context. Our findings suggest that motion-guided attention is a fundamental and efficient mechanism underlying collaborative decision making during social navigation.

Abstract PD03-04: Effects of Diabetes (DM), Hypertension (HTN) and Coronary Artery Disease (CAD) on Prognosis after 5 Years of Adjuvant Tamoxifen (TAM) and on Treatment Outcomes with the Use of Extended Letrozole (LET): NCIC CTG MA.17

Background: Women with early stage breast cancer and DM have poorer survival compared to non-DM women (Lipscombe 2008). Mechanisms include insulin dysregulation and/or DM related comorbidities such as HTN and CAD. MA.17 showed that adjuvant LET after five yrs of TAM reduced the risk of recurrence in women with ER+ early stage breast cancer and improved survival in node +ve disease. We evaluated the impact of DM, HTN, or CAD on prognosis after 5 yrs of TAM and the efficacy of LET in MA.17.

Methods: All 5170 women randomized to MA.17 were included. Four year disease free survival (DFS), distant disease free survival (DDFS) and overall survival (OS) were compared using Cox regression model adjusting for other prognostic factors: a) in women treated with placebo (PLAC) based on the presence or absence of baseline DM (n=462), HTN (n=1627), CAD (n=604) or any one of these comorbidities (n=2049), and b) between LET and PLAC groups in each comorbidity. Analyses based on nodal status were also performed. Test for interaction assessed for differential treatment effects in comorbidity groups. Results: Women with DM on PLAC had non-significant lower DFS (89.7 vs. 89.9%, p=0.68), DDFS (92.1 vs 93.9%, p=0.85), and OS (92.1 vs 95.2, p=0.37) than those without DM on PLAC. Treatment effect outcomes were similar between those with and without DM. Women with HTN on PLAC trended toward lower DDFS (92.2 vs 94.4%, HR=1.50, 95%CI: 0.98-2.3, p=0.06) and OS (93.7 vs. 95.5%, HR=1.61, 95%CI: 0.95-2.72, p=0.08) than non-HTN women on PLAC. The interaction between treatment and HTN status was significant for DDFS (p=0.004) with HTN women having significantly better outcome on LET vs PLAC (HR=0.27, 95%CI: 0.13 to 0.54; p=0.0002) compared to non-HTN women on LET vs PLAC (HR=0.82, 95%CI: 0.56-1.20; p=0.31). Women with CAD on PLAC did not have worse outcome, nor did CAD status have a treatment related effect. Women with at least one co-morbidity on PLAC had significantly lower OS (93.6 vs. 95.8%, HR=2.10, 95%CI:1.26-3.51, p=0.004) than those free of comorbidity. For node +ve women, the difference between LET and PLAC in DDFS was greater among women with at least one co-morbidity (HR=0.30, 95%CI:0.15-0.60, p=0.001) compared to those without any co-morbidity (HR=0.72, 95%CI:0.45-1.16, p=0.17) with interaction p=0.04.

Conclusions: Having at least one comorbidity was a negative prognostic indicator for OS after 5 yrs of TAM and led to improved DDFS for node +ve women taking LET. DM was not prognostic nor did it predict treatment outcomes. Explanations include not controlling for DM medications; as well, MA.17 enrolled women 5 yrs after TAM with evidence suggesting hyperinsulinemia being a risk for early rather than late recurrence. HTN was a potential risk factor with a trend for worse DDFS and OS. HTN also predicted for treatment benefit: HTN women on LET had improved DDFS compared to non-HTN women on LET. Hypothesis include antihypertensive agents slowing the metabolism of LET; alternatively there may be variations in VEGF levels between groups. HTN predictive effects will be further explored in MA.27 with potential to correlate with VEGF levels.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD03-04.

Overview of systemic therapy for colorectal cancer

Colorectal cancer (CRC) is the third most common cancer and second leading cause of death from cancer in North America. The authors provide an overview of the indications for both chemotherapy and targeted therapy, as well as discuss the efficacy and toxicity of systemic therapy. They highlight the key studies that lead to the initial historical use of fluorouracil (5FU) based chemotherapy in the adjuvant and metastatic setting, the recent adoption of 5FU plus leucovorin (LV) and oxaliplatin (FOLFOX) chemotherapy over 5FU when treating adjuvant patients, and the use of FOLFOX or 5FU plus LV and irinotecan (FOLFIRI) in metastatic patients. They also review the role of chemotherapy in treating rectal cancer and resectable liver metastatic disease. Future areas of research focus for systemic therapy of colorectal cancer are highlighted.

Caregiving arrangement and nutrition: good news with some reservations

The objective of this study was to assess the impact of caregiving arrangement on the iron and folate status of infants and toddlers reared at home or enrolled in centre-based, independent home, or licensed home care. One hundred and eighty-nine children aged 2 to 29 months were assessed 1 month prior to child care entry and at 6 months after entry into child care. Dietary (24-hour records), anthropometric (height, weight, head circumference) and biochemical (red blood cell folate, hematocrit, transferrin, and serum ferritin concentrations) methods were used to assess nutritional status. Frequency of illness was determined by a series of telephone interviews. Median intake of nutrients exceeded Canadian recommendations, regardless of care arrangement. Fifteen of 65 children had hematocrit values below age-specific cutoffs at the 6-month post-entry to child care visit. Children were frequently taken to obtain medical advice (average of 4 to 6 times during the study period) and 75% of subjects were prescribed at least one course of antibiotics. In conclusion, infants and toddlers in this study were generally well nourished, regardless of child care arrangement; however, iron status may remain an issue in this sample of infants and toddlers.

Comparison of Papanicolaou's and Wright-Giemsa stains in the examination of body fluids for Hodgkin's disease

We reviewed 36 body fluid specimens from 18 patients with Hodgkin's disease (HD) to characterize the cytologic features of HD as seen in Wright-Giemsa (WG)-stained cytocentrifuge preparations, and to compare diagnostic agreement between WG- and Papanicolaou-stained samples. Slides were examined independently by two pathologists without knowledge of the original diagnosis, and were classified as either positive, inconclusive, or negative for malignant cells. There was diagnostic agreement between both methods in 35 (97%) of 36 samples. Features in cytocentrifuged WG-stained specimens that were most helpful in recognizing HD included mirror image nuclei in typical Reed-Sternberg cells and an axis of symmetry in polylobate Reed-Sternberg variants, with even distribution of the nuclear material within the cytoplasm.

Polymicrobial bacteremic pneumonia: report of three cases caused by Staphylococcus aureus and Streptococcus pneumoniae

Three patients are reported with simultaneous bacteremia caused by Staphylococcus aureus and Streptococcus pneumoniae complicating community-acquired pneumonia. Polymicrobial bacteremia caused by pyogenic organisms has rarely been reported. Two of the patients had severe underlying hepatic disease, and the third had suffered a recent myocardial infarction. The infection ultimately proved fatal in each patient. The pathophysiologic aspects and clinical consequences of polymicrobial bacteremia arising from respiratory as well as from other sources is briefly reviewed.

Tumor-associated antigen expression of primary and metastatic colon carcinomas detected by monoclonal antibody 17-1A

Murine monoclonal antibody (MAb) 17-1A has been used in radioimmunodetection and immunotherapy trials of intestinal adenocarcinoma in humans. Tumor heterogeneity of antigen expression has been recognized as a potential limiting factor in such studies. The authors report a study designed to evaluate the degree of heterogeneity of 17-1A antigen expression among primary and metastatic human colon carcinomas. All 141 specimens, including 74 primary or metastatic colonic adenocarcinomas, were evaluated with the use of an avidin-biotin complex immunoperoxidase technic on briefly fixed frozen tissue sections. All of these showed at least focal staining with MAb 17-1A. However, well- or moderately differentiated tumors generally showed diffuse cytoplasmic immunostaining, whereas poorly differentiated tumors showed minimal immunostaining with no detectable antigen in most areas. In 16 cases that had both primary and metastatic adenocarcinomas or multiple metastatic tumors, 17-1A antigen expression was similar among the tumor sites except for one case. This case showed variation in tumor differentiation and corresponding variation in 17-1A antigen expression. Of 36 additional malignant tumors that were not of colonic epithelial origin, adenocarcinomas of the stomach, duodenum, endometrium, ovary, and breast showed 17-1A antigen expression.

Pulmonary artery sarcomas. A review and report of a case

We examined a case of primary pulmonary artery sarcoma and reviewed 45 cases that we found previously reported in the English literature, with particular attention given to the pathologic features. These sarcomas involve the pulmonary arterial trunk, left and right main pulmonary arteries, pulmonary valve, and right ventricular outflow tract. They have prominent intravascular growth along the arterial intima. Lung involvement commonly occurs by direct extension through the pulmonary vasculature or by distant metastases. These sarcomas contain a variety of heterologous components and areas of bone, cartilage, and fibrous tissue may be remarkably well-differentiated. Management of these sarcomas will be aided by an understanding of their biologic behavior and pathologic features.

Apical localization of pulmonary tuberculosis, chronic pulmonary histoplasmosis, and progressive massive fibrosis of the lung

We have reviewed the accumulated evidence for the explanation of the apical localization of pulmonary tuberculosis, chronic pulmonary histoplasmosis, and massive fibrosis of the lung due to silicosis and coal-workers pneumoconiosis. The effect of gravity on the erect human lung results in greatly diminished pulmonary artery blood flow in the apical and subapical areas. This in turn results in higher oxygen tensions but also impairment of tissue clearance mechanisms in these areas. Analysis of the accumulated evidence better supports the theory of lymph stasis and impaired clearance of antigenic substances as the major determinant of the apical localization of pulmonary tuberculosis rather than the presently favored oxygen tension theory. The impaired clearance theory also best explains the apical localization of chronic pulmonary histoplasmosis and progressive massive fibrosis of the lung.

Histoplasmosis of bone

A case of histoplasmosis of bone manifested by a single punched-out lesion in the humerus is reported in a man with asymptomatic mild chronic disseminated histoplasmosis. Roentgenologically evident lesions of bone due to Histoplasma capsulatum are rare, and this is the only report of a large punched-out lytic lesion. Such lesions are common in disseminated histoplasmosis due to the African strain H. duboisii. Although H. duboisii has been accorded species differentiation, there are only two clearly defined differences, compared to H. capsulatum. One is morphologic (size of yeast cell), and the other is a different clinical disease spectrum. Many believe that this organism is best viewed as a stable variant of H. capsulatum. At times, the two strains are indistinguishable morphologically, and at times, as in the case reported, there may be clinical similarities in their respective disease entities.

Pulmonary vein obstruction by bronchogenic carcinoma

Two patients with obstruction of the pulmonary veins by bronchogenic carcinoma, an unusual cause, are presented. These and other cases reported have had features suggestive of mitral stenosis. The differential diagnosis is discussed.

Chronic pulmonary histoplasmosis

Chronic pulmonary histoplasmosis is best regarded as an opportunist or saprophytic infection of abnormal pulmonary spaces by a fungus of very low human pathogenicity. Tissue disease results from host immune response to dispersions of soluble antigen from these focal sources. There are two distinct types of clinical and radiological response. One is an acute or subacute illness manifested by often large segmental pneumonic lesions which tend to heal and are designated as early lesions. The other, usually developing as a complication of the first, is a chronic disease marked by persistent cavitation, low gard chronic illness, and a tendency to promote pulmonary fibrosis and often progressive pulmonary insufficiency. The early lesion is a segmental interstitial pneumonitis with central areas of infarct-like necrosis often adjacent to bullous disease and often outlining prominent emphysematous spaces which appear as radiolucencies. These radiological findings are further characterized by early clearing of the interstitial components, infarct-like contraction of the necrotic zones, obliteration of much of the contained emphysematous and bullous spaces, and healing attended by considerable loss of lung volume. Symptoms are variable but tend to be mild. Malaise, fatigability, low-grade fever, aching chest pain and mild cough lasting a few days to a few weeks are usual. Symptoms are ameliorated by rest. Rest and diminished activity are recommended as treatment. Under these circumstances, 80% of early lesions heal completely and probably most of these would heal spontaneously. Any subsequent course of the disease depends on whether or nor large air spaces, adjacent to or contained within the area of pneumonitis, become infected and persist as cavities. This occurs in 20% of early lesions. Once established, an infected cavity tends to persist and to be attended by symptoms of chronic bronchitis with chronic cough and sputum, fatigability, anorexia, and weight loss. Persisting thickwalled cavities often induce gradual development of pulmonary fibrosis, particulary in the lung bases, apparently from aspiration of antigenic material. This and the accelerated obstructive bronchopulmonary disease often lead to progressive pulmonary insufficiency. The use of amphotericin B is recommended for all persistent thick-walled cavities and in some circumstances surgical resection may be indicated.