[ETV6-rearranged low-grade sinonasal non-intestinal-type adenocarcinoma: a clinicopathological analysis].

Objective: To investigate the clinicopathologic features, immunophenotype, molecular genetic changes of ETV6-rearranged low-grade sinonasal non-intestinal-type adenocarcinoma (ETV6-RLGSNAC). Methods: Primary sinonasal epithelial malignant tumors were collected from January 2015 to January 2020 in the Department of Pathology, Eye, Ear, Nose and Throat Hospital affiliated to Fudan University. Through morphological observation, immunohistochemical detection and fluorescence in situ hybridization (FISH), ETV6-RLGSNAC was screened out for clinicopathological feature analysis, and relevant literatures were reviewed. Results: There were 550 cases of primary sinonasal epithelial malignant tumors, among which 82 cases were adenocarcinoma. There were 29 cases of low-grade non-intestinal adenocarcinoma, only 3 cases of ETV6-RLGSNAC were screened out. Of the 3 patients, 2 cases were male and 1 case was female, with a mean age of 54 years (range 37-64 years). The main clinical manifestations were nasal stenosis, nasal obstruction and epistaxis. A neoplasm with smooth surfaces was observed under nasal endoscopy. Imaging showed an expansive mass in the sinonasal area. Gross examination showed gray-yellow cut surface with firm texture and a maximum diameter of 2-3 cm. Microscopically, tumors were non-encapsulated and well-circumscribed with expansive growth pattern. The tumor cells were small and mild, cylindrical and cuboidal, and arranged in regular glandular and trabecular patterns. The cytoplasm was eosinophilic and the nuclei were basally located with inconspicuous nucleoli. By immunohistochemistry (IHC), CK7, SOX-10, DOG1 and vimentin were positive and S-100 expressed in small clusters of cells in all cases. GCDFP-15, CD56, CK20, mammaglobin, TTF-1, NR4A3 were all negative. The Ki-67 value-added index of all cases was low (<5%). ETV6 gene rearrangement was confirmed in all the cases by FISH, and two cases had NTRK3 gene rearrangement. All three patients underwent radical resection after diagnosis, and one also had adjuvant radiotherapy. All three patients were available with a follow-up time of 12-25 months, and all were recurrence free. Conclusions: ETV6-RLGSNAC is a rare low-grade and newly named non-intestinal adenocarcinoma. The histomorphology is similar to other low-grade nasal sinonasal adenocarcinomas and some salivary gland tumors. IHC and FISH are useful for the diagnosis and differential diagnosis.

[Sinonasal renal cell-like adenocarcinoma: a clinicopathological analysis of five cases].

Objective: To investigate the clinicopathological features, immunophenotype, differential diagnosis and prognosis of sinonasal renal cell-like adenocarcinoma. Methods: Retrospective analysis was performed on the cases of sinonasal carcinoma from August 2014 to December 2018 at Eye, Ear, Nose and Throat Hospital, Fudan University. Renal cell-like adenocarcinoma was screened for clinicopathologic feature analysis, and relevant literatures were reviewed. Results: There were 460 cases of sinonasal carcinoma, among which 70 cases (15.2%) were adenocarcinoma, with five (1.1%) being renal cell-like adenocarcinomas. Four patients were male and one was female, with a mean age of 46.5 years (range 29-52 years). The main clinical manifestations were nasal obstruction and epistasis. A red polypoid mass was found under nasal endoscopy. Imaging showed nasal cavity and ethmoid sinus mass with invasion into surrounding structures and bone destruction. Microscopically, the tumor cells were arranged in nests, alveoli and microcapsules with abundant intervening capillaries, accompanied by hemorrhage. The cytoplasm of the cells was clear with low nuclear grade, and the nucleoli were inconspicuous. In some areas, the tumor invaded bone tissue. Immunohistochemical markers CKpan, CK7, CAⅨ, S-100 and vimentin were positive, with low Ki-67 proliferation index. RCC, CD10, PAX8, p63, SMA, HHF35, Calponin, CD117, TTF-1 and neuroendocrine markers Syn and CHG were all negative. EWSR1 and ETV6 gene rearrangements were not detected by FISH. All five patients underwent surgical resection after initial diagnosis. One patient underwent surgical resection after second recurrence and adjuvant radiotherapy, one patient received postoperative radiotherapy, one patient underwent surgical resection after recurrence, one patient had no recurrence and one patient received radiotherapy after recurrence. All five patients had no distant metastasis and survived without tumor up to December 2019. Conclusions: Primary sinonasal renal cell-like adenocarcinoma is a special subtype of low-grade non intestinal adenocarcinoma, with low incidence and inert biologic behavior. At present, most of the literatures are case reports. Before a diagnosis is made, other primary and metastatic clear cell tumors need to be excluded. Immunohistochemistry is helpful for diagnosis and differential diagnosis. Surgical resection is the mainstay of treatment, and may be supplemented by radiotherapy.

[SMARCB1 (INI1)-deficient sinonasal carcinoma: a clinicopathological analysis of six cases].

Objective: To study the clinicopathological features, diagnostic features and differential diagnoses of SMARCB1 (INI1)-deficient sinonasal carcinoma (SDSC). Methods: Six cases of SDSC diagnosed at Eye, Ear, Nose and Throat Hospital, Fudan University from 2016 to 2018 were retrieved; the clinical features, histomorphology, immunophenotype, radiology and outcome were analyzed with review of literature. Results: There were five men and one woman with age range of 37 years to 75 years (mean 56 years). One case was in stage T2, and 5 cases were in stage T4. Computer tomography and magnetic resonance imaging showed a mass occupying the sinonasal cavity with bone destruction in all six patients. Microscopically, the tumors had infiltrative margins. Four tumors were composed mostly of basaloid cells, which possessed high nuclear/cytoplasmic ratio,scant cytoplasm,and minimalnuclear pleomorphism; and the cells were arranged in sheets or nests in a desmoplastic stroma. Two tumors were composed of rhabdoid cells, which possessed abundant, eosinophilic cytoplasm and eccentric nuclei, often growing in a nests or sheets pattern. Immunohistochemical staining showed that 6/6 cases had complete loss of INI1, diffusely and strongly positive for CKpan, and were negative for S-100 and EBER ISH; 4/6 cases were focally positive for p63; 1/5 was focally positive for Syn and p16. The Ki-67 index was 30% to 70%. The follow-up period ranged 1-26 months, with one patient died of extensive metastases, one had local recurrence, and two had lymph node metastases; one was alive without disease, and one was lost to follow-up. Conclusions: SMARCB1 (INI1)-deficient sinonasal carcinoma is mostly aggressive, with rapid progression and poor prognosis. Histomorphological spectrum predominantly consists of basaloid type and rhabdoid type. The complete loss of nuclear expression of INI1 can help to distinguish this tumor from its many mimickers.

Solid state 27Al NMR investigation of Knight shift tensors of LnAl2 (Ln = Y, La and Lu) and correlation with DFT calculations.

The atomic and electronic structures of LnAl(2) (Ln=Y, La and Lu) on Al sites were characterized by (27)Al solid state NMR spectroscopy. (27)Al isotropic metallic shifts have been determined in these cubic laves phases under both static and magic angle spinning (MAS) conditions. Based on band structure calculations, we found a strong correlation of (27)Al isotropic metallic shifts and s character of the density of states at the Fermi level on Al sites. We also found tetrahedral distortion of Al centered clusters, which can be well characterized by quadruple coupling constants and Knight shift anisotropy.

NMR signature of evolution of ductile-to-brittle transition in bulk metallic glasses.

The mechanical properties of monolithic metallic glasses depend on the structures at atomic or subnanometer scales, while a clear correlation between mechanical behavior and structures has not been well established in such amorphous materials. In this work, we find a clear correlation of (27)Al NMR isotropic shifts with a microalloying induced ductile-to-brittle transition at ambient temperature in bulk metallic glasses, which indicates that the (27)Al NMR isotropic shift can be regarded as a structural signature to characterize plasticity for this metallic glass system. The study provides a compelling approach for investigating and understanding the mechanical properties of metallic glasses from the point of view of electronic structure.

Effects of phytosterol supplementation on growth performance, serum lipid, proinflammatory cytokines, intestinal morphology, and meat quality of white feather broilers.

The aim of this study was to evaluate the effects of dietary phytosterol (PS) addition at different levels on growth performance, serum lipid, proinflammatory cytokines, intestinal morphology, and meat quality in broilers. A total of 600, 1-day-old male broilers were allocated into five groups with six replicates and were fed a basal diet supplemented with 0 (control group), 10, 20, 40, or 80 mg/kg PS for 42 days. Compared with the control group, the administration of PS at doses of 40 and 80 mg/kg significantly increased the average daily feed intake and average daily gain of broilers during the experimental period. Similarly, PS at a dosage of 20 and 40 mg/kg increased the concentrations of interleukin-1ß, interferon-γ, interleukin-2, and interleukin-6 but decreased triglyceride, total cholesterol, and low-density lipoprotein cholesterol content of serum (P < 0.05). Dietary PS at less than or equal to 40 mg/kg level increased (P < 0.05) villus height, and villus height to crypt depth ratio in the duodenum and ileum. Supplementing PS increased the pH value at 45 min post-mortem and decreased drip loss and shear force of breast muscle (P < 0.05). Dietary PS administration at 20 and 40 mg/kg decreased malondialdehyde accumulation but increased total antioxidant capacity and superoxide dismutase activity of breast muscle compared with the control group (P < 0.05). PS increased the concentrations of total amino acids and flavor amino acids as well as eicosapentaenoic acid, docosahexaenoic acid, and total polyunsaturated fatty acids but decreased saturated fatty acids in breast muscle (P < 0.05). It was concluded that dietary PS supplementation, especially at 40 mg/kg, could improve growth performance, serum lipid, proinflammatory cytokines, intestinal morphology, and meat quality in broilers, providing insights into its application as a potential feed additive in broiler production.

Whole-body positron emission tomography with 18F-fluorodeoxyglucose is an effective method to detect extra-pelvic recurrence in uterine sarcomas.

PURPOSE OF INVESTIGATION: To assess the clinical use of F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) in the post-therapy surveillance of uterine sarcoma. METHODS: Eight whole-body FDG-PET studies were performed in seven women with previously treated uterine sarcoma. Conventional image studies (computed tomography) and physical examinations were performed for follow-up. All FDG-PET studies were indicated to localize suspected recurrences noted by conventional methods. RESULTS: The per case sensitivity of the FDG-PET studies and CT scans was 85.7% (6/7) and 100% (7/7), respectively (p = 0.174). FDG-PET was able to detect seven extrapelvic metastastic sites below the diaphragm (7/7, sensitivity: 100%), including the liver, spleen, paraaortic lymph node, spine and paracolic gutter, as well as pulmonary lesions in five patients, while the CT scan detected only three lesions (3/7, sensitivity: 42.9%; p = 0.070). FDG-PET detected only four recurrent pelvic lesions (4/6) and CT scan detected six (6/6) recurrent pelvic lesions (66.7% vs 100%, p = 0.455). CONCLUSIONS: The FDG-PET showed a better detection rate than the abdominal CT scan for extrapelvic metastatic lesions and a similar detection rate as well as abdominal CT scan. FDG-PET can serve as a useful detection tool for patients with uterine sarcomas because nearly 80% of recurrence involve an extrapelvic site.

Autofluorescence reveals menstrual phase in the endometrium.

OBJECTIVE: Tissue contains fluorophores that autofluoresce without additional dye or photosensitizer with the appropriate light excitation. This technique has been widely applied for discrimination between normal and precancerous tissue. The aim of this study was to explore the capability and reliability of autofluorescence phase determination in samples of human endometrium. METHODS: A total of 70 measurement sites from 31 endometrial tissue samples from hysterectomy were enrolled. Xenon light (330 nm) was directed at the endometrial tissue and the resultant autofluorescence intensity recorded. Spectra were then grouped according to the proliferative and secretory phase, with multivariant analysis, partial least square (PLS) and analysis of variance (ANOVA) used for evaluation of the statistical significance of phase determination. RESULTS: Both proliferative and secretory autofluorescence spectra showed a similar characteristic triple-peak curve shape pattern, however, each of the intensities at the three peaks between the two phases varied markedly (p < 0.01). PLS analysis confirmed that collagen, NADH and FAD autofluorescence were the principle determinants of endometrial spectrum; the sensitivity and specificity of phase determination by autofluorescent was 100% and 97%, respectively. CONCLUSION: Autofluorescence measurement provides real-time information on endometrial phase status and, based on our results, it appears reasonable to suggest that it may be promising as a clinical tool for prompt phase interpretation.

Presumed Stage IA primary epithelial ovarian carcinoma: the role of complete staging surgery.

PURPOSE: Proper staging is warranted in any patient with primary epithelial ovarian carcinoma (PEOC), but sometimes it cannot always be performed. The prognosis of patients with and without complete staging surgery is to be determined. METHODS: We retrospectively evaluated 61 patients with presumed Stage IA PEOC between January 1970 and December 1993. Inclusion criteria were: being referred patients; no ascites; an intact ovarian tumor without extra-spillage or rupture before, during or after operation; conventional regular exploratory laparotomy without urgency; more than a 5-year follow-up, except for recurrent diseases; a detailed pathology review; and no other systemic disease. Tumors of lower malignant potential (LMP) and cystectomy for removing tumor were excluded. Of the 61 patients, 17 patients received a close observation (Group A), and the others (44 patients) received a re-exploratory laparotomy to complete the staging surgery (Group B). RESULTS: The mean follow-up time was 7.4 years, ranging between 5.4 and 11.1 years, in Group A, and 8.1 years, ranging from 5.6 to 12.7 years, in Group B. Two patients (11.8%) in Group A and seven patients (15.9%) in Group B suffered from recurrence. Two patients finally died of disease, and both were in Group B. CONCLUSIONS: Based on the observation in this study that the recurrence rate of the two groups was not statistically different, close follow-up for patients with presumed Stage IA EOC, but without complete surgical staging surgery, might be acceptable when these patients are treated with postoperative adjuvant chemotherapy.

Invited Review Article: Tip modification methods for tip-enhanced Raman spectroscopy (TERS) and colloidal probe technique: A 10 year update (2006-2016) review.

Engineering atomic force microscopy tips for reliable tip enhanced Raman spectroscopy (TERS) and colloidal probe technique are becoming routine practices in many labs. In this 10 year update review, various new tip modification methods developed over the past decade are briefly reviewed to help researchers select the appropriate method. The perspective is put in a large context to discuss the opportunities and challenges in this area, including novel combinations of seemingly different methods, potential applications of some methods which were not originally intended for TERS tip fabrication, and the problems of high cost and poor reproducibility of tip fabrication.

Establishment and characterization of a tumorigenic trophoblast-like cell line from a human placenta.

A trophoblast-like cell line, TL, was established from a normal-term human placenta. The TL cells were epithelial in morphology with relatively large vesicular nuclei, prominent nucleoli, and numerous microvilli on the cell surface. Cytoplasmic organelles were generally sparse but mitochondria and polysomes were abundant. The cells grew as compact sheets with close membrane approximation interconnected occasionally by desmosome-like junctions. TL cells contained placental alkaline phosphatase, a placenta-associated antigen, cytokeratin, and prekeratin, but not keratin. In parallel, they were negative for factor VIII, vimentin, and fibronectin. Population doubling time was estimated to be about 34 h. TL cells were tumorigenic in nude mice and an increase in tumorigenicity was observed after a certain number of passages in vitro. Chromosome analysis revealed that TL cells were highly heterogenous and had a female aneuploid karyotype with a hypotriploid mode. Unlike trophoblastic cell lines established from neoplastic tissues, TL cells did not synthesize human chorionic gonadotropin or other gonadal hormones, and only a small amount of ferritin (40.3 ng/10(6) cells) could be detected in the cell supernatant and cell extract. Based on various morphological and histochemical criteria, we suggest that the TL cells are derived from the Langhans cells (villous cytotrophoblast), and due to their special features, the cells may be valuable for the study of the differentiation and tumorigenesis of trophoblastic cells.

The Gag-Myb-Ets fusion oncogene alters the apoptotic response and growth factor dependence of interleukin-3 dependent murine cells.

Expression of the avian E26-derived Gag-Myb-Ets fusion oncogene in interleukin-3(IL3)-dependent murine hematopoietic cell lines results in a pattern of cell line dependent changes in growth factor-induced proliferation and apoptosis. A drug-selectable retrovirus expressing p135Gag-Myb-Ets induced an erythropoietin(Epo)-responsive phenotype in the cell lines FDC-P2, BaF3 and 32Dc123. Gag-Myb-Ets expression alone did not increase expression of GATA-1 or the Epo receptor(EpoR) in the presence of IL3, and infected cell lines express increased GATA-1 and EpoR only when IL3 was replaced by Epo in the culture media. Indicative of Epo-induced erythroid differentiation, these cells also began to express beta-globin after 3-5 days growth in Epo. Unlike control cells, infected FDC-P2 cells failed to undergo programmed cell death (apoptosis) when transferred from IL3- to Epo-containing media, although a fraction of the cells failed to proliferate following the media shift. Three other IL3-dependent cell lines showed no changes in growth behavior when induced to express the fusion oncogene. Our data shows that Gag-Myb-Ets can have different affects on growth factor pathways depending on the cell background, suggesting a model in which the p135gag-myb-ets fusion oncogene promotes these different responses through its affect on apoptosis.

Radical hysterectomy: past, present, and future.

After an analysis of 3,441 radical hysterectomies performed in our department, we found, after modification of the operative technique in 1983, the more lateral the excision the less the recurrence rate. The recurrence rate for Stage 1b-2a and Stage 2b patients comparing the years before 1983 to the years after decreased to 12.4% from 15.7% (158/1,006 vs 268/2,163; p = 0.009) in Stage 1b-2a and 24.6% from 55.8% (38/68 vs 47/191; p = 0.0007) in Stage 2b, respectively. With the modern trend of aspiring for an easier lifestyle, most physicians practice earlier. Therefore only very few physicians study radical hysterectomy. As the skill of surgery needs a longer period of education and training, it may only interest physicians who work with medical professionals as part of a team at a medical center. In the future, we should provide gynecological residents not only with a training program using the classic textbooks, but also with different points of view on changes and developments in radical hysterectomy. We hope to promote an attitude of offering patients access to different choices and opportunities of therapy. Radical hysterectomy is in fact a treatment option for patients with bulky cervical lesions and Stage 2b in particular.

EBV-miR-BART7-3p promotes the EMT and metastasis of nasopharyngeal carcinoma cells by suppressing the tumor suppressor PTEN.

The epithelial-mesenchymal transition (EMT) is crucial to cancer progression and metastasis. Although multiple cellular miRNAs have been identified to regulate the EMT and metastasis in cancers, the role of viral miRNAs in cancer progression remains largely unknown. Nasopharyngeal carcinoma (NPC) is an Epstein-Barr virus (EBV)-associated malignancy typically characterized by its early metastasis. In the present study, we have discovered the involvement of a viral miRNA, EBV-miR-BART7-3p, in the EMT and metastasis of NPC cells. Initially, we observed that EBV-miR-BART7-3p was highly expressed in NPC and positively correlated with lymph node metastasis and clinical stage of NPC. Subsequently, we demonstrated that EBV-miR-BART7-3p enhanced cell migration/invasion in vitro, cancer metastasis in vivo, and particularly the EMT characterized by loss of epithelial markers and gain of mesenchymal features in NPC cells. Furthermore, mechanistic studies disclosed that EBV-miR-BART7-3p targeted a major human tumor suppressor PTEN, modulating PI3K/Akt/GSK-3ß signaling and eventually leading to the high expression and nuclear accumulation of Snail and ß-catenin, which favor EMT. Knockdown of PTEN could phenocopy the effect of EBV-miR-BART7-3p, whereas re-expression of PTEN resulted in a phenotypic reversion. Moreover, these findings were supported by an observation of an EBV-positive cell model in which silencing of endogenous EBV-miR-BART7-3p partially attenuated cell migration/invasion and altered EMT protein expression pattern via reverting PI3K/Akt, Snail and ß-catenin expression. Thus, this study suggests a novel mechanism by which EBV-miR-BART7-3p modulates the EMT and metastasis of NPC cells, and a clinical implication of EBV-miR-BART7-3p as a potential biomarker or therapeutic target.

A quantification of human cells using an ERV-3 real time PCR assay.

A novel approach to quantifying human cells using a real time PCR assay was developed. The target sequence used in the assay is a 135 bp segment within the unique 1.7 kb Hind III / Pst I fragment of the ERV-3 envelope gene. ERV-3 is a full-length human endogenous retrovirus present in known copy number in all human cells. The detection range of ERV-3 by real time PCR is from 10(6) to 10(1). The precision described, sensitivity and specificity of the assay indicate that the ERV-3 sequence is an accurate cell quantitation marker. The quantitative ERV-3 assay enables simple, fast, and reproducible detection and quantitation of the cell number. The assay can be used to determine the sample DNA conditions and also it can be used to adjust the quantitative DNA measurements of other target gene assays relative to the number of cell equivalents.

Laparoscopic bipolar coagulation of uterine vessels: a new method for treating symptomatic fibroids.

OBJECTIVE: To evaluate the effects of laparoscopic bipolar coagulation of uterine vessels in treating symptomatic fibroids. DESIGN: Prospective clinical study. SETTING: University-affiliated tertiary referral center. PATIENT(S): Eighty-seven women with symptomatic fibroids warranting surgical treatment and wanting to retain their uteri. INTERVENTION(S): Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries. MAIN OUTCOME MEASURE(S): Percentage reduction in the dominant fibroid size and clinical response evaluation. RESULT(S): Eighty-five (97.7%) of 87 patients underwent technically successful laparoscopic coagulation of uterine vessels without intraoperative complications. The mean follow-up time was 10.2 months. Symptomatic improvement was reported in 76 (89.4%) of 85 patients, including 18 (21.2%) with complete resolution of symptoms. Significant reductions in the dominant fibroid size (average, 76%) and the uterine volume (average, 46%) were sonographically demonstrated. Two patients conceived 4 and 9 months, respectively, after treatment. Three (3.5%) premenopausal women became postmenopausal postoperatively. CONCLUSION(S): Laparoscopic bipolar coagulation of uterine vessels appears to be a promising new method for treating fibroid-related menorrhagia and pelvic pain.

Successful treatment of symptomatic arteriovenous malformation of the uterus using laparoscopic bipolar coagulation of uterine vessels.

OBJECTIVE: To report a case of symptomatic arteriovenous malformation (AVM) of the uterus that was successfully treated with laparoscopic bipolar coagulation of uterine vessels. DESIGN: Case report. SETTING: University-affiliated tertiary referral center. PATIENT(S): A 66-year-old woman with symptomatic AVM of the uterus. INTERVENTION(S): Laparoscopic bipolar coagulation of uterine vessels. MAIN OUTCOME MEASURE(S): Clinical symptoms, color Doppler sonographic examination, and pelvic magnetic resonance imaging. RESULT(S): Remarkable shrinkage of the lesion size, obvious decrease in all of the impedance measurements (pulsatility, resistance, velocity indexes [systolic/diastolic]), and freedom from symptoms. CONCLUSION(S): This modality is a new alternative method for the management of patients with symptomatic AVM of the uterus who do not respond to conservative treatment.

Effects of tamoxifen and retinoic acid on cell growth and c-myc gene expression in human breast and cervical cancer cells.

The effects of estradiol, tamoxifen, and retinoic acid on the proliferation of breast and cervical cancer cells were investigated. Estrogen stimulated only MCF-7 cell growth, whereas tamoxifen and retinoic acid inhibited the proliferation of all cells studied. Northern blot analysis indicated that estradiol up-regulates c-myc mRNA level in all cell lines studied regardless of the estrogen receptor status in the cells. On the contrary, tamoxifen inhibits c-myc gene expression in all cell lines studied except in MCF-7 cells where the c-myc transcript was not affected. The inhibitory effect of tamoxifen on c-myc gene expression and cell proliferation in estrogen receptor-negative cells suggest an estrogen receptor-independent mechanism. The results also suggest that different mechanisms are involved in the regulation of cell growth and c-myc gene expression in different cancer cells by estrogen and tamoxifen.

A scoring system for predicting recurrence of cervical cancer.

An evaluation was made of factors that affect the recurrence of cervical cancer after primary surgery, these including age, clinical stage, histology, grade, involvement of uterine body, parametrium or vagina and lymph node metastases. During a period of at least 3 years, 702 of 1508 patients who underwent radical hysterectomy and pelvic lymph node dissection were studied by using a scoring system. A comparison between the group of women scored at or greater than 13 that scored less than 13 revealed that the risk of recurrence was higher in the former group. One hundred and twenty five of 702 patients found to have positive pelvic node involvement scored greater than 13, which rendered them eligible for further mangement as follows: the recurrence rate in 99 patients receiving multi-agent chemotherapy was 34.4%, compared with 65.4% in 26 patients receiving no treatment (P < 0.01). Applying this score to other patients in planning adjuvant therapy, the recurrence rate may be reduced further. The number of patients needlessly exposed to the toxic effects of multi-agent chemotherapy may be reduced also.