Assessment of hormone dependence of comedo ductal carcinoma in situ of the breast.

BACKGROUND: Ductal carcinoma in situ (DCIS) represents 20%-30% of breast cancers detected by clinical screening (i.e., mammography). More than 50% of DCIS lesions may be estrogen receptor negative and, therefore, hormone independent. However, the role of estrogen in the natural history of DCIS is unknown. PURPOSE: A novel in vivo (i.e., xenograft) model was developed to determine to what degree DCIS lesions depend on estrogen for growth. METHODS: Specimens of breast tissue were collected from 52 women during diagnostic or therapeutic surgical procedures. Portions of each specimen were randomly selected and analyzed by histology and thymidine labeling (to measure cell proliferation). The remainder of each specimen was implanted into five to 18 athymic BALB/c nu/nu mice (depending on the amount of tissue available), with eight pieces of approximately 2 mm x 2 mm x 1 mm implanted at different locations on the back of each mouse. Half of the mice received implants containing estrogen (2 mg 17 beta-estradiol), and the other half received placebo implants. Levels of cell proliferation in xenografts, recovered after 14, 28, 42, or 56 days in the mice, were measured by thymidine labeling or by immunohistochemistry through use of an antibody specific for the Ki-67 nuclear antigen. Immunohistochemistry was also used to measure the levels of estrogen receptor in the tissue specimens. Serum 17 beta-estradiol levels in the mice were measured by radioimmunoassay. RESULTS: Initial levels of cell proliferation were approximately 10-fold higher in 10 specimens with estrogen receptor-negative, comedo (i.e., more malignant in appearance) DCIS than in four specimens with estrogen receptor-positive DCIS (mean proliferation indices: 22% versus 1.9%, respectively; two-sided P < .001). Xenografts from the majority of specimens survived up to 56 days in the mice and maintained good architectural and cellular preservation. Estrogen treatment of the xenograft-bearing mice had no effect on the high level of cell proliferation observed in estrogen receptor-negative, comedo DCIS specimens (two-sided P = .89). In contrast, increased levels of cell proliferation in response to estrogen supplementation were measured in three estrogen receptor-positive, noncomedo DCIS specimens (two-sided P < .001). However, even with estrogen treatment, cell proliferation levels in estrogen receptor-positive DCIS specimens did not reach those seen in estrogen receptor-negative DCIS specimens. CONCLUSION AND IMPLICATION: Estrogen receptor-negative, comedo DCIS lesions appear to be estrogen independent; therefore, antiestrogen (e.g., tamoxifen) therapy may not benefit patients with comedo DCIS.

Effects of a pure antiestrogen on apoptosis and proliferation within human breast ductal carcinoma in situ.

Adjuvant antiestrogen (AE) therapy has been proposed for all women with ductal carcinoma in situ (DCIS). However, many cases of DCIS are of the high-grade, estrogen receptor (ER)-negative subtype that are unlikely to respond to AE treatment. Hormonal agents work by increasing apoptosis and/or decreasing cell proliferation; therefore, we studied the effect of a pure AE on levels of apoptosis and proliferation in human DCIS xenografts using an in vivo model. Women (n = 23) with mammographic microcalcification suggestive of DCIS were identified at the time of surgery (day 0), a sample of representative tissue was obtained, divided into multiple 2x2x1-mm xenografts, and implanted s.c. into female BALB/c nu/nu mice (eight xenografts/mouse). Day 0 grafts underwent immunohistochemical assessment of ER status. Fourteen days after implantation, four xenografts were retrieved and mice were randomly divided into one of three treatment groups: (a) insertion of a slow release 2-mg 17beta-estradiol pellet; (b) weekly 5-mg injections of the pure AE Faslodex (Zeneca Pharmaceuticals); and (c) injections of a control vehicle oil alone. After 2 weeks of treatment, the remaining four xenografts were retrieved from each mouse. Retrieved xenografts containing DCIS were assessed for morphological evidence of apoptotic cell death [apoptotic index (AI)] and cell proliferation (by immunohistochemical detection of the Ki67 proliferation antigen LI). Both AI and LI were higher in the day 0 specimens of 16 ER- DCIS lesions compared with 7 ER+ DCIS lesions (mean values, 1.47% versus 0.32% and 20.6% versus 3.1%; both P<0.0001). AI and LI values within ER- DCIS did not differ between xenografts exposed to 17beta-estradiol or AE treatment compared with the controls or pretreatment values (mean AI and LI in estradiol-treated, antiestrogen-treated, and control groups 1.04% versus 0.98% versus 1.29% and 17.2% versus 20.5% versus 17.7% respectively). In contrast, treatment of mice bearing ER+ DCIS xenografts with 17beta-estradiol raised both the AI (1.03% versus 0.40%, P = 0.03) and LI (11.0% versus 5.1%, P = 0.007) compared with controls. AE therapy of ER+ DCIS xenografts did not affect proliferation but resulted in higher apoptosis than in controls (0.9% versus 0.4% respectively, P = 0.04). AE therapy should be reserved for patients with estrogen receptor positive DCIS.

Assessment of tumour vascularity as a prognostic factor in lymph node negative invasive breast cancer.

The association between tumour vascularity and relapse was examined in 93 patients with lymph node negative (LNN) invasive breast cancer. Factor VIII-related antibody was used to stain the microvessels. Vascularity was defined by the number of vessels per field counted in the area of highest vascular density at 100 x magnification. These vascular counts were divided into three groups of vascular density (group I: < 67, group 2: 68-100, group 3: > 101 vessels/field). Cross-tabulation analysis revealed a significant relationship between vascular density and tumour grade (P = 0.027). No association was found between vascularity and tumour size, tumour type, age or menopausal status. Survival analysis showed no association between vascularity and relapse-free (P = 0.92) or overall survival (P = 0.99). Significant associations between tumour grade and relapse-free (P = 0.0048) and overall survival (P = 0.0064) and between tumour size at the cut off of 15 mm diameter and relapse-free (P = 0.0097) and overall survival (P = 0.0271) were found. When grade was taken into account the effect of tumour size became non-significant (P = 0.059). Our results suggest that assessment of vascularity is not an independent prognostic factor in LNN invasive breast cancer.

Villitis of unknown aetiology: its incidence and significance in placentae from a British population.

A histological study of 1000 randomly selected placentae from women delivered in Manchester, UK, revealed 136 cases of villitis; this is a higher incidence than that recorded in Australia and North America but lower than that noted in South America. There were no obvious clinical differences between mothers whose placentae showed a villitis and those in a control group whose placentae were free of villitis. As in other studies, there was an association between the presence of a villitis, particularly severe villitis, and fetal intrauterine growth retardation. The nature of this association cannot, however, be clarified until the aetiology of villitis is determined.

Multinucleated stromal giant cells of the colonic lamina propria in ulcerative colitis.

Multinucleated stromal giant cells were seen in the colonic mucosa in biopsy specimens from two patients with long-standing quiescent ulcerative colitis. Similar cells have been described at other sites associated with chronic inflammation, including the lower female genital tract, bladder and anus. The immunophenotype of the cells in the colonic mucosa suggested that they had originated from fibroblasts rather than histiocytes, in common with cells seen at other sites of inflammation. These examples lend support to the concept of there being a reactive morphological change possibly related to interaction with mast cells. These multinucleated giant cells are distinct from histiocytic giant cells and should not be confused with them.

Pulmonary vascular candidiasis and use of central venous catheters in neonates.

A retrospective study of infant deaths in this maternity hospital carried out from 1976-86 showed a recent increase in fatalities with systemic candidiasis. Ten of twenty five cases occurred between July 1985 and June 1986. Most of these infants had Candida plugging pulmonary vessels, often accompanied by vasculitis, thrombosis, and parenteral lipid embolism. The adoption of central venous catheters for prolonged parenteral feeding of very preterm infants may have accounted for this phenomenon. Over the same decade there was an increased incidence of Candida isolates from all admissions to the neonatal intensive care unit: the prolonged survival of very low birthweight infants and the use of multiple courses of antibiotics were also factors.

Method for showing human spermatogenesis using Arachis hypogaea (AHA) lectin.

Using biotinylated Arachis hypogaea agglutinin (AHA) or peanut lectin (PNA) and an avidin-peroxidase procedure, the various stages of spermatid development were visualised with great clarity; a light haematoxylin counterstain permitted the easy recognition of spermatogenic cells in the same section. This method is particularly useful in the interpretation of poorly fixed material and may be helpful in studies of cyclical maturation of spermatozoa, irrespective of whether the material is obtained at biopsy or necropsy.

Foreign body giant cell reactions and ossification associated with benign melanocytic naevi.

AIMS: To assess the incidence of foreign body giant cell reactions and ossification in benign/melanocytic naevi; and to examine their pathological features to gain an insight into their pathogenesis. METHODS: Intradermal (n = 185) and compound naevi (n = 110) from a routine histology service, together with 60 naevi submitted to an ophthalmic pathologist, were examined for foreign body reactions and ossification. Additional cases were identified prospectively in the course of routine reporting. The clinical and pathological features of positive cases were assessed. RESULTS: Foreign body reactions were identified in nine (4.9%) intradermal and four (3.6%) compound naevi, but in none of the naevi from around the eye. One intradermal naevus showed ossification. A further 11 naevi showing foreign body reaction and five showing ossification alone were identified prospectively. The 24 naevi showing a foreign body reaction had a similar age and sex distribution to controls but were more likely to occur on the head and neck. The reaction usually occurred deep to the naevus, sometimes in relation to a hair follicle, and fragments of hair or keratin were identified in most. Osteoid or bone was present within the reaction in five. In six other naevi, all from the head and neck of women, osteoid or mature bone was present deep to the naevus in the absence of a giant cell reaction. CONCLUSIONS: Foreign body giant cell reactions occur not uncommonly in relation to benign naevi, as a result of follicular damage, possibly due to trauma. The similar siting of foci of bone suggests that ossification occurs as a secondary phenomenon in these cases.

Can histopathologists diagnose bronchopneumonia?

OBJECTIVES: To assess histopathologists' ability to accurately diagnose bronchopneumonia, both on naked eye and microscopic examination; to extrapolate from the error rate to determine whether the role of the necropsy in monitoring the epidemiology of clinical error might be compromised. METHODS: Review of archival histological sections and necropsy reports from two teaching hospitals in Manchester. The main outcome measures identified were the proportions of macroscopic diagnoses of bronchopneumonia which were confirmed by the original pathologist on histological examination, and which could be confirmed on histological review by independent pathologists, together with the proportion of discrepant diagnoses remedied in the final report by the original pathologist. RESULTS: Of 279 cases where a macroscopic diagnosis of bronchopneumonia had been noted in the original provisional necropsy report, the original histopathologist described bronchopneumonia in only 206 (73.8%) in the subsequent final report, which took histology into account. Bronchopneumonia could be confirmed on independent histological review in only 193 (69.2%) of these cases. The original histopathologist diagnosed 74 cases of bronchopneumonia on histological grounds only, of which only 57 (77.0%) could be confirmed on review. Of a total of 160 discrepancies between the original naked eye diagnoses and the final reviewed diagnoses, only 130 (81.3%) had been remedied by the original pathologist. CONCLUSIONS: There is a considerable discrepancy rate between naked eye diagnoses of bronchopneumonia at necropsy and diagnoses confirmed on microscopy. If this discrepancy rate is extrapolated to other common lesions, then the role of the necropsy in clinical audit may be compromised. Pathologists need to take steps to monitor and improve their own diagnostic standards.

Endotoxin in blood and tissue in the sudden infant death syndrome.

Although the explanation for sudden infant death syndrome (SIDS) remains unknown, an increasing body of evidence now exists to suggest a possible role for bacterial toxins in the aetiology, and a number of investigators have considered that endotoxaemia could explain some of the associated features. Following the development of an animal model which confirmed that endotoxaemia could be detected after death, we studied endotoxin levels in blood and tissue samples taken at autopsy from SIDS infants, child controls and adult controls. There were significant correlations between endotoxin levels in blood and the various organs sampled particularly in SIDS cases and child controls, and blood endotoxin levels in SIDS cases were higher in those infants where there was histological evidence of mild to moderate inflammation. However, overall no significant differences were found between endotoxin levels in blood or tissue in the three study groups. Further studies into possible actions or interactions of endotoxin in SIDS are required.

Periductal inflammation and cigarette smoke.

BACKGROUND: Cigarette smoking has been implicated in the etiology of periductal mastitis. The mechanism by which it causes inflammation around the mammary ducts is unknown. STUDY DESIGN: Inflammation and dilatation of the mammary ducts were compared in two groups of women with proven histologic diagnoses of periductal mastitis (PDM, n = 133) and intraductal papilloma (IDP, n = 98) over an eight year period. This study was done to determine if the number of cigarettes smoked correlated with the amount of periductal inflammation seen in PDM. Duct dilatation, periductal inflammation, and squamous metaplasia were assessed objectively by two pathologists without knowledge of the clinical parameters. RESULTS: Women with PDM were significantly more likely to be smokers than women with IDP (p < 0.001). Women with severe periductal inflammation were more likely to be younger (p < 0.05) whereas those with duct dilatation were more likely to be older (p < 0.02). Women with PDM who were heavy smokers (more than ten cigarettes per day) had more periductal inflammation (p = 0.0006) and squamous metaplasia of the lactiferous ducts (p < 0.02) compared with light or nonsmokers. Duct dilatation did not correlate with smoking habits. CONCLUSIONS: Cigarette smoking appears to be an important etiologic factor in periductal mastitis and appears to have direct toxic effects on the mammary ducts.

Cytomegalovirus cholecystitis and colitis associated with the acquired immunodeficiency syndrome.

Cytomegalovirus (CMV) is an important cause of acalculous gangrenous cholecystitis in immunocompromised persons. We report a case of acalculous acute cholecystitis and active colitis associated with CMV in a patient suffering from the acquired immune deficiency syndrome. The condition was treated successfully with surgery and 9-(1,3,-dihydroxy-2-propoxymethyl)guanine intravenously.

Pulmonary hypoplasia in a regional perinatal unit.

83 cases of pulmonary hypoplasia were found in 709 perinatal necropsies in St. Mary's Hospital between 1976 and 1983. 49 of these infants were inborn, representing an incidence of 1.4 per 1000 births. Diaphragmatic hernia was present in 43% and was the commonest reason for referral, usually to the neonatal surgical unit, from an outside hospital. Renal malformation, often with oligohydramnios, was seen in 25%, and 11% had no other major disease. The respiratory symptoms associated with pulmonary hypoplasia in the absence of diaphragmatic hernia seem to have encouraged the referral of these infants to the neonatal medical unit. However, more than half the liveborn infants with pulmonary hypoplasia died during the first postnatal day. In comparison with first week deaths from other causes, short survival was a particular feature of pulmonary hypoplasia in infants weighing less than 2.5 kg and pneumothorax and pulmonary haemorrhage were commoner in term infants with hypoplastic lungs.

Survivin expression in in situ and invasive breast cancer relates to COX-2 expression and DCIS recurrence.

In lung cancer cyclooxygenase-2 (COX-2) expression has been reported to stabilise survivin, an inhibitor of apoptosis (IAP) which prevents cell death by blocking activated caspases. COX-2 expression limits the ubiquitination of survivin, protecting it from degradation. To determine if COX-2 expression in breast cancer showed an association with survivin expression, we assessed the levels of each protein in ductal carcinoma in situ (DCIS) and invasive breast cancer (IBC); relating expression patterns to recurrence of DCIS after surgery. Patterns of COX-2 and survivin expression were determined by intensity-graded immunohistochemistry of the primary tumours. Patients with DCIS (n=161) which had either recurred (n=47) or shown no evidence of recurrence (n=114) 5 years following primary surgery were studied. These were compared to 58 cases of IBC. Survivin was expressed in the cytoplasm of 59% of DCIS and 17% of IBC. High levels of both cytoplasmic survivin and COX-2 expression significantly correlated to DCIS recurrence. COX-2 expression was present in 72% of DCIS, and levels of expression positively correlated with cytoplasmic survivin expression in DCIS and invasive disease. The majority of DCIS that recurred expressed both proteins (69%) vs 39% nonrecurrent. Recurrence was not seen in DCIS lacking both proteins at 5 years (P=0.001). Expression of the IAP survivin is increased in DCIS and correlates closely with COX-2 expression. Increased expression of IAP, (leading to reduced apoptosis) may explain the effect of COX-2 in increasing recurrence of DCIS after surgical treatment.

Relationship between hormone receptor status and tumour size, grade and comedo necrosis in ductal carcinoma in situ.

BACKGROUND: Results of the National Surgical Adjuvant Breast Project B-24 trial indicate that adjuvant tamoxifen therapy is of benefit only in oestrogen receptor (ER)- positive ductal carcinoma in situ (DCIS). In the UK, ER status is not routinely determined in DCIS. The aim of this study was to assess the ER status in women with DCIS to determine whether any clinicopathological factors could predict positivity instead of immunohistochemical assessment. METHODS: The ER and progesterone receptor (PR) status of consecutive women diagnosed with DCIS during 2001 and 2002 was determined by immunohistochemistry. RESULTS: One hundred and nineteen tumours diagnosed between 2001 and 2002 were analysed; 73.0 per cent were ER positive and 61.1 per cent were PR positive. PR positivity was associated with ER positivity (P < 0.001). Increasing tumour grade correlated with a decrease in ER and PR positivity (both P = 0.002). Comedo necrosis was associated with ER negativity (P = 0.026), PR negativity (P = 0.033) and a lower percentage of ER expression in ER-positive tumours (mean(s.d.) 82(27) versus 93(10) per cent; P = 0.021). CONCLUSION: Tumour grade and comedo necrosis were not strong enough predictors to be used as surrogates for immunohistochemical assessment. ER status should be determined before commencing endocrine therapy.

Restricted feeding and human intestinal plasma cell development.

Small intestinal mucosa from 129 necropsies and 15 surgical specimens from infants aged from birth to 21 months was examined for the presence of cells containing IgA, IgM, and IgG using the PAP immunoperoxidase technique. Immunoglobulin containing cells were nearly always absent in infants under 1 week of age but occurred in the second week of life in infants who had had milk feeds. At this time, IgM containing cells were predominant, but IgA containing cells were more numerous by the sixth week. IgG containing cells were generally sparse. Parenterally fed infants who had received little or no intestinal milk showed significantly fewer immunoglobulin containing cells than those who had been fed normally, irrespective of gestation. Lack of stimulation by food and bacterial antigens may contribute to immunoglobulin containing cells failing to occur in these parenterally fed neonates.

Histological classification of chronic granulocytic leukaemia.

On the basis of the trephine marrow histology at presentation, 52 Ph1 positive cases of chronic myeloid leukaemia were divided into two subgroups, classical chronic granulocytic leukaemia (CGL) and chronic megakaryocytic granulocytic myelosis (CMGM). In 24 cases in which conventional therapy had preceded trephine biopsy, the distribution of cases between the two groups was found to have been significantly altered. Subsequent analysis was therefore confined to the remaining 28 untreated cases; of these 15 were classified as CGL and 13 as CMGM; no statistically significant difference was found between the two groups in respect of patient's age, leucocyte counts, platelet counts, NAP scores or of occurrence of 'blast' crisis. The differential diagnosis between idiopathic myelofibrosis (IMF) and CMGM subgroup is discussed. It was concluded that classification of chronic myeloid leukaemia on the basis of marrow histology should be restricted to Ph1 positive cases in order to obviate the possible inclusion of cases of IMF within the CMGM subgroup.

COX-2 expression is associated with an aggressive phenotype in ductal carcinoma in situ.

Cyclooxygenase type-2 (COX-2) is overexpressed in malignant tumours including breast cancers, though the mechanism of upregulation is unclear. This study aimed to determine COX-2 expression in ductal carcinoma in situ (DCIS) in comparison to invasive breast cancer (IBC) and normal breast, and also to investigate the relationship of COX-2 expression with HER-2 expression, oestrogen receptor (ER), tumour grade and cellular proliferation (Ki67) in DCIS. Cyclooxygenase type-2, HER-2, ER and Ki67 expression were determined by immunohistochemistry on paraffin tissue sections of DCIS (n=187), IBC (n=65) and normal breast reduction tissue (n=60). Cyclooxygenase type-2 expression in DCIS (67%, P<0.001) and IBC (63%, P<0.001) was significantly greater than in normal breast (23%). There was no difference in COX-2 expression level between DCIS and IBC (P=0.87) or between normal breast from reduction mammoplasty tissue and normal breast ducts around DCIS (22%, P=0.29). In DCIS, COX-2 expression was associated with higher cellular proliferation rates (P<0.0001), nuclear grade (P=0.003), with ER negativity (P=0.003) and with HER-2 positivity (P<0.0001). Cyclooxygenase type-2 expression is upregulated in in situ breast cancer and is associated with surrogate markers of an aggressive DCIS phenotype including nonoestrogen-regulated signalling pathways. Cyclooxygenase type-2 inhibition may potentially prevent the development of ER-positive and ER-negative breast cancers.