Antenatal ultrasound and postnatal autopsy findings in terminations after 12 weeks' gestation due to fetal abnormality: population-based study in Western Norway, 1988-2002.

BACKGROUND: Ultrasound screening has been part of antenatal care for several decades, and warrants high expertise to meet the criteria for a worthwhile screening program. In particular, the rate of false positives should be low. PURPOSE: To examine time trends of pregnancy terminations for fetal abnormality after 12 weeks' gestation, and to assess the agreement between antenatal ultrasound and post-termination autopsy findings for the main pathologies leading to termination. MATERIAL AND METHODS: During the period 1988 to 2002, 198 pregnancies were terminated for fetal abnormality after 12 weeks' gestation. We reviewed the case notes for those 151 who were autopsied (male/female/undetermined ;= ;91/56/4). Annual rates of live births and stillbirths were retrieved from the Medical Birth Registry of Norway. RESULTS: Antenatal ultrasound provided a correct diagnosis of the major abnormality in 149/151 cases (99%), based on post-termination autopsy findings. The annual rate of terminations after 12 weeks' gestation varied between 0.6 and 3.4 (mean 1.8) per 1000 live births, with a trend toward higher rates over the study period (P=0.001, chi-square test for linear-by-linear association). CONCLUSION: The specificity of antenatal ultrasound for major abnormalities was high, as compared to postnatal autopsy findings. The mean annual rates of termination after 12 weeks' gestation tended to increase over the 14-year study period.

Age and sex distribution of intestinal type and diffuse gastric carcinoma.

A twelve-year series of 375 patients with gastric carcinoma has been studied. Primary tumours were classified as intestinal type (58%) or diffuse (26%), whereas 16% were unclassifiable. The relative age and sex incidence rates of intestinal type and diffuse gastric carcinoma were estimated using the age and sex distribution of individuals in Norway as the basis for calculation. There was no difference in the rates of diffuse gastric carcinoma between the sexes. On the other hand, the rate of men with intestinal type carcinoma was more than twice as high as that of women. This difference was consistent within each age group from adolescence to senescence. The findings indicate that Laurén's two types of gastric carcinoma are aetiologically different. The rates of both types increased with age up to the 70-79 age group, whereas the rates in octogenarians tended to be lower than in septuagenarians. A comparison of our data with the data of incidence of gastric cancer in Norway indicates that some of the older patients do not come for surgery.

Underdiagnosis of carcinoma of the stomach in the elderly: a 25-year autopsy study.

Gastric carcinoma may present atypically in the elderly. Between 1955 and 1979, 571 autopsies on gastric carcinoma cases were carried out at the Gade Institute, Bergen. In 165 of them the diagnosis had not been made clinically. The latter patients were, on average, 10 years older at death than those in whom the diagnosis was made premortem, and their tumours were smaller. In 45 the tumour was considered an incidental autopsy finding, while 58 were diagnosed clinically as advanced cancer of unknown origin. In the remaining 62 cases the cancer was the underlying cause of death. Recognition of an elderly sub-group of patients whose gastric carcinomas presented atypically brings with it an increasing diagnostic challenge in our ageing population.

Concentrations of serum proteins and erythrocyte sedimentation rate in patients with different histological types of gastric carcinoma.

ESR and serum concentrations of IgG, IgA, IgM, C3, C4, C1-INH and CEA were quantified preoperatively in 195 patients with gastric carcinoma. The values were grouped according to the extent of disease (T1-3N0M0, T2-3N + M0, T4AnyNM0, AnyTAnyNM1) and according to the histological type of tumor (intestinal-type, diffuse and unclassifiable). The data were analysed using a two-way analysis of variance with unequal cell sizes. ESR, C4, C1-INH, IgG and CEA varied with the extent of disease. When the data were adjusted for this variation, we found that the values of ESR, C4 and CEA were different between the various histological types. The values were highest in patients with the intestinal-type tumor and lowest in those with diffuse tumor. The concentrations of IgG and C1-INH were not different between the histological types. Our results are relevant when ESR, C4 and CEA are used in the evaluation of patients with gastric carcinoma.

Preoperative prediction of extent and prognosis of gastric carcinoma by four serum proteins and erythrocyte sedimentation rate.

In 195 patients with gastric carcinoma the preoperative ESR and serum concentrations of IgG, C4, C1-INH and CEA varied significantly with the extent of disease. Extent of disease and prognosis were predicted from these variables by discriminant analysis. The discriminant rules were tested on the same patients in an unbiased way. Metastases or no metastases were correctly predicted in 75% of the patients. By an appropriate prior distribution 93% of the patients without metastases were identified. The disease extent was also predicted in subgroups of patients with and without metastases. Survival was correctly predicted preoperatively in 66% of the patients and 83% of the patients with a fair prognosis were identified. Of the patients preoperatively allocated to the non-survival group 94% did actually die during follow-up. When used in addition to other available information, our discriminant rules will contribute to the quality of the preoperative evaluation of patients with gastric carcinoma.

Who gets a second primary cancer after gastric cancer surgery?

Eleven patients presented with a second primary cancer during follow-up after surgery for gastric carcinoma. In these patients the serum concentrations of C1-INH and IgG prior to gastric cancer surgery were similar to those of 53 patients with recurrence of gastric cancer. In these two groups, the preoperative C1-INH concentrations were higher and IgG lower (P less than 0.001 and P less than 0.05) when compared to 36 patients alive and disease-free 5 years after surgery. The median time between surgery and signs of recurrence was 11 months, whereas the median time until signs of the second primary cancer was 4 years. A patient with gastric carcinoma who pre-operatively has high C1-INH and low IgG is liable either to have recurrence or to develop a second primary cancer. Our data indicate that these variables represent a cancer susceptibility feature appropriate to the host.

Survival after radical treatment for transitional cell carcinoma of the bladder.

AIMS: To investigate survival after radical treatment for transitional cell carcinomas of the bladder. METHODS: This retrospective study included 135 patients with transitional cell carcinoma of the bladder undergoing radical cystectomy or radiotherapy at Haukeland Hospital, Bergen, Norway, during the period 1981-1986. Forty-five patients had cystectomy and 90 underwent external high-dose radiotherapy. RESULTS: The overall 5- and 10-year survival rates were 39 and 23%, respectively. After cystectomy 10-year overall survival rates for superficial and muscle-infiltrating tumours were 67 and 26%; after radiotherapy, the corresponding survival rates for superficial and muscle-infiltrating tumours were 26 and 5%, respectively. CONCLUSIONS: Long-term survival and cure can be achieved after cystectomy in many patients with aggressive superficial or muscle-infiltrating bladder carcinoma. The introduction of orthotopic neobladder reconstruction should encourage the use of cystectomy in patients with aggressive superficial tumour.

The prognostic value of Laurén's histopathological classification system and ABO blood groups in patients with stomach carcinoma.

The prognostic value of Laurén's histopathological classification system and the ABO blood group system has been studied in 275 patients with cancer of the stomach. The study disclosed a higher rate of tumours of intestinal type in females aged 70 years or more compared with those under 70 years, but no such relation for males. We found no relation between histopathological classification and blood groups. For patients with blood group A the 5-year survival was 17.5%, compared to 8.4% for blood group O (P less than 0.05). Survival for patients with intestinal and diffuse tumours was 17.7% and 4.8% respectively (P less than 0.01). A multivariate analysis showed that the histopathological classification system, independently, was an important factor with respect to survival (all other factors constant). Blood group might also be of importance as a prognostic factor, but further studies are necessary to confirm this.

Is Lauren's histopathological classification of importance in patients with stomach cancer? A national experience. Norwegian Stomach Cancer Trial.

This study was performed to investigate the association between Lauren's histopathological classification system and different clinico-pathological characteristics in patients with gastric carcinoma. We revealed that the percentage of intestinal type tumour (ITT) increased with advancing age (52% in patients less than 60 years compared to 73% of octogenarians (P less than 0.001)). The male:female ratio was 1.7 for ITT versus 1.3 for diffuse type tumour (DTT (P = 0.12)). ITT was more common in proximally (fundus) localized tumours than in distal lesions (77% vs 65%; P less than 0.05). The proportion of patients with ITT decreased with advancing stages of the disease (70% in stage I and II vs 52% in stage IV (P less than 0.0001)). More patients with DTT had tumour infiltration in the resection margin (21% vs 9%; P less than 0.001). Intestinal metaplasia was found in 48% of those with ITT compared with 28% of those with DTT (P less than 0.001). No association was found between Lauren's classification and the ABO blood group or between the tumour types and infiltration in lymphatic or blood vessels. We conclude that gastric adenocarcinoma occurs in at least two different biological forms and that differentiation between the two is of relevance for treatment.

Flow cytometric DNA and p53 analysis in superficially infiltrating bladder carcinoma.

Mutations in the p53 gene occur frequently in bladder cancers. Better prognostic factors are needed to help select appropriate treatment for patients with TCC stage T1. Paraffin-embedded tumors from 73 patients with TCC stage T1 were processed for two-parameter flow cytometry, measuring both p53 protein and DNA. There were no statistically significant differences between the WHO grades with respect to p53 protein staining. Furthermore, there were no statistically significant differences between diploid, tetraploid and aneuploid tumors regarding content of mutant p53 protein. Neither were any statistically significant differences observed when ploidy and WHO grade were grouped together. Progression of disease was not correlated with positive p53 protein staining. These results indicate that mutant p53 protein cannot be used as a prognostic factor in TCC stage T1.

Diagnostic value of radiography in cases of perinatal death: a population based study.

OBJECTIVE: To examine the yield of radiographic abnormalities in a population based set of perinatal deaths, the diagnostic value of whole body postmortem radiographs in the same set, and previous factors that may increase the proportion of useful examinations. DESIGN: Retrospective population based study. SETTING: A region of Norway. PATIENTS: All infants from a well defined geographical area who were stillborn or had died soon after birth over an 11 year period (n=542), who had routinely undergone whole body radiography and autopsy. MAIN OUTCOME MEASURES: (a) Proportion of cases with abnormal radiographic findings. (b) Proportion of abnormal radiographs providing new information that was useful for postmortem diagnosis. RESULTS: Radiographs were abnormal in 162/542 cases (30%). These provided new information about, but did not help to confirm, the pathological process leading to death in 14/162 (8.6%), may have helped to confirm, but not establish, the cause(s) of death in 1/162 (0.6%), and were of vital importance for establishing the cause(s) of death in 5/162 (3.1%). Among infants with external malformations, the proportion of useful radiographs was 12/100 (12%), and among the remainder it was 8/436 (1.8%), a difference of 10.2% (95% confidence interval 3.7% to 16.7%; data missing for six cases). CONCLUSIONS: The diagnostic value of postmortem radiography in this population based set was low. However, radiographic findings were of vital importance for establishing the cause(s) of death in 5/542 cases (0.9%).

Local resection of rectal tumors by transanal endoscopic microsurgery: experience with the first 70 cases.

BACKGROUND: Transanal endoscopic microsurgery (TEM) can access the whole rectum up to 20 cm from the anal verge. Due to its excellent view and accurate dissection, TEM is useful for the removal of adenoma and selected low risk cancers of the rectum. We report our experience with the first 70 patients presenting. METHODS: A prospective descriptive study of 70 patients treated for rectal tumor with TEM from December 99 until October 2002 at Haukeland University Hospital. RESULTS: TEM was performed in 37 men and 33 women, median age 70.5 (19-90) years, for anticipated adenoma (n = 64), adenocarcinoma (n = 3), rectal ulcer (n = 1), and re-resection after snare resection of rectal polyp with adenocarcinoma (n = 1) and carcinoid tumor (n = 1). The median observation time was 12 (1-33) months. The distance from the anal verge to the lower tumor border was 5.5 (2.5-14) cm. The median resected area was 15.4 (1.5-132) cm(2). 56 of the 64 anticipated adenomas were true adenoma, resected without recurrences; 8 (12.5%) were unexpected adenocarcinoma. Three of these underwent a secondary rectal resection and 5 patients have been observed without recurrence. Of the 3 patients with known adenocarcinoma, there was one recurrence which was treated with a secondary curative rectal resection. CONCLUSIONS: TEM can access tumors in the whole rectum. Large tumors may be removed with low frequency of per- and postoperative complications and short hospital stay. TEM is highly useful for removal of rectal adenoma. A role for primary treatment of selected low-risk rectal cancers may emerge.

On the reputed decline in gastric carcinoma: necropsy study from western Norway.

Carcinoma of the stomach is said to be decreasing in many countries, Norway included. About 10% of all cases in Norway occur in the county of Hordaland. They do not differ in any known respect from cases in the rest of the country. A series of 575 cases coming to necropsy from Hordaland over 25 years was examined and the findings compared with the total number reported to the Norwegian Cancer Registry from the same district. Although the incidence of histological verification rose over the period from 49 to 85%, the number of histologically confirmed cases remained relatively constant, the considerable decline being confined to cases without such documentation. The results suggest that increased diagnostic effort has led to the exclusion of cases previously classified clinically as gastric carcinoma and that the incidence of the disease itself has not changed radically in the county of Hordaland.

Mast cell changes and tumour dissemination in human breast carcinoma.

In breast carcinoma metachromasia on staining the primary tumour with toluidine blue is related to mast cell changes and an infiltrative as opposed to an expansive growth form. In 73 patients the presence of metachromasia in the zone of host-tumour interaction, just beyond the edge of the tumour cells, was associated with poor short-term survival, giving greater discrimination than, for example, axillary nodal status or histological grade. 12 of 19 patients with metachromasia in this zone died within 5 years of operation. This indicates that the reaction is not only related to local infiltrative growth, but may also reflect the tumour potential for metastatic spread. In the absence of metachromasia in this zone death occurred mainly in patients with poorly differentiated tumours. The possible mechanisms involved are discussed. It is stressed that stromal metachromasia is not tumour specific, but that in certain areas, under defined circumstances, it may give information of both prognostic and biological interest.

The prognostic value of p53 in superficially infiltrating transitional cell carcinoma.

Approximately 1/3 of T1 bladder cancers treated by endoscopic resection alone will progress. Prognostic factors are needed to help selecting appropriate treatment for these tumors. The purpose of the present investigation was to study the relation between p53 nuclear overexpression and disease progression. Tumors from 59 patients were studied by means of immunohistochemical nuclear staining. Forty tumors showed p53 nuclear overexpression while 19 tumors scored negative for mutations. We could not demonstrate any correlation between mutations of the p53 protein and tumor grading. p53 nuclear overexpression was not related to disease progression.

[Etomidate in Intralipid. A solution for pain-free injection]. / Etomidat mit Intralipid. Eine Lösung zur schmerzfreien Injektion.

A new formula for solution of etomidate has been studied. Like other lipophilic drugs etomidate may be dissolved in a non-irritating oil emulsion and used for intravenous injection. Etomidate in Intralipid was compared as induction agent with etomidate in glycolic solution (Hypnomidate) and with methohexitone (Brietal). No pain on injection occurred when etomidate/Intralipid was used.

Serum C1-esterase inhibitor, an essential and independent prognosticator of gastric carcinoma.

The preoperative concentrations of IgG were lower (P less than 0.002) and the concentrations of C4 and C1-INH higher (P less than 0.01 and P less than 0.001) in 29 patients with recurrence after potentially curative resection of gastric carcinoma, than in 31 patients alive and disease-free 5 years after surgery. These differences between the two groups of patients were consistent within each of six groups of disease extent. In each of the two groups of patients, the preoperative concentrations of IgG, C4 and C1-INH had no significant variation with the extent of disease (P greater than 0.05 or greater). Of our variables, C1-INH was the most potent prognosticator and discriminated between patients with and without recurrence with 80% accuracy. Furthermore, the predictive prognostic value of C1-INH at the time of surgery was superior to the prognostic value of the extent of disease (F values 27.00 and 12.69). Apparently, the preoperative C1-INH concentration is an essential and independent prognostic parameter of gastric carcinoma. We assume that C1-INH reflects an additional prognostic feature appropriate to the tumour or the host. Our finding that the interval between surgery and death from recurrence had an inverse relation to the preoperative C1-INH concentration also supports this assumption.

The influence of the host on the course of gastric carcinoma.

Immunoglobulins (Ig) and some complement components (C) were quantified in sera from patients with gastric carcinoma before surgery and at regular intervals during a 5-year follow-up. The preoperative concentrations of C1-INH and C4 were higher (P < 0.0005 and P < 0.005) and IgG lower (P < 0.0005) in 50 patients with recurrence than in 46 5-year survivors. The prognostic significant of C1-INH was superior to that of the extent of disease (F-values 37.1 and 26.1). The preoperative immune data classified 76% of the patients correctly as to recurrence and no recurrence. Also, the preoperative C1-INH concentration had a highly significant effect on time to recurrence of cancer (P = 0.0007), adjusting for age and disease extent. After surgery the mean IgG concentrations were within normal range and without difference between the two groups. On the other hand, the concentrations of C1-INH and C4 in the individual patients in both groups remained the same from before to after surgery and throughout the observation period (P = 0.34). Apparently, the serum levels of C1-INH and C4 do not reflect the bearing of cancer. We therefore suggest that these variables represent an independent immune state that is appropriate to the host. A comparison of our variables with those of healthy individuals seems to support this idea. This immune state has a significant influence on whether a resected gastric cancer will recur, and also on how soon recurrence may be manifest.

Periodicity in metastatic tumour growth demonstrated in the human liver at autopsy. Preliminary report.

The present study is based on 1,069 autopsies made up of stomach, breast, renal and colonic cancer. Periodicity is described in the liver weight index (liver weight/body height) at death in patients with liver metastases. The seasonal variation tended to be more marked in females and among older patients, and it differed with tumour type. A period with maximum deaths tended to follow that of maximum liver weight index. A periodic difference previously reported in a small series of malignant melanomas is thus not an isolated phenomenon. This indicates that basic biological pathways concerned with the control of tumour growth may be involved. How the system works remains an open question.

The influence of age on the growth and spread of gastric carcinoma.

A twelve year series of 375 patients with gastric carcinoma has been studied. Patients were divided into TNM Groups. Tumours were classified as intestinal-type and diffuse. The patients with T1-3NOMO diffuse tumour were ten years younger than the patients with T1-3NOMO intestinal-type tumour. The mean age increased from T1 through T2 to those with T3 tumour. The age differences between the T-stages were the same in both groups, which indicate that once started, the diffuse and the intestinal-type tumours infiltrate the gastric wall at about the same rate. Among the patients with intestinal-type tumour, those with lymph node or distant metastases were three to seven years younger than the patients without metastases. On the other hand, the patients with diffuse tumour and metastases were as many years older than the patients without metastases. Apparently, tumour spread is age dependent and different between the two types of gastric carcinoma. The ill repute of the diffuse gastric carcinoma may therefore be explained by the advanced stage of that tumour at the time of treatment as compared to the intestinal-type tumour. The diffuse tumour seems to be clinically more silent and to give symptoms at a later stage than the intestinal-type tumour.