NDRG1 prognosticates the natural course of disease in WHO grade II glioma.

There is a lack of relevant prognostic and predictive factors in neurooncology besides mutation of isocitrate dehydrogenase 1, codeletion of 1p/19q and promoter hypermethylation of O (6) -methylguanine-DNA-methyltransferase. More importantly, there is limited translation of these factors into clinical practice. The cancer genome atlas data and also clinical correlative analyses suggest a pivotal role for the epidermal growth factor receptor /protein kinase B/mammalian target of rapamycin (mTOR) pathway in both biology and the clinical course of gliomas. However, attempts to stratify gliomas by activating alterations in this pathway have failed thus far. The tumors of 40 patients with WHO grade II gliomas without immediate postoperative genotoxic treatment and known progression and survival status at a median follow-up of 12.2 years were analyzed for expression of the mTOR complex 2 downstream target N-myc downstream regulated gene (NDRG)1 using immunohistochemistry. Baseline characteristics for NDRG1 absent/low versus moderate/high patients were similar. Time to reintervention was significantly longer in the NDRG1 group (P = 0.026). NDRG1 may become a novel biomarker to guide the decision which WHO°II glioma patients may be followed without postsurgical intervention and which patients should receive genotoxic treatment early on. Validation of this hypothesis will be possible with the observational arm of the RTOG 9802 and the pretreatment step of the EORTC 22033/26032 trials.

Gross total but not incomplete resection of glioblastoma prolongs survival in the era of radiochemotherapy.

BACKGROUND: This prospective multicenter study assessed the prognostic influence of the extent of resection when compared with biopsy only in a contemporary patient population with newly diagnosed glioblastoma. PATIENTS AND METHODS: Histology, O(6)-methylguanine-DNA methyltransferase (MGMT) promoter methylation status, and clinical data were centrally analyzed. Survival analyses were carried out with the Kaplan-Meier method. Prognostic factors were assessed with proportional hazard models. RESULTS: Of 345 patients, 273 underwent open tumor resection and 72 biopsies; 125 patients had gross total resections (GTRs) and 148, incomplete resections. Surgery-related morbidity was lower after biopsy (1.4% versus 12.1%, P = 0.007). 64.3% of patients received radiotherapy and chemotherapy (RT plus CT), 20.0% RT alone, 4.3% CT alone, and 11.3% best supportive care as an initial treatment. Patients ≤60 years with a Karnofsky performance score (KPS) of ≥90 were more likely to receive RT plus CT (P < 0.01). Median overall survival (OS) (progression free survival; PFS) ranged from 33.2 months (15 months) for patients with MGMT-methylated tumors after GTR and RT plus CT to 3.0 months (2.4 months) for biopsied patients receiving supportive care only. Favorable prognostic factors in multivariate analyses for OS were age ≤60 years [hazard ratio (HR) = 0.52; P < 0.001], preoperative KPS of ≥80 (HR = 0.55; P < 0.001), GTR (HR = 0.60; P = 0.003), MGMT promoter methylation (HR = 0.44; P < 0.001), and RT plus CT (HR = 0.18, P < 0.001); patients undergoing incomplete resection did not better than those receiving biopsy only (HR = 0.85; P = 0.31). CONCLUSIONS: The value of incomplete resection remains questionable. If GTR cannot be safely achieved, biopsy only might be used as an alternative surgical strategy.

c-kit/CD 117 positive cells in the myometrium of pregnant women and those with uterine endometriosis.

PURPOSE: Abnormal myometrial motility may play a role in the pathogenesis of endometriosis. Uterine contractility is a major contribution to labour. Myometrial motility might be controlled by CD 117-positive uterine smooth muscle cells. METHODS: Myometrial tissues from 8 cases with uterine endometriosis, 9 pregnant uteri (31.1 ± 8.7 weeks of gestation), 10 cases from non-pregnant pre-menopausal and 9 cases from post-menopausal women were immunohistochemically evaluated using a polyclonal antibody against c-kit/CD 117. The number of CD 117 positive cells was counted within 10 microscopic high power fields (× 400) and compared with the clinical diagnoses. RESULTS: Overall, a mean number of 15.7 (range 0-43) CD 117-positive cells within the myometrium was seen. Significant highest count occurred in the myometrium of non-pregnant pre-menopausal women without uterine endometriosis (30.78 ± 9.52), followed by post-menopausal women (15.5 ± 8.37) and those with uterine endometriosis (9.98 ± 4.9; p ≤ 0.01). The lowest count of CD 117-positive cells was seen in pregnant uteri (4.09 ± 2.33; p < 0.001). CONCLUSIONS: The lowest count of CD 117-positive cells was seen in the myometrium of pregnant women suggesting a role of preventing premature uterine contractility. There is no increase of CD 117-positive cells in the myometrium of women affected by uterine endometriosis.

DNA methylation, transcriptome and genetic copy number signatures of diffuse cerebral WHO grade II/III gliomas resolve cancer heterogeneity and development.

BACKGROUND: Diffuse lower WHO grade II and III gliomas (LGG) are slowly progressing brain tumors, many of which eventually transform into a more aggressive type. LGG is characterized by widespread genetic and transcriptional heterogeneity, yet little is known about the heterogeneity of the DNA methylome, its function in tumor biology, coupling with the transcriptome and tumor microenvironment and its possible impact for tumor development. METHODS: We here present novel DNA methylation data of an LGG-cohort collected in the German Glioma Network containing about 85% isocitrate dehydrogenase (IDH) mutated tumors and performed a combined bioinformatics analysis using patient-matched genome and transcriptome data. RESULTS: Stratification of LGG based on gene expression and DNA-methylation provided four consensus subtypes. We characterized them in terms of genetic alterations, functional context, cellular composition, tumor microenvironment and their possible impact for treatment resistance and prognosis. Glioma with astrocytoma-resembling phenotypes constitute the largest fraction of nearly 60%. They revealed largest diversity and were divided into four expression and three methylation groups which only partly match each other thus reflecting largely decoupled expression and methylation patterns. We identified a novel G-protein coupled receptor and a cancer-related 'keratinization' methylation signature in in addition to the glioma-CpG island methylator phenotype (G-CIMP) signature. These different signatures overlap and combine in various ways giving rise to diverse methylation and expression patterns that shape the glioma phenotypes. The decrease of global methylation in astrocytoma-like LGG associates with higher WHO grade, age at diagnosis and inferior prognosis. We found analogies between astrocytoma-like LGG with grade IV IDH-wild type tumors regarding possible worsening of treatment resistance along a proneural-to-mesenchymal axis. Using gene signature-based inference we elucidated the impact of cellular composition of the tumors including immune cell bystanders such as macrophages. CONCLUSIONS: Genomic, epigenomic and transcriptomic factors act in concert but partly also in a decoupled fashion what underpins the need for integrative, multidimensional stratification of LGG by combining these data on gene and cellular levels to delineate mechanisms of gene (de-)regulation and to enable better patient stratification and individualization of treatment.

Plasma homocysteine levels & 677C-->T methylenetetrahydrofolate reductase gene polymorphism in patients with coronary artery disease of different severity.

BACKGROUND & OBJECTIVE: Numerous studies have identified hyperhomocysteinemia as an independent risk factor for coronary artery disease (CAD). Furthermore, influences of polymorphysim of methylenetetrahydrofolate reductase (MTHFR) on homocysteine levels are documented. However, the relationship between severity of CAD and polymorphism of MTHFR has not been systematically evaluated. The present study was undertaken to evaluate this relationship in patients undergoing coronary artery bypass surgery. METHODS: Serum homocysteine and MTHFR polymorphism in relation to severity of CAD was examined in 113 male patients, who all underwent coronary artery bypass surgery. The prevalences of 677 C-->T transition of the MTHFR gene were determined in these patients. Two groups were compared according to GENSINI coronary score : mild atherosclerosis (CAD stenosis < 30) and severe atherosclerosis (CAD stenosis > 30). RESULTS: Patients with CAD showed a significantly higher serum concentration of homocysteine than control subjects (P < 0.01). The serum homocysteine level was significantly higher in patients with increased scores than in patients with mild CAD (Gensini score < 30) both with and without the MTHFR polymorphism. INTERPRETATION & CONCLUSION: The findings of our study showed that hyperhomocysteinemia was significantly related to the severity of CAD independent on MTHFR polymorphism.

Tumor size is of prognostic value in surgically treated FIGO stage II cervical cancer.

OBJECTIVES: Tumor size is a well recognized prognostic factor in early stage cervical carcinoma (CX). However, limited knowledge exists about the value of tumor size in surgically treated CX with extrauterine extension. METHODS: 245 cases of local advanced CX (FIGO stage IIA and IIB) who received upfront surgery were evaluated regarding tumor size, regarding the prediction of pelvic lymph node involvement and recurrence free and overall survival during a median follow-up time of 54 months (95% CI 45.4-62.6 months). Tumors larger than 4 cm were defined as bulky stage disease. RESULTS: Bulky disease was seen in 46.1% (113/245). 60.2% of these patients showed pelvic lymph node involvement, compared to 42.4% (56/132) in non-bulky tumors (p=0.006; odds ratio: 2.2 [95% CI: 1.3-3.6]). Patients with bulky tumors showed an increase of recurrent disease (40.2% vs. 28.0%; p=0.045). The relative risk for recurrent disease was 1.97 (95% CI: 1.3-3.0). The 5-year overall survival rate was significantly lower (67.7% [95% CI: 58.2-74.8] vs. 49.5% [95% CI: 36.8-59.1]; p=0.0015). In multivariate analysis, tumor stage, pelvic lymph node involvement and maximal tumor size were independent prognostic factors. CONCLUSIONS: The results suggest that tumor size, defining bulky disease as tumors larger than 4 cm, is of prognostic impact also in FIGO stage II cervical carcinomas. A revised FIGO/TNM classification system similar to the subgrouping of stage IB CX is recommended for stage II using a cut-off value of 4 cm as discriminator: stage IIA1 and stage IIB1 for tumors with 4 cm (i.e. bulky disease).

[Vocal efficiency parameters in children and adolescents: effect of physical development and singing activity]. / Stimmleistungsparameter bei Kindern und Jugendlichen: Einfluss der körperlichen Entwicklung und der sängerischen Aktivität.

The influence of physical development and singing activity on vocal efficiency in children and adolescents is well known from clinical experience. There is, however, no comparative study between singing and non-singing children which also considers the influence of age and gender. Therefore, standard values for evaluation in clinical practice are missing. We examined the following parameters in 164 healthy children and adolescents (90 boys, 74 girls; 11-16 years), 86 without singing activity (group A) and 78 members of children's and youth choirs (group B): frequency and dynamic range of voice and its borders with a voice range profile, mean fundamental frequency (normal and loud phonation), maximum voice intensity, and maximum duration of intonation. The statistical analysis was performed using three-way ANOVA. We found significantly higher ranges of frequency and intensity in singing children and adolescents (p<0.0001). The borders of the dynamic range and the upper border of the frequency range were significantly higher in group B (p<0.0001). The boys in group B used a higher mean fundamental frequency during loud phonation. There were no significant differences between groups in maximum voice intensity (p=0.051) but a tendency towards higher values in singing children. As an unexpected result, we found significantly higher values in maximum duration of intonation in group A (p<0.0001) independent of age and gender, which seems to be related to the methods used. Regular training of the singing voice results in positive effects on several voice parameters in children as well as adolescents. Our results can be used for estimating standard values in professional clinical and educational care of young singing voices and non-singing children. For this purpose, voice range profile is particularly suitable.

PRL as a novel potent cofactor for platelet aggregation.

Pregnancy (including puerperium) is a period of hypercoagulability and seems to be an independent major risk factor for venous thromboembolism (VTE). However, the basis of the increased risk of VTE in pregnancy and around delivery is unknown. We hypothesized that changes in PRL, which is a prominently increased hormone during pregnancy and lactation, might be involved in the activation of platelets. To investigate platelet functional abnormalities in pregnancy, we assessed the ADP-stimulated and nonstimulated P-selectin expression of platelets in 42 consecutive pregnant women, 22 normo- and hyperprolactinemic patients with pituitary tumors, and controls. In addition, the aggregation of platelets by human PRL in vitro was studied. We found a significant correlation between PRL values and ADP stimulation of platelets in pregnant women (r = 0.56; P < 0.0001) and patients with pituitary tumors (r = 0.57; P = 0.006). Hyperprolactinemic pregnant women or hyperprolactinemic patients with pituitary tumors revealed significantly higher ADP stimulation of platelets (P < 0.0001) than healthy controls or normoprolactinemic patients with pituitary tumors. These results were reconciled by increased in vitro stimulation and aggregation of platelets using human PRL. Our novel findings demonstrate that hyperprolactinemia causes increased platelet aggregation via ADP stimulation both in vitro and in vivo. Moreover, our data indicate that PRL may be a physiological cofactor of the delicate coagulation balance during pregnancy and puerperium that might explain the increased risk of VTE in pregnant women around delivery. Further studies of the interaction between PRL and platelets will clarify the clinical relevance of hyperprolactinemia as a potential risk factor for VTE.

Differences between thyrotropin receptor antibody bioactivity and inhibition of 125I-bovine thyrotropin binding.

Thyrotropin (TSHR) receptor antibodies that bind to the TSHR without stimulating the TSHR have been identified with a direct binding assay. Moreover, TSHR antibodies that exhibit thyroid epithelial cell stimulation without inhibition of 125I-bovine thyrotropin (bTSH) binding and vice versa have been described. These data suggest that stimulation or blocking of the TSHR by stimulating (TSAB) or blocking (TSBAB) TSHR antibodies could be possible without detectable bTSH-displacement activity. However, to date, possible differences between TSAB or TSBAB activity and inhibition of 125I-bTSH binding have not been systematically investigated. Therefore we compared inhibition of 125I-bTSH binding and TSAB or TSBAB activity of sera from 113 patients with Graves' disease treated with antithyroid drugs. To exclude the different assay conditions of previous investigations as possible confounding factors, we determined TSAB or TSBAB and inhibition of 125I-bTSH binding (TBIIW) with the same Chinese hamster ovary (CHO) cells expressing the human TSHR. Furthermore inhibition of 125I-bTSH binding was also determined as thyrotropin-binding inhibitory immunoglobulin (TBII) with solubilized porcine thyroid membranes (TRAK, Brahms, Berlin Germany) and the highly sensitive recombinant human TSH receptor assay (hTRAK, Brahms, Berlin Germany). Only 78% (54/69) of TSAB-positive and 78% (21/27) of TSBAB-positive sera detected with JP26 cells exhibit inhibition of 125I-bTSH binding measured as TBII or TBIIW. Furthermore, 59% (10/17) of sera without TSAB and TSBAB activity revealed inhibition of 125I-bTSH binding measured as TBII or TBIIW. We found significant differences between TSHR bioactivities (TSAB or TSBAB) and inhibition of 125I-bTSH binding. Moreover, there was no agreement between the detectable TSHR bioactivities (TSAB or TSBAB) and their detectable inhibition of 125I-bTSH binding. Therefore, it is very likely that TSH displacement by TSHR antibodies and stimulation or blocking of the TSHR by TSHR antibodies are different functions that do not need to occur together.

Influence of dietary intake and physical activity on annual rhythm of human blood cholesterol concentrations.

Seasonal variation in the plasma total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C) have been repeatedly reported, with contradictory results regarding the pattern of seasonal variation of these parameters. Furthermore, it is still not well established whether the variation is due to changes in the nutrition or changes in physical activity depending on the season. The aim of this study was therefore to determine plasma TC and HDL-C in different groups of healthy participants: 19 vegetarians with a constant diet independent of the season, 14 athletes with almost constant physical activity over the year, and 114 controls in the age groups 20-26 years (mean age 24 + 1.5 years) and 40-48 years (mean age 44.3 + 2.1 years). Over 2 years, blood samples were collected every 2-3 months and were analyzed for plasma TC and HDL-C. At all visits, body mass index (BMI) and waist-to-hip ratio (WHR) were calculated, and nutrition and physical activity profiles were obtained. The seasonal model was calculated using object-oriented software for the analysis of longitudinal data in S (OSWALD); multiple regression analysis was used to determine the influence of age, gender, diet, and physical activity on seasonal changes of the lipid parameters. In all groups, we found an annual rhythm of the plasma TC and HDL-C concentrations, which can be mathematically described by a sine curve with a maximum in winter and a minimum in summer. This rhythm was independent of the age, gender, BMI, diet, or physical activity. The observed seasonal differences between the maximum and the minimum were about 5%-10% for TC and about 5%-8% for HDL-C concentration. These differences were greater than the determined circadian (TC 3.5%, HDL-C 4%) and day-to-day changes for TC and HDL-C (coefficient of variation <5% for both). In conclusion, annual rhythm of TC and HDL-C is not primarily induced by seasonal differences in dietary intake or physical activity. Therefore, the annual rhythm in cholesterol levels is most likely determined by endogenous factors or factors directly related to seasonal changes in the environment.

Contribution of stack gases and solid process wastes to the organic pollutant output of thermal waste treatment plants.

Within the scope of fundamental investigations as well as individual research projects (W. Knorr, B. Hentschel, C. Marb. S. Schädel, M. Swerev, O. Vierle, J.-P. Lay, 1999. Rückstände aus der Müllverbrennung-Chancen für eine stoffliche Verwertung von Aschen und Schlacken. Initiativen zum Umweltschutz, 13 ed., Deutsche Bundesstiftung Ulmwelt, Erich Schmidt, Berlin), the Bavarian State Office for Environmental Protection performs emission measurements at thermal waste treatment plants to optimize operation, to accompany and support development of new technologies, and to study the effect of this kind of waste treatment technology on the environment. Based on recent studies (October 1995-July 1999) at six municipal solid waste incinerators (MSWI) in Bavaria all emission streams (solid and gas) are characterized with respect to organic pollutant contents and compared to the emissions of waste pyrolysis. The significant ranges of pollutant concentration as well as the specific congener patterns observed are similar for all MSWI, regardless of differences in technical design and waste input, but differ markedly from those of the pyrolysis products. The overall approach, including the sampling of all output streams and the determination of mass streams and volume flow rates, allows the calculation of the total output of different organic pollutants for waste incineration plants aand to estimate the relative contribution of each of the emission streams to the total pollutant load. Removal efficiencies are also calculated for the air pollution control (APC) systems of the different MSWI plants.

[Product certification of medical equipment: MedGV (Medical Equipment Act)-MPG (Medical Devices Directive [MDD])]. / Prüfzeichen für Medizinprodukte: MedGV-MPG.

The changeover from the old MedGV to the new MPG (MDD) may give rise to misinterpretations on the part of the user. The aim of the present article is to introduce the reader to the approval procedures involved.

[Model trial: use and evaluation of a problem-oriented learning program in internal medicine]. / Modellversuch: Einsatz und Evaluierung eines problemorientierten Lernprogrammes in der inneren Medizin.

BACKGROUND: Problem-based training is a new approach in medical education. It is in particular essential that students work actively with authentic medical cases. Modern software is appropriate for developing interactive case-based training systems and the use in teaching environments. This method is still rarely integrated within medical curricula. METHOD: In an educational trial with 287 students the conceptual background, feasibility and evaluation are discussed. The learning program CASUS was used to present the case of a macroprolactinoma for interactive training. A questionnaire with a return rate of 78% was used for evaluation. RESULTS: 96% of the students had no problems in learning how to handle and use the program. A major problem was to focus the contents of the program exactly to the students' needs. The students' judgement was independent of the individual computer skills. 82% of the students would like to use the program in the future. CONCLUSION: Case-based and computer-assisted learning increases motivation and probably improves the quality in medical education. Controlled trials have to be implemented in future to show the effectiveness and the long-term output of these learning systems.

A comprehensive analysis of vascular complications in 3,889 glioma patients from the German Glioma Network.

Ischemic strokes, intracranial hemorrhages (ICH) and deep venous thromboembolism (DVT) are clinically important events in patients with gliomas. In this multicentre, noninterventional observational study, current data pertaining to frequency, contributing factors and outcomes of vascular events during times of anti-angiogenic therapy with the antibody against vascular endothelial growth factor, bevacizumab (BEV) was collected from the German Glioma Network. Among 3,889 glioma patients, 70 ischemic strokes (1.8 %) and 123 ICH (3.2 %) were recorded. 143 DVT (5.0 %) were recorded in 2,855 patients. Rates of DVT and ICH, but not of ischemic strokes, increased with the World Health Organization (WHO) grade of glioma. In 81 BEV-treated patients, five ischemic strokes (6.2 %), one ICH (1.2 %) and six DVT (7.4 %) were documented. Compared to patients that were not treated with BEV, ischemic stroke rate was significantly higher during treatment with BEV (p < 0.001). The rates of DVT (p = 0.123) or ICH (p = 0.571) in BEV-treated patients did not differ. On cerebral magnetic resonance imaging (MRI), BEV-related ischemic strokes appeared as diffusion-restricted sites next to contrast-enhancing tumor. 67 % of ICH, 61 % of ischemic strokes and 18 % of DVT occurred postoperatively (within 30 days after tumor resection). Outcome after postoperative ICH was significantly worse than after spontaneous ICH (p = 0.008). Ischemic stroke outcomes did not differ between postoperative and spontaneous occurrence (p = 0.401). Rate of pulmonary embolism did not differ significantly between postoperative and spontaneous DVT (p = 0.133). Relatively low rates of ICH and DVT might be partially due to a high proportion of low-grade gliomas in this patient cohort. The finding of a relevant number of symptomatic, therapy-associated intracerebral diffusion restrictions should be controlled in ongoing phase III studies.

Peritumoral stromal remodeling, pattern of invasion and expression of c-met/HGF in advanced squamous cell carcinoma of the cervix uteri, FIGO stages III and IV.

OBJECTIVE: Different patterns of invasion (PIs) have prognostic impact in several types of cancer and are associated with different grades of peritumoral stromal remodeling, characterized by the desmoplastic stromal response (DSR). One key regulator influencing cellular motility and peritumoral stromal response is c-met/HGF. This study evaluates the association between different PI, peritumoral DSR and its correlation to the expression of c-met/HGF in squamous cell carcinomas of the uterine cervix (CX). STUDY DESIGN: 131 advanced stage CX (FIGO III/IV) were re-evaluated histologically regarding PI, using a two-level scoring system. The tumor grows in solid cords/trabeculae in finger-like PI and in very small groups or single cells in spray-like PI. DSR was categorized as none/weak and moderate/strong. The tumors were stained with antibodies against c-met and HGF. The staining of >30% of tumor cells was defined as overexpression. The PI was correlated to the prognostic outcome, different categories of DSR and expression status of c-met and HGF. RESULTS: 66.4% of the tumors showed a finger-like, and 33.6% a spray-like PI. The spray-like PI showed a reduced two-year overall survival when compared to the finger-like PI (14.0% vs. 29.1%, respectively; p=0.012), and was associated with moderate/strong DSR. The majority of the tumors showed overexpression of c-met (85.4%) and HGF (74.8%). There was no correlation between the expression status of c-met/HGF and the FIGO stage, peritumoral DSR or the prognostic outcome. CONCLUSIONS: Spray-like PI is of prognostic impact in cervical carcinoma FIGO III/IV and is associated with strong peritumoral stromal remodeling. There is no prognostic impact of the immunohistochemical expression of c-met/HGF in advanced stage cervical carcinomas.

Spatial input for temporal navigation in scientific visualizations.

Scientific-visualization tools can make time-varying simulations easier to understand. The growing efficiency of today's high-performance computers enables simulation of physical phenomena with a high temporal resolution. Consequently, visualization systems require efficient navigation in the temporal dimension. This 3D user interface employs direct-manipulation metaphors for temporal navigation in scientific visualizations. By interacting with objects using their 3D trajectory, users can navigate in time by specifying spatial inputs.

Pattern of invasion is of prognostic value in surgically treated cervical cancer patients.

OBJECTIVES: Different patterns of invasion (representing different grades of tumor cell dissociation) are associated with prognostic outcome in cancer. We evaluated the prognostic value of different patterns of invasion (PI) in cervical carcinomas (CX). METHODS: Six hundred eleven surgically treated CX (FIGO IB to IIB) were re-evaluated histologically regarding the PI, using a three-level scoring system. Closed PI was defined as cohesive growth with well-delineated (pushing) borders. In finger-like PI the tumor grows in solid cords/trabecles. Highly dissociative growth in small groups or single cells was defined as spray-like PI. Types of PI were correlated to tumor stage, histo-morphologic factors and prognostic outcome. RESULTS: Sixty percent of the tumors showed a spray-like PI, 30% a finger-like PI and only 7.4% were of the closed type. Spray-like PI showed a significant correlation with advanced stage disease, lymphovascular space involvement, poorly differentiated tumors and pelvic lymph node metastases. Spray-like PI was accompanied by a reduced 5-year overall survival when compared to the finger-like and closed PI (68.7% vs. 80.9% vs. 88.5%; P=0.0004). The prognostic impact of the PI disappeared in node-positive patients (P=0.06) but persisted in patients without pelvic lymph node disease (P=0.03). In multivariate analysis, using COX regression model, the PI represented as independent prognostic factor. CONCLUSIONS: Spray-like PI (i.e., highest degree of tumor cell dissociation) is associated with advanced tumor stages, increased rate of recurrency and a reduced overall survival. In separate analysis of patients with and without lymph node metastases, the impact of PI persisted only in node-negative cases as a prognostic factor.