High-risk human papillomavirus detection in self-sampling compared to physician-taken smear in a responder population of the Dutch cervical screening: Results of the VERA study.

In 2017 the cervical cancer screening program in The Netherlands will be revised. Cervical smears will primarily be tested for the presence of high-risk human papillomavirus (hrHPV) instead of cytology, and vaginal self-sampling will be offered to non-responders. This includes a potential risk that part of the women who would otherwise opt for a cervical smear will wait for self-sampling. However, self-sampling for hrHPV in a responder population has never been studied yet. The aim of this study was to investigate the applicability and accuracy of self-sampling in detecting hrHPV in a screening responder population. A total of 2049 women, aged 30-60years, participating in the screening program in The Netherlands were included from April 2013 to May 2015. After they had their cervical smear taken, women self-collected a cervicovaginal sample with a brush-based device, the Evalyn Brush. Both the cervical smear and self-sample specimen were tested with the COBAS 4800 HPV platform. The hrHPV prevalence was 8.0% (95% CI 6.9-9.2) among the physician-taken samples, and 10.0% (95% CI 8.7-11.3) among the self-samples. There was 96.8% (95% CI 96.0-97.5) concordance of hrHPV prevalence between self-samples and physician-taken samples. Women in our study evaluated self-sampling as convenient (97.1%), user-friendly (98.5%), and 62.8% preferred self-sampling over a physician-taken sampling for the next screening round. In conclusion, self-sampling showed high concordance with physician-taken sampling for hrHPV detection in a responder screening population and highly acceptable to women. Implementation of HPV-self-sampling for the responder population as a primary screening tool may be considered.

Epidural analgesia associated with better survival in colon cancer.

PURPOSE: Surgery remains the mainstay of treatment for potentially curable colon cancer. Otherwise, the surgical stress response might increase the likelihood of cancer dissemination during and after cancer surgery. There is growing evidence that the type of anaesthesia during cancer surgery plays a role in the metastatic process. Therefore, we assessed if the method of anaesthesia is associated with long-term survival after colon cancer surgery. METHOD: A retrospective single-centre study was conducted including 588 patients who underwent colorectal cancer surgery, TNM stage I-IV, in the Jeroen Bosch Hospital between 1995 and 2003. The Cox proportional hazard model was used for statistical analysis. Adjustments were made for age, sex, comorbidity, TNM stage, chemotherapy, emergency surgery status and year of incidence. RESULTS: Of the 588 primary colon cancer patients with a median age of 70 years, 399 (68 %) patients underwent colon surgery with epidural anaesthesia, whilst 189 (32 %) patients were operated without epidural anaesthesia. Five-year survival for patients not receiving epidural analgesia was 42 % versus 51 % for patients receiving epidural analgesia (p = 0.03). This effect remained after adjustment for relevant patient, tumour, and treatment characteristics (hazard ratio (HR) 1.30 (95 % confidence interval (CI) 1.05-1.59), p = 0.01). Subgroup analysis in patients of 80 years and older (n = 100) showed also a better overall survival after receiving epidural analgesia (HR 1.74 (95 % CI 1.11-2.72), p = 0.01). CONCLUSION: Epidural analgesia during colon cancer surgery was associated with a better overall survival. Prospective trials evaluating the effects of locoregional analgesia on colon cancer recurrence are warranted.

The diagnostic value of one-step nucleic acid amplification (OSNA) for sentinel lymph nodes in colon cancer patients.

BACKGROUND: Lymph node status in colon cancer is critical for prognosis estimation and treatment allocation. The purpose of this study was to compare the performance of one-step nucleic acid amplification (OSNA) through detection of cytokeratin 19 mRNA levels with routine pathological examination (RP) and multilevel fine pathological examination (FP) in sentinel lymph nodes (SLN), detected using the ex vivo SLN mapping (SLNM) procedure, in presurgically defined nonmetastatic colon cancer patients. METHODS: In this prospective study, 325 SLNs of 128 patients from the Jeroen Bosch Hospital in 's-Hertogenbosch and the Leiden University Medical Center were investigated by RP (H&E), FP (H&E and Keratin Pan immunohistochemical staining), and OSNA. The SLNs were harvested by the SLNM procedure, using Patent blue or Indocyanine green. SLNs were divided and separate parts were used for RP, FP, and the OSNA assay. RESULTS: The diagnostic value of OSNA was 82.1 and 100 % for both FP and combined method (OSNA and FP) compared with RP. An upstaging rate of 20.2 % was obtained with the use of OSNA only and 36.4 % with the use of FP only. An upstaging rate of 46.5 % was obtained by combining the two methods together. CONCLUSIONS: OSNA and FP appeared to be promising tools for the detection of lymph node micro- and macrometastases in SLNs after SLNM. The performances of OSNA and FP in this study were superior to RP. Because OSNA allows analysis of the whole lymph node, sampling bias can be avoided. OSNA therefore may improve tumor staging.

Node negative colorectal cancer patients: assesment of high-risk features on recurrence.

BACKGROUND: The introduction of population-based screening programs for colorectal cancer (CRC) results in less patients with advanced disease. There is an increase in the amount of node negative CRC, which makes adequate risk stratification for this particular group of patients necessary. The addition of more risk factors to the conventional histological high-risk factors is investigated in this retrospective study. PATIENTS AND METHODS: A cohort of 227 node negative (stage I and II) CRC patients who were not treated with adjuvant chemotherapy were selected from two previously conducted cohort studies. Detailed histopathological examination was performed by two independent observers and molecular background (BRAF/RAS mutations, microsatellite status (MSI)) was studied. Univariate analyses were used to analyse differences in histological and mutational characteristics between patients with and without recurrence. P-values below 0.05 were considered statistically significant. RESULTS: Poorly differentiated histology (p:0.002), BRAF mutation (p:0.002) and MSI status (p:0.006) were found significant relevant risk factors that were related to recurrent disease. Poorly differentiated histology was associated with intermediate/high tumor budding (TB) (p:0.001), a BRAF mutation (p:0.001) and MSI status (p:0.001). A combination of all three features (poorly differentiated histology, BRAF and MSI) was more often present in the recurrence group. CONCLUSIONS: Recurrence in node negative CRC patients could be better predicted when molecular features such as, BRAF mutation and MSI status are incorporated into a model with poorly differentiated CRC. Therefore, these features might help in the selection of patients who possibly will benefit from adjuvant treatment.

The value of an artificial neural network in the decision-making for prostate biopsies.

PURPOSE: In majority of patients who are subjected to prostate biopsies, no prostate cancer (PCa) is found. It is important to prevent unnecessary biopsies since serious complications may occur. An artificial neural network (ANN) may be able to predict the risk of the presence of PCa. METHODS: Included were all patients, who underwent transrectal ultrasound-guided prostate biopsies between June 2006 and June 2007 with a total PSA (tPSA) level between 2 and 20 microg/l. The patients were divided into two groups according to their tPSA level (2-10 microg/l and 10-20 microg/l). The ANN Prostataclass of the Universitätsklinikum Charité in Berlin was used. The predictions of the ANN were compared to the pathology results of the biopsies. RESULTS: Overall 165 patients were included. PCa was diagnosed in 53 patients, whereas the ANN predicted "no risk" in 19 of these patients (36%). The ANN output receiver operator characteristic (ROC) plots for the range of tPSA 2-10 microg/l and tPSA 10-20 microg/l showed an area under the curve (AUC) of 63 and 88% for the initial biopsy group, versus 69 and 57%, respectively, for the repeat biopsy group. CONCLUSIONS: The ANN resulted in a false negative rate of 36%, missing PCa in 19 patients. For use in an outpatient-clinical setting, this ANN is insufficient to predict the risk of presence of PCa reliably.

Influence of the positioning of a cementless glenoid prosthesis on its interface micromotions.

The positioning of the glenoid component in total shoulder arthroplasty is complicated by the limited view during operation. Malalignment and/or motion of the glenoid component with respect to the bone can be a cause of, or contribute to, failure of the implant. The aim of this paper is to determine the effect of the positioning of a cementless glenoid component on the micromotions between the implant and the bone during normal loading after surgery. For this study a three-dimensional finite element model of a complete scapula with a cementless glenoid component was used. In total, eight positions of the upper arm in both abduction and anteflexion were chosen to represent the patient's arm movement postoperatively. A previously published musculoskeletal model was used to determine the joint and muscle forces on the scapula with implant in each arm position. Five different alignments of the glenoid component (neutral, anterior, inferior, posterior, and superior inclinations), two different implantation depths ('optimal' and 'deeper' implantations), and two bone qualities (healthy and rheumatoid arthritis (RA) bone) were considered. Inclinations of 10 degrees with respect to a neutral alignment did not affect the overall interface micromotions in the optimal implantation depth. However, when the implantation depth was 3 mm deeper, anterior and inferior inclinations were more favourable than a neutral alignment and other inclinations. Micromotions in RA bone were always larger than in healthy bone.

Convective-Dispersion Modeling in 3D Contrast-Ultrasound Imaging for the Localization of Prostate Cancer.

Despite being the solid tumor with the highest incidence in western men, prostate cancer (PCa) still lacks reliable imaging solutions that can overcome the need for systematic biopsies. Dynamic contrast-enhanced ultrasound imaging (DCE-US) allows us to quantitatively characterize the vascular bed in the prostate, due to its ability to visualize an intravenously administered bolus of contrast agents. Previous research has demonstrated that DCE-US parameters related to the vascular architecture are useful markers for the localization of PCa lesions. In this paper, we propose a novel method to assess the convective dispersion (D) and velocity (v) of the contrast bolus spreading through the prostate from three-dimensional (3D) DCE-US recordings. By assuming that D and v are locally constant, we solve the convective-dispersion equation by minimizing the corresponding regularized least-squares problem. 3D multiparametric maps of D and v were compared with 3D histopathology retrieved from the radical prostatectomy specimens of six patients. With a pixel-wise area under the receiver operating characteristic curve of 0.72 and 0.80, respectively, the method shows diagnostic value for the localization of PCa.

Prognostic implications of occult nodal tumour cells in stage I and II colon cancer: The correlation between micrometastasis and disease recurrence.

INTRODUCTION: Occult nodal tumour cells should be categorised as micrometastasis (MMs) and isolated tumour cells (ITCs). A recent meta-analysis demonstrated that MMs, but not ITCs, are prognostic for disease recurrence in patients with stage I/II colon cancer. AIMS & METHODS: The objective of this retrospective multicenter study was to correlate MMs and ITCs to characteristics of the primary tumour, and to determine their prognostic value in patients with stage I/II colon cancer. RESULTS: One hundred ninety two patients were included in the study with a median follow up of 46 month (IQR 33-81 months). MMs were found in eight patients (4.2%), ITCs in 37 (19.3%) and occult tumour cells were absent in 147 patients (76.6%). Between these groups, tumour differentiation and venous or lymphatic invasion was equally distributed. Advanced stage (pT3/pT4) was found in 66.0% of patients without occult tumour cells (97/147), 72.9% of patients with ITCs (27/37), and 100% in patients with MMs (8/8), although this was a non-significant trend. Patients with MMs showed a significantly reduced 3 year-disease free survival compared to patients with ITCs or patients without occult tumour cells (75.0% versus 88.0% and 94.8%, respectively, p = 0.005). When adjusted for T-stage, MMs independently predicted recurrence of cancer (OR 7.6 95% CI 1.5-37.4, p = 0.012). CONCLUSION: In this study, the incidence of MMs and ITCs in patients with stage I/II colon cancer was 4.2% and 19.3%, respectively. MMs were associated with an reduced 3 year disease free survival rate, but ITCs were not.

Stress-concentrating effect of resorption lacunae in trabecular bone.

Analyses of the distributions of stress and strain within individual bone trabeculae have not yet been reported. In this study, four trabeculae were imaged and finite elements models were generated in an attempt to quantify the variability of stress/strain in real trabeculae. In three of these trabeculae, cavities were identified with depths comparable to values reported for resorption lacunae ( approximately 50 microm)-although we cannot be certain, it is most probable that they are indeed resorption lacunae. A tensile load was applied to each trabeculum to simulate physiological loading and to ensure that bending was minimized. The force carried by each trabecula was calculated from this value using the average cross sectional area of each trabecula. The analyses predict that very high stresses (>100 MPa) existed within bone trabecular tissue. Stress and strain distributions were highly heterogeneous in all cases, more so in trabeculae with the presumptive resorption lacunae where at least 30% of the tissue had a strain greater than 4000 micoepsilon in all cases. Stresses were elevated at the pit of the lacunae, and peak stress concentrations were located in the longitudinal direction ahead of the lacunae. Given these high strains, we suggest that microdamage is inevitable around resorption lacunae in trabecular bone, and may cause the bone multicellular unit to proceed to resorb a packet of bone in the trabeculum rather than just resorb whatever localized area was initially targeted.

Status epilepticus caused by a myxoedema coma.

The case of a 63-year-old woman who presented with status epilepticus, coma and hypoventilation is reported. A primary neurological cause was considered. Hypothermia led to further investigations and a diagnosis of severe hypothyroidism. The neurological complications of hyperthyriodism include alteration in mental status with slowness, decreased concentration and lethargy, headache, cranial nerve palsies, dysarthria, hoarseness, myopathy, neuropathy, reflex changes, ataxia, and psychotic episodes. Our patient suffered from a rare consequence of severe hypothyroidism presenting with status epilepticus and she died despite treatment. To our knowledge this is the second patient to be reported with myxoedema coma with this kind of presentation. Despite therapeutic options, there is a high mortality rate.

Incidence of axillary recurrence in 113 sentinel node negative breast cancer patients: a 3-year follow-up study.

BACKGROUNDS/AIMS: This study evaluates the 3-year follow-up period and recurrence rate in patients with a negative sentinel node biopsy (SNB) without an additional axillary dissection (ALND). METHODS: Between January 2000 and March 2002, 197 patients with an invasive breast cancer and clinically negative axillary nodes underwent a sentinel node biopsy. One hundred and thirteen patients were included in our study. The follow-up consisted of clinical examination every 3 months in the first year, followed by every 6 months after the first year. A mammography was obtained annually. Attention was paid to loco-regional recurrence, including axillary recurrence, and distant metastases. RESULTS: The mean duration of follow-up was 37.5 months (range 24-54). In this period, one patient was diagnosed with an axillary recurrence and one patient developed a supraclavicular lymph node metastasis. Two patients developed a second primary breast cancer in the contralateral breast. No patients were diagnosed with distant metastasis. CONCLUSION: These 3 year follow-up results suggest that SNB is a procedure with a low clinical recurrence rate, which can replace, when strict criteria are met, ALND if the sentinel node is negative.

A three-dimensional simulation of age-related remodeling in trabecular bone.

After peak bone mass has been reached, the bone remodeling process results in a decrease in bone mass and strength. The formation deficit, the deficit of bone formation compared with previous resorption, results in bone loss. Moreover, trabeculae disconnected by resorption cavities probably are not repaired. The contributions of these mechanisms to the total bone loss are unclear. To investigate these contributions and the concomitant changes in trabecular architecture and mechanical properties, we made a computer simulation model of bone remodeling using microcomputed tomography (micro-CT) scans of human vertebral trabecular bone specimens. Up to 50 years of physiological remodeling were simulated. Resorption cavities were created and refilled 3 months later. These cavities were not refilled completely, to simulate the formation deficit. Disconnected trabeculae were not repaired; loose fragments generated during the simulation were removed. Resorption depth, formation deficit, and remodeling space were based on biological data. The rate of bone loss varied between 0.3% and 1.1% per year. Stiffness anisotropy increased, and morphological anisotropy (mean intercept length [MIL]) was almost unaffected. Connectivity density increased or decreased, depending on the remodeling parameters. The formation deficit accounted for 69-95%, disconnected trabeculae for 1-21%, and loose fragments for 1-17% of the bone loss. Increasing formation deficit from 1.8% to 5.4% tripled bone loss but only doubled the decrease in stiffness. Increasing resorption depth from 28 to 56 microm slightly increased bone loss but drastically decreased stiffness. Decreasing the formation deficit helps to prevent bone loss, but reducing resorption depth is more effective in preventing loss of mechanical stiffness.

Mechanical consequences of bone loss in cancellous bone.

The skeleton is continuously being renewed in the bone remodeling process. This prevents accumulation of damage and adapts the architecture to external loads. A side effect is a gradual decrease of bone mass, strength, and stiffness with age. We investigated the effects of bone loss on the load distribution and mechanical properties of cancellous bone using three-dimensional (3D) computer models. Several bone loss scenarios were simulated. Bone matrix was removed at locations of high strain, of low strain, and random throughout the architecture. Furthermore, resorption cavities and thinning of trabeculae were simulated. Removal of 7% of the bone mass at highly strained locations had deleterious effects on the mechanical properties, while up to 50% of the bone volume could be removed at locations of low strain. Thus, if remodeling would be initiated only at highly strained locations, where repair is likely needed, cancellous bone would be continuously at risk of fracture. Thinning of trabeculae resulted in relatively small decreases in stiffness; the same bone loss caused by resorption cavities caused large decreases in stiffness and high strain peaks at the bottom of the cavities. This explains that a reduction in the number and size of resorption cavities in antiresorptive drug treatment can result in large reductions in fracture risk, with small increases in bone mass. Strains in trabeculae surrounding a cavity increased by up to 1,000 microstrains, which could lead to bone apposition. These results give insight in the mechanical effects of bone remodeling and resorption at trabecular level.

Detecting and tracking local changes in the tibiae of individual rats: a novel method to analyse longitudinal in vivo micro-CT data.

In this study we present the analysis of in vivo micro-CT scans using a new method based on image registration that accurately evaluates longitudinal micro-CT studies. We tested if detailed changes in the bone architecture could be detected and tracked in individual animals. A prototype in vivo micro-CT scanner (Skyscan 1076) was developed in which tibiae of rats that are lying on a bed under gas anaesthesia were scanned. For this study, three female Wistar rats were used: a sham-operated rat, an ovariectomised (OVX) rat and one rat that served as a reproducibility control. The reproducibility control rat was scanned twice in 1 day. The other animals were scanned at week 0, just before surgery, at week 4 and at week 14 after surgery. Architectural changes over time were detected by overlaying two data sets made at different time points using an algorithm that uses mutual information for optimal registration. The scans were segmented into binary data sets using a local thresholding algorithm. The reproducibility test showed small errors of less than 3% in bone volume measurements and errors less than 0.5% in measurements of trabecular thickness. The sham-operated rat showed no changes in total bone volume, though thinning and eventual loss of some small trabeculae could be detected, which could be related to the age of the animal. The OVX rat lost much trabecular bone volume, especially in the metaphysis (60% at week 4, 75% at week 14). The remaining trabeculae slowly increased in thickness. Following the different scans in time showed the forming of new trabecular structures. Additionally, small longitudinal growth at the growth plate could be detected after the first 4 weeks. Further, the OVX rat showed extensive modelling at the proximal endosteal lateral cortex. We have shown a new method that can detect and track changes in the local bone architecture and individual trabeculae in time, in an individual living animal. This method enables longitudinal in vivo micro-CT studies and has the potential to greatly contribute to experimental rat or mouse studies on pharmacological intervention and transgenic models.

Placenta morphology and absent or reversed end diastolic flow velocities in the umbilical artery: a clinical and morphometrical study.

The aim of the study was to investigate if a relation exists between absent or reversed end diastolic (ARED) flow in the umbilical artery and morphometric characteristics of the placenta. Geometric parameters were measured in the terminal villi of nine placentae, collected after a pregnancy complicated by ARED flow. Placentae from pregnancies with normal Doppler velocimetry in the umbilical artery were matched for gestational age and formed the control group. Mean placental weight in the ARED group was significantly lower than in the control group. Morphometric characteristics of the terminal placental villi did not differ substantially between the two groups before 30 weeks gestation. After 30 weeks mean villous profile cross sectional area and diameter were significantly smaller in the ARED group than in the control group. The mean profile cross sectional villous diameter in the ARED group did not differ substantially before and after 30 weeks of gestation (2287 microns2 and 2303 microns2, respectively). Accelerated maturation of terminal villi occurs in placentae delivered after a pregnancy with ARED flow in the umbilical artery. Morphometric characteristics are significantly different between placentae expelled after ARED velocities or after normal Doppler recordings in the umbilical artery. In ARED placentae, a significantly more uniform pattern of small villi is found compared with control placentae.

Histopathological classification of childhood rhabdomyosarcomas: relationship with clinical parameters and prognosis.

To define a useful and prognostically relevant classification system for rhabdomyosarcomas (RMSs), tissue sections of 113 well-documented, protocol-treated cases were retrieved from the files of the Emma Kinderziekenhuis Amsterdam, the Netherlands, and reclassified by a panel of pediatric pathologists. The following subtypes were recognized: embryonal RMS (n = 66), alveolar RMS (including the solid variant) (n = 16), botryoid RMS (n = 11), embryonal sarcoma (n = 6), and spindle cell RMS (n = 5). Nine cases were classified as RMS not otherwise specified (NOS). The above-mentioned histopathological subtypes correlated significantly with survival (P = .005) in patients with nonparameningeal tumors. Indeed, the best prognosis was observed in patients with spindle cell RMS, embryonal sarcoma, and botryoid RMS (10-year survival rates of 80% to 86%). Patients with embryonal RMS had an intermediate prognosis (10-year survival rate of 55%) and patients with alveolar RMS fared poorly (10-year survival rate of 9%). Survival rate was poor in patients with a localized parameningeal tumor, irrespective of histopathological subtype (10-year survival rate of 33%). Furthermore, this study confirmed the known impact on prognosis of localization (P = .008) and tumor node metastasis (TNM) stage (P = .0005). Classification of RMS subtypes proved to be fairly well reproducible (kappa ranging from 0.47 to 0.85 and percentage of concordance ranging from 50% to 85%). The best agreement was noted in botryoid RMS and the worst in embryonal sarcoma. However, improvement of agreement was noted for the latter subtype during the consecutive classification sessions. In summary, this study shows the strong prognostic value of histopathological subtypes and parameningeal tumor localization.

Monitoring serum CEA in women with primary breast tumours positive for oestrogen receptor and with spread to lymph nodes.

Serum carcinoembryonic antigen concentrations (serum CEA) in 80 patients with primary breast cancer were measured preoperatively, one month after operation, and thereafter serially every third month. These data were related to histological and morphometric features of the primary breast carcinoma and the lymph node metastases and to clinical follow up data. Analysis of the serum CEA values showed significant correlations with size of tumour, the presence of lymph node metastases, oestrogen receptor, and occurrence of distant metastases. Furthermore, the results indicated that serial determination of serum CEA in the first two years after operation may be useful in monitoring for the occurrence of distant metastases in patients with metastatic spread to lymph nodes and with large (greater than or equal to 2 cm) primary breast tumours positive for oestrogen receptor. In agreement with other studies, however, it was found that the predictive value of serum CEA concentrations in general is weak and costs may prohibit the implementation of the routine assessment of CEA concentrations.

Prospective evaluation of prognostic value of morphometry in patients with primary breast cancer.

In a prospective study the predictive value of a multivariate morphometric prognostic index was evaluated in 195 patients with primary breast cancer who had not been treated with any form of chemotherapy or hormonal treatment. The presence or absence of distant tumour recurrence combined with the scores of the prognostic index were compared with the survival curves predicted in a previous study. The value of the presence of lymph node metastases, number of positive nodes, tumour size, mitotic activity index, and oestrogen receptor status in prediction of prognosis were also investigated. In agreement with the results of the previous retrospective study, the prospective use of the index had the strongest predictive prognostic value, followed by the mitotic activity index. Statistical analysis showed that the actual prognoses of 43 of the 195 patients (22%) were more accurately determined by the prognostic index rather than by using the presence of the lymph node metastases as the classifying variable. The prognostic index is consistently reproducible by different technicians; it is a reliable method of predicting distant recurrence of tumour and hence the prognosis of patients with primary breast carcinoma. It provides more prognostic information than the presence of lymph node metastases alone, and the index should be incorporated in routine pathology reports.

Prognostic importance of DNA flow cytometric variables in rhabdomyosarcomas.

AIM: To determine whether DNA ploidy patterns and S phase fraction offer prognostic information in patients with rhabdomyosarcoma (RMS). METHODS: DNA flow cytometry was performed on formalin fixed, paraffin wax embedded samples from primary tumours, and metastatic deposits or recurrences in 70 patients. DNA histogram analysis was done using a semi-automated cell cycle analysis program. RESULTS: Of the 70 primary tumours, 23 were DNA diploid, 32 DNA aneuploid, eight DNA multiploid, and seven DNA tetraploid. The prognosis for DNA aneuploid patterns was favourable, intermediate within the group of DNA tetraploid tumours and poor among patients with DNA diploid and DNA multiploid tumours (p = 0.009). In multivariate analysis (Cox regression model) DNA ploidy was an important independent prognostic factor, along with TNM stage, localisation, and histopathological classification. Ten out of 32 patients with a high S phase fraction (> 15%) with primary RMS achieved long term survival in contrast to 20 out of 29 patients with a low S phase fraction (< or = 15%) (p = 0.008). In 24 cases the DNA ploidy of cases of relapse was analysed. Of the 15 cases, in which stem line changes had occurred, 13 died of disease. No stem line changes were noted in nine cases and in this group four patients died of disease (p = 0.02). CONCLUSIONS: Assessment of DNA ploidy and S phase fraction in primary RMS and evaluation of stem line changes in cases of relapse are important variables in predicting prognosis.

Peripheral primitive neuroectodermal tumour and extra-osseous Ewing's sarcoma; a histological, immunohistochemical and DNA flow cytometric study.

Although peripheral primitive neuroectodermal tumour (pPNET) and extra-osseous Ewing's sarcoma (EES) are thought to be closely related neoplasms, their clinical behaviour differs considerably. To determine the clinical relevance of the Schmidt classification scheme for differentiating pPNET and EES, 20 tumour specimens of poorly differentiated round cell tumours were evaluated. In addition, the diagnostic value of several neural markers and the prognostic value of quantitative morphological variables (DNA ploidy, S-phase fraction, and the mitotic activity) were assessed. Homer-Wright rosettes were present in 9 tumours. Neuron specific enolase (NSE) was expressed in 11 tumours, 8 of which expressed a second neural marker (CD57, S100, or neurofilament). According to the Schmidt classification, 11 pPNET and 5 EES were distinguished. HBA-71 was exclusively expressed in pPNET and EES. The remaining tumours were classified as sarcoma not otherwise specified (n = 2), rhabdomyosarcoma (n = 1), and desmoplastic tumour with divergent differentiation (n = 1). EES611 patients fared significantly better than the pPNET patients (100% versus 42% 5-year survival). Neither DNA ploidy nor S-phase fraction assessed in 12 evaluative histograms (9 pPNET and 3 EES), nor mitotic activity yielded information of additional prognostic value. On the basis of this study and the Schmidt classification scheme, it can be concluded that if the diagnosis of EES and pPNET is based on light microscopy (Homer-Wright rosettes) and/or immunohistochemistry (at least two neural markers, i.e. NSE, S-100, CD57, and neurofilament), the classification provides important clinical information. Furthermore, positivity for HBA-71 is helpful in differentiating pPNET and EES from all other small round cell tumours.