A giant guteal schwannoma with extension into the pelvis: a case report.

BACKGROUND: Schwannomas are uncommon slow growing tumours arising from the nerve sheath or Schwann cell. OBJECTIVE: To report a case and the surgical removal of a giant complex schwannoma and to highlight the value of extensive investigations including a preoperative histologic diagnosis in the successful surgical management of uncommon large benign tumours. METHODS: A 39-year-old man presented with a 15-year history of a large mass in the right gluteal region. He was clinically evaluated, subjected to imaging studies and surgery. RESULTS: Clinical examination revealed a 40 cm by 60 cm mass in the right gluteal region and continuous with a 25 cm by 15 cm pelvic mass. The ultrasound scan revealed a very complex (mixed solid and fluid containing) gluteal mass with extension to the pelvis. The CT scan showed a very large, well defined lobulated tumour with cystic spaces and enhancing nodules. The tumour extended through the ischiadic foramen into the pelvis and posteriorly into the thigh muscles. A Doppler scan of the pelvic vessels revealed that the right common and internal iliac arteries were both compressed but not occluded. An incisional biopsy was reported as a Schwannoma with xanthomatous changes and an immuno histochemistry profile of S-100+, Ki-67+ (less than 1% of the cells). A right foot drop following the surgery responded to physiotherapy. The duration of total hospital stay was 12 weeks. CONCLUSION: The staged excision of large and complex schwannomas is safe. It is essential that a preoperative histological diagnosis is made to establish that the tumor is truly benign.

Significant expression of IGFBP2 in breast cancer compared with benign lesions.

BACKGROUND/AIM: Insulin-like growth factors (IGFs) and IGF binding proteins (IGFBPs) play a role in the normal development of breast tissue, and possibly in breast cancer aetiology. IGFBP2, one of six members of the IGFBP superfamily, acts as regulator of the IGFs and has pleiotropic effects in normal and neoplastic tissues. Because IGFs have mitogenic effects on mammary epithelia, this study investigated IGFBP2 expression in mammary tissues of different benign and malignant entities. METHODS: Immunohistochemistry was used to study correlations between the presence and intensity of IGFBP2 staining and tumour type and grade, in addition to steroid hormone receptor status, in 120 breast specimens. Expression was measured by quantitative colour video image analysis and semiquantitative evaluation, and the measurements correlated well (r = 0.92; p<0.05). RESULTS: Both methods found no significant expression of IGFBP2 in normal glandular cells and hyperplasia (group I). Atypical hyperplasia showed a slightly increased cytoplasmic expression of IGFBP2, and carcinoma in situ showed a distinctive, membrane associated and cytoplasmic expression (group II). Infiltrating carcinomas strongly expressed cytoplasmic IGFBP2 (group III). There were significant differences between group I and II, and between group II and III. There were no significant differences between invasive lobular and invasive ductal carcinoma, or between grades I, II, and III within these entities. There was no significant correlation between IGFBP2 immunostaining and oestrogen or progesterone receptor positivity within the malignant group. CONCLUSIONS: IGFBP2 mitogenic signals of autocrine/paracrine regulatory mechanisms may be responsible for the growth of breast carcinomas and IGFBP2 may be an independent indicator of malignancy.

The delimitation of tubular carcinoma of the breast.

Five hundred consecutive breast carcinomas from the first screening round of the Breast Cancer Detection Demonstration Project were studied quantitatively and semiquantitatively for features relevant to the diagnosis of tubular carcinoma. Tubularity was defined as the proportion of tumor cells that were adjacent to an open lumen. Nuclear morphology and mitotic activity were graded 1 to 3, and the presence of apocrine snouts as absent, few, common, or prominent. In plots and statistical cluster analysis, tubular carcinoma appears as part of a continuous spectrum of morphologies and not as a distinct entity. In multivariate analysis, apocrine snouts had no significant association with either nodal status or deaths of breast cancer. Tumors with 70% or greater tubularity by our definition and mitosis and nuclear grades 1 were not associated with either nodal metastases or deaths of breast cancer. The question is raised whether tubular carcinoma at the benign end of a spectrum shades into benign glandular proliferations, with particular reference to microglandular adenosis. A uniform and precise definition of tubularity is needed for the attainment of sufficient collective experience to delimit tubular carcinoma both from more aggressive carcinomas and from benign proliferations.

Pilomatrix carcinoma with multiple metastases: report of a case and review of the literature.

Pilomatrix carcinoma, the malignant counterpart of pilomatrixoma, is rare, with only 55 cases reported, and only four cases with visceral metastases described in the literature. Here we present a case report and a literature review on this rare tumour. A 74-year-old male with a pilomatrix carcinoma from the left temporal region presented in July 1996 and the tumour was excised. One month after diagnosis, metastases to both lungs and to a regional lymph node were found and histologically verified. The patient also developed metastases in the abdomen, back and thoracic spine. The latter resulted in spinal cord compression and paraplegia. Despite systemic chemotherapy with intravenous cisplatin and 5-fluorouracil and localised radiotherapy to the thoracic spine, progression and deterioration led to death within 3 months from time of diagnosis. Pilomatrix carcinomas are usually indolent. In our patient, however, the malignant disease progressed rapidly and it appeared to be resistant to both chemotherapy and irradiation.

The relationship between diet and breast cancer in men (United States).

OBJECTIVES: The purpose of this paper was to investigate the relationship between food and beverage consumption and the development of breast cancer in men. METHODS: Possible relationships of dietary factors to risk of breast cancer in men were assessed in a case-control study conducted between 1983 and 1986. Cases (N = 220) were ascertained from ten population-based cancer registries. Controls (N = 291) were selected by random-digit dialing (< age 65) and from Health Care Financing Administration Medicare beneficiary lists (> or = age 65). RESULTS: No trends in risk were observed with increasing intakes of specific foods, except for an increase in risk with citrus fruits. No increase in risk with increasing amounts of specific fats, vitamins, or minerals or with amounts of protein, fiber, carbohydrate, starches, nitrites, or alcohol consumed was observed, except for an increase in risk with dietary vitamin C consumption. A decreasing trend in risk with dietary niacin and with coffee and an increasing trend in risk with tea consumption were observed. No associations were found with use of any dietary supplements, including vitamin C. CONCLUSIONS: The observed associations are not consistent with findings from studies of breast cancer in women and probably do not represent causal relationships. Dietary factors are unlikely to be strong determinants of breast cancer in men.

[Group learning in medical education]. / Gruppebasert undervisning i medisinstudiet.

The implementation of group learning in medical education puts special demands on the participants, but also offers pedagogical benefits, which may be conductive to the efficient learning of facts, skills and attitudes. The group makes it possible to verify or modify the learned material, which is an important part of preparing for a career as a doctor. Students develop a dependence on others when solving problems in groups, whereas as clinicians they are often alone when confronted with problems demanding quick decisions. In this article we discuss some of the pedagogical principles involved in group learning and make suggestions on how to apply them to learning based on problem solving and other forms of group learning in the medical curriculum.

Incidence of cervical intraepithelial neoplasia grade III, and cancer of the cervix uteri following a negative Pap-smear in an opportunistic screening.

BACKGROUND: To investigate the influence of screening history on the diagnosis of cervical intraepithelial neoplasia grade three (CIN III) and cervical cancer in an opportunistic screening program. DESIGN: Follow-up study of women with a negative Pap-smear at entry. MATERIALS: Records from 41212 women pertaining to cervical specimens in the Pathology Registry of the University Hospital in Tromsø. RESULTS: During the 175,673 person-years (pyr) of observation, 396 incident cases (379 of CIN III and 17 of cervical cancer) were identified. The age specific incidence rate was highest among women who were 25 to 29 years old (396 per 100,000 pyr). A Poisson multiple regression model yielded statistically significant positive associations between time since last negative Pap-smear and the incidence of CIN III and cervical cancer. Most CIN III cases were diagnosed subsequently to a CIN I or CIN II diagnosis. Including only women with a CIN III diagnosis directly after a negative Pap-smear in the analyses revealed that women with less than two years (Relative rate (RR)= 1.O; 95% CI 0.7-1.4) and three years (RR=0.8; 95% CI 0.4-1.4) since their last negative Pap-smear were not at an increased risk compared with the women with a negative Pap-smear within the last year. Women with three or more years since their last negative Pap-smear were at an increased risk (RR=1.3; 95% CI 0.6 3.2) for CIN III. No meaningful association between number of negative specimens and the risk of CIN III was revealed. CONCLUSION: This study indicates that time since last negative Pap-smear does, while number of such does not, influence the risk of CIN III and cervical cancer in an opportunistic screening.

Extra-tumoral breast tissue in breast-cancer patients: variations with a family history of breast cancer. WHO Collaborative Study of Neoplasia and Steroid Contraceptives.

In order to study the relationship between benign breast changes, a family history of breast cancer and breast cancer, extratumoral breast tissue from 1259 breast-cancer patients in the WHO Collaborative Study of Neoplasia and Contraceptives was classified histologically. The occurrence of ductal hyperplasia, ductal atypia, sclerosing adenosis, adenosis, lobular atypia, lactational metaplasia, cysts, apocrine metaplasia, apocrine hyperplasia and atypia, duct ectasia and the epithelial-stromal ratio was evaluated as absent, mild, moderate or marked, along with registration of the quality and number of slides. Information on occurrence of cancer in the family was available for patients' mothers and grandmothers. Logistic-regression analyses showed that the prevalence odds ratios for lactational metaplasia, cysts, duct ectasia and calcification were significantly increased in patients with a family history of breast cancer. Apocrine metaplasia and hyperplasia were not significantly increased. The prevalence rates of ductal atypia (ductal carcinoma in situ and atypical ductal hyperplasia), ductal hyperplasia, sclerosing adenosis, adenosis and high epithelial-stromal ratio did not differ significantly among patients with or without a family history of breast cancer. A family history of other types of cancer did not influence the occurrence of any of the benign components. The findings in the present study are strikingly similar to those in our earlier comparison of extra-tumoral breast tissue in patients from countries with high and low risk of breast cancer. It is reasonable to conclude from this that a history of breast cancer in a woman's mother or grandmother and the factors leading to higher risk of breast cancer in some countries than in others have similar effects on the morphologic evolution of breast cancer through benign and pre-cancerous changes.

Extratumoral breast tissue in breast cancer patients: a multinational study of variations with age and country of residence in low- and high-risk countries. WHO Collaborative Study of Neoplasia and Steroid Contraceptives.

With the aim of elucidating the relationships between breast cancer, risk factors and benign breast changes, extratumoral breast tissue in 1,506 women from the WHO Collaborative study of neoplasia and steroid contraceptives was studied histologically. Patients came from 3 countries with a high incidence of breast cancer (Israel, East Germany and Australia) and 6 low-risk countries (Thailand, China, Philippines, Mexico, Chile and Colombia). Ductal atypia, ductal hyperplasia, adenosis, lobular atypia, apocrine metaplasia, apocrine hyperplasia, apocrine atypia, cysts, duct ectasia, inflammatory reaction, calcification, lactational change and epithelial-stromal ratio were classified as absent/mild/moderate/marked. Prevalence odds ratios were calculated by logistic regression analyses. Increasing frequency with age was found for ductal hyperplasia, sclerosing adenosis, apocrine metaplasia and cysts, while adenosis, lactational change and the epithelial-stromal ratio decreased with age. No significant difference between high- and low-risk countries was found for ductal hyperplasia or sclerosing adenosis. Compared with cases from high-risk countries, those from low-risk countries had a significantly lower prevalence of apocrine metaplasia, apocrine hyperplasia and cysts, and a significantly higher prevalence of ductal atypia. When seen in conjunction with other studies, the results suggest that ductal hyperplasia and sclerosing adenosis have similar roles in cancer development in high- and low-risk countries and that the factors responsible for international differences in breast cancer may exert their effect by influencing the initial development of these changes. They also suggest a delayed progression from noninvasive to invasive carcinoma in low-risk countries.

Reproductive history and cigarette smoking as risk factors for thyroid cancer in women: a population-based case-control study.

A population-based case-control study was conducted in Northern Norway and Central Sweden to investigate hormonal and reproductive factors and cigarette smoking as determinants of papillary and follicular thyroid carcinoma in women. Information on 191 histologically confirmed cases and 341 age-matched controls was included. No clear association was found with regard to the number of live births, number of pregnancies, a history of incomplete pregnancies, or the use of oral contraceptives or hormonal replacement therapy. However, an early first childbirth (before 20 years of age, or less than 5 years after menarche) was associated with an increased risk of thyroid cancer. There was an increased risk of thyroid cancer among women with a history of artificial menopause compared to those with a spontaneous menopause [odds ratio (OR), 2.52; 95% confidence interval (CI), 0.96-6.62], which was more pronounced for the papillary carcinoma and after adjustment for age at menopause and use of replacement therapy. Cigarette smokers had a decreased risk of borderline statistical significance compared to nonsmokers (OR, 0.69; 95% CI, 0.47-1.01), particularly among premenopausal women (OR, 0.60; 95% CI, 0.38-0.96). This negative association persisted after adjustment for parity, hormonal treatments, and education. Women who started smoking before the age of 15 experienced a marked reduction in risk (OR, 0.38%; 95% CI, 0.18-0.80¿). Moreover, there was a suggestion of a dose-response effect with the amount of cigarettes smoked daily and with duration of the habit. Both the increased risk of artificial menopause and the negative association with smoking are compatible with a relation between levels of estrogens and thyroid cancer among women.

Cervical neoplasia in pap smears: risk of cervical intra-epithelial neoplasia (CIN) after negative or no prior smears in a population without a mass screening programme.

BACKGROUND: The aim of this study was to examine, in a population not submitted to mass screening, the risk of cancer and cervical intra-epithelial neoplasia (CIN) in Pap smears from women without previously reported positive smears. METHODS: In a logistic regression model consisting of 58,271 smears from 40,536 Norwegian women the risk of cytologically indicated CIN was studied according to age and time elapsed since last smear. RESULTS: The risk of CIN was highest in smears from women with no previously registered smears and in smears taken after an interval of > or = 5 years. Odds ratio for CIN I-II adjusted for age was highest in first time smears and in smears taken after an interval of 5 years. Odds ratio for CIN III was highest in first registered smears. No difference in risk of CIN III was found in smears taken within one year or 2-3 years after the last smear. The increased risk of CIN III in first smears was most pronounced in postmenopausal women ( > 50 years). Nine of 16 cases with cytological indication of cancer were found in women having a smear taken for the first time. All cases with malignancy in smears were > 50 years. CONCLUSIONS: The risk of cytologically diagnosed premalignant cervical conditions increases with time since the previous smear, but more than 5 years have to elapse before the risk is comparable with that in first smears taken. Postmenopausal women without previous smears run the highest risk of serious cervical premalignancies and cancer.

Subclassification of Hodgkin's disease, nodular sclerosis type. Prognostic value?

Recently, studies have suggested a subclassification of Hodgkin's disease, nodular sclerosis (HDNS). Between 1985-1994, twenty-four patients with HDNS were treated at the University Hospital of Tromsø, Norway. The cases were subclassified according to the histological criteria from the British National Lymphoma Investigation (BNLI) into NS1 (15 patients) and NS2 (9 patients). The relative frequencies of the two subtypes of HDNS in our region were in agreement with other reports. After a median follow up of 33 months, no significant difference between NS1 and NS2 with regard to complete remission rate (87% versus 100%) or predicted 5-year actuarial survival (93% versus 75%) were observed. Although our data are too small to draw specific conclusions, the discrepancy with some of the previous studies could be due to an improved response of the more aggressive type (NS2) to optimal treatment. We hope this study may initiate a raised interest in this field.

Use of pap-smears in a population without a mass screening program.

STUDY OBJECTIVE: To analyze the use of Pap-smears in a population where a screening program was not offered. DESIGN: Retrospective analysis of pathology registry data on women resident in two counties of Norway. SETTING: Evaluation of opportunistic screening by age and year of birth. Proportion of population tested during successive 3-year periods. MATERIAL: 353,665 smears from 88,048 women examined since 1973. For this purpose we concentrated on 257,951 smears from 77,431 women examined during the period 1981-90. RESULTS: Between 62 and 67% of women examined during each 3-year period were 20-39 years old, 14-16% were 50-69 years of age. Throughout the ten-year period the frequency of Pap-smear testing of women over 60 and under 20 increased slightly whereas it decreased for women 20-39 years old. Follow-up of positive or atypical smears comprised about 25% of all smears. The highest proportion of follow-ups was found among women 30-49 years old. About one third of women aged 20-59 years had more than one smear taken in a 3-year period, follow-up smears excluded. CONCLUSION: More than half of the women aged 50 and above have no smears or smears less than one every third year. This proportion increases with age. The use and distribution of smears by age is still far from the situation expected in an organized screening program although a slight amelioration was observed through the study period.

Multiple lymphomatous polyposis of the gut.

Multiple lymphomatous polyposis is very rare. We report two cases affecting duodenum, small intestine and colon/rectum, both with extensive disease, making radical surgery impossible and chemotherapy the treatment of choice. One patient died 23 days after initial treatment of myocardial infiltration, and the other is still alive 21 months after initial treatment.

Ionizing radiation and breast cancer in men (United States).

The purposes of this study were to determine whether exposure of the vestigial male breast to ionizing radiation is associated with an increase in risk of breast cancer and, if so, to determine whether the apparent effects on risk in men are similar to those reported for women. A population-based case-control study of breast cancer in men was conducted in 10 geographic areas of the United States. Information on possible prior exposure to ionizing radiation, and on other potential risk factors for breast cancer, was obtained from personal interviews of 227 cases and 300 controls who were recruited from October 1983 to September 1986. Evidence from this study that ionizing radiation can cause breast cancer in men includes: a modest trend of increasing risk with frequency of chest X-rays; an increase in risk in men with three or more radiographic examinations, especially if received prior to 1963; and an increase in risk in men who received X-ray treatments to the chest and adjacent body areas. Risk was increased only from 20 to 35 years after initial exposure from either radiographic examinations or X-ray treatments, and declined after three to four decades since last exposure, suggesting a wave of increased risk of finite duration following exposure. The doses of radiation received could not be estimated precisely, but those from diagnostic procedures were likely similar to those received by prepubertal females in prior studies, and the results of those and the present investigation are compatible. The carcinogenic effects of ionizing radiation may be similar in the male and prepubertal female breast.

[Brodie's abscess]. / Brodies abscess.

Brodie's abscess is a localized subacute or chronic osteomyelitis independent of any known previous acute infection. The entity is often mistaken for a bone tumour. The diagnosis requires biopsy. The treatment is curettage, drainage and antibiotics for a minimum of six weeks. We describe the characteristics of Brodie's abscess and describe a patient with an illustrating history, but with an unusual localization of the abscess (osilium).

Age distribution of histologic types of breast carcinoma.

The large number of cases in the Surveillance, Epidemiology and End Results (SEER) program of the US National Cancer Institute allowed a detailed analysis of the age distribution of the histologic types of invasive breast carcinoma. Between ages 50 and 85 years in females, the age-specific incidence rate shows little change for medullary, inflammatory and apocrine carcinomas; is about doubled for Paget's disease and for ductal, lobular, tubular and metaplastic carcinomas; and increases to 4 to 8 times the menopausal level for mucinous, papillary and signet-ring-cell carcinomas. The peri-menopausal break on the age-incidence curve is most marked for carcinomas of predominantly lobular origin and virtually absent for carcinomas of predominantly ductal origin. In males, the age distribution of papillary carcinoma is similar to that of all types combined, whereas that of mucinous carcinoma is skewed towards older ages, as in females.

Histologic types and hormone receptors in breast cancer in men: a population-based study in 282 United States men.

Histologic slides from 282 incident cases of breast cancer in men, that were identified in 10 population-based cancer registries in the United States, were reviewed by a single pathologist. Breast cancer more often presented in the noninvasive stage in men (10.8 percent of all cases) than would be expected among women. All noninvasive carcinomas were of the ductal type. Of invasive carcinomas, compared with women, men had smaller proportions of lobular and mucinous types and larger proportions of ductal and papillary types and Paget's disease. No case of tubular or medullary carcinoma was seen. The breast in men is composed only of ducts and normally contains no lobules, and the histologic types of breast carcinomas that predominate in men are likely of ductal origin. Estrogen and progesterone receptors were present in 86.7 percent and 76.3 percent of invasive carcinomas, respectively, which are higher proportions than would be expected among women. Also, unlike findings in women, receptor content was not associated with patient age at diagnosis.

The validity of frozen section diagnosis based on video-microscopy.

To investigate the accuracy of video-microscopy of frozen sections, two pathologists reexamined 80 cases of archival material, on which frozen sections had previously been performed. Diagnoses based on the two trials (Observer 1 and 2) and diagnoses obtained in the original frozen section situation were compared with the final diagnoses based on paraffin embedded material. Observer 1 had two false negative diagnoses, but no false positive, whereas Observer 2 had one false positive, but no false negative diagnosis when compared with the final diagnoses. No false positive or false negative diagnoses were made in the original frozen sections situation and the number of inconclusive diagnoses were 5, as compared with 6 and 8 in the two trials based on video-microscopy. More experience with video-microscopy will probably achieve a quality of frozen section diagnoses similar to that of direct light-microscopy.

[Quality assurance in a department of pathology and anatomy]. / Kvalitetssikring i en patologisk-anatomisk avdeling.

The author describes a quality assurance programme in a department of anatomic pathology. An internal quality assurance committee consisting of four consultants, two chief technicians and a chief secretary meets monthly to decide what measures should be carried out each month. The main activities have been to review random cases of surgical pathology, frozen sections, diagnostic revisions, turn-around times and single event reports. Problems of diagnosis are discussed at a medical staff meeting before they are put before the committee. The programme has been well received in the department.