[Diagnostic image (390). A man with hepatic and mesenterial gas]. / Diagnose in beeld (390). Een man met gas in lever en mesenterium.

A 78-year-old man presented with pneumatosis intestinalis and hepatic portal venous gas.

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.

Serial sectioning of sentinel nodes in patients with breast cancer: a pilot study.

BACKGROUND: Recent reports indicate that the sentinel node, defined as the first regional lymph node to receive lymphatic fluid from the breast, accurately represents the metastatic status of the primary breast cancer. However, routine single section examination of the regional nodes, including the sentinel node, underestimates the true incidence of metastases. The goal of this study is to determine whether multiple sectioning of sentinel nodes will detect occult metastases in operable breast cancer. METHODS: Nineteen patients with invasive breast cancers were injected with technetium-99m sulfur colloid solution around the tumor or at the biopsy site before lumpectomy and axillary lymph node dissection (ALND) or mastectomy. The labeled sentinel lymph nodes (SLND) were bivalved, and a central section was taken for hematoxylin and eosin (H & E) examination. The sentinel nodes of 13 patients, which were reported to be negative for metastases, were serially sectioned at 0.5-mm intervals and stained with H & E and a cytokeratin stain, CAM 5.2. RESULTS: In the 13 node-negative patients, occult metastases were found in the sentinel nodes of 3 patients (23%). Two were seen on H & E and one by cytokeratin stain. The mean numbers of SLND and ALND in this series were 2.6 and 12.5, respectively, and the average number of sections for the two groups was 14 and 1, respectively. CONCLUSION: Multiple sectioning of the sentinel node or nodes detects occult metastases and changes the staging of breast cancer.

The influence of fixation delay on mitotic activity and flow cytometric cell cycle variables.

Proliferation variables such as mitotic activity and the percentage of S-phase cells have been shown to be of prognostic value in many tumors, especially in breast cancer. However, some studies reported a decrease in mitotic activity caused by delay in fixation of the tissue. In contrast, other studies showed that the identifiability of mitotic figures decreases after fixation delay, but the total number of mitotic figures and also the percentage of S-phase cells remain unchanged. Most studies have been done on small numbers of experimental tumors, thus introducing the risk of selection bias. The aim of this study was to reinvestigate the influence of fixation delay on mitotic activity and cell cycle variables assessed by flow cytometry in an adequate number of resected human tissues to reach firmer conclusions. Resection specimens of 19 and 21 cases, respectively, for the mitotic activity estimate and the flow cytometric percentage of S-phase calculation were collected directly from the operating theater using lung, breast, and intestinal cancers and normal intestinal mucosa. The tissues were cut in pieces, and from each specimen, pieces were fixed in 4% buffered formaldehyde (for mitosis counting) as well as snap frozen (for flow cytometry) immediately after excision, as well as after a fixation delay of 1, 2, 4, 6, 8, 18, and 24 hours. Moreover, during the fixation delay, one series from each specimen was kept in the refrigerator and the second at room temperature. Thus, a total of 304 (19 X 16) and 336 (21 X 16) specimens were investigated for the mitotic activity estimate and the percentage of S-phase cells calculation, respectively. With regard to the estimation of the mitotic activity, both clear and doubtful mitotic figures were registered separately, obtaining an "uncorrected" and "corrected" (for doubtful mitotic figures) mitotic activity estimate. The percentage of S-phase cells was obtained by cell cycle analysis of flow cytometric DNA-histograms. The results showed that the quality of the material decreased during the fixation delay, as reflected by poorer cellular morphology in the hematoxylin-and-eosin-stained slides, resulting in more difficult identification of mitotic figures and a more time-consuming procedure with regard to the mitosis counts, but not in a worse intraobserver and interobserver reproducibility, which was acceptable. The reduction in quality of the tissues also was shown by the flow cytometric measurements because the coefficient of variation and percentage of debris increased after 4 hours or more of fixation delay. However, the mean values of the "uncorrected" mitotic activity and the "corrected" mitotic activity showed no decreasing trend; neither did the average percentage of S-phase cells. In conclusion, within the time investigated, fixation delay has no clear influence on the proliferation features studied. Because of the decreasing quality of the histological sections, resulting in more difficult identification of mitoses and interpretation of DNA histograms, fixation delay should be kept as short as possible, keeping the tissue at 4 degrees C until fixation.

Heterogeneity of mitotic activity in breast cancer.

The aim of this study was to investigate to what extent mitotic activity index assessments are influenced by tumour heterogeneity. Ten invasive breast carcinomas of varying size were completely embedded, yielding 2-7 paraffin blocks per tumour. From each block, three H&E stained skip sections were cut and, in all sections, the mitotic activity index (MAI) and the mitoses per volume (M/V-)index were assessed. Coefficients of variation were calculated for the three different sampling levels (tumours, blocks, sections). In addition we recorded in how many tumours threshold discrepancies (values on both sides of the prognostic thresholds) occurred. Nested analysis of variance showed that most of the total variance occurred between the tumours. Threshold discrepancies occurred in four (40%) and five tumours (50%) for mitotic activity index and the mitoses per volume index, respectively. However, when grouping all sections from the same tumour and subjectively selecting the one showing the highest proliferation, the section with the highest mitotic activity was selected in nine of the 10 cases. In the other single case a prognostically correct value was still obtained. Thus, there is a noteworthy intra-tumour heterogeneity in mitotic activity in invasive breast cancer. We therefore propose the need to take multiple blocks per tumour and carefully scan all sections for the highest proliferative area.

Comparison of the prognostic value of four methods to assess mitotic activity in 186 invasive breast cancer patients: classical and random mitotic activity assessments with correction for volume percentage of epithelium.

Proliferation markers and especially the Mitotic Activity Index (MAI) are strong and reproducible prognosticators in invasive breast cancer. Traditionally, the MAI has been defined as the total number of mitoses counted in 10 consecutive high-power fields (objective, x40; numeric aperture, .75; field diameter, 450 microns), in the most cellular area at the periphery of the tumor, with the subjectively highest mitotic activity. No correction for epithelial percentage or cellularity was applied. This study investigates whether the prognostic value of mitotic activity could be improved by a random sampling procedure or correction for percentage of epithelium present. For this purpose the prognostic value of four methods used to assess mitotic activity in invasive breast cancer was compared in 4-microns-thick hematoxylin-eosin (H&E)-stained sections of 186 primary invasive breast cancer patients. These were the MAI, the random MAI (rMAI), the Mitosis per Volume (M/V) Index, and the random M/V Index (rM/V Index). The rMAI was defined as the total number of mitotic figures counted in 10 random fields through the whole outlined tumor at x400 magnification. A correction for the volume percentage of epithelium assessed with stereology yielded the M/V Index and the rM/V Index, respectively. The results of all four methods showed moderate to high correlations. Univariate survival analysis (Kaplan-Meier curves; Mantel-Cox test) confirmed that all four methods had a strong prognostic value (P < .001). The MAI, however, produced the best results (Mantel-Cox value, 17.1). Multivariate analysis showed that all four methods had additional prognostic value to tumor size and lymph node status. The M/V Index provided most additional prognostic information, followed by the MAI. Assessment of rMAI took 20 to 30 minutes on average, about two times longer than MAI. The correction for volume percentage of epithelium took about 10 minutes longer for both methods than the uncorrected methods. In conclusion, the rMAI gives an impression of the mitotic activity through the whole tumor, with almost similar prognostic value as the traditional MAI, especially when correcting for percentage of epithelium. Nevertheless, the MAI is still to be preferred, because the assessment is easy to apply and less time consuming.

At convenience and systematic random sampling: effects on the prognostic value of nuclear area assessments in breast cancer patients.

This study compares the influence of two different nuclear sampling methods on the prognostic value of assessments of mean and standard deviation of nuclear area (MNA, SDNA) in 191 consecutive invasive breast cancer patients with long term follow up. The first sampling method used was 'at convenience' sampling (ACS); the second, systematic random sampling (SRS). Both sampling methods were tested with a sample size of 50 nuclei (ACS-50 and SRS-50). To determine whether, besides the sampling methods, sample size had impact on prognostic value as well, the SRS method was also tested using a sample size of 100 nuclei (SRS-100). SDNA values were systematically lower for ACS, obviously due to (unconsciously) not including small and large nuclei. Testing prognostic value of a series of cut off points, MNA and SDNA values assessed by the SRS method were prognostically significantly stronger than the values obtained by the ACS method. This was confirmed in Cox regression analysis. For the MNA, the Mantel-Cox p-values from SRS-50 and SRS-100 measurements were not significantly different. However, for the SDNA, SRS-100 yielded significantly lower p-values than SRS-50. In conclusion, compared with the 'at convenience' nuclear sampling method, systematic random sampling of nuclei is not only superior with respect to reproducibility of results, but also provides a better prognostic value in patients with invasive breast cancer.