Tumor size and axillary metastasis, a correlative occurrence in 1244 cases of breast cancer between 1980 and 1995.

A review of 1244 breast cancer cases from the Tumor Registry of Northwest Community Hospital between 1980 and 1995 was carried out to investigate the incidence of axillary metastasis. There were 442 patients (35.45%) with positive nodes. The small lesions were graded to ascertain if size and grade of small tumors can be used to predict axillary metastasis. One hundred and seventy-nine cases of < or = 1.0 cm were retrospectively reviewed by one pathologist. Tumors <0.4 cm had negative nodes. Those with nuclear and histologic grades of 1 had 3% positive nodes, the remainder had positive nodes ranging from 11% to 19%. Infiltrating duct cancers of nuclear grade 3, histologic grade 2, and positive nodes, showed a 40% mortality. Eighteen patients died in the 0.5-1.0 cm tumor size range, mostly of histologic grade 2 and nuclear grade 3. Nuclear and histologic grade 1 tumors with infiltrating duct cancers had negative nodes and showed a good prognosis. Based on this study, node dissection can be omitted in these patients and in those with tumors < or = 0.4 cm. For all other lesions, full axillary node dissection and detailed pathologic examination is still the gold standard for evaluating the axilla.

Malignant fibrous histiocytoma of the soft tissues of the trunk and extremities.

Malignant fibrous histiocytoma (MFH) is the most commonly diagnosed soft-tissue sarcoma. Of 408 retrospectively reviewed patients with MFH, 220 patients had primary, localized, previously untreated tumors involving the extremities or limb girdles. Univariate statistical analysis of results revealed five prognostic factors that were significantly related to poor outcome: old age, deeply seated lesions, surgical grade, large size, and marginal or intralesional surgery. Multivariate analysis revealed only three factors that were significantly related to poor prognosis: old age, deeply seated lesions, and inadequate surgery.

The fate of patients following polypectomy alone for polyps containing invasive carcinoma.

Eighty-two patients with colon and rectal polyps containing invasive adenocarcinoma treated by polypectomy alone were studied. Seven of 34 patients (21 percent) with sessile lesions had an adverse outcome, including five local recurrences and two distant metastases. They occurred from 4 to 68 months after the polypectomy. Forty-seven pedunculated polyps with invasion to the head (Level 1) or to the stalk (Level 3) and one polyp to the base of the stalk (Level 4) had no evidence of local recurrence or signs of metastasis. Twenty-eight percent of patients were found to have adenomatous polyps, and 4 percent had malignant polyps during the follow-up examinations (range, 3-119 months; mean, 53 months). The findings suggested that pedunculated polyps with invasion to the head (Level 1), neck (Level 2), or stalk (Level 3) can be safely treated with a complete polypectomy provided that the carcinoma is not undifferentiated. Sessile lesions as well as Level 4 pedunculated lesions should be treated aggressively. If resection is not performed, a long-term follow-up in these patients is essential.

Correlation of DNA ploidy, histopathology, stage and clinical outcome in gastric carcinoma.

The determination of nuclear DNA ploidy from paraffin-embedded specimens was performed by flow cytophotometry on 277 surgically resected primary gastric carcinomas to assess the relationship of various pathological findings and DNA content with survival. The preparation of samples was performed by a modification of Hedley's technique and the staining method of Vindelov. Eighty-nine (32%) carcinomas were DNA diploid, 69 (25%) were DNA tetraploid, and 119 (43%) were DNA aneuploid. DNA non-diploid patterns were significantly associated with macroscopic ulcerative appearance, location of the tumour in the proximal stomach, histological grade, and advanced stage of tumour. Patients with DNA non-diploid cancers, and specifically DNA aneuploid cancers, exhibited significantly poorer survival than patients with DNA diploid tumours. These data support the prognostic value of tumour DNA content in patients with resected gastric carcinoma.

Does histologic grade in soft tissue sarcoma influence response rate to systemic chemotherapy?

To assess whether chemosensitivity in metastatic soft tissue sarcoma (STS) is influenced by the histologic grade of the tumor, the authors retrospectively analyzed tumor responses to doxorubicin-based chemotherapy in four prospective studies conducted at the Mayo Clinic, Rochester, Minnesota, between 1976 and 1984. A total of 131 patients with metastatic STS were included in these trials. All pathologic material was reviewed by one pathologist (H.M.R.) and graded according to the four-tier grading system of Broders. One hundred and sixteen patients were accepted for analysis. Objective regression rates according to grade were as follows: Grade 4, 55% (22 of 40 patients); Grade 3, 23% (7 of 31 patients); Grade 2, 19% (5 of 27 patients); and Grade 1, 0% (0 of 3 patients). Fifteen nongradable sarcomas were analyzed separately (27% [4 of 15]). In contrast to several reports suggesting that grade does not effect response, the authors found differences in response rates to be statistically significant for Grade 2 versus Grade 4 (P = 0.003) and Grade 3 versus Grade 4 (P = 0.006), but not for Grade 2 versus Grade 3 (P = 0.7). Additional comparisons adjusted for the histologic type of STS, chemotherapeutic regimen, performance status, age, and prior treatment confirmed these results. These results suggested that, in addition to being an important prognostic factor for survival in newly diagnosed STS, histologic grade may correlate with the probability of response and should be considered a stratification factor in future studies.

Treatment of primary squamous cell carcinoma of the upper urinary tract.

Forty-six patients with primary squamous cell carcinoma of the upper urinary tract treated over a 44-year period were studied. The lack of characteristic presentation caused delay in diagnosis. Associated urinary calculi were found in only five (11%) of the patients. Almost all of the tumors were histologically high grade; at surgery, 84% of the tumors were locally advanced or metastatic. Prognosis is poor independent of treatment; the overall 24-month survival rate was 22%. Comparison with a previous study of renal pelvic transitional cell carcinoma indicates that these two forms of urothelial neoplasm are biologically different.

DNA ploidy and cell kinetic measurements as predictors of recurrence and survival in stages B2 and C colorectal adenocarcinoma.

DNA content and cell proliferation were measured by flow cytometry on paraffin-embedded Stage B2 or C colorectal adenocarcinomas from 694 patients enrolled in adjuvant trials conducted by the North Central Cancer Treatment Group. Patients with diploid tumors had a higher survival rate than those with nondiploid tumors (P less than 0.001). The proliferation index (the sum of the percent of cells in S-phase plus those in G2M phase) was also a strong prognostic factor (P less than 0.001). The ploidy and proliferation data were combined, and the patients in the favorable group (diploid and low proliferative index) had a 5-year survival of 74% compared with 54% for the unfavorable group (high proliferative index or nondiploid, P less than 0.001). This grouping was prognostic for survival in B2 (P less than 0.001), C (P = 0.013), colon (P less than 0.001), and rectal (P = 0.026) patient subsets. This study indicates that cell kinetic parameters are important and independent prognostic factors for Stages B2 and C colorectal cancer.

Particle shedding and migration from silicone genitourinary prosthetic devices.

Of 26 patients undergoing revision of genitourinary prostheses the surrounding reactive fibrous capsule was biopsied in 25 and the draining lymph nodes also were biopsied in 4. The prostheses included 16 inflatable and 14 flexible penile devices, and 10 artificial urinary sphincters. Tissue was examined by light and transmission electron microscopy. X-ray microanalysis was done on intracellular and extracellular foreign material from each specimen. Silicone was found in 18 of the 25 periprosthetic specimens and in all 4 lymph nodes. Foreign body granulomas were identified in 14 of these 29 specimens. Examination of new and explanted versions of each prosthesis by scanning electron microscopy revealed free particles of silicone or silicates on the surface of most devices. Pitting and microfissuring were seen on a few of the new devices and on nearly all of the used ones. Thus, genitourinary prostheses shed silicone particles that can be found in the fibrous capsule and draining lymph nodes.

The risk of lymph node metastasis in colorectal polyps with invasive adenocarcinoma.

One hundred fifty-one patients with colorectal polyps containing invasive adenocarcinoma treated by resection were studied to determine the incidence of lymph node metastasis and whether lymph node metastasis was related to the depth of invasion. Other variables evaluated included size and configuration of the polyp, grade of adenocarcinoma, presence or absence of lymphovascular invasion, and degree of differentiation. In patients with sessile polyps, the incidence of lymph node metastasis was 10 percent. Eighty percent of these lesions had lymphovascular invasion. For pedunculated polyps, the overall incidence of lymph node metastasis was 6 percent. However, there was no incidence of lymph node metastasis when the depth of invasion was limited to the head, neck, and stalk of the polyp (Levels 1, 2, and 3). Only when the depth of invasion reached to the base of the stalk (Level 4) was the risk of lymph node metastasis high (27 percent). The other risk factors were not associated with lymph node metastasis. We concluded that the most significant risk factor for lymph node metastasis in patients with invasive carcinoma in a polyp was invasion into the submucosa of the bowel wall (Level 4).

Cutaneous and subcutaneous leiomyosarcoma: a clinicopathological review of 14 cases with reference to antidesmin staining and nuclear DNA patterns studied by flow cytometry.

Among 14 patients (11 female and three male) with cutaneous and subcutaneous leiomyosarcomas, metastatic spread occurred in six of the 13 patients with adequate follow-up. The tumours were classified with regard to tumour grade, number of mitotic figures per 10 high-power fields, reactivity to antidesmin antibodies, and DNA pattern as assessed by flow cytometry. Antidesmin antibody staining was present in only six cases and seemed to be less common in the higher-grade tumours. The DNA pattern was aneuploid in five cases and non-classifiable in one case; all of these cases had metastatic spread. None of the eight remaining diploid cases had metastatic spread. DNA content was a strong predictor of metastatic potential.

Intravesical condyloma acuminatum with progression to verrucous carcinoma.

Condyloma acuminatum is a common form of venereal disease. Most patients with condylomata acuminata suffer from only the local cosmetic and irritative effects of the lesions. Few patients have progression to aggressive, regionally distributed lesions that can be life-threatening. We describe a forty-three-year-old white woman who had a seventeen-year history of scleroderma with extravesical and intravesical condylomata acuminata. During two years of conservative management with transurethral excision, electrocoagulation, and intravesical chemotherapy, the disease progressed to involve the entire bladder and resulted in obstructive renal insufficiency that required anterior exenteration and urinary diversion. The natural history of the disease is described, and the relevant literature is reviewed.

Nonendocrine cancer of the pancreas in patients under age forty years.

In an attempt to determine the natural history of ductal adenocarcinoma of the pancreas in patients under 40 years of age, we reviewed the surgical outcomes of all such patients seen at the Mayo Clinic from 1970 to 1985. Histologic sections were reviewed; islet cell tumors and cystadenocarcinomas were carefully excluded. Twenty-six patients were identified. Their mean age was 34 years, with only one patient less than 25 years old. Symptoms included primarily abdominal pain, weight loss, and jaundice. One third of patients had a recent or past history of pancreatic disease including pancreatitis, pseudocysts, benign cystadenoma, and choledochal cyst. The tumor was located in the head of the gland in 62% of patients. "Curative" resections were possible in only three patients (12%); the remaining patients underwent palliative bypass (38%), biopsy alone (42%), or a palliative resection (8%). The hospital mortality rate was 12%, with actual 1-, 2-, and 5-year survival rates of 19%, 8%, and 4%, respectively, with a median survival of 4 months. The only long-term survivor underwent biliary bypass at age 15 years for a large neoplasm in the head of the gland; despite biopsy-proved liver metastases at that time, she continues to do well 5 years later. Histologic review indicated this tumor to be a "solid and papillary neoplasm of the pancreas." Ductal adenocarcinoma of the pancreas in young patients is an aggressive tumor with a poor prognosis behaving much like ductal adenocarcinoma in older patients (greater than 40 years). In rare instances a more favorable outcome can be expected when a solid and papillary neoplasm is found.

Squamous cell carcinoma of the renal pelvis: nuclear deoxyribonucleic acid ploidy studied by flow cytometry.

From 1944 to 1987, 28 patients with squamous cell carcinoma of the upper urinary tract were treated and also had tumor specimens that were fully evaluable by flow cytometric nuclear deoxyribonucleic acid ploidy analysis: 22 had squamous cell carcinoma of the intrarenal collecting system, 4 had tumors of the ureter, and 2 had tumors of the renal pelvis and ureter. Eight patients (29%) had deoxyribonucleic acid diploid, 11 (39%) tetraploid and 9 (32%) aneuploid ploidy patterns. Ploidy pattern significantly correlated with histological grade and tumor stage. Almost all tumors were histologically of high grade; among the patients with high grade tumors ploidy analysis separated fair and poor prognosis groups. Pathological stage was the dominant clinical variable. A total of 14 patients (50%) had advanced stage disease and all died within 12 months of diagnosis. Nearly all of these patients showed abnormal ploidy patterns and ploidy analysis was not useful prognostically for this group. In contrast, all 3 patients with squamous cell carcinoma of the renal pelvis who were long-term survivors had deoxyribonucleic acid diploid tumors. However, there is no clear statistical evidence from this study that ploidy analysis provides important prognostic information independent of stage and grade for patients with squamous cell carcinoma of the renal pelvis.

Neurofibrosarcoma of skin and subcutaneous tissues.

In this report, we describe 13 cases of primary neurofibrosarcoma of the skin. The tumor presumably arises from small cutaneous nerves, is locally aggressive, and has a potential for metastasis. Characteristic histopathologic features include proliferating atypical spindle cells with slender wavy and pointed nuclei; hypocellular areas with loose, myxoid stroma; and areas of organoid organization such as palisading, whorly, storiform, and tactile body-like formations. The S-100 stain is positive in about 60% of cases. In the current series, most tumors arose in deep dermis and were grade 2 malignant lesions with a moderate degree of cytologic atypia and 2 or fewer mitoses in 10 high-power fields. Three patients died of their malignant lesion. Only two tumors metastasized. Of the 10 patients who had local recurrence, 5 had multiple recurrent lesions. Neurofibrosarcoma should be considered in the differential diagnosis of malignant tumors of the skin. A complete surgical resection of the primary tumor with adequate margins of surrounding normal-appearing tissue is advised.

Extraosseous Ewing's sarcoma. A study of 42 cases.

Fifty patients at the Mayo Clinic (Rochester, MN) from 1935 to 1985 met the histologic criteria for extraosseous Ewing's sarcoma. Forty-two had soft tissue primaries without bony involvement and formed the basis for this retrospective study of the clinical behavior and management of extraosseous Ewing's sarcoma. There were 19 male and 23 female patients (mean age, 22 years). Metastases were documented in 30 of the patients, six at the time of presentation and 24 occurring up to 11 years later, most commonly to lungs or bone. Three patients were lost to follow-up. Sixteen of 35 patients (46%) had local recurrence. Overall survival was 15 of 39 (38.5%) at 5 years. Decreased survival was noted with pelvic tumors, incomplete resections, and presence of metastatic disease, whereas increased survival was associated with wide surgical resection with negative microscopic margins, adjuvant local radiation therapy, and presentation since 1970 (48% 5-year survival compared with 28% before 1970).

Management of retroperitoneal sarcomas.

The records of 116 adult patients who underwent operative treatment for retroperitoneal sarcomas at the Mayo Clinic during the years 1963 to 1982 were reviewed. Clinical, pathologic, and treatment variables were analyzed for their influence on recurrence and death from disease. Leiomyosarcomas, liposarcomas, and malignant fibrous histiocytomas represented 93% of the tumors. The primary tumor was completely excised in 54% of patients. Recurrent tumor developed in 68% of patients (median time to recurrence, 1.3 years). Tumor fixation to adjacent structures (T3 tumor) or a high-grade tumor (G2-4) identified patients at increased risk for recurrent disease. Five-year and 10-year survival rates were 40% and 22%, respectively. Survival was significantly better for patients who had (1) complete surgical excision of their tumors, (2) low-grade tumors (G1), (3) tumors not fixed to adjacent retroperitoneal structures (T1 and T2 sarcomas), and (4) tumors without metastases when initially seen. Complete surgical excision offers patients with retroperitoneal sarcomas the best chance for long-term survival, but recurrent disease remains a vexing problem. The therapeutic challenges in the treatment of retroperitoneal sarcomas continue to be the development of therapy that will increase the rate of complete resection, decrease the rate of local recurrence, and enhance patient survival.

Soft-tissue sarcomas of the head and neck.

We reviewed the charts of 352 patients at the Mayo Clinic who were diagnosed and treated for primary soft-tissue sarcomas of the head and neck from 1962 to 1982. The age at diagnosis ranged from 6 weeks to 91 years; 28 percent were pediatric patients. Regional or distant metastases were present at the time of primary diagnosis in 8 percent of patients. Nonorbital rhabdomyosarcoma was the most common tumor type (17 percent), and neuroblastoma was the rarest (2 percent). In children, rhabdomyosarcomas were proportionally more common, as was overall involvement of the orbit. Surgical excision was the sole method of tumor control in 49 percent of patients; excision with adjuvant radiotherapy or chemotherapy was used in 33 percent. In those with localized disease, overall survival was 81 percent at 2 years, 68 percent at 5 years, and 60 percent at 10 years postoperatively. Patients with angiosarcoma and nonorbital rhabdomyosarcoma experienced the poorest survival rates.

Soft tissue fibrosarcoma. A clinicopathologic study of 132 cases.

Over the last 20 to 30 years, a recognition and general acceptance of the entity of malignant fibrous histiocytoma and monophasic synovial sarcoma has occurred. The introduction of these diagnostic categories among the generic group of spindle cell sarcomas now requires a reevaluation of the more traditional and historic entity of fibrosarcoma and the clinical ramification of this diagnosis. A review of 132 cases of fibrosarcoma using current diagnostic criteria was undertaken to clarify the behavior of fibrosarcoma as diagnosed in current patients. Special attempts were made to correlate histologic grade and Enneking stage in fibrosarcomas in an effort to correlate their predictive value in metastatic rate and survival.