A Dukes/Jass combination--is it more discriminating?

BACKGROUND: In 1987 Jass described a modified staging system for colorectal cancer using two anatomical criteria in common with the Dukes system; extent of spread through the bowel wall and the presence or absence of lymph node involvement. Additionally it used two 'biological' criteria; the nature of the expanding margin of the tumour (pushing or infiltrating), and the presence or absence of lymphocytic infiltration within the tumour. This study aims to determine whether a combination of the Dukes and Jass staging systems provides a better predictor of five year survival in patients with colorectal cancer than Dukes stage alone. METHOD: The Dukes and Jass stages along with vital status at five years were recorded for all 612 patients undergoing resection for colorectal cancer at the Royal Bolton Hospital and the Beaumont (BMI) Hospital, Bolton between 1991 and 1998. Kaplan-Meier survival curves with log rank test were used to show how survival correlated with Jass group stratified by Dukes stage. RESULTS: Both the Dukes B and the Dukes C tumours could be divided into groups with significantly different five year survival rates when stratified by Jass group. Five year survival for Dukes stage B, Jass group II tumours was 73.74% compared to Dukes B Jass III tumours whose survival was 51.38% (P = 0.0018). Five year survival for Dukes C Jass III tumours was 43.18% and for Dukes C Jass IV survival was 24.39% (P = 0.0029). CONCLUSION: By combining the biological criteria of the Jass staging system with the anatomically based Dukes system, both Dukes B and C tumours can be divided into groups with significantly different five year survival figures.

Incomplete excision of basal cell carcinoma: a prospective multicentre audit.

The audit of incomplete excision of basal cell carcinoma can be used as a parameter for clinical governance in plastic surgery units. However, there are no national standards, and all the previous reports from the UK have been retrospective and from regional units only. This 1 year prospective audit was undertaken simultaneously in the plastic surgery units of three different categories of hospital: a regional plastic surgery unit (University Hospital of South Manchester), a supraregional cancer hospital (Christie Hospital) and a district general hospital (Royal Bolton Hospital). A total of 757 lesions were excised from 600 patients, with 34 lesions (4.5%) being incompletely excised. The incidences of incomplete excision were similar in the regional unit (3.2%) and the district general hospital (3.1%), but higher in the supraregional cancer hospital (7.5%). The commonest site for incomplete excision was the eyebrow, followed by the postauricular area, the nose and the temple. There were no statistically significant differences in the distributions of the age and sex of the patients, the site and size of the lesions or the methods of repair between the three hospitals. However, there were significant differences in the distribution of syndromal, multiple and recurrent lesions, the grade of surgeon, and the clinical and histological subtypes. When the various confounding factors were adjusted by logistic regression, the variables most likely to have affected the incidence of incomplete excision were found to be grade of surgeon, minimal excision margin and histological subtype.

A study of four cases of extra-orbital giant cell angiofibroma with documentation of some unusual features.

AIMS: To document the clinical, light microscopic, immunohistochemical and ultrastructural features of four cases of extra-orbital giant cell angiofibromas. METHODS AND RESULTS: Sections of formalin-fixed paraffin-embedded specimens were studied by haematoxylin and eosin, reticulin and immunohistochemical stains. Electron microscopy was carried out in two cases on tissue fixed in formalin. The age of the patients ranged from 30 to 41 years. Two patients presented with a soft tissue swelling in the left groin, one patient had a left axillary soft tissue lump and one patient presented with a parotid lump. All lesions were well circumscribed and contained variably cellular and vascularized tissue composed of round to spindle cells with a patternless arrangement, scattered multinucleate giant cells and pseudovascular spaces conforming to the description of giant cell angiofibroma. Mononuclear and multinucleate tumour cells were both positive for vimentin and CD34; one tumour exhibited focal S100 protein and GFAP positivity. Both of the tumours examined by electron microscopy showed fibroblastic features, but in addition one contained cells having Schwannian features. All four patients were well without recurrent disease on follow-up (average 25 months). CONCLUSION: Giant cell angiofibroma shares many features with solitary fibrous tumour and giant cell fibroblastoma and shows a wider distribution than initially recognized. Rarely, Schwannian differentiation may be observed in these tumours.

Pseudoangiosarcomatous carcinoma of the genitourinary tract.

Two cases of pseudoangiosarcomatous carcinoma of the genitourinary tract, arising in the vulva in one and the bladder in the other, are presented. In case 1, an 84 year old woman, the vulvectomy specimen contained an irregular ulcerated tumour, infiltrating the left labia and extending into the clitoris. In case 2, a 59 year old woman, the excised bladder showed diffuse thickening of its wall by infiltrating haemorrhagic tumour. Both tumours showed focal keratinisation. This, in association with the presence of atypical squamous epithelium, immunohistochemistry and ultrastructural analysis, led to a diagnosis of pseudosarcomatous carcinoma in both cases. Pseudoangiosarcomatous carcinoma should be considered in the differential diagnosis of malignant angiomatoid tumours, particularly those that arise at sites, like the genitourinary tract, where angiosarcoma is rare.

Audit of tumour histopathology reviewed by a regional oncology centre.

AIMS: To analyse the diagnostic differences in reporting tumour histopathology between a district general hospital and a regional oncology centre. METHODS: Tumour histopathology reports (n = 227) extracted from Bolton General Hospital files between 1988 and 1992 were compared with the corresponding Christie Hospital (oncology centre) reports, the same material having been seen at both hospitals. RESULTS: Diagnostic agreement existed in 77% of all cases. The incidence of major discrepancies was 8.37%. Of the diagnoses, 19 (36%) cases involved major discrepancies and 34 (64%) cases minor discrepancies. Most discrepancies occurred in the lymphoma group and involved subclassification of Hodgkin's and non-Hodgkin's lymphoma. Ki1 anaplastic large cell lymphoma and T cell rich B cell lymphoma were problematic diagnoses. The correct grading of follicle centre cell lymphomas using the Kiel classification was another problem area. In 19 cases certain aspects of immunohistochemistry produced discrepancies. In one case an incorrect diagnosis was made at the oncology centre and in another both centres gave an incorrect diagnosis. CONCLUSIONS: Areas of diagnostic difficulty mainly involve the subclassification of lymphomas. Review of tumour pathology by experts is recommended, at least in certain categories, to ensure correct diagnosis and uniformity in subclassification of tumours.

Histopathological features of failed prosthetic Leeds-Keio anterior cruciate ligaments.

Artificial ligaments such as the Leeds-Keio ligament are inserted into knee joints to treat cruciate ligament trauma. Three cases of prosthetic ligament failure are reported, showing foreign body granulomatous inflammation around implanted fibres, together with abundant fibre particles within giant cells. It is suggested that intra-operative fibre fragmentation can produce a sufficient quantity of dendritic particles to elicit a granulomatous reaction, which can ultimately lead to ligament instability and failure.

Cribriform intra-tubular epididymal change and adenomatous hyperplasia of the rete testis--a consequence of testicular atrophy?

We have observed an unusual change in the epididymal tubules, ranging from focal epithelial proliferation forming bridges, to a pronounced intra-tubular cribriform pattern of the epithelium. This often occurs in association with adenomatous hyperplasia of the rete testis which is an uncommon, usually incidental finding. Both processes appear associated with underlying testicular atrophy and may be related to local hormonal imbalance.

Light- and electron-microscopic studies on multinucleated giant cells in sarcoid granuloma: new aspects of asteroid and Schaumann bodies.

Ultrastructural studies using transmission, analytical, electron, and light microscopy were performed on epithelioid granulomata in 4 lymph nodes from a case of sarcoidosis, emphasizing the organization of asteroid and Schaumann bodies in multinucleated giant cells and the deposition of chemical elements. Serial sectioning at semithin level showed a single multinucleated giant cell can contain up to 4 asteroid and 1 Schaumann body. Microtubules and centrioles were not found in asteroid bodies, although a centriolar field was present in 1 giant cell close to the plasma membrane, completely unrelated to the asteroid body. In 1 asteroid body, tubulelike structures were observed in a focus showing filament dissociation. A principal ultrastructural finding is intimate envelopment of radiating filamentous arms of the asteroid body by myelinoid membranes, extensive forms of which are also present between the arms. Elemental analysis revealed a definite peak of calcium and a probable phosphorus peak in relation to the asteroid body and associated myelinoid membranes. Calcium and phosphorus with smaller quantities of aluminum and iron were found in Schaumann bodies. Our studies indicate that organization of the asteroid body is more complex than hitherto described, independent of the centriolar and microtubular systems. Evidence for the possible developmental pathway of the Schaumann body is provided by morphological changes within myelinoid figures intimately related to the asteroid body.