Calibration of medium-resolution monochrome cathode ray tube displays for the purpose of board examinations.

This report discusses calibration and set-up procedures for medium-resolution monochrome cathode ray tubes (CRTs) taken in preparation of the oral portion of the board examination of the American Board of Radiology (ABR). The board examinations took place in more than 100 rooms of a hotel. There was one display-station (a computer and the associated CRT display) in each of the hotel rooms used for the examinations. The examinations covered the radiologic specialties cardiopulmonary, musculoskeletal, gastrointestinal, vascular, pediatric, and genitourinary. The software used for set-up and calibration was the VeriLUM 4.0 package from Image Smiths in Germantown, MD. The set-up included setting minimum luminance and maximum luminance, as well as positioning of the CRT in each examination room with respect to reflections of roomlights. The calibration for the grey scale rendition was done meeting the Digital Imaging and communication in Medicine (DICOM) 14 Standard Display Function. We describe these procedures, and present the calibration data in. tables and graphs, listing initial values of minimum luminance, maximum luminance, and grey scale rendition (DICOM 14 standard display function). Changes of these parameters over the duration of the examination were observed and recorded on 11 monitors in a particular room. These changes strongly suggest that all calibrated CRTs be monitored over the duration of the examination. In addition, other CRT performance data affecting image quality such as spatial resolution should be included in set-up and image quality-control procedures.

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.

An autopsy: A historical vignette.

This paper recounts a case report from 1853 that describes the circumstances surrounding the death of a young woman, the request for and granting of permission for an autopsy, and exposition of how the autopsy findings were used from the point of view of education, quality control of practice, and vital statistics. There is, in addition, a description of the evolution of the use of the word autopsy.

Survival advantage differences by age. Evaluation of the extended follow-up of the Breast Cancer Detection Demonstration Project.

BACKGROUND: This study considers breast cancer survival patterns by age group among women diagnosed in the Breast Cancer Detection Demonstration Project (BCDDP) to provide insight into the nature of breast cancer and suggest a possible explanation as to why the results of the randomized clinical trials differ for women younger than 50 and those 50 or older. Based on the findings of several randomized clinical trials, there is a general consensus that breast cancer screening provides a significant benefit for women aged 50-69. From these trials, there is little evidence of a short term benefit and uncertainty regarding any long term benefit of mammographic screening for women aged 40-49. METHODS: The BCDDP was not a randomized trial, but a nationwide breast cancer screening program conducted between 1973-1980, in which all participants received annual physical and mammographic examinations. Using the BCDDP data, this study calculated 14-year breast cancer survival among 4051 women diagnosed with breast cancer between 1973 and 1980 and followed through 1988 and 1989. RESULTS: In all, 598 women died of breast cancer, resulting in an overall 14-year breast cancer survival of 83.4% (standard error = 0.007). Breast cancer survival varied by tumor type, lymph node status, tumor size, and stage at diagnosis. For most of the cases, however, both the distribution and breast cancer survival rates were similar for women aged 40-49, 50-59, and 60-69 across all prognostic indicators. Only breast cancer survival among women with invasive breast cancer who had a primary tumor 5 cm or larger or with positive lymph nodes differed by age, with women aged 60-69 at diagnosis having poorer survival. Analyses by modality of detection conducted in a subset of 2739 cases indicated that the 34.6% of the cases detected by mammography alone had the highest overall breast cancer survival rates (90.9%), while the 32.2% of the cases detectable by both physical examination and mammography had the lowest breast cancer survival (79.0%). Overall, women diagnosed with breast cancer in the BCDDP had a survival advantage if diagnosed with either a smaller tumor or no positive lymph nodes, or if their breast cancer was detected by mammography alone. For women with large tumors (> or = 5 cm), the survival was 80.8% for ages 40-49, 72.1% for ages 50-59, and 61.7% for ages 60-69. DISCUSSION: Due to the higher breast cancer survival rates among women aged 40-49 with poorer prognostic characteristics, the breast cancer survival advantage for having a smaller tumor, no positive lymph nodes, or breast cancer detected by mammography alone was lower for women aged 40-49 than women aged 50 or older at diagnosis. These differences in survival advantage may help to account for the differences in mortality by age in the randomized clinical trials.

Breast cancer risk associated with proliferative breast disease and atypical hyperplasia.

BACKGROUND: Women with proliferative breast disease (PD) have been observed to have an increased risk of breast cancer. The authors evaluated the effect of PD on breast cancer risk in a case-control study among participants of the Breast Cancer Detection Demonstration Project (BCDDP). METHODS: More than 280,000 women were screened in the BCDDP at 29 centers. Study subjects were selected from BCDDP participants who underwent biopsy that revealed benign breast tissue. There were five BCDDP centers for which histologic slides were available on more than 85% of the benign biopsy specimens. Case patients for this study were the 95 women from these five centers who had breast cancer develop during follow-up. Two matched control patients who did not have breast cancer develop were selected for each case. The biopsy slides were reviewed by two pathologists who were blinded with regard to cancer outcome. RESULTS: Women with atypical hyperplasia (AH) had 4.3 times the breast cancer risk of women without PD (95% confidence interval [CI], 1.7-11). In women with PD lacking AH, the relative risk was 1.3 (95% CI, 0.77-2.2). A family history of breast cancer (FH) increased breast cancer risk 2.4 times (95% CI, 1.4-4.3). The joint occurrence of FH and AH had a strong synergistic effect on breast cancer risk. CONCLUSIONS: AH is a reliable marker of increased breast cancer risk among women undergoing breast biopsy.

Pathology trainee manpower. Historical perspectives.

Discussions of pathology manpower typically involve short-term projections. For example, the best current data indicate a significant shortage of community-hospital/private-laboratory pathologists over the 5-year period from 1988 through 1993. Even though such short-term predictions are important in the debate over strategic planning in pathology, they need to be placed in a broader historical context. Therefore, we present the long-term trends in pathology trainee manpower. These trends indicate why predictions of a shortage should not come as a surprise.

Exploration of factors affecting mammography behaviors.

Of an estimated pool of 1,700 potential participants, only 382 (22%) eligible women participated in a low-cost breast cancer screening program offered to university and medical center employees. Because most women were still available and data were needed to understand why the opportunity to participate was refused by so many, a survey was done to determine factors related to mammography behavior. Three distinct groups of women were identified according to health beliefs, mammography behaviors, and modifying factors. Women who participated in the mammogram program were predominantly well-educated working women who were aware of mammography and its relationship to the breast cancer trajectory; they were affected by cost and convenience issues. One group of women did not participate in the program offered because they had had a recent mammogram; these women were at high risk for breast cancer and perceived mammography to be beneficial. The women who did not participate for other reasons were in nonprofessional jobs, had lower levels of education, and tended not to participate in the health care system as readily as women in the other groups; they perceived themselves less susceptible to breast cancer, valued mammography less, and knew less about breast cancer.

Breast cancer detection epoch.

The Action and Planning Committee on Breast Cancer Control was formed in 1970 by the American Cancer Society, based on their earlier successful experience with early-detection programs for uterine cancer. The original intention was to support 12 centers for 2 years, but with the passage of the Conquest of Cancer Act in 1971, and the consequent availability of more funds for cancer programs, the American Cancer Society and the National Cancer Institute decided jointly to expand the program to 27 Breast Cancer Detection Demonstration Project Centers, with 280,000 women participating, who would be examined annually for 5 years. Data from the examinations, which included history, physical examination, mammogram, and thermogram, were subjected to a continuing computer analysis. The thermogram was deleted after the second year. Although patients were randomly selected, there was an almost identical number of subjects in two age groups--35-49 years and 50-75 years. The results of the study are presented, and the importance of the program's efforts at breast self-examination education as contained in the program's original protocol, is discussed.

Mastopathy in insulin-dependent diabetics.

A type of mastopathy is unique to insulin-dependent diabetic patients. The characteristic change is a connective tissue overgrowth with vasculitis and some proliferation of duct epithelium. It is not the type of change typically associated with an increased risk of breast cancer. Clinically this change is indistinguishable by physical or radiographic findings from breast malignancy. Eleven biopsies showing these characteristics were performed on insulin-dependent patients who had diabetes mellitus from childhood. Every patient had some major complication of diabetes mellitus, usually diabetic retinopathy. In every instance the mastopathy continued to manifest itself as a part of the healing process. The probability is that this is an evidence in the breast of collagen cross-linking changes seen in patients with diabetes mellitus. This observation should help in the supervision of patients with a clinical background compatible with this study.

Urothelial carcinogenesis and portocaval anastomosis in the rat.

Portacaval anastomoses were performed in the rat to study urothelial carcinogenesis in this model and the promoting effect of dietary tryptophan. We were unable to produce any urothelial cancers or premalignant changes; some animals formed uric acid stones and developed papillary hyperplasia in the bladder. We conclude that the initiating carcinogen is likely to be exogenous and may be dietary in those experiments that have produced urothelial cancers.

Prognostic significance of tumor grade in clinical trials of adjuvant therapy for breast cancer with axillary lymph node metastasis.

The prognostic significance of histologic tumor grade has been evaluated in 1537 women entered into the Ludwig Trials I-IV of adjuvant therapy for node-positive breast cancer. Tumor grade was determined on histologic review of primary tumor sections by two central review pathologists using a modification of the Bloom and Richardson grading system. The 5-year overall survival rates (+/- SE) were: Grade 1, 86% +/- 2; Grade 2, 70% +/- 2; and Grade 3, 57% +/- 2 (P less than 0.0001). This survival difference was seen in both premenopausal (P less than 0.0001) and postmenopausal (P less than 0.0001) women. Significant differences in disease-free survival (DFS) by tumor grade were also observed (P less than 0.0001). The tumor grade determined by the 75 contributing local clinic pathologists was also highly significant for predicting DFS and overall survival. Tumor grade remained a statistically significant prognostic factor for DFS (P less than 0.0001) and overall survival (P less than 0.0001) in multivariate analyses controlling for nodal status, tumor size, estrogen receptor status, menopausal status, age, peritumoral vessel invasion, and treatment assigned. In postmenopausal patients for whom adjuvant treatment was compared with no adjuvant therapy, the prognostic significance of tumor grade was modified by the effect of treatment. The presence of vessel invasion by primary tumor cells was a stronger predictor of early recurrence than was increasing tumor grade in postmenopausal patients who received no adjuvant therapy. The higher failure rates for patients with high-grade tumors was due to a larger number of failures in regional and visceral sites. Tumor grade can be determined by any pathologist and allows for selection of a subpopulation of breast cancer patients at high risk for early mortality.

Prognostic significance of peritumoral vessel invasion in clinical trials of adjuvant therapy for breast cancer with axillary lymph node metastasis.

To assess the prognostic significance of peritumoral vessel invasion, data were examined for 1,510 women entered into the Ludwig Breast Cancer Group Trials I to IV evaluating adjuvant therapy for operable breast cancer with axillary nodal metastasis. Vessel invasion by tumor cells was identified by routine light microscopy in 59 per cent (889 of 1,510) of the patients and was equally distributed between premenopausal/perimenopausal (60 per cent, 468 of 778) and postmenopausal (58 per cent, 421 of 732) women. In logrank analyses stratified by nodal status (one to three or four or more positive nodes), the four-year disease-free survival (DFS) rate was significantly lower in patients with vessel invasion than in women without vessel invasion (50 per cent versus 65 per cent, P less than 0.0001). This DFS difference was seen for both premenopausal/perimenopausal (P = 0.0004) and postmenopausal (P = 0.0002) patients. The four-year overall survival rate was also lower in patients with vessel invasion (71 per cent versus 82 per cent, P = 0.0006), both for premenopausal/perimenopausal (P = 0.002) and postmenopausal (P = 0.04) women. The presence of vessel invasion was significantly associated with increasing numbers of positive axillary lymph nodes, rising tumor grade, nonstellate tumor border growth pattern, and higher steroid hormone receptor content of the primary tumor. The assessment of peritumoral vessel invasion continued to have prognostic significance for DFS (P less than 0.0001) and overall survival (P = 0.003) when evaluated in multivariate models controlling for treatment assigned, nodal status, tumor size, estrogen receptor status, menopausal status, and age. Depending on the subpopulation, patients with vessel invasion had a 41 per cent to 54 per cent greater risk of treatment failure than those without vessel invasion and a 29 per cent to 64 per cent greater risk of death. The percentage of treatment failures at distant sites was higher for women with than for those without vessel invasion (27 per cent versus 18 per cent, P = 0.003). In patients with axillary lymph node metastases, peritumoral vessel invasion may be a sign of increased systemic disease burden.

Graduate medical education: what will happen under DRGs?

Changing methods of reimbursement could cause the number of Graduate Medical Education programs to fall, the author says. Here, he explores how this will affect competition in and funding of the programs, and the programs themselves.

Histologic review of breast cancer cases in survivors of atomic bombs in Hiroshima and Nagasaki, Japan.

A panel of Japanese and American pathologists reviewed existing histologic material used to study breast cancer risk among the A-bomb survivors in Hiroshima and Nagasaki, a population in which incidence studies have found a strong relationship between breast cancer risk and radiation dose. The primary charge to the panel was to define a body of confirmed cases in the Life Span Study sample of the Radiation Effects Research Foundation that would require little or no review for inclusion in future studies of breast cancer incidence. Broad agreement on histologic type was reached for 298 of 300 confirmed cases. The distribution of histologic types was, overall, similar to that seen in other studies of breast cancer in Japanese women, and did not appear to depend on dose; thus radiation-induced breast cancer appeared to be no different histologically from other breast cancer. Also, no evidence was found of variation in histologic type by city, age at exposure, age at diagnosis, or calendar time.

[Intratumoral regional differences in hormone receptor status of breast cancer]. / Intratumorale regionäre Unterschiede im Hormonrezeptor-Status des Mammakarzinoms.

Biopsy specimens of tissue were taken from 32 invasive carcinomas of the breast, in each case from the centre of the tumour, the tumour margin and the surrounding mammary gland tissue. After preparation of a frozen section for tissue identification, the concentration of oestrogen and progesteron receptors (ER and PR, respectively) was determined in each specimen by means of the dextrane-coated charcoal method. On the basis of these measured values, the receptor status of each specimen was classified either as positive (R+), borderline value (BL) or as negative (R-). Various morphological parameters were compared with the measured data. 9 (28%) of the 32 carcinomas demonstrated such high intratumoural differences in receptor concentration that the receptor status was classified quite differently in each of them. Formation of tubuli of the invasive ductal carcinomas was more marked with the R+ tumours (p = 0.005) than with the R- tumours. The quantitative ER content did not correlate with the abundance of the tissue specimen (r = 0.182). The regional differences in receptor status could not be explained, neither by the abundance in cells nor by morphological peculiarities of the tumour. - It follows from the results of this study that intratumoural regional variations in ER and PR concentrations can occur in carcinoma of the breast, and that such variations can have clinical significance.

Receptor heterogeneity of human breast cancer as measured by multiple intratumoral assays of estrogen and progesterone receptor.

Multiple intratumoral tissue samples from the primary mass of 30 consecutive invasive breast cancer patients were assayed for estrogen receptor (ER) and progesterone receptor (PR) by the dextran-coated charcoal method following frozen section histopathological examination. Steroid receptor status of each sample was classified as positive (R+) or negative (R-), based only upon quantitative guide lines from the ER/PR results. Four out of 32 (12.5%) of the invasive cancers had an intratumoral sample classified as R+ and one sample as R-. R+ invasive ductal carcinomas has a highly significant degree of tubule formation (P = 0.005) when compared with R- invasive ductal cancers. While the quantitative ER content (r = 0.18) and the degree of quantitative variation in ER content (P = 0.04) did not correlate with the tumor cellularity of the individual samples, tumor cellularity (P = 0.005) and ER content (P = 0.005) were lower in the samples from the tumor border than from the central tumor samples. Variations in ER and PR content may be found on a regional basis within a breast tumor mass resulting from heterogeneity of tumor subpopulations and/or differences in tumor cellularity.