Rectal lymphoma in ulcerative colitis treated with azathioprine.

Primary malignant lymphoma of the bowel is a rare complication of inflammatory bowel disease. The association of gastrointestinal lymphoma, inflammatory bowel disease and prior immunosuppression remains unclear. We report the first case of azathioprine-treated ulcerative colitis developing rectal lymphoma.

The parallel stripes mystery.

A series of artefacts seen on intra-oral radiographs are described. These have been shown to be caused by contamination from fixing solution on the clips used to hold the films during processing. Thorough cleaning of these clips between uses prevented recurrence of these artefacts.

Intestinal obstruction secondary to uterine perforation: an unusual cause of vaginal bleeding.

A patient with intestinal obstruction is described in whom small bowel was incarcerated within the uterine lumen. This is thought to have arisen as a result of undiagnosed uterine perforation during a previous dilatation and curettage.

Pathology of common bile duct stenosis in cystic fibrosis.

A case of cystic fibrosis complicated by common bile duct stenosis is described. Surgery successfully relieved the obstruction, but was complicated by Candida septicaemia. The previously unreported histological abnormalities of the common bile duct are discussed.

Cutaneous haemangioendothelioma: a possible link with chronic exposure to vinyl chloride.

A patient who worked with polyvinyl chloride developed a malignant haemangioendothelioma of a toe. This rare tumour is more commonly found in the liver where it has been reported to arise in association with exposure to the vinyl chloride monomer.

Jejunal carcinoma associated with non-absorbable suture material.

A case of adenocarcinoma of the jejunum arising at the site of non-absorbable surgical material is reported. This appears to be a unique observation.

Idiopathic spontaneous haemoperitoneum.

A case is described of bleeding arising from the falciform ligament which occurred in the absence of obvious local pathology. Spontaneous bleeding from this site hitherto has not been reported. Previously described cases of idiopathic spontaneous haemoperitoneum and factors implicated in the aetiology of this rare condition are reviewed.

Expression of HLA-D sub-region products on human colorectal carcinoma.

The major histocompatibility complex (MHC) status of normal, inflamed, pre-malignant and malignant epithelia of the human gastrointestinal tract was investigated by immunocytochemical methods using monoclonal antibodies (MAbs) directed against heavy (alpha)- and light (beta 2m)-chain Class-I molecules and sub-locus products (DP, DQ, DR) of the HLA-D region. Class-I expression on epithelial cells appeared to vary little with pathological status except in the case of 4/32 (13%) colorectal carcinomas in which the antigens were undetectable or scanty. The pattern of Class-II expression was more complex. The antigens were readily detectable on normal stomach epithelium, in villous adenomas and in inflammatory bowel mucosa. In each of these situations DR was the predominant specificity, followed by DP and DQ. Expression on normal colonic epithelium was usually negative but, in the vicinity of a neoplasm or an area of marked leukocyte infiltration, Class-II molecules (DR greater than DP much greater than DQ) were detectable. A similar pattern of non-coordinate expression was found on 23/32 (72%) colorectal carcinomas, but on the remaining 28% no Class-II products were detectable, under conditions wherein stromal leukocytes were strongly stained. The data suggest that in a significant proportion (nearly 30%) of primary colorectal carcinomas, the capacity for Class-II induction, a constitutive or acquired feature of normal colorectal epithelium, is either diminished or lost. Also, tumor Class-II status is not correlated to Dukes' stage or differentiation.

The effect of oestrogen and progesterone receptors on recurrence and survival in patients with carcinoma of the breast.

Recurrence and survival rates were studied in 175 women with breast cancer who, until the development of recurrent disease, received no treatment other than a modified radical (Patey) mastectomy, and in whom the oestrogen (REc) and progesterone (RPc) receptor content of the primary tumour was measured. At the time of first relapse most patients received endocrine therapy. At a minimum follow-up of 58 months post menopausal patients who possessed REc had an increased relapse-free survival (RFS) (P = 0.02). When examined by node status patients with 1-3 axillary nodes containing tumour also had an improvement in RFS (P = 0.02). There was no benefit for node-negative or premenopausal patients. In 163 patients in whom RPc was measured, RFS was unaffected by the possession of this receptor regardless of the degree of node involvement or menopausal status. Patients with REc had a significantly longer survival following mastectomy than patients without it (P = 0.006). This was most marked in post-menopausal (P = 0.003) and node-positive (P = 0.03) patients. Survival following mastectomy was also increased in patients possessing RPc (P = 0.04) and again was most marked for post-menopausal patients (P = 0.01), although no difference could be identified within node subgroups. There were significant differences in the post-relapse survival of REc and RPc positive and negative patients (REc P = 0.03, RPc P = 0.001). Patients with both receptors survived approximately 37 months longer than their receptor-negative counterparts. This study failed to confirm that the measurement of REc and RPc can reliably predict early relapse in breast cancer. The greater overall survival of receptor-positive patients is mainly due to an increase in survival following relapse. This may reflect the response of receptor-positive tumours to endocrine therapy given for recurrent disease.

Controlled trial of adjuvant chemotherapy with cyclophosphamide, methotrexate, and fluorouracil for breast cancer.

327 patients with cancer of the breast and involvement of axillary lymph nodes were randomised, after total mastectomy and axillary clearance, to receive either no additional treatment or oral cyclophosphamide 80 mg/m2 on days 1-14, intravenous methotrexate 32 mg/m2 on days 1 and 8, and intravenous fluorouracil 480 mg/m2 on days 1 and 8 (CMF), which was repeated every 28 days for twelve cycles. There was a significantly longer relapse-free survival (RFS) in patients treated with CMF. A prolonged RFS was seen in premenopausal patients, those with 1-3 nodes involved, and those with 4 or more nodes involved, but a similar trend in postmenopausal patients failed to reach statistical significance. RFS was greater in patients with CMF-induced amenorrhoea than in controls and in treated patients whose primary tumour contained progesterone receptors. Dose of chemotherapy did not have a significant effect on RFS. Survival was not influenced by treatment.

The association of cytosol oestrogen and progesterone receptors with histological features of breast cancer and early recurrence of disease.

Two hundred and eighty-eight primary breast tumours were examined for the presence or absence of oestrogen (REc) and progesterone (RPc) receptors. Analysis has shown a relative interdependence between the steroid receptor status of primary breast cancer and other prognostic variables such as histological grade, lymphocytic infiltration and tumour elastosis. There were significant associations between epithelial cellularity, stromal fibrosis and the value of REc in those tumours in which the receptor was present. Cellularity and fibrosis were unrelated to the presence or absence of oestrogen receptor. By contrast, neither the presence or absence nor the value of RPc could be related to cellularity or fibrosis. The value of REc and RPc analysis as an indicator of prognosis was examined in a sub-group of 175 patients receiving no additional treatment following mastectomy. Overall relapse-free survival (RFS) was no different for those patients with receptors compared to those without them (REc P = 0.11, RPc P = 0.7). There was no difference in RFS of receptor positive and negative tumours when the axillary node status was taken into account.

Controlled trial of adjuvant chemotherapy with melphalan for breast cancer.

370 patients who had carcinoma of the breast with involved axillary lymph-nodes were randomised after total mastectomy and axillary clearance to receive either no additional treatment or melphalan 6 mg/m2 daily for 5 days every 6 weeks for sixteen cycles. There was a trend towards longer relapse-free survival (RFS) in patients treated with melphalan, but this was not significant either in the whole series or in sub-groups according to menopausal status or extent of nodal involvement. In patients receiving melphalan RFS was not significantly affected by either the occurrence of amenorrhoea or the dosage of melphalan received. Overall survival did not differ significantly between the two groups. The results of this trial suggest that there is no place for the use of melphalan as adjuvant therapy in the management of early breast cancer.

Oestrogen receptor status and management of breast cancer.

PIP: In Manchester, England, the authors studied 175 women who had a Patey mastectomy with a full axillary dissection and in whom the histological status of the axillary nodes was known accurately. The mean length of follow-up was 34 months. Unlike workers from Liverpool, Edinburgh, and the National Cancer Institute, the authors found no difference between the recurrence rates of estrogen receptors, ER+ and ER- tumors in patients without axillary metastases. Others have reported similar findings. No difference was found in patients with extensive nodal disease. In patients with only 1-3 axillary nodes affected, a significant difference between the recurrence rates of tumors with and without ER was found. In these patients not only is recurrence less frequent in thos who have ER but also the frequency of recurrence for ER+ patients is similar to that in patients with no nodal metastases, regardless of receptor status. It could be argued that patients who have minimal axillary node involvement and who also have tumor ER should not be given chemotherapy, for they are no more at risk of recurrence than are node-negative patients. The wide spectrum of opinion of the value of estrogen receptors (ER) as a guide to prognosis serves to emphasize that any beneficial effect is at best marginal.^ieng

Serum glycoprotein hormone alpha subunit, hormone receptors and disease stage in patients with breast cancer.

The concentration of the common alpha subunit of the glycoprotein hormones was high in the serum of 21/56 (38%) of premenopausal patients and 22/106 (21%) of postmenopausal patients with primary breast cancer, at the time of presentation. 7/59 (12%) of patients with benign disease also had high alpha subunit levels. Tumour cytosol oestrogen and progesterone receptor status was determined in 80% of the patients with cancer, and there was a trend towards higher alpha levels in patients without receptors, but this was not statistically significant. In the premenopausal patients with cancer there was a significant correlation between alpha subunit level and disease stage, R = 0.47, P = 0.0001, but not in the postmenopausal patients. In view of the correlation with disease stage, high levels of alpha subunit in premenopausal patients with breast cancer at presentation with the primary tumour may indicate poor prognosis.