CHOP-based chemotherapy is as effective as alternating PEEC/CHOP chemotherapy in a randomised trial in high-grade non-Hodgkin's lymphoma. Scotland and Newcastle Lymphoma Group.

The aim of this study was to test whether survival for patients with high-grade non-Hodgkin's lymphoma (NHL) can be improved with a non-cross-resistant regimen as compared to a CHOP-based regimen. This is a multicentre study comprising 325 adult patients, median age 58 years, with high-grade non-Hodgkin's lymphoma: patients of any age and performance status were eligible provided they were able to receive the drugs in the regimens. Patients were randomised to either B-CHOP-M (bleomycin, cyclophosphamide, doxorubicin, vincristine, prednisolone and methotrexate) or PEEC-M (methylprednisolone, vindesine, etoposide, chlorambucil and methotrexate) alternating with B-CHOP-M. At a median follow-up of 9 years, there was no significant difference in overall survival or disease-free survival between the two arms. Toxicities for the two regimens were equivalent. This study confirms that for relatively unselected patients with high-grade non-Hodgkin's lymphoma, an alternating multidrug regimen does not improve upon the results obtained with B-CHOP-M.

Malignant melanoma in Scotland 1979-1983.

1318 cases of primary malignant melanoma of the skin first presenting in Scotland in the years 1979-83 and registered with the Scottish Melanoma Group are described. The annual age-adjusted incidence rate is 4.75 per 100 000 for females and 2.77 per 100 000 for males. Incidence rose by an annual average of 2.5% over the five-year period. The female: male ratio was 2:1, and 48.5% of all cases were of the superficial spreading histogenetic variety. Five-year survival rates for the patients registered in 1979 confirm the prognostic value of the tumour-thickness (Breslow) measurement. They were 93% for patients with tumours less than 1.5 mm thick (39% of patients), 67% for those with tumours 1.5-3.49 mm thick (30%), and 37% for those with tumours thicker than 3.5 mm (31%). This study shows that methods for early recognition of thin tumours should be encouraged.

Incidence of familial Hodgkin's disease.

The family histories of 131 patients with histologically defined Hodgkin's disease (HD) were studied and 2,517 first and second degree relatives and spouses were identified and followed-up. The causes of death in deceased relatives were ascertained from death certificates. The numbers of deaths from selected causes were compared with the numbers that would be expected if the relatives had suffered the same mortality rates as the Scottish national population. A 4-fold increase in deaths due to HD was found among first and second degree relatives of patients with the disease (6 cases observed compared with 1.4 expected). Five of the 6 familial cases were related to index patients with the mixed cellularity form of the disease, the remaining case was the brother of a patient with the lymphocyte-depleted form of the disease. The increased risk was seen among relatives of both young and older patients and there was no consistent intrafamilial similarity in age of onset or time of onset of disease.

Prognostic value of measurement of elastosis in breast carcinoma.

The extent of elastosis in the stroma within the anatomical "tumour" in 80 patients with breast carcinoma was assessed by observational microscopy using a 4-point grading system, and measured by semiautomated histometry as an area percentage with a Quantimet 720 image-analysing computer. In this retrospective study, measurement of elastosis in tissue removed at time of initial diagnosis was shown to have little value for prediction of duration of survival.

Jejunal morphology in multiple sclerosis.

In a prospective survey jejunal biopsy samples from 11 patients with multiple sclerosis on normal diets were compared with those from controls matched for age and sex. Quantitative histology, morphometry, and electron microscopy showed no difference between the two groups. Since there was no evidence that gluten sensitivity plays a role in the aetiology of multiple sclerosis, the wide adoption of gluten exclusion by patients seems unjustified.

Differential cell counts in the histiocytic variant of lymphocytic predominance subtype of Hodgkin's disease.

Differential cell counts were made on a lymph node, the structure of which was replaced by the histiocytic variant of the lymphocytic predominance subtype of diffuse Hodgkin's disease. In terms of numbers of cells in various categories, this lymph node bears a closer relationship to the mixed cellularity subtype than to the classical lymphocytic predominance subtype. In this node, unlike the mixed cellularity subtype, the histiocytes are largely differentiated into epithelioid cells; the significance of this cellular adaptation for defence against neoplastic cells is not known.

Cytological basis of histological typing of diffuse Hodgkin's disease. Demonstration of an implied misnomer in the terminology of the Rye classification.

Differential cell counts were made on nine lymph nodes whose structure was replaced by diffuse Hodgkin's disease; two of these nodes had the classical histological appearance of the lymphocytic predominance subtype, four of the mixed cellularity subtype, and three of the lymphocytic depletion subtype. Our attempts to achieve valid sampling methods are recorded. The counts, in general, confirm the postulated histological basis of the Rye classification of the subtypes of the diffuse disease. The major discrepancy is that, contrary to the histological descriptions, our direct counts have shown that lymphocytes, are, in general, more numerous in the lymphocytic depletion than in the mixed cellularity subtypes. The cell counts also show that normal mononuclear cells (mainly fibroblasts and macrophage-type cells) are much more numerous in the mixed cellularity subtype than in the other forms of diffuse Hodgkin's disease; this feature has not been emphasised in the Rye classification. On the basis of our differential counts, a hypothesis is proposed that could explain the natural history of the different subtypes of diffuse Hodgkin's disease as the resultant of three processes: (a) tumour aggressiveness, (b) specific cell-mediated immunological reactions, and (c) non-immunological stromal responses.

A case of Lennert's lymphoma.

A 73-year-old man who presented with a tonsillar mass and generalised lymphadenopathy died two months after admission to hospital. The appearances in the surgical biopsy material resembled those of Lennert's lymphoma, while the necropsy findings were those of a diffuse lymphocytic lymphoma composed mainly of cells with small nuclei showing only slight irregularity. The implication of these findings in relation to the nature of Lennert's lymphoma are briefly discussed.

Malignant histiocytosis (histiocytic medullary reticulosis) with spindle cell differentiation and tumour formation.

Malignant histiocytosis (histiocytic medullary reticulosis) in a 45-year-old white man is described. Unusual features were presentation as a surgical emergency with signs of obstruction and peritonitis due to an ileal tumour and extensive spindle cell differentiation. Problems in the differential diagnosis of malignant histiocytosis are briefly discussed.

Problem solving cases in teaching of applied pathology.

A "problem solving case" method of teaching practical pathology is described, illustrated and compared with more traditional teaching methods. This method offers many advantages-the most important being that it shows the effect of pathological lesions in an actual patient, thus emphasizing the relevance of pathology to clinical medicine. Other advantages are that self-assessmetn is encouraged; guidance is given on the depth of knowledge expected from a student; student response is favourable; no elaborate or expensive equipment is required; the method is economic in the use of staff time, and it is very flexible in use in terms both of time and place.

Mucosal metaplasia in the appendix.

Metaplastic foci do not appear to have been previously described in the mucosa of the appendix. Eight examples are reported, two of which were found in a series of 100 consecutive appendicectomies.

Medullary carcinoma of the thyroid with parathyroid adenoma and hypercalcaemia.

A patient with hyperparathyroidism due to a parathyroid adenoma was found to have metastatic medullary carcinoma in lymph nodes close to the thyroid gland. The finding of normal calcitonin and parathormone concentrations after removal of the adenoma suggested that the parathyroid lesion was not the result of the hypocalcaemic action of calcitonin produced by the tumour in the thyroid. Seventeen other examples of the association between medullary carcinoma and parathyroid enlargement are briefly reviewed.The pathogenesis of the parathyroid lesions is discussed, and it is suggested that some may be caused by the hypocalcaemic action of calcitonin, while others may be part of a syndrome of multiple endocrine adenomatosis.

The problem of "chronic mastitis" with epitheliosis.

The incidence of breast cancer complicating chronic mastitis with epitheliosis has been reported to be as high as 45% and as low as 6%. At least part of this discrepancy appears to be due to difficulty in distinguishing between benign and malignant intraduct epithelial proliferation.A small series is presented here in which the incidence of invasive cancer after local excision of breast tissue showing chronic mastitis with epitheliosis was nil. It is concluded that it is necessary to follow up larger series of cases longer before it can be said that severe epitheliosis and borderline lesions should in all cases be treated by anything more radical than local excision.

Two cases of cryptococcosis.

Two cases of Cryptococcus neoformans infection are described, both complicating chronic renal failure. In one case the use of prednisone and immunosuppressive drugs may have predisposed to infection.