Psycho-oncology: where have we been? Where are we going?

This article reviews the development of the subspeciality of psycho-oncology and its contributions to patient care, encouraging more attention to and research into the care of the total patient: the physical, psychological, social and spiritual aspects of care. The result is enhanced quality of life as the patient is studied in the domains of living that are important, extending across the continuum of care from diagnosis to palliative care. In addition, cancer prevention and early detection depends largely on changing attitudes and behaviours that put people at greater risk. This is an important area of research for psycho-oncologists. In the past two decades, research has contributed to our understanding of the psychological responses that accompany a cancer diagnosis. Oncologists better recognise psychological distress and psychiatric disorders such as anxiety, depression and delirium (in hospitalised patients) as frequent comorbid disorders. The development of valid assessment tools for the patients' self-report has been important. Increasingly, outcome measures in controlled trials of new therapies include quality of life, and no longer look at survival alone. The future will continue to bring new challenges to psycho-oncology as patients face new challenges in treatment. A major aim of the next century will be to bring this integrated approach to all patients in an affordable manner.

Cytologic findings in the differential diagnosis of C-cell hyperplasia and medullary carcinoma by fine needle aspiration. A case report.

BACKGROUND: The cytologic features of C-cell hyperplasia of the thyroid have not been previously addressed in the literature. We describe the first case, to our knowledge, of C-cell hyperplasia that was suggested by fine needle aspiration. CASE: Cellular material was obtained from a nonnodular region of the thyroid gland in a 67-year-old male with chronic diarrhea, unexplained elevated serum calcitonin, no clinically detectable thyroid mass and no known medical or family history of an endocrine disorder. Aspiration yielded a scant bimodal cell population composed of benign follicular cells and a second population of larger cells, later confirmed as C-cells via immunohistochemistry. Although the diagnosis of medullary carcinoma was entertained, the absence of a discrete mass clinically and the presence of two interspersed, distinct cell populations suggested the alternate diagnosis, C-cell hyperplasia, which was confirmed by subsequent thyroidectomy. CONCLUSION: C-cell hyperplasia can mimic medullary carcinoma biochemically, and this case suggests the possible role of fine needle aspiration of the thyroid to distinguish between the two. In patients with elevated serum calcitonin and absence of a discrete thyroid nodule, the finding of clusters of calcitonin-positive cells intermixed with normal follicular cells by fine needle aspiration may provide a means of making a presurgical diagnosis of C-cell hyperplasia.

Cytology of sex cord tumor with annular tubules: a case report.

The cytologic findings of a sex cord tumor with annular tubules (SCTAT) that ruptured during laparoscopy are described. Features useful in distinguishing SCTAT from other ovarian sex cord tumors include the presence of highly cellular tubular formations containing well-delimited glassy pink material and absence of single cells. To the best of our knowledge, the cytology of SCTAT has not been previously reported.

Contralateral axillary lymph node metastasis as the first evidence of locally recurrent breast carcinoma.

BACKGROUND: Carcinoma of the breast infrequently presents initially as axillary adenopathy. In such cases, after biopsy proves the presence of metastatic carcinoma, the primary tumor generally is assumed to be in the ipsilateral breast, despite negative mammographic findings and the lack of a clinically palpable breast mass. METHODS: The authors recently studied a case of a 50-year-old woman in whom recurrent neuroendocrine carcinoma of the breast presented as a contralateral axillary lymph node metastasis. After mastectomy ipsilateral to the metastasis proved negative for tumor, a histologic comparison of the previous contralateral tumor with that in the lymph node was performed, followed by biopsy of the clinically and mammographically negative original lumpectomy site. RESULTS: Histologic and immunohistochemical studies proved that the original, metastatic, and locally recurrent tumors were identical, sharing unusual neuroendocrine features. The patient is currently disease free after chemotherapy. CONCLUSION: Contralateral mammary carcinoma should be considered in the workup of a patient who presents with evidence of an axillary lymph node metastasis. Locally recurrent breast carcinoma may be clinically and mammographically occult. Histologic review of prior biopsy material and comparison with current tissue is essential in proper patient management.

Survival with colorectal cancer in ulcerative colitis. A study of 102 cases.

OBJECTIVE: This study was undertaken to correlate postoperative survival of patients with ulcerative colitis-associated colorectal cancer with the stage, configuration, size, and mucin content of the tumor. SUMMARY BACKGROUND DATA: The factors influencing prognosis in colorectal cancer in the general population are well accepted, but less is known about their influence in cases of colorectal cancer associated with ulcerative colitis. METHODS: The authors reviewed the records of 102 patients with ulcerative colitis-associated colorectal cancer admitted to The Mount Sinai Hospital between 1959 and 1988. Tumors were classified on independent pathologic review according to histologic stage, configuration, size, and mucin content. Comparisons among survival curves were tested by the generalized Wilcoxon test. Cox regression models were used to examine the joint effects of selected clinicopathologic features on postoperative survival rates. RESULTS: Complete follow-up was obtained for 93 patients (92%). Overall 5-year actuarial survival was 52%. When factors were analyzed one at a time, survival was significantly poorer among patients with advanced cancer stage, larger tumor size, infiltrating and ulcerating configuration, and high mucin concentration. On multivariate analysis by the Cox regression model, however, only cancer stage emerged as a factor independently predicting survival. CONCLUSIONS: For colitis-associated colorectal cancers, as for noncolitic cancers, histologic stage is the most important variable determining postoperative survival. The distribution of stages in our series and the survival rates within each stage did not differ appreciably from the distributions and survival rates reported for noncolitic colorectal cancers.

Fine needle aspiration of a renal cell carcinoma with eosinophilic globules. A case report.

Fine needle aspiration (FNA) of a renal cell carcinoma with hyaline eosinophilic globules is presented. The cytology of the tumor cells was characterized by intracytoplasmic, dense, well-circumscribed globules that had a bright magenta appearance on Diff-Quik staining. Tissue sections demonstrated the globules to be located predominantly within the cytoplasm of the clear cells of the carcinoma. Immunohistochemical and ultrastructural evaluation is discussed, as is the significance of this finding.

Colorectal carcinoma associated with ulcerative colitis: a study of prognostic indicators.

Fifty-two patients with ulcerative colitis and colorectal cancer undergoing colectomy at the Mount Sinai Hospital between 1973 and 1988 were studied retrospectively to determine the correlation of age, sex, duration of colitis, tumor location, number of cancers, tumor differentiation, colloid content, presence of signet ring cells, Dukes' classification, and DNA ploidy with survival. The mean age was 45 years, with a mean duration of colitis of 21 years. Five patients (10%) had Dukes' A lesions, 17 (33%) had Dukes' B lesions, 17 (33%) had Dukes' C lesions, and 13 (25%) had distant metastases. Thirty patients (58%) had well- or moderately differentiated tumors, whereas tumors were poorly differentiated in 22 (42%). Twenty-eight patients (54%) had colloid tumors, and, in 14 (27%), signet ring cells were present. Thirty-one patients (60%) had nondiploid tumors. Actuarial analysis revealed that the 5-year survival rate was significantly worse for patients with nondiploid tumors (76% versus 32%). When stratified by stage, only patients with Dukes' C lesions showed a significant difference in survival for diploid versus nondiploid tumors. Multivariate analysis showed that the Dukes' classification was the best prognostic indicator, followed by tumor differentiation and DNA ploidy. Tumor location, colloid content, number of cancers, duration of disease, age, and sex did not correlate with the prognosis.

ras and c-myc protein expression in colorectal carcinoma. Study of cancer-prone patients.

This study was performed to determine the correlation of tumor ras and c-myc oncogene expression with clinical and prognostic variables in patients prone to develop colorectal cancer. One hundred eighteen patients with colorectal cancer were studied; mean age was 40 years. Fifty-three were young patients (age 40 or less), 49 had ulcerative colitis, and 16 had multiple polyposis coli. Immunoperoxidase stains of paraffin-embedded cancer sections were performed for the c-myc and ras proteins. ras staining was found to correlate with Dukes stage and prognosis. Patients with tumors negative for ras protein stain had an actuarial five-year survival of 61 percent versus 44 percent for those tumors with a positive stain (P less than 0.05). This correlation was not seen with the c-myc stain. Positive ras oncogene stain appears to be a useful indicator of advanced stage and poor prognosis in colorectal cancer occurring in cancer-prone patients.

Malignant melanoma in inflammatory bowel disease.

Malignant melanoma occurred in 11 patients with inflammatory bowel disease (IBD). Six cases occurred in patients with ileocolitis, two in regional enteritis, one in granulomatous colitis, and two in patients with ulcerative colitis. The mean age at development of IBD was 24 yr, and at development of melanoma was 40 yr: the mean duration from onset of IBD to development of melanoma was thus 16 yr. All patients for whom complete information was available, except two, had received steroids and azulfidine for approximately a decade, as well as blood transfusions, usually multiple, and on repeated occasions. Six of the 11 patients had undergone one to seven prior operations (mean 3.5). All patients had wide radical excision of the melanoma, with or without concomitant or subsequent nodal dissection. Two patients (ages 25 and 36 yr) died rapidly from widely disseminated malignant melanoma. These cases may be coincidental, or else there may be an association between IBD and melanoma, related to immunosuppression either from the disease itself, from the medical and surgical therapy, and/or from x-ray exposure.

DNA ploidy of colorectal cancer and synchronous polyps in polyposis coli.

Sixteen patients with polyposis coli and cancer were studied retrospectively to determine the incidence of DNA ploidy abnormalities in the tumors and synchronous polyps. Six patients (37 percent) had nondiploid tumors. Nondiploid tumors were more likely to be advanced and had a significantly worse prognosis (17 percent vs. 76 percent 5-year survival; P less than 0.01). Only 4 of 20 polyps studied were nondiploid. There was no association between tumor and polyp ploidy. All nondiploid polyps were found in patients with synchronous diploid cancers. Patients with nondiploid polyps were more likely to be older and have more advanced tumors than those with diploid polyps. DNA ploidy abnormalities seem to occur with the same frequency in polyposis coli as in the nonpolyposis population, and tumor ploidy correlates with prognosis.

Correlation of nuclear morphometry and DNA ploidy in rectal cancer.

Several investigators have used morphometric measurements to determine differences in the nuclear size and shape of normal and neoplastic colorectal tissue. Changes in nuclear morphometric parameters have also been shown to correlate with prognosis in a variety of noncolorectal cancers. The association of nuclear morphometry with prognostic indicators in rectal cancer has not been well studied. Measurements of the nuclear area, perimeter, longest cord, and circularity factor from 39 primary rectal adenocarcinomas were compared with DNA content, degree of tumor differentiation, Dukes' class, and patient survival. Nuclear circularity was found to correlate with DNA ploidy. Nondiploid tumors with a DNA index greater than 1.3 had significantly more circular nuclei than tumors with diploid or near-diploid DNA content. There was no correlation between nuclear morphometry and Dukes' class or patient survival. Significant increases in DNA content of rectal cancers appear to be reflected by measurable changes in nuclear shape. Nuclear morphometric measurements may provide useful information in the study of the progression of neoplastic changes in colorectal cancer.

Synchronous carcinoma of the colon and rectum.

Reports on the incidence of synchronous carcinoma of the colon and rectum have varied from 2 to 11 per cent. The variability is a result of a lack of uniformity in criteria of diagnosis, differences in the population studied and differences in time period used. In this study, we evaluated the incidence and distribution of synchronous lesions during a recent time period before the use of colonoscopy became widespread. We reviewed the records of all patients with newly diagnosed adenocarcinoma of the colon and rectum who were operated upon at our institution between 1976 and 1981. In a total group of 1,000 patients of which 52 per cent were men, there were 54 patients or 5.4 per cent who had synchronous carcinomas. The group of patients with synchronous carcinomas were older than the group with nonsynchronous carcinomas (72.4 versus 68.8 years). There was also a higher incidence of associated benign polyps in the group with synchronous carcinomas (70 versus 30 per cent for a nonsynchronous carcinomas). The anatomic distribution of carcinomas of the colon and rectum in the group with synchronous lesions (111 in total) revealed a higher percentage of carcinomas located on the right side (29.7 versus 22.5 per cent), although the difference did not reach statistical significance. Synchronous carcinomas were located in nonadjacent segments of the colon in 37 per cent. There was no difference in stage between the groups with and without synchronous carcinomas. The preoperative identification of synchronous lesions by either colonoscopy or barium enema is important for the proper treatment of patients with carcinoma of the colon and rectum. Failure to locate these tumors may lead to the demise of the patient.

Significance of DNA content abnormalities in small rectal cancers.

Several studies have shown that the presence of DNA content abnormalities, measured by flow cytometry, may correlate with a poor prognosis in a variety of cancers. The predictive value of DNA content in patients with small rectal cancers has not been well determined. Thirty-nine patients with primary rectal adenocarcinoma smaller than 3 cm were studied in a comparison of DNA content with established prognostic variables. The following covariates were evaluated for their prognostic value: sex, age, tumor size, location, distal margin, Dukes' classification, tumor differentiation, and DNA content. DNA content was assessed by flow cytometric analysis, and each tumor was categorized as diploid or nondiploid. Of the parameters studied, Dukes' classification and tumor DNA content were found to be independent prognostic indicators. Determination of DNA content seems to provide additional useful prognostic information in patients with small rectal tumors.

Ultrasonic mucosal proctectomy in patients with ulcerative colitis.

A technique for performing mucosal proctectomy in patients with ulcerative colitis using ultrasonic fragmentation is described. Twenty-eight patients undergoing colectomy and ileoanal anastomosis were studied. Removal of the mucosal layer of the distal rectum was performed using a titanium probe vibrating at 23 kHZ with an amplitude of 300 microns. This method produces complete mucosal destruction and the resulting debris and irrigating fluid is removed through the hollow central portion of the probe. Healing of the ileoanal anastomosis does not appear to be adversely affected by the use of this technique. Because ultrasonic fragmentation is not dependent on the integrity of the submucosal plane, it may be advantageous in those cases in which severe inflammation and submucosal scarring make manual dissection of the rectal mucosa difficult to perform.

Prognostic significance of DNA content abnormalities in young patients with colorectal cancer.

Several studies have shown that the presence of DNA ploidy abnormalities, measured by flow cytometry, may correlate with a poor prognosis in a variety of cancers. The predictive value of these DNA abnormalities in young patients with colorectal cancer has not been well studied. Fifty patients aged 40 years and younger with colorectal adenocarcinoma were studied to determine the correlation of tumor DNA abnormalities with survival. DNA content was determined by flow cytometric analysis and each tumor was categorized as diploid or nondiploid. Of the parameters studied, Dukes' classification and tumor DNA ploidy were found to be significant prognostic indicators. Determination of DNA content seems to provide additional useful prognostic information in young patients with colorectal cancer.

The hairy polyp: a benign teratoma of the colon.

A 76-year-old female presented with bright red rectal bleeding. Endoscopic evaluation revealed a polypoid lesion sprouting hair in the sigmoid colon. Histologically the resected polyp was composed of elements of all three germ layers, fulfilling the criteria for a teratoma. The differential diagnosis of this benign polyp and its significance are discussed.

Correlation of presence of granulomas with clinical and immunologic variables in Crohn's disease.

Approximately 50% of patients with Crohn's disease have epithelioid granulomas present in the diseased intestine. Some studies have associated the presence of granulomas with a good prognosis. In this prospective study, 44 patients with Crohn's disease requiring surgery were followed up for five years. Twenty-two patients (50%) had granulomas. Patients with granulomas were younger and had a shorter duration of disease. They also had more extensive disease and a greater degree of peripheral lymphopenia. Follow-up showed a trend toward greater recurrence rate in the patients with granulomas. It seems that patients with aggressive and extensive Crohn's disease are not protected from the development of symptomatic early recurrence by the presence of epithelioid granulomas.

In vivo ethane production in vitamin E-deficient rats with DMH-induced colon cancer.

The effect of both a vitamin E-deficient and a high polyunsaturated fat (PUFA) diet was tested on rats injected with the colon carcinogen 1,2-dimethylhydrazine (DMH). In vivo lipid peroxidation was monitored by measuring exhaled ethane from the animals. Higher mean weights were found in animals fed high PUFA and vitamin E-sufficient diets. There was no difference in ethane exhalation between DMH-treated and control animals regardless of diet. Mean ethane exhalation was highest in animals fed either vitamin E-deficient or high PUFA diets. There was no difference in tumor formation between the vitamin E-deficient and the vitamin E-sufficient groups. The high PUFA groups had more tumors than the low PUFA groups. Diet was shown to be the major factor affecting ethane exhalation. There was no evidence that vitamin E-deficiency promoted DMH-induced tumors or that DMH caused increased lipid peroxidation.