The prognostic value of histological grading and mean nuclear volume in human prostatic cancer.

Fifty-eight consecutive patients diagnosed with prostatic cancer at transurethral resection in the period 1979-1983 were classified using histological grade according to Shelley, and using an unbiased estimate of mean nuclear volume. We find that both histological grade and mean nuclear volume appear to be significantly associated with survival. In eight of nine patients still alive after 89-130 months mean nuclear volume at diagnosis was in normal range and the histological grade showed a highly differentiated cancer in eight of the nine cases. These findings suggest highly differentiated cancer and normal range of mean nuclear volume may be important for long-term survival. In patients with advanced disease requiring endocrine treatment both histological grading and mean nuclear volume estimates failed to show any prognostic properties with regards to time to progression and time of survival. In patients not subjected to endocrine treatment histologic grade, but not mean nuclear volume, was found to be significantly associated with survival. Subtle changes in disease progression may be diagnosed early by repeated biopsies due to the accuracy and high reproducibility of mean nuclear volume measurements; however, a single estimate of mean nuclear volume has not been shown to offer advantage over histological grade with respect to prognostic properties.     

Malignancy grading in breast cancer as assessed by nuclear DNA content

The relationship between nuclear DNA content measured by cytofluorometry and the prognostic factors, especially the histological lymph node metastasis was investigated in patients with breast cancer. Nuclear DNA content was measured in 82 cases to evaluate its clinical significance concerning the malignancy grading. Histograms of DNA content were classified into two basic ploidy patterns based on presence or absence of a prominent peak at the 2c (diploid) region. D type (diploid type) which had a prominent peak at the 2c region resembled the histogram pattern of normal cells more closely than N type (non-diploid type). The rate of lymph node metastasis of N type (57.4%) was significantly higher than that of D type (28.6%) (p less than 0.05). The rate of lymph node metastasis of N type was higher than D type regardless of the tumor size or histological types. The five year cumulative survival rate of D type (91.7%) was significantly higher than that of N type (68.2%) (p less than 0.05). Despite the lymph node metastasis, the survival rate of D type was higher than that of N type. From a view point of the relationship between nuclear DNA content and lymph node metastasis, breast cancers of D type might be much safer indications for modified radical mastectomy. From this study, it was suggested that the measurement of nuclear DNA content of the breast cancer would bring the important informations about the malignancy grading and decision of the operative procedure.     

Potential of nuclear morphometry and volume-corrected mitotic index in grading transitional cell carcinoma of the urinary bladder

The potential of nuclear morphometry and volume-corrected mitotic index (M/V index) in grading cases of transitional cell carcinoma of the urinary bladder was studied. 30 cases of bladder cancer including all three WHO grades were evaluated. Four investigators selected independently the most atypical field from paraffin sections, and one investigator measured the nuclear areas from these fields using the IBAS 1&2 image analyzer system. Following the same sampling rule, four investigators counted the mitotic figures per area of neoplastic tissue in the microscopic image at an objective magnification of X40. The mean nuclear areas covered values from 28.1 to 139.0 microns 2 (mean +/- SD 57.2 +/- 18.9). The total variance of measurements was 359.1 and the mean variance between corresponding fields 110.2 (about 30% of the total variation). The efficiency was evaluated by estimating the fraction of falsely classified cases. Instrumental morphometry of nuclear area in a three-grade system gave an efficiency of 79% and of 90%, in a two-grade system. The M/V index varied from 0 to 54 (mean +/- SD 12.3 +/- 10.9). The total variance was 119.8 and the methodological variance 15.5 (about 13% of total variance). In a three-grade system this would correspond to an efficiency of about 75%; in a two-grade system the efficiency would be 88%. The results suggest that nuclear area and M/V index estimates constitute efficient grading systems in bladder carcinoma.     

Relationship between histologic grading and serum prostate specific antigen in prostatic carcinoma

Prostate specific antigen (PSA) is the most important tumour marker which, used routinely, proved to have a positive correlation with tumour volume and pathological stage. To evaluate the relationship between serum PSA and histologic grading of prostatic carcinoma, preoperative PSA determinations were made in 25 patients with prostatic cancer. Biopsy materials were evaluated and the Gleason scores were adjusted for histologic grading. The higher values of PSA were proportional to the Gleason scores of the primary prostatic biopsy.     

Hormone dependency and histological types of prostatic carcinoma

In comparative histological and cytological studies on 270 prostatic carcinoma patients highly and moderately differentiated tumors were found to be more frequent histologically than cytologically. An early and reliable sign of response to hormone therapy proved to be reticularization and vacuolization of the nuclear chromatin. Follow-up studies by means of multiple aspiration biopsies with cytologic examinations seem to be more reliable in prognostic terms than examination of the histological tumor structure.     

Histological grading of prostatic carcinoma and its clinical evaluation.

The clinical control of patients with T1--T3, N0--M0 prostatic carcinomas allows us to draw the following conclusions regarding the grading. (1) The grading of the primary tumor is of great help in establishing the prognosis. (2) The results of the various applied treatments, like radical prostatectomy, radiation, and heterosexual hormone therapy, depend on the primary grade. The use of cytostatics in badly or undifferentiated prostatic carcinomas deserves on the contrary, better attention. (3) The changing of the grading at the various check-ups is of great therapeutical significance.     

Relationship between the nuclear DNA content and the prognosis in squamous cell carcinoma of the lung

Analysis of the nuclear DNA content from paraffin-embedded specimens using flow cytometry was performed on 86 patients in squamous cell carcinoma of the lung. There were no relationships between the site of tumor origin and the nuclear DNA content or the survival of the patients. The frequency of DNA aneuploidy was 74.4% among tumors, and it significantly (p less than 0.05) increased with advanced stage. The patients with DNA aneuploidy were significantly (p less than 0.01) less favorable prognosed than those with DNA diploidy. Similar results were demonstrated in patients of absolute or relative curative resections. These results indicate that DNA aneuploidy is of higher grade malignant intensity than DNA diploidy in squamous cell carcinoma of the lung. In patients with absolute or relative curative resection, DNA aneuploid tumors occurred much more often in distant metastasis. In conclusion, there were no relationships between the site of tumor origin and the biological features or the prognosis of patients in squamous carcinoma of the lung. DNA ploidy pattern is related to relapse and prognosis of the tumors. If the DNA ploidy pattern of patients on whom absolute curative resection was performed is DNA aneuploidy, adjuvant therapy should be strongly performed and carefully followed up as long as possible.     

Prognostic value of nuclear DNA content in medullary thyroid carcinoma

The prognostic value of nuclear DNA content in medullary thyroid carcinoma was studied in 36 patients. Eleven patients are still living 13–35 years after diagnosis. Twenty-five patients died of medullary thyroid carcinoma between 10 months and 23 years following diagnosis. DNA measurements in morphologically identified single tumor cells were performed either on fine-needle aspiration biopsy material or on histologic sections from the primary tumor. Metastases or local recurrences were also examined in 18 cases. In the survivors, the majority of tumors exhibited cells with DNA amounts approximating the normal diploid value, whereas the tumors of the nonsurvivors had significantly higher DNA values. The primary tumors and their metastases or local recurrences exhibited in all cases essentially similar DNA content. The data suggest that DNA measurements in medullary thyroid carcinoma contribute valuable prognostic information that adds to standard clinical and morphological parameters.

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Resumen Los análisis del contenido nuclear de DNA de las células tumorales en pacientes con carcinoma prostático, carcinoma mamario y condrosarcoma ha demostrado ser un mejor indicador de pronóstico que los exámenes histopatológicos convencionales. Recientemente también se han realizado estudios de DNA en células tumorales de pacientes con carcinoma papilar de tiroides y tumores foliculares de tiroides. El contenido de DNA de las células tumorales se correlaciona bien con la evolución clínica. Las células tumorales de aquellos pacientes que sobrevivieron por no menos de 10 años frecuentemente exhibieron un contenido de DNA comparable al de las células normales, en tanto que los pacientes que murieron por carcinoma tiroideo exhibieron células con valores elevados del DNA, claramente diferentes de los de las células normales.El valor pronóstico del contenido nuclear de DNA en carcinoma medular de tiroides fue estudiado en 36 pacientes. Once pacientes viven entre 13 y 35 años después de realizado el diagnóstico. Veinticinco pacientes murieron de carcinoma medular de tiroides entre 10 meses y 23 años después del diagnóstico. Las mediciones de DNA en células tumorales aisladas, morfológicamente identificadas, fueron realizadas bien en material obtenido por aspiración biopsia con aguja fina o en secciones histológicas del tumor primario. Metástasis o recurrencias locales también fueron examinadas en 18 casos. En los sobrevivientes la mayoría de los tumores exhibió células con contenidos de DNA generalmente alrededor del valor diploide normal, en tanto que los tumores de los pacientes que murieron tenían valores de DNA significativamente más altos. Los tumores primarios y sus metástasis o recurrencias locales exhibieron, en todos los casos, esencialmente similares contenidos de DNA. Estos datos sugieren que las determinaciones de DNA en el carcinoma medular de tiroides contribuye una información valiosa desde el punto de vista pronóstico, adicional a los parámetros clínicos y morfológicos usuales.

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Résumé La valeur pronostique de l'ADN nucléaire du cancer thyroidien médullaire a été étudiée chez 36 males. Onze malades sont encore en vie de 13 à 35 ans après que le diagnostic ait été porté, vingt-cinq malades sont décédés de 10 mois à 23 ans après que le cancer ait été reconnu. Le dosage de l'ADN au niveau des cellules néoplasiques a été porté sur le spécimen recueilli par la biopsie aspiration ou la pièce opératoire. Il a été également effectué dans 18 cas de métastases ou de récidives locales du cancer. Chez les survivants le taux d'ADN au niveau des cellules diploides était voisin de la normale alors qu'il était significativement plus élevé chez les opérés qui sont décédés. Les tumeurs primitives, les métastases, les récidives avaient dans tous les cas un taux identique d'ADN. Ces données suggèrent que le dosage de l'ADN cellulaire dans les cas de cancer de type médullaire possède une valeur pronostique qui s'ajoute à celle des paramètres cliniques et morphologiques.

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Supported by The Cancer Society in Stockholm and by The Swedish Cancer Society.     

Incidental versus manifest prostatic carcinoma

The problem in managing incidental prostatic carcinoma is whether deferred treatment or active therapy should be preferred. Eighty-six consecutive patients with prostatic carcinoma diagnosed at TUR-P during 1979–83 were studied retrospectively. Seventeen of the patients (20%) had incidental prostatic carcinoma. Incidental carcinomas were significantly more well differentiated histologically than manifest carcinomas. The striking difference between incidental and manifest prostatic carcinomas appeared when the clinical course was considered. Only one patient with incidental carcinoma developed symptoms requiring endocrine therapy, against 31 patients with manifest carcinoma (p<0.01). It is therefore concluded that the distinction between manifest and incidental prostatic carcinoma is justified and that deferred treatment is sufficient in most patients presenting with incidental prostatic carcinoma at TUR-P.     

Prognostic value of nuclear DNA content in papillary thyroid carcinoma

The prognostic value of nuclear DNA content in papillary thyroid carcinoma was studied retrospectively in 90 patients. Eighty survived for at least 10 years, and 10 died, of papillary thyroid carcinoma, between 6 months and 12 years after diagnosis. Clinical data as well as morphological tumor characteristics were examined. DNA measurements in morphologically identified single tumor cells were performed either on fine-needle aspiration material or on histologic sections. The tumors of the survivors were composed of cells with a DNA content comparable to that of normal cells, whereas the tumors of the non-survivors had significantly higher DNA values. The data suggest that DNA measurements in papillary thyroid carcinoma offer a valuable adjunct to standard clinical and microscopic analysis.

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Resumen El análisis del contenido de DNA en carcinoma prostático, carcinoma mamario y condrosarcoma ha sido demostrado como una mejor guía de pronóstico que los exámenes clínicos y microscópicos convencionales. El propósito de este estudio fue el de evaluar si la determinación del contenido de DNA puede significar un parámetro confiable de pronóstico en pacientes con carcinoma papilar de tiroides.El valor pronóstico del contenido nuclear de DNA en el carcinoma papilar fue estudiado retrospectivamente en 90 pacientes. Ochenta sobrevivieron por no menos de 10 años, y 10 fallecieron de carcinoma papilar entre 6 meses y 12 años después de efectuado el diagnóstico.Los datos clínicos y las características morfológicas del tumor fueron analizados. Las determinaciones de DNA en células únicas morfológicamente identificadas fueron hechas sobre material de aspiración con aguja fina o sobre secciones histológicas. Los tumores de los supervivientes aparecieron compuestos por células con un contenido de DNA comparable al de las células normales, en tanto que los tumores de los pacientes que no sobrevivieron presentaron valores de DNA considerablemente más altos. Estos datos sugieren que las determinaciones de DNA en el carcinoma papilar significan un valioso parámetro de pronóstico adyuvante del análisis clínico y microscópico ordinario, puesto que existe una correlación entre la supervivencia y el contenido de DNA de las células tumorales. La hemitiroidectomía puede ser una forma adecuada de tratamiento en pacientes con tumor unilateral y medición de DNA que indique un pronóstico favorable, en tanto que los pacientes, aún aquellos con un tumor muy pequeño, en quienes las determinaciones de DNA indiquen un pronóstico pobre, pueden exigir una forma más agresiva de tratamiento.

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Résumé La valeur pronostique de l'ADN (DNA) nucléaire en cas de cancer papillaire de la thyroïde a été étudiée chez 90 malades. Quatre-vingts des opérés ont survécu plus de 10 ans mais 10 moururent entre 6 mois et 12 ans après le diagnostic. Les données cliniques aussi bien que les caractères histologiques des lésions furent étudiés. La mesure de l'ADN (DNA) sur les cellules tumorales fut pratiquée soit après biopsie aspiration à l'aiguille fine, soit sur la coupe histologique. Les tumeurs des malades qui survécurent étaient constituées par des cellules dont le taux d'ADN (DNA) était comparable à celui des cellules normales, alors que les cellules des malades qui mouraient présentaient un taux d'ADN (DNA) significativement plus élevé.Cette étude suggère que la mesure de l'ADN (DNA) en présence d'un cancer papillaire de la thyroïde constitue un appoint utile aux données classiques de la clinique et de l'histologie.

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Presented at the International Association of Endocrine Surgeons at Hamburg, September 1983.

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Supported by the Cancer Society in Stockholm grant no. 83:24 and by the Swedish Cancer Society grant no. 83:198     

Correlation between histologic grading and prognosis of prostatic cancer--comparing the grading system of the Japanese general rules of prostatic cancer with Gleason's grading

To evaluate the correlation between the histological grade and the prognosis, we reviewed 100 cases of prostatic cancer according to the Japanese General Rules of Prostatic Cancer (JGRPC) and Gleason grading system. The study led to the following results: (1) There was a close relation between the JGRPC grade and Gleason score (GS). (2) The JGRPC grade and Gleason score were equally concerned with the clinical stage. (3) There were significant differences in survival rate between well and moderately, well and poorly differentiated groups by the JGRPC grading system, and between GS 2-4 and GS 5-7, GS 2-4 and GS 8-10 groups by Gleason score. (4) In proportion to the JGRPC grade, the cancer death rate increased linearly in each stage. (5) When the patients were grouped according to their JGRPC grades of main lesion and accompanied lesion, the cancer death rate increased in the cases with lower differentiated elements. We conclude that the JGRPC grading system is easily comprehensible, and equal with the Gleason grading system to predict the prognosis of prostatic cancer.     

Problems in grading of prostatic carcinoma: interobserver reproducibility of five different grading systems

Summary In order to investigate the reproducibility of grading systems for prostatic carcinoma currently in use, a comparative histological grading study was done. These studies were carried out on tissue sections from radical prostatectomy specimens (N=50) stained with hematoxylin and eosin. Five pathologists with varying professional experience participated in the study, using five different grading systems: those of Broders, Brawn, Gleason (for statistical compilation the modified version), Mostofi, and a modified Mostofi grading method recently described by Schroeder and Mostofi. Weighted kappa coefficients ranged from 0.21 to 0.52. None of the systems investigated demonstrated a high degree of reproducibility (k>0.70). Reproducibility of the systems described by Broders and Brawn was reasonably good (k=0.52 and 0.41, respectively). With the modified Gleason method (rearrangement of Gleason scores into 3 grades), a considerable difference was noted between the numerical agreement score (among at least 3 observers) and the measured kappa value (100% and 0.30, respectively). The methods described by Mostofi and Schroeder-Mostofi revealed only limited reproducibility (k=0.21 and 0.34, respectively).     

Diagnostic and prognostic significance of cytological malignancy grading of prostatic carcinoma

Clinical staging and morphological grading are very important for treatment of prostatic carcinoma. In 1980 a German pathological-urological study group of prostate cancer completed a new cytological grading system. This system has grades I-III of malignancy, based on six cellular criteria, whose relevance for prognosis was shown by cellkinetical investigations. The present study demonstrates less "undergrading" from transrectal fine needle biopsy and cytological diagnosis than from punch-biopsy and histological diagnosis. The cytological grade correlates well with the local extent of the tumor and metastases to pelvic lymph nodes. Despite of the wellknown problems with morphological grading on a biopsy it gives us very important information.     

Flow cytometric analysis of the nuclear DNA content of hepatocellular carcinoma

The nuclear DNA content of 77 resected specimens from 65 cases of hepatocellular carcinoma (HCC) was measured by means of flow cytometry. The DNA index (DI) was calculated and the correlation between the DNA ploidy pattern and clinicopathological findings was studied. In the cases of HCC with a diameter of less than 5 cm, the 3-year survival rate of the aneuploid cases was 44.5 per cent, which was significantly lower than the 91.4 per cent of the diploid cases (p less than 0.001). Serum AFP levels were over 1000 ng/ml in 46.4 per cent of the aneuploid tumors and 18.5 per cent of the diploid tumors (p less than 0.05). The DI's were investigated in several sites of the same tumor and no difference was seen among the different sites in 16 out of 17 tumors. From 8 recurrent cases out of 12 who underwent a second resection, seven did not show any significant differences in DI from their primary tumor. On the other hand, four cases of second primary tumors showed different DI's to those of their first primary tumor. Intra-hepatic metastatic tumors exhibited the same DI's as their primary tumors. Thus, the nuclear DNA ploidy pattern may serve as a stable and valuable marker in predicting the malignant potential and prognosis of HCC.     

The prognostic significance of nuclear DNA content in non-small-cell lung carcinoma

The nuclear DNA content of paraffin-embedded specimens of primary non-small-cell lung carcinomas was analysed using flow cytometry in 210 patients (80 squamous cell carcinomas, 99 adenocarcinomas, 19 large cell carcinomas and 15 others). The relationship between nuclear DNA content and prognostic factors was studied using multivariate analysis with Cox's proportional hazard model. 1) The frequency of DNA aneuploidy was 77.3% among 210 patients, and it significantly (p less than 0.05) increased with advanced stage and the presence of lymph node metastasis. 2) The patients with DNA aneuploid tumors had a significantly (p less than 0.001) less favorable prognosis than those with DNA diploid tumors among 179 patients with non-small-cell lung carcinomas. Similar results were demonstrated in 79 patients with stage I carcinomas and in 85 patients who underwent absolute curative resection. 3) Multivariate analysis using Cox's proportional hazard model showed that DNA ploidy was an independent prognostic factor for survival. Especially in the patients with absolute curative resection, DNA ploidy was the most important prognostic factor. In conclusion, flow cytometric nuclear DNA content analysis provided useful biological information, and DNA ploidy was an important and major independent prognostic factor in non-small-cell lung carcinoma.     

Flow cytometric analysis of the nuclear DNA content of hepatocellular carcinoma

The nuclear DNA content of 77 resected specimens from 65 cases of hepatocellular carcinoma (HCC) was measured by means of flow cytometry. The DNA index (DI) was calculated and the correlation between the DNA ploidy pattern and clinicopathological findings was studied. In the cases of HCC with a diameter of less than 5 cm, the 3-year survival rate of the aneuploid cases was 44.5 per cent, which was significantly lower the 91.4 per cent of the diploid cases (p<0.001). Serum AFP levels were over 1000 ng/ml in 46.4 per cent of the aneuploid tumors and 18.5 per cent of the diploid tumors (p<0.05). The DI’s were investigated in several sites of the same tumor and no difference was seen among the different sites in 16 out of 17 tumors. From 8 recurrent cases out of 12 who underwent a second resection, seven did not show any significant differences in DI from their primary tumor. On the other hand, four cases of second primary tumors showed different DI’s to those of their first primary tumor. Intra-hepatic metastatic tumors exhibited the same DI’s as their primary tumors. Thus, the nuclear DNA ploidy pattern may serve as a stable and valuable marker in predicting the malignant potential and prognosis of HCC.     

Prognostic significance of nuclear morphometry in renal cell carcinoma

OBJECTIVE: To assess nuclear morphometry as a predictor of prognosis in patients with renal cell carcinoma (RCC). PATIENTS AND METHODS: The study included 65 consecutive patients with RCC who underwent radical nephrectomy and were followed up for a median (range) of 80 (27-138) months. Nuclear morphometry was assessed using a computer-assisted image analysis system on histological sections and characterized by five nuclear variables (area, perimeter, major and minor diameter, and form factor). From the patients' records and pathology specimens, the clinicopathological prognostic variables (histological type, Fuhrman grade and pathological stage) were recorded. The proliferative activity was assessed using immunohistochemical staining with Ki-67 antibody. RESULTS: Higher values of mean nuclear area, perimeter, and major and minor diameter were significantly related to higher nuclear grade, proliferative activity and advanced tumour stage. They were significant predictors of disease progression and survival, together with grade, stage, sarcomatoid histology and proliferative activity. Of all significant prognostic factors predicting progression-free survival, only stage was independent (T4 vs T1, hazard ratio 6.55, 95% CI 1.63-26.13, P=0.008). CONCLUSION: Although the significance of these preliminary results must not be overstated, nuclear morphometry might provide significant prognostic information in predicting survival and tumours at high risk of progression in RCC.     

Human prostatic carcinoma in tissue culture: correlations between histological diagnosis and in vitro parameters

Prostatic cell biology is still largely unknown so that even the natural history of prostatic carcinoma is unpredictable. In order to correlate new observations with the prognosis of patients with prostatic carcinoma of various grades, we followed up 24 in vitro samples from surgical specimens of prostatic carcinoma. Fragments from 7 grade-I, 10 grade-II, 6 grade-III; and 1 grade-IV tumors were cultivated in Dulbecco's modified Eagle's medium supplemented with 10% fetal calf serum, 10% horse serum and 50 ng/ml each of hydrocortisone and insulin. Epithelial cells grown from the explants continued to grow for a maximum of 120 days and their morphology varied from a fairly regular monolayer of polygonal cells to irregular patterns of overlapping growth with many giant multinucleated cells. Although our data need a longer clinical follow-up time and larger numbers to achieve any statistical significance, the present findings seem to indicate rather clearly that a short life span in culture, a regular growth and a positive secretion activity is typical of low-grade tumors and that a longer life span, an irregular growth and a negative secretion in vitro are characteristics of high-grade tumors. A longer clinical follow-up of these patients will be important in the future to indicate whether these findings can be of any real prognostic value.