Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control.

PURPOSE: Quality assessment and assurance are important issues in modern health care. For the evaluation of surgical procedures, there are indirect parameters such as complication, recurrence, and survival rates. These parameters are of limited value for the individual surgeon, and there is an obvious need for direct parameters. We have evaluated criteria by which pathologists can judge the quality or completeness of the resection specimen in a randomized trial for rectal cancer. PATIENTS AND METHODS: The pathology reports of all patients entered onto a Dutch multicenter randomized trial were reviewed. All participating pathologists had been instructed by workshops and videos in order to obtain standardized pathology work-up. A three-tiered classification was applied to assess completeness of the total mesorectal excision (TME). Prognostic value of this classification was tested using log-rank analysis of Kaplan-Meier survival curves using the data of all patients who did not receive any adjuvant treatment. RESULTS: Included were 180 patients. In 24% (n = 43), the mesorectum was incomplete. Patients in this group had an increased risk for local and distant recurrence, 36.1% v. 20.3% recurrence in the group with a complete mesorectum (P =.02). Follow-up is too short to observe an effect on survival rates. CONCLUSION: A patient's prognosis is predicted by applying a classification of macroscopic completeness on a rectal resection specimen. We conclude that pathologists are able to judge the quality of TME for rectal cancer. With this direct interdisciplinary assessment instrument, we establish a new role of the pathologist in quality control.     

PERINATAL, NEUROLOGICAL, ENVIRONMENTAL AND DEVELOPMENTAL CHARACTERISTICS OF SEVEN-YEAR-OLD CHILDREN WITH STABLE BEHAVIOUR PROBLEMS

From a large sample of 7-yr-olds in Dunedin, New Zealand, a group of 52 boys and 32 girls with stable behaviour problems was selected and compared with the remainder of the sample. The groups did not differ in terms of perinatal problems except for a higher prevalence of being small for gestational age in the problem group. The mothers of the problem children tended to be younger, to have lower mental ability and poorer health than the rest of the sample. The families of the problem children were rated as having poorer relationships, and there was more parental separation and solo parenting in this group. Finally, the children with stable problems showed cognitive delays at age 7 yr.     

Squamous cell carcinoma of the vagina: A clinical study of the location of the tumor

Sixty-seven cases of primary squamous cell carcinoma of the vagina were treated between 1956 and 1975. Irradiation was the principal mode of therapy and overall 5-year survival was 38.8%. Lesions involving the lower vagina had a propensity for metastasis, particularly to the inguinofemoral nodes. Radical surgery is suggested for selected cases with lesions of the upper third or the posterior wall of the vagina with removal of the inguinofemoral nodes where appropriate.     

Moving further upstream: from toxics reduction to the precautionary principle

Early policies to reduce the amount of toxic waste in the environment focused on cleaning up downstream sources of pollution, such as toxic disposal sites. Public attention in the 1980s encouraged both industry and government to develop an alternative to this command-and-control approach. This article describes the emergence of that alternative-pollution prevention-and its application in Massachusetts through the 1989 Toxics Use Reduction Act. Pollution prevention focuses on the sources of pollution, both metaphorically and physically, more upstream than its predecessors. The success of the Toxics Use Reduction Act in Massachusetts helped create an opportunity where an alternative pollution prevention paradigm could develop. That paradigm, the precautionary principle, is popular among environment activists because it focuses further upstream than pollution prevention by calling attention to the role the social construction of risk plays in decisions regarding the use of hazardous substances. The authors examine the evolution of the precautionary principle through an investigation of three major pathways in its development and expansion. The article concludes with a discussion of the increased potential for protecting public health and the environment afforded by this new perspective.     

Preimplantation Genetic Diagnosis Using Fluorescent Polymerase Chain Reaction: Results and Future Developments

Purpose: Fluorescent polymerase chain reaction (PCR) is a multipurpose technique that can be used for diagnosing sex, single-gene defects, and trisomies as well as determining DNA fingerprints from single cells. However, its effectiveness must be assessed before clinical preimplantation genetic diagnosis (PGD) application. Methods: Single and multiplex fluorescent PCR was applied to single cells and blastomeres. Results: Fluorescent PCR can be used to diagnose sex from blastomeres and has been successfully applied in a clinical PGD sexing program resulting in a confirmed pregnancy. A further major advantage of fluorescent PCR is the ability to multiplex, providing multiple diagnoses and DNA fingerprints with a high reliability (~75% for trisomy, 86% for DNA fingerprint) and good accuracy (70–80%). Allele dropout in multiplex PCR is ~20% per allele and does not appear to be associated with the fragment size. Conclusions: Fluorescent PCR is a powerful technique for PGD, and the effects of allele dropout must be considered, particularly in multiplex PCR.     

An evaluation of the variability of tumor-shape definition derived by experienced observers from CT images of supraglottic carcinomas (ACRIN protocol 6658)

PURPOSE: Accurate target definition is considered essential for sophisticated, image-guided radiation therapy; however, relatively little information has been reported that measures our ability to identify the precise shape of targets accurately. We decided to assess the manner in which eight "experts" interpreted the size and shape of tumors based on "real-life" contrast-enhanced computed tomographic (CT) scans. METHODS AND MATERIALS: Four neuroradiologists and four radiation oncologists (the authors) with considerable experience and presumed expertise in treating head-and-neck tumors independently contoured, slice-by-slice, his/her interpretation of the precise gross tumor volume (GTV) on each of 20 sets of CT scans taken from 20 patients who previously were enrolled in Radiation Therapy Oncology Group protocol 91-11. RESULTS: The average proportion of overlap (i.e., the degree of agreement) was 0.532 (95% confidence interval 0.457 to 0.606). There was a slight tendency for the proportion of overlap to increase with increasing average GTV. CONCLUSIONS: Our work suggests that estimation of tumor shape currently is imprecise, even for experienced physicians. In consequence, there appears to be a practical limit to the current trend of smaller fields and tighter margins.