conjunctival melanoma was found among indivdiuals with AIDS, despite the three-fold to six-fold increased risk for skin melanoma for those with other immune deficiency conditions.3 By contrast, the relative risk for squamous-cell carcinoma of the conjunctiva was significantly increased, and after AIDS it may have been as high as that for non-Hodgkin lymphoma.4 With standard techniques5 we found no increased risk of trend for squamous carcinoma of the conjunctiva in San Francisco or the entire Surveillance, Epidemiology and End Results (SEER) US cancer surveillance system (data not shown). Thus, despite the significantly increased relative risk with AIDS, overall rates were unaffected and the absolute risk for squamous-cell carcinoma of the conjunctiva remains very low in the USA. The higher rate for conjunctival cancer in Uganda than in the USA suggests heterogeneity in other environmental factors, such as ultraviolet radiation, certain high-risk types of human papillomavirus, vitamin A deficiency, or xeroderma pigmentosum, an autosomal recessive condition that is common in northern African countries and that predisposes to sunlight-induced cancers of the skin and conjunctiva. *James J Goedert,
Timothy
2
3 4
5
*Y-J Bignon, Y Fonck, M-C Chassagne Oncology Genetics, INSERM CRI 9402, Centre J Perrin,
BP 392, 63011 Clermont-
Ferrand, France
1
R Coté
Viral Epidemiology Branch, National Cancer Institute, Rockville, MD 20852, USA
1
Our results accord with the major data of Jacquemier’s group in BRCA-1 linked breast cancers, but adjust the importance of the relation between hereditary susceptibility and histoprognostic grade. No more than 45% of hereditary breast cancers are attributable to BRCA-1,’ and other genes are at least as important. In hereditary predisposition to breast cancer, without knowledge of the involved gene, the proportion of grade 3 compared with other grades is quite similar to that in sporadic breast cancerdespite the fact that in young women an over-representation of grade 3 tumours was found. Moreover, we showed no worsened outcome in our pateints: 80% (20 of 25) are still alive at 6-4 years, and all grade 3 patients aged under 50 are alive (median follow-up 4-5 years). Grade 3 in hereditary breast cancer probably has a different biological importance than for sporadic breast cancer.
2
Easton DF, Bishop DT, Ford D, Crockford GP, and Breast Cancer Linkage Consortium. Genetic linkage analysis in familial breast and ovarian cancer: results from 214 families. Am J Hum Genet 1993; 52: 678-701. Page DL, Anderson TJ. Diagnostic histopathology of the breast. London: Churchill Livingstone, 1987: 300-11.
Melbye M, Coté TR, Kessler L, Gail M, Biggar RJ, the AIDS Cancer Working Group. High incidence of anal cancer among AIDS patients. Lancet 1994; 343: 636-39. Feldman AR, Kessler L, Myers MH, Naughton MD. The prevalence of cancer: estimates based on the Connecticut Tumor Registry. N Engl J Med 1986; 315: 1394-97. Greene MH, Young TI, Clark WH Jr. Malignant melanoma in renal-transplant recipients. Lancet 1981; i: 1196-99. Biggar RJ, Curtis RE, Coté TR, Rabkin CS, Melbye M. Risk of other cancers following Kaposi’s sarcoma: relation to acquired immunodeficiency syndrome. Am J Epidemiol 1994; 139: 362-68. Rabkin CS, Yellin F. Cancer incidence in a population with a high prevalence of infection with human immunodeficiency virus type 1. J Natl Cancer Inst 1994; 86: 1711-16.
Histoprognostic grade in tumours from families with hereditary predisposition to breast
cancer
SIR-Jacquemier and colleagues (June 10, p 1503) showed a surprising high frequency of infiltrating ductal carcinoma of the breast in women with BRCA-1-associated hereditary predisposition to breast cancer. More strikingly, all breast cancers (eight of eight) in women aged under 40 years were grade 3 infiltrating ductal carcinomas. We have examined a series of 25 infiltrating ductal carcinomas in French families, least four cases of breast cancer in women under age 60, without any male breast cancer. Unlike Jacquemier’s patients, our families had no significant positive lod-score with chromosome 17ql2-q21 micro satellite markers (lodand no BRCA-1 germ-line mutation. All scores <+1), histological sections were reviewed by one of us (YF). The distribution of histoprognostic grades 1, 2, and 3 was, respectively, 24% (six of 25), 52% (13 of 25), and 24% (six of 25). Mean age at diagnosis was 48-4 years (34-68, 28% under 40); 46-3 for grade 1 group, 51-2 years for grade 2, and 44-7 for grade 3. In the seven patients aged under 40, one had grade 1 disease, three grade 2, and three grade 3. In the 12 aged 40-49, three had grade 1 disease, five grade 2, and four grade 3. Thus, in our French families with strong positive lod-score with chromosome 17q12-21 markers or BRCA-1 germ-line mutation, we confirmed in seven patients aged under 40, a predominance of grade 3 infiltrating ductal carcinoma.
with
258
at
Pathologist
or
laboratory physician?
SIR-Through the courtesy of The Lancet’s columns I hereby relinquish my professional title "pathologist" and take on my new title "laboratory physician". The reason is that I am sick and tired of my professional activities being equated with dead patients. No matter how much sense of humour you have, how firm your determination to take things in stride, and how thick a skin you have, it hurts and it embarrasses when everybody including your clinician colleagues, friends, and strangers whom you meet for the first time regards you as a dead person’s doctor. I am proud of what I do in the post-mortem
room
and of the contributions of necropsy
pathology to medicine, but I do not want to be a subject of jokes and derogatory remarks any more. It should be emphasised that a pathologist also undertakes tasks other than necropsy pathology (surgical pathology, chemical pathology, immunopathology). Let us adopt the titles of laboratory medicine and laboratory physicians for the discipline and professionals in these specialties, respectively. I would define the terms laboratory medicine as the discipline dealing with the laboratory studies of tissues and other samples from patients and laboratory physician as the one who conducts and interprets these studies with respect to aetiology, pathogenesis, diagnosis, and prognosis of the suspected disease. The inclusion of the term "physician" in the professional title indicates that for the interpretation of laboratory data the person takes into consideration the clinical and other aspects of the disease.
Vijay
suspected
V Joshi
Department of Pathology and Laboratory Medicine, East Carolina University, School of Medicine, Greenville, NC 27858, USA
DEPARTMENT OF ERROR Which anticonvulsant for women with eclampsia?-In table 3 of this article (June 10, p 1455), the CI for relative risk for death in the comparison magnesium sulphate versus phenytoin should read 024-105. On p 1460, the end of the first paragraph should read 2p=006.