1402
FOLATE AND VITAMIN
+
B’2 DEFICIENCY IN
HIV- INFECTED PERSONS
= raised. — =!owered, normal NSnon-supptemented. S= supplemented
because the link between demyelination and folate deficiency7 or defective methyl-group metabolism, as reported by Dr Surtees and colleagues (March 17, p 619), has been highlighted in children with AIDS, and may play a part in the neurological damage of HIV infection. The association between vitamin B12 deficiency and HIV infection was less striking. A clearly decreased vitamin B12 level was recorded in only 10% of patients, less than the 25% previously reported.2 Because low vitamin B12 levels may be associated with an increased risk of haematological toxic effects in patients on zidovudine,9 and because folic acid treatment may cause neurological injury when given to patients with vitamin B12 deficiency,10 assays for serum vitamin B12 are advised for HIVinfected patients. POL BOUDES
JACQUELINE ZITTOUN
Hôpital Henri Mondor,
ALAIN SOBEL
94010 Créteil, France
1. Zittoun R, Zittoun J Les anémies par carence en vitamine B12 et en acide folique. Rev Prat 1970; 20: 573-97 2 Beach RS, Mantero-Atienza E, Eisdorfer C, Fordyce-Baum MK. Altered folate metabolism in early HIV infection JAMA 1988; 259: 518 3. Tilkian SM, Lefevre G, Coyle C, et al. Altered folate metabolism m early HIV
infection. JAMA 1988, 259: 3128-29. 4. Herbert V. Nutrition science
as a
continually unfolding story
the folate and vitamin
B12 paradigm. Am J Clin Nutr 1987; 46: 387-402 5. Fuchs
6.
7. 8. 9.
D, Reibnegger G, Wachter H, et al Neoptenn as a marker for activated cell-mediated immunity: application in HIV infection Immunol Today 1988; 9: 150-54. Habibi P, Strobel S, Smith I, et al. Neurodevelopmental delay and focal seizures as presenting symptoms of human deficiency virus 1 infection. Eur J Pediatr 1989; 148: 315-17. Smith I, Howells DW, Kendall B, Levmsky R, Hyland K Folate deficiency and demyelination in AIDS. Lancet 1987; ii:; 215. Boudes P Manifestations endocriniennes et métaboliques au course de l’infection VIH. Sem Hôp (Paris) 1989; 65: 1331-35. Richman DD, Fischl MA, Gneco MH, et al. The toxicity of azidothymidine (AZT) m the treatment of patients with AIDS and AIDS-related complex. N Engl Med J
1987; 317: 192-97. 10. Butterworth CE, Tamura T Folic acid safety and toxicity:
DISTRIBUTION OF HISTOLOGICAL DIAGNOSES OF SURGICAL BREAST SPECIMENS 1968 AND 1988
reconstructive and plastic surgery specimens from hypertrophic female breasts, mainly adolescent type, which increased from 0-3% in 1968 to 14-5% in 1988. In 1968 the diagnosis of a breast lesion was based upon palpation and surgical biopsy. In that year the pathology department did 135 frozen sections on breast biopsies (90 malignant, 45 benign) while these days the number does not exceed 5 a year. Today preoperative diagnostic evaluation means that frozen sections are hardly ever required. Furthermore mammographically detected lesions suspicious of malignancy are often small and need histological investigation on material undamaged by frozen section procedures. In the 1970s fine needle aspiration biopsy and mammography developed into reliable preoperative diagnostic tools for use in tandem with clinical investigation. The diagnosis is usually established before surgery so that the alternatives can be discussed with the patient. The increase in breast cancer between 1968 and 1988 was especially true for cases with characteristic mammographic findings, and mammographic screening has provided new knowledge about histological c1assification.1 Today the diagnosis of a breast lesion is based upon the combined skills of surgeons, oncologists, radiologists, cytologists, and pathologists. The pattern has been changed most remarkably by a decrease in fibrocystic disease and fibrosis, which are now looked upon as structural changes within the normal range (ie, "nondisease"2). Pathologists themselves have contributed to earlier misconceptions by supplying surgeons with a convenient diagnosis to justify intervention. Fibrocystic disease (or fibrosis) is not a histopathological entity. This benign breast disorder is an ANDI (aberration of normal development and involution 3). The changes we found had developed unnoticed for years. Similar studies from other breast clinics and screening centres would be interesting but the changes will probably not be seen at all in the absence of well-developed cytology and mammography services. University Department of Pathology, General Hospital, S-21401 Malmo, Sweden
a
brief review. Am J
FOLKE LINELL
GÖREL ÖSTBERG FRITZ RANK
Clin
Nutr 1989; 50: 353-58.
1 Linell 2
F, Rank F. Breast cancer: comments on histologic classifications with reference histogenesis and prognosis. Lund Dialogos, 1989. Love SM, et al Fibrocystic "disease" of the breast. a non-disease? N Engl J Med 1982;
3.
Hughes LE, Mansel RE, Webster DJT. Benign disorders and diseases of the breast.
to
Changes in diagnostic pattern in breast pathology SIR,-When change in the pattern of histological on diagnoses surgical specimens from breast lesions we decided to compare data for 1968 with those from 1988. In the city of Malmo (population about 250 000) all the women attend the only hospital (Malmö General). There was a moderate increase in malignancies and a sharp fall in the diagnosis of fibrosis or fibrocystic disease we
noted
307: 1010-14.
London: Ballierère Tindall, 1989: 1-4, 15-25.
a
(table). The material from breast cancer patients (table) includes some non-malignant specimens because final mastectomy specimens without residual cancer are taken into account. Breast cancers numbered 140 in 1968 and 184 in 1988. The number of surgical breast specimens fell by more than half because of the disappearance of fibrocystic disease and fibrosis. The designation "various" refers to lesions such as malformations, hamartoma, gynaecomastia, adenosis, papilloma, radial scar, epithelial hyperplasia, duct ectasia, and cysts, some of which in 1968 would probably have been labelled "fibrocystic disease". Also included under "various" are
Mesorectal spread and involvement of lateral resection margin in rectal cancer SIR,-Dr Cawthorn and colleagues (May 5, p 1055) describe the prognostic value of mesorectal spread and resection margin involvement in rectal cancer. It is unfortunate that they repeat the transgression of Quirke et all by describing the mesorectal resection margin as "lateral". Tumour may spread in any plane in the mesorectum and therefore deep or radial, not lateral, spread is the appropriate designation. Cawthorn et al promote the usefulness of mesorectal spread as an independent prognostic indicator in rectal cancer. Jass and colleagues2 from St Mark’s Hospital have shown, with similar meticulous pathological technique but much larger patient groups, that the degree of spread in the mesorectum does not contribute independent prognostic significance in the face of more powerful
FOLATE AND VITAMIN
+
B’2 DEFICIENCY IN
HIV- INFECTED PERSONS
= raised. — =!owered, normal NSnon-supptemented. S= supplemented
because the link between demyelination and folate deficiency7 or defective methyl-group metabolism, as reported by Dr Surtees and colleagues (March 17, p 619), has been highlighted in children with AIDS, and may play a part in the neurological damage of HIV infection. The association between vitamin B12 deficiency and HIV infection was less striking. A clearly decreased vitamin B12 level was recorded in only 10% of patients, less than the 25% previously reported.2 Because low vitamin B12 levels may be associated with an increased risk of haematological toxic effects in patients on zidovudine,9 and because folic acid treatment may cause neurological injury when given to patients with vitamin B12 deficiency,10 assays for serum vitamin B12 are advised for HIVinfected patients. POL BOUDES
JACQUELINE ZITTOUN
Hôpital Henri Mondor,
ALAIN SOBEL
94010 Créteil, France
1. Zittoun R, Zittoun J Les anémies par carence en vitamine B12 et en acide folique. Rev Prat 1970; 20: 573-97 2 Beach RS, Mantero-Atienza E, Eisdorfer C, Fordyce-Baum MK. Altered folate metabolism in early HIV infection JAMA 1988; 259: 518 3. Tilkian SM, Lefevre G, Coyle C, et al. Altered folate metabolism m early HIV
infection. JAMA 1988, 259: 3128-29. 4. Herbert V. Nutrition science
as a
continually unfolding story
the folate and vitamin
B12 paradigm. Am J Clin Nutr 1987; 46: 387-402 5. Fuchs
6.
7. 8. 9.
D, Reibnegger G, Wachter H, et al Neoptenn as a marker for activated cell-mediated immunity: application in HIV infection Immunol Today 1988; 9: 150-54. Habibi P, Strobel S, Smith I, et al. Neurodevelopmental delay and focal seizures as presenting symptoms of human deficiency virus 1 infection. Eur J Pediatr 1989; 148: 315-17. Smith I, Howells DW, Kendall B, Levmsky R, Hyland K Folate deficiency and demyelination in AIDS. Lancet 1987; ii:; 215. Boudes P Manifestations endocriniennes et métaboliques au course de l’infection VIH. Sem Hôp (Paris) 1989; 65: 1331-35. Richman DD, Fischl MA, Gneco MH, et al. The toxicity of azidothymidine (AZT) m the treatment of patients with AIDS and AIDS-related complex. N Engl Med J
1987; 317: 192-97. 10. Butterworth CE, Tamura T Folic acid safety and toxicity:
DISTRIBUTION OF HISTOLOGICAL DIAGNOSES OF SURGICAL BREAST SPECIMENS 1968 AND 1988
reconstructive and plastic surgery specimens from hypertrophic female breasts, mainly adolescent type, which increased from 0-3% in 1968 to 14-5% in 1988. In 1968 the diagnosis of a breast lesion was based upon palpation and surgical biopsy. In that year the pathology department did 135 frozen sections on breast biopsies (90 malignant, 45 benign) while these days the number does not exceed 5 a year. Today preoperative diagnostic evaluation means that frozen sections are hardly ever required. Furthermore mammographically detected lesions suspicious of malignancy are often small and need histological investigation on material undamaged by frozen section procedures. In the 1970s fine needle aspiration biopsy and mammography developed into reliable preoperative diagnostic tools for use in tandem with clinical investigation. The diagnosis is usually established before surgery so that the alternatives can be discussed with the patient. The increase in breast cancer between 1968 and 1988 was especially true for cases with characteristic mammographic findings, and mammographic screening has provided new knowledge about histological c1assification.1 Today the diagnosis of a breast lesion is based upon the combined skills of surgeons, oncologists, radiologists, cytologists, and pathologists. The pattern has been changed most remarkably by a decrease in fibrocystic disease and fibrosis, which are now looked upon as structural changes within the normal range (ie, "nondisease"2). Pathologists themselves have contributed to earlier misconceptions by supplying surgeons with a convenient diagnosis to justify intervention. Fibrocystic disease (or fibrosis) is not a histopathological entity. This benign breast disorder is an ANDI (aberration of normal development and involution 3). The changes we found had developed unnoticed for years. Similar studies from other breast clinics and screening centres would be interesting but the changes will probably not be seen at all in the absence of well-developed cytology and mammography services. University Department of Pathology, General Hospital, S-21401 Malmo, Sweden
a
brief review. Am J
FOLKE LINELL
GÖREL ÖSTBERG FRITZ RANK
Clin
Nutr 1989; 50: 353-58.
1 Linell 2
F, Rank F. Breast cancer: comments on histologic classifications with reference histogenesis and prognosis. Lund Dialogos, 1989. Love SM, et al Fibrocystic "disease" of the breast. a non-disease? N Engl J Med 1982;
3.
Hughes LE, Mansel RE, Webster DJT. Benign disorders and diseases of the breast.
to
Changes in diagnostic pattern in breast pathology SIR,-When change in the pattern of histological on diagnoses surgical specimens from breast lesions we decided to compare data for 1968 with those from 1988. In the city of Malmo (population about 250 000) all the women attend the only hospital (Malmö General). There was a moderate increase in malignancies and a sharp fall in the diagnosis of fibrosis or fibrocystic disease we
noted
307: 1010-14.
London: Ballierère Tindall, 1989: 1-4, 15-25.
a
(table). The material from breast cancer patients (table) includes some non-malignant specimens because final mastectomy specimens without residual cancer are taken into account. Breast cancers numbered 140 in 1968 and 184 in 1988. The number of surgical breast specimens fell by more than half because of the disappearance of fibrocystic disease and fibrosis. The designation "various" refers to lesions such as malformations, hamartoma, gynaecomastia, adenosis, papilloma, radial scar, epithelial hyperplasia, duct ectasia, and cysts, some of which in 1968 would probably have been labelled "fibrocystic disease". Also included under "various" are
Mesorectal spread and involvement of lateral resection margin in rectal cancer SIR,-Dr Cawthorn and colleagues (May 5, p 1055) describe the prognostic value of mesorectal spread and resection margin involvement in rectal cancer. It is unfortunate that they repeat the transgression of Quirke et all by describing the mesorectal resection margin as "lateral". Tumour may spread in any plane in the mesorectum and therefore deep or radial, not lateral, spread is the appropriate designation. Cawthorn et al promote the usefulness of mesorectal spread as an independent prognostic indicator in rectal cancer. Jass and colleagues2 from St Mark’s Hospital have shown, with similar meticulous pathological technique but much larger patient groups, that the degree of spread in the mesorectum does not contribute independent prognostic significance in the face of more powerful
