Borderline Malignant Potential Research Articles

Intraoral epithelioid hemangioendothelioma: A case report and review of the literature

The epithelioid hemangioendothelioma (EH) is an uncommon angiocentric neoplasm of borderline or intermediate malignant potential, between the hemangioma and conventional angiosarcoma. It is characterized by the proliferation of endothelial cells with epithelioid or histiocitóide morphology with vacuolated cytoplasm and occasional eosinophilic spindle cells. Shows potential for local recurrence as well as the ability to metastasize. Rarely affects the oral cavity, it have been described from 1975 until 2008 only 27 oral cases. Morphologically the EHs may be confused with other lesions, from a hemangioma to a squamous cell carcinoma, and thus immunohistochemical analysis is required. This paper reports the clinical and immunohistochemical characteristics of a case of EH in the gingiva of the tooth 35 of a 17 years-old-white-female. We present a review of the clinicopathological and immunohistochemical characteristics of the intraoral epithelioid hemangioendothelioma cases previously reported.

Analysis of malignant and borderline ovarian tumors, comparing pre- and post-laparoscopic diagnoses

Purpose: To evaluate the incidence, character, and prognosis of ovarian tumors diagnosed as benign before laparoscopic surgery but identified as malignant or of borderline malignancy by postoperative histopathology.Subjects: Of 1,066 laparoscopic ovarian tumor resections at Tohoku Kosai Hospital from April 2001 to May 2010, a total of 22 patients were postoperatively confirmed as having overt or borderline malignancies. Methods: For this patient subset, the following factors were analyzed: postsurgical histopathology, patient age, tumor size, solid tumor component, CA125 and CA19-9 markers, laparoscopic technique, tumor capsule status, adjunctive therapy, and prognosis.Results: The rate of preoperative diagnostic error was 2.2% (22/1,066). Of the 22 misinterpreted tumors, five were clearly malignant, and 17 were of borderline malignant potential. Although no specific tendencies were evident, based on analysis of preoperative features, malignant lesions were more likely in older patients or in those with large sized cysts. For two of the five patients with malignancies, definitive cancer surgery was performed, followed by chemotherapy, while the other three received chemotherapy alone. Three of the 17 patients with borderline malignancy also opted for surgery. Endometrial carcinoma was found in one patient with malignancy, and recurrent mucinous cysts occurred in two patients with borderline tumors, but the long-term prognosis for these patients in close follow-up was fairly good.Conclusion: Preoperative misdiagnosis of ovarian malignancies may be unavoidable, despite thorough assessment. However, even with laparoscopic resection, the prognosis of such tumors is not poor, given adequate adjunctive therapy and/or careful clinical follow-up.

Unique vascular tumor primary arising in the liver and exhibiting histopathological features consistent with so‐called polymorphous hemangioendothelioma

Reported herein is an unusual vascular tumor primary arising in the liver and exhibiting unique histopathological features. A 47-year-old woman underwent left hepatectomy because of a large hepatic mass. On histology the tumor had a composite pattern, consisting of angiomatous, retiform and solid areas, formed by oval to cuboidal to spindle cells, that expressed only endothelial markers (CD31 and factor VIII-related antigen). These findings led to the diagnosis of a low-grade vascular neoplasm with morphological features consistent with so-called polymorphous hemangioendothelioma. The tumor was completely resected. At 24 month follow up the patient was alive, without evidence of disease. Polymorphous hemangioendothelioma is a rare vascular neoplasm, with borderline malignant potential, which usually occurs in lymph nodes and, rarely, at extranodal sites. Its classification as an entity has been questioned recently. The unusual morphological features of the present case, which do not fit neatly with any other recognized hemangioendothelioma subtype, indicate that the family of vascular tumors is broader than currently accepted. In addition the present case widens the spectrum of primary vascular tumors arising in the liver.

Solid Pseudopapillary Tumor of the Pancreas: An Unexpected Finding After Minor Abdominal Trauma

A 20-year-old female college student presented to the emergency department with epigastric pain and vomiting several hours after being struck in the abdomen with a soccer ball. She had no significant past medical or surgical history. On examination the patient was afebrile and hemodynamically stable. Her abdominal examination was significant for epigastric and right upper quadrant tenderness. Computed tomography (CT) of the abdomen and pelvis was obtained to rule out traumatic intra-abdominal injury. CT revealed a multi-septated cystic mass at the pancreatic neck measuring 6.1 9 6.6 cm, with associated mural nodules and rim enhancement (Fig. 1). The mass appeared to invade the posterior wall of the stomach and compress the portal vein near the confluence of the superior mesenteric vein and splenic vein. Lymphadenopathy of the celiac axis and greater curvature of the stomach was noted. The patient was admitted and underwent endoscopic ultrasound with fine needle aspiration of the cystic pancreatic mass. Cytology from this procedure showed clusters of polygonal cells with abundant cytoplasm, surrounding fibrovascular structures in a background of blood and necrotic debris. Mitotic figures were not apparent. The findings were interpreted as consistent with solid pseudopapillary tumor of the pancreas. The patient was taken for surgical resection at which time there was noted to be extensive inflammatory change surrounding the tumor, involving the duodenum and transverse mesocolon, with adherence of the tumor to the SMV, portal vein and hepatic artery. The patient ultimately required total pancreatectomy, duodenectomy, splenectomy, partial gastrectomy and right hemicolectomy for complete resection. Final pathology revealed a solid pseudopapillary neoplasm with borderline malignant potential, 6.5 cm in greatest dimension, with negative lymph nodes (0/25). There was submucosal inflammation and necrosis of the adjacent posterior wall of the stomach, but microscopic examination showed no evidence of tumor invasion into any adjacent structures. The patient recovered from surgery and received an insulin pump for insulin replacement. With three-year follow up with CT surveillance, she has no evidence of tumor recurrence.

Laryngeal kaposiform hemangioendothelioma: Case report and literature review

The kaposiform hemangioendothelioma (KHE) is an uncommon vascular neoplasm of borderline or intermediate malignant potential in which involvement of the head and neck region is rare. A 5-year-old girl was admitted to the emergency room with abrupt massive hemoptysis. Transoral laryngoscopy revealed a round, reddish mass with active bleeding on the anterior portion of the left vocal fold region. Since re-hemoptysis and large amount of aspiration caused breathing difficulties for the patient, suspension exam was performed under general anesthesia. Mass excision and thorough bleeding control was performed with laser assisted laryngo-micro system. Postoperatively, there was no further bleeding. The pathologic diagnosis of the tumor was KHE. To the best of our knowledge, this is the first report of a KHE in the larynx presenting as recurrent hemoptysis in childhood.

Nodal and Extranodal Soft Tissue Polymorphous Hemangioendothelioma: A Case Report and Review of the Literature

Polymorphous hemangioendothelioma is a rare vascular tumor of borderline malignant potential and only 10 cases have been described in the literature so far. We report a case of nodal and extranodal polymorphous hemangioendothelioma and review the literature. A 66-year-old man with an unremarkable past medical history was admitted for a left submandibular mass. The main nodule was composed of angiosarcoma-like areas mixed with angiomatous features; some vascular spaces with hobnail endothelium were seen. The tumor involved two adjacent lymph nodes. Immunohistochemically, the neoplastic cells were strongly positive for CD31 and vimentin. After a few months the tumor recurred and the patient was treated with radiation therapy. Polymorphous hemangioendothelioma is a distinct entity in the hemangioendothelioma group with its own clinical and histological features.

Epitheloid hemangioendothelioma of urinary bladder

Epitheloid hemangioendothelioma is an uncommon vascular neoplasm and has an unpredictable clinical behavior. It is characterized by round or spindle-shaped endothelial cells with cytoplasmic vacuolation. Most often, epitheloid hemangioendothelioma arise from the soft tissues of the upper and lower extremities and it has borderline malignant potential. We describe the first reported case of epitheloid hemangioendothelioma in the urinary bladder, which was treated by transurethral resection. The diagnosis was confirmed by immunohistochemistry.

Serous Cystadenoma of the Epididymis

Tumors reminiscent of müllerian epithelial tumors of the ovary have been reported outside of the ovary, including in the pancreas and paratesticular region. The latter are most commonly serous tumors of borderline malignant potential and involve the tunicae. We present the first case of a serous cystadenoma of the epididymis in English reports with a brief literature review.

Epithelioid Haemangioendothelioma of the Palate

Epithelioid haemangioendothelioma is a vascular neoplasm of borderline or intermediate malignant potential. The tumour occurs predominantly in the extremities and is rarely found in the oral cavity. A 22-year-old female with an epithelioid haemangioendothelioma in the palate is reported.

Primary cutaneous adenomyoepithelioma

An 83-year-old Caucasian woman presented to her dermatologist with a 5-cm subcutaneous tumor on her right thigh. The lesion had been present for many years, but had recently enlarged. Incisional biopsy showed a multinodular tumor composed of variably sized glands comprised of a luminal layer of epithelial cells surrounded by one or more layers of myoepithelial cells. The histopathologic features resembled those of adenomyoepithelioma, an uncommon neoplasm usually encountered within the breast. Primary cutaneous adenomyoepithelioma is very rare yet shares histopathologic features with common cutaneous lesions such as spiradenomas and benign mixed tumors (chondroid syringomas). Primary cutaneous adenomyoepithelioma is part of the spectrum of epithelial-myoepithelial tumors that includes benign mixed tumor, myoepithelioma and myoepithelial carcinoma. This rare tumor may mimic malignant lesions including metastatic adenocarcinoma. Like its breast counterpart, primary cutaneous adenomyoepithelioma should probably be regarded as a neoplasm of borderline malignant potential.

Epithelioid haemangioendothelioma in the parapharyngeal space

Epithelioid haemangioendothelioma (EHE) is an uncommon vascular neoplasm which occurs rarely in the head and neck and has an unpredictable clinical behaviour. It is characterized by round or spindle-shaped endothelial cells with cytoplasmic vacuolation. Most often, EHE arises from the soft tissues of the upper and lower extremities, and it has borderline malignant potential. We describe the first reported case of EHE in the parapharyngeal space, which was treated successfully via a transcervical-transparotid approach (following angiography with embolization), without massive intra-operative bleeding or facial nerve damage.

Epithelioid hemangioendothelioma of the oral cavity: Report of two cases and review of the literature

The epithelioid hemangioendothelioma is an uncommon vascular neoplasm of borderline or intermediate malignant potential. Although numerous sites of involvement are possible, these tumors most commonly arise in soft tissue, liver, and lung. Involvement of the oral cavity is rare. Only 12 cases of intraoral epithelioid hemangioendothelioma have been reported in the English language literature. We review the salient features of these previously reported cases and present 2 additional intraoral cases--one presenting as an asymptomatic radiolucency in the posterior mandible of a 23-year-old female, and the other presenting as an asymptomatic, erythematous to purplish gingival nodule in a 28-year-old female. Intraoral tumors most commonly involve the gingival soft tissues and often are associated with adjacent alveolar bone resorption. Although it is not possible to estimate with accuracy the potential for recurrence and metastasis among intraoral tumors given the small number of previously reported cases, wide local excision with close clinical follow-up appears to be the treatment of choice for these tumors because of their unpredictable clinical behavior.

Association between glutathione-S-transferase GSTP1 genotypes, GSTP1 over-expression, and outcome in epithelial ovarian cancer.

Ovarian cancer accounts for the majority of deaths from gynaecological malignancy, and polymorphisms in genes encoding the glutathione-S-transferase (GST) GSTP1 detoxifying enzymes may lead to variation in detoxification of carcinogens. We describe a study involving 81 women with invasive epithelial ovarian cancer. A number of important clinical variables and outcome data were obtained. GSTP1 genotyping was undertaken using PCR-based techniques, and GSTP1 expression was quantified using immunohistochemistry (IHC). A Cox's proportional hazard regression model was used to analyze the effects on outcome. We also independently examined 11 women with borderline or low malignant potential (LMP) tumors using IHC only. The mean age of the women was 61.5 years +/- 12 (1 SD) (range 36-88 years), the median overall survival was 26 months, and median progression free interval (PFI) 21 months. There was a significant association between GSTP1 (Val(104)/Val(104)) genotypes, and reduced survival (P = 0.05) and the GTP1 (Ile(104)/Val(104)) genotype appeared to have the best outcome (HR = 0.34, P = 0.045, 95% CI = 0.12-0.98). There was no significant association between the GSTP1 genotypes and any clinico-pathological parameters; there were also no associations between GSTP1 genotypes and response to postoperative chemotherapy. Specific nuclear GSTP1 over-expression was associated with less residual disease (P = 0.05); specific cytoplasmic GSTP1 over-expression with more favourable performance status (P = 0.014)). We found that 10/11 (91%) of the LMP (borderline) tumors over-expressed nuclear GSTP1 compared to only 52% of the invasive tumors (chi(2) ((1)) = 5.95, P = 0.015). There was no significant association between the level of GSTP1 expression and response to postoperative chemotherapy. The overall level of GSTP1 expression and the subcellular localization of GSTP1 expression were not associated with either survival or PFI. There was a significant association between the GSTP1 (Ile(104)/Ile(104)) genotypes and increased overall GSTP1 expression (P = 0.049), and the GSTP1 (Ile(104)/Val(104)) genotypes and reduced overall GSTP1 expression (P = 0.046). We speculate that GSTP1 Ile(104)/Val(104) genotypes are associated with improved outcome because the protein/enzyme, which is expressed, may provide a better balance between the effects of detoxification of carcinogens and the effects of metabolism of chemotherapy agents. In addition, over-expression of nuclear GSTP1 appears to be associated with more favorable ovarian tumor characteristics. In our preliminary study, we also reported a relationship between overall GSTP1 expression and certain GSTP1 genotypes. As far as we are aware, this is the first time that a relationship between the GSTP1 genotypes, GSTP1 expression and outcome has been described in ovarian cancer. Whether the genotype directly determines GSTP1 expression is at present unclear and the precise mechanism of this interaction is unknown.

Association between glutathione-S-transferase GSTP1 genotypes, GSTP1 over-expression, and outcome in epithelial ovarian cancer

Ovarian cancer accounts for the majority of deaths from gynaecological malignancy, and polymorphisms in genes encoding the glutathione-S-transferase (GST) GSTP1 detoxifying enzymes may lead to variation in detoxification of carcinogens. We describe a study involving 81 women with invasive epithelial ovarian cancer. A number of important clinical variables and outcome data were obtained. GSTP1 genotyping was undertaken using PCR-based techniques, and GSTP1 expression was quantified using immunohistochemistry (IHC). A Cox's proportional hazard regression model was used to analyze the effects on outcome. We also independently examined 11 women with borderline or low malignant potential (LMP) tumors using IHC only. The mean age of the women was 61.5 years ± 12 (1 SD) (range 36–88 years), the median overall survival was 26 months, and median progression free interval (PFI) 21 months. There was a significant association between GSTP1 (Val104/Val104) genotypes, and reduced survival (P= 0.05) and the GTP1 (Ile104/Val104)genotype appeared to have the best outcome (HR = 0.34,P= 0.045, 95% CI = 0.12–0.98). There was no significant association between the GSTP1 genotypes and any clinico-pathological parameters; there were also no associations between GSTP1 genotypes and response to postoperative chemotherapy. Specific nuclear GSTP1 over-expression was associated with less residual disease (P= 0.05); specific cytoplasmic GSTP1 over-expression with more favourable performance status (P= 0.014)). We found that 10/11 (91%) of the LMP (borderline) tumors over-expressed nuclear GSTP1 compared to only 52% of the invasive tumors (χ2(1)= 5.95,P= 0.015). There was no significant association between the level of GSTP1 expression and response to postoperative chemotherapy. The overall level of GSTP1 expression and the subcellular localization of GSTP1 expression were not associated with either survival or PFI. There was a significant association between the GSTP1 (Ile104/Ile104) genotypes and increased overall GSTP1 expression (P= 0.049), and the GSTP1 (Ile104/Val104) genotypes and reduced overall GSTP1 expression (P= 0.046). We speculate that GSTP1 Ile104/Val104genotypes are associated with improved outcome because the protein/enzyme, which is expressed, may provide a better balance between the effects of detoxification of carcinogens and the effects of metabolism of chemotherapy agents. In addition, over-expression of nuclear GSTP1 appears to be associated with more favorable ovarian tumor characteristics. In our preliminary study, we also reported a relationship between overall GSTP1 expression and certain GSTP1 genotypes. As far as we are aware, this is the first time that a relationship between the GSTP1 genotypes, GSTP1 expression and outcome has been described in ovarian cancer. Whether the genotype directly determines GSTP1 expression is at present unclear and the precise mechanism of this interaction is unknown.

Hemangioendotelioma epitelioide de pene

A case of EH of the penis in a sixtyfour-year-old patient is described. This is a rare –in this location- vascular tumor of borderline malignant potential between hemangioma and angiosarcoma. Local excision of the tumor with a cut-off of normal tissue and careful follow-up of the patient is the accepted procedure. Immunohistochemistry is essential for the diagnosis.

Ovarian mucinous cystadenocarcinoma as a cause of Zollinger-Ellison syndrome:: Report of a case and review of the literature

Gastrin producing ovarian tumor is a rare cause of the Zollinger-Ellison syndrome. We report the case of an ovarian carcinoma showing increased plasma gastrin concentration. A 60-yr-old woman presented with epigastric pain and diarrhea. Physical examination showed a large mass in the lower abdomen. Computed tomography revealed a large multilocular ovarian cyst. Upper gastrointestinal endoscopy examination showed multiple ulcerations of the stomach and duodenum. The plasma gastrin level was 1500 pg/ml. No tumors were found in the pancreas and duodenum, and salpingo-oophorectomy was performed. Histologic examination revealed a mucinous tumor of borderline malignant potential. Immunoperoxidase studies for gastrin showed many gastrin-producing cells within the epithelium of the tumor. There have been 11 cases (including our patient) of gastrin-producing ovarian tumor reported in the literature. We review here the relevant literature. Although ovarian gastrinoma is extremely rare, it should be considered as a possible cause of the Zollinger-Ellison syndrome in women.

Ovarian tumors of borderline malignancy (tumors of low malignant potential): a critical appraisal.

Before the designations borderline malignancy and low malignant potential were used, the surface epithelial-stromal tumors of the ovary were simply classified into benign and malignant categories. The introduction of the borderline category of tumors has been a great advancement in classification, because it has set apart from the general group of surface epithelial cancers a subgroup with a much better prognosis, stage-for-stage, than that of conventional ovarian carcinomas. Over the last 20 years, pathologists have learned to recognize the distinctive clinicopathologic features of serous borderline tumors as well as the adverse prognostic significance of the associated invasive peritoneal lesions, whether they may represent true implants or independent primary tumors. We have urged our surgical colleagues to search for the peritoneal lesions, and sample them meticulously, and advised our fellow oncologists not to administer adjuvant therapy to patients with noninvasive implants lacking malignant epithelial cells. There is now convincing evidence in the literature that the only fatal cases of serous borderline tumors are those associated with invasive implants, and chemotherapy is indicated only for these rare tumors. It has also been demonstrated that Stage I intestinal mucinous borderline tumors and noninvasive well-differentiated mucinous carcinomas both have an almost equally good prognosis. The current treatment for pseudomyxoma peritonei is still unsatisfactory, but we have recently learned that most of the mucinous ovarian tumors associated with pseudomyxoma peritonei are secondary to similar tumors of the appendix. In the remaining cases, however, the ovarian tumor appears to be responsible for the pseudomyxoma peritonei. Borderline tumors also exist in the endometrioid, clear cell, and Brenner surface epithelial categories, but these tumors have been too rare for clear delineation of their clinical and pathologic features. Recently, some investigators have proposed to abandon the borderline category and to return to the old benign-malignant classification system by dividing unevenly the borderline tumors into a larger group of atypical proliferative epithelial cystadenomas and a smaller category of recently described but still not well-characterized noninvasive carcinomas. In the author's opinion, such a recommendation is misleading because it ignores the possibility of rare but significant behavioral exceptions on each of these two groups of tumors. Furthermore, careful tumor staging is mandatory in both instances regardless of the type of terminology used. It is hoped that by keeping the borderline designation, knowledge on this group of ovarian tumors will continue to expand as it has been until now.

Prevalence and significance of HER-2/neu amplification in epithelial ovarian cancer.

Amplification of the HER-2/neu oncogene was assessed in 80 cases of epithelial ovarian tumors using differential polymerase chain reaction. HER-2/neu gene was amplified in 22 of 46 invasive cancers (48%) and in 5 of 34 borderline cancers (15%), but none of the 20 specimens of normal ovaries showed amplification. THis difference is statistically significant (p = 0.00004). The incidence of HER-2/neu amplification in late stage (III-IV, 77%) was significantly higher than that in early stage (I-II, 21%) in invasive epithelial carcinoma (p = 0.0004). There was no correlation between HER-2/neu amplification and cell type or grade of tumor. In cases of ovarian tumors of borderline malignant potential, the amplification of HER-2/neu was not correlated with clinicopathologic features. Follow-up with a mean of 22 months (6-50 months) was available for 39 cases of invasive ovarian cancers and all 34 borderline ovarian cancers. The incidence of HER-2/neu amplification in the invasive cancer and borderline cancer patients who were alive with disease was 50 and 50%, and is not statistically different from that in the patients who were alive with no evidence of disease (p = 0.662 and 0.345, respectively). The incidence of amplification in the invasive cancers of patients who died of the disease (86%) was higher than that in the patients who were still alive (44%), but the difference is not statistically significant (p = 0.175). This study supports the association of HER-2/neu amplification with progression of invasive ovarian cancer. It also suggests that HER-2/neu amplification may be an adjunctive prognostic factor of invasive epithelial ovarian cancer, shown to be associated with an unfavorable clinical course. In addition, HER-2/neu amplification occurs relatively infrequently in early invasive and borderline ovarian cancers, making it unlikely that such amplification is a general early event in ovarian carcinogenesis.

Parity, age at first childbirth, and risk of ovarian cancer

SummaryIncreasing parity is associated with a reduction in the risk of ovarian cancer, but it is not clear whether this association applies to different histopathological types and to borderline tumours. Moreover, the temporal relations are poorly understood, and the possible role of age at first birth remains unequivocal. We have investigated these issues in a case-control study nested in a nationwide cohort of women born between 1925 and 1960 in Sweden. During follow-up until 1984, 3486 invasive ovarian cancers (2992 epithelial, 330 stromal, 149 germ-cell, 15 not classifiable) and 510 tumours of borderline malignant potential were diagnosed. 5 individually age-matched controls (total 19 980) were selected for each case woman. After simultaneous adjustment for parity and age at first birth, increasing parity was associated with a pronounced consistent decrease in relative risk of all invasive cancers (odds ratio for each additional birth 0·81 [95% CI 0·77-0·85]), epithelial cancer (0·81 [0·77-0·86]), stromal cancer (0·84 [0·72-0·98]), and germ-cell cancer (0·71 [0·48-1·05]), but a less consistent decrease for borderline tumours (0·92 [0·81-1·04]). The risk of ovarian cancer decreased by about 10% for each 5-year increment in age at first childbirth (odds ratios 0·89 [0·84-0·94] epithelial cancer, 0·92 [0·77-1·10] stromal cancer, 0·92 [0·65-1·32] germ-cell cancer, 0·93 [0·80-1·09] borderline tumours).Because our findings cannot be readily explained by theories invoking incessant ovulation or high serum concentrations of gonadotropins, new aetiological hypotheses are needed. Pregnancy-dependent clearance from the ovaries of cells that have undergone malignant transformation could explain the reproductive risk factors for ovarian cancer.

The behavior of serous tumors of low malignant potential: are they ever malignant?

Although the literature describing the clinicopathologic features of serous borderline or low malignant potential (LMP) tumors of the ovary is extensive, the behavior of these neoplasms is not well understood. While some studies indicate a 30 to 40% mortality for advanced stage tumors, it is not clear whether this poor outcome is related to "benign" complications of the disease, such as bowel obstruction from adhesions, or to development of carcinomatosis from malignant transformation. In an effort to determine more clearly the cause of death of patients with serous LMP tumors and to assess the malignant potential of these tumors, defined by progression to invasive serous carcinoma, we reviewed 22 series, totalling 953 patients. Analysis of these studies reveals that for patients with stage I tumors, survival is 99%. For advanced stage disease, survival is 92%. Advanced-stage tumors associated with so-called invasive implants were excluded from this analysis because they were considered invasive serous carcinomas at the time of diagnosis rather than noninvasive LMP tumors. Various causes of death in patients with advanced-stage tumors include complications of the disease, complications of therapy, and, rarely, malignant transformation. Our review of 953 cases disclosed only seven (0.7%) tumors that appeared to have undergone malignant transformation, resulting in death from intraabdominal carcinomatosis. Because the rate of malignant transformation is exceedingly low and because classifying these tumors as malignant often leads to unnecessary treatment, we believe that the term low malignant potential or borderline tumor is not justified.(ABSTRACT TRUNCATED AT 250 WORDS)