Nottingham System Research Articles

Ki-67 and mitotic index in triple-positive breast cancer.

e12551 Background: A grade in breast cancer is the strongest prognostic factor. In the new edition of the AJCC 8th, the tumor grade is one of the criteria that determines patients with breast cancer in the prognostic groups. According to the Nottingham system the mitotic count (MC) mostly determines the grade. Interobserver reproducibility for MC is not as good as for IHC marker phh3. The group of triple-positive breast cancer (TPBC) is characterized by the presence of a crosstalk mechanism between the signaling pathways of ER and HER2, which leads to the development of resistance to therapy. However, according to the 8th AJCC, patients with ER+/HER2+ belong to a more favorable prognostic group. Methods: We selected 284 patients with early BC who received treatment at our centre from 2012 to 2020 and didn’t receive presurgical therapy. The patients were divided according to the surrogate subtype into triple-positive (n = 90) and other subtypes (n = 194). The Ki-67, the number of nuclei of tumor cells stained with anti-phh3 antibody, the cell density of the tumor per 1 mm2 and the number of phh3 + per 1000 tumor cells were assessed. Results: Visually accessed number of mitoses was grade 3 in 30% of tumors in the TPBC group and 29% in the second group. There was no statistically significant difference in the Ki-67 index of proliferative activity in the two studied groups. In the TPBC group the median Ki-67 was 16.8%, in the second group - 18.3% (p = 0.376516), while the groups differed significantly in terms of the phh3 index (the median in the TPBC was 23.7/mm2, the median in the second group - 16.06/mm2, p = 0.024703). The groups also significantly differed in the number of nuclei of tumor cells that directly entered the mitotic phase (5.1/1000 nuclei in the TPBC group versus 3.2/1000 nuclei in the second group, p = 0.003901). Conclusions: Despite similar indices of proliferative activity in the TPBC and non-TPBC groups, mitotic activity and the number of directly dividing tumor cells in the TPBC group are significantly higher than in the rest of the BC population. Considering the criteria for assessing phh3 (MC 1 < 4/mm2, MC 2 2 4 to 7/mm2, MC 3 > 7/mm2), most TPBCs will have a histological malignancy grade of 3, which according to AJCC 8th places them in the group of poor outcome. We suggest that these differences may be due to the crosstalk mechanism. The second conclusion of our study is the fact that Ki-67 is a poor predictor of the MC.

Морфологические характеристики резидуальной опухоли молочной железы

Objective: to evaluate the morphological characteristics of a residual tumor of breast. Materials and methods. A histological examination of breast tumor biopsy samples before treatment ( core-biopsy ) and surgical material after neoadjuvant therapy was conducted in 113 breast cancer patients receiving Taxane containing regimens. The samples were compared case-by -case to biopsy, residual tumor and axillar lymph node metastasis. Results. The degree of grading of the primary breast tumor was estimated using the Nottingham system and the significance of changes in the components of Grade residual tumor, the morphological characteristics of the “tumor bed” and the percentage of achievement of the pathologic complete response (pCR). Primary tumor regression was detected in 20.4% (n=23) cases, however, 2 cases (21.7%) were not attributed to pCR due to the presence of metastases in regional lymph nodes, thus, pCR was achieved in 18.6% (n=21). When evaluating a residual tumor, a statistically significant change in the degree of malignancy (Grade) was not detected (p=0.593), however, a statistically significant change in the assessment of nuclear polymorphism was 46.67% (p=0.000). Conclusion. The anatomical criteria for determining the stage of the breast tumor coincide both in the clinical classification (cTNM) and in the pathology (pTNM), thus restoring the residual tumor after neoadjuvant treatment in accordance with the AJCC (TNM) classification approaches clearly and reliably allows to evaluate the response breast tumors in the form of a reduced stage.

The Association between Molecular Subtypes of Breast Cancer with Histological Grade and Lymph Node Metastases in Indonesian Woman

Objective:Breast carcinoma is a heterogeneous disease which is rich in diversity. Molecular subtypes of breast cancer, histological grade and lymph node metastases are strong prognostic and predictive factors. In Indonesia, only a limited number of studies have investigated the correlation between molecular subtypes with histological grade and lymph node metastases.Methods:We analyzed 247 invasive breast carcinoma cases from the Anatomic Pathology Installation of Dr. Sardjito General Hospital Yogyakarta between 2012-2015. The slides were stained for estrogen receptors (ER), progesterone receptors (PR), HER2, Ki-67 and CK5/6 for classification into breast cancer subtypes (BCS). Histological grade using the Nottingham system and lymph node status were obtained from anatomic pathology records. The association between histological grade and lymph node status with BCS was examined with Chi-square tests.Results:The immunohistochemical features of 247 cases of women with invasive breast carcinoma were examined. There were 102 (41.3%) patients with Luminal A, 34 (13.8%) patients with Luminal B, 48 (19.4%) patients with HER2-positive, and 63 (25.5%) patients with triple negative breast cancer (TNBC). There were 148 (59.9%) patients with negative lymph node status and 99 (40.1%) with positive status. Among 63 TNBC cases, 37 (58.7%) patients were positive for CK5/6 staining (basal-like). Statistically, there were significant differences between histological grade and subtypes (p=0.013). However, no significant differences were found for lymph node metastases (p=0.540).Conclusion:Among subtypes, Luminal A has the highest frequency, followed by TNBC, HER2-positive and Luminal B. Histological grade was associated with molecular subtypes of breast carcinoma in Yogyakarta. Grade I was associated with Luminal A, while Grade III was associated with Luminal B, HER2 and TNBC subtypes.

Validation of the Glasgow Facial Palsy Scale for the assessment of smile reanimation surgery in facial paralysis

To evaluate the Glasgow Facial Palsy Scale as a tool to assess facial reanimation surgery in facial palsy. Software analysis of digital video data is used to measure facial movements, comparing the affected to the normal side. We present the first use of the Glasgow Facial Palsy Scale following facial re-animation surgery. A comparison of the Glasgow Facial Palsy Scale against the Nottingham scoring system. Subjects undergoing unilateral surgical smile reanimation procedures were selected. Comparison was made with the Nottingham facial palsy scale and the House-Brackmann Scale pre- and postoperatively. Patients were recruited in the facial palsy clinic of Canniesburn Plastic Surgery Unit, Glasgow. Seven consecutive patients were selected who were due to undergo unilateral facial reanimation. The difference in pre- and post-surgical facial movement as measured using the Glasgow Facial Palsy Scale with this value being compared to that obtained using the Nottingham scoring system. Note was also taken of the correlation with House-Brackmann system and clinical correlation. Statistical analysis indicated a linear relationship between the Glasgow Facial Palsy Scale and the Nottingham System. The Pearson correlation test was used to confirm the relationship between the two methods giving a result of -0.587, which indicates significant correlation between the two methods. We conclude that the Glasgow Facial Palsy Scale is a standardised objective method of assessing the change in facial movement following smile reanimation surgery. We commend it as a useful tool to objectively assess surgical results in this challenging field.

History of Disease, Facial Nerve Grading Systems & Clinical Evaluation

AbstractObtaining an accurate history of the onset, progress and associated symptoms of newly acquired facial nerve palsy is extremely helpful in determining the potential cause of the palsy. More importantly it serves as a guide for prognosis and timing of any necessary surgical intervention. Acute versus chronic facial nerve palsy, complete versus incomplete facial nerve palsy, recovery and recurrence of the disease will be discussed. The gold standard for grading facial nerve function is the House‐Brackmann grading scale. Due to the limitations and subjectivity of this scale, several new scales of various degrees of objectivity and ease of use have been introduced. These include the Nottingham system, the Sunnybrook scale, the Yanagihara and the Sydney system, all with their advantages and disadvantages. Clinical evaluation of a patient with facial nerve palsy include evaluation of upper eyelid retraction, blink reflex, lagophthalmos, brow ptosis, paralytic ectropion, midface ptosis, mouth symmetry, platysma muscle strength, hearing, corneal sensation, Bell’s phenomenon, tear function and synkinesis.

History of disease, facial nerve grading systems & clinical evaluation

AbstractObtaining an accurate history of the onset, progress and associated symptoms of newly acquired facial nerve palsy is extremely helpful in determining the potential cause of the palsy. More importantly it serves as a guide for prognosis and timing of any necessary surgical intervention. Acute versus chronic facial nerve palsy, complete versus incomplete facial nerve palsy, recovery and recurrence of the disease will be discussed. The gold standard for grading facial nerve function is the House‐Brackmann grading scale. Due to the limitations and subjectivity of this scale, several new scales of various degrees of objectivity and ease of use have been introduced. These include the Nottingham system, the Sunnybrook scale, the Yanagihara and the Sydney system, all with their advantages and disadvantages. Clinical evaluation of a patient with facial nerve palsy include evaluation of upper eyelid retraction, blink reflex, lagophthalmos, brow ptosis, paralytic ectropion, midface ptosis, mouth symmetry, platysma muscle strength, hearing, corneal sensation, Bell’s phenomenon, tear function and synkinesis.

Mitotic index of invasive breast carcinoma. Achieving clinically meaningful precision and evaluating tertial cutoffs.

● Context.—Mitotic figure counts are related to breast cancer behavior but have not been sufficiently reproducible to be accepted for clinical decision-making. Objective.—To improve reproducibility and accuracy of the mitotic count. Design.—Mitotic index (MI) was defined as the mitotic cell count per 10 high-power fields (HPFs), an area 0.183 mm 2 . Two to 6 replicate sets of 10 HPFs were counted from 328 invasive breast carcinomas. Standard errors and coefficients of variation for mean MI were compared with expected results predicted by the binomial distribution. Results.—The boundaries for MI that separated the data into equal thirds (tertials) were 1.14 and 5.33. Standard errors and coefficients of variation for MI followed distributions predicted by binomial probability. Mean coefficient of variation was 147% for the low tertial, 72% for the midtertial, and 34.6% for the upper tertial. Conclusions.—Standard errors for MI based on a single count of 10 HPFs are too broad and coefficients of variation too large to be acceptable for clinical use. This is explained as a binomial probability effect, possibly with a contribution from tumor heterogeneity. Errors can be reduced in proportion to the square root of the number of sets of 10 HPFs counted. Tertial cutoffs of MI of the Nottingham system currently used in breast carcinoma grading are too high to be applicable to the population we studied. We recommend validation of cutoffs before they are applied to a particular population of breast carcinomas. Counting 5 sets of 10 HPFs is necessary to accurately rank carcinomas with low MIs. (Arch Pathol Lab Med. 2009;133:1826–1833)

Mitotic Index of Invasive Breast Carcinoma

Abstract Context.—Mitotic figure counts are related to breast cancer behavior but have not been sufficiently reproducible to be accepted for clinical decision-making. Objective.—To improve reproducibility and accuracy of the mitotic count. Design.—Mitotic index (MI) was defined as the mitotic cell count per 10 high-power fields (HPFs), an area 0.183 mm2. Two to 6 replicate sets of 10 HPFs were counted from 328 invasive breast carcinomas. Standard errors and coefficients of variation for mean MI were compared with expected results predicted by the binomial distribution. Results.—The boundaries for MI that separated the data into equal thirds (tertials) were 1.14 and 5.33. Standard errors and coefficients of variation for MI followed distributions predicted by binomial probability. Mean coefficient of variation was 147% for the low tertial, 72% for the midtertial, and 34.6% for the upper tertial. Conclusions.—Standard errors for MI based on a single count of 10 HPFs are too broad and coefficients of variation too large to be acceptable for clinical use. This is explained as a binomial probability effect, possibly with a contribution from tumor heterogeneity. Errors can be reduced in proportion to the square root of the number of sets of 10 HPFs counted. Tertial cutoffs of MI of the Nottingham system currently used in breast carcinoma grading are too high to be applicable to the population we studied. We recommend validation of cutoffs before they are applied to a particular population of breast carcinomas. Counting 5 sets of 10 HPFs is necessary to accurately rank carcinomas with low MIs.

Large-scale computations on histology images reveal grade-differentiating parameters for breast cancer

BackgroundTumor classification is inexact and largely dependent on the qualitative pathological examination of the images of the tumor tissue slides. In this study, our aim was to develop an automated computational method to classify Hematoxylin and Eosin (H&E) stained tissue sections based on cancer tissue texture features.MethodsImage processing of histology slide images was used to detect and identify adipose tissue, extracellular matrix, morphologically distinct cell nuclei types, and the tubular architecture. The texture parameters derived from image analysis were then applied to classify images in a supervised classification scheme using histologic grade of a testing set as guidance.ResultsThe histologic grade assigned by pathologists to invasive breast carcinoma images strongly correlated with both the presence and extent of cell nuclei with dispersed chromatin and the architecture, specifically the extent of presence of tubular cross sections. The two parameters that differentiated tumor grade found in this study were (1) the number density of cell nuclei with dispersed chromatin and (2) the number density of tubular cross sections identified through image processing as white blobs that were surrounded by a continuous string of cell nuclei. Classification based on subdivisions of a whole slide image containing a high concentration of cancer cell nuclei consistently agreed with the grade classification of the entire slide.ConclusionThe automated image analysis and classification presented in this study demonstrate the feasibility of developing clinically relevant classification of histology images based on micro- texture. This method provides pathologists an invaluable quantitative tool for evaluation of the components of the Nottingham system for breast tumor grading and avoid intra-observer variability thus increasing the consistency of the decision-making process.

Special types of invasive breast cancer, with clinical implications.

Analysis of invasive breast cancers by histopathology has generally revolved around the analysis of individual characteristics such as nuclear pleomorphism and/or gland formation (grading) or categorization by specific histologic patterns (special type carcinomas). Recognition of special types of invasive breast carcinoma allows for the identification of women with an extremely good prognosis often approaching or equaling that of the general population of the same age (with unique problems for medullary). The distinguishing features of special types of breast cancer are present in complete or classic form in the pure examples of these cases, and the features recognizing these types may be present in lesser degrees in many carcinomas of no special type or not otherwise specified in which they often have important clinical correlates other than strong indicators of survival, such as recognizing the diffusely invasive feature of lobular and lobular-like cancers. Many other features have been noted as contenders for types of breast cancer (such as squamous, cystic, clear cell, histiocytoid, and lipid rich). These terms are not discussed here because they have no special clinical correlates relevant to diagnosis or prognosis. It should be reemphasized here that combined histologic grade (Nottingham system favored) with nuclear, glandular, and mitotic evaluation is expected by most authorities for clarification of diagnosis in all but rare, pure medullary cancers. (5, 13, 14, 27) The Nottingham grade 11 interacts with nodal status to produce a very strong prognostic index. The mitotic count may be the most important part of the grading system, certainly for prognosis within 5 years of diagnosis. (22, 26)

Stent-graft migration after endovascular repair of abdominal aortic aneurysm.

To report the incidence of graft migration in patients after endovascular repair of abdominal aortic aneurysms (AAA) and assess the significance of neck diameter changes in patients with and without suprarenal stent implantation. The medical records and imaging studies of 176 consecutive patients (175 men; median age 71 years, range 48-88) who had endovascular AAA repair with the Nottingham aortomonoiliac system were reviewed. The following parameters were recorded: preoperative neck diameter and length, presence of intraoperative and late graft migrations, time to onset of late migration, length of late migration, and neck diameter changes in patients with documented late graft migration. The patients were divided into 2 groups based on the placement of an endograft with or without suprarenal bare stent fixation. Median follow-up was 15 months (range 1-48). There were 15 (8.5%) graft migrations (6 intraoperative and 9 late). Of those, 14 (10.9%) were in the 128-patient infrarenal fixation group and 1 (2.1%) in the 48-patient suprarenal stent group. Median neck diameters on preoperative and postoperative computed tomography scans in patients with late migration were 22.2 mm and 23.0 mm, respectively (p>0.05). The median time to graft migration was 14 months after the original operation (range 6-36). Distal device migration occurred frequently with the Nottingham system. Late graft migration was not associated with neck enlargement. Endografts with a suprarenal stent may have a decreased incidence of graft migration.

Facial nerve grading systems (1985-2002): beyond the House-Brackmann scale.

OBJECTIVE To assess methods of evaluating the function of the facial nerve that have been introduced over the past 15 years, particularly in comparison with the House-Brackmann scale. DATA SOURCES A Medline search was undertaken of the English-language medical literature between 1983 and 2000 to identify proposed methods of evaluating facial nerve function. STUDY SELECTION Although all grading systems were considered, attention was focused on the systems that provided improvements in either precision or ease of use. CONCLUSIONS Because of the limitations and subjectivity of the House-Brackmann scale, several new scales of various degrees of objectivity and ease of use have been introduced. The Nottingham system offers a more objective but easy-to-use facial nerve grading system that has been demonstrated to be valid and that would be easy for the average practitioner to adopt. The authors propose a more systematic evaluation of this system to determine whether its widespread application is appropriate.

Histopathologic grading of ovarian carcinoma: a review and proposal.

The histopathologic grade of ovarian epithelial carcinoma has generally been found to be of prognostic significance, but the grading system used has varied among published reports, and often has not been specified at all. The major proposed grading systems are reviewed, and a new system is proposed, which is modeled on the Nottingham system of breast cancer grading and is designed to be applied to all invasive epithelial carcinomas of the ovary. Results obtained in studies using this system are presented. When grading is compared with histopathologic typing of ovarian carcinoma, the latter is less valuable in predicting survival but better at predicting tumor responsiveness to chemotherapy, and can also suggest the chemotherapeutic agents to be used. Thus, both grade and type should be specified in the surgical pathology report for any ovarian carcinoma.

To the Editor

Abstract Objective. Because there is no universally accepted grading system for ovarian epithelial carcinoma, we attempted to compare the prognostic utility of the individual components used in some systems—both architectural and cytologic features, as well as mitotic activity and histologic tumor type—to determine which of these components fit best with survival. Methods. We studied 461 patients with invasive ovarian carcinoma who had uniform treatment, complete clinical data including staging and follow-up, and slides available for review. Each tumor was assigned a histologic subtype, architectural grade (based on whether the predominant pattern was glandular, papillary or solid), nuclear grade, mitotic count, and FIGO grade (based on the system for endometrial carcinoma). These features were compared with each other and with tumor stage and survival. Results. The architectural grade, nuclear grade, and mitotic count were independent variables both in stage I/II and stage III/IV disease. Each of them correlated with survival for most combinations of histologic type and stage. By multivariate analysis, in stage I/II cancer, nuclear grade and architectural grade were significantly correlated with survival, mitotic count showed only a trend, and FIGO grade did not correlate. In stage III/IV disease, nuclear grade, architectural grade 3, and mitotic count were significant, and FIGO grade was not. Conclusion. The new architectural grading system proposed worked better than the FIGO system in this study. Furthermore, it could be applied to all histologic subtypes of carcinoma. The nuclear grade and mitotic count were also independent of each other, correlated with survival, and could be utilized for all histologic types. These data support the development of a grading system which combines these architectural, nuclear, and mitotic features and can be applied regardless of the histologic type of carcinoma, modeled after the Nottingham system for grading of breast carcinoma.

Toward the Development of a Universal Grading System for Ovarian Epithelial Carcinoma: I. Prognostic Significance of Histopathologic Features—Problems Involved in the Architectural Grading System

Objective.Because there is no universally accepted grading system for ovarian epithelial carcinoma, we attempted to compare the prognostic utility of the individual components used in some systems—both architectural and cytologic features, as well as mitotic activity and histologic tumor type—to determine which of these components fit best with survival.Methods.We studied 461 patients with invasive ovarian carcinoma who had uniform treatment, complete clinical data including staging and follow-up, and slides available for review. Each tumor was assigned a histologic subtype, architectural grade (based on whether the predominant pattern was glandular, papillary or solid), nuclear grade, mitotic count, and FIGO grade (based on the system for endometrial carcinoma). These features were compared with each other and with tumor stage and survival.Results.The architectural grade, nuclear grade, and mitotic count were independent variables both in stage I/II and stage III/IV disease. Each of them correlated with survival for most combinations of histologic type and stage. By multivariate analysis, in stage I/II cancer, nuclear grade and architectural grade were significantly correlated with survival, mitotic count showed only a trend, and FIGO grade did not correlate. In stage III/IV disease, nuclear grade, architectural grade 3, and mitotic count were significant, and FIGO grade was not.Conclusion.The new architectural grading system proposed worked better than the FIGO system in this study. Furthermore, it could be applied to all histologic subtypes of carcinoma. The nuclear grade and mitotic count were also independent of each other, correlated with survival, and could be utilized for all histologic types. These data support the development of a grading system which combines these architectural, nuclear, and mitotic features and can be applied regardless of the histologic type of carcinoma, modeled after the Nottingham system for grading of breast carcinoma.

Measurement of facial movement with computer software.

To adapt desktop computer software to objectively grade facial movement. The criteria of the facial nerve grading system by House and Brackmann, the current "gold standard," are prone to ambiguous interpretation. Proposed objective grading systems compare the movement of points on each side of the face or use subtraction and thresholding of digitized images of the face to yield images that represent moving areas of the face. The movement of a point on the face and the area of motion determined by digital subtraction were compared during an increasing smile in healthy subjects. The Nottingham system (calculated using measurement of the movement of 4 points on the face) using desktop computer software (Adobe Photoshop 3.0, Adobe Systems Inc, Mountain View, Calif) to measure movement of the points was compared with the system by House and Brackmann. The computer software was used to subtract digitized images and derive a facial movement score, which was compared with the scores of the systems by Nottingham and House and Brackmann. Academic otologic practice. Nine patients with varying degrees of facial nerve disability and 7 individuals with normal facial nerve function. The movement of the oral commissure compared with the apparent area of movement of the face determined by digital subtraction had high intersubject variability. In patients with facial weakness, the Nottingham score had a correlation coefficient of -0.97 compared with the House and Brackmann grade, and the digital subtraction score had a correlation coefficient of -0.62 (paired Student t test). The desktop computer software can be used to calculate the Nottingham score. Digital subtraction as a measure of facial function warrants further study.

Toward the development of a universal grading system for ovarian epithelial carcinoma: testing of a proposed system in a series of 461 patients with uniform treatment and follow-up.

Most published series of ovarian carcinoma find a correlation between histologic grade and survival, but the grading system used commonly is not specified, and several different systems exist, some of which use different criteria for different histologic types. However, several studies have shown marked interobserver variability in distinguishing among the histologic types of ovarian carcinoma. The authors attempted to derive a universal grading system for all invasive ovarian carcinomas (IOC), based on the Nottingham system for grading all types of mammary carcinoma. The authors studied 461 patients with IOC of different histologic types and clinicopathologic stages who were treated in a uniform manner between 1980 and 1994 with surgery and cisplatin-based chemotherapy. All slides were reviewed and the tumors graded as follows: Architectural pattern (predominant): Glandular = 1, Papillary = 2, and Solid = 3; Nuclear pleomorphism: Slight = 1, Moderate = 2, and Marked = 3; Mitotic activity (mitotic figures per 10 high-power fields [1 HPF = 0.345 mm2]) in most active region: 0-9 = 1, 10-24 = 2, and > or = 25 = 3; Grade 1 = total score (adding three values obtained earlier) 3-5, Grade 2 = 6 or 7, and Grade 3 = 8 or 9. Tumor grade correlated with survival in both early and advanced stage disease and for all major histologic types of IOC except clear cell carcinoma (CCC). Results for CCC approached but did not reach clinical significance. By multivariate analysis, only this tumor grade and performance status were significant in Stage I/II IOC. For Stage III/IV tumors, the new tumor grade also was significant, as were performance status, residual tumor size, response to chemotherapy, and mucinous (unfavorable) or transitional cell (favorable) histologic type. International Federation of Gynecology and Obstetrics grade (based primarily on architectural features) did not correlate significantly with survival except in Stage III/IV serous and Stage I/II mucinous carcinomas. The new grading system reported is simple, reproducible (among the current study authors), and useful for all histologic types and clinical stages of IOC. Further testing for reproducibility and clinical utility is recommended.

The Nottingham System: objective assessment of facial nerve function in the clinic.

The House-Brackmann is the most widely accepted system for the clinical assessment of facial nerve function. It is, however, being subjective and discontinuous, prone to interobserver variation. The need for an objective system persists. The Nottingham System is described and compared to the Burres-Fisch system in a study of 29 subjects with varying degrees of facial nerve function, ranging from normal to total paralysis. Within-group component of variance analysis was 7% for the Nottingham System compared to 26% for the Burres-Fisch system. Bland and Altmans' analysis showed the Burres-Fisch system to be biased, overestimating small percentage scores, and underestimating large ones. The Nottingham System proved unbiased. The Nottingham System is recommended as an accurate objective continuous grading system for the rapid assessment of facial nerve function in the clinic.

Tracheostomy self care: the Nottingham System.

Tracheostomy self care at home can be a problem for some patients. The Nottingham System attributes a competence ratio to each patient. Those liable to develop problems can be identified early and the appropriate support provided. The Nottingham System is described.

The Nottingham System of Photographic Classification

The Nottingham System of Photographic Classification