Detection of disseminated tumor cells in peripheral blood of patients with breast cancer: correlation to nodal status and occurrence of metastases

OBJECTIVE

Soon after breast cancer becomes invasive, it sheds cancer cells into the blood stream or the cancer cells are spread via lymphatic vessels. The early and unambiguous detection of these disseminated tumor cells (DTC) is of importance for the evaluation of the tumor process and for monitoring therapy response. The detection of disseminated tumor cells by immunocytochemistry (ICC) without previously performing tumor cell enrichment is time consuming and may miss a considerable part of these cells. Therefore, we have applied a negative immunomagnetic enrichment of disseminated tumor cells from the peripheral blood of patients with breast cancer by the depletion of CD45(+) leukocytes using automated magnetic activated cell separation (autoMACS).

METHODS

One hundred twenty-five blood samples from 83 breast cancer patients were investigated for occurrence of disseminated tumor cells by autoMACS technique and immunocytochemical cytokeratin staining. Frequency of disseminated tumor cells was analyzed statistically for correlation to clinical data.

RESULTS

Thirty-three of the 125 blood samples (26%) originating from 29 of 83 breast cancer patients (35%) carried cytokeratin positive (CK(+)) tumor cells. The occurrence of CK(+) tumor cells correlated significantly with the nodal status (P = 0.009) and with the occurrence of metastases at the time of primary tumor resection (P = 0.003).

CONCLUSIONS

The finding that occurrence DTC detected in peripheral blood of breast cancer patients correlated with nodal stage and metastases is described for the first time. It suggests that disseminated tumor cells identified in peripheral blood by autoMACS are associated with tumor characteristics of breast cancer.

DNA-flow cytometry, DNA-image cytometry and proliferation index (MIB-5) in irradiated rat salivary glands and salivary gland tumors

AIM

Salivary glands (SG) can become atrophic following radiation exposure. Malignant transformation of SG in a radiation field is another known sequela of patients who have been treated by radiotherapy for a malignant tumor in the head and neck region. The aim of this study was to investigate cytogenetic alterations and to determine the proliferation index (PI) of SG of rats subjected to various total dosages of fractionated X-rays.

MATERIALS AND METHODS

We investigated rat SG, subjected to 20, 40, or 60 Gy exposure by X-rays to the left neck and skull base. Non-irradiated rats served as a control group. Tumors originating from the SG were histologically-diagnosed following the descriptions for human SG tumors. The MIB-5 antibody was used to determine the PI. The ploidy was determined by flow and image cytometry (FCM, ICM).

RESULTS

We consistently recorded diploid histograms in the FCM in irradiated glands. ICM revealed aneuploid histograms in 6/22 tumors, 3 of them were Auer Type III or IV. The PI showed a dose- and time-dependent course, indicative of variable regeneration properties of the parenchyma. Statistically significant differences were found for the PI within the irradiation groups and comparing irradiated SG and tumors.

CONCLUSION

Irradiation of rat SG can cause almost complete loss of function. On the other hand, the PI remained in animals subjected to 40 Gy and investigated 1 year after completion of radiation at a level up to 10-fold higher than in untreated controls. The PI in carcinoma is higher in this species than in irradiated SG. Constantly elevated PI could support the development of cancer in SG.

Enhancement of lymph node metastasis and distant metastasis of thyroid carcinoma

BACKGROUND

The mechanisms of local and distant metastases are imperfectly understood. The goal of the current study was to add to the body of knowledge regarding local and distant metastases of thyroid malignancies.

METHODS

The authors performed multivariate analysis of 573 patients who underwent surgery between November 1994 and May 2002 for follicular (FTC; n = 100), papillary (PTC; n = 236), or medullary thyroid carcinoma (MTC; n = 237) at a university hospital.

RESULTS

In multivariate analysis, extrathyroidal extension consistently evolved as the key risk factor for both lymph node metastasis and distant metastasis. This correlation was most pronounced in MTC and least pronounced in FTC. The risk of lymph node metastasis also increased with reoperative status in patients with MTC and with primary tumor diameter in patients with MTC (tumor diameter > 10 mm) and patients with PTC (tumor diameter > 20 mm). In the PTC group, lymph node metastasis was more common among patients younger than age 45. In the MTC group, extrathyroidal growth and distant metastasis were associated exclusively with lymph node metastasis. Lymph node metastasis was the only secondary risk factor for distant metastasis. In the analysis of risk factors for distant metastasis in the FTC and PTC groups, no interaction was found between extrathyroidal growth and lymph node metastasis. This finding suggests that extrathyroidal growth and lymph node metastasis of FTC and PTC, and presumably also MTC, represent separate mechanisms and routes of distant metastasis.

CONCLUSIONS

Screening for both local residual disease and distant metastases should be intensified in the high-risk population of patients whose primary tumors exhibit large diameters, extrathyroidal growth, or lymph node metastasis.

Tumor Volume and Tumor Hypoxia in Head and Neck Cancers

BACKGROUND

The prognostic impact of tumor volume and hypoxia is well established. We have investigated a possible prognostic impact of the hypoxic tumor volume which can be calculated as the product of tumor volume and hypoxia.

PATIENTS AND METHODS

125 patients with squamous cell cancer of the head and neck were investigated. All had locoregionally confined disease. The total tumor volume was calculated from pretreatment CT scans as the sum of all visible macroscopic tumor lesions (e.g., primary tumor plus neck nodes), and all patients underwent measurement of tumor oxygenation by pO2 histography. The hypoxic tumor volume was calculated as the product of the total tumor volume and the relative frequency of pO2 readings < 5 mmHg. The nonhypoxic volume was the difference between total tumor volume hypoxic volume.

RESULTS

The total tumor volume ranged from 2 to 283 cm3 (mean 47 +/- 53 cm3), the hypoxic volume from 0 to 199 cm3 (mean 18 +/- 30 cm3), and the nonhypoxic volume from 1 to 237 cm3 (mean 29 +/- 34 cm3), and there was a strong correlation between the three parameters. 84 patients died and 41 survived in the observation period with a median survival of 12.5 months. Tumor volume and tumor oxygenation had a significant impact on survival. The tumor volume was significantly different in patients who had died as compared to surviving patients (mean 54 vs. 34 cm3; p = 0.017). The hypoxic volume was also different (11 vs. 22 cm3; p = 0.009), whereas the nonhypoxic volume was not significantly different (24 vs. 32 cm3; p = 0.2). If the impact of large versus small tumor volumes (total volume, hypoxic volume, and nonhypoxic volume, subdivision according to each median) on survival was analyzed, a significant impact of total tumor volume (median survival 298 vs. 485 days; p = 0.03) and a marginal impact of the hypoxic volume (342 vs. 404 days; p = 0.08), but no impact of the nonhypoxic volume were found (383 vs. 374 days; p = 0.6). In a multivariate Cox regression model, the hypoxic tumor volume was a strong and independent prognostic factor for survival (p = 0.001) and more important than the total tumor volume (p = 0.02) whereas the nonhypoxic volume had no impact on prognosis (p = 0.33).

CONCLUSIONS

The total tumor volume is a major prognostic factor, but its impact mainly results from the hypoxic volume and can be explained by the strong correlation between total tumor volume and hypoxic volume. The nonhypoxic volume had no impact on survival. As a consequence, methods to measure and localize the hypoxic volume should be further developed.

Reduced expression of hMSH2 protein is correlated to poor survival for soft tissue sarcoma patients

BACKGROUND

Deregulation of DNA mismatch repair is a common mechanism for the development of hereditary nonpolyposis colon carcinoma and related familiar cancers, but it also plays a role in the tumorigenesis of sporadic cancers. Although the protein expression of the two main components of DNA mismatch repair, hMSH2 and hMLH1, has been described in soft tissue sarcoma (STS) patients, its prognostic impact is yet to be determined.

METHODS

The authors investigated the expression of the DNA repair proteins hMSH2 and hMLH1 by Western blot analysis in tumor samples of 57 STS patients. The correlation between the expression of hMSH2/hMLH1 and survival was studied in a Cox proportional hazards regression model, which was adjusted for the prognostic effects of staging, tumor entity, and radicality of tumor resection.

RESULTS

Nine of 57 STS (16%) showed reduced expression of hMSH2 and reduced expression of hMLH1 was detected in seven STS patients (12%). In a Kaplan-Meier analysis, the median survival for patients with reduced expression of the hMSH2 protein was 18 months, whereas the patients with a normal expression of hMSH2 survived for an average of 68 months. A multivariate Cox proportional hazards regression model revealed a significant correlation between the reduced expression of the hMSH2 protein and poor survival (relative risk = 4.7; 95% confidence interval [CI]: 1.3-17.2; P = 0.019).

CONCLUSIONS

Reduced expression of the hMSH2 protein is an independent negative prognostic factor for STS patients.

Expression and distribution of basement membrane proteins in rat larynx and trachea following irradiation

OBJECTIVE

Basement membranes-(BM) influence polarization, differentiation, migration and proliferation of cell and play an important role in maintaining structural and functional tissue integrity. While BM alterations have been reported in various lesions (e.g. inflammation, tumors) of laryngeal-tracheal tissues, reports on radiogenic BM alterations are rare. External irradiation (IRR) of advanced head and neck tumors often includes "normal tissues" (tissues without cancer) of the larynx. In these normal tissues both single-cell damage (necrosis, apoptosis, functional cell death) and interstitial damage (edema, fibrosis, vascular alterations, cellular infiltrations) resulting in tissue remodeling can occur, depending on various IRR parameters. In this study, we set out to add to our knowledge on the phenotypic characterization of the radiogenic BM expression pattern in laryngo-tracheal tissues.

MATERIALS AND METHODS

In 63 laryngo-tracheal specimens from Wistar rats, we investigated the laminin (LA) and collagen IV (CIV) expression profile and distribution pattern depending on the IRR dose (fractionated IRR, 2 Gy/day, up to a total dose of 20, 40, or 60 Gy), the time since IRR (6 months vs 12 months) and animal age (1 year vs 1.5 years) using immunohistochemical methods, semiquantitative assessment, and multivariate analysis.

RESULTS

In specimens irradiated with more than 20 Gy, both BM constituents predominantly showed dose-dependent increases and sometimes fluctuations in staining at slight to moderate levels. The expression differed in frequency and level among the various tissue structures. In some structures there was decreased expression. In the vocalis muscle, laryngeal and esophageal nerve endings, recurrent laryngeal nerve and laryngeal and tracheal muscles, LA was detected at levels significantly stronger than in controls. BM surrounding gland structures, nerve endings of the piriform sinus and esophageal muscles showed a marked tendency towards increased LA expression. However, the BM underlying the mucosal layer of the supra- and subglottic region revealed decreasing LA immunoreaction up to 40 Gy IRR, but a distinct increase in expression at 60 Gy. In the esophageal and tracheal muscles, tracheal perichondrium, recurrent laryngeal nerve and capillaries, CIV was detected at significantly stronger levels than in the controls. The vocal ligament exhibited positive CIV immunoreactions adjacent to interstitial and infiltrate cells and CIV-positive BM condensations, resulting in increased staining of these structures. CIV reactions of laryngeal and hypopharyngeal nerve endings tended towards increased expression. In contrast, BM staining surrounding vocal muscle cells revealed significantly decreased expression. In addition, there was a tendency towards decreased expression for supraglottic, subglottic and hypopharyngeal muscle cells. Age and time since irradiation had no significant effect on staining.

CONCLUSION

The BM constituents laminin and collagen IV showed prominent dose-dependent increases and sometimes fluctuations in expression. This expression pattern persisted up to one year after completion of the irradiation. Thus, these findings must be related to late radiation effects. The altered BM expression may play a role, at least in part, in structural (e.g. laryngeal edema) and functional (voice disorders) changes associated with irradiation of the head and neck area.

The expression pattern of collagen I in irradiated mandibular salivary glands of rats

Irradiation damage to salivary glands leads to loss of function and fibrosis. Immunohistochemical analysis of extracellular matrix proteins might give a more precise insight into the irradiation damage of glands. Collagen I (C-I) is a major component of the extracellular space. The aim of this study was to analyse the effects of irradiation on the distribution pattern of C-I in the salivary glands of rats.

MATERIALS AND METHODS

Sixty female Wistar rats were fractionated irradiated up to 60 Gy (left side of the neck; 2 Gy/d, 5d/week; total dosage either 20, 40 or 60 Gy). The glands were explanted after 6 or 12 months following supravital anesthesia, the shielded right gland serving as internal control. C-I was detected immunohistochemically.

RESULTS

In non-irradiated animals the immunoreaction was mainly homogeneous and slight around the ductal epithelia, in the area of the capsule and septae and the peri- and epineurium of nerves. A statistically significant difference was identified in the irradiated rats vs control animals and comparing in-the-radiation field (left side) vs outside-the-radiation field (right side) situated glands. Multivariate analysis revealed a statistically significant increase in staining of irradiated rats concerning the excretory ducts, the area of the capsule and septae, the nerves and striated ducts and adventitia of vessels [p = 0.0001]. The increase of immunoreaction in irradiated glands started above 20 Gy total dosage and was at its maximum after 60 Gy. However, the expression profile was inhomogenous following 20 Gy exposure and did not differ statistically from glands of control animals. Neither the age of the animals nor the latency period following exposure to the radiation source yielded a statistically significant effect on the immunoreaction.

CONCLUSION

Studies on irradiation damage to the salivary glands require a more detailed description of the proteins accumulating in the extracellular space, thereby forming the so-called "fibrosis". These accumulations of proteins, e.g. C-I, may both support apoptosis and support a hypoxic environment giving rise to transformed cells.

Elevated expression level of survivin protein in soft-tissue sarcomas is a strong independent predictor of survival

PURPOSE

Survivin is a member of the inhibitor-of-apoptosis gene family and is known to be overexpressed in a number of tumor types. The aim of this study was to evaluate the prognostic value of survivin protein expression in tumor tissue extracts in a group of well-characterized soft-tissue sarcoma (STS) patients.

EXPERIMENTAL DESIGN

In this investigation, malignant tissue samples from 63 STS patients as well as from a panel of tumor cell lines were investigated, with nonmalignant tissues serving as controls. The survivin protein level was quantified by a novel ELISA and by Western blot analysis. Results obtained by both methods were compared with clinicopathological parameters regarding tumor grade and tumor entity, and they were then correlated to survival in a multivariate Cox regression model.

RESULTS

High survivin levels were detected by ELISA and Western blot analysis in tumor tissue extracts and in lysates of tumor cell lines. None or only weak expression of survivin protein was found in nonmalignant cells and tissues. When comparing survivin values obtained by ELISA or Western blot, we found a significant correlation between both methods (P = 0.013, Pearson test). Our findings revealed that, in multivariate Cox regression analyses, survivin levels measured by ELISA and Western blot were significantly associated with tumor-related death in STS patients (P = 0.001, RR = 19.8, and P = 0.004, RR = 5.1, respectively). However, in a direct comparison of both survivin protein detection assays, we found a higher sensitivity and a stronger correlation to prognosis in survivin ELISA as compared with the Western blot assays. Furthermore, a higher tumor grade and more aggressive STS entity showed an elevated survivin protein expression level.

CONCLUSION

Altogether, an elevated survivin content in tumor tissue extracts has a significant and independent negative predictive value on the survival-rate of STS patients. This finding corresponds well to data obtained for the mRNA level of survivin, as shown previously (M. Kappler et al., Int. J. Cancer, 95: 360-363, 2001).

SCC antigen in the serum as an independent prognostic factor in operable squamous cell carcinoma of the cervix

The aim of this study was to retrospectively examine whether the occurrence of squamous cell carcinoma (SCC) antigen tumour marker in the serum has prognostic significance in operable SCC of the cervix at the International Federation of Gynaecology and Obstetrics (FIGO) stages IA2-IIB. A total of 129 patients who had undergone a radical hysterectomy for SCC of the uterine cervix at the Department of Gynecology of the Martin-Luther University, Halle-Wittenberg in 1991-2000 were included. SCC antigen (Ag) was measured by IMx SCC-Ag microparticle enzyme immunoassay (Abbott Laboratories, Abbott Park, IL, USA). To assess the prognostic value of SCC antigen in the serum, we used a step-by-step multivariate analysis based on the Cox proportional hazard regression model. Using a cut-off value of 3.0 ng/ml, we detected preoperative SCC antigen in the serum as an independent prognostic factor in SCC of the cervix, both for recurrence-free and overall survival (P=0.003 and 0.0078). In this retrospective analysis the value of the SCC antigen tumour marker correlates with prognosis in operable SCC of the cervix, independent of tumour size, pelvic nodal status, cervical stroma infiltration, parametrial spread and tumour grading.

Anemia and elevated systemic levels of vascular endothelial growth factor (VEGF)

BACKGROUND

Tissue hypoxia is a major stimulus for the up-regulation of vascular endothelial growth factor (VEGF). Anemia might theoretically impact on angiogenesis via impairment of tissue oxygenation. We have investigated this hypothesis in patients with solid cancers and benign diseases.

PATIENTS AND METHODS

49 patients with untreated locoregionally confined solid cancers of the head and neck, cervix, rectum and lung and 59 additional patients with non-malignant diseases (36 normemic patients without serious diseases and 23 patients with renal anemia) were enrolled and the impact of anemia on plasma VEGF levels were determined. VEGF was measured with a commercially available sandwich enzyme immunoassay technique.

RESULTS

Plasma levels of VEGF were 16.2 +/- 12.7 pg/ml in 36 normemic patients without malignant disease, 49.2 +/- 34.5 pg/ml in 49 patients with cancers (p < 0.001), and 89.9 +/- 67.8 pg/ml in 23 patients with renal anemia (p = 0.001). VEGF levels in cancer patients were significantly correlated with hemoglobin (hb) levels and platelet counts (each p = 0.001), but not with type of tumor, stage, histology or age. Patients with cancers had higher plasma levels of VEGF than patients with non-malignant diseases in case of hb > or = 12 g/dl (33.1 +/- 17.5 vs 16.6 +/- 13.0 pg/ml, p < 0.001) and in case of hb between 11.0 and 11.9 g/dl (56.1 +/- 26.4 vs 18.5 +/- 14.5 pg/ml, p = 0.038). In case of a hb < 11 g/dl, plasma VEGF levels were significantly elevated in patients with and without cancers (67.0 +/- 47.5 vs 88.9 +/- 68.8 pg/ml, n.s.). In a multivariate model, a significant association between low hb levels and increased plasma levels of VEGF was confirmed. In 16 patients with renal anemia, changes in hb under erythropoietin treatment were inversely correlated with changes in plasma VEGF levels with decreasing VEGF after increase in hb (p = 0.01).

CONCLUSIONS

Anemic patients have elevated levels of VEGF. The data suggest that anemia might impact on the progression of angiogenesis in malignant and benign diseases.

The effect of external fractionated irradiation on the distribution pattern of extracellular matrix proteins in submandibular salivary glands of the rat

INTRODUCTION

The aim of this study was to analyse the distribution pattern of extracellular matrix proteins in the irradiated and non-irradiated rat submandibular salivary gland in order to provide a more detailed profile of the radiation injury following radiotherapy of the head and neck.

MATERIAL AND METHODS

External X-ray exposure, restricted to the left skull base and neck region, was performed in 60 female Wistar rats, fractionated to daily applications of 2 Gy, up to total dosages of 20, 40 or 60 Gy. Both submandibular glands were excised after supravital anaesthesia 6 months or 1 year after completion of the irradiation. Spatial and temporal patterns of extracellular matrix proteins were investigated histologically and immunohistochemically.

RESULTS

The polyclonal anti-human antisera used, identified the same antigens in rat tissue as in human tissues. The alterations in staining patterns and staining intensities between irradiated and non-irradiated salivary glands showed statistically significant differences. Different structures in irradiated glands reacted with different intensities, e.g. nerve tissue and the basement membranes of excretory ducts were intensely laminin-positive, fibronectin was predominantly found around the excretory ducts with transition to the interstitial tissues.

CONCLUSION

Irradiation leads to statistically significant differences in the amount and composition of the extracellular matrix in salivary glands. The amount of extracellular matrix proteins in irradiated glands is dose-dependent. The higher the dosage the more extracellular matrix can be expected. Consecutively, total dosage is associated with greater loss of acini. Scatter effects of irradiation have also to be recognized. Immunohistochemical studies on salivary glands have to consider the pretreatment status, in particular those studies that investigate degenerative changes.

[Origin of shoulder pain after "neck dissection". Importance of the cervical plexus]

BACKGROUND

The role of sensitive parts of the cervical plexus for the development of neuropathic pain is not yet clear. Our study investigated the correlation between shoulder pain and cervical plexus damage after different types of neck dissection (ND).

MATERIAL AND METHODS

The sensitivity for warm/cold and sharp/blunt was tested in the dermatomes of C2, C3, C4, and the minor occipital nerve. Shoulder pain was measured semiquantitatively by a rating scale.

RESULTS

Motion-dependent shoulder pain was observed 6 months postoperatively in 50% after resection and in 29.2% after preservation of these structures. Pain occurred more frequently following radical ND than after modified radical types 1 and 3 ND.

DISCUSSION

Our investigations showed that the superficial cervical plexus function is assessable by cutaneous sensitivity tests. The minor occipital nerve seemed to be less affected. Fewer pain symptoms in cases with preserved cervical plexus could be demonstrated. We can conclude that preservation of the superficial cervical plexus is important to diminish postoperative shoulder pain.

High bad and bcl-xL gene expression and combined bad, bcl-xL, bax and bcl-2 mRNA levels: molecular predictors for survival of stage 2 soft tissue sarcoma patients

The role of the bcl-2 gene family members in promoting or antagonizing apoptosis in malignant tumors, including soft tissue sarcomas (STS), is well known. However, the impact of mRNA expression of bcl-2 family genes on prognosis has not been thoroughly investigated in STS. Samples from 82 STS patients were analyzed for mRNA expression of bad, bax, bcl-xL and bcl-2 by a high-throughput quantitative RT-PCR approach, using validated assays based on TaqMan technology. The mRNA data, related to glyceraldehyde-3-phosphate dehydrogenase expression measured in the same sample, were analysed for their correlation to tumor stage and overall survival of patients. In a Kaplan-Meier analysis none of the mRNA levels investigated differed significantly with regard to their impact on survival (log-rank test). However, after including the tumor stage in the statistical analysis, a borderline significance was observed for bad mRNA expression (p=0.068) indicating a stage-specific impact of mRNA expression on prognosis. Considering STS patients of tumor stage 2, multivariate Cox analysis revealed that bad mRNA values > or = 10 (p=0.0039; RR=9.08), bcl-xL > or = 1.5 (p=0.067; RR=4.59), bax > or = 0.005 (p=0.1; RR=2.84) and bcl-2 < 3 (p=0.42; RR=1.7) were associated with a poor prognosis. Combined high bad/bcl-xL mRNA expression levels revealed a 20-fold increase in the relative risk of tumor-related death (p=0.016) when comparing the poor and good prognosis groups. There was a 14.5-fold and 6.5-fold increase in the risk for the combinations of high bax/bcl-xL mRNA (p=0.018) and bax/bcl-2 mRNA expression (p=0.017), respectively. In conclusion, high bad mRNA levels and combined values of bad/bcl-xL bax/bcl-xL and bax/bcl-2 appear to be independent prognostic factors at least for stage 2 STS patients. In the combinations of mRNA levels there was more than an additive effect pointing to different pathways of prognostic relevance.

Microscopic (R1) and macroscopic (R2) residual disease in patients with resected non-small cell lung cancer

OBJECTIVES

This retrospective study evaluates the probability of survival in patients who had undergone resection for non-small cell lung cancer (NSCLC) and in whom residual disease at the resection margins was found.

METHODS

During a period of 6 years, 596 patients with NSCLC were operated upon with curative intention. Residual disease at the resection margin was divided into microscopic (R1) and macroscopic (R2).

RESULTS

Twenty-six patients (4.4%) showed R1 and 12 (2%) R2 residual disease. An extrabronchial (thoracic wall, vessels) R1 situation was found in five patients and a bronchial R1 infiltration in 21 cases. The bronchial resection margin was subject to peribronchial infiltration in most cases (16/21). A total of 17/21 (65%) patients with bronchial infiltration had N2 disease. Thirty day lethality was 3.8% in the R1 group. Fifteen patients had postoperative irradiation. The 5-year survival rate for patients with R1 resection was 14%. The differences in survival between patients with extrabronchial vs. bronchial infiltration and N0/N1 vs. N2 were significant using univariate analysis. Adjuvant radiation did not result (especially in N2 disease) in a survival benefit. Among 12 patients with macroscopic residual disease (R2), 3/12 (25%) died within the first 30 days after the operation, and none of the R2 patients survived the first year after the operation.

CONCLUSIONS

Patients with an R1 situation have a survival rate of 14% comparable to curative resected patients (RO) in stage III. Adjuvant radiation had no clear effect on survival. Patients with macroscopic tumor (R2) should receive palliative treatment after the operation depending on their condition.

Co-expression of survivin and TERT and risk of tumour-related death in patients with soft-tissue sarcoma

Increased expression of survivin has been shown to be a negative predictor of survival in patients with soft-tissue sarcoma. We investigated 89 adults with soft-tissue sarcomas to ascertain the relation between co-expression of survivin and human telomerase reverse transcriptase (TERT) transcripts and prognosis. We quantified mRNA expression of survivin and TERT transcripts. Cox's proportional-hazards regression model showed co-expression of both genes to be a significant negative prognostic factor for patients with stage I to stage IV tumours (p=0 small middle dot0004; relative risk 20 small middle dot1, 95% CI 3 small middle dot8-106 small middle dot4) and for those at stage II and III (p=0 small middle dot0002; 42 small middle dot1, 6 small middle dot0-294 small middle dot9) compared with low expression of both genes. Co-expression of survivin and TERT transcripts identifies patients at high risk of tumour-related death.

Increased survivin transcript levels: an independent negative predictor of survival in soft tissue sarcoma patients

Survivin, a recently identified inhibitor of apoptosis protein (IAP), is expressed in diverse embryonic tissues and in various human cancers. We have investigated the quantitative expression of survivin mRNA by a sensitive TaqMan-based RT-PCR assay in tissue samples from 94 patients with soft tissue sarcomas (STS). Survivin transcript levels were measured and normalized to GAPDH transcripts. By using a multivariate Cox regression analysis, we found an inverse correlation between the level of survivin mRNA (ratio >2 zmol survivin/amol GAPDH) and the rate of overall survival (p = 0.009, RR = 2.7). Survivin transcript variants as detected by qualitative RT-PCR analysis were revealed in 36 of 56 STS patients (64%). Only survivin DeltaEx3 and/or full-length survivin variants but not survivin 2B were identified. Our results suggest that a higher level of survivin mRNA is an independent predictor of survival for STS patients.

Increased survivin transcript levels: an independent negative predictor of survival in soft tissue sarcoma patients

Survivin, a recently identified inhibitor of apoptosis protein (IAP), is expressed in diverse embryonic tissues and in various human cancers. We have investigated the quantitative expression of survivin mRNA by a sensitive TaqMan-based RT-PCR assay in tissue samples from 94 patients with soft tissue sarcomas (STS). Survivin transcript levels were measured and normalized to GAPDH transcripts. By using a multivariate Cox regression analysis, we found an inverse correlation between the level of survivin mRNA (ratio >2 zmol survivin/amol GAPDH) and the rate of overall survival (p = 0.009, RR = 2.7). Survivin transcript variants as detected by qualitative RT-PCR analysis were revealed in 36 of 56 STS patients (64%). Only survivin DeltaEx3 and/or full-length survivin variants but not survivin 2B were identified. Our results suggest that a higher level of survivin mRNA is an independent predictor of survival for STS patients.

Prognostic significance of local recurrence in breast cancer after postmastectomy radiotherapy

PURPOSE

We have retrospectively analyzed the impact of local recurrence in patients with adjuvant radiation therapy after mastectomy for breast cancer.

PATIENTS AND METHODS

From January 1985 through December 1993, 959 patients were irradiated after mastectomy for breast cancer. The age ranged from 34 to 79 years, the median follow-up was 3.1 years (range: 0.3-12.2 years). 368 (38%) were pre- and 591 (62%) postmenopausal. 35% had T3-4 tumors, 62% had axillary lymph node involvement, and 66% received additional systemic hormonal and/or cytotoxic therapy. Postmastectomy radiotherapy was administered in case of positive axillary nodes and in high-risk pN0-patients. The chest wall and lymphatics (axilla, parasternal and supraclavicular nodes) were irradiated with an anterior photon field with 50 Gy and the chest wall with an electron field with 44 Gy in 2-Gy fractions.

RESULTS

The overall survival was 70.5% after 5 and 59.8% after 10 years. 53 patients (5.5%) developed a locoregional recurrence 2-96 months after treatment (median 26 months). The local control rate was 92.7% after 5 and 86.4% after 10 years. Axillary lymph node involvement was the most important and (in a multivariate analysis the only) risk factor for local recurrence (p = 0.0001). Patients with local control had a significantly better 10-year distant-disease-free survival and overall survival as compared to patients with local recurrence (44.5% vs 15.4%, p = 0.002 and 62.1% vs 34.8%, p = 0.004). Local recurrence increased the risk of death by a factor of 1.7 and in a Cox regression model, axillary lymph node status, T-category and local recurrence were significant prognostic factors for overall survival. In patients with local recurrence, the initial axillary lymph node status was the most important prognostic factor for survival after local recurrence. The 3-year survival after local relapse was 86% for patients with pN0 status vs 27% in with positive axillary nodes (p = 0.025).

CONCLUSIONS

Local recurrence after treatment of breast cancer with mastectomy + radiotherapy +/- systemic therapy is associated with a significantly higher risk of distant metastases and death. In this analysis, local recurrence was a strong and, besides lymph node status and T category, an independent risk factor for survival. Minimizing the risk of local recurrence is therefore an essential goal of a curative treatment concept.

Tumor hypoxia and systemic levels of vascular endothelial growth factor (VEGF) in head and neck cancers

BACKGROUND

Hypoxia is the most important stimulus for the up-regulation of vascular endothelial growth factor (VEGF), one of the key cytokines for angiogenesis. We have investigated the possible relationship between tumor hypoxia and systemic levels of VEGF.

PATIENTS AND METHODS

56 patients with head and neck cancers underwent measurement of tumor volume (pretreatment CT scans), tumor oxygenation (pO2 histography) and serum levels of VEGF. The hemoglobin level ranged from 9.1 to 16 g/dl. The absolute amount of hypoxic tumor (hypoxic tumor volume) was determined as the product of the absolute tumor volume and the relative frequency of hypoxic (< 5 mm Hg) measurements in the pO2 histography.

RESULTS

The serum VEGF levels in the 56 head and neck cancer patients ranged from 102 to 1699 pg/ml (median 405 pg/ml, mean 527 +/- 396 pg/ml). Elevated serum-VEGF levels (> 700 pg/ml) were found in 14/56 patients (25%). Serum-levels of VEGF were significantly and independently correlated with hypoxic tumor volume (R2 = 0.63, p < 0.001), but also with total tumor volume, hemoglobin levels, platelet counts and tumor hypoxia. There was no correlation with T and N category, histological grading, and age.

CONCLUSIONS

The strong and independent impact of the hypoxic tumor volume on systemic VEGF levels suggests that the absolute amount of hypoxia within a tumor represents the most important stimulus for up-regulation of angiogenesis. Anemia acts as a co-factor via worsening of tumor tissue oxygenation.

Multivariate analysis of clinicopathologic parameters for the insular subtype of differentiated thyroid carcinoma

HYPOTHESIS

Insular carcinoma represents a more aggressive subtype of differentiated thyroid cancer on multivariate analysis after controlling for various clinicopathologic parameters.

DESIGN

Retrospective analysis.

SETTING

Tertiary referral center at a university hospital.

PATIENTS

One hundred twenty-seven consecutive patients having a histological diagnosis of the follicular variant of papillary thyroid carcinoma or follicular thyroid carcinoma.

MAIN OUTCOME MEASURE

A logistic regression model was used to examine the relationship between various clinicopathologic parameters and the insular subtype.

RESULTS

The insular subtype involved 14 of 127 tumors. Unlike extrathyroidal extension and nodal metastasis, primary tumor diameter (> 40 mm vs < or = 40 mm; P = .008) and distant metastasis (P = .003) correlated with the insular subtype. Both parameters were interrelated since tumors greater than 40 mm displayed distant metastasis more often (30% vs 8%; P = .008) than tumors measuring 40 mm or less.

CONCLUSIONS

These findings suggest that an unidentified somatic event may induce an accelerated proliferation of the transformed thyrocytes, which may ultimately result in enhanced rates of distant metastasis with increasing tumor volume.

[In vitro determination of the cytotoxic activity of saliva samples of smokers]

BACKGROUND

The question arised whether saliva can be included in populations monitoring of high risk groups for the development of head and neck squamous cell carcinomas. Cytotoxic mechanisms strongly influence the carcinogenesis of squamous cell carcinomas.

PATIENTS AND METHODS

Saliva specimen of 131 abusing and non-abusing probands were tested on their biological (cytotoxic) effects to draw conclusions on the individual cancer risk. To determine the cytotoxic activity of saliva, we used the "plating efficiency index" of lungfibroblasts of the chinese hamster.

RESULTS

We found significantly increased cytotoxic effects in the saliva of smoking probands (p < 0.002). Regularly combined smoking and drinking of alcohol led to a highly significant increased risk of cytotoxic saliva in the tested persons (odds ratio: 17.4; p < 0.005).

CONCLUSIONS

Including patients with head and neck squamous cell carcinomas, ongoing studies must prove the practical relevance of this biomarker for estimating the relative cancer risk in the upper aerodigestive tract.