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Ingle JN, Kardinal CG, Suman VJ, Veeder MH, Schaefer PL, Kirschling RJ, Mailliard JA. Mitoxantrone dose augmentation utilizing filgrastim support in combination with fixed-dose 5-fluorouracil and leucovorin in women with metastatic breast cancer. Breast Cancer Res Treat 1997; 43:193-200. [PMID: 9150898 DOI: 10.1023/a:1005749115033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Based on reports of substantial antitumor efficacy of the combination of mitoxantrone (DHAD), 5-fluorouracil (FU) and leucovorin (LV), a clinical trial was performed to attempt augmentation of the dose of DHAD with filgrastim support. The doses and schedules, all intravenous, were DHAD (total dose divided over days 1 and 2), level I, 16 mg/m2; II, 20 mg/m2; III, 24 mg/m2; IV, 32 mg/m2; and LV, 300 mg, followed by FU, 350 mg/m2, on days 1-3. Filgrastim was given at 5 micrograms/kg/day subcutaneously on days 4-13. The planned cycle length was 21 days. Three or 4 patients were to be entered at each dose level and the maximum tolerated dose (MTD) was defined as the dose immediately below that which resulted in 2 patients with dose-limiting toxicity (DLT) in cycle 1. Once an apparent MTD was identified, an additional 6 patients were to be entered. Twenty patients (pts) were entered: level I: 3 pts; II: 3 pts; III: 10 pts: IV: 4 pts. The major toxicity was found to be cumulative thrombocytopenia with platelet counts < or = 20,000/microL occurring after cycle 1 at all levels beyond level I and five pts (25%) were removed from treatment solely because of platelet toxicity. Additional serious toxicities included grade 4 stomatitis in one patient (level IV) and cardiac toxicity in 2 patients with prior doxorubicin exposure. Ten pts had measurable and 8 had evaluable disease, and in 17 pts assessed, 5 (29%) achieved an objective response. The response rates in this study are lower than reported in the literature for the combination of DHAD, 5FU, LV and this may be related to the fact that only 40% of the patients were removed from protocol treatment because of disease progression. On the basis of limited DHAD-dose augmentation, toxicities observed, and modest response rate, the filgrastim-supported DHAD, 5FU, LV regimen as utilized in this study cannot be recommended for further development for treatment of women with metastatic breast cancer.
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Schomberg PJ, Shanahan TG, Ingle JN, Donohue JH, Kuske RR, Sternfeld WC, Wold L, Cha SS, Petersen IA, Brindle JS, Halyard MY, Bollinger JW, Hawkins R, Pisansky TM. Accelerated hyperfractionation radiation therapy after lumpectomy and axillary lymph node dissection in patients with stage I or II breast cancer: pilot study. Radiology 1997; 202:565-9. [PMID: 9015091 DOI: 10.1148/radiology.202.2.9015091] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE To prospectively assess tolerance to accelerated hyperfractionation radiation therapy in patients undergoing breast-conservation therapy and to exclude, with 90% confidence, a 20% or greater risk of an acute toxic reaction of at least grade 3 (severe). MATERIALS AND METHODS Thirty-seven patients (aged 33-80 years) with evaluatable cases received 48 Gy in twice-daily 1.6-Gy fractions to the breast and regional lymph nodes (if three or more lymph nodes were involved) and a boost of 9.6 Gy in twice-daily 1.6-Gy fractions. Acute and late effects were scored by using the Radiation Therapy Oncology Group and European Organization for the Research and Treatment of Cancer radiation morbidity criteria. RESULTS One patient developed a grade 3 acute skin toxic reaction and another grade 3 (continuous) acute edema. There have been no grade 4 (life-threatening) acute toxic reactions, local recurrences, or cancer- or treatment-related deaths. CONCLUSION This breast-conservation accelerated hyperfractionation radiation therapy schedule is tolerable. Additional follow-up is necessary to determine long-term morbidity and cosmesis, and further study in a larger patient group is necessary to confirm efficacy.
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Ingle JN, Twito DI, Suman VJ, Krook JE, Maillard JA, Windschitl HE, Marschke RF. Evaluation of intravenous 6-thioguanine as first-line chemotherapy in women with metastatic breast cancer. Am J Clin Oncol 1997; 20:69-72. [PMID: 9020292 DOI: 10.1097/00000421-199702000-00015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
6-Thioguanine (6-TG) is a purine analog that has marked variability in plasma concentration after oral administration. Following the development of a multiple-day i.v. regimen, we performed a phase II trial of this agent as first-line chemotherapy in women with metastatic breast cancer. Forty-one patients with measurable (31 patients) or evaluable (10 patients) disease were entered into this trial. 6-TG was administered i.v. over a 10 min period daily for 5 consecutive days, with a planned cycle length of 35 days. The daily dosage level was 55 mg/m2 in the first 15 patients, but this was increased to 65 mg/m2 in the remaining patients due to inadequate myelosuppression at the lower dose. Six patients, all with measurable disease, achieved a complete response (CR) (two patients) or a partial response (PR) (four patients). Three responses occurred at the 55 mg/m2 level and three at the 65 mg/m2 level. The 95% confidence interval (CI) for the true response rate among patients with measurable disease was 6-39%. The median time to progression was 140 days and median survival time was 460 days. The regimen was well tolerated. We conclude that 6-TG, as given in this study, has limited activity as first-line chemotherapy for women with metastatic breast cancer.
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Albain KS, Green SR, Lichter AS, Hutchins LF, Wood WC, Henderson IC, Ingle JN, O'Sullivan J, Osborne CK, Martino S. Influence of patient characteristics, socioeconomic factors, geography, and systemic risk on the use of breast-sparing treatment in women enrolled in adjuvant breast cancer studies: an analysis of two intergroup trials. J Clin Oncol 1996; 14:3009-17. [PMID: 8918499 DOI: 10.1200/jco.1996.14.11.3009] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To investigate the frequency of breast-sparing treatment among breast cancer patients subsequently enrolled in national cooperative group studies of adjuvant chemotherapy. PATIENTS AND METHODS A data base was formed of 5,172 patients randomized onto two intergroup trials. Lumpectomy rates were analyzed within study-defined risk strata and across geographic regions. Significant predictors of lower lumpectomy usage were determined in multivariate analyses with variables that described patient and disease characteristics, systemic risk strata, geographic region, and socioeconomic indicators based on zip code of residence. RESULTS Breast-conservation rates were 30% in the node-negative and 15% in the node-positive trials, with a wide geographic variation within each study (range, 14% to 49% and 9% to 31%, respectively). Lumpectomy use declined with increasing tumor size and did not exceed 40% even for tumors < or = 1 cm with negative nodes. With increasing risk of systemic relapse, frequency of lumpectomy declined (rates for five strata in order of increasing systemic risk: 41%, 33%, 24%, 18%, and 11%), even though these strata were not known at the time of the surgical decision. A logistic model confirmed the joint significance of geographic region and systemic risk. An exploratory model that adjusted for all important variables identified the following significant predictors of lower lumpectomy use: positive nodes; many positive nodes, increased systemic risk; tumor size > or = 2.0 cm; older age; South, Central or non-New England regions; and either lack of college degree or lower income levels. CONCLUSION Breast-sparing therapy was used in the minority of women subsequently accrued to two national adjuvant breast cancer studies, even though this cohort and their referring surgeons represented a select population. Although multiple concrete factors were independent predictors of lower lumpectomy rates, prospective research is needed into how patients and their physicians approach the mastectomy versus lumpectomy decision.
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Alberts SR, Ingle JN, Roche PR, Cha SS, Wold LE, Farr GH, Krook JE, Wieand HS. Comparison of estrogen receptor determinations by a biochemical ligand-binding assay and immunohistochemical staining with monoclonal antibody ER1D5 in females with lymph node positive breast carcinoma entered on two prospective clinical trials. Cancer 1996; 78:764-72. [PMID: 8756370 DOI: 10.1002/(sici)1097-0142(19960815)78:4<764::aid-cncr12>3.0.co;2-t] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The measurement of estrogen receptors (ER) in breast cancer specimens has traditionally been assessed with a dextran-coated charcoal assay (DCCA). More recently the immunohistochemical staining (IHC) method has gained increasing popularity because of its ability to use fixed tissue, assess needle biopsies, and reduce cost. Controversy exists over the accuracy of IHC compared with that of DCCA in determining ER. We compared these two techniques using tumor tissue obtained from a large group of females with lymph node positive breast carcinoma with long term follow-up. METHODS Breast carcinoma tissue was obtained from a large group of females with node positive breast carcinoma participating in two adjuvant chemotherapy trials. ER was determined by the traditional DCCA method and by IHC using the ER1D5 antibody. Disease free survival (DFS) and overall survival (OS) were assessed by each of these methods. RESULTS ER status was determined by DCCA and IHC in tumor tissue obtained from 316 females. A concordance of 79% was observed for the determination of ER-positive tumors. Of the discordant results, the majority of DCCA-negative, IHC-positive tumors could be explained by a low level of DCCA positivity (< 10 fmol) or IHC staining of nonmalignant cells. A much higher rate of discordant results was observed in premenopausal females. Of the DCCA-negative, IHC-positive patients 97% were premenopausal and of the DCCA-positive, IHC-negative patients 79% were premenopausal. ER by DCC appears to perform better than ER by IHC as a prognostic factor in terms of DFS and OS. CONCLUSIONS When compared with DCCA, IHC with monoclonal antibody ER1D5 appears to be a reasonable substitute for the determination of ER. Although DCCA appeared to perform better as a determinant of prognosis, ER detection is used primarily for deciding on hormonal therapy. Review of discordant cases indicates IHC may more accurately reflect the ER status of malignant cells in some patients. Attention must be paid to quality control considerations in performance of IHC staining.
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Pisansky TM, Loprinzi CL, Cha SS, Fitzgibbons RJ, Grant CS, Hass AC, Reuter NF, Wold LE, Ingle JN, Kardinal CG. A pilot evaluation of alternating preoperative chemotherapy in the management of patients with locoregionally advanced breast carcinoma. Cancer 1996; 77:2520-8. [PMID: 8640701 DOI: 10.1002/(sici)1097-0142(19960615)77:12<2520::aid-cncr15>3.0.co;2-u] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This prospective trial was conducted to evaluate the outcome of patients treated with preoperative and post operative chemotherapy, mastectomy, and irradiation for locoregionally advanced breast carcinoma. METHODS Between June 1986 and September 1990, 71 patients received 2 cycles of doxorubicin that alternated with 2 cycles of cyclophosphamide, methotrexate, and 5-fluorouracil prior to mastectomy; irradiation was administered when the tumor was not amenable to surgical resection. Additional chemotherapy and tamoxifen, in hormone receptor-positive tumors, was used after mastectomy. Post-operative irradiation was given on a selective basis for patients at high risk for locoregional disease recurrence. RESULTS Although 5 patients (7%) had disease progression, clinical partial or complete tumor response to preoperative chemotherapy was noted in 46 patients (65%). Sixty-eight patients (96%) underwent mastectomy. With a median follow-up of 52 months, the relapse-free and overall survival rates at 5 years were 42% and 57% respectively. Locoregional tumor recurrence occurred in 14 patients (20%), and 28 patients (39%) developed metastatic disease. Menopausal status, clinical presentation (noninflammatory vs. inflammatory), and American Joint Committee on Cancer clinical stage were independent covariates associated with patient outcome. CONCLUSIONS Preoperative alternating chemotherapy, with the selective use of irradiation, resulted in significant locoregional disease regression and the successful integration of mastectomy into the therapeutic strategy. Locoregional tumor control and relapse-free and overall survival estimates for the approach described herein compared favorably with other comtemporary reports for this condition.
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Dhodapkar MV, Ingle JN, Cha SS, Mailliard JA, Wieand HS. Prognostic factors in elderly women with metastatic breast cancer treated with tamoxifen: an analysis of patients entered on four prospective clinical trials. Cancer 1996; 77:683-90. [PMID: 8616760 DOI: 10.1002/(sici)1097-0142(19960215)77:4<683::aid-cncr14>3.0.co;2-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Information regarding prognostic factors and survival in elderly women with metastatic breast cancer treated with tamoxifen is limited. METHODS The data from 4 prospective clinical trials were analyzed, including information on 396 postmenopausal women with advanced breast cancer who received tamoxifen as initial therapy for metastatic disease. Emphasis was placed on 184 elderly patients (age greater than 65 years) to characterize the response to therapy, time to progression TTP), overall survival (OS), prognostic factors, and treatment-related toxicity. RESULTS Among 363 patients with measurable or evaluable disease, the objective response rates were higher in the elderly patients (46% versus 33%, P = 0.06); but age did not achieve significance in a logistic regression analysis (P= 0. 1). The median TTP (10.5 months versus 6.2 months, log rank P = 0.002) and OS (35.7 months versus 28.8 months, log rank P = 0.02) were superior in the elderly cohort. In multivariate analysis, age at diagnosis approached statistical significance (P = 0.055) for TTP but was not significant for OS (P = 0.17). Among elderly patients, disease free interval (DFI) (greater than 5 years), dominant disease site (soft tissue), prior adjuvant chemotherapy, positive estrogen/progesterone receptor (ER/PgR) and performance status (PS) were independent prognostic factors. Hot flashes were common in both younger and older cohorts (25% versus 33%, P = 0.14), while anorexia (14% versus 22%, P = 0.04) and mood changes (2% versus 6%, P = 0.03) were more common in the elderly patients. CONCLUSIONS There was no indication that elderly women with metastatic breast cancer treated with tamoxifen have a poorer outcome with regard to response rate, TTP or OS; in fact, they appeared to have a slightly better prognosis although this was not significant after adjustment for other prognostic factors. In elderly patients, DFI, PS, positive ER or PGR, and dominant disease site are independent prognostic factors.
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Cobau CD, Declercq K, Neuberg D, Ingle JN, Tormey DC. A randomized trial of megestrol acetate with or without premarin in the treatment of potentially responsive metastatic breast cancer. A Study of the Eastern Cooperative Oncology Group (E2185). Cancer 1996; 77:483-9. [PMID: 8630955 DOI: 10.1002/(sici)1097-0142(19960201)77:3<483::aid-cncr9>3.0.co;2-l] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Human breast cancer cells in vitro exhibit increased levels of progestin receptors (PgR) after brief exposure to physiologic concentrations of estrogens. Prior clinical studies have positively correlated the responsiveness of metastatic breast cancer to progestin therapy with the level of PgR in the tumor cells. METHODS These observations were used as the scientific basis for a randomized clinical trial by the Eastern Cooperative Oncology Group (ECOG) to compare the effectiveness of megestrol acetate (MEG) alone in a daily dose of 160 mg with MEG alternated with premarin in a dose of 1.25 mg/day on the first 3 days of a 14 day cycle (PRE/MEG). From 1985 through 1989, 266 eligible and fully evaluable patients were randomized to 1 of the treatment arms and accrued to this trial. All patients were postmenopausal with biochemical estrogen cytosol protein receptor (ER) positive (> or = 10 fm/mg) tumors. The treatment groups were balanced with respect to performance status, number of involved organ systems, and PgR levels. RESULTS Forty-five of 135 (33%) (95% confidence interval [CI], 25-42%) patients receiving MEG experienced a partial (PR) or complete (CR) response. Thirty-one of 131 (23%) (95% CI, 17-32%) patients receiving PRE/MEG achieved a PR or CR. Survival was not influenced by treatment selection. However, median time to progression was seven months for patients receiving MEG and four months for the group receiving PRE/MEG (P = 0.03). The treatment failure hazard rate was higher for patients with a short disease free interval after primary treatment of the breast cancer, poor performance status, non-white race, and visceral disease. Survival was negatively impacted by short disease free interval, administration of prior radiation therapy, prior treatment for metastatic disease, and hepatic involvement. CONCLUSIONS Sequential treatment with premarin and megestrol acetate is not superior to treatment with megace alone in potentially hormone responsive patients with advanced breast cancer.
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Ingle JN, Kardinal CG, Suman VJ, Krook JE, Hatfield AK. Octreotide as first-line treatment for women with metastatic breast cancer. Invest New Drugs 1996; 14:235-7. [PMID: 8913847 DOI: 10.1007/bf00210797] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Octreotide is a synthetic somatostatin analogue which has shown inhibitory activity against human breast cancer cells in culture. Ten patients with metastatic breast cancer and no prior hormonal therapy exposure received octreotide at 150 micrograms subcutaneously thrice daily. No objective responses were observed and the median time to treatment failure was short at 57 days.
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Ingle JN, Krook JE, Mailliard JA, Hartmann LC, Wieand HS. Evaluation of ifosfamide plus mesna as first-line chemotherapy in women with metastatic breast cancer. Am J Clin Oncol 1995; 18:498-501. [PMID: 8526193 DOI: 10.1097/00000421-199512000-00009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Ifosfamide is an oxazaphosphorine analogue of cyclophosphamide with proven activity in breast cancer but substantial urotoxicity. The introduction of mesna as a uroprotective agent provided a stimulus for reexamination of ifosfamide for therapy of women with metastatic breast cancer. Twenty women with measurable (18 patients) or evaluable (2 patients) disease were entered into a phase II clinical trial of ifosfamide plus mesna as first-line chemotherapy. Ifosfamide was administered i.v. at a dose of 1,800 mg/m2 in 1 L D5W over 2 h on five consecutive days. Mesna was administered i.v. at a dose of 400 mg/m2 over 15 min immediately before and 1 h after ifosfamide, and then every 4 h for three more doses. The last three doses could be given either i.v. or orally. The planned cycle length was 28 days. Three patients (15%), all with measurable disease, achieved a partial response (95% confidence interval: 3 to 38%). Median time to progression was 137 days and median survival was 407 days. Toxicities included cumulative myelosuppression and substantial nausea and emesis. Four patients were removed from treatment because of toxicity alone and a fifth refused further therapy. We conclude that ifosfamide, plus mesna, as given in this protocol has definite but limited antitumor activity and poor tolerability.
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Dupree EA, Watkins JP, Ingle JN, Wallace PW, West CM, Tankersley WG. Uranium dust exposure and lung cancer risk in four uranium processing operations. Epidemiology 1995; 6:370-5. [PMID: 7548343 DOI: 10.1097/00001648-199507000-00007] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We examined the relation between uranium dust exposure and lung cancer mortality among workers employed in four uranium processing or fabrication operations located in Missouri, Ohio, and Tennessee. Among workers who had at least 30 years of potential follow-up, we identified 787 lung cancer cases from death certificates and matched one control to each case. Health physicists estimated individual annual lung doses from occupational exposure primarily to insoluble uranium compounds, using contemporary monitoring data. With a 10-year lag, cumulative lung doses ranged from 0 to 137 centigrays (cGy) for cases and from 0 to 80 cGy for controls. Health physicists assigned annual external radiation doses to workers having personal monitoring records. Archivists collected smoking information from occupational medical records. Odds ratios for lung cancer mortality for seven cumulative internal dose groups did not demonstrate increasing risk with increasing dose. We found an odds ratio of 2.0 for those exposed to 25 cGy and higher, but the 95% confidence interval of 0.20 to 20 showed great uncertainty in this estimate. There was a suggestion of an exposure effect for workers hired at age 45 years or older. Further analyses for cumulative external doses and exposures to thorium, radium, and radon did not reveal any clear association between exposure and increased risk, nor did dichotomizing workers by facility.
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Wold LE, Ingle JN, Pisansky TM, Johnson RE, Donohue JH. Prognostic factors for patients with carcinoma of the breast. Mayo Clin Proc 1995; 70:678-9. [PMID: 7791392 DOI: 10.4065/70.7.678] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Abstract
BACKGROUND Data regarding the effects of estrogen replacement therapy (ERT) and its withdrawal in patients with breast cancer are limited. METHODS Four cases were observed involving estrogen replacement therapy withdrawal as management of metastatic breast cancer. RESULTS Three patients with a history of primary breast cancer developed metastatic disease while on ERT. A fourth patient presented with metastatic breast cancer while on ERT. Withdrawal of this "physiologic" ERT alone as the only therapeutic intervention resulted in regression of metastatic disease in all four patients. CONCLUSIONS In patients receiving ERT who develop metastatic breast cancer, withdrawal of ERT alone is a therapeutic option. Awareness of this phenomenon may be of value in management of these patients. The role of ERT and value of ERT withdrawal in patients with breast cancer deserve further study.
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Cunningham JM, Ingle JN, Jung SH, Cha SS, Wold LE, Farr G, Witzig TE, Krook JE, Wieand HS, Kovach JS. p53 gene expression in node-positive breast cancer: relationship to DNA ploidy and prognosis. J Natl Cancer Inst 1994; 86:1871-3. [PMID: 7990162 DOI: 10.1093/jnci/86.24.1871] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Hartmann LC, Ingle JN, Wold LE, Farr GH, Grill JP, Su JQ, Maihle NJ, Krook JE, Witzig TE, Roche PC. Prognostic value of c-erbB2 overexpression in axillary lymph node positive breast cancer. Results from a randomized adjuvant treatment protocol. Cancer 1994; 74:2956-63. [PMID: 7954259 DOI: 10.1002/1097-0142(19941201)74:11<2956::aid-cncr2820741111>3.0.co;2-v] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND This study was designed to evaluate the prognostic importance of c-erbB2 overexpression in a standardized cohort of patients with axillary lymph node positive breast cancer. METHODS Paraffin embedded primary breast cancers from 354 patients with axillary lymph node positive breast cancer, treated on a North Central Cancer Treatment Group adjuvant protocol, were studied immunohistochemically. c-erbB2 staining was classified as negative, weak (1+), moderate (2+), or strong (3+) and was assessed for effectiveness as a predictor of outcome in univariate and Cox model multivariate analyses. RESULTS Twenty percent of specimens exhibited moderate or strong c-erbB2 staining. The median disease free survival period of the strong staining group was 2.9 years, compared with 7.1 years for all other patients (P = 0.01). The median overall survival for the strong staining group was 5 years, compared with 12 years for all other patients (P = 0.03). A definite correlation was noted between degree of nodal involvement and the likelihood of strong c-erbB2 staining (P = 0.001). There was also a significant correlation between c-erbB2 staining and higher nuclear grade and estrogen receptor negativity. In a multivariate analysis, c-erbB2 staining was not a significant predictor of either disease free survival or overall survival. CONCLUSION According to this analysis, the strong correlation between c-erbB2 expression and degree of nodal involvement, higher grade disease, and estrogen receptor negativity suggests expression of this protooncogene product in a biologically more aggressive form of breast cancer. In a multivariate analysis, c-erbB2 expression was not an independent prognostic factor. Thus, c-erbB2 assessment did not appear to add significantly to the information provided by currently available standard disease parameters.
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Ingle JN, Kuross SA, Mailliard JA, Loprinzi CL, Jung SH, Nelimark RA, Krook JE, Long HJ. Evaluation of piroxantrone in women with metastatic breast cancer and failure on nonanthracycline chemotherapy. Cancer 1994; 74:1733-8. [PMID: 8082075 DOI: 10.1002/1097-0142(19940915)74:6<1733::aid-cncr2820740615>3.0.co;2-d] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Doxorubicin generally is considered to be the most effective single chemotherapeutic agent for the treatment of breast cancer. The major cumulative dose-limiting toxicity is cardiac toxicity, which may be related to the formation of free radicals with subsequent lipid peroxidation, leading to membrane damage. The anthrapyrazoles, of which piroxantrone is a member, were synthesized in an attempt to eliminate this toxicity. METHODS A Phase II clinical trial was conducted in 30 women with metastatic breast cancer in whom piroxantrone was administered at a dose of 160 mg/m2 by 1-hour infusion. The planned cycle length for retreatment was 3 weeks. Measurable metastatic disease and failure on one prior chemotherapy regimen, but no prior anthracycline exposure, were required for response evaluation. RESULTS Twenty-nine patients were evaluable for response, and 6 (21% and 95% confidence intervals: 10-43%) achieved an objective response (1 complete, 5 partial responses), with a median response duration of 244 days. The median time-to-disease progression for all patients was 124 days. Eight patients received cumulative doses of piroxantrone approaching or exceeding 1000 mg/m2, and all had reductions in the resting left ventricular ejection fraction (LVEF). The estimated median decrease in LVEF at 1000 mg/m2 was 16%, with a range of 10-28%. Clinical findings of congestive heart failure developed in two patients. CONCLUSIONS Piroxantrone had definite antitumor activity in women who had metastatic breast cancer and failure on prior chemotherapy that did not include an anthracycline. The 95% confidence interval for response probability was broad, but the level of activity observed was relatively low. The clear association with cardiac toxicity combined with the relatively low efficacy led to the conclusion that piroxantrone cannot be recommended for further development as therapy for women with breast cancer. Further study of other anthrapyrazoles is necessary to determine if the promise of this new class of agents can be fulfilled.
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Witzig TE, Ingle JN, Cha SS, Schaid DJ, Tabery RL, Wold LE, Grant C, Gonchoroff NJ, Katzmann JA. DNA ploidy and the percentage of cells in S-phase as prognostic factors for women with lymph node negative breast cancer. Cancer 1994; 74:1752-61. [PMID: 8082078 DOI: 10.1002/1097-0142(19940915)74:6<1752::aid-cncr2820740618>3.0.co;2-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Previous cell kinetic studies have shown that the percentage of cells in S-phase (%S) of the tumor may be an important prognostic factor for relapse-free survival (RFS) and overall survival (OS) in patients with resected lymph node negative breast cancer. METHODS This study examined DNA ploidy and %S from the paraffin embedded primary tumors of 265 patients who had surgery between 1975 and 1981, had lymph node negative cancer, and had no adjuvant therapy. The %S and %G2M values were calculated using a debris and aggregate subtraction model. RESULTS The results of the DNA ploidy analysis revealed 130 (49%) DNA diploid tumors and 135 (51%) DNA nondiploid tumors. Ploidy was not significant for either RFS (P = 0.20) or OS (P = 0.13). The total %S (using a cutoff of 8%) was a statistically significant prognostic factor for RFS (P = 0.003) and borderline for OS (P = 0.08). The proliferation fraction (%S + %G2M), using a cutoff of 12.5, was a statistically significant prognostic factor for RFS (P = 0.01) and for OS (P = 0.01). In a Cox multivariate analysis for RFS, the total %S remained significant (P = 0.05) along with tumor size. In the analysis of OS, the proliferation fraction remained significant (P = 0.03) along with tumor size and age. DNA ploidy was not significant in any multivariate analysis. CONCLUSIONS This study suggests that tumor size and cell proliferation parameters are independent prognostic factors for patients with resected lymph node negative breast cancer. However, the clinical usefulness of the cell kinetic parameters appears limited.
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Pisansky TM, Halyard MY, Weaver AL, Donohue JH, Grado GL, Grant CS, Hartmann LC, Ingle JN, Schomberg PJ, Wold LE. Breast conservation therapy for invasive breast cancer: a review of prior trials and the Mayo Clinic experience. Mayo Clin Proc 1994; 69:515-24. [PMID: 8189756 DOI: 10.1016/s0025-6196(12)62241-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To assess the role of breast conservation therapy in the management of early-stage invasive breast cancer. DESIGN We reviewed the results of previously published trials and summarized 165 cases of breast conservation surgical procedures and irradiation at the Mayo Clinic between January 1979 and September 1989. MATERIAL AND METHODS From the prior clinical trials, the criteria for selection of patients, the surgical and radiation techniques used, the complications of treatment, the cosmetic results, and the follow-up assessment and survival were analyzed. The 165 Mayo patients were also characterized, and their results were described. RESULTS Breast conservation therapy consists of excision of the primary tumor followed by irradiation. A coordinated multidisciplinary approach should be used for selection of patients. Several large-scale clinical trials have demonstrated that breast conservation therapy is an appropriate option for most women with early-stage breast cancer and provides tumor control and survival rates equivalent to mastectomy. With a collaborative treatment program and judicious application of contemporary standards of practice, a good-to-excellent cosmetic outcome can be achieved in most patients, and the risk of treatment-related sequelae is minimal. The Mayo Clinic experience with breast conservation therapy is consistent with these observations and compares favorably with other institutional and clinical trial results. CONCLUSION Patients should be fully educated about the options for primary management of early-stage breast cancer because the selection of therapy may profoundly influence psychologic adjustment and acceptance of the treatment program.
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Ingle JN, Foley JF, Mailliard JA, Krook JE, Hartmann LC, Jung SH, Veeder MH, Gesme DH, Hatfield AK, Goldberg RM. Randomized trial of cyclophosphamide, methotrexate, and 5-fluorouracil with or without estrogenic recruitment in women with metastatic breast cancer. Cancer 1994; 73:2337-43. [PMID: 8168039 DOI: 10.1002/1097-0142(19940501)73:9<2337::aid-cncr2820730916>3.0.co;2-q] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The fraction of breast cancer cells undergoing DNA synthesis at any one time is relatively low, which is problematic because most chemotherapeutic agents are most effective against dividing cells. Estrogens administered in vitro and in vivo can increase breast cancer cell proliferation. A randomized clinical trial was performed to determine if estrogenic recruitment could increase the effectiveness of combination chemotherapy. METHODS One hundred sixty-five women were randomized, with two excluded from these analyses, to either an intravenous cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) regimen alone (cyclophosphamide, 600 mg/m2; methotrexate, 40 mg/m2; 5-fluorouracil, 600 mg/m2) or CMF preceded by 3 days of diethylstilbestrol (DES) at a dose of 1 mg orally per day. The planned cycle length was 3 weeks. RESULTS Objective responses were seen in 20 of 80 patients (25%) treated with CMF and 32 of 83 patients (39%) treated with DES-CMF, and this difference almost achieved statistical significance (chi-square, two-sided P = 0.06). However, duration of response, time to disease progression, and survival time were similar for the two regimens. CONCLUSIONS Estrogenic recruitment with DES as used in this study does not substantially increase the efficacy of a CMF regimen administered intravenously every 3 weeks.
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Pisansky TM, Ingle JN, Schaid DJ, Hass AC, Krook JE, Donohue JH, Witzig TE, Wold LE. Patterns of tumor relapse following mastectomy and adjuvant systemic therapy in patients with axillary lymph node-positive breast cancer. Impact of clinical, histopathologic, and flow cytometric factors. Cancer 1993; 72:1247-60. [PMID: 8339215 DOI: 10.1002/1097-0142(19930815)72:4<1247::aid-cncr2820720418>3.0.co;2-s] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND This analysis was conducted to evaluate the impact of selected clinical, histopathologic, and flow cytometric factors on sites of initial tumor relapse after postmastectomy adjuvant systemic therapy. METHODS Five hundred sixty-four patients with axillary node-positive breast cancer were entered in two prospectively randomized trials and received cyclophosphamide, 5-fluorouracil and prednisone with or without tamoxifen as sole adjuvant therapy. These patients were studied to assess the risk of locoregional recurrence and to identify factors that might predict tumor relapse site. RESULTS With a median follow-up of 9.3 years, the 8-year cumulative incidences of initial locoregional or distant relapse were 20% and 35%, respectively. Pathologic tumor stage, estrogen receptor content, and number of involved axillary nodes were independent predictive factors for an increased risk of locoregional recurrence. With the exception of tumor stage, these factors also were associated with an increased risk of distant relapse so that tumor stage (T3a) remained the sole factor predictive of increased relative risk for initial locoregional (versus distant) recurrence in patients with tumor progression. Clinical and flow cytometric factors were not predictive of initial locoregional or distant relapse. CONCLUSIONS Exploratory data analysis of two prospective trials of postmastectomy adjuvant systemic therapy has demonstrated a significant risk for initial isolated locoregional recurrence in certain patients with node-positive breast cancer. The benefit of improved locoregional tumor control in appropriately selected patients with axillary node-positive breast cancer who receive adjuvant systemic therapy requires additional investigation.
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Abstract
PURPOSE This report describes a previously unreported clinical phenomenon that occurs in some patients after completion of combination chemotherapy. METHODS AND RESULTS Eight case reports are presented. Affected patients developed a syndrome of myalgias/arthralgias within several months of completing cyclophosphamide/fluorouracil (5FU)-containing adjuvant combination chemotherapy for breast cancer. These symptoms did not appear to be related to cancer recurrence or any common rheumatologic disorder. The syndrome generally resolved over several months. CONCLUSION Postchemotherapy rheumatism is a syndrome of myalgias/arthralgias that usually develops 1 to 3 months after completion of adjuvant chemotherapy. Recognition of this syndrome can limit the need for extensive work-ups to exclude recurrent breast cancer or inflammatory rheumatologic diseases.
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Witzig TE, Ingle JN, Schaid DJ, Wold LE, Barlow JF, Gonchoroff NJ, Gerstner JB, Krook JE, Grant CS, Katzmann JA. DNA ploidy and percent S-phase as prognostic factors in node-positive breast cancer: results from patients enrolled in two prospective randomized trials. J Clin Oncol 1993; 11:351-9. [PMID: 8426213 DOI: 10.1200/jco.1993.11.2.351] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
PURPOSE AND METHODS To help clarify the clinical utility of flow-cytometric parameters, we performed flow cytometry on archival paraffin-embedded primary breast cancers from 502 patients treated on two adjuvant chemotherapy protocols performed by the North Central Cancer Treatment Group (NCCTG) and Mayo Clinic. DNA ploidy and percent S-phase (%S) were examined in univariate and Cox model multivariate analyses along with tumor size, menopausal and estrogen receptor status, Quetelet's index (QI), number of positive nodes and nodes examined, and Fisher and nuclear grades. RESULTS Ploidy analysis showed that 40% of tumors were DNA diploid and 60% were DNA nondiploid (12% tetraploid and 48% aneuploid). There was no difference in relapse-free survival (RFS) (P = .82) or overall survival (OS) (P = .78) between the ploidy groups. Tetraploid patients had the longest RFS and OS of any group, but this did not achieve statistical significance. The %S was computed in 98% of cases and the medians were 9.0% for all patients, 6.4% for diploid patients, and 11.7% for nondiploid patients (P < .0001). By use of a %S greater than 12.3 as a prognostic variable in a univariate analysis, there was a significant difference in the RFS (P = .02) and OS (P = .007) of patients with low- versus high-proliferative tumors. However, when the %S was adjusted for clinical characteristics in the multivariate analysis, it was not a significant factor for RFS (P = .23) or OS (P = .36). CONCLUSION These results indicate that DNA content and %S measurements by flow cytometry are not clinically useful independent prognostic factors in women with resected node-positive breast cancer administered adjuvant chemotherapy.
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Witzig TE, Gonchoroff NJ, Therneau T, Gilbertson DT, Wold LE, Grant C, Grande J, Katzmann JA, Ahmann DL, Ingle JN. DNA content flow cytometry as a prognostic factor for node-positive breast cancer. The role of multiparameter ploidy analysis and specimen sonication. Cancer 1991; 68:1781-8. [PMID: 1913523 DOI: 10.1002/1097-0142(19911015)68:8<1781::aid-cncr2820680822>3.0.co;2-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The DNA content was analyzed in paraffin-embedded material from 167 patients with node-positive breast cancer to learn whether specimen sonication and multiparameter ploidy analysis (MPPA) (using DNA content and light scatter) could improve the strength of ploidy as a prognostic variable. Sonicated specimens were found to have fewer aggregates, a lower percentage of cells in S-phase (%S) and G2M phase than the corresponding nonsonicated specimens. The results using MPPA predicted the prognosis better because they allowed detection of small aneuploid peaks in histograms classified as diploid or tetraploid using DNA content alone. Ploidy was a significant univariate factor, and patients with tetraploid tumors had the best survival. In the multivariate analysis, if other routine factors were examined preferentially, ploidy and %S did not provide additional prognostic information for survival. This study of paraffin-embedded breast cancers suggested that sonication and MPPA may improve the ploidy analysis in certain cases and that tetraploidy may be a favorable ploidy pattern in this group.
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Hartmann LC, Marschke RF, Schaid DJ, Ingle JN. Systemic adjuvant therapy in women with resected node-negative breast cancer. Mayo Clin Proc 1991; 66:805-13. [PMID: 1861552 DOI: 10.1016/s0025-6196(12)61198-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Currently, the role of adjuvant systemic therapy in women with node-negative breast cancer is being determined. Several studies of adjuvant hormonal therapy and adjuvant chemotherapy have demonstrated a moderate reduction in the risk of recurrence in the treated patients. With relatively limited follow-up, however, overall survival has not improved with use of adjuvant therapy. The use of prognostic factors to select those patients at highest risk for relapse is an active area of oncologic research. The decision to recommend adjuvant therapy necessitates assessment of the probability of recurrence, the expected reduction of risk with adjuvant therapy, the toxic effects of therapy, and the influence of treatment on the patient's overall quality of life.
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