EUS in preoperative staging of pancreatic cancer

BACKGROUND

Endoscopic ultrasound (EUS) is believed to be highly accurate in the local (T) and nodal (N) staging of pancreatic cancer. However, there are scant data concerning the predictive value of EUS for resectability of pancreatic adenocarcinoma. This study was performed to determine the accuracy of TNM staging by EUS in patients with pancreatic adenocarcinoma and to evaluate the role of preoperative TNM staging by EUS for determining resectability in patients with pancreatic adenocarcinoma.

METHODS

This is a retrospective review of a cohort of 89 patients evaluated preoperatively with EUS for pancreatic adenocarcinoma between January 1995 and December 1997. Preoperative TNM classification by EUS was compared with surgical and histopathologic TNM staging. Resectability rates were determined and compared with the preoperative TNM staging by EUS.

RESULTS

The overall accuracy of EUS for T and N staging was found to be 69% and 54%, respectively. The overall proportion of tumors that were deemed resectable by EUS and were actually found to be resectable during surgical exploration was 46%. The proportion of tumors staged as T4 N1, T4 N0, T3 N1 and T3 N0 by EUS that were found to be resectable during surgical exploration was 45%, 37%, 44% and 62%, respectively.

CONCLUSIONS

In a tertiary referral patient population, EUS is not as accurate as previously reported in the T and N staging of pancreatic cancer. EUS is also not predictive of resectability in stage T3 or T4 pancreatic cancer.

p21WAF1 expression is associated with improved survival after adjuvant chemoradiation for pancreatic cancer

BACKGROUND

Cell cycle arrest after DNA damage is partly mediated through the transcriptional activation of p21(WAF1) by the p53 tumor suppressor gene. p21(WAF1) and p53 are both critical in maintaining cell cycle control in response to DNA damage from radiation or chemotherapy. Therefore, we examined the role of p21(WAF1) and p53 in the determination of outcome for patients who receive radiation and/or chemotherapy for pancreatic cancer.

METHODS

p21(WAF1) and p53 protein expression were determined (with the use of immunohistochemistry) in specimens from 90 patients with pancreatic cancer. Forty-four patients underwent surgical resection, and 46 patients had either locally unresectable tumors (n = 9 patients) or distant metastases (n = 37 patients). Seventy-three percent of the patients who underwent resection and 63% of the patients who did not undergo resection received radiation and/or chemotherapy.

RESULTS

p21(WAF1) expression was present in 48 of 86 tumors (56%) and was significantly (P<.05) associated with advanced tumor stage. Median survival among patients with resected pancreatic cancer who received adjuvant chemoradiation with p21(WAF1)-positive tumors was significantly longer than in patients with no p21(WAF1) staining (25 vs. 11 months; P = .01). Fifty of 89 tumors (56%) stained positive for p53 protein. p53 overexpression was associated with decreased survival in patients who did not undergo resection.

CONCLUSIONS

Normal p21(WAF1) expression may be necessary for a beneficial response to current adjuvant chemoradiation protocols for pancreatic cancer. Alternate strategies for adjuvant therapy should be explored for patients with pancreatic cancer who lack functional p21(WAF1).

Omitting axillary surgery for low-risk breast cancer patients--a Swedish prospective cohort study

The effects of mammography screening are a decrease in the sizes of tumours and a shift in stage. Very few small breast cancers (< or = 10 mm) have lymph node metastases when screening-detected, the rate being as low as 7%. Axillary clearance is not necessary for all such small tumours. A Swedish prospective cohort study, scheduled for 1500 patients, is being launched, where axillary surgery is omitted for screening-detected breast cancers of < or = 10 mm showing Elston grade I or II/and/or S-phase < or = 10%. Axillary surgery, with the associated disadvantages, will not be performed in 970 women out of 1000 expecting an axillary recurrence rate of 3%. Nordic breast cancer centres are welcome to join the study, which has already recruited around 500 patients.

Relation between appropriateness of primary therapy for early-stage breast carcinoma and increased use of breast-conserving surgery

BACKGROUND

Breast-conserving surgery is a more complex treatment than mastectomy, because a separate incision is needed for axillary lymph-node dissection, and postoperative radiotherapy is necessary. We postulated that adoption of this therapy into clinical practice might have led to discrepancies between the care recommended and that received.

METHODS

We used records of the US national Surveillance, Epidemiology, and End Results tumour registry to study 144,759 women aged 30 years and older who underwent surgery for early-stage breast cancer between 1983 and 1995. We calculated the proportion undergoing at least the minimum appropriate primary treatment (defined, in accordance with the recommendations of a National Institutes of Health Consensus Conference in 1990, as total mastectomy with axillary node dissection or breast-conserving surgery with axillary node dissection and radiotherapy) during each 3-month period.

FINDINGS

The proportion of women receiving appropriate primary therapy fell from 88% in 1983-89 to 78% by the end of 1995. This decline was observed in all subgroups of age, race, stage, and population density. Of all women in the cohort, the proportion undergoing an inappropriate form of mastectomy remained stable at about 2.7% throughout the study period. The proportion undergoing an inappropriate form of breast-conserving surgery (omission of radiotherapy, axillary node dissection, or both) increased from 10% in 1989 to 19% at the end of 1995.

INTERPRETATION

Although most women undergo appropriate care, the appropriateness of care for early-stage breast cancer in the USA declined from 1990 to 1995. Because the proportion of all women who were treated by breast-conserving surgery increased, and because this approach was more likely than was mastectomy to be applied inappropriately, the proportion of all women having inappropriate care increased.

Axillary surgery in breast cancer management--background, incidence and extent of nodal spread, extent of surgery and accurate axillary staging, surgical procedures

The prime objectives of axillary surgery in the management of breast cancer are 1) accurate staging, 2) treatment to cure and 3) quantitative information of metastatic lymph nodes for prognostic purposes and allocation to adjuvant protocols. It is generally agreed that axillary node status in potentially curable breast cancer is considered the single best predictor of outcome and the main determinant of allocation to adjuvant therapy. No physical examination, no imaging techniques, and no molecular biologic markers can today replace axillary surgery for staging purposes. The objectives of axillary surgery are best obtained by carrying out a complete axillary clearance. Nonetheless, less radical surgery is generally performed by carrying out a sampling procedure with a yield of about 4 nodes or a partial axillary dissection level I-II with at least 10 nodes recovered. Understaging the axilla is detrimental to outcome and, furthermore, locoregional tumor control is important for survival. Axillary surgery should therefore be conducted in accordance with high professional standards.

Impact of axillary dissection on staging and regional control in breast tumors < or = 10 mm--the DBCG experience. The Danish Breast Cancer Cooperative Group (DBCG), Rigshisoutalet, Copenhagen, Denmark

Data from 4771 patients with tumor diameters < or = 10 mm were analyzed. Results of surgery and pathoanatomical examinations indicated that nodal status was related to diameter, but not to number of nodes removed. More axillary metastases were found in group T1b tumors than in T1a. In 8% of tumors, at least 4 positive nodes were identified. Mean number of positive nodes was related to number of nodes removed, and when 10 or more nodes were removed a significantly lower axillary recurrence rate and better recurrence-free survival were demonstrated, confirming that axillary surgery has two goals: staging and regional disease control. Age, receptor status, grade and histological type, but not tumor location, were related to prognosis. In accordance with the classical prognostic factors, it was not possible to define a patient group where axillary surgery was superfluous. We conclude that proper staging and regional control renders a full axillary level I-II dissection necessary.

Glutamatergic drugs exacerbate symptomatic behavior in a transgenic model of comorbid Tourette's syndrome and obsessive-compulsive disorder

We previously created a transgenic mouse model of comorbid Tourette's syndrome and obsessive-compulsive disorder (TS+OCD), by expressing a neuropotentiating cholera toxin (CT) transgene in a subset of dopamine D1 receptor-expressing (D1+) neurons thought to induce cortical and amygdalar glutamate output. To test glutamate's role in the TS+OCD-like disorder of these transgenic mice (D1CT-7 line), the effects of glutamate receptor-binding drugs on their behavior were examined. MK-801, a non-competitive NMDA receptor antagonist that indirectly stimulates cortical-limbic glutamate output, aggravated a transgene-dependent abnormal behavior (repetitive climbing and leaping) in the D1CT-7 mice at doses insufficient to induce stereotypies, and more readily induced stereotypies and limbic seizure behaviors at high doses. NBQX, a seizure-inhibiting AMPA receptor antagonist, reduced only the MK-801-dependent stereotypic and limbic seizure behavior of D1CT-7 mice, but not their transgene-dependent behaviors. These data imply that TS+OCD-like behavior is mediated by cortical-limbic glutamate, but that AMPA glutamate receptors are not an essential part of this behavioral circuit. Our findings lead to the prediction that the symptoms of human Tourette's syndrome and obsessive-compulsive disorder are elicited by excessive forebrain glutamate output.

Evaluation of herpes simplex thymidine kinase mediated gene therapy in experimental pancreatic cancer

BACKGROUND

Despite of recent improvements in the treatment of many malignant diseases, pancreatic ductal adenocarcinoma is still a disease with an extremely poor prognosis with current modes of treatment. Gene therapy has been suggested as a novel approach also against pancreatic cancer. Previous studies have been carried out predominantly with immunodeficient animal models and with tumors growing in environments other than the pancreas. We have attempted to mimic a more clinically relevant situation and investigated suicide gene therapy strategy for experimental pancreatic cancer in animals with an intact immune system.

METHODS

We used herpes simplex virus thymidine kinase (HSV-tk) and ganciclovir (GCV) strategy in both in vitro and in vivo settings.

RESULTS

In vitro studies demonstrated that retro- as well as adenovirally transduced HSV-tk-positive DSL-6A/C1 rat pancreatic carcinoma cells were sensitive to low concentrations of GCV when compared with parental, nontransduced cells. In addition, a strong bystander effect was observed. In in vivo studies, subcutaneously transplanted HSV-tk-positive DSL-6A/C1 cells were killed after GCV treatment, whereas parental, HSV-tk-negative cells continued to grow and developed into ductal adenocarcinomas. In in vivo HSV-tk-transduced pancreatic tumors, GCV treatment caused tumor necrosis and the necrosis volume was significantly more extensive when compared with control groups.

CONCLUSIONS

HSV-tk gene transfer followed by GCV treatment is efficient in killing pancreatic cancer cells in vitro, in a transduced subcutaneous tumor model, as well as in in vivo transduced pancreatic tumors using an immunocompetent animal model. These results highlight the potential of gene therapy to treat experimental pancreatic cancer.

Treatment of resectable and locally advanced pancreatic cancer

BACKGROUND

Pancreatic cancer is the fifth leading cause of cancer death in the United States, with an overall 5-year survival rate of less than 5%. A minority of patients are candidates for surgical resection, but most treatment strategies focus on palliative care.

METHODS

We discuss strategies in the diagnosis and treatment of resectable and locally advanced pancreatic cancer by reviewing available phase II and phase III trials, as well as large retrospective studies.

RESULTS

Surgical resection for pancreatic cancer is done today with an operative mortality rate below 5% and a 5-year survival rate of approximately 25%. There is evidence that chemoradiation may improve survival and quality of life in both the adjuvant setting and for locally advanced disease. Operative, minimally invasive, and endoscopic techniques are successful in palliating pain and jaundice.

CONCLUSIONS

The diagnosis and treatment of pancreatic cancer continue to improve although most patients will succumb to their disease. Novel methods of earlier detection and more effective systemic therapies are needed to significantly improve outcomes.

Endoscopic ultrasound in the clinical staging and management of pancreatic cancer: its impact on cost of treatment

BACKGROUND

Surgical resection for pancreatic cancer carries a 5% 5-year survival rate. Most conventional methods of imaging do not detect small pancreatic tumors and do not accurately stage pancreatic neoplasms. There is a significant impact on medical resources despite the relatively small number of patients affected. For these reasons, careful selection of patients for surgical resection is necessary.

METHODS

Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) have been developed to overcome limitations of conventional staging. We address the issues of how EUS may provide cost-effective treatment in the patient with pancreatic cancer.

RESULTS

EUS produces high-resolution images of the pancreas, which can detect small pancreatic tumors and accurately stage pancreatic neoplasms. Evaluation with EUS-guided FNA selects patients who would benefit most from surgical resection. EUS also can be used to deliver palliative treatment for pain at the initial time of staging. EUS with FNA identifies patients most likely to benefit from surgical resection and thus channels health care resources more appropriately.

CONCLUSIONS

Defining this patient population helps to reduce direct medical care costs in pancreatic cancer. However, prospective data are lacking in this regard and will need to be addressed in the future. When palliative care is the goal for patients, EUS-guided fine-needle injection techniques can be used for celiac neurolysis and possibly in the future use of antitumor agents.

[Surgical treatment of pancreatic cancer: curative resections]

Curative resection of pancreatic adenocarcinoma can only be performed in 10% of patients. This review article reports resectability rates and criteria, results of pancreatic resection and prognostic factors. Lymph node and/or vascular involvement and retroperitoneal tissue invasion constitute very poor prognostic factors; however, lymph node involvement limited to the first draining nodes and limited invasion of the mesenteric-portal vein do not constitute contraindications to surgical resection. Cephalic pancreaticoduodenectomy is still the reference procedure and its postoperative mortality has greatly decreased. The risk of pancreatic fistula mainly depends on the friability of the pancreatic stump. Median survival rate after tumour resection is usually limited between 12 and 18 months. Five-year actuarial survival rate is no more than 5%, but after curative resection (RO), it may be as high as 20 to 25% in recent surgical series. Concomitant or neoadjuvant chemotherapy-radiotherapy, currently under evaluation, may increase resection and survival rates.

Neoadjuvant radio-chemotherapy in advanced primarilynon-resectable carcinomas of the pancreas

AIM

To investigate the feasibility of neoadjuvant radio-chemotherapy (RCT) in the treatment of primarily non-resectable pancreas carcinoma the parameters tumour regression, possibility of subsequent resection and tolerability were examined.

METHOD

Between 1995 and 1997, 27 patients with locally inoperable (assessed by CT criteria) pancreatic carcinoma received radio-chemotherapy for 5 weeks comprising irradiation (55.8 Gy) and chemotherapy with 5-fluorouracil (5-FU, 1000 mg/m(2)/day; 120 h continuous infusion) and mitomycin C (10 mg/m(2)i.v.-bolus, day 2 and day 30) during the first and fifth week of radiotherapy. Two target volumes were irradiated with fractionated doses of 1.8 Gy up to a total of 50.4 Gy. Radiation was applied once a day five times a week and target volume 1 was irradiated with the same fractionated dose, and an additional boost of 5.4 Gy to make an overall total of 55.8 Gy.

RESULTS

Sixteen patients underwent explorative laparotomy, 10 of these were resected (eight Whipple's procedures, two distal pancreatic resections), while six could not be resected due to peritoneal carcinosis (n=3), local irresectability (n=2) and liver cirrhosis (n=1). A further nine patients were found to have unresectable tumours on CT and did not undergo surgery after restaging (five of these patients were staged as <<locally irresectable>>, three patients had distant metastases and one patient refused surgery). In two patients RCT was abandoned because of progression of disease.

CONCLUSIONS

The study protocol described is feasible without significant acute toxicity and when used the resectability rate was improved; the survival rate, however, was not improved. Additional intra-arterial or intraportal application of such drugs as mitomycin C or cisplatin may be necessary.

Association of poor prognosis with loss of 12q, 17p, and 18q, and concordant loss of 6q/17p and 12q/18q in human pancreatic ductal adenocarcinoma

OBJECTIVE

Pancreatic cancer is one of the diseases with the poorest prognosis, but the associated genetic alterations are not yet well understood. The genetic alterations reported to date in pancreatic cancer include frequent mutations of the KRAS, TP53, p16, and SMAD4 genes. Mutation of the TP53 gene was reported to be associated with a poor prognosis. In this study, we analyzed the association of loss of heterozygosity (LOH) with clinicopathological features to attempt to devise effective methods in the future for clinically applying our results to diagnosis and treatment.

METHODS

A total of 55 tumors from patients with primary pancreatic ductal carcinomas (34 men and 21 women, mean average age 63.9 yr) in which all the relevant clinical and pathological data were available were analyzed. A total of 46 cases were surgically resected, and nine cases were not. Tumor cells as well as corresponding normal cells were collected by microdissection under a microscope, and DNAs were purified. Allelotype analysis was performed by the PCR-based method, and the results were statistically analyzed.

RESULTS

LOH of > or =30% were observed on chromosome arms 17p (47%, 17/36), 9p (45%, 14/31), 18q (43%, 15/35), 12q (34%, 10/29), and 6q (30%, 10/33). LOH of 12q, 17p, and 18q were significantly associated with a poor prognosis. Concordant losses of 6q with 17p and 18q were significantly associated with a poor prognosis. Concordant losses of 6q with 17p and of 12q with 18q were also found.

CONCLUSIONS

Because LOH of 12q, 17p, and 18q are significantly associated with a poor prognosis, mutation of the putative tumor suppressor genes on these chromosome arms may play significant roles in the disease progression. Concordant losses of 6q with 17p and of 12q with 18q suggest that protein products of putative tumor suppressor genes on 6q and 12q may function in association with TP53 and SMAD4, respectively.

Survival advantage of combined chemoradiotherapy compared with resection as the initial treatment of patients with regional pancreatic carcinoma. An outcomes trial

BACKGROUND

Resection of pancreatic carcinoma is resource-intensive with a limited impact on survival. Chemotherapy and/or radiotherapy (RT) have been shown to be effective palliation. To examine whether preoperative chemoradiotherapy as the initial treatment improves survival for patients with a regional pancreatic adenocarcinoma with a minimal chance of being resected successfully, an outcomes trial was conducted.

METHODS

Patients with radiologically regional tumors were staged by laparotomy and/or computed tomography followed by endoscopic ultrasonography, angiography, and/or laparoscopy. Those with locally invasive, unresectable, regional pancreatic adenocarcinoma initially were treated with simultaneous split-course RT plus 5-fluorouracil, streptozotocin, and cisplatin (RT-FSP) followed by selective surgery (Group 1). Patients determined to have a resectable tumor initially underwent resection without preoperative chemoradiotherapy, with or without postoperative chemoradiotherapy (Group 2).

RESULTS

Over 8 years 159 patients presenting with nonmetastatic pancreatic adenocarcinoma were administered RT-FSP or underwent surgery for resection. Group 1, comprised of 68 patients initially treated with RT-FSP, had a 0% mortality rate within 30 days of entry. In 20 of 30 patients undergoing surgery after RT-FSP, tumors were downstaged and resected. Group 2, comprised of 91 patients who initially underwent successful resection, had a 5% mortality rate within 30 days of entry. Postoperatively, 63 of these patients received chemotherapy with or without RT. The median survival for Group 1 was 23.6 months compared with 14.0 months for Group 2 (P = 0.006) despite more advanced disease cases in Group 1. Survival favored RT-FSP regardless of whether lymph nodes were malignant. The dominant prognostic factor of earlier stage pancreatic carcinoma having an expected survival advantage was reversed by the initial nonoperative treatment.

CONCLUSIONS

Based on a reversal of the expected trend that patients with earlier stage resectable carcinoma (T1,2, N0,1, M0) who undergo removal of their tumors survive longer than patients with more advanced regional disease (T3, N0,1, M0), survival was found to improve significantly for patients reliably staged as having locally invasive, unresectable, nonmetastatic pancreatic adenocarcinoma when initially treated with RT-FSP.

The grade of pancreatic ductal carcinoma is an independent prognostic factor and is superior to the immunohistochemical assessment of proliferation

Tumour grade is one of the prognostic factors in pancreatic ductal adenocarcinoma, but its value is controversial. In this study, the predictive value and the reproducibility of the WHO grading system were reconsidered and the possibility of supplementing it with the immunohistochemically assessed proliferative activity was investigated. Seventy resected ductal adenocarcinomas of the head of the pancreas were evaluated. A total of 60 HPF fields on two to four sections per tumour were screened for glandular differentiation, mucin production, mitosis, and nuclear atypia by two observers with different degrees of experience. Each criterion was scored and the grade was calculated from the mean value of all single scores. Corresponding slides were immunohistochemically stained with the proliferation marker Ki-S5. The percentage of positive nuclei was assessed and a proliferation index (PI) assigned (<10%=1; 10-50%=2; >50%=3). Multivariate analysis (Cox regression) identified grade and R stage as the most significant factors for predicting survival. The PI determined on the basis of Ki-S5 staining did not prove to be an independent prognostic factor. In 30 of 70 carcinomas, it correlated with the tumour grade. Within a given tumour grade, the cases with the least favourable prognosis could be distinguished on the basis of their PI. The inter-observer variability was considerable, with the main differences occurring in the group of G1 tumours. According to the refined WHO criteria, the histopathological grade of pancreatic ductal carcinoma is an important independent prognostic factor, but reproducibility depends on the expertise of the observer. Criteria that relate to cellular and structural differentiation seem to be more predictive than those related to proliferation.

The clinical and economic impact of alternative staging strategies for adenocarcinoma of the pancreas

OBJECTIVE

Several innovative imaging modalities, including endoscopic ultrasound, have increased the number of available preoperative staging methods in patients with adenocarcinoma of the pancreas. Our goal was to estimate the clinical outcomes and cost-effectiveness of alternative staging strategies for pancreatic adenocarcinoma.

METHODS

Decision analysis was used to simulate alternative staging strategies. Cost inputs were based on Medicare reimbursements; clinical inputs were obtained from the available literature. Model endpoints of interest were cost per curative resection and appropriateness of treatment allocation based on pathological stage.

RESULTS

Endoscopic ultrasound followed by laparoscopy yielded the lowest cost per curative resection ($37,600) and minimized the number of unnecessary surgical explorations (5.4 per 100 patients staged). Requiring angiographic confirmation when endoscopic ultrasound demonstrated an unresectable tumor yielded an intermediate cost-effectiveness ratio and virtually eliminated the risk of overstaging. Laparoscopy alone maximized the resection rate, but each additional resection would cost approximately $2 million relative to a strategy employing both endoscopic ultrasound and angiography.

CONCLUSIONS

Staging strategies incorporating endoscopic ultrasound may improve treatment allocation and are cost-effective relative to angiography-based strategies. A staging protocol that does not incorporate an imaging modality to detect vascular invasion dramatically increases the cost per additional curative resection compared with more comprehensive staging protocols.

Sentinel Lymph Node Biopsy in Breast Cancer

One of the most important prognostic indicators in patients with breast cancer is axillary lymph node status. Sentinel lymph node (SLN) biopsy has emerged as a potential alternative to routine axillary dissection in clinically node-negative early breast cancer. This procedure requires a specialized but multidisciplinary approach utilizing the surgeon, nuclear radiologist and pathologist. SLN biopsy allows adequate assessment of the axillary nodal status in patients with early breast cancer, with minimal—if any—morbidity. Blue dye and lymphoscintigraphy are complementary techniques, and the success rate is maximized when the two methods are used together. Focused histopathologic examination on one or two lymph nodes most likely to contain metastases [SLN(s)], using serial sectioning and immunohistochemical techniques, allows an improved staging to be performed. Detection of metastases on SLN(s) is not only a prognostic indicator, but it also dictates whether the patient should receive further surgery and adjuvant chemotherapy. Until data regarding the long-term results of the SLN biopsy are available, this method should be considered investigational and be performed by surgeons experienced in this technique to achieve a failure rate of less than 2 per cent.

Breast cancer patients treated without axillary surgery: clinical implications and biologic analysis

OBJECTIVE

To evaluate the impact of breast carcinoma (T1-2N0) surgery without axillary dissection on axillary and distant relapses, and to evaluate the usefulness of a panel of pathobiologic parameters determined from the primary tumor, independent of axillary nodal status, in planning adjuvant treatment.

METHODS

In a prospective nonrandomized pilot study, 401 breast cancer patients who underwent breast surgery without axillary dissection were accrued from January 1986 to June 1994. At surgery, all patients were clinically node-negative and lacked evidence of distant metastases after clinical or radiologic examination. A precise 4-month clinical and radiologic follow-up was performed to detect axillary or distant metastases. Patients with clinical evidence of axillary nodal relapse were considered for surgery as salvage treatment. Biologic characteristics of primary carcinomas were investigated by immunohistochemistry, and four pathologic and biologic parameters (size, grading, laminin receptor, and c-erbB-2 receptor) were analyzed to determine a prognostic score.

RESULTS

The 5-year follow-up of these patients revealed a low rate of nodal relapses (6.7%), particularly for T1a and T1b patients (2% and 1.7%, respectively), whereas T1c and T2 patients showed a 10% and 18% relapse rate, respectively. Surgery was a safe and feasible salvage treatment without technical problems in all 19 cases of progressive disease at the axillary level. The low rate of distant metastases in T1a and T1b groups (<6%) increased to 15% in T1c and 34% in T2 patients. Analyzing the primary tumor with respect to the panel of pathologic and biologic parameters was predictive of metastatic spread and therefore can replace nodal status information for planning adjuvant treatment.

CONCLUSIONS

Middle-term follow-up shows that the rate of axillary relapse in this patient population is lower than expected, suggesting that only a minimal number of microembolic nodal metastases become clinically evident. Avoidance of axillary dissection has a negligible effect on the outcome of T1 patients, particularly in T1a and T1b tumors with no palpable nodes, because the rate of axillary node relapse is very low for both. In T1 breast carcinoma, postsurgical therapy should be considered on the basis of biologic characteristics rather than nodal involvement. The authors' prognostic score based on the primary tumor identified patients who required postsurgical treatment, providing a practical alternative to axillary status for deciding on adjuvant treatment. Conversely, in the T2 group, the high rate of salvage surgery for axillary relapses, which is expected in tumors larger than 2.5 cm or 3.0 cm, represents a limit for avoiding axillary dissection. Preoperative evaluation of axillary nodes for modification of surgical dissection in this subgroup would be more useful more than in T1 breast cancer because of the high risk. Complete dissection is feasible without technical problems if precise follow-up detects progressive axillary disease.

Does sentinel lymphadenectomy improve staging and alter therapy in elderly women with breast cancer?

BACKGROUND

Routine axillary lymph node dissection (ALND) for elderly women with invasive breast cancer has been questioned because it rarely alters therapy yet carries a significant morbidity rate. Sentinel lymphadenectomy (SLND) improves axillary staging and alters therapy in women with T1 breast cancer, but it is not clear whether SLND alters therapy in elderly women with breast cancer.

METHODS

A prospective breast cancer data base was used to identify women 70 years old and older who underwent SLND for axillary staging of invasive breast cancer between 1991 and 1998.

RESULTS

There were 75 invasive breast cancers in 73 women. The mean patient age was 74.5 years (range, 70-90 years). Median tumor size was 1.4 cm (range, 0.1-6.2 cm). Of the 75 tumors, 42 (56%) had favorable primary characteristics; the remaining tumors had unfavorable characteristics. SLND was performed alone in 17 cases (23%) and was followed by completion ALND in 58 cases (77%). Positive lymph nodes were identified in 32 cases (43%); 26 (81.3%) were detected by hematoxylin and eosin stains, and 6 (18.7%) were detected by immunohistochemistry alone. Five patients (6.9%) received adjuvant chemotherapy. Seven patients (9.6%) received axillary/supraclavicular radiation for positive nodes. Ten (13.7%) of 73 patients had obvious alterations in therapy because of axillary nodal status. As a result of SLND, 3 (13.6%) of 22 patients with tumors 1.0 cm or smaller received tamoxifen, and 7 (15%) of 46 patients with tumors between 1.0 and 3.0 cm in size had changes in therapy. When patient and tumor characteristics were analyzed to determine relationships to therapeutic decision-making, nodal status was the variable most significantly associated with changes in therapy (P = .0001).

CONCLUSIONS

SLND improves axillary staging in elderly women with invasive breast cancer. Results of immunohistochemistry do not alter therapy in this group of individuals (P = .6367). In patients with small primary tumors, SLND alters therapy by increasing the number of patients receiving tamoxifen. In addition, SLND affects adjuvant systemic chemotherapy and regional radiotherapy in a significant number of patients with larger tumors, particularly tumors between 1.0 and 3.0 cm.

Factors influencing survival after resection for periampullary neoplasms

BACKGROUND

The purpose of this study was to determine predictors of survival after resection for periampullary neoplasms.

METHODS

Over a 15-year period, 208 patients underwent laparotomy for periampullary neoplasms. Data were analyzed to assess predictors of survival.

RESULTS

Pathologic examination showed pancreatic cancer (n = 136; 65%), ampullary cancer (n = 28; 13%), distal common bile duct cancer (n = 10; 5%), duodenal cancer (n = 4; 2%), neuroendocrine tumor (n = 11; 5%), cystadenocarcinoma (n = 4; 2%), cystadenoma (n = 5; 2%), and other (n = 10; 5%). A total of 129 patients underwent pancreatic resection (71 Whipples, 35 total pancreatectomies, 21 distal pancreatectomies, and 2 partial pancreatectomies) whereas 79 patients were found to be unresectable and underwent palliative bypass and/or biopsy. Median survival was 20.4 months for resectable patients versus 4.5 months for unresectable patients (P<0.001). Of the 129 resected patients, factors significantly (P<0.05) favoring long-term survival on univariate analysis included well-differentiated histology, common bile duct or ampullary adenocarcinoma, early stage, tumor diameter <2 cm, negative margins, and absence of lymph node metastases, perineural, or vascular invasion. Age, sex, race, and type of procedure had no influence on survival. On multivariate analysis, only tumor differentiation appeared independently related to survival. Using Kendall's tau analysis, tumor type and grade correlated significantly with all other predictors.

CONCLUSIONS

Of all variables studied, tumor type and poor tumor differentiation in periampullary neoplasms appear to be markers that predict a constellation of other adverse findings.

Quality of life and long-term survival after surgery for chronic pancreatitis

The objective of this study was to evaluate the short-term and long-term outcome as well as quality of life in patients undergoing surgical management of chronic pancreatitis. Between January 1980 and December 1996, a total of 255 patients underwent surgery for chronic pancreatitis at The Johns Hopkins Hospital. The etiology of the disease, indications for surgery, patient characteristics, and long-term survival were analyzed. A visual analog quality-of-life questionnaire containing 23 items graded on a scale of 0 to 10 (0 = worst and 10 = best) was sent to patients postoperatively. Visual analog responses relating to before and after the chronic pancreatitis surgery were compared using a paired t test. During the17-year review period, 263 operations were performed for chronic pancreatitis in 255 patients. The most common presenting symptoms were abdominal pain (88%), weight loss (36%), nausea/vomiting (30%), jaundice (14%), and diarrhea (12%). The cause of the pancreatitis was resumed to be alcohol in 43%, idiopathic in 38%, pancreas divisum in 5%, ampullary abnormality in 4%, and gallstones in 3%. Pancreaticoduodenectomy was the most common procedure in 96 patients (37%), followed by distal pancreatectomy in 67 (25%), Puestow procedure in 52 (19%), sphincteroplasty in 37 (14%), and Duval procedure in five (2%). The overall mortality and morbidity rates were 1.9% and 35%, respectively. Two hundred twenty-seven (89%) of the 255 patients were alive at last follow-up. For the entire cohort of patients, the 5- and 10-year actuarial survivals were 88% and 82%, respectively. One hundred six (47%) of the 227 living patients responded to the visual analog quality-of-life questionnaire. Patients reported improvements in all aspects of the quality-of-life survey including enjoyment out of life, satisfaction with life, pain, number of hospitalizations, feelings of usefulness, and overall health (P < 0.005). In addition to improved quality of life after surgery, narcotic use was decreased (41% vs. 21%, P < 0.01) and alcohol use was decreased (59% vs. 33%, P < 0.001). However, patients often became insulin-dependent diabetics (12% vs. 41%, P < 0.0001) and required pancreatic enzyme supplementation (34% vs. 55%, P < 0.01) after surgical intervention. These data suggest that surgery for patients with chronic pancreatitis can be performed safely with minimal morbidity and excellent long-term survival. Moreover, this study evaluates quality of life in a standardized analog fashion, with highly significant improvement reported in all quality-of-life measures. We conclude that surgery remains an excellent option for patients with chronic pancreatitis.

The risk of nodal metastases in breast cancer patients with clinically negative lymph nodes: a population-based analysis

A population-based study was performed to assess the likelihood of axillary lymph node metastases in patients with clinically negative lymph nodes, according to patient age, tumor size and site, estrogen receptor status, histologic type and mode of detection. Data were obtained from the population-based Eindhoven Cancer Registry. During the period 1984-1997, 7680 patients with invasive breast cancer were documented, 6663 of whom underwent axillary dissection. Of the 5125 patients who were known to have clinically negative lymph nodes and underwent axillary dissection, 1748 (34%) had positive lymph nodes at pathological examination. After multivariate analysis, histologic type, tumor size, tumor site and the number of lymph nodes in the axillary specimen remained as independent predictors of the risk of nodal involvement (P < 0.001). Lower risks were found for patients with medullary or tubular carcinoma, smaller tumors, a tumor in the medial part of the breast and patients with less than 16 nodes examined. This study gives reliable estimates of the risk of finding positive lymph nodes in patients with a clinically negative axilla. Such information is useful when considering the need for axillary dissection and to predict the risk of a false-negative result when performing sentinel lymph node biopsy.

Prospective observational study of sentinel lymphadenectomy without further axillary dissection in patients with sentinel node-negative breast cancer

PURPOSE

Immediate complete axillary lymphadenectomy (ALND) after sentinel lymphadenectomy (SLND) has confirmed that tumor-negative sentinel nodes accurately predict tumor-free axillary nodes in breast cancer. Therefore, we hypothesized that SLND alone in patients with tumor-negative sentinel nodes would achieve axillary control, with minimal complications.

PATIENTS AND METHODS

Between October 1995 and July 1997, 133 consecutive women who had primary invasive breast tumors clinically </= 4 cm in diameter and no axillary lymphadenopathy were prospectively entered onto a trial of SLND using vital blue dye. Sentinel nodes were examined by standard microscopy or immunohistochemistry. SLND was the only axillary surgery if sentinel nodes were tumor-free. Completion ALND was performed only if sentinel nodes contained metastases or if they were not identified. Excluded from subsequent analysis were patients with unsuspected multifocal carcinoma and those who refused completion ALND. The complication and axillary recurrence rates after SLND without ALND were determined.

RESULTS

Sentinel nodes were identified in 132 (99%) of 133 patients. Eight patients were excluded from further analysis. Of the 125 assessable patients, 57 had tumor-positive sentinel nodes and one had an unsuccessful mapping procedure; these patients underwent completion ALND. In the remaining 67 patients (54%), SLND was the only axillary procedure. Complications occurred in 20 patients (35%) undergoing ALND after SLND but in only two patients (3%) undergoing SLND alone (P =.001). There were no local or axillary recurrences at a median follow-up of 39 months.

CONCLUSION

Complication rates are negligible after SLND alone. An absence of axillary recurrences supports SLND as an accurate staging alternative for breast cancer and suggests that routine ALND can be eliminated for patients with histopathologically negative sentinel nodes.

Role of axillary surgery in early breast cancer: review of the current evidence

BACKGROUND

Controversy continues to surround the best practice for management of the axilla in patients with early breast cancer (EBC), particularly the clinically negative axilla. The balance between therapeutic and staging roles of axillary surgery (with the consequent morbidity of the procedures utilized) has altered. This is due to the increasing frequency of women presenting with early stage disease, the more widespread utilization of adjuvant chemoendocrine therapy and, more recently, the advent of alternative staging procedures, principally sentinel node biopsy (SNB). The aim of the present review is to critically analyse the current literature concerning the preferred management of the axilla in early breast cancer and make evidence-based recommendations on current management.

METHODS

A review was undertaken of the English language medical literature, using MEDLINE database software and cross-referencing major articles on the subject, focusing on the last 10 years. The following combinations of key words have been searched: breast neoplasms, axilla, axillary dissection, survival, prognosis, and sentinel node biopsy.

RESULTS

Despite the trend to more frequent earlier stage diagnosis, levels I and II axillary dissection remain the treatment of choice in the majority of women with EBC and a clinically negative axilla.

CONCLUSIONS

Sentinel node biopsy has no proven superiority over axillary dissection because no randomized controlled trials have been completed to date. Despite this, SNB will become increasingly utilized due to encouraging results from major centres responsible for its development, and patient demand. Therefore if patients are not being enrolled in clinical trials strict quality controls need to be established at a local level before SNB is allowed to replace standard treatment of the axilla. Unless this is strictly adhered to there is a significant risk of an increase in the frequency of axillary relapse and possible increased understaging and resultant inadequate treatment of patients.

Rationale of the so-called extended resection for pancreatic invasive ductal carcinoma

It has generally been recognized that for adenocarcinoma of the pancreas, surgical resection provides the only chance for cure. In this study, we have analyzed the long-term survival of 141 patients with invasive ductal adenocarcinoma of the pancreas who received macroscopically curative resection. Multivariate analysis demonstrated that comprehensive stage of the tumor, curability of the resection, and adjuvant radiation therapy were independent prognostic factors. Pancreatectomy in this study was done with an extensive retroperitoneal clearance of para-aortic lymph node and nerve tissues, so-called extended resection. Survival curves of these patients revealed that the R0 resection is essentially necessary for long-term survival. Survival curve without microscopic lymph node metastasis was significantly better than that with node metastasis; however, 3 patients with node metastasis have been alive for more than 3 years. The survival curve of the patients who received adjuvant radiation therapy was better than of those who underwent surgery alone, and postoperative regional chemotherapy with continuous 5-FU infusion decreased hepatic metastases within 6 months. The results suggest that local recurrence of pancreatic cancer might possibly be controlled by extended resection and adjuvant irradiation, and early development of hepatic metastases might be controlled with regional chemotherapy.

Adenocarcinoma of the distal bile duct. A clinicopathologic outcome analysis after curative resection

BACKGROUND/AIMS

Primary distal bile duct adenocarcinomas (DBDAs) are unusual neoplasms, necessitating pancreaticoduodenectomy for cure. The aims of this study were to evaluate the prognostic importance of lymphatic and perineural invasion, long-term outcome of patients after resection, and differences in outcome with hilar cholangiocarcinoma and pancreatic carcinoma.

METHODS

The medical records and histopathological slides of 15 patients (8 men and 7 women) with documented DBDA after curative pancreaticoduodenectomy were reviewed.

RESULTS

Nine standard and 6 pylorus-preserving pancreaticoduodenectomies were performed. TNM staging included 1, 3, 2, 8, and 1 patient in stages I, II, III, and IVA and IVB, respectively. Lymphatic and perineural invasion was present in 4 (27%) and 9 (60%) patients, respectively. With multivariate analysis only serum bilirubin was a significant prognostic factor. Median survival was 21 months, and 2- and 5-year actuarial survivals were 40 and 20%, respectively. Median survival with adjuvant therapy (n = 6) was 21 months, with 5-year survival of 33%. Five-year actuarial survivals when lymphatic or perineural invasion was present were 0 and 11%, respectively.

CONCLUSION

DBDA is aggressive, but entails a better prognosis than pancreatic ductal or more proximal bile duct carcinoma. Lymphatic and/or perineural invasion worsen survival.

Lymphatic mapping and sentinel lymph node biopsy in patients with breast cancer

The standard of care for the evaluation of axillary nodal involvement remains complete lymph node dissection. Lymphatic mapping and sentinel lymph node (SLN) biopsy are changing this long-held paradigm; indeed, several leading institutions already reserve complete axillary dissection for patients with metastasis to the SLN. In addition to reviewing the literature, this chapter describes our lymphatic mapping experience at the H Lee Moffitt Cancer Center and Research Institute with 1147 breast cancer patients. Our results, in addition to a meta-analysis of data from 12 institutions comprising an additional 1842 patients undergoing complete axillary dissection, demonstrate that SLN biopsy is an accurate method of axillary staging. Although the results from small series may exaggerate the probability of false negative results, the risk of nodal disease based on tumor size and other risk factors should be evaluated when considering the results of SLN sampling.

Challenging the myth of exercise-induced lymphedema following breast cancer: a series of case reports

Women who have had axillary lymph nodes removed for the management of breast cancer are at increased risk of developing upper extremity lymphedema. Physical therapists, surgeons, and other health professionals have warned these women to avoid vigorous, repetitive, or excessive upper body exercise, believing that such types of exercise might actually induce lymphedema. The purpose of this series of case reports was to challenge that belief by systematically measuring the arm circumferences, across three points in time, of 20 women who had received axillary dissection and who were competing in the vigorous, upper body sport of Dragon Boat racing. Measurably different change was defined as an increase in circumference of the ipsilateral upper extremity at any of the four landmarks of >0.5 inches between Time 1 and Time 2 or between Time 1 and Time 3; only two women showed a measurably different change (5/8 in). Furthermore, none of the women showed a clinically significant difference in arm circumference between the ipsilateral and contralateral extremities at Time 3.

Clinical applications of telomerase in cancer treatment

Telomerase activity has been found in most cancer cells, but not in the majority of normal differentiated tissues. Therefore, telomerase has been considered a relatively selective and widely expressed tumor marker to be used as a diagnostic tool, and in some cases, as a potential prognostic indicator. Telomerase activity can also be used to evaluate chemosensitivity of neoplastic cells obtained from cancer patients, by measuring residual telomerase activity after drug treatment. Finally, telomerase has been considered to represent a suitable target for designing new anticancer strategies. This review focuses on present and future clinical applications of telomerase studies in cancer management. Copyright 2000 Harcourt Publishers Ltd.

Long-term survival after multimodality treatment for resectable pancreatic cancer

BACKGROUND

The prognosis of pancreatic adenocarcinoma after radical pancreatectomy is poor, especially in advanced-stage disease.

STUDY AIM

To determine the survival rates and evaluate the effectiveness of multimodality treatment for advanced pancreatic cancer.

METHODS

From November 1983 to January 1993, 30 patients with pancreatic adenocarcinoma including 9 with carcinoma of the body and tail were treated by a multimodal approach consisting of extended pancreatectomy, intraoperative radiotherapy (IORT), and hepatic artery or portal vein infusion of mitomycin C (MMC) followed by systemic bolus injection. All surviving patients were followed for more than 8 yr and survival rates were calculated by the Kaplan-Meier method.

RESULTS

There were no operative or hospital deaths. Eight patients survived for more than 5 yr, 3 of whom survived more than 10 yr. The 5-yr survival rate for 27 patients excluding 3 with metastasis to the liver, peritoneum, or lung was 31%, with a median survival of 31.1 mo. Among them, the 1-, 3-, and 5-yr survival rates for 19 patients with regional nodal metastasis were 95, 50, and 28%, respectively, with a median survival of 36.0 mo.

CONCLUSION

The multimodality treatment combined with IORT and MMC chemotherapy appeared to have a benefit for prognosis of advanced pancreatic adenocarcinoma.

Chemotherapy for upper gastrointestinal tumours

The aim of this review is to identify current chemotherapy treatment for tumours of the oesophagus, stomach, pancreas, and liver. The role of both neoadjuvant, adjuvant, and palliative chemotherapy regimens will be discussed. This review will be of interest to oncologists in clarifying current issues regarding chemotherapy, and to physicians in other medical specialties, to increase their general understanding of benefits and drawbacks of chemotherapy in this patient group.

Defining a role for endoscopic ultrasound in staging periampullary tumors

BACKGROUND

The goal of the preoperative workup in patients with suspected periampullary carcinoma is to establish the diagnosis with a high degree of certainty. In this study we compared endoscopic ultrasonography (EUS) and computed tomography (CT) scans for the detection of tumor, lymph node metastasis, and vascular invasion in patients with suspected periampullary carcinoma in order to define a role for EUS in the preoperative staging of these patients.

METHODS

Thirty-seven consecutive patients received EUS and CT scanning followed by operation for presumed periampullary carcinoma during a 30-month period. Both imaging modalities were reviewed in a blinded fashion and the results compared with pathology and operative reports on all patients.

RESULTS

Sensitivity, specificity, positive predictive value, and negative predictive value for tumor detection by EUS were 97%, 33%, 94%, and 50%, respectively, compared with 82%, 66%, 97%, and 25% for CT scan. For lymph nodes the values were 21%, 80%, 57%, and 44%, respectively, for EUS compared with 42%, 73%, 67%, and 50% for CT. For vascular invasion, the values were 20%, 100%, 100%, and 89%, respectively, for EUS, compared with 80%, 87%, 44%, and 96% for CT.

CONCLUSIONS

CT is the initial study of choice in patients with suspected periampullary tumors. EUS is superior for detecting tumor and for predicting vascular invasion. Therefore, EUS should be used for patients in whom CT does not detect a mass and for those with an identifiable mass on CT in whom vascular invasion cannot be ruled out.

The grade of pancreatic ductal carcinoma is an independent prognostic factor and is superior to the immunohistochemical assessment of proliferation

Tumour grade is one of the prognostic factors in pancreatic ductal adenocarcinoma, but its value is controversial. In this study, the predictive value and the reproducibility of the WHO grading system were reconsidered and the possibility of supplementing it with the immunohistochemically assessed proliferative activity was investigated. Seventy resected ductal adenocarcinomas of the head of the pancreas were evaluated. A total of 60 HPF fields on two to four sections per tumour were screened for glandular differentiation, mucin production, mitosis, and nuclear atypia by two observers with different degrees of experience. Each criterion was scored and the grade was calculated from the mean value of all single scores. Corresponding slides were immunohistochemically stained with the proliferation marker Ki-S5. The percentage of positive nuclei was assessed and a proliferation index (PI) assigned (<10%=1; 10-50%=2; >50%=3). Multivariate analysis (Cox regression) identified grade and R stage as the most significant factors for predicting survival. The PI determined on the basis of Ki-S5 staining did not prove to be an independent prognostic factor. In 30 of 70 carcinomas, it correlated with the tumour grade. Within a given tumour grade, the cases with the least favourable prognosis could be distinguished on the basis of their PI. The inter-observer variability was considerable, with the main differences occurring in the group of G1 tumours. According to the refined WHO criteria, the histopathological grade of pancreatic ductal carcinoma is an important independent prognostic factor, but reproducibility depends on the expertise of the observer. Criteria that relate to cellular and structural differentiation seem to be more predictive than those related to proliferation.

High expression of vascular endothelial growth factor is associated with liver metastasis and a poor prognosis for patients with ductal pancreatic adenocarcinoma

BACKGROUND

Vascular endothelial growth factor (VEGF), a recently identified growth factor with significant angiogenic properties, is a multifunctional angiogenic cytokine that is expressed in many tumors. High VEGF expression has been shown to correlate with the incidence of metastasis and poor prognosis in various cancers. In this study, the authors investigated VEGF expression and microvessel density (MVD) in ductal pancreatic adenocarcinoma and examined the correlations among VEGF expression, clinicopathologic factors, and clinical outcome. The authors especially focused on the correlation between VEGF expression and liver metastasis.

METHODS

Paraffin embedded tumor specimens of 142 surgically resected pancreas carcinoma were immunohistochemically stained for VEGF and MVD. The correlations among VEGF expression and MVD, clinicopathologic factors, and clinical outcome were then statistically analyzed.

RESULTS

One hundred thirty-two (93%) of 142 ductal pancreatic adenocarcinomas were positive for VEGF protein by immunohistochemistry. A significant correlation was observed between VEGF positivity and MVD (P < 0.0001). Multivariate logistic regression analysis indicated a significant association between high VEGF expression and liver metastasis (P = 0.010) but no other factors, such as age, tumor size, histologic type, lymph node metastasis, venous invasion, neural invasion, peritoneal metastasis, or local recurrence. Patients with tumors that showed moderate or high VEGF expression had significantly shorter survival than patients with low VEGF expression or none at all in their tumors (P < 0.05).

CONCLUSIONS

These results indicate that VEGF expression is closely correlated with MVD and seems to be an important predictor for both liver metastasis and poor prognosis in ductal pancreatic adenocarcinoma.

Pancreatic cancer surveillance in a high-risk cohort. Is it worth the cost?

Pancreatic adenocarcinoma is the 10th most common malignancy and 4th largest cancer killer in adults. Earlier tumor detection through screening of high risk groups, presumably to increase the percentage of cases resectable for cure in these cohorts, has emerged as a prominent strategy to combat this disease. This article examines the feasibility of this strategy in patients with hereditary pancreatic cancer (HPC) and hereditary pancreatitis (HP). Because of a variety of factors, specific cost projections for screening with HPC kindreds are problematic at best. Patients with HP exhibit a 53-fold increased risk of pancreatic cancer, with a cumulative risk of 40% by age 70. The authors discuss the modalities available to screen this cohort and subsequently perform a theoretical cost analysis. The authors' findings suggest that screening has the potential to be cost-effective only in hereditary pancreatitis patients = 50 years-of-age. The most cost-effective option will likely combine an initial serologic test with high sensitivity and a subsequent serologic or pancreatic juice test with sufficient specificity to act as a "gatekeeper" to imaging with endoscopic ultrasound (EUS). Banking of blood and pancreatic juice samples should be mandatory in any screening protocol. The lower tumor yield in other high-risk groups (e.g., non-hereditary chronic pancreatitis) will effectively preclude the use of such screening protocols. The vast majority of patients will continue to present with unresectable disease.

Incidence of chromosomes 1 and 17 aneusomy in breast cancer and adjacent tissue: an interphase cytogenetic study

BACKGROUND

Characterization of the biopathologic events underlying the early steps of breast carcinogenesis may have a dramatic impact on reducing breast cancer mortality. Genes involved in breast tumorigenesis are localized on chromosomes 1 and 17, and numeric aberrations of these chromosomes have been correlated with breast cancer tumorigenesis and progression. According to the field cancerization hypothesis, specific chromosome aberrations may be present in breast cancer and in normal-appearing adjacent tissue. The latter changes reflect the genomic damage that follows longterm carcinogenic exposure and precede the morphologically detectable neoplastic transformation. We hypothesize that detection of these aberrations in benign breast epithelium may provide a tool for molecular risk assessment.

STUDY DESIGN

Using fluorescence in situ hybridization with centromere-specific probes, we determined the status of chromosomes 1 and 17 in fresh imprints of 28 samples of primary tumors and 54 samples of their surrounding uninvolved parenchyma taken from patients undergoing operations for breast carcinoma. Ten contralateral breast biopsy specimens collected from patients with previous breast carcinoma were also evaluated as a surrogate of a high-risk group to rule out the hypothesis that chromosomal aneusomy in tumor-adjacent tissue could be related to a paracrine effect of the primary tumor. Ten samples of benign breast tissue taken from patients at low risk were used as controls to define tolerance limits for aneusomy definition.

RESULTS

Using threshold values of 40% of signal loss and 13% of signal gain to define chromosome aneusomy (ie, mean + 3 SDs of the control group signals), we found the following: 1) almost all primary breast tumors were aneusomic for chromosomes 1 and 17; 2) primary breast tumor and adjacent uninvolved parenchyma shared the same pattern of chromosomes 1 and 17 aneusomy in 66.7% of patients; and 3) chromosomes 1 and 17 aneusomies in contralateral benign breast samples from high-risk patients were not different from those in primary breast tumor or adjacent tissue samples.

CONCLUSIONS

These results suggest that chromosomes 1 and 17 aneusomy may represent an intermediate biomarker of breast tumorigenesis potentially useful to detect patients at high risk of breast carcinoma who may benefit from preventive interventions.

Sentinel lymph node mapping in early-stage breast cancer: technical issues and results with vital blue dye mapping and radioguided surgery

BACKGROUND AND OBJECTIVES

Axillary lymph node status is the most important prognostic factor in patients with operable breast cancer. Recent studies have demonstrated the possibility of identifying the sentinel lymph node (sN) as a reliable predictor of axillary lymph node status in both cutaneous melanoma and breast cancer. Sentinel lymph node identification proved feasible by either peritumoral dye injection (Patent Blue-V) or radiodetection, with identification rates of 65-97% and 92-98%, respectively. However, some important issues need further definition, namely (a) optimization of the technique for intraoperative detection of the sN, (b) predictive value of the sN with regard to axillary lymph node status, and (c) reliability of intraoperative histology of the sN. We reviewed our experience in sN detection in patients with stage I-II breast cancer to assess the feasibility and accuracy of lymphatic mapping, by vital blue dye or radioguided surgery, and sN histology as a predictor of axillary lymph node status.

METHODS

Two groups of patients (55 and 48) were recruited between May 1996 and May 1997 and between October 1997 and February 1998; the patients of the first series underwent vital blue dye lymphatic mapping only, whereas those of the second series had a combined approach with both vital blue dye mapping and radioguided detection of the sN.

RESULTS

In the first set of patients, the sN was identified in 36/55 patients (65.4%); sN histology predicted axillary lymph node status with a 77% sensitivity (10/13), a 100% specificity (23/23), an 88.5% negative predictive value (23/26), and an overall 91.5% accuracy (33/36). The sN was the quasi-elective site of lymph node metastases because in clinically N0 patients nodal involvement was 20-fold more likely at histology in sN than in non-sN (30% and 1.5%, respectively). In the second set of patients, 49 lymphadenectomies were performed because 1 patient had bilateral breast cancer; the sN was identified in 45/49 lymphadenectomies (92%). The sN was intraoperatively negative at frozen-section examination in 33 cases, and final histology confirmed the absence of metastases in 31/33 cases (94%), whereas in 2 cases (6%) micrometastases only were detected. Final histology of the sN predicted axillary lymph node status with an 87.5% sensitivity (14/16), a 100% specificity (29/29), a 93.5% negative predictive value (29/31), and an overall 95.5% accuracy (43/45).

CONCLUSIONS

Sentinel lymphadenectomy can be better accomplished when both mapping techniques (vital blue dye and radioguided surgery) are used. In this group of patients, agreement of intraoperative histology of the sN with the final diagnosis was 94%, and sN histology accurately predicted axillary lymph node status in 43/45 lymphadenectomy specimens (95.5%) in which an sN was identified.

Surgical management of hereditary pancreatic cancer

Pancreatic cancer continues to be a leading cause of cancer death in the United States. Seven genetic syndromes are now known to be associated with an increased incidence of pancreatic cancer. Other familial forms of pancreatic cancer exist although the genetic basis for this predisposition remains elusive. The similarities in the genetic and clinical manifestations of the sporadic and familial forms of pancreatic cancer suggest that pretreatment staging and management of patients with established pancreatic cancer should be similar. For carcinomas of the pancreatic head, pancreaticoduodenectomy should be performed according to current surgical practice, whereas the use of total pancreatectomy should be limited to cases in which margins are found to be positive or if the anatomy precludes a safe pancreaticojejunostomy. Total pancreatectomy may be considered in high-risk kindreds who strongly desire prophylactic surgery and in those with premalignant lesions. Identification of the precise genetic basis for inherited pancreatic cancer will someday make it possible to examine scientifically the effectiveness of specific management strategies.

Growth factors, receptors, and molecular alterations in pancreatic cancer. Putting it all together

Because of the dismal prognosis of advanced ductal pancreatic adenocarcinoma, recent investigational strategies have focused on improved detection and therapeutic intervention in early-stage pancreatic cancer. The obvious cost constraints of screening populations at risk but with a low tumor yield will restrict screening protocols to only the highest risk groups (hereditary pancreatitis = age 50, certain hereditary pancreatic cancer kindreds). The vast majority of patients, either lacking or exhibiting an inherited predisposition to pancreatic cancer, will continue to present with disease not resectable for cure. The authors believe that the best hope for these patients lies in the further delineation of the integrative pathophysiology driving tumor growth; this would facilitate the future development of a computer program or other modality that would predict the dominant pathways driving the growth and spread of each tumor based on its "molecular profile." This article reviews the authors' current knowledge regarding the growth factors, receptors, and molecular alterations driving uncontrolled proliferation, local invasion, and metastatic spread of these tumors. The current and potential contributions of studies in cohorts with an inherited predisposition to pancreatic cancer to this pathophysiologic model are also discussed. The future strategy for incorporating this information into a working pathophysiologic road map with clinical relevance is subsequently outlined.

Interferon-based adjuvant chemoradiation therapy improves survival after pancreaticoduodenectomy for pancreatic adenocarcinoma

BACKGROUND

Based on a 2-year survival of 43%, the Gastrointestinal Tumor Study Group (GITSG) recommended adjuvant 5-FU-based chemoradiation for resected patients with adenocarcinoma of the pancreatic head. Here we report improved survival over the GITSG protocol with a novel adjuvant chemoradiotherapy based on interferon-alpha (IFNalpha).

METHODS

From July 1993 to September 1998, 33 patients with adenocarcinoma of the pancreatic head underwent pancreaticoduodenectomy (PD) and subsequently went on to adjuvant therapy (GITSG-type, n = 16) or IFNalpha-based (n = 17) typically given between 6 and 8 weeks after surgery. The latter protocol consisted of external-beam irradiation at a dose of 4,500 to 5,400 cGy (25 fractions per 5 weeks) and simultaneous three-drug chemotherapy consisting of (1) continuous infusion 5-FU (200 mg/m2 per day); (2) weekly intravenous bolus cisplatin (30 mg/m2 per day); and (3) IFNalpha (3 million units subcutaneously every other day) during the 5 weeks of radiation. This was then followed by two 6-week courses of continuous infusion 5-FU (200 mg/m2 per day, given weeks 9 to 14 and 17 to 22). Risk factors for recurrence and survival were compared for the two groups.

RESULTS

A more advanced tumor stage was observed in the IFNalpha-treated patients (positive nodes and American Joint Committee on Cancer [AJCC] stage III = 76%) than the GITSG group (positive nodes and stage III = 44%, P = 0.052). The 2-year overall survival was superior in the IFNalpha cohort (84%) versus the GITSG group (54%). With a mean follow-up of 26 months in both cohorts, actuarial survival curves significantly favored the IFNalpha group (P = 0.04).

CONCLUSIONS

With a limited number of patients, this phase II type trial suggests better survival in the interferon group as compared with the GITSG group even though the interferon group was associated with a more extensive tumor stage. The 2-year survival rate in the interferon group is the best published to date for resected pancreatic cancer. The interferon/cisplatin/5-FU-based adjuvant chemoradiation protocol appears to be a promising treatment for patients who have undergone PD for adenocarcinoma of the pancreatic head.

Pancreatic cancer: a review of emerging therapies

The incidence of adenocarcinoma of the pancreas has risen steadily over the past 4 decades. Since pancreatic cancer is diagnosed at an advanced stage, and because of the lack of effective therapies, the prognosis of such patients is extremely poor. Despite advances in our understanding of the molecular biology of pancreatic cancer, the systemic treatment of this disease remains unsatisfactory. Conventional chemotherapy has not produced dramatic improvements in response rates or patient survival. New treatment strategies are clearly needed. This paper reviews emerging therapies for pancreatic carcinoma. A more profound understanding of the molecular biology of cell growth and proliferation, as well as of neoplastic cell transformation, has led to advances in several areas, including the use of somatostatin analogues and antiandrogens as adjuvant therapy; inhibition of tumour growth and metastasis by inhibitors of matrix metalloproteinases and angiogenesis, and by small molecules such as retinoids, which interfere with progression through the cell cycle; immunotherapy with monoclonal antibodies; disruption of intracellular signal transduction with farnesyltransferase inhibitors; and finally gene therapy with specifically designed vaccines.