Identification of women with T1-T2 breast cancer at low risk of positive axillary nodes

BACKGROUND AND OBJECTIVES

The diagnostic and therapeutic significance of axillary dissection has been questioned. We sought to define a subgroup of patients with early-stage breast cancer who are at low risk for positive axillary nodes.

METHODS

Between 1970 and 1995, 1,598 women with stage I and II breast cancer underwent level I-II axillary dissection with a minimum of 10 nodes removed. The following factors were examined in univariate analysis for predicting positive nodes: race, method of detection, location of the primary tumor, age, menopausal status, obesity, ER status, PR status, pathologic tumor size, lymphatic vascular invasion, tumor grade, and histology.

RESULTS

Four hundred and forty-five of the 1,598 patients (27.8%) had histologically positive axillary nodes. Significant factors in univariate analysis for positive nodes included: tumor size, lymphatic vascular invasion, grade, method of detection, primary tumor location, and age. The only group of women with a 0% risk of axillary nodes were those in whom the pathologic tumor size was < or = 5 mm and mammographically detected. A 5-10% risk of positive axillary nodes was identified in women with (1) pathologic tumor size 6-10 mm, mammographically detected, and age < or = 40 years, and (2) tubular carcinoma < or = 10 mm. Tumors detected on physical examination with or without mammography and women < or = 40 years had a significantly increased risk of nodes. In multivariate analysis lymphatic vascular invasion (P < 0.001), method of detection (P = 0.026), location (P = 0.01), and pathologic tumor size (P = 0.002) were significant predictors of positive axillary lymphadenopathy.

CONCLUSIONS

The decision to forego an axillary dissection should be considered in (1) tumors mammographically detected and < or = 5 mm (2) mammographically detected, pathologic size 6-10 mm, age > 40 and (3) tubular carcinoma < or = 10 mm. All other groups had a > 10% risk of nodes and may benefit from axillary dissection.

Progress report. A randomized multicenter European study comparing adjuvant radiotherapy, 6-mo chemotherapy, and combination therapy vs no-adjuvant treatment in resectable pancreatic cancer (ESPAC-1)

CONCLUSION

The ESPAC-1 trial is the largest study of its kind in pancreatic cancer and should definitively address the question of the role of conventional methods of adjuvant treatment in pancreatic cancer.

BACKGROUND

At the joint International Association of Pancreatology and the European Pancreatic Club meeting in Mannheim, Germany (June 12-15, 1996) a satellite meeting of the European Study Group for Pancreatic Cancer (ESPAC) met to discuss the progress of the ESPAC-1 trial.

METHODS

A randomized multicenter study to address which, if any, of the following adjuvant treatments are of benefit in patients with resectable pancreatic cancer: radiotherapy (40 Gy with 5-FU as a sensitizing agent), 6 mo of chemotherapy (5-FU and folinic acid), or a combination of these treatments.

RESULTS

From February 1994 to June 1996 (the time of the Mannheim meeting) 221 patients so far have been recruited into the three treatment arms and one control arm.

Radioimmunoscintigraphy in patients with breast adenocarcinoma using technetium-99m labelled monoclonal antibody 170H.82: report of a phase II study

Fifty-three women with clinical evidence of adenocarcinoma of the breast were studied with technetium-99m labelled monoclonal antibody (MAb) 170H.82 at protein doses of 1, 2 and 4 mg. An overall per lesion efficacy of 83.5% sensitivity and 97.7% positive predictive value was obtained. Efficacy appears higher in lesions restricted to the breast and local regional disease than systemic metastases. For the 2 mg dose the breast/local regional disease efficacy was 90% sensitivity and 90.2% positive predictive value. The biodistribution of this MAb was best represented by a two-compartment model with a distribution-phase half-life of 4.0+/-1.4 h, followed by an elimination-phase half-life of 39.6+/-6.6 h. In all six patients studied, the critical organ was the kidney, with a mean radiation absorbed dose of 37+/-6.9 mGy/GBq. The accuracy of this imaging technique allows the development of diagnostic strategies for the routine use of the compound in patients with breast cancer.

Practical grouping of positive lymph nodes in pancreatic head cancer treated by an extended pancreatectomy

BACKGROUND

Until recently long-term survival has not been expected when at least one positive node was detected at any site in pancreatic head cancer treated by conventional pancreatectomy. However, even when nodal involvement is seen, there has been an increasing number of long-term survivors after extended pancreatectomy in which a wide range of lymphatic and connective tissues were cleared. Thus the purpose of the present study was to establish a practical rational grouping of positive lymph nodes in pancreatic head cancer treated by extended pancreatectomy.

METHODS

In 81 patients who tolerated extended pancreatectomy for cancer of the pancreatic head, a mean of 56 +/- 23 (range, 28 to 89) lymph nodes in each patient were examined under a microscope to determine the presence or absence of cancer. They were classified anatomically into 14 lymph node groups, and the incidence, distribution, and number of positive nodes were examined. A simplified grouping was made on the basis of the histologic findings and was checked against long-term survival rates.

RESULTS

Nodal involvement was detected in 59 (73%) of 81 patients, and positive nodes were more commonly observed in the posterior pancreaticoduodenal (PPD), superior mesenteric (SM), and anterior pancreaticoduodenal (APD) groups than in the 11 other groups (p < 0.05). The PPD, APD, and SM groups offered the sole sites of nodal involvement with incidence levels of 23%, 17%, and 6%, respectively, whereas none of the 11 other groups did. Thus patients were classified into four groups: (a), negative in all 14 lymph node groups (n = 22); (b), positive but limited to the PPD/APD groups (n = 14); (c), also positive in the SM group, but negative in the 11 other groups (n = 13); and (d), also positive in at least one of the 11 other groups (n = 32). This classification was associated well with the 5-year survival rate: 59% in group (a), 53% in group (b), 15% in group (c), and 0% in group (d) [p < 0.05; group (b) versus group (c)]. Also this grouping associated well with the total number of positive nodes (p < 0.05). The 5-year survival rate in patients with one to three positive nodes was 47% and was more than 6% in patients with four to seven positive nodes (p < 0.05).

CONCLUSIONS

In the clinicopathologic staging of the lymphatic spread from carcinoma of the pancreatic head, the PPD and APD groups were considered the first stations of lymphatic metastasis, whereas the 12 other groups-including the SM group-were categorized as second or more distant stations.

Arm morbidity after sector resection and axillary dissection with or without postoperative radiotherapy in breast cancer stage I. Results from a randomised trial. Uppsala-Orebro Breast Cancer Study Group

The incidence and time course of arm morbidity after sector resection and axillary dissection with or without postoperative radiotherapy to the breast was assessed in a prospective randomised trial among 381 patients with stage I breast cancer. At 3-12 months, arm symptoms were reported by 59/110 of the patients who had > or = 10 lymph nodes found in the axillary specimen versus 85/253 in whom < 10 lymph nodes were found (P = 0.002); at 13-36 months, the corresponding figures were 35/106 versus 44/225 (P = 0.001). Postoperative wound complications increased the incidence of arm symptoms at 3-12 months from 104/283 to 39/79 at 3-12 months (P = 0.03). Employed patients and patients < 65 years of age reported arm symptoms at 3-12 months in 86/161 and 94/191 compared to 58/207 and 50/177 among retired patients and patients > or = 65 years of age, respectively (P = 0.0001 and P = 0.0002, respectively). In a multivariate logistic regression analysis at 3-12 months, only young age (relative risk = 0.93 per year of increasing age, 95% CI 0.91-0.97) and the number of lymph nodes found in the axillary specimen (relative risk = 1.11 per lymph node found, 95% CI 1.05-1.18) remained statistically significant. No negative impact on arm morbidity was found by the addition of postoperative radiotherapy only to the breast, either in univariate or multivariate models. We conclude that factors directly related to the extent of the surgical procedure and young age are determinants of arm morbidity after breast preserving treatment for stage I breast cancer. Arm symptoms are most common during the first year after treatment and are reduced over the subsequent 2-3 years by around 40-50%.

Spiral CT and the pre-operative assessment of pancreatic adenocarcinoma

AIM

To determine the value of spiral computed tomography (CT) in the pre-operative assessment of pancreatic carcinoma.

PATIENTS AND METHODS

Fifty patients with proven pancreatic carcinoma referred for pancreatoduodenectomy underwent pre-operative spiral CT using a dedicated pancreatic protocol to determine tumour resectability. Twenty-eight patients subsequently underwent surgical exploration.

RESULTS

Pre-operative imaging suggested that 15 tumours were resectable, and macroscopic clearance was complete in 13 giving a positive predictive value (PPV) of 87%. PPV of irresectability was 92%. CT underestimated locally advanced disease (n = 2), missed small hepatic metastases (n = 1), and lymphadenopathy (n = 1). CT overestimated SMV encasement in 1 case, otherwise prediction of vascular patency and compromise was correct. The conspicuity of small resectable carcinomas was improved by spiral scanning.

CONCLUSION

The optimised pancreatic parenchymal enhancement and vascular opacification achieved by spiral CT improves tumour detection of small carcinomas, allows accurate assessment of peripancreatic vessels, and reliably predicts both resectable and irresectable disease. CT remains inherently limited in the prediction of early extrapancreatic non-vascular spread and of lymphatic metastases.

Progress of fundamental research in Wilms' tumor

The progress of fundamental research on the histopathological and molecular genetic properties, model systems, growth factor involvement, and tumor markers of clinical nephroblastoma (Wilms' tumor) are reviewed. Histologically, Wilms' tumor (WT) has been found to reveal a disorganized renal developmental process in which blastema and epithelia are randomly interspersed in varying amounts of stroma. Anaplasia is the only criterion for assigning a WT as having an "unfavorable histology." Cytogenetic analysis identified WT genes at chromosome 11p13 (WT1), 11p15 region (WT2), and 16q (WT3). Permanent in vitro WT cell lines and in vivo WT models, such as human xenografts, have been established which provide indefinite sources of tumor material for fundamental, as well as therapy-directed, research. Abnormalities of growth factor (GF) expression in WT indicate that GF may play an important role in WT pathogenesis. A series of monoclonal antibodies was tested in WT by immunohistochemical techniques to identify specific diagnostic and prognostic markers. p53 expression in anaplastic WT is significantly higher than in differentiated WTs, indicating p53 may be a prognostic marker. Although significant progress has been made in the fundamental research, our basic knowledge of this malignancy is still limited. The availability of suitable experimental models, particularly the human xenograft system, offers the opportunity for further study of the cell biological and molecular aspects of WT and its clinical progression.

Long-term prognostic and predictive factors in 107 stage II/III breast cancer patients treated with anthracycline-based neoadjuvant chemotherapy

The heterogeneity of therapeutic modalities and eligibility criteria and the lack of long-term follow-up in most reports of neoadjuvant chemotherapy for breast cancer preclude us from drawing conclusions about its value in clinically relevant patient subgroups. The present study aims to identify predictive and prognostic factors in 107 non-inflammatory stage II/III breast cancer patients treated between November 1980 and October 1991 with an anthracycline-based induction regimen before locoregional surgery. Preoperative chemotherapy comprised 3-6 cycles of doxorubicin (pirarubicin after 1986), vindesine, cyclophosphamide and 5-fluorouracil. Type of subsequent surgery and adjuvant treatment were decided individually. In analysis of outcome, univariate comparisons of end points were made using the log-rank test, and significant (P < or = 0.05) pre- and post-therapeutic factors were incorporated in a Cox multivariate analysis. With a median follow-up of 81 months (range 32-164+ months), the median disease-free survival (DFS) is 90.5 months while median overall survival has not yet been reached. Cytoprognostic grade and histopathological response in both the primary and lymph nodes were independent covariates associated with locoregional relapse with or without DFS and overall survival. Eleven patients with pathological complete response remain free of disease with a 68-month median follow-up, while the 18 with residual microscopic disease on the specimen showed a 60% cumulative incidence of locoregional recurrence. Despite encouraging response rates based on clinical or radiological evaluation (87% or 70%), neither method showed any significant correlation with pathological response and failed to contribute prognostic information on patients' outcome. Pathological evaluation of antitumoral activity of primary chemotherapy remains a major source of prognostic information and might be used to select patients in need of additional adjuvant treatment.

pp32 overexpression induces nuclear pleomorphism in rat prostatic carcinoma cells

Nuclear pleomorphism is an important diagnostic factor in tumour pathology. Traditionally, nuclear pleomorphism is evaluated qualitatively or semiquantitatively, often as a component of tumour grade; the molecular basis of nuclear pleomorphism, however, remains unclear. In this study, we investigated the quantitative effects on nuclear morphology of overexpressing pp32, a recently described nuclear phosphoprotein highly expressed in self-renewing and neoplastic cell populations. Assessment of Feulgen-stained transfected and control lines of AT3.1, a rat prostatic carcinoma cell line, using a computerized Cellular Image Analysis System (BD CAS-200) showed that stable overexpression of human pp32 in AT3.1 cells is accompanied by marked increases in the coefficient of variation of nuclear shape, nuclear size and chromatin textures but not in DNA content. In contrast, stable transfection with control vector, with ras, or with bcl-2 failed to affect nuclear morphology. Cell cycle analysis further showed that pp32-related increases in variation of nuclear structure manifested principally in G1. These studies suggest that pp32 plays a role either directly or indirectly in the control of nuclear shape of G1 cells.

Significance of lymph node metastases in patients with pancreatic cancer undergoing curative resection

BACKGROUND

Recent reports suggest an improved survival following resection for patients with pancreatic carcinoma. However, the prognosis for patients with lymph nodes metastases remains uncertain. The purpose of this study was to determine if the presence of lymph node metastases significantly alters survival in patients with otherwise potentially curable pancreatic carcinoma.

PATIENTS AND METHODS

Between 1970 and 1995, 401 patients with pancreatic adenocarcinoma, including 327 patients with pancreatic head tumors, were evaluated and treated.

RESULTS

One hundred (31%) patients underwent pancreatoduodenectomy. Operative mortality was 3% and morbidity was 22%. Median survival for 97 patients discharged from the hospital following resection was 14 months (range 2 to 293). The estimated 1-, 2-, and 5-year survivals were 61%, 43%, and 20%, respectively. Median survival was 11.5 months (range 2 to 87) for patients with positive lymph nodes (n = 56) and 24 (range 0 to 293) months for patients with negative lymph nodes (n = 41; P = 0.0003). Ten patients (10%) survived longer than 5 years, and 9 (90%) of them had negative lymph nodes. Elderly patients (> or = 70 years) had a median survival twice as long as younger patients (24 versus 12 months, P = 0.03).

CONCLUSIONS

Lymph node metastases are found in 56% of patients undergoing resection. Pancreatoduodenectomy can be performed with low operative mortality in patients of all ages. It offers good palliation for patients with lymph nodes metastases and encouraging long-term survival rates as well as a chance for cure in patients with negative lymph nodes.

Impact of endoscopic ultrasound with fine-needle aspiration on the surgical management of pancreatic cancer

BACKGROUND

Endoscopic ultrasound (EUS) with EUS-guided fine-needle aspiration (EUS-FNA) enables one to visualize the pancreas and surrounding structures and can provide access for FNA of those structures that appear suspicious for tumor.

PATIENTS AND METHODS

From 1993 to 1995, 50 patients suspected of having pancreatic cancer underwent EUS/EUS-FNA and abdominal computed tomography (CT). Malignancy was found in 30 (60%) cases, which included 24 (48%) pancreatic adenocarcinomas.

RESULTS

Endoscopic ultrasound/EUS-FNA identified 26 of the 30 malignancies (85%) and 21 of the 24 pancreatic adenocarcinomas (88%), with no false positives. Thirteen of the 24 pancreatic cancer patients had lymph nodes that were sampled with EUS/EUS-FNA. Seven of these 13 patients (62%) were found to have metastatic spread to lymph nodes. Operations were performed on 11 of the pancreatic cancer patients. Of these 11, the 5 that were predicted to be resectable by EUS/EUS-FNA underwent successful resection. Of the 6 predicted to be unresectable, 5 had palliative biliary bypasses, and 1 had a grossly positive margin of resection.

CONCLUSIONS

Endoscopic ultrasound/EUS-FNA can identify patients for curative surgical resection. It can also preoperatively identify patients with regional nodal disease for inclusion in appropriately designed clinical trials.

Reoperative pancreaticoduodenectomy for periampullary carcinoma

BACKGROUND

We have noted a continued increase in the number of patients referred to our institution for presumed or biopsy-proven periampullary carcinoma following an "exploratory" laparotomy during which tumor resection was not performed. Although previous work has demonstrated the safety of reoperative pancreaticoduodenectomy (PD), the need to avoid nontherapeutic laparotomy in these patients is obvious. In the current study, we sought to determine why PD was not performed at the initial operation.

METHODS

Using the prospective pancreatic cancer database, we identified all patients who underwent reoperative PD at our institution between June 1990 and October 1995. Radiologic imaging prior to reoperation was standardized and based on thin-section, contrast-enhanced computed tomography (CT); helical CT was used in more recent cases. Pathologic data were obtained, and initial outside operative reports were reviewed to determine why a PD was not performed at the initial procedure.

RESULTS

Twenty-nine patients underwent reoperative PD. Resection was not performed at the initial laparotomy because of the surgeon's assessment of local unresectability (17 patients), lack of a tissue diagnosis of malignancy (9), misdiagnoses (2), and error in intraoperative management (1). In the 17 patients deemed to have unresectable disease, successful reoperative PD required vascular resection in 10. All 10 of these patients had resection with negative microscopic margins of excision. Of the 9 patients who did not have resection owing to diagnostic uncertainty, all 9 had undergone multiple intraoperative biopsies interpreted as negative for malignancy; 6 of 9 had carcinoma confirmed on permanent-section analysis of the biopsy specimens. Four patients suffered major complications from intraoperative large-needle biopsy.

CONCLUSIONS

Detailed preoperative imaging and a clearly defined operative plan would have allowed successful resection at the initial operation in 27 of 29 patients who underwent reoperative PD. Avoidable patient morbidity and the cost of unnecessary surgery argue strongly against "exploratory" surgery in patients with presumed periampullary neoplasms.

T1 breast carcinoma in women 70 years of age and older may not require axillary lymph node dissection

BACKGROUND

The current trend in breast cancer treatment is toward breast conservation and selective use of axillary lymph node dissection. Patient eligibility criteria for treatment without axillary dissection are evolving.

METHODS

We retrospectively reviewed the tumor registry over a 10-year period at Naval Medical Center San Diego and included all women aged 70 and older with T1 breast carcinoma (n = 78). Data included tumor size, surgical therapy, post-operative therapy, recurrence, and survival. The women were divided into groups by the approach taken toward the axilla.

RESULTS

No patient was given adjuvant chemotherapy. There were no axillary cancer recurrences in our patients. No statistically significant difference existed, regardless of the approach to the axilla, in recurrence or survival between groups.

CONCLUSION

Axillary dissection in this population did not influence postoperative treatment, decrease recurrence, or improve survival. Our study suggests breast cancer treatment in this population should not include axillary dissection.

The value of axillary dissection in T1a breast cancer

BACKGROUND

Some authors have stated the undesirability of axillary lymph node dissections for very small breast cancers, because so few of their patients have lymph node metastases (3% for T1a lesions in one series).

METHODS

Of 6,308 breast cancer cases reviewed from three large urban hospitals 3,077 single primary cases with both axillary dissection and accurate tumor measurements were statistically analyzed.

RESULTS

For T1a lesions we found axillary metastases to be four times higher (12%) than others have reported. For each tumor size there was a statistically significant difference in the percentage of axillary metastases. There was also a statistically significant difference in the breast cancer-specific survival of patients with different tumor sizes (n = 3,077) at the 3-year, 5-year, 7-year, and 10-year periods.

CONCLUSION

These results justify axillary node dissections even for very small invasive cancers of the breast, particularly for invasive ductal histology.

Pancreatic adenocarcinoma

Pancreatic carcinoma is one of the most enigmatic and aggressive malignant disease facing oncologists. A precocious propensity to spread along peripancreatic neurons and lymphatic channels conspires with the limited activity of standard chemotherapeutic agents and the inability to deliver large doses of radiotherapy to the upper abdomen, leaving radical surgical resection as the primary treatment capable of influencing long-term survival. Theoretically, when the tumor is small and confined to the pancreas, adequate locoregional control is possible by radical resection of the tumor, lymph nodes, peripancreatic neurons, and surrounding soft tissue. Realistically, at the time of initial diagnosis, 50% of patients have distant metastases to the liver or peritoneal surface, and more than 80% of the remaining patients have locally advanced tumors. Fewer than 10% of all patients with a small pancreatic adenocarcinoma confined to the pancreas are candidates for cure by use of radical resection as the sole treatment modality. Given these sobering statistics on the late presentation of this tumor, it is not surprising that, even after radical resection, the overall median survival time is only 18 to 20 months and the overall 5-year survival is approximately 10%. These dismal results led to a call in the early 1970s for abandonment of radical therapy in this disease and for treatment of all patients with palliative care only. These statistics are discouraging, but over the last 10 years a therapeutic renaissance has erupted. This resurgence has been driven by surgeons performing pancreaticoduodenectomy with low perioperative mortality rates and excellent functional results. It has been fueled by the use of adjuvant and neoadjuvant chemoradiotherapy protocols. Improved radiographic imaging techniques such as endoscopic retrograde cholangiopancreatography, helical computed tomography scan, and endoscopic ultrasonography are beginning to show promise in facilitating an earlier diagnosis and in providing highly accurate tumor staging without operation. It is hoped that recent observations on the molecular genetics of pancreatic adenocarcinoma will lead to a better understanding of tumor biology, which in turn should result in a more rational application of new diagnostic and therapeutic strategies. Effective percutaneous, endoscopic, and laparoscopic techniques have been developed concomitant with the recent advances in radiographic and endoscopic imaging. These minimally invasive options can now provide meaningful, long-lasting palliation and improved quality of life for the large number of patients with unresectable or metastatic disease who have no other treatment options. The therapeutic nihilism so pervasive in previous decades has no place in the contemporary treatment of patients with pancreatic adenocarcinoma. True long-term survival seems possible for a growing proportion of patients, and minimally invasive, effective palliation is achievable in the vast majority of patients. It is only through aggressive recruitment of patients for treatment, application of novel diagnostic and therapeutic protocols, and further laboratory investigation into the biology of pancreatic cancer that the momentum of the last decade toward improved outcome and quality of life can be sustained.

Axillary dissection: when and how radical?

Since the 1970s, axillary dissection has been regarded primarily as a staging procedure, with a secondary purpose of maintaining local control in the axilla. The widespread administration of adjuvant systemic therapy to women with breast cancer, as well as the increasingly frequent detection of very small breast cancers by mammography, has prompted an examination of the need for axillary dissection in all women with invasive breast cancer. This article reviews the rationale for eliminating axillary dissection, the incidence of nodal metastases in small and apparently favorable breast cancers, and discusses how often the findings of axillary dissection actually alter therapy in patients with clinically node-negative breast cancers. The extent of axillary dissection necessary to provide accurate staging and maintain local control is examined, and patients who will benefit from axillary dissection are identified.

Preoperative chemoradiotherapy for localized pancreatic carcinoma. A perspective

BACKGROUND

The role of chemotherapy (CTX) in the treatment of localized adenocarcinoma of the pancreas must be enhanced if current results are to be surpassed. It is postulated that histologic response to various chemotherapeutic agents may offer an assessable endpoint intermediate to and perhaps as or more meaningful than survival analysis.

METHODS

A history of trials assessing the value of adjuvant preoperative and postoperative chemotherapy and radiation therapy (RT) is provided. Experiences with histologic assessment of treatment response are reviewed.

RESULTS

There has been no clear benefit from adjuvant CTX, either when delivered with RT or as postoperative maintenance. Imaging tests were much less sensitive than histologic grading in determining responses (7% vs. 71% partial responses) of patients with resected pancreatic cancers previously treated with RT/CTX. This suggests that standard imaging assessments of pancreatic carcinoma response to chemotherapy and radiation therapy may be inaccurate.

CONCLUSIONS

Preresectional delivery of chemotherapeutic agents with RT allows response rates to be quantified histologically. This method of response analysis, being much more sensitive than analysis by computed tomographic scanning, may allow the more rapid development of improved chemotherapeutic programs for this malignancy.

Pancreatic carcinoma in perspective. A continuing challenge

There are approximately 27,000 new cases of carcinoma of the pancreas each year and most afflicted patients will die of the disease. Although smoking is a common denominator, chronic pancreatitis is considered an important precursor lesion in a smaller number of cancers. Pancreatic cancer is primarily a disease of the pancreatic ducts. The molecular events are under intense study, but c-K-ras mutation is involved in approximately 80% of the cases and p53 to a slightly lesser degree (60-80%). Early manifestations are usually occult, but jaundice is a common manifestation in patients with cancers of the pancreatic head. Thin-slice computed tomography, portography, and endoscopic retrograde cholangiopancreatography are currently the most sensitive detection techniques. The developing use of endoscopic ultrasound and laparoscopy appear to enhance detection and are under evaluation. In many patients with advanced disease, endoscopic bypass may eliminate the need for unnecessary surgery, although gastrointestinal bypass is still required in some patients (10-15%). Curative resection is possible in selected patients (perhaps 10-15%), with expectation of extended survival ranging from 6->20% in some series. The survival differences may be related to stage, patient selection, and the expertise of the operative team. Preoperative chemotherapy/radiation is under study and may improve outcome. Clinical trial participation is essential for improvement in treatment outcomes.

Pancreatic cancer. The need for critical reassessment

A review of results of 60 years of resections for pancreatic cancer reveals no consistency in reporting. Resected survivors have been reported up to seven times, even from different countries, and nonresected survivors are overlooked. The claimed 5-year survival rate of 30-55% is achieved by reducing the subset on which calculations are based and using methods such as the Kaplan-Meier, which lead to higher figures the more patients are lost to followup (censored). The excess cost of resection versus bypass can be expected to be ca. $150,000, with one in 30 patients living for 5 years. The overall survival rate is < 0.4%; the best proven surgical result is 3.6% and the best nonsurgical result is 1.7%. Resections have had no discernible impact on survival.

DNA image analysis study of lesions of the gallbladder and biliary system

DNA ploidy analysis of 22 lesions arising from the intrahepatic and extrahepatic biliary systems and gallbladder was performed on Feulgen-stained 5-microns sections from archival paraffin-embedded tissue on an image analyzer (CAS-200). The cases included intrahepatic cholangiocarcinoma (n = 6), extrahepatic bile duct carcinoma (n = 5), carcinoma of the gallbladder (n = 11), and appropriate controls. All malignancies were stage III and IV adenocarcinomas with the exception of 1 stage II moderately differentiated gallbladder adenocarcinoma. No correlation with ploidy and stage could be made, most likely because of the advanced stage of the tumors at the time of presentation. When DNA ploidy was compared with the grade of tumor, the 3 well-differentiated adenocarcinomas (2 cholangiocarcinomas, 1 bile duct carcinoma) were predominantly diploid; however, diploid peaks were also found in moderately differentiated adenocarcinomas of all 3 sites and in a poorly differentiated adenocarcinoma of the extrahepatic bile ducts. Finally, 15 of 22 (68%) of cases showed only aneuploid populations. Multiple populations were observed in 19 of the 22 cases; this finding may reflect intratumoral heterogeneity and correlate with the advanced stage and aggressive nature of malignancies of the gallbladder and biliary system.

Genotypic characterization of a primary mucoepidermoid carcinoma of the parotid gland by cytogenetic, fluorescence in situ hybridization, and DNA ploidy analysis

We present a case of mucoepidermoid carcinoma with t(3;12)(q24;p13) and polysomy X by cytogenetic and fluorescence in situ hybridization (FISH) techniques. Flow cytometric DNA analysis of the primary tumor showed DNA aneuploidy and analysis of cultured tumor cells showed DNA diploidy indicating restricted growth of the diploid tumor cells in short-term tissue culture. Interphase cytogenetic analysis of chromosomes 1, 3, 6-12, 16-18, and X in the primary tumor showed polysomy 1, 9, 18, and X, monosomy 8 and 17, and disomy 3, 6, 7, 10-12, and 16. Except for chromosome X, other numerical chromosomal abnormalities were not detected by conventional cytogenetic analysis. Our combined approach allowed for better characterization of the genotypic features of this neoplasm.

Pancreaticoduodenectomy. Does it have a role in the palliation of pancreatic cancer?

OBJECTIVE

The authors define the role of palliative pancreaticoduodenectomy in patients with pancreatic carcinoma.

BACKGROUND

Decreases in perioperative morbidity and mortality and improved long-term survival associated with pancreaticoduodenectomy for patients with pancreatic carcinoma have clearly established a role for this operation when performed with curative intent. However, most surgeons remain hesitant to perform pancreaticoduodenectomy unless surgical margins are widely clear, choosing rather to perform palliative biliary and gastric bypass.

METHODS

A single-institution retrospective review was performed comparing the outcome of 64 consecutive patients undergoing pancreaticoduodenectomy for pancreatic carcinoma with gross or microscopic evidence of adenocarcinoma at the surgical resection margins, and 62 consecutive patients found to be unresectable at the time of laparotomy because of local invasion without evidence of metastatic disease (stage III). Combined biliary and gastric bypass were performed in 87% of patients not resected.

RESULTS

The two groups were similar with respect to age, gender, race, and presenting symptoms. The hospital mortality rate was identical in both groups (1.6%). Fifty-eight percent of patients undergoing pancreaticoduodenectomy had an uncomplicated postoperative course compared with 68% of patients undergoing palliative bypass (not significant). The length of postoperative hospital stay after pancreaticoduodenectomy was 18.4 days, which was significantly longer (p < 0.05) than for patients undergoing palliative bypass (15.0 days). The overall actuarial survival (Kaplan-Meier) was improved significantly in patients undergoing pancreaticoduodenectomy (p < 0.02). Postoperative chemotherapy and radiation therapy improved survival in both groups.

CONCLUSIONS

Pancreaticoduodenectomy can be performed with a similar perioperative morbidity and mortality and only a minimal increase in hospital stay when compared with traditional surgical palliation. Pancreaticoduodenectomy with postoperative chemotherapy and radiation therapy is associated with improved long-term survival when compared with patients treated with surgical bypass. These data support the role of palliative pancreaticoduodenectomy in patients with pancreatic carcinoma and with local residual disease.

Gastrointestinal problems in diabetes

Gastrointestinal symptoms are often encountered in patients with diabetes mellitus. Symptoms may arise in any region of the alimentary tract; common symptoms are heartburn, nausea, vomiting, diarrhea, constipation, fecal incontinence, and abdominal pain. This article reviews practical approaches to the identification of the pathophysiologic mechanisms involved in diabetic enteropathies and their complications and briefly outlines strategies to treat these symptoms. Particular emphasis is placed on applied physiologic tests and the choice of pharmacotherapy (e.g., cisapride, erythromycin, or octeotide). The current role of pancreatic transplantations also is briefly reviewed.

Molecular diagnosis of exocrine pancreatic cancer using a percutaneous technique

BACKGROUND

The K-ras oncogene is activated by point mutations at codon 12 in most patients with exocrine pancreatic cancer. Mutant-enriched polymerase chain reaction (PCR) amplification can enhance the detection of mutated K-ras. This technique was applied to patients undergoing percutaneous fine-needle aspiration (FNA) biopsy of suspect pancreatic lesions.

METHODS

Twenty-five patients underwent percutaneous FNA of the pancreas for cytologic and molecular analysis. After preparing cytologic smears, the 22-gauge needle and syringe used for FNA were rinsed in RPMI-1640. The specimen was centrifuged, and DNA was extracted from the supernatant and subjected to mutant-enriched PCR using appropriate mismatched primers that introduce a BstNI restriction endonuclease clevage site at codon 12 of wild-type, but not mutant, K-ras. After digestion with BstNI, the DNA was reamplified. To increase assay sensitivity, the final five PCR cycles were completed incorporating 5 microCi of (alpha-32P)dCTP. The DNA was then redigested and subjected to gel electrophoresis and autoradiography.

RESULTS

The median amount of DNA retrieved per specimen was 3.33 micrograms. Mutant K-ras was detected as a band of 143 bps; residual wild-type DNA was seen as a 114-bp fragment. Twenty-one of 25 specimens demonstrated mutated K-ras DNA. Two patients with nondiagnostic cytology results had mutated K-ras DNA; adenocarcinoma of pancreatic origin was confirmed in both cases after pancreatectomy.

CONCLUSION

The molecular diagnosis of pancreatic cancer through identifications of mutations in K-ras can be readily performed on specimens obtained by percutaneous FNA. As aggressive multimodality management of this disease becomes more common, pretreatment analysis of molecular determinants may have greater clinical significance.

A predictive index of axillary nodal involvement in operable breast cancer

We investigated the association between pathological characteristics of primary breast cancer and degree of axillary nodal involvement and obtained a predictive index of the latter from the former. In 2076 cases, 17 histological features, including primary tumour and local invasion variables, were recorded. The whole sample was randomly split in a training (75% of cases) and a test sample. Simple and multiple correspondence analysis were used to select the variables to enter in a multinomial logit model to build an index predictive of the degree of nodal involvement. The response variable was axillary nodal status coded in four classes (N0, N1-3, N4-9, N > or = 10). The predictive index was then evaluated by testing goodness-of-fit and classification accuracy. Covariates significantly associated with nodal status were tumour size (P < 0.0001), tumour type (P < 0.0001), type of border (P = 0.048), multicentricity (P = 0.003), invasion of lymphatic and blood vessels (P < 0.0001) and nipple invasion (P = 0.006). Goodness-of-fit was validated by high concordance between observed and expected number of cases in each decile of predicted probability in both training and test samples. Classification accuracy analysis showed that true node-positive cases were well recognised (84.5%), but there was no clear distinction among the classes of node-positive cases. However, 10 year survival analysis showed a superimposible prognostic behaviour between predicted and observed nodal classes. Moreover, misclassified node-negative patients (i.e. those who are predicted positive) showed an outcome closer to patients with 1-3 metastatic nodes than to node-negative ones. In conclusion, the index cannot completely substitute for axillary node information, but it is a predictor of prognosis as accurate as nodal involvement and identifies a subgroup of node-negative patients with unfavourable prognosis.

An image analysis study of DNA content in early colorectal cancer

The DNA content of 168 consecutive T3,N0,M0 (Dukes' B, Astler-Coller B2) colorectal cancers was studied using image analysis on formalin-fixed paraffin-embedded tissues. 72 cases (43%) were classified as diploid and the remaining 96 (57%) as non-diploid. After a median follow-up period of 6.7 years, a significant survival advantage was found for diploid compared with non-diploid cases (logrank test; P = 0.008). The long-term (8 year) survival rate was 70% for diploid and 46% for non-diploid tumours. Subgroup analysis showed that the survival advantage conferred by tumour diploidy was greatest in large (> or = 5 cm) cancers and was found both in colonic and rectal cancer cases. These data indicate that tumour ploidy status measured by image analysis might be useful in determining risk of colorectal cancer recurrence and death in patients following resection of early colorectal cancer.

Inpatient vs. outpatient bowel preparation for elective colorectal surgery

BACKGROUND

Recent pressures to decrease the cost of medical care have mandated preoperative outpatient bowel preparation (OBP) for elective colorectal surgery without any data documenting equivalent quality of care. This study examined the safety and efficacy of OBP compared with inpatient bowel preparation (IBP).

METHODS

Records of all patients who underwent OBP for elective colorectal resection since the inception of the OBP program from July 1993 to June 1994 were compared with records of all patients who received IBP for elective procedures from January to June 1993.

RESULTS

The two groups, 90 patients who underwent OBP and 98 patients who had IBP, were well matched for age, sex, diagnosis, and operations performed. The OBP group had a shorter length of hospital stay (median, 7 vs. 9 days; P < 0.0001; chi-squared analysis), whereas the complication rate was similar (19 percent in the OBP group vs. 18 percent in the IBP group), including infectious complications (10 percent in the OBP group vs. 7 percent in the IBP group). Although operating time was similar (mean, 199 vs. 213 minutes) and estimated blood loss (mean, 528 vs. 536 ml), the OBP group had significantly higher perioperative fluid requirements: intraoperative fluids (median, 4300 vs. 3700 ml; P < 0.05; Student's t-test), intraoperative colloid administration (48 vs. 29 percent; P < 0.0002; chi-squared), 24-hour postoperative fluids (3224 vs. 2700 ml; P < 0.0001; Student's t-test), and postoperative fluid challenges (50 vs. 20 percent; P < 0.0001; chi-squared analysis).

CONCLUSION

Outpatient bowel preparation for elective colorectal surgery is safe and effective. It offers shorter hospital stay, and, therefore, potentially reduces medical care cost. Patients with multiple medical problems may not tolerate extensive fluid shifts; therefore, other preoperative arrangements, such as inpatient or outpatient intravenous fluid therapy, need to be considered to minimize complications that may outweigh potential cost savings.

Immunohistochemical evaluation of HER-2/neu expression in pancreatic adenocarcinoma and pancreatic intraepithelial neoplasms

Although several morphological and molecular genetic studies have implicated various grades of pancreatic duct hyperplasia as precursor lesions to infiltrating pancreatic adenocarcinoma, the identity of preinvasive pancreatic neoplasms remains controversial. In the present study, the authors examined the expression of the epidermal growth factor receptor homologue, HER-2/neu (c-erbB-2), in pancreatic duct lesions adjacent to infiltrating pancreas cancers in a series of 19 cases of pancreatic duct adenocarcinoma. HER-2/neu expression was examined because it has been identified in a proportion of infiltrating pancreas cancers and because it may provide early neoplasms with a growth advantage over adjacent nonneoplastic epithelium. In normal pancreatic ducts and ductules, HER-2/neu expression was absent in all but one case. By contrast, HER-2/neu was expressed in 82% (P = .008 vs normal ) of ducts with flat mucinous hyperplasia, 86% (P = .03 vs normal) of ducts with papillary mucinous hyperplasia without atypia, 92% (P = .001 vs normal) of ducts with atypical papillary mucinous hyperplasia, and all specimens with carcinoma in situ. HER-2/neu expression was observed in 69% (P = .002 vs normal) of the moderately differentiated infiltrating carcinomas and none of the poorly differentiated infiltrating carcinomas. These data establish HER-2/neu as a potential mediator of growth factor-related signal transduction in pancreatic duct lesions, and provide additional support for the hypothesis that lesions formerly regarded as various grades of hyperplasia instead may represent intraepithelial neoplasms with the potential for subsequent invasion and metastasis.

Cost-effective preoperative evaluation, operative treatment, and postoperative follow-up in the breast cancer patient

Although medical criteria based on retrospective and prospective studies form the basic foundation for the strategies enunciated in this article, efficiency in management and cost effectiveness follow because of the simplification that has been found to be appropriate by analyzing reports over the past decade and using common sense. In addition, the realization of the effectiveness of mammographic screening programs should encourage all surgeons to promote and practice yearly mammographic screening in appropriately aged women. At present, this means women between the ages of 50 and 75, but there is increasing evidence that women between the ages of 40 and 49 may benefit. A compromise would suggest women over 45 years of age as appropriate, recognizing the controversy now raging over the effectiveness of screening in women 40 to 49 years old. Wide appreciation of the major gains in breast cancer detection by use of mammographic screening programs needs to be emphasized. We have predicted that within a decade the median maximum diameter of all invasive breast cancer in the United States will be only 1 cm if mammographic screening programs are widespread. If this occurs, there would be extraordinary gains in reduced patient morbidity and cost savings and undoubtedly changes will occur in the previously unyielding age-adjusted mortality rate. The goal of entirely outpatient management in the vast majority of breast cancer patients can be achieved by such mammographic screening as well as by the adaptation of induction chemotherapy and breast conservation in the majority of advanced primary breast cancer patients that still appear.

Malignant obstructive jaundice. Evaluation and management

A large number of laboratory tests, radiologic studies, and endoscopic techniques are available for the evaluation of the jaundiced patient. Similarly, the therapeutic options have increased with the development and improvement of endoscopic, percutaneous, and laparoscopic procedures, and the morbidity and mortality rates associated with open surgery have decreased. The challenge is to select, on an individual basis, the most efficient and cost-effective evaluation as well as the management with the lowest morbidity and mortality rates and the best short- and long-term goals.

The value of minimal access surgery in the staging of patients with potentially resectable peripancreatic malignancy

OBJECTIVE

The purpose of this study was to determine if an endosurgical approach that mimics open exploration would improve the accuracy of simple diagnostic laparoscopy. SUMMARY BACKGROUND DATA; Most patients with peripancreatic malignancy are found at exploration to be unable to undergo resection. Laparoscopy has been suggested as a sensitive method for detecting metastatic disease in this group of patients. However, the ability to assess resectability with simple diagnostic laparoscopy remains relatively low (<40%).

METHODS

Between December 1992 and August 1994, 115 patients with radiologically resectable peripancreatic tumors underwent extended laparoscopy before undergoing a planned curative resection. This technique required assessment of the peritoneal cavity, liver, lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels.

RESULTS

Sixty male and 55 female patients were included in the current study. The pancreatic head was involved in 74 patients (64%), followed by the body in 21 (18%), tail in 8 (7%), ampulla in 8 (7%), duodenum in 3 (3%), and distal bile duct in 1 (1%). An abdominal computed tomography (CT) scan was performed for all patients before laparoscopy, ultrasonography for 74 patients (64%), endoscopic retrograde choleangiopancreatography for 59 patients (51%), and mesenteric angiography for 9 patients (8%). Pneumoperitoneum was established successfully in all but 2 cases (98%). A complete examination of 108 patients was performed. Sixty-seven patients were considered to have resectable disease, and 61 resections were performed. Laparoscopy failed to identify hepatic metastases in 5 patients and portal venous encasement in 1 patient. Unresectable disease was identified in 41 patients. Hepatic metastases were observed in 20 patients, mesenteric vascular encasement in 14, extrapancreatic/peritoneal involvement in 16, and celiac or portal lymphatic metastases in 8. There were no intraoperative or postoperative complications related to the laparoscopic procedure. The positive predictive index, negative predictive index, and accuracy of laparoscopy were 100%, 91%, and 94%, respectively.

CONCLUSIONS

This study demonstrates that extended laparoscopy is accurate and safe and makes exploration unnecessary in many patients with potentially resectable peripancreatic malignancy. In this series, 76% of patients explored were resected, compared with the authors' experience between 1983 and 1993 of 35%. The authors believe that laparoscopy is an important component in the staging of this group of patients and should be performed before exploration.

Nuclear DNA content and pathology in radically treated pancreatic carcinoma. The prognostic significance of DNA ploidy, histology and nuclear grade

BACKGROUND

Nuclear DNA content and pathology are considered to be prognostically relevant in several solid tumors, but controversial findings have emerged in pancreatic carcinoma (PC). Histopathology and DNA ploidy were each correlated with survival in radically treated PC to ascertain the hierarchy of their prognostic significance.

METHODS

DNA ploidy was assessed by flow cytometry (FC) in neoplastic tissue samples from 60 patients with PC who were followed until death. Representative neoplastic areas were obtained by microdissection from archival paraffin embedded material (excluding any carcinoma with a coefficient of variation of the G0/G1 peak higher than 8%). Histologic data and FC patterns were related to prognostic behavior using univariate multivariate statistical analysis.

RESULTS

Aneuploid cancers were detected in 39 of 60 patients. Univariate analysis showed that histologic grade, nuclear grade, and ploidy were significantly related to prognosis. On multivariate analysis, only histologic grade and DNA ploidy (diploid vs. aneuploid) were significant with significant interaction.

CONCLUSIONS

The prognostic value of pathology and ploidy was demonstrated in patients treated radically for PC. As in other tumors characterized by a short survival, the clinical usefulness of any prognostic parameters is somewhat limited. However, the significant relationship between prognosis and DNA ploidy might be of interest in a cost-benefit analysis for selecting patients in whom an attempt at radical surgical treatment or adjunctive chemotherapy may be justified.

Reversal of multi-drug resistance in vitro by fatty acid-PEG-fatty acid diesters

Fatty acid ester surfactants, e.g., Cremophor EL and Solutol HS 15, that modulate multi-drug resistance (MDR) have been described; however, the drug potential of these preparations is unclear because of the molecular heterogeneity of these and other commercial surfactants. In previous experiments, an active but still polydisperse preparation, designated CRL 1337, was synthesized by reacting purified oleic acid with a 20-fold molar excess of ethylene oxide. We have subjected this preparation to chromatographic separation, and infrared analysis of the active fractions revealed a significant component of diester structures (fatty acid-PEG-fatty acid). A new generation of diester compounds has now been synthesized. Preparations comprised of 99% diesters were significantly more potent than monoester preparations for MDR modification activity in vitro. As previously determined for ethylene oxide-derived preparations similar to CRL 1337, the nature of the fatty acid domains proved to be important for activity, as was the relative length of the polyethylene glycol domain (which determines the hydrophile-lipophile balance). The ester linkage appeared unimportant since homologous diethers and diamides had activity similar to that of diesters. Stearic acid diester was 1.5- to 7-fold more potent than CRL 1337 when tested in cell proliferation inhibition assays. In light of these structural restrictions on drug potentiation, and since these surfactants are active at relatively low concentrations (below 1 microgram/ml), investigations of their mechanism of action were initiated by exploring specific interactions with P-glycoprotein. Both active and inactive diesters inhibited azidopine labeling of P-glycoprotein, suggesting that fatty acid-PEG diesters can interfere with P-glycoprotein substrate binding. Other attributes of these preparations must contribute to their ability to reverse MDR.

Preoperative chemoradiation, pancreaticoduodenectomy, and intraoperative radiation therapy for adenocarcinoma of the pancreatic head

BACKGROUND

Local recurrence in the bed of the resected pancreas is the most common site of tumor recurrence following a standard pancreaticoduodenectomy (PD) for adenocarcinoma of the pancreatic head. In an attempt to improve local and regional disease control and thereby enhance the quality and length of survival in patients undergoing potentially curative PD, we have used a protocol of preoperative multimodality therapy.

PATIENTS AND METHODS

All patients were treated with external-beam radiation (30.0 or 50.4 Gy) and concomitant 5-fluorouracil (300 mg/m2 per day) prior to PD. Electron-beam intraoperative radiation therapy was given to the bed of the resected pancreas before reconstruction. Patients were assessed for recurrence by physical examination, chest roentgenography, and computed tomography scan performed at 3-month intervals following treatment.

RESULTS

Thirty-nine patients completed all therapy; 1 perioperative death occurred. Thirty-eight tumor recurrences have been documented in 29 patients at a median of 11 months from the date of diagnosis; 23 patients died of disease. The liver was the most frequent site of recurrence, and liver metastases were a component of treatment failure in 53% of patients. Isolated local or peritoneal recurrences were documented in only 4 patients (11%). The only significant clinical or pathologic variable predictive of local-regional recurrence was a previous laparotomy and intraoperative biopsy. The median survival of all 39 patients was 19 months, and the 4-year actuarial survival rate was 19%.

CONCLUSIONS

Preoperative chemoradiation, PD, and electron-beam intraoperative radiation therapy for adenocarcinoma of the pancreatic head have resulted in improved local-regional tumor control, with distant metastatic disease becoming the predominant site of tumor recurrence. Future treatment strategies should incorporate effective multimodality therapy for local-regional disease as demonstrated in this study. Major improvements in overall survival will likely await the development of systemic or regional therapy for liver metastases.

Carcinoma of the periampullary region: who benefits from portal vein resection?

BACKGROUND

The prognosis of patients with carcinoma of the periampullary region infiltrating the portal vein is dismal.

PATIENTS AND METHODS

We assessed the morbidity, mortality, and prognosis of pancreatoduodenectomy in 31 patients in whom a tangential excision (n = 9) or a segmental resection (n = 22) of the portal vein or superior mesenteric vein was performed in an attempt to achieve complete tumor removal.

RESULTS

There was no postoperative mortality. Tumor infiltration of the resected vein could be documented histopathologically in 19 of the 31 (61.3%) patients. All patients with pancreatic or bile duct carcinoma (n = 29) died within 16 months of the resection (median survival 8 months). In contrast, 2 patients with cystadenocarcinoma and acinous cell carcinoma are alive with no evidence of recurrence at 23 and 54 months, respectively.

CONCLUSION

Portal vein resection does not prolong survival in patients undergoing partial pancreatoduodenectomy for carcinoma of the pancreas or distal bile duct. Only the occasional patient with a rare tumor at this region may benefit from this approach.

Review of known prognostic variables

The prognosis of patients with primary breast cancer depends on prognostic factors per se and on treatment. In certain subgroups of patients, the overall treatment benefits of systemic adjuvant therapy are modest. Therefore, proper selection of patients and treatment modalities is absolutely necessary. Patients with primary breast cancer and a very good prognosis can be classified by known prognostic factors such as tumor size T < or = 1 cm, grade 1, hormone receptor positive tumors, and no other factors indicating poor prognosis. [table: see text] Patients with very poor prognosis are characterized by young age (< 35 years), large tumor size (T > 3 cm), grade 3, hormone receptor-negative tumors, and high S-phase fractions. Tumor size is the best prognostic factor for the decision to treat (breast conservation surgery, primary preoperative or adjuvant systemic therapy) or not to treat. Table 4 shows possible treatment decisions (type and timing of therapy) in primary breast cancer based on known prognostic and predictive variables. The decision to treat or not to treat outside clinical trials should be based on this kind of information. The type and aggressiveness of adjuvant systemic treatment should depend on the receptor status of the tumor and on the age and menopausal status of the patient, as classical predictive factors; however, prognosticators which can describe the metastatic potential of breast cancer cells have yet to be defined.

Combined use of nuclear morphometry and DNA ploidy as prognostic indicators in nonresectable adenocarcinoma of the pancreas

The introduction of combined modality treatment has only marginally affected the prognosis in nonresectable pancreatic carcinoma. Evaluation of easily accessible prognostic variables could be of clinical importance when selecting patients for proper therapy. DNA ploidy and morphometric variables were chosen as prognostic markers and assessed on cytologic material obtained by fine-needle aspiration biopsy (FNAB) from 128 patients with pancreatic carcinoma. The nuclear DNA content was measured by image cytometry. Patients were categorized as short-term (< or = 6 mo) and long-term survivors (> 6 mo). Ninety-eight of 116 nonresectable patients were possible to evaluate. There were significant differences between short- and long-term survivors with regard to DNA ploidy (p < 0.01) and the morphonuclear variable anisokaryosis (p < 0.001). In patients with either DNA aneuploid tumors or anisokaryosis > or = 0.6, the survival time was 6 mo or less in 85 and 93%, respectively. When both these criteria were fulfilled, only 5% survived for more than 6 mo. Thus, DNA ploidy and morphometry, separately or in combination, may provide prognostic information in nonresectable pancreatic carcinoma.