Axillary lymph nodes and breast cancer: a review

BACKGROUND

The value of surgical staging and treatment of the axillary lymph nodes with either surgery or radiotherapy in the initial management of patients with Stage I or II invasive breast cancer is controversial.

METHODS

A review of retrospective and prospective clinical studies was performed to assess the risks of axillary lymph node involvement and the effectiveness and morbidity of various treatment options.

RESULTS

The risk of axillary lymph node involvement is substantial for most patients, even those with small tumors. The morbidity resulting from a careful Level I/II axillary dissection or moderate-dose axillary radiotherapy is limited. Such treatment is highly effective in preventing axillary recurrence. The symptoms resulting from axillary failure can be controlled in many, but not all, patients. The available data suggest, but do not prove, that the initial use of effective axillary treatment may result in a small improvement in long term outcome in some patient subgroups.

CONCLUSIONS

Most patients should be treated with either axillary surgery or irradiation. Highly selected subgroups of patients may have such low risks of involvement that specific axillary treatment is of little value. However, such subgroups have not yet been well defined. Treatment approaches that do not involve specific axillary treatment should be considered investigational at present, and the patients should be informed as to their potential risks. Prospective clinical studies of these issues should be pursued.

Identification of the aberrant hepatic artery with axial spiral CT

PURPOSE

To determine whether axial spiral computed tomography (CT) allows detection of the replaced hepatic artery as part of preoperative planning for pancreatic tumor resection.

MATERIALS AND METHODS

Axial spiral CT scans (8-mm section thickness, 4-mm overlapping reconstructions) were obtained in 50 patients with periampullary tumor and were examined by three radiologists. Readers' interpretations were compared with angiographic results.

RESULTS

Eight patients had an aberrant hepatic artery. Two of the three readers detected or suspected all of these abnormalities (100% sensitivity), and one reader identified seven of eight aberrant arteries (88% sensitivity). However, readers requested angiographic confirmation in 14 of 24 tests. Sensitivity, specificity, and accuracy were 96%, 87%, and 88%, respectively, for all readers.

CONCLUSION

Axial spiral CT may simplify preoperative evaluation of periampullary tumors. However, angiographic support was necessary in most cases in this study. Improvements in CT techniques may eventually allow spiral CT to replace angiography in the examination of these patients.

Clinical behavior and prognostic factors of periampullary adenocarcinoma

OBJECTIVE

The authors evaluated the outcome and potential prognostic factors of 60 patients with surgically resected periampullary tumors.

SUMMARY BACKGROUND DATA

Periampullary carcinomas exhibit different clinical behaviors according to their site of origin. There are no prognostic factors for deciding the type of surgery to be used or for choosing patients with tumors that have a poor prognosis for adjuvant treatment.

METHODS

A retrospective review was performed of 15 clinical and pathologic variables encountered among 60 patients with periampullary tumors. Tumors were divided into four groups according to their site of origin. Kaplan-Meier survival curves of the four groups were plotted and differences were evaluated with the log-rank test. Cox's proportional hazards model was used to test for separate and combined independent predictors of disease-free survival.

RESULTS

Twenty-nine ampullary carcinomas, 20 ductal pancreatic carcinomas, 7 distal common bile duct carcinomas, and 4 carcinomas of the periampullary duodenum were found. Five-year disease-free survival was 43%, 0%, 0%, and 75%, respectively. According to the Cox analysis, absence of neural invasion and use of adjuvant chemotherapy were significant factors for longer survival of patients with ampullary tumors. Lymphatic invasion was related to a shorter survival in patients with pancreatic carcinoma.

CONCLUSIONS

Five-year disease-free survival of patients with periampullary tumors is related to tumor type. Prognosis was better for ampullary tumors if neural invasion was absent and if adjuvant chemotherapy was used. Lymphatic invasion was associated with a shorter recurrence-free survival among patients with pancreatic carcinoma.

Diagnosis and staging of pancreatic neoplasms

The relative value of current approaches to the diagnosis and staging of pancreatic cancer is discussed. A rational sequence of testing is recommended based on the clinical presentation of the patient and the local institutional expertise and facilities that are available.

Long-term survival following pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas

Survival following pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas has clearly improved over the past several decades. Evidence from the Johns Hopkins Hospital series indicates that it has continued to improve from the 1970s to the 1980s to the 1990s. The reasons for this improvement are multiple. Between the 1970s and 1980s a decrease in operative and hospital mortality clearly played an important role. In addition, the markedly decreased number of blood transfusions given during pancreaticoduodenectomy in the 1980s probably contributed to the improvement in long-term survival. Positive resection margins were more common in the 1970s than in the 1980s and 1990s, and that probably played a major role. It is unlikely, however, that any of these factors played a role in the improvement in survival between the 1980s and 1990s. Perhaps the increasing use of adjuvant therapy is primarily responsible for the most recent improvement. Whatever the reasons, more patients are surviving pancreaticoduodenectomy, and among those patients who survive the operation, more people are surviving for prolonged periods. It is clear that we now have an effective operation for patients with adenocarcinoma of the head of the pancreas who are detected early, prior to lymph node spread. If we can find a tumor marker that allows us to identify more patients prior to nodal spread, substantial improvement in survival will accrue. In addition, better adjuvant therapy is needed, as the adjuvant regimens used today, which clearly prolong survival, almost certainly can be improved upon.

Surgical palliation of unresectable pancreatic carcinoma

The decision to perform surgical versus nonoperative palliation for unresectable pancreatic cancer is influenced by a number of factors. In most cases, patient symptoms clearly dictate the management. In patients with symptoms of duodenal obstruction at the time of presentation, surgery is the only option. In patients with obstructive jaundice alone, the options for management must be weighed against factors such as overall health status, projected survival, and procedure-related morbidity and mortality. A prospective multicenter trial recently analyzed factors influencing perioperative morbidity and mortality following both curative and palliative surgery for pancreatic cancer. This analysis demonstrated that preoperative diabetes, low Kanofsky's index, and liver metastases are significant risk factors in predicting perioperative morbidity and mortality in patients undergoing palliative procedures for pancreatic cancer. Another analysis focusing on tumor characteristics suggested that for patients with Stage I and Stage II disease (i.e., with no evidence of systemic metastases), survival and the potential for late duodenal obstruction favor surgical management. In summary, although patient management must be individualized, most patients with pancreatic cancer in good medical health and with no evidence of systemic disease are most appropriately managed with surgical palliation. This option affords patients the best chance of avoiding the late complications of recurrent jaundice, duodenal obstruction, and disabling pain. Surgical palliation can generally be completed with an acceptable perioperative morbidity and mortality and a hospital stay of approximately 2 weeks. Finally, only surgical exploration can offer full opportunity for resection for cure.

Curative treatment for pancreatic neoplasms. Standard resection

In the mid-1990s pancreatoduodenectomy can be performed at regional referral centers with an operative mortality of 1% to 2%. In addition, a number of centers around the world are now reporting 5-year survivals between 20% and 30% for patients with resected pancreatic cancer. In recent years a debate has continued as to the proper extent of resection for these patients, in part because numerous resective and reconstructive options are available. In broad terms, operations can be categorized as "standard" or "radical." In general, standard operations tend to have lower postoperative morbidity and mortality. Multiple factors influence postoperative survival, including intraoperative blood loss, perioperative transfusions, type of operation, hospital mortality, tumor biology, and adjuvant therapy. Among these parameters, tumor biology is the most important by multivariate analysis. Recent data suggest that the quality of survival is better with standard operations and best with the pylorus-preserving pancreatoduodenectomy. Nevertheless, debate will continue about the proper extent of resection until a well-controlled randomized trial has addressed this issue.

A search for prognostic factors in cancer of the pancreatic head: the significance of the DNA ploidy pattern

Using flow cytometry after the nuclear isolation and staining of tissue specimens, the significance of the DNA ploidy pattern as a prognostic factor in cancers of the head of the pancreas has been evaluated in 33 patients who underwent a pancreatic cancer resection. In addition to the DNA ploidy pattern, the size of the tumour, regional lymph node involvement, the tumour's histopathological grade and the results of a curative resection were also evaluated as prognostic factors. The results of a univariate analysis revealed that the survival rate was significantly higher for patients with a diploid tumour (n = 20) than for patients with an aneuploid tumour (n = 13) (P < 0.001). Furthermore, survival rates were significantly better for patients with a T1 tumour than with a T2 or T3 tumour (P < 0.001), for patients without positive lymph node involvement than for those with positive lymph nodes (P < 0.001), for patients with well-differentiated adenocarcinomas (G1) than for those with moderately differentiated (G2) or poorly differentiated (G3) adenocarcinomas, and for patients who underwent a curative resection than for those who underwent a non-curative resection (P < 0.005). A multivariate analysis revealed significant prognostic differences in the DNA ploidy pattern (P < 0.001), the frequency of a curative resection (P < 0.001), regional lymph node involvement (P < 0.05), and in the tumour's histopathological grading (P < 0.05) but not its size. This study has found the DNA ploidy pattern to be the most significant prognostic factor (chi 2 value: 38.1).

Familial pancreatic cancer and the genetics of pancreatic cancer

In our current understanding of pancreatic carcinoma, these neoplasms can arise either sporadically or in familial clusters. Extensive chromosome abnormalities are frequent, as is loss of heterozygosity at loci known to contain the tumor suppressor genes DCC, p53, and MTS1. Although the genetic examination of all pancreatic cancers is important, the examination of familial cases is especially useful in that these allow the identification of uniform genetic alterations that are inherited through the germ line. Much additional work needs to be done before the genetic basis of pancreatic cancer is completely understood. Although our knowledge is limited, it is clear that genetic analyses can be used to establish the prognosis for a patient with pancreatic cancer and, it is hoped, will someday be used in the management, treatment, and detection of pancreatic cancer.

Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients

OBJECTIVE

This single-institution study examined the outcome after pancreaticoduodenectomy in patients with adenocarcinoma of the head of the pancreas.

SUMMARY OF BACKGROUND DATA

In recent years, pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas has been associated with decreased morbidity and mortality and, in some centers, 5-year survival rates in excess of 20%.

METHODS

Two hundred one patients with pathologically verified adenocarcinoma of the head of the pancreas undergoing pancreaticoduodenectomy at The Johns Hopkins Hospital between 1970 and 1994 were analyzed (the last 100 resections were performed between March 1991 and April 1994). This is the largest single-institution experience reported to date.

RESULTS

The overall postoperative in-hospital mortality rate was 5%, but has been 0.7% for the last 149 patients. The actuarial 5-year survival for all 201 patients was 21%, with a median survival of 15.5 months. There were 11 5-year survivors. Patients resected with negative margins (curative resections: n = 143) had an actuarial 5-year survival rate of 26%, with a median survival of 18 months, whereas those with positive margins (palliative resections; n = 58) fared significantly worse, with an actuarial 5-year survival rate of 8% and a median survival of 10 months (p < 0.0001). Survival has improved significantly from decade to decade (p < 0.002), with the 3-year actuarial survival of 14% in the 1970s, 21% in the 1980s, and 36% in the 1990s. Factors significantly favoring long-term survival by univariate analyses included tumor diameter < 3 cm, negative nodal status, diploid tumor DNA content, tumor S phase fraction < 18%, pylorus-preserving resection, < 800 mL intraoperative blood loss, < 2 units of blood transfused, negative resection margins, and use of postoperative adjuvant chemotherapy and radiation therapy. Multivariate analyses indicated the strongest predictors of long-term survival were diploid tumor DNA content, tumor diameter < 3 cm, negative nodal status, negative resection margins, and decade of resection.

CONCLUSIONS

The survival of patients with pancreatic adenocarcinoma treated by pancreaticoduodenectomy is improving. Aspects of tumor biology, such as DNA content, tumor diameter, nodal status and margin status, are the strongest predictors of outcome.

Resection of the pancreatic head with or without gastrectomy

Early and late results of proximal pancreatoduodenectomy were determined in a personal and consecutive series of 100 patients (64 men, 36 women, mean age 51.9 years). Final diagnoses were chronic pancreatitis in 35, idiopathic bile duct stricture in 1, carcinoma of the head of pancreas in 27, and other periampullary tumors in 37 (duodenal carcinoma 11, ampullary carcinoma 11, neuroendocrine tumor 10, cholangiocarcinoma 5). Mean follow-up period was 30.5 months (range 3.5-132.0 months). Resection was conventional (including distal gastrectomy) in 39 patients and conservative (retaining the stomach, pylorus, and duodenal cap) in 61 patients. Resection for inflammatory disease caused greater operative blood loss (mean 2.29 versus 1.75 L; p = 0.054) and a longer operative time (6.2 versus 5.2 hours; p = 0.040) than resection for neoplastic disease. There were four operative deaths, two from leakage of the pancreatic anastomosis; another two patients survived pancreatojejunostomy leaks. Twenty patients developed postoperative complications, seven of whom required reoperation. Good pain relief was obtained in 76% of patients with chronic pancreatitis, but five required completion distal pancreatectomy at a mean 22.8 months after the first resection. Mean survival of patients with pancreatic cancer was 13.2 months. Sixteen patients with other periampullary cancers are still alive 41.6 months after the operation.

Acute-phase protein response and survival duration of patients with pancreatic cancer

BACKGROUND

Current methods to predict survival duration of patients with pancreatic cancer are limited. The aim of this study was to determine whether certain nutritional indices and the acute-phase protein response are prognostic factors independent of disease stage for patients with unresectable pancreatic cancer.

METHODS

Variables at the time of diagnosis of 102 patients with unresectable pancreatic cancer were entered into a Cox's proportional hazards model. Included in the analysis were the serum concentration of C-reactive protein (CRP) and albumin, the extent of weight loss, age, sex, and disease stage (International Union Against Cancer criteria).

RESULTS

A multivariate analysis in which each factor was adjusted for the influence of the other factors revealed the patient age, disease stage, serum albumin, and serum CRP to be independent predictors of survival. The presence of an acute-phase protein response was the most significant independent predictors of survival duration. The median survival of those with an acute-phase protein response (CRP > 10 mg/L, n = 45) was 66 days compared with 222 days for those with no acute-phase protein response (n = 57, P = 0.001, Mann-Whitney U test).

CONCLUSION

The acute-phase protein response is a useful prognostic indicator for patients with unresectable pancreatic cancer. Moreover, the metabolic disturbances associated with an acute-phase protein response of patients with pancreatic cancer may be a worthwhile therapeutic target.

Carcinoma of the pancreatic head and periampullary region. Tumor staging with laparoscopy and laparoscopic ultrasonography

OBJECTIVE

The authors performed a prospective evaluation of staging laparoscopy with laparoscopic ultrasonography in predicting surgical resectability in patients with carcinomas of the pancreatic head and periampullary region.

SUMMARY BACKGROUND DATA

Pancreatic resection with curative intent is possible in a select minority of patients who have carcinomas of the pancreatic head and periampullary region. Patient selection is important to plan appropriate therapy and avoid unnecessary laparotomy in patients with unresectable disease. Laparoscopic ultrasonography is a novel technique that combines the proven benefits of staging laparoscopy with high resolution intraoperative ultrasound of the liver and pancreas, but which has yet to be evaluated critically in the staging of pancreatic malignancy.

METHODS

A cohort of 40 consecutive patients referred to a tertiary referral center and with a diagnosis of potentially resectable pancreatic or periampullary cancer underwent staging laparoscopy with laparoscopic ultrasonography. The diagnostic accuracy of staging laparoscopy alone and in conjunction with laparoscopic ultrasonography was evaluated in predicting tumor resectability (absence of peritoneal or liver metastases; absence of malignant regional lymphadenopathy; tumor confined to pancreatic head or periampullary region).

RESULTS

"Occult" metastatic lesions were demonstrated by staging laparoscopy in 14 patients (35%). Laparoscopic ultrasonography demonstrated factors confirming unresectable tumor in 23 patients (59%), provided staging information in addition to that of laparoscopy alone in 20 patients (53%), and changed the decision regarding tumor resectability in 10 patients (25%). Staging laparoscopy with laparoscopic ultrasonography was more specific and accurate in predicting tumor resectability than laparoscopy alone (88% and 89% versus 50% and 65%, respectively).

CONCLUSIONS

Staging laparoscopy is indispensable in the detection of "occult" intra-abdominal metastases. Laparoscopic ultrasonography improves the accuracy of laparoscopic staging in patients with potentially resectable pancreatic and periampullary carcinomas.

Current management of pancreatic carcinoma

OBJECTIVE

The author seeks to provide an update on the current management of pancreatic carcinoma, including diagnosis and staging, surgical resection and adjuvant therapy for curative intent, and palliation.

SUMMARY BACKGROUND DATA

During the 1960s and 1970s, the operative mortality and long-term survival after pancreaticoduodenectomy for pancreatic carcinoma was so poor that some authors advocated abandoning the procedure. Several recent series have reported a marked improvement in perioperative results with 5-year survival in excess of 20%. Significant advances also have been made in areas of preoperative evaluation and palliation for advanced disease.

CONCLUSION

Although carcinoma of the pancreas remains a disease with a poor prognosis, advances in the last decade have led to improvements in the overall management of this disease. Resection for curative intent currently should be accomplished with minimal perioperative mortality. Surgical palliation also may provide the optimal management of selected patients.

Overexpression of HER2/neu oncogene in pancreatic cancer correlates with shortened survival

For the purpose of determining the prognostic significance of HER2/neu oncogene in pancreatic and ampullary cancers, 21 pancreatic cancers of ductal origin and six cancers of the ampulla of Vater were studied immunohistochemically using the monoclonal antibody (MAb) CB11, specifically reactive with HER2/neu product. Staining of the epithelium of the normal duct and acini was negative or weakly positive. Moderately and strongly positive reactions indicated the overexpression of this gene, and were found in 10 of 21 (47.6%) pancreatic cancers of ductal origin and in 2 of 6 (33.3%) ampullary adenocarcinomas. Overexpression of HER2/neu was closely and inversely related to the survival of the patients with pancreatic cancer of ductal origin: 19.1 +/- 11.7 mo for those not overexpressing vs 7.3 +/- 3.8 mo for the overexpressors (p < 0.01). Among the pancreatic cancer group, 11 patients underwent cancer resection. The average survival for the 7 with nonoverexpressing cancer was 21.4 +/- 14.3 mo vs 10.5 +/- 3.6 mo for those with overexpressing tumor. Among those not undergoing resection, the average survival for the 4 with nonoverexpressing cancer was 15.0 +/- 3.8 mo as contrasted to 5.2 +/- 2.1 mo for the overexpressors (p < 0.01). Although the number of patients is small, these findings suggest that the overexpression of HER2/neu gene product may be frequently found in pancreatic cancer of ductal origin and may be one of the useful prognostic biomarkers for this cancer.

Management of pancreatic carcinoma

Pancreatic cancer is the fifth-leading cause of cancer death in the United States. It is estimated that 27,000 patients die each year with this diagnosis. The overall five-year survival of patients with pancreatic cancer remains less than 5%, but some subsets of patients may have a better prognosis. Advanced imaging and laparoscopy have improved staging to better select patients for potentially curative surgery, while the operative morbidity and mortality of the Whipple resection have decreased in recent years. Non-surgical therapies in current use include chemotherapy, external-beam radiation therapy, and brachytherapy, as well as pain management. More recently, gene insertion therapy has shown promise in animal models. This review discusses current diagnostic and treatment strategies for these patients and documents the need for new strategies in the future.

Comparative DNA analysis by image cytometry and flow cytometry in non-small cell lung cancer

To determine whether image cytometry (ICM) is advantageous for clinical DNA analyses of tumor cells, nuclear DNA contents measured by ICM were compared with those by flow cytometry (FCM), using 46 samples of non-small cell lung cancers. ICM was performed on smear specimens of fresh materials (f-ICM) and cell suspensions obtained from paraffin-embedded tumors (p-ICM). The same cell suspensions were also analyzed by FCM (p-FCM). Aneuploid rates/coefficient of variation (CV) of f-ICM, p-ICM, and p-FCM were 76.1/4.90, 71.7/5.01 and 60.9/5.31%, respectively. There was a high correlation in the DNA indices between p-ICM and p-FCM (r = 0.80). In the comparative DNA analysis, there were seven discordant samples. Six of them were estimated as aneuploid by p-ICM, but they were miscounted as diploid or undefinable (impossible) by p-FCM. This was caused by measuring condensed nuclei or debris. All "impossible" samples in p-FCM were squamous cell carcinoma with necrosis. In cell cycle analysis, the S and S+G2/M phase fractions in diploid samples were higher in p-ICM than those in p-FCM (P < 0.005), because the G0/G1 phase (2N) fraction presented by FCM was composed of cancer and non-malignant cells in diploid cancers. In ICM, they can be separately measured by means of morphological selection. These findings indicated that ICM is superior to FCM, especially for the practical DNA measurement of a few cancer cells and in the evaluation of the proliferation rates.

Radiotherapy and the management of the axilla in early breast cancer

The role of radiotherapy in the management of the axilla in early breast cancer is examined. A few, carefully selected, clinically node-negative postmenopausal women may require no intervention to the axilla. Otherwise, surgical clearance is the preferred sole management of the axilla, resulting in an excellent level of local control and providing optimal information for the use of systemic adjuvant therapy. Axillary radiotherapy can also provide equivalent levels of long-term control in the clinically node-negative axilla, but the chronic disabling syndrome of brachial plexopathy is documented at all radiation doses that can sterilize microscopic disease, irrespective of the radiotherapy technique. A combination of radiotherapy and axillary surgery results in an increased morbidity rate compared with either alone. Women who receive radiotherapy to the breast alone are not at risk of brachial plexopathy.

Preoperative chemoradiation for adenocarcinoma of the pancreas and duodenum

PURPOSE

This study was designed to evaluate the effects of preoperative chemoradiation on resectability, response, local control, and survival in patients with local or local-regional involvement from carcinoma of the pancreas or cancer of the duodenum and to assess the associated toxicity of such treatment.

METHODS AND MATERIALS

This prospective pilot study of preoperative chemoradiation was initiated in 1986 for patients with clinical evidence of adenocarcinoma of the pancreas or duodenum without evidence of distant metastases. Radiation was given at 1.8 Gy per day to a total dose of 50.4 Gy. Two cycles of chemotherapy were given concurrent with radiation. On days 2-5 and 29-32, 5-fluorouracil (1 gm/m2/24 h x 4 days) was given, while mitomycin-C (10 mg/m2) was given on day 2 only. Surgical resection was 4-6 weeks following completion of chemoradiation. Thirty-one patients (17 male and 14 female) were entered on the protocol with a median potential follow-up of 4.5 years (range 6 months to 7.5 years). The median age was 64 years (range 32-73 years). Twenty-seven patients had pancreatic cancer (25 head, two body), while four patients had carcinoma arising from the duodenum. Twenty-one patients were initially judged to be unresectable and ten potentially resectable prior to chemoradiation.

RESULTS

Twenty-nine of 31 patients completed the entire course of radiation and both cycles of chemotherapy. Acute toxicity from chemoradiation consisted of nausea, vomiting, diarrhea, stomatitis, or hematologic suppression which was moderate to severe (Grade 3 or 4) in seven patients (23%). One patient died of sepsis following the first week of therapy. Seventeen patients (55%) underwent curative resection with subtotal or total pancreatectomy or Whipple resection (four duodenum, 13 pancreas) and two (2/17) had pathologic nodal involvement, while (0/17) none had involved margins. A complete pathologic response was seen in all four (4/4) patients with duodenal cancer and in none (0/13) with pancreatic cancer who underwent resection. The median postoperative hospitalization stay was 22 days (range 4-144 days). Of 17 patients who underwent curative resection, there were two postoperative mortalities (12%). Late complications have included abscess, one; and nonmalignant ascites, five. Ten of the 31 patients are alive. For patients with pancreatic cancer the median survival is 9 months, while survival at 1 year and 3 years are 36% and 19% overall and 60% and 43% at 1 and 3 years for those undergoing resection. Six of the 27 patients (22%) with pancreatic cancer are alive without recurrence. All four patients with duodenal cancer are alive without recurrence (12 months, 23 months, 35 months, 90 months).

CONCLUSION

Preoperative chemoradiation for cancer of the pancreas and duodenal region was relatively well-tolerated and enhanced resectability and downstaging of nodal metastases were suggested. The 3-year survival, particularly in patients who underwent resection, was high. For these reasons the applicability of this treatment regimen for pancreatic cancer is presently being studied in a group-wide multi-institutional Phase II trial. Chemoradiation for duodenal cancer has produced a complete pathologic response in all patients and survival has been excellent, suggesting efficacy of this regimen for duodenal cancer.

The human Ha-ras oncogene induces genomic instability in murine fibroblasts within one cell cycle

Many human tumors contain an activating mutation in one of the ras protooncogenes. Additionally, these tumor cells are often heteroploid and characterized by chromosome breaks and rearrangements that are consequences of the genomic instability that is thought to contribute to tumor progression. The concurrence of ras mutations and genomic instability in tumors prompted us to ask whether selective induction of an activated Ha-ras gene could render a genome unstable. The NIH 3T3 cells used in this study contained mutant p53 genes and carried a selectively inducible activated (EJ) Ha-ras transgene under the control of bacterial lactose regulatory elements. When stably transfected cells were induced to express activated Ha-ras by isopropyl beta-D-thiogalactoside administration, there was a marked increase in the number of gross chromosomal aberrations including acentric fragments, multicentric chromosomes, and double minutes, which occurred within the time frame of a single cell cycle from the time of induction. To confirm that these aberrations occurred within the first cell cycle after mutant Ha-ras induction, the cells were arrested in G1 phase by serum depletion and, subsequently, released by administration of isopropyl beta-D-thiogalactoside or serum. The mitoses from cells released with isopropyl beta-D-thiogalactoside contained a 3-fold elevation in the fraction of chromosomes containing aberrations compared to mitoses from parallel cell cultures that were released with serum. Thus, the induction of activated Ha-ras gene expression in these cells results in genomic instability that can be detected as aberrant chromosomes at the next mitosis.

Chromosome abnormalities in pancreatic adenocarcinoma

Adenocarcinoma of the pancreas is the fifth most common cause of cancer deaths in the United States, yet few cytogenetic studies of this tumor have been reported. We analyzed 26 primary tumors to identify which chromosome abnormalities occur most frequently in this neoplasm. One carcinoma was well differentiated and mucin producing, 18 were moderately well differentiated, and seven were poorly differentiated. Only normal karyotypes were obtained from nine carcinomas. The remaining 17 carcinomas frequently had normal metaphase cells in addition to simple to highly complex karyotypes. The modal chromosome number in 20 carcinomas was diploid or near-diploid; four carcinomas had both a major near-diploid and near-triploid or near-tetraploid component, and two were near-tetraploid. Numerical abnormalities included loss of whole copies of chromosomes 6, 17, and 18, and gains of chromosome 20. Structural abnormalities were frequent, with 1p, 2p, 3p, 4q, 6q, 7q, 11q, and 17p recurrently involved. Results of this study were combined with karyotypes of 19 other primary adenocarcinomas of the pancreas reported in the literature. The combined data involving 117 breakpoints suggest that careful analysis of chromosome 20, proximal 1q, 6q, proximal 8p, and proximal 17p could be productive in defining genes involved in adenocarcinoma of the pancreas.

Prediction of axillary lymph node metastases in a screened breast cancer population. South-East Sweden Breast Cancer Group

To define a subgroup of patients, in whom axillary dissection could be omitted, we analysed the frequency of pathologically confirmed lymph node metastases depending on tumour size, hormonal receptors, DNA ploidy, S-phase fraction (SPF), and clinical nodal status among 1,145 patients with stage I-II breast cancer from an area with ongoing screening. Clinical nodal status and tumour size were strongly correlated to pathological nodal status. Also SPF > 10% was strongly correlated to node positivity in univariate analysis. In multivariate analysis there was still a significant correlation among cases with tumour size < or = 20 mm. In conclusion, patients with clinically negative nodal status, and tumour size < or = 20 mm and < or = 10 mm had pathologically positive nodes in 25% and 15% of cases respectively. The addition of SPF did not lower these figures significantly since small tumours with high SPF are few.

Factors influencing survival after resection of pancreatic cancer. A DNA analysis and a histomorphologic study

BACKGROUND

The influence of DNA content on prognosis in stomach cancer has been investigated rarely, and the results are controversial.

METHOD

The prognostic relevance of the DNA content and histomorphologic parameters was evaluated in 41 patients after resection of pancreatic cancer.

RESULTS

In the univariate analysis, the DNA content, tumor size, lymph node status, tumor stage, nuclear grade, and type of resection had a statistically significant influence on the prognosis. No association was found between the DNA content and the histomorphologic features. Apart from the operative procedure, the DNA content was the strongest indicator of prognosis in the multivariate analysis.

CONCLUSIONS

Further investigations are necessary to find out if DNA analysis can be performed preoperatively on material obtained by fine-needle aspiration.

Discrepancies of DNA content of various solid tumours before and after culture measured by image analysis. Comparison of cytogenetical data

Parallel cytophotometric ploidy studies and cytogenetic analysis were performed on 15 various human solid tumours. The quantification of DNA by image analysis was carried out on cytological imprints of fresh tumours and on smears obtained after cell culture. The results obtained by both sets of calculations were compared with each other and with the cytogenetic results. 6 cases (40%) showed concordance between the 3 techniques. One case was aneuploid for both DNA image analysis measurements but the cytogenetic data showed only a diploid stem line. In 3 cases out of 15 (20%), smears DNA analysis and cytogenetic results were concordant: in 2 tumours, the culture step failed to preserve aneuploid stem lines that were present in the imprint analysis. In the third one, a minority tetraploid peak observed after culture was absent on the imprint slide. Concordance between imprints and cytogenetic data and discordance with smears' analysis was observed in 3 cases (20%). These 3 cases were diploid or near diploid but the DNA analysis on the smears after culture showed an aneuploid stem line in each case. The last 2 cases showed a total disagreement between the 3 techniques. By measuring the DNA content with an image analyser, the observer can ensure that only tumoral cells are taken into account. The present study revealed that cytogenetic data represent only about 60% of the population that is effectively present in the culture dish and that the cultured population represents only 47% of the population present on the fresh tumour imprint.

The role of selective visceral angiography in the management of pancreatic and periampullary cancer

A prospective study was undertaken to evaluate selective visceral angiography (SVA) in the management of patients with pancreatic and periampullary cancer. Over a 30-month period 52 patients with potentially resectable pancreatic or periampullary cancer underwent SVA; 4 patients had obvious angiographic evidence of widely disseminated disease and were not subjected to laparotomy while 2 further patients were eventually considered too frail for resection. The remaining 46 patients (median age 58 years, range 37-73 years, males 26, females 20) had no evidence of disseminated disease on ultrasonography and/or CT scanning and had both SVA and surgery and form the basis of this study. Vascular anomalies were detected in 16/46 (35%) patients. Hepatic metastases were wrongly diagnosed by angiography in 7 out of 9 patients (77%). SVA correctly predicted resectability or irresectability in 28/46 patients (overall predictive value 61%). Of the 27 patients who proved to have irresectable disease at operation, 11 were correctly identified by SVA (sensitivity 41%). Of the 13 patients reported to have irresectable disease, 2 underwent resection (false-positive rate 15%). Of the 33 patients reported to have resectable disease, 16 were irresectable (false-negative rate 48%). Overall there was a poor relationship between resectability and the angiographic features. On the basis of these data, SVA cannot be considered a sufficiently accurate means of assessing resectability. Its use for this purpose in patients with pancreatic and periampullary cancer is not justified.

Neoadjuvant chemoradiation in pancreatic and duodenal carcinoma. A Phase II Study

BACKGROUND

Low resectability rate and high locoregional recurrence are major factors contributing to the failure of surgical treatment for localized pancreatic adenocarcinoma. A Phase II study involving preoperative 5-fluorouracil (5-FU) and mitomycin C and radiation therapy was evaluated.

METHODS

Thirty-one patients with biopsy-proven carcinoma (24, head of pancreas; 2, body; 5 duodenum) were treated with preoperative radiation therapy, 5040 cGy (180 cGy/fraction, 5 days/week), concurrent with 5-FU, 1000 mg/m2/day continuous infusion (days 2-5, 28-32) and mitomycin C 10 mg/m2 bolus (day 2). Ten patients had previous laparotomy or bypass surgery and were deemed unresectable; 21 had percutaneous, endoscopic retrograde choleangiopancreatic, or transhepatic stent biopsies.

RESULTS

Toxicity included neutropenic fever (2 patients), biliary sepsis (2 patients), and nausea and vomiting requiring total parenteral nutrition. One patient died of biliary sepsis before completion of chemoradiation and 11 patients showed evidence of metastatic disease (clinical or occult). Resectability rate was 38% (10/26) for pancreatic carcinoma and 80% (4/5) for duodenal carcinoma. Pathology of the resected specimens revealed extensive necrosis and hyalinization with clear margins in all cases. Lymph node metastases were found in one case of pancreatic carcinoma. The four resected duodenal carcinomas contained no residual tumor in the specimens. At a median follow-up of 29 months, the median survival time for those with pancreatic carcinoma was not yet reached in the resection group and was 8 months in the nonresection group. The corresponding actuarial 5-year survival rates were 58% and 0%, respectively.

CONCLUSIONS

Neoadjuvant chemoradiation therapy was given safely to patients with pancreatic and duodenal carcinoma. It facilitated complete resection in 38% of patients with pancreatic carcinoma and 80% of those with duodenal carcinoma. A significant downstaging of positive margins and regional lymph nodes occurs as a result of preoperative chemoradiation.

K-ras oncogene activation in adenocarcinoma of the human pancreas. A study of 82 carcinomas using a combination of mutant-enriched polymerase chain reaction analysis and allele-specific oligonucleotide hybridization

We examined 82 surgically resected or biopsied, formalin-fixed, paraffin-embedded primary adenocarcinomas of the pancreas for the presence of activating point mutations in codon 12 of the K-ras oncogene. Mutations were detected using primer-mediated, mutant-enriched, polymerase chain reaction-restriction fragment length polymorphism analysis and characterized further by allele-specific oligonucleotide hybridization. This combination of mutant-enriched polymerase chain reaction-restriction fragment length polymorphism analysis and allele-specific oligonucleotide hybridization results in a rapid and sensitive characterization of the mutations in codon 12 of K-ras. Sixty-eight (83%) of the 82 carcinomas examined harbored a point mutation. Of the 68 mutations, 33 (49%) were guanine to adenine transitions, 27 (39%) were guanine to thymine transversions, and eight (12%) were guanine to cytosine transversions. Mutations were found in carcinomas of the head (61 of 75, 81%) as well as in carcinomas of the body or tail (seven of seven, 100%) of the pancreas. The overall prevalence of K-ras point mutations in adenocarcinomas of the pancreas obtained from patients who smoked cigarettes at some point during their lives (88%; 86% in current smokers and 89% in ex-smokers) was greater than that seen in pancreatic adenocarcinomas from patients who never smoked cigarettes (68%, P = 0.046). The presence of K-ras point mutations did not correlate with tumor ploidy, tumor proliferating index, or patient survival. These results demonstrate that primer-mediated, mutant-enriched polymerase chain reaction-restriction fragment length polymorphism analysis combined with allele-specific oligonucleotide hybridization can be used to detect and characterize mutations in codon 12 of the K-ras oncogene in formalin-fixed, paraffin-embedded tissues, and the results confirm that activating point mutations in codon 12 of the K-ras oncogene occur frequently in adenocarcinomas of the pancreas.

DNA ploidy as a major prognostic factor in resectable ampulla of Vater cancers

The archival paraffin-embedded specimens from 63 ampulla of Vater cancers after pancreaticoduodenectomy between 1965 and 1991 were analyzed by flow cytometry. Of the 63 cancers, 31 (49.2%) were diploid DNA cancers and 32 (50.8%) were aneuploid. Patients with diploid DNA cancer had a median survival time of 159.0 months, and patients with aneuploid DNA cancer had 24.0 months. This difference is statistically significant (P = 0.0257). The aneuploid group did have a poorer prognosis than the diploid group. The multivariate analysis demonstrated that DNA ploidy was an independent and very important prognostic factor, even stronger than the stage and lymph node status. There was a tendency toward higher values of S-phase fraction, proliferative index, and total aneuploid DNA fraction in the shorter survival groups, but they were of no statistical significance. These data suggest that DNA ploidy appears to be the most important and the only pre-operative predictor of prognosis in resectable ampulla of Vater cancers since endoscopic biopsy is feasible.

Nuclear DNA content as a prognostic predictor in carcinoma of the pancreas

Eighty-six patients with carcinoma of the pancreas were studied retrospectively. Paraffin-embedded specimens and flow cytometry were used to evaluate the accuracy of the measurement of nuclear DNA as a predictor of the postoperative prognosis. From the series of 86 patients, 72 with a diagnosis of tubular adenocarcinoma (Japanese classification) were selected, and their DNA ploidy pattern and clinical and pathological features were correlated; 52.3% of the 86 patients and 52.8% of the 72 tubular adenocarcinoma patients showed DNA aneuploidy. Histological examinations of the tubular adenocarcinomas showed 42.9% DNA aneuploidy in well differentiated, 56.8% in moderately differentiated, and 71.4% in poorly differentiated types. The DNA ploidy showed a statistically significant positive correlation with the T category. The presence or absence of retroperitoneal invasion was thought to be the most important prognostic factor. Cumulative survival rates showed that the prognosis for patients with retroperitoneal invasion and DNA aneuploidy was significantly worse than for those with DNA diploidy or those without retroperitoneal invasion.

Evidence for altered cell-cycle traverse of the non-modal cells of the heteroploid MCa-11 line

Classic stem cell theory states that the growth of heteroploid cell populations is due to the proliferation of 'main stemline' cells with modal DNA content and chromosome number. Cells with non-modal DNA content and chromosome number are thought to be blocked and/or destroyed at mitosis. To test this, we studied two chromosomally stable cell populations (mouse bone marrow and WCHE-5 cells) and one heteroploid, chromosomally diverse cell line (MCa-11). The heteroploid MCa-11 cells showed significant [3H]dT labelling for cells with DNA contents below the modal G0/G1 peak and above the modal G2 peaks (P < 0.001). This was consistent with the presence of cells with the non-modal DNA content that were engaged in replicative DNA synthesis. A percentage labelled mitosis analysis showed that MCa-11 cells with non-modal DNA content and chromosome number were able to complete mitosis, although with prolonged pre-karyokinetic time. These results suggest that many non-modal cells present in heteroploid cell populations are capable of continued proliferation.

Expression of argyrophilic nucleolar organizer regions in ductal adenocarcinoma of the pancreas and its relationship to prognosis

The aim of the present study was to investigate the relationship between Ag-NOR count levels and survival in 33 patients undergoing resection for ductal adenocarcinoma of the pancreas at Kanazawa University Hospital from 1985 to 1991. To determine the biologic behavior of invasive ductal adenocarcinoma of the pancreas, 33 tumors were classified into two groups according to the median value of Ag-NOR counts: Group 1, Ag-NOR count > or = 3.25 (higher Ag-NOR count group); Group 2, Ag-NOR count < 3.25 (lower Ag-NOR count group). As a result, we found that tumors with a higher Ag-NOR count were more likely to have liver or peritoneal metastasis than those with a lower Ag-NOR count, although the differences were not statistically significant. Tumors with lower Ag-NOR count levels were associated with favorable prognoses 2 and 3 yr after surgery, whereas those with higher Ag-NOR count levels were related to poor prognosis. Our results indicate that a Ag-NOR count level is a reliable prognostic parameter in resected pancreatic ductal adenocarcinoma.

Diagnosis and staging of pancreatic adenocarcinoma with dynamic computed tomography

We assessed the accuracy of dynamic contrast-enhanced computed tomography (CT) in the diagnosis and staging of 213 patients with pancreatic carcinoma and compared it with the accuracy of angiography and surgery. A correct CT diagnosis of pancreatic carcinoma was made in 207 of 213 (97%) patients. Tumors were located in the pancreatic head in 64%, the body in 22%, and the tail in 10%, and enlarged the pancreas diffusely in 4%. CT staged 25 (12%) patients as having potentially resectable tumors and 188 (88%) as having unresectable tumors on the basis of local extension (72%), contiguous organ invasion (43%), vascular invasion (82%), and distant metastases (50%). Compared with angiography in 60 patients, CT detected vascular invasion missed on angiography in 20%, and angiography detected invasion missed by CT in 5%. In these latter cases, other CT criteria of unresectability were present, and angiography provided no significant staging information. Compared with surgery in 71 patients, CT accurately predicted unresectable tumors in 100% of patients and resectable tumors in 72% of patients. Eleven of the patients with CT-resectable tumors underwent resection. Median survival was 22.7 months, with four patients alive at a median of 15.5 months postoperatively. Palliative resections were performed in six patients, and median survival was 14.4 months.

Preoperative visceral angiography alters intraoperative strategy during the Whipple procedure

To determine the importance of preoperative visceral angiography prior to pancreaticoduodenectomy, all Whipple procedures performed between 1985 and 1991 at the Virginia Mason Medical Center were retrospectively reviewed. During this period, 77 pancreaticoduodenectomies were performed for both neoplastic disease (n = 54, 70%) and chronic pancreatitis (n = 23, 30%). Sixty-four preoperative angiograms were obtained, of which 39 (61%) were abnormal findings. Thirty percent (19 of 64) of the angiograms revealed a significant vascular abnormality that required specific preoperative or intraoperative measures that might not have been performed without knowledge of these findings. Examples include celiac axis revascularization for celiac occlusion, hepatic artery preservation for replaced vessels, preoperative embolization for pseudoaneurysm or arteriovenous fistula, and splenectomy for splenic vein thrombosis. Because of the high percentage of significant findings requiring an intraoperative or preoperative technical change, we recommend the use of angiography in order to diminish morbidity in all patients preparing to undergo pancreaticoduodenectomy.

A comparison of flow cytometric and absorption cytometric DNA values as prognostic indicators for pancreatic carcinoma

BACKGROUND

The DNA content of 30 adenocarcinomas of the head of the pancreas was measured by flow and absorption cytometric analysis.

METHODS

Each of the patients in this study had curative pancreatoduodenectomy. The absorption cytometric measurements were done in a research laboratory, and the flow cytometric measurements were performed in a commercial laboratory. The DNA measurements were done on nuclei disaggregated from pancreatic cancer tissue blocks without the examiner knowing whether the patient had survived.

RESULTS

Twenty-one of the 30 cancers were found to be aneuploid by absorption cytometric analysis, whereas only 1 of the 30 cancers was aneuploid by flow cytometric analysis. This difference was statistically significant (P < 0.001).

CONCLUSIONS

Univariate and multivariate analyses showed that the absorption cytometric DNA measurements were stronger prognostic determinants for patient survival than were the flow cytometric DNA measurements, indicating that some caution may be warranted in the interpretation of commercially obtained DNA distributions of pancreatic carcinomas.

Prognostic indicators for survival after resection of pancreatic adenocarcinoma

From October 1983 to October 1990, 799 patients with the diagnosis of pancreatic adenocarcinoma were admitted to Memorial Sloan-Kettering Cancer Center, and their records were entered into a prospective database. Curative resection was possible in 146 patients (18%), with a 30-day operative mortality of 3.4%. Median follow-up of survivors in the resection group was 28 months. Actuarial 5-year survival in patients who did not undergo resection was 0% (n = 653), compared with 24% in the patients who had resection (p < 0.00001). Of 52 patients available for 5-year follow-up, 10 (19%) were alive at 5 years. Tumors with lymph node involvement, poor histologic tumor differentiation, and tumor size greater than 2.5 cm were predictors of a significantly worse survival in both univariate and multivariate analysis. Other factors, including blood transfusion, blood loss, and operative time, had no significant effect on survival. The majority of patients with pancreatic adenocarcinoma have unresectable disease with a poor prognosis. For patients who undergo curative resection, their prognosis appears to be determined by the biology of the tumor rather than factors involved in the resection.

Preoperative indications for extended pancreatectomy for locally advanced pancreas cancer involving the portal vein

This retrospective study attempted to determine the indications for extended pancreatectomy for locally advanced carcinoma of the pancreas, in terms of postoperative prognosis. An extended pancreatectomy with portal vein or superior mesenteric vein (PV/SMV) resection and regional lymphadenectomy was performed in 35 of 50 consecutive cancers that extended into the retroperitoneal spaces and involved the PV or SMV. Among the many background factors in the 35 resected specimens, the degree of PV/SMV invasion by the cancer was most closely associated with prognosis, despite resection of all involved PV/SMV. This factor generally correlated with the preoperative findings on the portal phase of superior mesenteric arteriograph. In 17 selected patients in whom PV/SMV invasion had been angiographically both semicircular or less and 1.2 cm (1.4 cm on the film) or less in length, the 3-year survival rate was 59%. This survival rate was significantly higher than the 29% 3-year survival rate in all 35 patients (p less than 0.05). Conversely, among the 18 patients in whom invasion was angiographically either beyond semicircular or more than 1.2 cm (1.4 cm on the film) in length, there were no 1.5-year survivors, and this result was even worse than that of 15 nonresectable cases. Based on postoperative survival, the degrees of PV/SMV invasion on preoperative angiography (narrowing pattern and length) are good indicators for aggressive pancreatectomy for locally advanced pancreatic cancer.