Association between tumour angiogenesis and tumour cell shedding into effluent venous blood during breast cancer surgery

Radiofrequency ablation induces tumor cell dissemination in a mouse model of hepatocellular carcinoma

BACKGROUND

We tested the hypothesis that radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) promotes tumor cell release and explored a method for reducing these effects.

METHODS

A green fluorescent protein-transfected orthotopic HCC model was established in 99 nude mice. In vivo flow cytometry was used to monitor circulating tumor cell (CTC) dynamics. Pulmonary fluorescence imaging and pathology were performed to investigate lung metastases. First, the kinetics of CTCs during the periablation period and the survival rate of CTCs released during RFA were investigated. Next, mice were allocated to controls, sham ablation, or RFA with/without hepatic vessel blocking (ligation of the portal triads) for evaluating the postablation CTC level, lung metastases, and survival over time. Moreover, the kinetics of CTCs, lung metastases, and mice survival were evaluated for RFA with/without ethanol injection. Pathological changes in tumors and surrounding parenchyma after ethanol injection were noted. Statistical analysis included t-test, ANOVA, and Kaplan-Meier survival curves.

RESULTS

CTC counts were 12.3-fold increased during RFA, and 73.7% of RFA-induced CTCs were viable. Pre-RFA hepatic vessel blocking prevented the increase of peripheral CTCs, reduced the number of lung metastases, and prolonged survival (all p ≤ 0.05). Similarly, pre-RFA ethanol injection remarkably decreased CTC release during RFA and further decreased lung metastases with extended survival (all p ≤ 0.05). Histopathology revealed thrombus formation in blood vessels after ethanol injection, which may clog tumor cell dissemination during RFA.

CONCLUSION

RFA induces viable tumor cell dissemination, and pre-RFA ethanol injection may provide a prophylactic strategy to reduce this underestimated effect.

RELEVANCE STATEMENT

RFA for HCC promotes viable tumor cell release during ablation, while ethanol injection can prevent RFA induced tumor cell release.

KEY POINTS

• RFA induced the release of viable tumor cells during the ablation procedure in an animal model. • Hepatic vessel blocking can suppress tumor cells dissemination during RFA. • Ethanol injection can prevent RFA-induced tumor cell release, presumably because of the formation of thrombosis.

Wedge Resection of Tumor Before Lobectomy for Lung Cancer Could Be a No-touch Isolation Technique

BACKGROUND/AIM

Circulating tumor cells (CTCs) can be a surrogate biomarker of prospective prognosis. Surgical manipulation can promote the dissemination of CTCs. Prognosis improvement is expected with the no-touch isolation technique (NTIT), preventing surgical manipulation. The Wedge resection of the tumor site before lobectomy could prevent surgical manipulation during lobectomy for non-small cell lung cancer (NSCLC) and reduce the shedding of tumor cells, similar to a NTIT. This study aimed to evaluate the effect of wedge resection technique.

PATIENTS AND METHODS

A total of 624 resected NSCLC patients were retrospectively analyzed. Patients were divided in two groups: Wedge and Non-Wedge. Overall survival (OS) curves were plotted using the Kaplan-Meier method.

RESULTS

The 5-year OS rates were 89.9% and 84.0% in the Wedge and Non-Wedge groups, respectively (p=0.033).

CONCLUSION

The OS in the Wedge group was significantly better than that in the Non-Wedge group. Wedge resection technique for NSCLC may be a NTIT.

Artery-first vs vein-first surgical technique for segmentectomy of non-small cell lung cancer: A protocol for systematic review and meta-analysis

BACKGROUND

Surgery for lung cancer squeezes the tumor, further promoting the circulation of tumor cells, which may be one of the reasons for lung cancer metastasis and recurrence. In theory, the potential risk of tumor cell proliferation can be minimized if the outflow veins are ligated first (via veins first [V-first]) rather than arteries first (via arteries first [A-first]). However, due to the lack of sufficient evidence, this technical concept has not been widely accepted as a standard in surgical oncology in the current guidelines. This systematic review and meta-analysis will be used to determine which techniques will yield longer patient survival and benefit patients during segmentectomy.

METHODS

We will search PubMed, Web of Science, Embase, Cancerlit, the Cochrane Central Register of Controlled Trials, and Google Scholar databases for relevant clinical trials published in any language before January 1, 2021. Randomized controlled trials (RCTs), quasi-RCTs, propensity score-matched comparative studies, and prospective cohort studies of interest, published or unpublished, that meet the inclusion criteria will be included. Subgroup analysis of the type of operation, tumor pathological stage, and ethnicity will be performed.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

As far as we know, this study will be the first meta-analysis to compare the efficacy of the vein-first and artery-first surgical technique of segmentectomy for patients diagnosed with resectable non-small cell lung cancer. Due to the nature of the disease and intervention methods, RCTs may be inadequate, and we will carefully consider inclusion in high-quality, non-RCTs, but this may result in high heterogeneity and affect the reliability of the results.INPLASY registration number: INPLASY202080062.

Vein-first vs artery-first surgical technique for lobectomy of non-small cell lung cancer: A protocol for systematic review and meta-analysis

BACKGROUND

The operation of lung cancer may squeeze the tumor and further promote the spread of tumor cells to the circulation, which may be one of the reasons for the metastasis and recurrence of lung cancer. The potential risk of tumor cell dissemination can theoretically be minimized if the effluent veins were ligated first (via the vein-first [V-first] technique), instead of having the artery ligated first (via the artery-first [A-first] technique). However, this technical concept has not yet been widely accepted as a standard of surgical oncology in current guidelines owing to a lack of sufficient evidence. This systematic review and meta-analysis will be performed to determine which technique during lobectomy will achieve longer patient survival and be more beneficial for patients.

METHODS

We will search PubMed, Web of Science, EMBASE, Cancerlit, the Cochrane Central Register of Controlled Trials, and Google Scholar databases for relevant clinical trials published in any language before October 1, 2020. Randomized controlled trials (RCTs), quasi-RCTs, propensity score-matched comparative studies, and prospective cohort studies of interest, published or unpublished, that meet the inclusion criteria will be included. Subgroup analysis of the type of operation, tumor pathological stage, and ethnicity will be performed. INPLASY registration number: INPLASY202050060.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

As far as we know, this study will be the first meta-analysis to compare the efficacy of the vein-first and artery-first surgical technique of lobectomy for patients diagnosed with resectable non-small cell lung cancer. Due to the nature of the disease and intervention methods, randomized controlled trials may be inadequate, and we will carefully consider inclusion in high-quality, non-randomized controlled trials, but this may result in high heterogeneity and affect the reliability of the results.

Timing of breast cancer surgery during the menstrual cycle-is there an optimal time of the month?

An intriguing relationship between menstrual cycle phase at the time of breast cancer surgery and clinical outcomes was first proposed in the late 1980s. Despite a number of clinical studies conducted to address this, as well as meta-analyses and systematic reviews, there remains significant controversy surrounding the effect of menstrual cycle phase at time of surgery on the prognosis of premenopausal breast cancer. While some studies have suggested that surgery performed during the luteal phase results in the most favourable outcome, other studies report the follicular phase is more favourable, and others show no association. Given the conflicting results, there remains insufficient evidence to determine whether there is an optimal time of the month to perform surgery. This issue has dogged breast cancer surgery for decades; knowledge of an optimal time of the month to conduct surgery would be a simple approach to improving patient outcomes. This review explores the potential biological mechanisms through which the hormonal milieu might contribute to differences in prognosis, and why clinical findings are so variable. It is concluded that a significant problem with current clinical research is the lack of insight from mechanistic studies. While there are a number of plausible biological mechanisms that could lead to altered survival, supporting evidence is limited. There are also variable approaches to defining the menstrual cycle phase and hormone receptor status of the tumour and few studies controlled for prognostic factors such as tumour size and stage, or addressed the impact of adjuvant treatments. Elucidation of the specific confounding factors, as well as biological mechanistic pathways that could explain the potential relationship between timing of surgery and survival, will greatly assist in designing robust well-controlled prospective clinical studies to evaluate this paradigm.

Less micrometastatic risk related to circulating tumor cells after endoscopic breast cancer surgery compared to open surgery

BACKGROUND

Increase of circulating tumor cells (CTCs) has been found after surgery for various carcinomas but not confirmed for breast cancer, and whether endoscopic surgery confers identical effect to CTCs as open surgery did is not clear. The present study aimed to investigate whether CTCs increase after surgery and whether there is a difference between open surgery and endoscopic surgery.

METHODS

Pre- and postoperative peripheral blood (5 mL) obtained from 110 female patients with operable breast cancer (53 underwent endoscopic surgery, 57 underwent open radical mastectomy). Quantitative real-time reverse transcription-PCR was done to detect cytokeratin 19 mRNA-positive CTC. CTC detection rate, cell number and the increase after surgery (named micrometastasis) were compared between the two groups.

RESULTS

In the open group, CTC positive rate before and after surgery were 22.81 and 33.33%; median CTC number before and after surgery were 0.21 and 0.43 and 17 patients (29.82%) had increased micrometastatic risk. In the endoscopic group, CTC positive rate before and after surgery were 24.53 and 28.30%; median CTC number before and after surgery were 0.27 and 0.36, and 8 patients (15.09%) had increased micrometastatic risk. There was a suggestive higher postoperative CTC detection rate and CTC number and a significant increased postoperation micrometastatic risk was observed in the open group compared to the endoscopic group (OR = 3.19, 95%CI: 1.05-9.65) after adjustment for clinicopathologic characteristics.

DISCUSSION

CTC tends to increase in breast cancer patients after surgery, and the micrometastatic risk was higher for open surgery compared to endoscopic surgery.

TRIAL REGISTRATION

This study was prospectively registered at Chinese Clinical Trial Register (ChiCTR-OCH-10000859, 24 April 2010).

Effect of Vein-First vs Artery-First Surgical Technique on Circulating Tumor Cells and Survival in Patients With Non-Small Cell Lung Cancer: A Randomized Clinical Trial and Registry-Based Propensity Score Matching Analysis

Importance

It is important to develop a surgical technique to reduce dissemination of tumor cells into the blood during surgery.

Objective

To compare the outcomes of different sequences of vessel ligation during surgery on the dissemination of tumor cells and survival in patients with non-small cell lung cancer.

Design, Setting, and Participants

This multicenter, randomized clinical trial was conducted from December 2016 to March 2018 with patients with non-small cell lung cancer who received thoracoscopic lobectomy in West China Hospital, Daping Hospital, and Sichuan Cancer Hospital. To further compare survival outcomes of the 2 procedures, we reviewed the Western China Lung Cancer database (2005-2017) using the same inclusion criteria.

Interventions

Vein-first procedure vs artery-first procedure.

Main Outcomes and Measures

Changes in folate receptor-positive circulating tumor cells (FR+CTCs) after surgery and 5-year overall, disease-free, and lung cancer-specific survival.

Results

A total of 86 individuals were randomized; 22 patients (25.6%) were younger and 64 (74.4%) older than 60 years. Of these, 78 patients were analyzed. After surgery, an incremental change in FR+CTCs was observed in 26 of 40 patients (65.0%) in the artery-first group and 12 of 38 (31.6%) in the vein-first group (P = .003) (median change, 0.73 [interquartile range (IQR), -0.86 to 1.58] FU per 3 mL vs -0.50 [IQR, -2.53 to 0.79] FU per 3 mL; P = .006). Multivariate analysis confirmed that the artery-first procedure was a risk factor for FR+CTC increase during surgery (hazard ratio [HR], 4.03 [95% CI, 1.53-10.63]; P = .005). The propensity-matched analysis included 420 patients (210 with vein-first procedures and 210 with artery-first procedures). The vein-first group had significantly better outcomes than the artery-first group for 5-year overall survival (73.6% [95% CI, 64.4%-82.8%] vs 57.6% [95% CI, 48.4%-66.8%]; P = .002), disease-free survival (63.6% [95% CI, 55.4%-73.8%] vs 48.4% [95% CI, 40.0%-56.8%]; P = .001), and lung cancer-specific survival (76.4% [95% CI, 67.6%-85.2%] vs 59.9% [95% CI, 50.5%-69.3%]; P = .002). Multivariate analyses revealed that the artery-first procedure was a prognostic factor of poorer 5-year overall survival (HR, 1.65 [95% CI, 1.07-2.56]; P = .03), disease-free survival (HR, 1.43 [95% CI, 1.01-2.04]; P = .05) and lung cancer-specific survival (HR = 1.65 [95% CI, 1.04-2.61]; P = .03).

Conclusions and Relevance

Ligating effluent veins first during surgery may reduce tumor cell dissemination and improve survival outcomes in patients with non-small cell lung cancer.

Trial Registration

ClinicalTrials.gov identifier: NCT03436329.

Impact of time from diagnosis to chemotherapy in advanced gastric cancer: A Propensity Score Matching Study to Balance Prognostic Factors

BACKGROUND

It is unclear whether treatment delay affects the clinical outcomes of chemotherapy in advanced gastric cancer (A-GC).

AIM

To assess whether treatment delay affects the clinical outcomes of chemotherapy in A-GC.

METHODS

This single-center retrospective study examined consecutive patients with A-GC between April 2012 and July 2018. In total, 110 patients with stage IV A-GC who underwent chemotherapy were enrolled. We defined the wait time (WT) as the interval between diagnosis and chemotherapy initiation. We evaluated the influence of WT on overall survival (OS).

RESULTS

The mean OS was 303 d. The median WT was 17 d. We divided the patients into early and elective WT groups, with a 2-wk cutoff point. There were 46 and 64 patients in the early and elective WT groups, respectively. Compared with the elective WT group, the early WT group had significantly lower albumin (Alb) levels and higher neutrophil/lymphocyte ratios and C-reactive protein (CRP) levels but not a lower performance status. The elective WT group underwent more combination chemotherapy than did the early WT group. OS was different between the two groups (230 d vs 340 d, respectively). Multivariate analysis revealed that higher CRP levels, lower Alb levels and monotherapy were significantly related to a poor prognosis. To minimize potential selection bias, patients in the elective WT group were 1:1 propensity score matched with patients in the early WT group; no significant difference in OS was found (303 d vs 311 d, respectively, log-rank P = 0.9832).

CONCLUSION

A longer WT in patients with A-GC does not appear to be associated with a worse prognosis.

The Amide Local Anesthetic Lidocaine in Cancer Surgery-Potential Antimetastatic Effects and Preservation of Immune Cell Function? A Narrative Review

Surgical removal of the primary tumor in solid cancer is an essential component of the treatment. However, the perioperative period can paradoxically lead to an increased risk of cancer recurrence. A bimodal dynamics for early-stage breast cancer recurrence suggests a tumor dormancy-based model with a mastectomy-driven acceleration of the metastatic process and a crucial role of the immunosuppressive state during the perioperative period. Recent evidence suggests that anesthesia could also influence the progress of the disease. Local anesthetics (LAs) have long been used for their properties to block nociceptive input. They also exert anti-inflammatory capacities by modulating the liberation or signal propagation of inflammatory mediators. Interestingly, LAs can reduce viability and proliferation of many cancer cells in vitro as well. Additionally, retrospective clinical trials have suggested that regional anesthesia for cancer surgery (either with or without general anesthesia) might reduce the risk of recurrence. Lidocaine, a LA, which can be administered intravenously, is widely used in clinical practice for multimodal analgesia. It is associated with a morphine-sparing effect, reduced pain scores, and in major surgery probably also with a reduced incidence of postoperative ileus and length of hospital stay. Systemic delivery might therefore be efficient to target residual disease or reach cells able to form micrometastasis. Moreover, an in vitro study has shown that lidocaine could enhance the activity of natural killer (NK) cells. Due to their ability to recognize and kill tumor cells without the requirement of prior antigen exposure, NKs are the main actor of the innate immune system. However, several perioperative factors can reduce NK activity, such as stress, pain, opioids, or general anesthetics. Intravenous lidocaine as part of the perioperative anesthesia regimen would be of major interest for clinicians, as it might bear the potential to reduce the risk of cancer recurrence or progression patients undergoing cancer surgery. As a well-known pharmaceutical agent, lidocaine might therefore be a promising candidate for oncological drug repurposing. We urgently need clinical randomized trials assessing the protective effect of lidocaine on NKs function and against recurrence after cancer surgery to achieve a “proof of concept.”

Survival and time to initiation of adjuvant chemotherapy among breast cancer patients: a systematic review and meta-analysis

The relationship between survival and time to the start of adjuvant chemotherapy (AC) among breast cancer patients is unclear. In order to illustrate the effect of delaying the initiation of AC on survival we have undertaken a systematic review and meta-analysis.

We identified 12 available studies in the meta-analysis including 15 independent analytical groups. This meta-analysis showed that a 4-week delay before AC was associated with a significantly worse overall survival (OS)(HR=1.13; 95% confidence interval [CI], 1.08–1.19) and disease free survival (DFS)(HR=1.14; 95%CI, 1.05–1.24). Two studies categorized patients into hormone receptor-positive, ERBB2-positive, and triple-negative breast cancer (TNBC) patients according to the clinicopathological features of breast cancer. The HRs for OS between waiting time (WT) ≤30 days and 31–60 days in the subgroups were extracted and analyzed. The analysis demonstrated that a WT of 31–60 days was related to worse OS among patients with TNBC (HR, 1.26; 95% CI, 1.08–1.48), but had no significant effect on OS among those with hormone receptor-positive (HR, 1.02; 95% CI, 0.89–1.15) or ERBB2-postive (HR, 0.95; 95%CI, 0.79–1.14) tumors.

In this meta-analysis of the eligible literatures reviewing the time to AC, a longer waiting time to adjuvant chemotherapy may lead to worse survival in breast cancer patients, especially in TNBC patients.

Lack of Impact of Robotic Assisted Laparoscopic Radical Prostatectomy on Intraoperative Levels of Prostate Cancer Circulating Tumor Cells

PURPOSE

While the significance of circulating tumor cells in clinically localized cancer remains controversial, it has been reported that surgical tumor manipulation can increase circulating tumor cells, including during open prostatectomy. To our knowledge it is unknown whether this cell shedding also occurs during minimally invasive prostatectomy, which minimizes tumor palpation and uses earlier vascular control. We tested the impact of robotic assisted laparoscopic radical prostatectomy on intraoperative circulating tumor cell levels.

MATERIALS AND METHODS

Circulating tumor cell counts were compared in peripheral blood specimens from 25 patients treated with robotic assisted laparoscopic radical prostatectomy preoperatively vs intraoperatively after prostate excision, in addition to 11 healthy blood donors. Circulating tumor cell detection was performed using EpCAM immunomagnetic enrichment and multiparametric flow cytometry quantification of viable EpCAM positive/prostate specific membrane antigen positive/CD45 negative cells. Intraoperative cell counts and increases were tested in univariable analyses for associations with perioperative variables, histopathology and postoperative progression.

RESULTS

Circulating tumor cells were detected in 0% of healthy controls compared to 48% and 52% of prostatectomy cases preoperatively and intraoperatively, respectively (range 1 to 8 cells). There was no difference in the incidence or mean number of circulating tumor cells preoperatively vs intraoperatively. Of the patients 60% had no intraoperative change from preoperative levels. Intraoperative cell increases vs decreases were equally infrequent (each 20%) with no intraoperative increase greater than 1 circulating tumor cell. Intraoperative circulating tumor cell detection was not significantly associated with prostatectomy operative characteristics, histopathology or early postoperative progression at a median 21-month followup.

CONCLUSIONS

Robotic assisted laparoscopic radical prostatectomy does not cause significant intraoperative increases in circulating tumor cells in contrast to historical reports of open prostatectomy. These findings may aid urologists in counseling candidates for robotic assisted laparoscopic radical prostatectomy regarding the possibility of intraoperative tumor cell shedding.

Sequential molecular analysis of circulating MCAM/MUC18 expression: a promising disease biomarker related to clinical outcome in melanoma

MCAM/MUC18 is a cell adhesion molecule associated with higher incidence of relapse in melanoma. The purpose of our study was to evaluate its role as a promising disease biomarker of progression through sequential molecular MCAM/MUC18 RT-PCR assay on serial blood samples collected during the clinical follow-up of 175 melanoma patients in different American Joint Committee on Cancer (AJCC) stages. MCAM/MUC18 molecular detection, found at least once in 22 out of the 175 patients, was significantly associated with poor prognosis and death (p < 0.001), regardless of the AJCC stages. Positive expression, either if primarily present or later acquired, was associated with melanoma progression, whereas patients primarily negative or with subsequent loss gained clinical remission or stable disease, even if in advanced stages (p < 0.005). Six AJCC advanced stages always MCAM/MUC18 negative are in complete remission or with a stable disease (p < 0.007). Semiquantitative immunohistochemical MCAM/MUC18 staining on corresponding primary melanomas was related to peripheral molecular expression. Correlations between circulating molecular and tissutal immunohistochemical detection, primary tumour thickness, AJCC stages and clinical outcome were statistically evaluated using Student's t test, ANOVA, Spearman's rank correlation test, Pearson χ (2)-test and McNemar's test. In our investigation, MCAM/MUC18 expression behaves as a "molecular warning of progression" even in early AJCC patients otherwise in disease-free conditions. Achievement of this molecule predicted the emergence of a clinically apparent status, whereas absence or persistent loss was related to a stable disease or to a disease-free status. If confirmed in larger case series, MCAM/MUC18 molecular expression could predict good or poor clinical outcome, possibly becoming a promising prognostic factor.

Psychological factors in immunomodulation induced by cancer surgery: a review

The immune system's efficacy in detecting and destroying cancer cells varies considerably throughout the stages of cancer development and its role may be critical particularly during the surgical period. Although surgery causes tumor cells to shed into the blood, immune cells have the capacity to destroy these tumor cells. However, surgery also suppresses cytotoxic capacity. It is particularly during this surgical period that psychological factors can have a significant dampening or strengthening impact on surgery-related immunomodulation response, thus exerting an effect on survival. This review describes the immune changes during the peri-surgical period and the influences psychological factors have on immune function, including the immune effects caused by psychological interventions in cancer patients. We recommend that future studies exploring the role of psychological factors on immune function and survival focus more on their influence during the peri-surgical period.

Optimal timing of adjuvant treatment in patients with early breast cancer

It is well established that adjuvant treatment reduces mortality after early breast cancer. However, the optimal timing of adjuvant treatment is not well described. To determine the optimal timing of adjuvant treatment, 402 breast cancer patients who received adjuvant treatment at Ankara Oncology Research and Training Hospital between January 1995 and August 2002 were evaluated retrospectively. Three hundred and fifty-seven (88.8%) patients received adjuvant chemotherapy, 204 (50.7%) of these patients received only adjuvant chemotherapy and 153 (38%) patients received tamoxifen following chemotherapy. Remaining 45 (11.2%) patients received only adjuvant tamoxifen. The median time to start adjuvant treatment after surgery was day 21 (range, days 4 to days 258), and the median follow-up was 50 months (range, 6-105 months). The patients were divided into 5 groups according to starting time of chemotherapy (shorter than 14 days, between days 15-29, between days 30-44, between days 45.-59 and more than 59 days). Overall survival (OS) and disease-free survival (DFS) were not shown significantly different between for 5 groups (P>0.05). Secondly, patients were divided into two groups as starting adjuvant treatment equal to or shorter than 44 days and longer than 44 days (n=344, 85.6% and vs. n=58, 14.4%, respectively). OS was significantly better in patients who started to receive adjuvant treatment within 44 days after surgery compared to patients who received adjuvant treatment after 44 days (92 vs. 83.3%, P=0.03) for 5 years, but DFS was not significantly different between two groups (83.4 vs. 82.2%, P>0.05). According to our study, adjuvant treatment of breast cancer should be initiated earlier after surgery.

Melanoma-associated markers expression in blood: MUC-18 is associated with advanced stages in melanoma patients

BACKGROUND

Multimarker reverse transcriptase-polymerase chain reaction (RT-PCR) was originally reported to reveal melanoma-associated mRNAs (MAMs) in melanoma cells but not in the peripheral blood of healthy individuals.

OBJECTIVES

To evaluate the expression of MAMs in the peripheral blood of melanoma patients at different American Joint Committee on Cancer (AJCC) stages, and to correlate their presence with early and/or advanced stages of the disease.

MATERIALS AND METHODS

One hundred blood samples of melanoma patients (AJCC I-IV) were analysed using multimarker RT-PCR to assess the co-expression of Tyr-OH, MART-1, MAGE-3, MUC-18/MCAM and p97. Patients were stratified into two disease categories: early and advanced stages. The former includes in situ and melanoma stages AJCC I-II, the latter AJCC III-IV. chi(2) and Fisher's exact tests were used to statistically evaluate the association between each MAM and disease categories. The recognized significant associations were subsequently resubmitted to univariate logistic regression. Furthermore, sensitivity and specificity were established.

RESULTS

At least one MAM could be detected in 24% of our series. Tyr-OH was the most common marker (14%), followed by MUC-18 (12%), MART-1 (5%), MAGE-3 (4%) and p97 (3%). No significant association among Tyr-OH, MART-1, MAGE-3, p97 and disease stages were evidenced. Only MUC-18 was statistically associated (P < 0.009) with advanced stages alone or co-expressed with other MAMs. According to logistic regression univariate analysis, MUC-18 increases the probability (odds ratio: 33) being in advanced stages and the incidence of recurrences (95% CI 2.9-374).

CONCLUSIONS

MUC-18 RT-PCR assay could be proposed as an adjunctive molecular method in the management of melanoma patients and is useful in the monitoring of study protocols.

Surgical resection of the primary tumor is associated with increased long-term survival in patients with stage IV breast cancer after controlling for site of metastasis

BACKGROUND

The benefit of surgical resection in patients presenting with metastatic breast cancer is not established. We hypothesized that surgical excision of primary tumors in patients with stage IV breast cancer would be associated with increased survival.

METHODS

Chart review identified 409 patients with stage IV breast cancer treated from 1996 to 2005; 187 received surgical excision of their primary tumor and 222 did not. One hundred and two patients had bone-only metastases, 281 had metastases to other organs +/- bone, and 26 had no metastases recorded. Patient characteristics were compared between groups using the chi-squared test. Cox regression models were used to calculate adjusted hazard ratios (aHR). The log-rank test compared the differences in survival between patients who did or did not undergo surgical resection.

RESULTS

Mean age at diagnosis of all 409 patients was 57.8 +/- 15.0 years. After controlling for age, comorbidity, tumor grade, histology, and sites of metastasis, patients who underwent surgical resection had longer median survival when compared with patients who did not undergo surgical resection (31.9 vs. 15.4 months, p < 0.0001; aHR 0.53 [95% CI 0.42-0.67]).

CONCLUSIONS

Surgical excision of the primary breast tumor was associated with significantly longer survival in this cohort of stage IV breast cancer patients, even after controlling for other factors associated with survival. Randomized clinical trials are needed to validate these findings.

Perioperative endocrine status and prognosis in early breast cancer

Although the relationship between breast cancer and hormones has been known for almost two centuries, it is only during the last 16 years that evidence suggesting the hormonal profile of the patient at the time of surgery can affect the outcome, came to light. A series of studies investigated the hypothesis that unopposed estrogen (observed during the follicular phase of the cycle) may adversely affect the overall and/or disease-free survival of women operated on at that time. The findings have been, at times, contradictory. The retrospective nature of the studies, poor recording of last menstrual period, small study size, and the possible effect of the timing of the diagnostic procedures (cytology or core biopsy) on the outcome may be responsible for the conflicting results. Despite this, more sophisticated studies based on pathological or hormonal observations/measurements, confirmed the relation of luteal phase surgery to better outcome. Estrogen-induced increased protease activity activates a cascade of proteolysis and allows the more discohesive tumor cells to gain access to the circulation. Moreover, disseminated cells might be able to proliferate easier because of several estrogen-dependent growth factors. Diminished immune function during the follicular phase, because of natural killer cell activity and mononuclear cell phagocytic activity down-regulation may also be implicated in the dissemination of viable tumor cells. Taken together these findings provide a framework for explaining the observation that luteal phase surgery can lead to an improved outcome. By altering the perioperative hormonal milieu it may be possible to reduce deaths from breast cancer in a simple and nontoxic manner.

Phase I safety, pharmacokinetic and pharmacodynamic studies of 2-methoxyestradiol alone or in combination with docetaxel in patients with locally recurrent or metastatic breast cancer

PURPOSE

We report the first phase I trials of 2-methoxyestradiol (2ME2, Panzem Capsules, EntreMed, Rockville, MD), alone and in combination with docetaxel, in patients with metastatic breast cancer (MBC).

PATIENTS AND METHODS

In Trial 001, 2ME2 monotherapy was administered orally once (200-1000 mg/d, cohorts 1-5) or twice daily (200-800 mg/q12h, cohorts 6-9) for 28 days followed by a 14-day observation period, continuously thereafter. In Trial 002, docetaxel 35 mg/m(2) was administered weekly for four of six weeks for a maximum six cycles; 2ME2 (200-1000 mg/d) was given orally once daily for 28 days followed by a 13-day observation period in cycle one, continuously thereafter. In both trials, responding or stable patients continued 2ME2 until progression.

RESULTS

Trial 001 enrolled 31 patients; there were no objective responses. Trial 002 enrolled 15 patients; ORR was 20% including one CR. There were no Grade IV toxicities; MTD was not reached in either study. When combined with docetaxel, three patients had significant transaminase elevations that returned to normal with continued treatment (in two of three patients). There was significant inter-patient variability and extensive metabolism to 2-methoxyestrone (2ME1). Steady-state AUC and trough concentrations of 2ME2 increased linearly up to 400-600 mg/d; doses above 400-600 mg/d did not increase 2ME2 levels. The target trough concentration (3-25 ng/mL) was not attained. Combined administration did not alter docetaxel or 2ME2 pharmacokinetics.

CONCLUSION

2ME2, alone or in combination with docetaxel, was well tolerated in patients with MBC but systemic exposure remained below the expected therapeutic range.

Influence of Timing of Initiation of Adjuvant Chemotherapy Over Survival in Breast Cancer: A Negative Outcome Study by the Spanish Breast Cancer Research Group (GEICAM)

PURPOSE

This retrospective trial evaluates whether the timing of initiation of the adjuvant chemotherapy has any influence over survival in early-stage breast cancer.

PATIENTS AND METHODS

A total of 2782 patients from El Alamo project (from 1990 to 1997; n = 15,400) were selected with stages I-III, surgery and adjuvant chemotherapy. Data were gathered about prognostic factors such as age, tumor size, vessel permeation (vascular or lymphatic), histological grade, and number of involved nodes, hormonal receptor status and administration of hormone therapy. The time interval between surgery and initiation of chemotherapy, and dates of relapse, second primary breast tumor and death were recorded. Patients were assigned in four groups according to the surgery-chemotherapy interval: <3 weeks (group A), 3-6 weeks (group B), 6-9 weeks (group C) and >9 weeks (group D).

RESULTS

There were no differences in disease-free survival (DFS), nor in 5-year overall survival (OS), according to the timing of initiation of adjuvant chemotherapy. Cox proportional hazards model was used to adjust analysis for known prognostic factors but the effect of surgery-chemotherapy interval remained non-significant. The variable timing of initiation of adjuvant chemotherapy has also been assessed as a continuous variable and no differences have been detected.

CONCLUSION

The optimum time of initiation of adjuvant chemotherapy in early stages of breast cancer is unknown. The delay in the initiation of adjuvant chemotherapy has no influence over survival in the analyzed time intervals. Retrospective analysis like this one with enough statistical power would be necessary to detect differences among groups.

Randomized phase III trial of capecitabine compared with bevacizumab plus capecitabine in patients with previously treated metastatic breast cancer

PURPOSE

This randomized phase III trial compared the efficacy and safety of capecitabine with or without bevacizumab, a monoclonal antibody to vascular endothelial growth factor, in patients with metastatic breast cancer previously treated with an anthracycline and a taxane.

PATIENTS AND METHODS

Patients were randomly assigned to receive capecitabine (2,500 mg/m2/d) twice daily on day 1 through 14 every 3 weeks, alone or in combination with bevacizumab (15 mg/kg) on day 1. The primary end point was progression-free survival (PFS), as determined by an independent review facility.

RESULTS

From November 2000 to March 2002, 462 patients were enrolled. Treatment arms were balanced. No significant differences were found in the incidence of diarrhea, hand-foot syndrome, thromboembolic events, or serious bleeding episodes between treatment groups. Of other grade 3 or 4 adverse events, only hypertension requiring treatment (17.9% v 0.5%) was more frequent in patients receiving bevacizumab. Combination therapy significantly increased the response rates (19.8% v 9.1%; P = .001); however, this did not result in a longer PFS (4.86 v 4.17 months; hazard ratio = 0.98). Overall survival (15.1 v 14.5 months) and time to deterioration in quality of life as measured by the Functional Assessment Of Cancer Treatment--Breast were comparable in both treatment groups.

CONCLUSION

Bevacizumab was well tolerated in this heavily pretreated patient population. Although the addition of bevacizumab to capecitabine produced a significant increase in response rates, this did not translate into improved PFS or overall survival.

Relative microvessel area of the primary tumour, and not lymph node status, predicts the presence of bone marrow micrometastases detected by reverse transcriptase polymerase chain reaction in patients with clinically non-metastatic breast cancer

About 50% of patients with breast cancer have no involvement of axillary lymph nodes at diagnosis and can be considered cured after primary locoregional treatment. However, about 20–30% will experience distant relapse. The group of patients at risk is not well characterised: recurrence is probably due to the establishment of micrometastases before treatment. Given the early steps of metastasis in which tumour cells interact with endothelial cells of blood vessels, and, given the independent prognostic value in breast cancer of both the quantification of tumour vascularisation and the detection of micrometastases in the bone marrow, the aim of this study was to determine the relationship between vascularisation, measured by Chalkley morphometry, and the bone marrow content of cytokeratin-19 (CK-19) mRNA, quantified by real-time reverse transcriptase polymerase chain reaction, in a series of 68 patients with localised untreated breast cancer. The blood concentration of factors involved in angiogenesis (interleukin-6 and vascular endothelial growth factor) and of factors involved in coagulation (D-dimer, fibrinogen, platelets) was also measured. When bone marrow CK-19 relative gene expression (RGE) was categorised according to the cut-off value of 0.77 (95th centile of control patients), 53% of the patients had an elevated CK-19 RGE. Patients with bone marrow micrometastases, on the basis of an elevated CK-19 RGE, had a mean Chalkley count of 7.5 ± 1.7 (median 7, standard error [SE] 0.30) compared with a mean Chalkley count of 6.5 ± 1.7 in other patients (median 6, SE 0.3) (Mann–Whitney U-test; P = 0.04). Multiple regression analysis revealed that Chalkley count, not lymph node status, independently predicted CK-19 RGE status (P = 0.04; odds ratio 1.38; 95% confidence interval 1.009–1.882). Blood parameters reflecting angiogenesis and coagulation were positively correlated with Chalkley count and/or CK-19 RGE. Our data are in support of an association between elevated relative microvessel area of the primary tumour and the presence of bone marrow micrometastases in breast cancer patients with operable disease, and corroborate the paracrine and endocrine role of interleukin-6 and the involvement of coagulation in breast cancer growth and metastasis.

Bone Marrow Micrometastases and Markers of Angiogenesis in Esophageal Cancer

BACKGROUND

Tumor angiogenesis is critical for metastasis development. The detection of bone marrow micrometastases may indicate a metastatic phenotype. We aim to establish if the detection of bone marrow micrometastases associates with elevated markers of angiogenesis and adverse histopathologic features of esophageal cancer.

METHODS

Bone marrow aspirates from 49 patients with esophageal cancer were assessed and assigned to be positive or negative for micrometastases. Routine histologic assessment of the primary tumor was also undertaken. Circulating and tumor levels of the angiogenic cytokine vascular endothelial growth factor were determined in plasma and tumor homogenate. Intratumor microvessel density was evaluated by counting anti-CD34 positive neovessels.

RESULTS

Twenty-two patients were positive for bone marrow micrometastases (44.9%). The detection of micrometastases was associated with advanced T stage (T3/4 vs T1/2; p = 0.023), circumferential margin involvement (p = 0.002) and lymphovascular invasion (p = 0.024). Plasma vascular endothelial growth factor was significantly more elevated in micrometastatic-positive patients than in those without micrometastases (p = 0.018). No difference was noted in tumor vascular endothelial growth factor expression. For adenocarcinomas alone, intratumor microvessel density was significantly higher in micrometastatic positive cases (p = 0.03). This was not the case for squamous cell carcinomas.

CONCLUSIONS

The detection of bone marrow micrometastases is associated with esophageal tumors of advanced T stage and specifically for adenocarcinomas with tumor vascularity. Plasma vascular endothelial growth factor is elevated in micrometastatic positive cases and might be derived from sources other than the primary tumor.

Breast cancer: the role of angiogenesis and antiangiogenic therapy

Angiogenesis plays a role in breast cancer development. Preclinical and clinical evidence is reviewed. Development of targeted antiangiogenic agents provides new challenges to clinical trial design. Current antiangiogenic therapy with traditional agents and novel agents are classified and reviewed.

Preoperative and perioperative chemotherapy with 5-fluorouracil as continuous infusion in operable breast cancer expressing a high proliferation fraction: cytotoxic treatment during the surgical phase

BACKGROUND

Experimental data on perioperative chemotherapy (PeCT) indicate that its initiation might be most useful if administered as close as possible to the time of first 'disturbance of the tumour'. Regimens including 5-fluorouracil (5-FU) as continuous infusion are commonly used in the preoperative setting, especially for large tumours and locally advanced disease. We therefore evaluated the role of PeCT with 5-FU as continuous infusion after preoperative chemotherapy (PreCT), covering the surgical phase and acute wound healing period, in patients with breast cancer too large to attempt breast-conserving surgery upon diagnosis.

PATIENTS AND METHODS

Breast cancer patients, clinical stages T2-T3, N0-N2, M0, and Ki-67 labelling index >/= 20%, were treated every 3 weeks with a maximum of six courses of vinorelbine 20 mg total dose intravenously (i.v.) on days 1 and 3, cisplatin 60 mg/ m(2) i.v. on day 1 and 5-FU 200 mg/m(2)/day as a continuous infusion (ViFuP regimen). Patients who achieved a clinical and radiological objective remission with PreCT were also treated with perioperative 5-FU that was continued until 30 min before, and restarted immediately after surgery, prolonging infusion until 15 days after surgery.

RESULTS

Following preoperative treatment, 39 of 49 evaluable patients [80%; 95% confidence interval (CI) 70% to 90%] had an objective response. Pathological complete remission (pCR) was achieved in 14 (29%) patients. No relevant clinical or haematological toxicity due to PeCT was observed. In 36 patients submitted to PeCT the rate of pCR was 33% (95% CI 18% to 48%). The highest response of the primary tumour to PreCT and PeCT was observed in women with tumours not expressing estrogen and progesterone receptors (pCR 46%; 95% CI 19% to 73%).

CONCLUSIONS

Preoperative therapy can be protracted into the surgical (and wound healing) period without significant additional short-term toxicity. Proper selection of patients according to biological features might improve the therapeutic yield of preoperative therapies.

Tumor angiogenesis of non-small cell lung cancer

Lung cancer is one of the commonest causes of cancer death in developed countries. Recent evidence suggests that angoigenesis is related to poor prognosis in many solid tumors including non-small cell lung cancer (NSCLC). Angiogenesis is regulated by a complex interaction among growth factors and cytokines and influenced by proteolytic enzymes such as plasminogen activators and matrix metalloproteases, expression of adhesion molecules, and distribution of extracellular matrices. Fibroblasts, macrophages, mast cells, and endothelial cells themselves also affect angiogenesis. This review concentrates on angiogenic growth factors including vascular endothelial growth factor, angiopoietins, platelet derived endothelial growth factor, and basic fibroblast growth factor, proteases, adhesion molecules including vascular endothelial cadherin and integrins, osteopontin, and mast cell products in tumor angiogenesis of NSCLC.

Assessment of highly angiogenic and disseminated in the peripheral blood disease in breast cancer patients predicts for resistance to adjuvant chemotherapy and early relapse

The assessment of tumor molecular features in combination with the detection of occult malignant cells may provide important clinical information, beyond the standard staging of breast cancer. Using a nested RT-PCR technique, we assessed prospectively the presence of cytokeratin-19 (CK19) mRNA positive cells in the blood of 100 operated patients with breast cancer before the initiation of adjuvant chemotherapy and local radiotherapy. Tissue samples were prospectively collected and analyzed for estrogen (ER) and progesterone (PgR) receptor, c-erbB-2 overexpression, mutant-p53 and bcl-2 protein accumulation, proliferation index and microvessel density (MVD). CK-19 mRNA-positive cells were detected in the peripheral blood of 33% of patients. Simultaneous display of high intratumoral MVD and of CK-19 mRNA-positive cells, which characterized highly angiogenic and disseminated in the peripheral blood (HAD) disease was noted in 25% of patients. Detection of CK-19 positive cells was significantly associated with increased MVD (p = 0.002). In univariate analysis (median follow-up 30 months) CK19 mRNA detection and MVD were the most significant factors related to a short relapse-free survival (RFS), (p < 0.0001). In multivariate analysis, CK19 positivity, high MVD and c-erbB-2 overexpression were the only significant and independent variables associated with relapse (p = 0.0005, 0.03 and 0.04, respectively). Patients with HAD had an expected relapse rate close to 70% vs. <5% in the remaining patients irrespectively of the used chemotherapy regimen. The simultaneous presence of high MVD and CK19-positive cells in the blood of patients with early breast is linked with poor prognosis, which cannot be improved with standard chemotherapy regimens.

Intra-tumoural microvessel density in human solid tumours

Over the last decade assessment of angiogenesis has emerged as a potentially useful biological prognostic and predictive factor in human solid tumours. With the development of highly specific endothelial markers that can be assessed in histological archival specimens, several quantitative studies have been performed in various solid tumours. The majority of published studies have shown a positive correlation between intra-tumoural microvessel density, a measure of tumour angiogenesis, and prognosis in solid tumours. A minority of studies have not demonstrated an association and this may be attributed to significant differences in the methodologies employed for sample selection, immunostaining techniques, vessel counting and statistical analysis, although a number of biological differences may account for the discrepancy. In this review we evaluate the quantification of angiogenesis by immunohistochemistry, the relationship between tumour vascularity and metastasis, and the clinicopathological studies correlating intra-tumoral microvessel density with prognosis and response to anti-cancer therapy. In view of the extensive nature of this retrospective body of data, comparative studies are needed to identify the optimum technique and endothelial antigens (activated or pan-endothelial antigens) but subsequently prospective studies that allocate treatment on the basis of microvessel density are required.

Uveal melanomas express vascular endothelial growth factor and basic fibroblast growth factor and support endothelial cell growth

BACKGROUND

Tumour microvascularity is a significant determinant of prognosis for a large number of different tumours, including uveal melanoma. The development of blood vessels within these and other tumours is partly controlled by soluble pro-angiogenic cytokines, of which basic fibroblast growth factor (bFGF) and vascular endothelial growth factor-A (VEGF) are the best described.

METHODS

Because VEGF has been inconsistently found within uveal melanomas and bFGF is described as an autocrine growth factor in cutaneous melanoma, the authors looked at the expression of these cytokines in uveal melanomas using immunohistochemistry and reverse transcriptase polymerase chain reaction (RT-PCR). The cross talk between uveal melanoma cells and endothelial cells was then assessed in an in vitro co-culture model.

RESULTS

While most tumour cells expressed bFGF at the protein level by immunohistochemistry (89%), relatively few (22%) expressed VEGF, and this was of limited extent. All 20 tumours tested by RT-PCR contained mRNA for both bFGF and VEGF. Co-culture experiments using an ATP based bioassay showed that uveal melanomas could support the growth of a rat brain endothelial cell line (GPNT) and human umbilical vein endothelial cells (HUVEC), and that this could be modulated by cytokines and anti-cytokine antibodies.

CONCLUSION

These results suggest that angiogenesis within uveal melanoma may be the result of a complex interplay between endothelial and tumour cells, and that bFGF and VEGF could play a part.

Lymphatic dissemination of tumour cells and the formation of micrometastases

Most human cancers show evidence of metastatic spread to regional lymph nodes, and the extent of lymph-node involvement is directly related to dinical outcome. Increased expression of vascular endothelial growth factor C in primary tumours is associated with increased dissemination of tumour cells to regional lymph nodes in various human carcinomas. Arguments favouring the activation of pre-existing lymphatic endothelium and the de novo formation of lymphatic capillaries (lymphangiogenesis) are discussed. We highlight recent advances in the molecular detection and characterisation of lymph-node micrometastases, as well as potential microenvironmental factors, such as chemokines, which may influence the migration and growth of metastatic tumour cells. Finally, we examine the clinical significance of lymphatic-mediated tumour-cell dissemination and the formation of lymph-node micrometastases.

The intratumoral expression of vascular endothelial growth factor and interleukin-8 associated with angiogenesis in nonsmall cell lung carcinoma patients

BACKGROUND

Angiogenesis has important effects on tumor growth and metastasis. It is regulated by a variety of angiogenic and angiostatic factors.

METHODS

To evaluate the effects of tumor cell-derived angiogenic factors, we performed an immunohistochemic study to evaluate the intratumoral expression of vascular endothelial growth factor (VEGF) and interleukin-8 (IL-8) in relation to intratumoral microvessel density (IMD) in tumors from 104 nonsmall cell lung carcinoma (NSCLC)patients.

RESULTS

Fifty-four carcinomas were VEGF-positive, 47 carcinomas were IL-8-positive, and 53 carcinomas were hypervascular tumors. There was no significant correlation between the percentages of positive VEGF-staining and positive IL-8-staining in NSCLCs (rho = 0.174, P = 0.080). The IMD of VEGF-positive carcinomas was significantly greater than that of VEGF-negative carcinomas (P = 0.023). In addition, the IMD of IL-8-positive carcinomas was significantly greater than that of IL-8-negative carcinomas (P =0.013). The overall survival rate of patients with hypervascular tumors was significantly lower than that of patients with hypovascular tumors (41.0% versus 67.0%, P = 0.004). Cox proportional-hazards regression model also demonstrated that angiogenesis was one of the significant factors in predicting the survival of NSCLC patients (relative risk = 1.944, P = 0.041).

CONCLUSIONS

Intratumoral expression of VEGF and IL-8 was associated with angiogenesis in NSCLCs. Tumor angiogenesis significantly affected the prognosis of NSCLC patients.

A novel synthetic Arg-Gly-Asp-containing peptide cyclo(-RGDf==V-) is the potent inhibitor of angiogenesis

Arg-Gly-Asp (RGD)-containing peptide is a ligand for integrin alpha(V)beta3 and acts as an angiogenic inhibitor. A novel cyclic RGD peptide, cyclo(-RGDf==V-) (f==V), was synthesized and its biological activities were characterized and compared with its analogs, cyclo(-RGDfV-) (fV) and cyclo(-RGDf-MeV-) (fMeV). It bound to integrin alpha(V)beta3 with almost the same affinity as the fV and fMeV analogs. All three compounds inhibited the adhesion and growth of HUVEC cells in a dose-dependent manner in vitro. Out of three, fMeV had the strongest effect, f==V was almost as strong as fMeV, and fV had the least effect. However, in vivo, f==V significantly decreased the intratumoral microvessel density (MVD) in the DLD-1 (human colon cancer cell) inoculated mice, while fMeV had little effect. These results suggest the potential usefulness of the cyclo(-RGDf==V-) as an antiangiogenic agent for clinical use in the future.

Molecular determinants of occult metastatic tumor cells in bone marrow

The success of mammographic screening for breast cancer is that it involves increasingly more patients with small primary tumors formerly thought to have an overall excellent prognosis. Yet, only approximately two thirds of these patients actually have this favorable prognosis, while the remaining third develops metastatic disease. Thus, there is emerging evidence that epithelial tumor cells can disseminate into secondary organs at an earlier stage of primary tumor development than appreciated by current risk classifications. Bone marrow is one of the most prominent secondary organs screened for the presence of disseminated tumor cells. The current data suggest that bone marrow micrometastases represent a selected population of dormant and heterogeneous cancer cells. The analysis of micrometastatic cells opens a new avenue by which to assess the molecular determinants of both early tumor cell dissemination and subsequent outgrowth into overt metastases. Moreover, identifying therapeutic target structures (e.g., HER2/neu), monitoring the elimination of bone marrow micrometastases, and assessing treatment-resistant tumor cell clones might help to understand the current limitations of adjuvant systemic therapy. This review summarizes the current knowledge of the biological characteristics of micrometastatic cancer cells in bone marrow of breast cancer patients.

Enhanced VEGF production and decreased immunogenicity induced by TGF-beta 1 promote liver metastasis of pancreatic cancer

TGF-betas are multifunctional polypeptides that regulate cell growth and differentiation, extracellular matrix deposition, cellular adhesion properties, angiogenesis and immune functions. In this study, we investigated the effect of TGF-beta1 on liver metastasis and its mechanism by using human pancreatic cancer cell lines Panc-1, Capan-2, and SW1990. Capan-2 and SW1990 cells demonstrated enhanced liver metastatic potential by in vivo splenic injection with TGF-beta1. Consequently, we examined the role of TGF-beta1 on in vitro angiogenesis and received cytotoxicity by peripheral blood mononuclear leukocytes (PBMLs). While TGF-beta1 slightly decreased cell proliferation, it also upregulated VEGF production in all cancer cells examined. The binding of PBMLs to cancer cells and cancer cell cytotoxicity during co-culture with PBMLs were remarkably decreased by treatment with TGF-beta1. Panc-1 cells revealed no liver metastasis despite their high immunogenetic and angiogenetic abilities, which was attributed to a lack of expression of the cell surface carbohydrates that induce attachment to endothelial cells. We concluded that the presence of TGF-beta1 in the microenvironment of tumour site might play an important role in enhancing liver metastasis of pancreatic cancer by modulating the capacity of angiogenesis and immunogenicity.

Characterization of disseminated tumor cells

The most prominent secondary organs screened for the presence of occult disseminated tumor cells are regional lymph nodes and bone marrow. The current data suggest that micrometastatic cells represent a selected population of dormant cancer cells, which still express a considerable degree of heterogeneity. The analysis of micrometastatic cells will open a new avenue to assess the molecular determinants of both early tumor cell dissemination and subsequent outgrowth into overt metastases. Moreover, identifying therapeutic target structures (e.g., HER2), monitoring the elimination of bone marrow micrometastases, and assessing treatment-resistant tumor cell clones may help in understanding the current limitations of adjuvant systemic therapy. This review summarizes the current knowledge on the biological characteristics of micrometastatic cancer cells in bone marrow and lymph nodes of cancer patients.

Pattern of distribution and prognostic value of angiogenesis in pancreatic duct carcinoma: a semiquantitative immunohistochemical study of 45 patients

In specimens obtained from resected pancreata, the intratumoral microvessel density (IMD), the proliferation rate of the neoplastic parenchymal cells, and their p53 protein expression were assessed. The sources of errors were great in the measurements of the IMD. This statement can be illustrated by the finding that when the IMD was calculated by manual counting in five areas of intense neovascularization (hot spot regions), using x200 and x400 magnifications, the numbers of microvessels per square millimeter were 65+/-23 and 106+/-8, respectively, which reflects a significant difference. Two patterns of microvessel distribution could be identified: one with hot spots only in the stroma (n = 19) and one in which the hot spots were located in areas of neoplastic parenchyma (including its stroma) (n = 26). The IMD was significantly greater in the latter group. There was no general correlation of neoplastic disease with the IMD. However, when a scoring system was used to assess the angiogenesis, hot spots in areas of neoplastic parenchyma were associated with a greater proliferation rate of the tumor cells, and with a short length of survival of the patients from their neoplastic disease.

Pitfalls in the detection of disseminated non-hematological tumor cells

There is not yet a consensus on the reliability of the methods that should be used for the detection of rare disseminated tumor cells from non-hematological malignancies. In this review, we will discuss the advantage and drawbacks of the classical approach of immunocytochemistry and the molecular detection by reverse transcriptase polymerase chain reaction (RT-PCR). The interpretation of the biological significance of circulating tumor cells and the pitfalls of the detection techniques are the main causes of discrepancy between the conclusions of different tumor-cell detection (TCD) studies.

Toward checkmate: biology and breast cancer therapy for the new millennium

A better understanding of the biology of breast cancer should lead to the rational development of new treatments and the ability to customize therapy for individual patients. Though promising in theory, translating advances in biological knowledge to the clinic has been difficult. Recently several areas of research have produced treatments which have entered clinical trials: three will be reviewed here. The growth of breast cancer is regulated by growth factors and their receptors; amplification or overexpression is associated with poor prognosis. As such inhibition of growth factors and/or growth factor receptors may provide an ideal therapeutic target. Herceptin binds to c-erbB-2, a member of the epidermal growth factor receptor family. Significant responses were seen in patients with c-erbB-2 overexpressing breast cancer with Herceptin administered as a single agent or in combination with chemotherapy. Herceptin was approved by the Food and Drug Administration in late 1998. Breast cancer invasion and metastasis requires degradation of the surrounding basement membrane by matrix metalloproteinases and other proteolytic enzymes. Synthetic inhibitors of these enzymes are now in clinical trials. Breast cancers must stimulate angiogenesis, the growth of new blood vessels, in order to grow beyond a few millimeters in diameter. This nascent vascular network provides another opportunity for therapy. Preclinical models support the critical role of angiogenesis and the therapeutic benefit of angiogenesis inhibition; clinical trials are underway.

Rectal cancer recurrence: factors and mechanisms

OBJECTIVE

There have been significant developments in treatment for rectal carcinoma, both in surgical and adjuvant therapy. They may however have associated morbidity and hence individualized therapy for rectal cancer is desirable, to optimize treatment but avoid over-treatment for cases where the risk of recurrence is low.

MATERIALS AND METHODS

A literature review was undertaken of the reported incidence of recurrence of rectal carcinoma following curative surgery, factors which predispose to recurrence and proposed mechanisms for recurrence, and the evidence for each critically evaluated.

RESULTS

The incidence of local recurrence of rectal carcinoma following curative resection ranges from 2.6% to 32%, with an average of 15%. Tumour stage is the strongest predictor of tumour recurrence. Upstaging using molecular biology may predict increased risk of recurrence but is not yet proven. Histological factors including differentiation and vascular invasion increase recurrence but are imprecise. Tumour microvascular density and vascular endothelial growth factor (VEGF) levels may be predictive but need refinement. Adequate resection margins are important but recurrence may occur despite this. Tumour cell spillage and distant dissemination may be a mechanism for tumour recurrence following curative resection, but further research is required before this could be applied clinically.

CONCLUSION

Recurrence of rectal cancer remains a significant problem following 'curative' surgery. Multiple factors may influence recurrence risk, though currently however only tumour stage and histological resection margins have demonstrated sufficient importance for management decisions to be made upon them.

Early start of adjuvant chemotherapy may improve treatment outcome for premenopausal breast cancer patients with tumors not expressing estrogen receptors. The International Breast Cancer Study Group

PURPOSE

The proper time to commence adjuvant chemotherapy after primary surgery for breast cancer is unknown. An analysis of the International (Ludwig) Breast Cancer Study Group (IBCSG) Trial V at a median follow-up of 11 years suggested that early initiation of adjuvant chemotherapy might improve outcome for premenopausal, node-positive patients whose tumors did not express any estrogen receptor (ER).

PATIENTS AND METHODS

We investigated the relationship between early initiation of adjuvant chemotherapy, ER status, and prognosis in 1,788 premenopausal, node-positive patients treated on IBCSG trials I, II, and VI. The disease-free survival for 599 patients (84 with ER-absent tumors) who commenced adjuvant chemotherapy within 20 days (early initiation) was compared with the disease-free survival for 1,189 patients (142 with ER-absent tumors) who started chemotherapy 21 to 86 days after surgery (conventional initiation). The median follow-up was 7.7 years.

RESULTS

Among patients with ER-absent tumors, the 10-year disease-free survival was 60% for the early initiation group compared with 34% for the conventional initiation group (226 patients; hazard ratio [HR], 0. 49; 95% confidence interval [CI], 0.33 to 0.72; P =.0003). This difference remained statistically significant in a Cox multiple regression analysis controlling for study group, number of positive nodes, tumor size, age, vessel invasion, and institution (HR, 0.60; 95% CI, 0.39 to 0.92; P =.019). Conversely, early initiation of chemotherapy did not significantly improve disease-free survival for patients with tumors expressing ER (1,562 patients; multiple regression HR, 0.93; 95% CI, 0.79 to 1.10; P =.40).

CONCLUSION

In premenopausal patients with ER-absent tumors, early initiation of systemic chemotherapy after primary surgery might improve outcome. Further confirmatory studies are required before any widespread modification of current clinical practice. In premenopausal patients with tumors expressing some ER, gains from early initiation are unlikely to be clinically significant.

VEGF, flt-1, and KDR/flk-1 as prognostic indicators in endometrial carcinoma

OBJECTIVE

Tumor angiogenesis is a highly regulated process under the influence of the host microenvironment and mediators. Studies of breast cancer and, more recently, ovarian and cervical cancer, demonstrate that neovascularization correlates with the likelihood of metastasis and recurrence. Vascular endothelial growth factor (VEGF), an important regulator of tumor angiogenesis in the endometrium, flt-1, and KDR/flk-1 are good markers of vascular proliferation. Being that angiogenesis is a precursor to the development of progressive disease, we hypothesize that quantifying VEGF, flt-1, and KDR/flk-1 expression in uterine malignancies is a superior predictor of metastatic potential and survival than is FIGO grade of tumor, depth of invasion, and histology.

METHODS

The histologic slides of 47 patients with uterine malignancies (35 adenocarcinomas, 6 papillary serous, and 6 carcinosarcomas) were reviewed. The paraffin blocks from the primary tumor were obtained. Immunohistochemistry staining was performed for VEGF, flt-1, and KDR/flk-1. Microvessel density, used to analyze VEGF and receptor concentrations, was determined by two independent investigators, who were blinded to the patients clinical status. The impact of VEGF, flt-1, and KDR/flk-1 as well as stage, grade, depth of invasion, and nodal status on the incidence of metastases, recurrence, and survival was determined using logistic regression analysis and product limit life system survival analysis, respectively.

RESULTS

Results indicated that when evaluating all three histologic types, only stage and grade of tumor were found to impact upon the incidence of recurrence and survival. When patients with carcinosarcoma and papillary serous adenocarcinoma were excluded from the analysis, once again only stage and grade of tumor were significant prognostic indicators of recurrence and survival. Only grade of tumor and depth of uterine invasion were significant predictors of a tumor's metastatic potential. VEGF, flt-1, and KDR/flk-1 proved to be of little significance in predicting metastases, recurrence, and survival. Patients with advanced disease in all three histologic subtypes often had low VEGF and receptor positivity.

CONCLUSIONS

In this study, VEGF, flt-1, and KDR/flk-1 receptor concentrations did not correlate with the incidence of metastases, recurrence, and survival.

Detection of circulating melanoma cells by immunomagnetic cell sorting

We developed a cellular approach to the identification of circulating melanoma cells in peripheral blood using immunomagnetic cell sorting. One hundred seventy-eight blood samples from 129 melanoma patients and 30 samples from healthy persons and nonmelanoma patients were examined. After density gradient centrifugation the interphase was incubated with the mAb 9.2.27. Positive cells were labeled with magnetic microbeads and enriched by immunomagnetic cell sorting. Cells were stained using an alkaline phosphatase-antialkaline phosphatase assay and examined by light microscopy. In spiking experiments, melanoma cells seeded at a concentration of one melanoma cell per ml whole blood could be detected reliably with the assay. Circulating melanoma cells were not found in 30 controls examined, nor were 9.2.27-positive cells found in 41 patients with primary malignant melanoma. In patients with regional lymph node metastases and in patients with disseminated disease, circulating 9.2.27-positive cells could be detected in 3 out of 22 patients (13.6%) and 10 out of 66 patients (15.2%) examined. We present a sensitive and specific immunocytological approach to detect circulating melanoma cells in peripheral blood. The method is not suitable for early detection of metastases but is a valuable tool for further investigating biological characteristics of circulating melanoma cells.