Impact of clinical, pathologic, and treatment-related factors on outcome in patients with locally advanced breast cancer treated with multimodality therapy

Effects of hyperthyroidism and diabetes mellitus on spermatogenesis in peri- and post-pubertal mice

Introduction

Diabetes and thyroid dysfunction often co-exist. One autoimmune disorder always invites another and it has been reported that such co-morbid ailments always become detrimental to the health of the patients.

Materials and methods

In our previous work, we elucidated the interactions of diabetes and hypothyroidism on testicular development and spermatogenesis. However, the present study illuminates the interface between diabetes and hyperthyroidism, where 16 ICR pregnant primiparous mice were used and subsequently 48 male pups were randomly selected (n=12/group) and separated into 4 groups: control (C), diabetic (D), diabetic + hyperthyroidism (DH) and hyperthyroidism (H).

Results

Computerized sperm analyses showed significant reductions in count by 20% and increases of 15% in D and H animals, respectively, vs. controls. However, rapid progressive sperm motility was significantly lower only in D (30%) compared with C mice. Our histomorphometric investigation depicted damaging effects on testicular and epididymal tissues; the stroma adjacent to the seminiferous tubules of the D mice revealed edematous fluid and unstructured material. However, in the epididymis, germ cell diminution contraction of tubules, compacted principal and clear cells, lipid vacuolization, atypical cellular connections, exfoliated epithelial cells, and round spermatids were conspicuous in DH mice.

Discussion

Collectively, our experiment was undertaken to ultimately better recognize male reproductive disorders in diabetic-hyperthyroid patients.

Steroid hormone secretion in inflammatory breast cancer cell lines

Inflammatory breast carcinoma (IBC) is a special type of breast cancer with a poor survival rate. Though several IBC cell lines have been established, recently a first IMC cell line was established. The aims of this study were: (1) to validate a highly sensitive, reliable, accurate and direct amplified enzyme immunoassay (EIA) to measure several cell-secreted steroid hormones: progesterone (P4), androstenedione (A4), testosterone (T), 17β-estradiol (E2) and estrone sulfate (SO4E1) in the culture medium. (2) To assess whether hormone production profile by IPC-366 cells validates the IMC model for human IBC. We validated a non-competitive amplified EIA for inflammatory breast cancer cell lines based on the results of accuracy, precision, sensitivity and parallelism. The low detection limits of the technique were: P4=13.2 pg/well, A4=2.3 pg/well, T=11.4 pg/well, E2=1.9 pg/well and SO4E1=4.5 pg/well. Intra- and inter-assay coefficient of variation percentages were <10%. The mean recovery rate of hormone added to the culture medium was >90%. In all hormones studied SUM149 have higher levels (1.4 times, but not significant) than IPC-366, and the correlation index between SUM149 and IPC-366 concentrations were >97%. We can coclude that cells of both cell lines, IPC-366 and SUM149, are capable to produce steroid hormone in culture media. The presented EIA methodology is very valuable for the detection of steroid production in culture media and could be used in hormone regulation studies and therapeutic agents in cell lines of inflammatory and non-inflammatory mammary carcinoma or other cancer cell lines in preclinical studies.

Different role of COX-2 and angiogenesis in canine inflammatory and non-inflammatory mammary cancer

Human inflammatory breast cancer (IBC) and canine inflammatory mammary cancer (IMC) are the most aggressive and fatal types of mammary cancer, and both have a very poor prognosis and low survival rate. Human IBC is characterised by exacerbated angiogenesis, lymphangiogenesis, and lymphangiotropism. Lymphangiotropism is also characteristic of IMC, but microvascular density (MVD) and lymphangiogenesis have not been previously studied in canine IMC. In this study immunohistochemical expression of several angiogenesis-related factors (cyclooxygenase [COX]-2, vascular endothelial growth factors A and D [VEGF-A, VEGF-D], and vascular endothelial growth factor receptor 3 [VEGFR-3]), MVD, lymphatic proliferation index (LPI), and Ki-67 tumour proliferation index (PI) were studied in 21 canine IMC samples, 20 canine high-grade malignant non-IMC mammary tumours (MMTs), and four normal mammary gland samples (NMGs). All mammary neoplasms were histologically categorised as grade III. COX-2 values were also analysed by RT-PCR in seven IMCs, six MMTs and four NMGs. The expressions of COX-2, VEGF-A, and VEGF-D were significantly higher in IMC, MVD and LPI tumours, but not PI. In MMTs, COX-2 immunoexpression was significantly associated with VEGF-A, while in IMCs COX-2 was associated with VEGF-D (lymphangiogenic factor), its receptor VEGFR-3, and LPI. These results suggested that lymphangiogenic pathway stimulation isa specific role of COX-2 in IMC angiogenesis, which justifies the use of COX-2-based targeted palliative therapies in dogs. The exacerbated angiogenesis and lymphangiogenesis and the increased expression of angiogenesis-related factors further support canine IMC as a natural model for the study of human IBC.

Steroid pathway and oestrone sulphate production in canine inflammatory mammary carcinoma

Spontaneous canine mammary inflammatory carcinoma (IMC) shares epidemiologic, histopathologic and clinical characteristics with the inflammatory breast carcinoma (IBC) disease in humans. We have analysed the steroids levels in serum and in tissue homogenates of IMC, the expression of two of their receptors (androgen and beta-estrogen) and of three enzymes included in the steroidogenesis pathway (aromatase (CYP19A1), steroid sulphatase (STS) and estrogen sulfotransferase (EST)) trying to explain the specific accumulation of steroids in IMC tissues generating deposits in the form of lipid droplets whose presence can be attributed to steroids secreted by IMC cells. According to our working hypothesis, oestrone sulphate would be the main component of these lipid droplets. The presence of these steroid deposits would contribute to the intense proliferation and invasive behaviour of IMC and IBC, although their involvement in angiogenesis is yet to be demonstrated.

Guidelines to assure quality in breast cancer surgery

The outcome of breast cancer surgery, with respect to cosmetic results, loco regional control and prognostic information from nodal staging, may vary substantially. Optimal breast cancer care starts with a proper surgical act, which can only be performed when optimal imaging and preoperative diagnosis are available. Next, on the basis of all peroperative findings, the right surgical procedure should be indicated after multidisciplinary consultation and discussion, keeping the objective of the final outcome in mind. The surgical act itself is best performed by an experienced surgeon who has maintained their experience after sufficient training. The outcome of the different procedures can be measured according to simple criteria and prospective registration. All possible surgical procedures, the indication-objectives, the training-objectives and outcome measures are described.

Management of Women who Present with T4 Breast Cancer

The purpose of this study was to review the clinical presentation and outcome of women who present with large or locally invasive (T4) breast carcinoma. This retrospective study was conducted at the University of Mississippi Medical Center, a state tertiary care referral institution. One hundred twenty-nine women between the ages of 28 and 85 years (mean, 55 years) presented with T4 breast carcinoma. Follow-up was available for 128 women. Only 23 women have survived (18%), 5 of whom (21.7%) have metastatic disease. Mean survival for those who died was 21.6 months, compared to 76.3 months for survivors. Survival was not influenced by tumor characteristics ( P > 0.5), but was strongly influenced by nodal status ( P < 0.001) and by the presence of metastases at the time of diagnosis ( P < 0.001). Survival was strongly related to mode of therapy ( P < 0.01), but this was principally related to very high mortality rates in women who received no therapy (100%), surgery only (92.3%), or chemotherapy only (95%). The best survival was seen in women who received chemotherapy prior to surgery (40%); their survival was superior to that of women treated initially by surgery, followed by chemotherapy (16.3%, P = 0.04). However, when women who presented with metastatic disease were excluded, survival was not different between these two groups ( P = 0.18). Despite public education efforts and the wide availability of screening programs for breast carcinoma, many women still present with locally advanced disease. Outcome can be favorable in the absence of node involvement or metastatic disease, even in the presence of large, fungating tumors. Multimodality therapy gives the best results, but early surgery may be required for progression of disease during chemotherapy or because of extensive ulceration at initial presentation.

Changes in management techniques and patterns of disease recurrence over time in patients with breast carcinoma treated with breast-conserving therapy at a single institution

BACKGROUND

The authors reviewed changes in the initial clinical presentation, management techniques, and patterns of disease recurrence over time (1981-1996) in patients with breast carcinoma treated with breast-conserving therapy (BCT) at a single institution. The goals of the current study were to determine the frequency and use of optimal local and systemic therapy techniques and to evaluate the impact of these changes on treatment efficacy.

METHODS

Six hundred seven patients with American Joint Committee on Cancer Stage I or II invasive breast carcinomas treated with BCT at William Beaumont Hospital (Royal Oak, MI) constituted the study population. All patients received at least an excisional biopsy of the primary tumor, an axillary lymph node staging procedure, and postoperative radiotherapy (RT) (a median tumor bed dose of 61 Gray [Gy] was administered). All sides were reviewed by one pathologist. Numerous clinicopathologic and treatment-related factors were analyzed to monitor changes that occurred over time. Changes in patterns of disease recurrence and treatment efficacy over time also were analyzed.

RESULTS

Over the time period analyzed, changes at initial presentation included an increase in the mean age at diagnosis (age 56.1 years vs. 61.4 years; P < 0.001), a decrease in the number of patients with clinically palpable tumors (78% vs. 36%; P < 0.001), a decrease in the mean tumor size (2.2 cm vs. 1.6 cm; P < 0.001), but no change in the percentage of patients with negative lymph nodes (79% vs. 78%; P = 0.83). No differences over time were observed in mean tumor grade (2.0 vs. 1.9; P = 0.2) or the presence of angiolymphatic invasion (27% vs. 26%; P = 0.25). Changes in surgical management and pathologic assessment included the more frequent use of reexcision (46% vs. 81%; P < 0.001), larger mean total volumes of breast tissue specimens excised (115 cm3 vs. 189 cm3; P = 0.001), a larger percentage of patients with final negative surgical margins (74% vs. 97%; P < 0.001), and a small increase in the mean number of lymph nodes excised (13.8 lymph nodes vs. 14.1 lymph nodes; P = 0.01). The only other significant change in the pathologic management of patients over time included a doubling in the mean number of slides examined (10.6 slides vs. 21.1 slides; P < 0.001). Changes in adjuvant local and systemic therapy included an increase in the percentage of patients treated with > 60 Gy to the tumor bed (66% vs. 95%; P < 0.001), a doubling in the mean number of days from the last surgery to the start of RT (24 days vs. 50 days; P < 0.001), and a decrease in the use of regional lymph node RT (24% vs. 8%; P < 0.001). The use of adjuvant tamoxifen increased from 10% to 61% (P < 0.001). Finally, improvements were observed in the 5-year and 12-year actuarial rates of local disease recurrence (8% vs. 1% and 21% vs. 9%, respectively; P = 0.001) and distant metastases (12% vs. 4% and 22% vs. 9%, respectively; P = 0.006). No changes in the mean number of years to ipsilateral (6.5 years vs. 6.4 years; P = 0.59) or distant disease recurrence (4.6 years vs. 3.8 years; P = 0.73) were observed.

CONCLUSIONS

The impact of screening mammography and substantial changes in surgical, pathologic, RT, and systemic therapy recommendations were observed over time in the study population. These changes were associated with improvements in 5-year and 12-year local and distant control rates and suggested that improvements in outcome can be realized through adherence to best practice guidelines and continuous monitoring of treatment outcome data.

Noninflammatory breast carcinoma with skin involvement

BACKGROUND

According to the TNM Supplement, only breast carcinoma with macroscopic 'classic' skin changes (e.g., edema, peau d'orange, ulceration) should be placed in the T4 category; the classification of tumors with histologically proven skin involvement but no clinical skin changes or only discreet changes should be based on the size of the tumor (T1-3). To the authors' knowledge, no data supporting these recommendations have been reported to date.

METHODS

Seventy-six patients with noninflammatory breast carcinoma and histologically proven skin involvement were classified based on the degree of their skin involvement. Fifty patients (66%) presented with clinically obvious skin involvement (Group A), and 26 patients (34%) had breast carcinoma with histologically proven skin involvement but without clinical skin changes (Group B). Reclassification was undertaken to assess the malignant potential of tumors independent of the morphologic parameter 'skin involvement'.

RESULTS

Patients in Group A presented significantly more frequently with extensive disease at regional or distant sites (Stages IIIC and IV; P=0.009). The clinical outcome of patients in Group B was significantly more favorable (P=0.0003). The adjusted 3-year survival rates in Group A and Group B were 46.7% and 92.3%, respectively, and the 5-year rates were 38.1% and 83.7%, respectively. Patients in Group B were found to have significantly better (P=0.036) distant recurrence-free survival (DRFS) rates. The DRFS rate at 3 years was 63.6% in Group A, compared with 91.7% in Group B, and the DRFS rate at 5 years was 56.9% in Group A, compared with 82.0% in Group B. Using a cutoff point of tumor size=3 cm, similar findings were made.

CONCLUSIONS

Both study groups exhibited distinct clinical entities with significant differences in clinical course and prognosis. Cases with histologic skin involvement, relative to those with classic skin involvement, were found to have much less malignant potential. This corroborates the recommendation that cases with only histologic skin involvement should not be placed in the T4 category of the TNM classification.

Canine inflammatory mammary carcinoma: histopathology, immunohistochemistry and clinical implications of 21 cases

Human inflammatory breast carcinoma (IBC) is the most malignant type of breast cancer with an extremely poor prognosis. The dog is the unique animal species in which spontaneous inflammatory mammary carcinoma (IC) has been reported, although it is not well documented. The purpose of this study was to characterize histopathologically and immunohistochemically the canine IC, considering associated clinical features. Twenty-one dogs diagnosed with IC and with known clinical and necropsy data were included in the study. Tissue samples from necropsies underwent a histopathological review and an immunohistochemical study (Ki-67, estrogen receptor (ER), progesterone receptor (PR), and P53 tumor suppressor protein). The histological study revealed several types of carcinomas (solid, tubular, papillary, and adenosquamous) and three lipid-rich carcinomas. All tumors were ER negative. Two histological patterns of neoplastic dermal infiltration were observed: tubular/papillary and sarcomatous-like. Dermal sarcomatous-like infiltration was significantly related to previous treatments with progestagens (p = 0.006), primary type of IC (p = 0.03), extreme local pain (p = 0.02), reduced observation of emboli in dermal lymphatic vessels (p = 0.01), and increased expression of p53 (p = 0.001). PR expression was significantly higher in secondary post-surgical IC (p = 0.04). The absence of PR was related to the existence of pulmonary metastases at necropsy (p = 0.04). Canine primary IC is the most aggressive form of this disease with distinct histopathological and immunohistochemical characteristics. Progestins and endocrine-related mechanisms seem to be involved in canine IC development. Canine IC could serve as a spontaneous model for human IBC, particularly in studies concerned with new therapeutics approaches.

Prediction of outcome in locally advanced breast cancer by post-chemotherapy nodal status and baseline serum tumour markers

In spite of the apparent improvement in outcome in locally advanced breast cancer, the prognosis remains dismal in many patients. The aim of this study was to define prognostic subgroups within this heterogeneous entity. Between 1990 and 1999, 104 consecutive patients with locally advanced breast cancer were treated by a multimodality programme consisting of 4-6 courses of CAF induction chemotherapy followed by surgery, breast-conserving when feasible. In most cases, chemotherapy was then resumed, up to a total of eight courses, followed by locoregional radiation therapy. Patients with hormone receptor-positive tumours received tamoxifen (20 mg day(-1)) for 5 years. At a median follow-up of 57 months, the 5-year overall survival for the entire group and the disease-free survival for the 94 operated patients were 65% and 53%, respectively. Univariate analysis identified 10 prognostic factors of overall and disease-free survival, of which four retained significance on multivariate analysis: inflammatory breast cancer (P=0.0000, P=0.0004, respectively), baseline tumour markers (P=0.003 for both), post-chemotherapy number of involved nodes (P=0.003; P=0.017) and extracapsular spread (P=0.052; P=0.014). In conclusion, besides inflammatory features, baseline tumour markers and post-chemotherapy nodal status are strong predictors of outcome in locally advanced breast cancer.

Surgery in breast cancer

This year (1999) has been filled with new information on the prevention of breast cancer and new literature trying to address some of the long-term adverse consequences of our surgical therapies. As the complexities of our therapies continue to increase at exponential rates, we now also have the ability to more accurately predict the consequences of both our therapeutic actions and our failure to act. Nowhere is this more evident than in the literature devoted to long-term consequences of treatment for breast cancer. As we are more successful in achieving our goals of increased survival from this dreaded disease, the future needs of these long-term survivors must play an ever-increasing role in our current management. Advances reported this year are laying down a new basis for efforts to improve the quality of life for breast cancer survivors.