MDCT Is Very Useful for Evaluating the Spread of DCIS

Introduction: Ductal carcinoma in situ (DCIS) may occasionally spread widely in the duct-lobular segment, thereby complicating the complete resection of the lesion in breast-conserving surgery. In order to perform a safe operation for DCIS, the lesion area must be precisely evaluated in the preoperative imaging studies. We performed multidetector-row computed tomography (MDCT) for patients with DCIS and investigated the potential of MDCT for detecting DCIS lesions.Patients and methods: A total of 74 patients with DCIS underwent MDCT. The size of the DCIS lesion in each patient was measured in the volume-rendering view, and these sizes were compared with the lesion sizes obtained by mapping from the pathological tests. The differences between the lengths obtained from pathological tests and those obtained from MDCT (L-path-L-CT) were calculated, and the relationships between the differences and some factors were investigated.Results: Among the 74 DCIS patients who underwent MDCT, DCIS was detected in 61 patients (82.4%). Among these 61 cases, 45.8% were cases of comedo-type DCIS, but the detection rates for comedo and noncomedo cases were not different. The L-path-L-CT values for histological grade I DCIS (1.55 cm) and grade II & III DCIS (0.23 cm) were statistically different. Higher-grade DCIS was more detectable than low-grade DCIS (p = 0.013). Among the other factors, the MDCT assessments and the pathological assessments for comedo-type DCIS and Her-2-positive cases were more consistent than the corresponding results for noncomedo DCIS and Her-2-negative cases. However, these differences were not significant.Conclusion: MDCT shows high efficiency in detecting DCIS. More aggressive types of DCIS, such as higher grade, comedo type, and Her-2-positive DCIS were more precisely detected by MDCT. In comparison with magnetic resonance imaging (MRI), the patient's position during MDCT testing is more similar to that during surgery. Therefore, MDCT is a highly useful presurgical imaging technique for the assessment of DCIS.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5029.

Utility of Breast CT in the Management of Breast Cancer – Results from a Prospective Multi-Institutional Study

Background:In order to obtain negative margins after breast conserving surgery (BCS), even repeated surgery is widely accepted. Before surgery, it is important to conduct a precise assessment of the extent of the breast cancer so that each patient can receive individualized surgery. To evaluate the utility of breast computed tomography (CT) as a tool to manage BCS, a multi-institutional prospective study was conducted in Japan.Patients and Methods:Patients were eligible to participate in this study if they had histologically proven breast cancer and were determined to be BCS candidates based on palpation, mammography (MMG) and ultrasonography (US). Written informed consent was obtained from each patient. First, the surgeon marked the line of planned excision on the skin using information from the MMG and US. Next, an expired angiographic catheter was placed on the mark to show the original surgical margin on the CT image. Breast CT was scanned 60 seconds after the bolus injection of the contrast material in the supine surgical position. The surgeon determined the extent of surgery based on the breast CT results. Surgical specimens were serially sectioned in 5-mm slices.Results:Three hundred and two patients were enrolled in this study. The CT scanners used in this study varied from a single helical CT to a 64-row multidetector CT. The results of the breast CT changed the extent of resection in 14.7% of patients. Among the 5 patients who were recommended to undergo a mastectomy, 4 patients had multicentric tumors pathologically and 1 patient had a widely spread intraductal component. The other patients were recommended to have a quadrantectomy based on the extent of breast cancer that was visualized by CT. Three patients (1%) who required conversion from a lumpectomy to quadrantectomy resulted in overexcision. In short, breast CT correctly changed the extent of surgery in 13.7% of the examined patients.Conclusion:This prospective study suggested that breast CT is useful for hospitals equipped with any type of CT and can be used to provide patients with individualized surgery.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5021.

The combination of capecitabine and cyclophosphamide for metastatic breast cancer patients

e12025

Background: Capecitabine (X) is converted into 5-FU by thymidine phospholylase (TP). Cyclophosphamide (C) has been shown to make TP higher in the preclinical study. Therefore, the combination of capecitabine and cyclophosphamide (XC) is thought to have a synergistic activity. We explored the efficacy of XC for metastatic breast cancer patients. Methods: 50 metastatic breast cancer patients were treated with XC in our medical center between April 2004 and December 2008. Median patient age was 58 years old (range: 34–79 years old). 36 patients were postmenopausal. X was 1675mg/m2 days 1–21 and C was 67mg/m2 days 1–14 on a 28-day cycle in all-oral combination. This therapy was continued until progression of disease or unacceptable toxicities occurring. Results: Median time to treatment failure was 28 weeks (range: 2–158 weeks). 9 patients were not evaluable for tumor response. Among 41 evaluable patients, complete response (CR) was observed in 2.4% (1 patient) and partial response (PR) was 29.2% (12 patients). Stable disease (SD) was 41.4% (17 patients) and progression of the disease (PD) was 26.8% (11 patients). The objective response rate (CR+PR) was 31.7% and the overall clinical benefit (CR+PR+SDÅÜ24 weeks) was 53.6%. Significant toxicities were uncommon: grade 3 toxicities were encountered for neutropenia in 1 patient, anorexia in 1 patient and hand-foot syndrome in 2 patients. Conclusions: XC is an effective regimen in metastatic breast cancer, and this therapy is of an easy administration and very well tolerated.

No significant financial relationships to disclose.

Invasive and non-invasive breast cancer can be distinguished from normal mammary gland or benign breast tumor by apparent diffusion coefficient in magnetic resonance imaging

Abstract #4011

Introduction: MRI (magnetic resonance imaging) has become increasingly important in the diagnosis of breast cancer and evaluation of the area to be resected. However, large amounts of information are buried in plain MRI, including apparent diffusion coefficient (ADC). This study measured ADC for normal breast tissue, benign breast tumor and malignant breast tumor, and tested the ability to differentiate malignant lesions from benign breast tumor or normal mammary gland.
 Patients and Methods: ADC was measured for 122 consecutive patients who visited our institute with breast abnormality from January 2007. Malignant breast tumor was diagnosed in 101 patients (invasive breast cancer, n=81; non-invasive cancer, n=20) and 21 patients displayed benign breast tumor (n=11) or normal mammary gland (n=10). A 3.0-T MRI system was used in this study and the motion-providing gradient added was 0 and 1000 s/mm2.
 Results: Mean ADC for the 101 breast cancer patients was 0.939±0.225 10-3 mm2/s, lower than that of the 26 benign or normal patients, at 1.247±0.269 10-3 mm2/s (p>0.0001, t test). Among breast cancers, mean ADC was 0.892±0.021 10-3 mm2/s for invasive lesions and 1.081±0.247 10-3 mm2/s for ductal carcinoma in situ. Each showed significantly lower ADC than benign or normal breast tissues (p>0.0001 each). Three cases of micro-papillary cancer were identified, and this type of cancer is known to display a worse prognosis. Mean ADC for these cases was 0.660±0.089 10-3 mm2/s, lower than the average for breast cancer. Furthermore, mean ADC in 46 cancer cases with histological grade II III was 0.857 10-3 mm2/s, lower than that of the 23cases with grade I tumor, at 1.023 10-3 mm2/s (p=0.0029).
 Conclusion: This study revealed that even non-invasive breast cancer can be distinguished from benign lesions by ADC. As ADC can be obtained rapidly without use of contrast enhancers, this approach has potential for application in breast screening. Furthermore, as aggressive cancers such as invasive micropapillary cancer or high-grade cancer show low ADC, use of ADC values as potential prognostic markers should be investigated.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4011.

Sentinel node biopsy with technetium-99m colloidal rhenium sulphide in patients with breast cancer

Background

Sentinel node biopsy is emerging as a technique to replace routine axillary lymph node dissection. The lymphatic mapping technique is still at a developmental stage and no standard technique exists. This study used technetium-99m colloidal rhenium sulphide with a mean particle size of 100 (range 50–200) nm for sentinel node mapping.

Methods

Eighty-seven patients with breast cancer, but no clinical evidence of axillary metastasis, were studied. One day before operation technetium-99m colloidal rhenium sulphide was injected at four points into breast tissue surrounding the tumour. Lymphoscintigraphy was performed 2 h after injection, and surgery was usually performed after 20 h. A hand-held γ probe guided sentinel node biopsy.

Results

Lymphoscintigraphy revealed axillary hot spots in all patients. During operation, the sentinel node was identified in all 87 patients (100 per cent). The number of sentinel nodes per patient ranged from 1 to 5 (mean 2). Metastatic sentinel nodes were identified in 37 of 87 patients. There were no false negatives.

Conclusion

This study suggests that technetium-99m rhenium sulphide is a suitable agent for sentinel node mapping in patients with breast cancer.

Giant mammary hamartoma diagnosed by stereomicroscopic analysis of the mammary glandular tree in an adolescent girl: report of a case

This report describes a rare case of a giant hamartoma that developed in the right breast of a 17-year-old girl. No abnormalities were found by endocrinological studies and a well-circumscribed tumor, approximately 20 cm in diameter, was easily enucleated without bleeding during surgery, following which the bilateral breasts became nearly symmetrical. Histologic features revealed predominant fibrous stroma and scattered normal or occasionally dysplastic mammary glands without neoplastic properties. No distorted lobular structures indicating fibroadenoma characteristics were observed. Subgross and stereomicroscopic analysis of serial 2-mm-thick sections revealed mature normal lobules and predominant fibrous interstitial components. Therefore, the tumor was diagnosed as a giant hamartoma of the breast, according to the histologically non-neoplastic features and the delimited macroscopic appearance. This is a rare mammary gland disease characterized by the fact that although each of the histological components seemed to be normal, their constitution was abnormal. It appears that not only histological features but also clinical details are indispensable for the diagnosis of this disease.

[Intermittent administration of 5-FU and isovorin to patients with advanced and recurrent colon cancer]

We attempted a new regimen of intermittent administration of 5-FU and low-dose Isovorin (F.I) to four patients with advanced and recurrent colon cancer. A partial response (PR) was achieved in two of four patients who had evaluable lesions for this treatment. We observed few side effects among these patients. Only one patient among four showed grade 1 neuropathy after two administrations of this chemotherapy. However, after a two-week pause in administration, the neuropathy disappeared and we could continue the therapy. This patient with multiple liver metastases achieved a partial response. Other patients had no side effects such as bone marrow suppression or digestive symptoms. This intermittent F.I treatment might be an effective and promising therapy with few side effects even for patients with poorer conditions.

Computer-assisted complete three-dimensional reconstruction of the mammary ductal/lobular systems: implications of ductal anastomoses for breast-conserving surgery

BACKGROUND

The intraductal spread of breast carcinoma can occur along the mammary ductal/lobular systems (MDLS) with no invasion of tissues. Because ductal anastomoses in the MDLS are considered to be a possible risk factor for extensive intraductal spread of breast carcinoma, the architecture of the MDLS has important therapeutic implications for patients treated with breast-conserving surgery.

METHODS

An entire breast resected by subcutaneous mastectomy from a 69-year-old woman with ductal carcinoma in situ (DCIS) was examined in submacroscopic sections by stereomicroscopic and histologic techniques. Serial 2-mm sections underwent computer-assisted complete three-dimensional reconstruction of all MDLS.

RESULTS

The entire breast that was studied contained 16 MDLS that were arranged radially, with the nipple at the center. Of these 16 MDLS, 4 (25.0%) had ductal anastomoses whereas the remaining 12 MDLS had no ductal anastomoses and completely independent regional anatomy. Ductal anastomoses were observed at 11 sites in the 4 MDLS. The 2 of 11 ductal anastomoses that connected different MDLS (18.2%) were situated > 4 cm from the nipple. The remaining nine ductal anastomoses connected ducts within the same MDLS; their location varied from near the nipple to the peripheral region. In the specimen examined, DCIS extended only within a single MDLS and did not spread between different MDLS via ductal anastomoses.

CONCLUSIONS

To the authors' knowledge, the current study is the first time the complete architecture of all MDLS in an entire breast has been studied three-dimensionally. The risk of promoting the intraductal spread of disease during surgery may be greater when intraductal lesions extend more peripherally than centrally. The features of ductal anastomoses may provide a significant anatomic clue regarding negative surgical margins in breast-conserving surgery.

[Clinical experience of intermittent administration of 5-FU and CDDP to patients with advanced and recurrent gastric cancer]

We administered 5-FU and CDDP (FP) intermittently to four patients with advanced and recurrent gastric cancer. A minor response (MR) and partial response (PR) were achieved in two of four patients who had evaluable lesions for this treatment, and few side effects were observed. Only one patient among six showed grade 2 leucocytopenia after 15 administrations of this chemotherapy, when she had attained a partial response in a lung metastasis. The other patients had no side effects such as bone marrow suppression or digestive symptoms. This intermittent FP treatment may be an effective and promising therapy with few side effects even for the patients with serious conditions.

Scattered fat invasion: an indicator for poor prognosis in premenopausal, and for positive estrogen receptor in postmenopausal breast cancer patients

BACKGROUND

Intracrine mechanisms which accelerate cancer cell growth are becoming well known in breast cancer research. In this study, microscopic invasive patterns of breast cancer cells into surrounding stromal tissues were evaluated.

PATIENTS AND METHODS

174 patients (110 patients < or = 50, and 64 > or = 60 years) underwent total or partial mastectomy from 1985 to 1993. In these patients the microscopic invasive pattern (especially scattered invasion into fat, SIF), influence on hormone receptor status, survival, and adjuvant therapy effectiveness were studied.

RESULTS

A correlation was shown between being SIF- and estrogen receptor-positive only in older (> or = 60 years) patients (chi(2) test, p = 0.058). In younger patients, SIF was also related to a poorer prognosis (log rank test, p = 0. 0004). These results were also confirmed by multivariate analysis. Adjuvant therapy activity was influenced by SIF status in premenopausal patients.

CONCLUSION

In older patients, SIF may be related to an intracrine supply of estrogen. In younger patients, SIF seems to work by a different mechanism for survival. These results also suggest some influence of SIF on adjuvant chemo-endocrine therapy results.

Adenoid cystic carcinoma of the breast: report of a case

Adenoid cystic carcinoma of the breast is an uncommon form of cancer, and only a few articles have described the cytological findings of this disease. We report herein the case of a 48-year-old woman who presented with a breast mass beneath the nipple, the aspirate from which consisted of globules of mucous balls surrounded by epithelial cells with scant cytoplasm and hyperchromatic nuclei. Microscopically, the tumor was formed by myoepithelial cells and glandular epithelial cells in a biphasic pattern. Immunohistochemical study revealed positivity for smooth muscle actin. A left total mastectomy with axillary lymph node dissection was performed. None of the 22 axillary lymph nodes contained metastases, and the patient remains well and free from recurrence 29 months after her operation. This case report provides some information about the cytological diagnosis and the accuracy of fine-needle aspiration, which must be considered despite the rarity of this disease.

[Support system for cancer patients in the north area of Fukushima]

The purpose of this study was to elucidate the support system for cancer patients in the north area of Fukushima. The support system includes 3 general hospitals, 2 clinics with home-care hospice, 4 self-help groups, 5 volunteer groups, 3 doctors and nurses from special interest groups and 7 home-care medical services. We displayed this system on Internet (http://www.fmu.ac.jp/home/kanwa).

Molecular analysis of the h-warts/LATS1 gene in human breast cancer

Loss of heterozygosity (LOH) on chromosome 6q is often observed in breast cancer, suggesting the existence of a putative tumor suppressor. Recently, a human homolog of the Drosophila warts tumor suppressor gene, h-warts/LATS1, was identified and mapped at chromosome 6q24-25.1. Mutation analysis of the h-warts/LATS1 was performed using 25 breast cancer tissues by RT-PCR SSCP analysis. Although LOH of the h-warts/LATS1 was found in one patient, no mutations were found. Two polymorphisms were found, but neither of them caused amino acid substitutions. Further investigations are necessary to elucidate the role of the h-warts/LATS1 gene in the carcinogenesis of breast cancer.

Fatty acid synthase expression in Japanese breast carcinoma patients

Fatty acid synthase (FAS) is the key enzyme required for the conversion of dietary carbohydrates to fatty acids. Recent studies have demonstrated that high levels of FAS expression occur in a variety of cancers, including breast cancer. We evaluated 243 primary breast cancer patients in the period between 1989 and 1996. Immunohistochemical staining for FAS was performed on formaline-fixed, paraffin-embedded sections. FAS staining intensity was graded as low or high. The expression of FAS was high in 145 (60%) and low in 98 cases (40%). A weak correlation between FAS expression and nodal status was noted in premenopausal patients (p=0. 01). FAS was associated with estrogen receptor (p=0.0022) and progesterone receptor (p=0.0085) status. We found that a low expression of FAS was significantly related to a shorter disease-free survival (DFS) rate in estrogen receptor positive patients (p=0.024) and a similar trend was recognized in progesterone receptor positive patients (p=0.083). The low FAS group showed better DFS and OS in all but ER-/PgR- cases (p=0.011, 0.076). This study showed close correlations between immunohistochemical FAS expression and steroid hormone receptors in premenopausal patients. The use of FAS expression may increase the diagnostic utility of ER and PgR in premenopausal patients. FAS may be able to predict the responsiveness of tumors to endocrine therapy.

Tamoxifen-induced apoptosis in breast cancer cells relates to down-regulation of bcl-2, but not bax and bcl-X(L), without alteration of p53 protein levels

Tamoxifen (TAM) has been shown to induce apoptosis in breast cancer cells. bcl-2 family genes, which can interact with each other, have been shown to interfere with apoptosis after various stimuli. In this study, we investigated the effects of TAM on bcl-2 family gene products bcl-2, bax, and bcl-X(L) and on p53 levels in estrogen receptor-positive MCF-7 breast cancer cells. We found that TAM induced time- and concentration-dependent down-regulation of bcl-2 at both the mRNA and protein level. Down-regulation of bcl-2 correlated with TAM-induced apoptosis. In addition, estradiol treatment significantly increased bcl-2 protein expression and blocked the reduction of bcl-2 by TAM. TAM did not, however, affect bax, bcl-X(L), or p53 expression at the mRNA or protein level. Our results demonstrate that TAM can induce apoptosis in a time- and dose-dependent manner by modulating bcl-2 levels in breast cancer cells, and down-regulation of bcl-2 induced by TAM was not accompanied by alterations in p53 levels.

Immunohistochemical Image Analysis of Estrogen and Progesterone Receptors in Breast Cancer

BACKGROUND: Recently objective quantification of immunohistochemical estrogenreceptor (ER) and progesterone receptor (PgR) staining in breast cancer by image cytometry has been predominantly performed by measuring the area of positivelystained cells. However, in sample preparations of immunostained hormone receptors, both the stained area and the intensity of staining vary. In this study, we performed quantification of the stained area by measuring, tailing intensity using image cytometry. METHODS: Quantitative analysis of ER and PgR immunohistochemistry was performed using image cytometry. The obtained values were presented as % of positive staining (% PS). Comparison of % PS with values obtained by EIA and with clinicopathological features was performed. RESULTS: The % PS values and the natural logarithm of the EIA levels of the hormone receptors showed a significant positive correlation for both ER and PgR. The concordance of the results obtained by the two methods was 96.3% for ER and 73.7% for PgR. The ER-% PS values of postmenopausal patients were significantly higher than those of premenopausal patients, whereas the PgR-% PS values of the former group were significantly lower than those of the latter group. CONCLUSION: The quantification of ER and PgR in immunostained preparations using % PS as a parameter was reproducible and showed a high correlation with values obtained by EIA. It was shown that only menopausal status affects hormone receptor levels when analyzing the relationship between % PS measurements and clinicopathological features.

The role of bcl-2 expression in breast carcinomas (Review)

The proto-oncogene bcl-2 is demonstrated to block a final common pathway leading to apoptosis and is expressed in more than half of human breast cancers. Invasive breast cancer has reduced bcl-2 immunostaining compared with normal breast epithelia and preinvasive breast lesions. As an inhibitor of apoptosis, bcl-2 should correlate with highly aggressive tumor biology and resistance to hormonal/cytotoxic therapy. However, high bcl-2 expression has been shown to associate with a number of favorable prognostic factors including ER positivity, PgR positivity, low histological grade, well-differentiated tumor, absence of c-erbB-2 and p53. Unexpectedly, numerous studies have shown that tumors with high bcl-2 expression are more responsive to hormone therapy and have more favorable disease-free and overall survival. The clinical significance of bcl-2 in tumorigenesis and prognosis of breast carcinomas from the data recently published are reviewed. Its role in modulation of hormonal/cytotoxic therapy and future directions are also discussed.

Clinical characteristics of breast cancer patients with family history

This study was conducted to acquire information as to the clinicopathological characteristics of breast cancer patients with family history. Of 583 patients with breast cancer, 60 (10.3%) had family history in at least one relative within the second-degree. The affected family member was most frequently a sister (43%), followed by the mother (23%) and an aunt (20%). Comparison of the data for the patients between with and without family history revealed no significant differences for any of mean age, menopausal status, histological type, histological staging, and estrogen receptor status. Although the sample size was small, neither the survival rate nor the bilaterality of disease was influenced by the family history of breast cancer.

Apoptotic index correlates to bcl-2 and p53 protein expression, histological grade and prognosis in invasive breast cancers

Apoptosis is considered to play a critical role in tumorigenesis. In order to clarify the significance of apoptosis in breast cancers, we quantitated apoptotic cells by light microscopy in 126 patients with invasive breast cancers. The expression of bcl-2, and p53, as regulators of apoptosis, was immunohistochemically analyzed. Apoptotic index (AI) detected in the patients ranged from 0 to 48 per mm2 of breast cancer cells (mean +/- SE, 11.0 +/- 0.97). Significantly highly AI was found for the tumors with grade 3 (p < 0.0001), high mitotic index (p < 0.0001), and bcl-2 negatively (p = 0.004) compared with those with grade 1 or 2, low mitotic index, and bcl-2 expression, respectively. Moreover, high AI was associated with larger tumor size (p = 0.008), positive lymph nodes (p = 0.01), p53 positivity (p = 0.01), and advanced TNM stage (p = 0.03). In survival analysis, we found that low AI, like bcl-2 and other conventional prognostic indicators, was significantly predictive of better prognosis in terms of both disease-free survival (DFS) and overall survival (OS) (each, p < 0.0001). In multivariate analysis, AI failed to retain an independent significant value for DFS or OS. Our results indicate that low AI is related to a number of clinicopathologic and biologic parameters known to predict a lower risk of recurrence and is associated with a favourable survival in invasive breast cancer. However, it was not an independent prognostic factor for clinical outcome in this patient series.

[Correlation between apoptotic index, bcl-2 protein expression and progression and prognosis in breast carcinoma]

Apoptosis is considered to play a critical role in tumorigenesis. It has been shown that apoptosis is controlled by both pro-oncogenes bcl-2, c-myc and tumor-suppressor genes p53. We determined the apoptotic index (AI) on light microscopy and detected immunohistochemically the expression of bcl-2 and p53 in patients with breast cancer. The correlations between AI and clinicopathological factors, bcl-2 and p53 were also analyzed. Our results showed that bcl-2 expression was down-regulated in the process from normal breast epithelial cells to intraductal carcinoma and from intraductal carcinoma to invasive carcinoma. We failed to detect p53 protein in normal breast epithelial cells, and p53 positivity was 24% and 30% in intraductal and invasive cancer tissues, respectively. Moreover, AI was significantly associated with histological grade, mitotic index, and bcl-2 and p53 expression. In univariate analyses, lower AI and bcl-2 expression was significantly predictive of a better prognosis for both disease-free survival and overall survival. These results suggest that apoptosis and apoptosis-related gene (bcl-2, p53) are related to progression and prognosis in breast cancer.

Correlation between the expression of apoptosis-related bcl-2 and p53 oncoproteins and the carcinogenesis and progression of breast carcinomas

The proto-oncogene bcl-2, which is implicated in the regulation of cell death by inhibiting apoptosis, is reported to be expressed in breast tissues. The wild-type p53 has been shown to induce apoptosis, which can be inhibited by bcl-2 expression. However, the role of bcl-2 and p53 expression in breast carcinogenesis has not been clarified. The purpose of this study was to evaluate bcl-2 and p53 expression in normal breast epithelia cells, as well as in intraductal and invasive cancerous lesions of breast cancer tissue using an immunohistochemical method and to clarify their role in the development of breast cancer. The nuclear accumulation of p53 was also evaluated by quantitative image analysis. Expression of bcl-2 was found in 79 of 82 (96%) normal ductal epithelial cells, in 50 of 63 (79%) intraductal carcinomas, and in 62 of 137 (45%) invasive carcinomas, respectively. Higher bcl-2 expression was observed in normal epithelial cells than in intraductal and invasive cancerous cells (P < 0.0001). Furthermore, bcl-2 positivity in intraductal lesions was significantly higher than in invasive cancerous lesions (P < 0.05). No p53 nuclear accumulation was observed in normal breast epithelial cells. Fifteen of 63 (23.8%) intraductal cancerous lesions and 41 of 137 (30%) invasive cancerous lesions were positive for p53 expression. An inverse relationship was shown between bcl-2 and p53 expression in invasive carcinomas. We demonstrated that bcl-2 expression exists in most of normal ductal epithelial cells and gradually decreases during the development of breast cancer, i.e. , from a normal epithelium to intraductal carcinoma, and from intraductal to invasive carcinoma, and that p53 expression may occur early in breast cancer development and increases during progression.

Role of age as a prognostic factor in breast cancer

The effect of age on the prognosis of breast cancer remains controversial. To investigate the role of age, we reviewed 316 patients with stage I or II breast cancer. There were 14 patients below 34, 146 between 35 and 49, 115 between 50 and 65, and 41 over 66 years of age. No correlations were observed between age and clinicopathological variables. Breast cancer patients aged 34 or less had a significantly worse survival compared to those in the older age groups. Multivariate analysis also showed younger age to be a significant factor, followed by lymph node status. Therefore, younger age at onset is considered to be an independent prognostic factor.

Lack of the relationship between menstrual status and timing of surgery in survival of premenopausal patients with breast cancer

To clarify the relation between menstrual cycle at surgery for breast cancer and prognosis, we have retrospectively investigated 159 women with premenopausal breast cancer. The end of follicular phase was determined putatively as 15 days before the coming menstrual period, and the luteal phase was assumed to commence with the fourteenth day. The mean observation period was 49.7 months. At surgery, 86 patients were in the follicular phase and 73 in the luteal. There was no difference in distribution of age, family history, parity, tumor size or nodal status between the two groups. There were no differences in disease-free or overall survival rate. The follow-up period was not sufficient, but the current result found no relation between the timing of surgery and prognosis.

The evaluation of mammographic microcalcification as biological malignancy in breast cancer

The biological significance of mammographic microcalcification (MM) was investigated in breast cancer. 119 (39.8%) had evidence of microcalcification, while 170 were negative. Fifty-three (44.5%) of those with MM had nodal metastases. There is no significant correlation between MM and nodal metastases. Five-year survival of patients with MM was significantly shorter than that without. This suggests that MM may be of biological significance in breast cancer, and thereby attention should to be paid to assessing breast cancer patients with mammographic microcalcification.

Prognostic value of nuclear grading assessed by image cytometry for node negative breast cancer patients

BACKGROUND

Although nuclear grading is a useful prognostic factor for node-negative breast cancer, it is difficult to evaluate objectively. In this study, we show the heterogeneity of the nuclear area (NA), and predictive value of NA evaluated by image cytometry.

MATERIALS AND METHODS

The NA of over 100 cancer cell nuclei were measured by two types of image cytometer on 182 primary lesions of node negative (nO) breast cancer patients. The mean NA of invasive and intraductal cells were measured on separated regions. The nuclei for evaluation were selected using three different methods: all cells, invasive cells alone, and larger cells. The prognoses were compared after the cases were divided at mean + SD/2.

RESULTS

No differences were observed in the mean NA of each portion. The difference of disease free survival between the two subgroups by log rank test and the p-value of each method were, 0.82, 0.21 and 0.0076.

CONCLUSIONS

Only when larger nuclei were selected, was NA a significant prognostic factor for node negative breast cancer patients. The cancer cells with larger nuclei possibly represent the malignant potential of each case.

[Flow cytometric DNA analysis of malignant potential in colorectal cancer]

Significance of flow cytometric DNA analysis for assessing malignant potential and survival of colorectal cancer was investigated using paraffin-embedded materials from 163 patients who underwent resection of curability A from 1971 to 1985, excluding intramucosal carcinoma. DNA diploid was confirmed in 46% (75 cases) of the patients and DNA aneuploid in 54% (88 cases). No significant correlation was seen between DNA ploidy and clinicopathological factors, such as tumor location, macroscopic type, histological type, depth of invasion, lymph node metastasis and stage. Cumulative survival rates after curable resection of colorectal cancer were significantly lower in patients with DNA aneuploid tumor than those with DNA diploid tumor. Furthermore, in patients in stage of II and III, survival rates were lower in DNA aneuploid patients than DNA diploid patients, respectively. A multivariate analysis of survival data using Cox's proportional hazard model showed that DNA ploidy was the significant discriminating factor on survival in stage II and III cancer. In conclusion, nuclear DNA ploidy in patients with stage II and III colorectal cancer undergoing curable resection may represent malignant potential and may be an independent prognostic factor.

Immunohistochemical evaluation of lymph node micrometastases from breast cancer

The lymph node micrometastasis was retrospectively immunohistochemically investigated in 185 patients with node-negative breast cancer and compared with the routine conventional findings. The monoclonal antibodies to epithelial membrane antigen (EMA) and mucinous-like carcinoma antigen (MCA) were used. Of 19 EMA-positive cases, 16 were false positive. Therefore only 3 cases were found to show staining with both EMA and MCA. The patients are all living and well and free of recurrence. No micrometastasis was immunhistochemically demonstrated in 11 node-negative breast cancer patients with subsequent metastases. The results of the present study indicate that the detection rate containing occult cells afforded by conventional routine evaluation is sufficient, at least in Japanese.

p53 mutations and overexpressions in Japanese breast cancer

Mutations in the p53 gene were analysed in 50 cases with breast cancer by PCR-SSCP and direct DNA sequencing. Mutations were found in 10 of 50 cases (20%) including a case with Tis, and loss of the normal allele was found in five of these cases. Eight of the 10 mutations occurred within highly conserved domains, but no mutational hot spots were found. GC to AT transitions were the most frequent mutations (six of 10 cases), while mutations at CpG dinucleotides were found in three cases (30%). AT to TA transversions were the second most frequent mutation (20%). The level of expression of p53 protein was assessed by Western blot analysis in 62 cases. Overexpression of p53 protein was detected in 21 of 62 cases (34%) including a case with Tis. There was a strong correlation between missense mutations in the p53 gene and overexpression of p53 protein. Overexpression of p53 protein was closely associated with increasing tumour size and ER-negative status among the various factors investigated, suggesting that p53 overexpression may reflect the lack of differentiation in breast cancer.

Intraductal extension of primary invasive breast carcinoma treated by breast-conservative surgery. Computer graphic three-dimensional reconstruction of the mammary duct-lobular systems

BACKGROUND

Intraductal tumor extension is a characteristic feature of primary breast carcinoma, and is an important consideration in patients undergoing breast conservative surgery. However, there have been no reports of studies of intraductal extension within the mammary ductal tree.

METHODS

Quadrantectomy specimens from 20 patients with primary invasive breast carcinoma were examined by subgross and stereomicroscopic technique to visualize intraductal tumor extension. Serial 2 mm-thick sections were subjected to two-dimensional (2-D) tumor mapping, measuring the distances and angles of extension, and to three-dimensional (3-D) reconstruction of the mammary duct-lobular systems by means of computer graphics.

RESULTS

Intraductal tumor extension was found in 16 of 20 specimens (80.0%), extending continuously from the primary invasive carcinoma through the mammary ductal tree. The distances and angles of extension were larger in tumors with microcalcifications, papillotubular invasive ductal carcinoma, 30% or more of intraductal component, and comedo-type intraductal tumor extension. The 3-D reconstructions demonstrated three types of extension; central (11 cases), peripheral (3 cases), and mixed (2 cases). Further, there were some ductal branches anastomosing with different mammary duct-lobular systems at various sites. In one specimen, intraductal tumor extended widely from the primary invasive carcinoma through a branch connecting adjacent mammary duct-lobular systems.

CONCLUSIONS

Three-dimensional reconstruction images of intraductal extension of invasive breast carcinomas are presented for the first time to the authors' knowledge. Examples of ductal anastomoses were observed, and should be considered as a risk factor for possible widespread intraductal extension through multiple mammary duct-lobular systems.

Evaluation of aspiration biopsy cytology and combined preoperative tests in the diagnosis of breast cancer

This study was conducted to investigate the usefulness of aspiration biopsy cytology (ABC) and other combined tests for the preoperative diagnosis of breast cancer. In an analysis of 599 aspirates of breast tumors, "suspicious" cases were included among the positive, while "borderline" cases were considered to be negative. The sensitivity of ABC was 87.3%, the specificity was 92.3%, and the predictive value of a positive diagnosis was 92.8%. A total of 207 cases of breast cancer were evaluated to determine the diagnostic significance of breast cancer, particularly for tumors less than 2.0cm by means of quadruple test including physical examination, mammography (MMG), ultrasonography (US), and ABC. The combined tests of MMG or US, and ABC resulted in a sensitivity of 96.2% and 94.9%, respectively, and were considered to complement each other in the diagnosis of small breast cancer. Surgical biopsy is thus not always necessary in malignant cases that are conclusively diagnosed by the combined quadruple test.

Six cases of heterochronous gastrointestinal cancer preceded by breast cancer

Among 432 women with primary breast cancer, six (1.4%) were diagnosed as having gastrointestinal cancer more than six months after operation for the breast cancer. This paper presents these six cases. The patients ranged from 56 to 78 years of age at the time of breast cancer surgery, and the interval after surgery until diagnosis of the second cancer ranged from 7 months to 5 years 1 month. The second cancer was gastric cancer in 3, esophageal cancer in 2, and hepatic cancer in 1. All of the 6 patients had received postoperative adjuvant chemotherapy for breast cancer. The most frequent histological type of breast cancer was solid-tubular carcinoma (3 patients). Three patients died, due to the second cancer, 4 days, 2 months, and 6 months, respectively, after diagnosis of the second cancer, and the other patients are alive 2, 3, and 4 years after diagnosis. The Japanese literature regarding multiple cancer among breast cancer patients is reviewed. It is concluded that care should be taken to examine breast cancer patients with gastrointestinal symptoms, which are likely to be dismissed as a side effect of postoperative chemotherapy.

[Efficacy of combination therapy consisting of cyclophosphamide, adriamycin, UFT and oophorectomy/tamoxifen for advanced or recurrent breast cancer]

Combination therapy consisting of cyclophosphamide (CPA), adriamycin (ADR), UFT and endocrine therapy of oophorectomy or tamoxifen (TAM) was given female patients with advanced or recurrent breast cancer. Premenopausal patients initially underwent oophorectomy, then were administered 300 mg/day of CPA and 30 mg/day of ADR intravenous injection every 2 weeks, and 300 mg/day of UFT orally every day. Postmenopausal patients, on the other hand, were administered the same three chemotherapeutic drugs and 30 mg/day of TAM orally every day instead of receiving castration. A total of 10 patients were registered, and nine of them were eligible. Premenopausal cases were six, and postmenopausal cases were three. The objective response rates were 50% (3/6) for premenopausal women and 33% (1/3) for postmenopausal women. Complete response was observed in one patient and partial response in three patients. The therapy was effective for lymph nodes (2/2), lung (3/4), breast (2/3), skin or subcutis (1/2), but it showed no effect on bone, pleural effusion or ascites. The overall 5-year survival rate was 53.3%. The main side effects of more than Grade 1 were leucopenia 33% (3/9), anorexia 22% (2/9) and malaise 22% (2/9). They were relatively mild for therapy involving ADR. This therapy was considered useful for advanced or recurrent breast cancer.

[Diagnosis in early breast cancer]

To improve the survival in breast cancer, it is important to detect and treat breast cancer early. Physical examination (PE), mammography (MMG), ultrasonography (US), and aspiration biopsy cytology (ABC) are routinely assessed in the diagnosis of breast cancer. When three procedures including ABC are positive in a diagnosis of breast cancer, it is an absolute indication for surgery. Of all 238 breast cancers between 1987 and 1992, 86 cases were T1. The sensitivity of each procedure was PE 58.9%, MMG 70.0%, US 74.4% and ABC 86.2%, indicating that PE was less sensitive for small cancer. The recent accuracy of ABC in our series was satisfactory, and the combination diagnosis had a good result for T1 tumor because the findings from these procedures were complimentary. The high accuracy of ABC therefore suggests that lumpectomy has two aspects, definite diagnosis, and therapy as conservative surgery for breast cancer. The nineteen cases of T0 cancer encountered were almost entirely detected by nipple discharge or MMG. In conclusion, the combination diagnosis including ABC was very effective, and it is very important to detect and diagnose clinically small or non-palpable breast cancer.

Squamous cell carcinoma of the breast. Report of a case diagnosed by fine needle aspiration cytology

A 66-year-old woman presented with pure squamous cell carcinoma of the breast, a rare occurrence. The incidence of pure squamous cell carcinoma of the breast is lower than that of the mixed type. The preoperative diagnosis could be made by fine needle aspiration cytology. A modified radical mastectomy was performed. The patient was doing well, with no evidence of recurrence, 17 months after surgery.

Immunohistochemical overexpression of C-erbB-2 in the prognosis of breast cancer

Immunohistochemical c-erbB-2 protein overexpression was detected in 34 of 124 (27.4%) paraffin-embedded breast cancer specimens. Although no difference was seen between the c-erbB-2 positive and negative groups in 5-year disease-free survival, 5-year overall survival was significantly less favorable in the c-erbB-2 positive group. Furthermore, patients graded as having positive c-erbB-2 staining and aneuploid DNA showed significantly poorer survival than those in other categories. The significant prognostic factors, determined by a multivariate analysis, were nodal status and c-erbB-2 overexpression. Our findings therefore suggest that c-erbB-2 expression is a prognostic factor in breast cancer and that it could be useful in the determination of postoperative adjuvant therapy.

[Different growth rate and contracting activity of collagen gel between fibroblasts from breast cancer tissue and normal breast tissue]

We have already reported that stromal fibroblasts of breast cancer tissue (CaF) promoted the growth of breast cancer cells in vitro. It was found that CaF and fibroblasts in normal breast tissue (NF) showed the different growth and contracting activity. Materials were obtained from cancer tissue and normal breast tissue. Cells were prepared by collagenase digestion. The CaF's growth was more rapid than NF's. After a reconstitution of type I collagen, monolayer cultures of CaF and NF were done on collagen gel for 24 hours, then collagen gel was detached from the dish and was being float. After 2 days incubation, an area of collagen gel was measured. A contraction of CaF's gel was greater than that of NF. This showed that CaF had more contracting activity than NF. These results might be indicated that the function of CaF was to contribute the invasive growth of breast cancer cell as well as to secrete the growth factors. Therefore, it is considered, a control of the fibroblasts derived from cancer stroma may play an important role in the treatment of breast cancer.

[S-phase fraction and malignant potential in DNA diploid colorectal cancer]

Patients with DNA diploid tumor have a significantly longer survival than those with DNA aneuploid in colorectal cancer, but some patients with diploid tumor show poor survival. For assessing malignant potential in diploid colorectal cancer, flow cytometric analysis of S-phase fraction (SPF) was investigated using paraffin-embedded materials from 79 carcinoma patients who had been treated from 1971 to 1989. There was no significant correlation between SPF and clinicopathological factors (such as sex, tumor size, tumor location, macroscopical type, depth of invasion, node metastasis, peritoneal dissemination, liver metastasis and clinical stage). Mean SPF was significantly higher in poorly differentiated type carcinomas than in well differentiated type carcinomas. Patients with higher SPF had a tendency to poorer survival than those with lower SPF. From these results, it was concluded that SPF represents histological differentiation and that SPF may be a prognostic indicator, in diploid colorectal cancer.

[Surgery in the treatment of stage I, II breast cancer]

Stage I and II breast cancer is thought to be operable cancer. Possible surgical methods for such breast cancer could be grossly divided total mastectomy and breast preserving surgery (BPS) with axillary node dissection. In is necessary to obtain clear surgical margin after performing BPS. However it is difficult to know preoperatively the exact resected margin which is either clear or not. In order to select the cases performing BPS, we intended to compare the degree of coexisting intraductal component with histologic types and some factors such as DNA ploidy. ER and expression of cerb B-2 which is concerned in the malignant potential of breast cancer. Intraductal component is more frequently seen in papillotubular carcinoma. Diploid tumor is increased with increasing intraductal component in breast cancer. Precise postoperative microscopic study of resected specimen and tight observation of the patients received PBS for long period should be emphasized. We used methylsalicylate packed method on 2mm slice in thick by Wellings for postoperative histological study and investigated the intraductal architectural spreading under the dissecting microscope. This method is useful to define the three-dimensional architecture of spreading of intraductal carcinoma. After proving clear surgical margin by this analysis, we usually do not recommend the radiation therapy.

The relationship of estrogen receptor status to DNA ploidy in breast cancer

The relationship of estrogen receptor (ER) status to DNA ploidy was investigated in 121 patients with breast cancer who underwent surgery. Lymph node status was evaluated histologically and ER levels were determined by the dextran-coated charcoal method, with a level of 3 fmol/mg.protein being considered positive. Flow cytometric DNA content was analyzed using paraffin-embedded tissue blocks. Sixty-three percent of the specimens were ER+, while 37 percent were negative. Sixty-one patients (50.4 percent) were diploid and 60 aneuploid. A statistically significant correlation between the ER positivity rate and diploid DNA was found. Higher ER levels were seen in the postmenopausal patients with diploid tumors than in those with aneuploid tumors and there was a significant tendency for ER levels to be higher in the diploid tumors. Nodal status was not correlated with ER positivity or ploidy pattern. The present results indicate that ER levels are correlated with DNA ploidy, and reflect the degree of functional differentiation.