Prognostic Impact of Ectopic Fat Deposition within Psoas Muscle in Stage IV Gastric Cancer Patients Undergoing Systemic Chemotherapy

Aims: In this study, we focused on the fat ratio within psoas muscle (FRPM) and sought to clarify the impact of FRPM on overall survival (OS) in stage IV gastric cancer (GC) patients undergoing systemic chemotherapy (n = 79, median age = 69 years, 59 males). Methods: The median FRPM was 1.67 %. Forty patients with FRPM ≥1.67 % were defined as the FRPM-high group, and the remaining 39 patients was defined as the FRPM-low group. The median PMI in male and female patients was 4.35 cm²/m² and 2.88 cm²/m². Thirty male patients with PMI ≥4.35 cm²/m² and 10 female patients with PMI ≥2.88 cm²/m² was defined as the PMI-high group, and the remaining 39 patients was defined as the PMI-low group. Results: The 1-, 2- and 3- year cumulative OS rate for all cases was 70.8%, 24.3% and 14.6%. The proportion of ECOG-PS 2 or 3 in patients with FRPM-high and FRPM-low was 17.5% (7/40) and 2.6% (1/39). The 1-, 2- and 3- year cumulative OS rate in patients with FRPM-high and FRPM-low was 67.3%, 14.3% and 7.6% in the FRPM-high group and 74.8%, 40.5% and 32.4% in the FRPM-low group (P = 0.0341). The 1-, 2- and 3- year cumulative OS rate in patients with PMI-high and PMI-low was 86.7%, 40.4% and 30.0% in the PMI-high group and 55.8%, 12.8% and 6.4% in the PMI-low group (P < 0.0001). In the multivariate analysis of factors associated with OS, PMI (P = 0.0047) and FRPM (P = 0.0019) were independent predictors for the OS. Conclusion: Higher FRPM can be associated with decreased physical activity, and not only skeletal muscle mass but also skeletal muscle function can be an essential prognostic factor in stage IV GC patients undergoing systemic chemotherapy.

Grip Strength in Patients with Gastrointestinal Diseases

We sought to elucidate factors contributing to the grip strength (GS) decline in patients with gastrointestinal diseases (Ga-Ds, n = 602, 379 males, median age = 72 years). The GS decline in males and females was defined as <28 kg and <18 kg, respectively, following the current Asian guidelines. The median GS (male) was 28.8 kg, and GS decline (male) was found in 169 patients (44.6%). The median GS (female) was 17.5 kg, and GS decline (female) was found in 122 patients (54.7%). Advanced cancer was identified in 145 patients (24.1%). In terms of the univariate analysis of parameters of the GS decline, age (p < 0.0001), gender (p = 0.0181), body mass index (BMI, p = 0.0002), ECOG-PS (p < 0.0001), SARC-F score (p < 0.0001), hemoglobin value (p < 0.0001), total lymphocyte count (p < 0.0001), serum albumin value (p < 0.0001), C reactive protein (CRP) value (p < 0.0001), and estimated glomerular filtration rate were statistically significant. In terms of the multivariate analysis, age (p < 0.0001), BMI (p = 0.0223), hemoglobin value (p = 0.0186), serum albumin value (p = 0.0284), the SARC-F score (p = 0.0003), and CRP value (p < 0.0001) were independent parameters. In conclusion, the GS decline in patients with Ga-Ds is closely associated with not only the primary factor (i.e., aging) but also secondary factors such as inflammatory factors and nutritional factors.

Pharmacokinetics of Dexamethasone when Administered with Fosaprepitant for Chemotherapy-Induced Nausea and Vomiting and Differences in Dose-Dependent Antiemetic Effects

BACKGROUND

Fosaprepitant, an NK1 receptor antagonist, inhibits and induces cytochrome P450 3A4 (CYP3A4) as its substrate. Contrarily dexamethasone is metabolized by CYP3A4. Therefore, in combination therapy wherein both agents interact with each other, it is recommended that the dexamethasone dose be reduced in the first two days. Thus far, there are only a few studies on the optimum dose of dexamethasone after day 3. Thus, we aimed to determine the pharmacokinetics of dexamethasone on day3 when administered together with fosaprepitant and investigate the dose-dependent differences in its antiemetic effect in patients with cancer.

METHODS

Twelve patients with esophageal, stomach, or lung cancer received primary highly emetogenic chemotherapy (HEC). We intravenously administered 9.9 mg and 6.6 mg of dexamethasone on days 1 and 2, respectively, and 6.6 mg or 13.2 mg on day 3 together with the administration of 150 mg fosaprepitant and 0.75 mg palonosetron. We assessed the pharmacokinetics of dexamethasone on day 3 by dose and examined the dose-dependent antiemetic effect.

RESULTS

No differences were observed in the time-to-maximum concentration and blood half-life of dexamethasone between patient groups that received dexamethasone at doses of 6.6 mg and 13.2 mg. In contrast, the area under the blood concentration-time curve and the maximum concentration of dexamethasone correlated with its dose. Moreover, the blood dexamethasone concentration on day 3 increased by twofold after the administration of a higher dose than after a lower dose. The severity of nausea in the delayed phase significantly decreased in a dose-dependent manner.

CONCLUSION

Administration of a higher dexamethasone dose on day 3 improved the antiemetic effect of the combined regimen in patients with cancer who underwent HEC.<br />.

The comparison of mFOLFOXIRI with CAOX/SOX as neoadjuvant chemotherapy for locally advanced rectal cancer

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Background: The standard therapy for the locally advanced rectal cancer (LARC) (Ra or Rb, T2Npsitive, T3/4Nany) is chemoradiotherapy (CRT) followed by surgery. The CRT prevents local recurrence, although problems such as complications or the improvement of distant recurrence still remain. Several studies about the neoadjuvant chemotherapy (NAC) without radiation showed favorable R0 resection rate and outcome, however the best regimen of NAC is unclear. The aim of this study is to investigate the efficacy and safety of mFOLFOXIRI and CAPOX/SOX as NAC. Methods: We examined the patients (pts) with LARC who were planned to receive mFOLFOXIRI (5FU 2400mg/m2/day1-2, leucovorin 200mg/m2, oxaliplatin 85mg/m2, irinotecan 150mg/m2, every 2 weeks) or CAPOX/SOX(capecitabine 2000mg/m2 or S-1 mg/m2 80day1-14, oxaliplatin 130mg/m2, day1, every 3weeks) for 8-12 weeks as NAC, retrospectively. Results: Forty-nine pts received mFOLFOXIRI and thirty-two pts received XELOX/SOX between Jan 2015 and Mar 2019. The characteristics of mFOLFOXIRI and XELOX/SOX were as follows; median age, 64 (37-80) and 65 (33-68); PS 0/1, 46(94%)/3(6%) and 14(44%)/18(56%); Ra/Rb-P, 4(8%)/45(92%) and 0/32; clinical T2/3/4, 4(7%)/27(55%)/19(39%) and 1(3%)/18(56%)/13(41%); clinical N0/1/2, 13(27%)/26(53%)/10(20%) and 7(22%)/17(53%)/8(25%). The pathological response rate which was defined as tumor affected area over one-third were 61.2% in mFOLFOXIRI and 65.6% in CAPOX/SOX including complete remission of 4.1% and 12.5%, respectively. Six of 49 pts withdrew from mFOLFOXIRI due to toxicities, whereas one of 32 pts from CAPOX/SOX. One pt received CRT after SOX because of lack of efficacy. The major grade 3/4 toxicities of mFOLFOXIRI were neutropenia (n = 22, 45%), thrombocytopenia and febrile neutropenia (n = 4, 8%) and anorexia (n = 3, 6%), whereas CAPOX/SOX neutropenia (n = 3. 9%), thrombocytopenia (n = 1, 3%) and hand-foot syndrome (n = 1, 3%). The one year of relapse free survival rate were 85.4% and 83.6%. Conclusions: Although the pathological response of mFOLFOXIRI was comparable with CAPOX/SOX, CAPOX/SOX was less toxic.The further investigation including 5 year overall survival rate rate was needed.

The efficacy of aprepitant for the patients receiving FOLFOXIRI and FOLFIRINOX: A phase II study

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Background: Aprepitant (APR) showed the efficacy for the prevention of chemotherapy-induced nausea and vomiting (CINV) with highly emetogenic chemotherapy. The combination chemotherapies of moderately emetoegnic agents of oxaliplatin and irinotecan are classified as moderately emetogenic risk according to ASCO guideline, but showed severe vomiting and nausea. Methods: This phase II trial evaluated the efficacy of APR (day1;125mg, day2-3; 80mg) in patients receiving mFOLFOXIRI(oxaliplatin; 85 mg/m2, irinotecan; 150 mg/m2, leucovorin; 200 mg/m2, 5-FU infusional; 2400 mg/m2/46hour, every 2 weeks) and FOLFIRINOX (oxaliplatin; 85 mg/m2, irinotecan; 180 mg/m2, leucovorin;200 mg/m2, 5-FU bolus; 400 mg/m2, 5-FU infusional; 2400 mg/m2/46hour, every 2weeks). The primary objective was the complete vomiting inhibitation rate (CVIR) during first cycle. The null hypothesis and expectation of CVIR were 30% and 60% (one-sided α = 0.05, β = 1.0), so 23 patients were needed. CVIR was assessed according to MAT (MASCC Antiemesis Tool). Results: 25 patients were enrolled. The characteristics were as follows; median age (range), 65 (39-71); male/ female, 16/9; PS0/ 1, 11/ 14; mFOLFOXIRI/ FOLFIRINOX, 20/ 5; BMI < 22/ 22 or more, 14/ 11; history of alcohol yes/ no, 11/ 14. The CVIR was 92% (95%CI: 74-99) and complete response (no vomiting and no rescue medication use) rate was 72% (95%CI: 51-88%). The toxicities (all grade/ grade 3 or 4) were as follows; nausea, 17/ 2; vomiting, 3/ 0; fatigue, 16/ 2; constipation, 6/ 0. Conclusions: APR was effective for CVIR. Further prevention of nausea is expected.

Efficacy and feasibility of neoadjuvant chemotherapy and chemoradiotherapy for elderly patients with stage IB/II/III (excluding T4) esophageal cancer: Retrospective study

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Background: Neoadjuvant chemotherapy (NAC) of 5-fluorouracil plus cisplatin infusion (FP) is standard therapy for stage IB/II/III (excluding T4) esophageal cancer from results of JCOG9907 and definitive chemoradiotherapy (dCRT) of FP is one of the curative options for resectable esophageal cancer with organ preservation results of JCOG9906 in Japan. However, the efficacy and feasibility of NAC FP and CRT for elderly patients (pts) are unclear. Methods: We examined stage IB/II/III (excluding T4) esophageal cancer pts aged 70 or over, who received NAC FP or dCRT at our institution between April 2008 and August 2015, retrospectively. Results: 16 pts received NAC FP at least 1 course, while 5 pts received dCRT because of intolerability for surgery, reject of surgery, and patient's wish. Median age was 73/75 (NAC FP/dCRT) and pts in NAC FP had more advanced stage cancer compared with pts in dCRT (p = 0.02). With respect to the toxicity, bone marrow depression developed in dCRT with more high frequency compared with NAC FP, but no pts had febrile neutropenia. Adverse effects of fatigue, nausea and appetite loss developed in both group frequently. 3 pts were not performed surgery because of decreased respiratory function, decreased PS and progression disease and 4 pts did not achieved 4 cycle of FP infusion because of leukopenia, decreased renal function, and gastrointestinal toxicity. 12 pts in NAC FP undergone R0 resection surgery and 4 pts had a complete remission. The 5-year progression free survival rate was 50% (95% CI: 12-86%) in dCRT and 50% (95% CI: 20-80%) in NAC FP (p = 0.69). The 5-year overall survival rate was 50% (95% CI: 12-86%) in dCRT and 67% (95% CI: 36-88%) in NAC FP (p = 0.83). Conclusions: NAC FP and dCRT for stage IB/II/III (excluding T4) esophageal cancer might be effective even in pts ≥ 70 years of age. The therapy of dCRT might be one of options for elderly inoperative patients.

[A Case of Esophageal Neuroendocrine Carcinoma for Which Irinotecan and Cisplatin Combination Therapy Was Effective]

A 72-year-old previously healthy man visited our hospital with complaints of hoarseness and dysphagia. Computed tomography showed wall thickening of the thoracic esophagus; invasion to the left main bronchus, aorta, and right supraclavicular lymph nodes (LNs); right recurrent nerve LNs; and cardiac LN swelling. Esophagogastroduodenoscopy revealed an elevated tumor in the middle thoracic esophagus, which was similar to a submucosal tumor and had a longitudinal ulcer at its center. Pathologicexamination showed a tumor with a high N/C ratio, and immunohistochemical staining showed the tumor was CD56 and NSE positive, with a Ki-67 index >80%. We diagnosed esophageal neuroendocrine carcinoma (NEC), cT4N3M0, Stage IVa. We started chemotherapy with irinotecan and cisplatin (IP therapy) according to a regimen for small-cell lung cancer. After 3 courses of chemotherapy, the primary lesion and the LN swelling had almost disappeared. Esophageal NEC is relatively rare disease, so there are no standard established treatments. We report a case of esophageal NEC for which IP therapy was effective with the relevant literature cited.

The efficacy of prophylactic GCSF for FOLFIRINOX

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Background: Granulocyte Colony-Stimulating Factors (GCSF) is used as supportive care in cancer management when patients (pts) receive chemotherapy with high risk of febrile neutropenia (FN). Peg-GCSF is unapproved in Japan at the time of Aug 2014. Hence, phase II study of combination chemotherapy regimen consisting of oxaliplatin, irinotecan, fluorouracil, and leucovorin (FOLFIRINOX) for Japanese pts with advanced pancreatic cancer showed FN; 22% and severe neutropenia; 77.8%. Purpose of this retrospective study was to describe the incidence of FN and severe neutropenia during the first cycle of FOLFIRINOX with prophylactic GCSF (pGSF). Methods: Between January 2014 and August 2014, the pts who received FOLFIRINOX with pGCSF were examined retrospectively. The adverse events and detail of pGCSF administration during first cycle were investigated. Results: Among five pts administered FOLFIRINOX, 4 pts received pGSF in first cycle. All patients received FOLFIRINOX without dose reduction. The patient characteristics were as follows: median age (range), 58 (50-66); male/ female, 3/1; PS 0/1, 1/3. The detail of UTG1A1 (*6/ *28) was as follows: (wild type/ wild type), 2pts; (wild/ hetero), 1pt; (hetero/ hetero), 1pt. Hematological adverse events (grade 1/2/3/4) were as follows: leukopenia (0/1/2/0), neutropenia (0/1/0/1), thrombocytopenia (0/4/0/0), FN (0/0/1/0). The patient who occurred grade4 neutropenia and grade3 febrile neutropenia had UTG1A1 *6 hetero/ *28 hetero. Non-hematological adverse events (grade 1/2/3/4) were as follows: elevated GOT (2/1/0/0), elevated GPT (2/1/0/0), elevated T-Bil (0/0/0/0), anorexia (1/2/1/0), fatigue (2/1/0/0), nausea (0/1/2/0), diarrhea (1/1/0/0). The median starting date of pGSF administration was 4.5 (3-7). The median number of pGSF administration was 7.5 (6-9). Conclusions: Although this was retrospective and small study, pGSF appeared to be effective for prevention of severe neutropenia and FN. Hence pGSF might increase dose intensity of FOLFIRINOX.

Efficacy and feasibility of neoadjuvant chemotherapy for elderly patients with stage II/III esophageal cancer: Retrospective study

220

Background: From the result of JCOG 9907 study, which showed the supremacy of neoadjuvant chemotherapy (NAC) of 5-fluorouracil plus cisplatin infusion (FP) over adjuvant chemotherapy, NAC FP is standard therapy for stage II or III esophageal cancer in Japan. However, the efficacy and feasibility of NAC FP for elderly patients (pts) still remains unclear. Methods: We examined stage II or III esophageal cancer patients aged 70 or over, who received NAC FP at our institution between April 2008 and August 2014, retrospectively. Results: 12 pts received NAC FP at least 1 course. The pts characteristics were as follows: median age (range), 73 (70-78); male/ female, 11/1; PS 0/1, 3/9. Location of primary tumor and clinical stage based on UICC 2009 were as follows: upper/middle/lower, 3/6/3; stage IIA/IIB/IIIA/IIIB, 3/3/3/3. 2 pts (16.7%) occurred grade3/4 neutropenia (16.7%). grade3/4 non-hematotoxicities were nausea; 2 pts (16.7%), vomiting; 1 pt (8.3%), appetite loss; 4 pts (33.3%), stomatitis; 1 pt (8.3%) and acute kidney injury; 1 pt (8.3%). 3 pts were underwent surgery after 1 course of NAC FP due to renal dysfunction. 3 pts were not performed surgery because of decreased respiratory function, decreased PS and progression disease. 9 pts were performed surgery after NAC FP. The histological efficacy was 1a/1b/2/3; 4/3/1/1 and curativity was R0 (degree A)/R0 (degree B); 8/1. 4 pts (44%) had down staging. Median follow-up time was 16.5 months (range; 4-63), the 5-year relapse free survival rate was 19.0% (95% CI: 2.7-66.4%) and the 5-year overall survival rate was 67% (95% CI: 32-89%). Conclusions: NAC FP for stage II/III esophageal cancer might be effective even in pts ≥70 years of age. However, gastrointestinal toxicity and renal toxicity were developed frequently, therefore the indication of NAC FP for elderly pts must be decided carefully.

Efficacy of Prophylactic G-CSF in Patients Receiving FOLFIRINOX: A Preliminary Retrospective Study

OBJECTIVE

Recent guidelines have adopted an incidence of febrile neutropenia (FN) threshold of 20% for the use of prophylactic granulocyte colony-stimulating factor (G-CSF). In a Japanese phase II study of a combination chemotherapy regimen consisting of oxaliplatin, irinotecan, fluorouracil and leucovorin (FOLFIRINOX) for Japanese patients with advanced pancreatic cancer, the incidence of FN and severe neutropenia were 24.7% and 77.8%, respectively, without G-CSF prophylaxis. The aim of this retrospective study was to investigate the incidence of FN or severe neutropenia induced by full-dose FOLFIRINOX administration with G-CSF prophylaxis during the first cycle of treatment.

METHODS

Patients with advanced pancreatic cancer who received FOLFIRINOX with G-CSF prophylaxis during the first cycle of treatment from January 2014 to August 2014 were investigated and the frequency of adverse events during the first cycle was measured.

RESULTS

Among seven patients who received FOLFIRINOX, six patients met the eligibility criteria. The patient characteristics were as follows: median age (range), 57 (50-66); men/women, 3/3; performance status 0/1, 2/4. Grade 3/4 hematological adverse events were as follows: leukopenia in 33% of the patients, neutropenia in 33% of the patients, thrombocytopenia in 33% of the patients and FN in 17% of the patients. One patient was heterozygous for the UGT1A1*6 and UGT1A1*28 polymorphisms and experienced FN. Grade3/4 non-hematological adverse events were as follows: anorexia in 33% of the cases and nausea in 50% of the cases.

CONCLUSION

Although the present study was retrospective and small, the simultaneous administration of G-CSF might be effective for the prevention of severe neutropenia and FN in patients treated with FOLFIRINOX.

Retrospective study as first-line chemotherapy combined anti-VEGF antibody with fluoropyrimidine for frail patients with unresectable or metastatic colorectal cancer

BACKGROUND/AIM

Combination chemotherapies of oxaliplatin or irinotecan with fluoropyrimidine and molecular target drug were reported to be active in several clinical studies and so regarded as a first-line standard therapy for unresectable or metastatic colorectal cancer. However, the incidence of adverse events is not so low. We investigated the efficacy and safety of chemotherapy combined bevacizumab with fluoropyrimidine as a first-line treatment for frail patients.

METHODS

Twenty-six patients with unresectable or metastatic colorectal cancer who were treated with first-line chemotherapy combined bevacizumab with S-1 or 5FU/LV (modified Roswell Park Memorial Institute regimen) at our hospital between October 2007 and December 2010 were retrospectively investigated.

RESULTS

The median age was 72 years (range 66-84). Performance status was 0, 1 and 2 in 8, 17 and 1 patient, respectively. The primary lesion was located in the colon in 14 patients and in the rectum in 12. Twenty patients were with resection of the primary lesion and 6 were without, 8 were with postoperative adjuvant chemotherapy and 18 were without. The number of metastasized organs was 1, 2 and 3 in 17, 9 and 0 patients, respectively. The liver, lung, lymph node and peritoneum were metastasized in 9, 9, 11 and 5 patients, respectively. The KRAS gene was wild in 11, mutated in 7 and unknown in 8 patients. Bevacizumab with S-1 was used in 17 patients and bevacizumab with 5FU/LV was used in 9. Response and disease control rates were 50 and 100%, respectively. The median duration of progression-free survival was 9.1 months and the median time to treatment failure was 9.0 months. The incidences of all grades of neutropenia and hypertension were 31%, those of grade 3 or severer were 12%, and those of other adverse events were low. Grade 3 cerebral hemorrhage, grade 4 pulmonary embolism and grade 5 febrile neutropenia each occurred in 1 patient.

CONCLUSION

The first-line chemotherapy combined bevacizumab with fluoropyrimidine for frail patients with unresectable or metastatic colorectal cancer in Japan was comparable to the safety and efficacy of combination therapy reported previously in Western countries.

[Chemotherapy for gastrointestinal cancer in elderly patients]

Since elderly people have decreased renal function along with increased risks for complications of cardiac disorders such as hypertension and decreased physical strength, compared to in younger people, drug therapy for them is associated more with concern about drug-related toxicity. Therefore, dose reduction or discontinuation of drug administration is sometimes considered during earlier stages of therapy. On the other hand, there are some reports suggesting that as long as proper organ function is maintained, the elderly can be treated in the same way as younger people. However, given limited information and depending on the therapeutic goal of each patient, it should be carefully considered whether the same medicinal strategy used for younger patients is appropriate for treating elderly patients or not.

Mammary involvement in a patient with sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown etiology. Sarcoidosis affects multiple organs; the lungs, lymphoid system, eyes and skin are usually involved. Commonly, any organ system may be affected. Sarcoid involvement in the nervous system, locomotor system, lacrimal and salivary glands, heart, kidney and liver has been recognized in patients with sarcoidosis. However, sarcoid involvement of the breast parenchyma has been extremely rare in patients with sarcoidosis. Herein, we report a patient with a sarcoid breast mass who had bilateral hilar lymphadenopathy and lymphocytosis in bronchoalveolar lavage analysis.

UFT and mitomycin plus tamoxifen for stage II, ER-positive breast cancer. Hokkaido ACETBC Study Group

A trial was designed to examine the combination of UFT and mitomycin (Mutamycin) plus tamoxifen (Nolvadex) as postoperative adjuvant therapy in the treatment of patients with stage II, estrogen receptor (ER)-positive primary breast cancer. Mitomycin was administered intravenously at 13 mg/m2 on the day of surgery. Patients judged to be ER-positive were randomly allocated to either group A, which received oral tamoxifen 20 mg/day 14 days after surgery for 2 years, or group B, receiving oral UFT 400 mg/day plus tamoxifen 20 mg/day. A total of 219 patients were enrolled in group A, of which 213 (97.3%) were determined to be eligible; 225 patients enrolled in group B and 223 (99.1%) were eligible. The 5-year survival rates were 93.0% for group A and 95.4% for group B, with no significant difference between groups. The 5-year relapse-free survival rates were 83.1% for group A and 90.7% for group B, a significant advantage (P = .020) for the UFT plus tamoxifen group. Combination therapy with mitomycin, tamoxifen, and UFT proved to be an effective postoperative chemoendocrine therapy for stage II, ER-positive breast cancer.

A randomized controlled comparative study of oral medroxyprogesterone acetate 1,200 and 600 mg in patients with advanced or recurrent breast cancer

A randomized controlled comparative study of oral medroxyprogesterone acetate (MPA) 1,200 mg (arm I) and 600 mg (arm II) was conducted in 80 patients with advanced or recurrent breast cancer. There were no significant differences between arm I and arm II in terms of response rate, duration of response and survival, or in terms of incidence and severity of adverse reactions. The lowest serum MPA concentration in responders tended to be higher than that in nonresponders. In the cohort of this study, the lowest concentration in partial response was 17.4 ng/ml, suggesting that this level may be the required minimum serum concentration.

High proportion of missense mutations of the BRCA1 and BRCA2 genes in Japanese breast cancer families

Mutations in either of two recently identified genes, BRCA1 and BRCA2, are thought to be responsible for approximately two-thirds of all cases of autosomal-dominantly inherited breast cancer. To examine the nature and frequency of BRCA1 and BRCA2 mutations in Japanese families exhibiting a high incidence of breast cancer, we screened 78 unrelated families in this category for mutations of these two genes. Examining the entire coding sequences as well as exon-intron boundaries of both genes by polymerase chain reaction (PCR) single-strand conformation polymorphism (SSCP) and multiplex-SSCP analysis, we identified possible disease-causing alterations in BRCA1 among affected members of 15 families and in BRCA2 in another 14 families. In 15 of those 29 families, the affected individuals carried missense mutations, although most germline mutations reported worldwide have been deletions or nonsense mutations. Our results, indicating that missense mutations of BRCA1 and BRCA2 tend to predominate over frameshifts or nonsense mutations in Japanese breast cancer families, will contribute significantly to an understanding of mammary tumorigenesis in Japan, and will be of vital importance for future genetic testing.

Histological evaluation of the effects of intraarterial chemotherapy for advanced breast cancer: a long-term followup study with respect to the survival rate

To evaluate the effects of intraarterial infusion chemotherapy (IAIC) for advanced breast cancer, we examined the grade of histological responses of preoperative IAIC on tumors at the time of operation and estimated the patients' prognoses for 19 years. IAIC was done preoperatively using timely epochal anticancer drugs on 105 patients with locally advanced (Stage IIIa, IIIb) and metastatic (Stage IV) breast cancer. The survival rate of the Stage IIIb patients who showed a good histological response (Grade IIb< or =) to IAIC was 68.1% for 5 years, and 62.4% for 10 years, respectively. This was in contrast to that of the patients classified as Stage IIIb who showed a poor histological response (Grade IIa> or =) to IAIC. On the other hand, there was no significant difference in the survival rates between the Stage IIIa and IV patients with good and poor histological responses to IAIC. However, the findings showed that a good histological response to IAIC reflected a prolonged survival while the Stage IIIb and IV patients acquired a "down clinical staging" by IAIC. These results strongly suggest that IAIC thus appears to be a useful modality in the multidisciplinary treatment of advanced breast cancer, especially for Stage IIIb patients.

[Phase I study of TAT-59 (a new antiestrogen) in breast cancer. TAT-59 Study Group]

Phase I study of TAT-59 (Miproxifen), an antiestrogen developed in Japan for breast cancer, was conducted with the collaboration of 12 hospitals. A single dose of 1.25, 5, 10, 20, 40 and 80 mg, or 5 consecutive daily doses of 1.25, 5, 10, 20 and 40 mg/day, were given orally. After single dosing, no clinical adverse effects were found. Decrease of serum Na, Cl, Ca level and increase of serum LDH level were observed in one patient after a single dose of 5 mg of TAT. An increase in the serum LDH level was also observed in one patient after a single dose in the of 10 mg of TAT. An increase in the serum LDH level and total bilirubin, increase of eosinophil, K and milky serum were also observed in one patient after a single dose of 40 mg of TAT, respectively. All of these abnormal values returned to the normal level within 26 days after final administration of TAT. No adverse clinical findings nor abnormal laboratory findings were observed after consecutive administration of TAT. After postprandial single dosing, the time to reach the maximum serum concentration (Tmax) of DP-TAT, dephosphorylated metabolite of TAT, and its demethylated metabolite, DMDP, ranged from 5.0 to 7.3 hr and from 17.0 to 42.8 hr, respectively. The maximum serum concentration (Cmax) and AUC of DP and DMDP elevated in a dose-dependent manner. T1/2 of DP and DMDP ranged from 24.2 to 41.5, and from 91.9 to 214.7 hr, respectively. There were no significant differences between pharmacokinetics of TAT before and after food intake. Based on the above results, we concluded that a Phase II study should be conducted to evaluate the efficacy, safety and optimal dose of TAT.

Effects of medroxyprogesterone acetate therapy on advanced or recurrent breast cancer and its influences on blood coagulation and the fibrinolytic system

The effects of medroxyprogesterone acetate (MPA) therapy on advanced or recurrent breast cancer and its influence on blood coagulation and the fibrinolytic system were compared among three different therapy regimens consisting of cyclophosphamide, adriamycin, and 5-fluorouracil (CAF) + MPA and CAF or MPA alone. A clinical response was observed in 42.9% (9/21) of the patients for CAF + MPA, 36.4% (8/22) for CAF and 23.8% (5/21) for MPA alone. No marked thrombosis or its prodromal condition was observed in any group. The effects on the test values for blood coagulation and the fibrinolytic system did not significantly change in the CAF group. However, both AT-III and protein C significantly increased above the normal ranges in the CAF+MPA and MPA groups. Increases in factor X, plasminogen, and alpha 2-plasmin inhibitor/plasmin complex (PIC) and decreases in fibrinogen, tissue plasminogen activator, and D-dimer, were all observed in the MPA and CAF + MPA groups, especially in the MPA group, although these changes remained within the normal ranges. The data indicated that MPA has various influences on blood coagulation and the fibrinolytic system, but these changes did not suggest activation of the blood coagulation system.

[Intra-arterial infusion chemotherapy for advanced or recurrent breast cancers]

Ideally, in preoperative intra-arterial infusion chemotherapy (regarding advanced breast cancer) is to obtain the most significant effects concerning histological features. Intra-arterial infusion chemotherapy using epirubicin (EPI), used in conjunction with daily doses of 1,200 mg medroxyprogesterone acetate (MPA), have recently been performed. This procedure has shown remarkable histological effects in the metastatic lymph nodes as well as in the primary lesions. These results were especially remarkable in the patients who were administered MPA (daily) two weeks prior to EPI infusion. These patients showed a complete disappearance of tumor cells. The results were interesting in view of the mechanism of action. Intra-arterial infusion chemotherapy combined with MPA may also be valuable in treating metastatic liver tumors and recurrent lesions in the regional lymph nodes such as supraclavicular tumors. A high response rate was obtained in the chemo-endocrine therapy when combined with MPA as a pretreatment. Thus, MPA may be expected to be available as a systemic therapy, too. In the future, a new development in the field of intra-arterial infusion chemotherapy may be achieved by utilizing a combination of angiogenesis inhibitors and peripheral blood stem cell transplantation.

[Several medical problems for ideal relationship between breast cancer patients and surgeons in Japan]

Recently, breast cancer is one of the most important disease in Japanese women. It is now recognized from prospective studies that Japanese women are at an increased risk of developing breast cancer. In this paper, the author mentioned the several problems of Q.O.L., informed consent and medical system for breast cancer patients in Japan. It is well-known that the patients with recurrent breast cancer showed low level of Q.O.L. compared with the patients free from the disease. So it is important to make a good result of the recurrent rate of conservative treatment of breast cancer as well as radical mastectomy.

Antioxidant enzyme activities and oxidative stress in human breast cancer

We have analysed products of lipid peroxidation reactions and activities of antioxidant enzymes in cancerous breast tissue and in corresponding reference tissue. In addition, the serum lipid peroxidation and peroxyl-radical-trapping capacity of breast cancer patients were compared to those of healthy subjects. A total of 23 patients with breast cancer participated in this study. In the cancerous tissue, catalase activity was lower than in the reference tissue, while the activities of superoxide dismutase, glutathione peroxidase and the hexose monophosphate shunt were elevated. The content of thiobarbituric-acid-reactive material was slightly lower in the cancerous tissues, but the levels in serum were found to be elevated in patients with breast cancer. The amounts of conjugated diene double bonds were essentially equal both in the cancerous and in the reference tissue. Moreover, in breast cancer patients the serum levels of diene conjugation and the peroxyl-radical-scavenging capacity did not differ from those measured in healthy subjects. This study indicates that the antioxidant defence system is altered in cancerous breast tissues, but does not support the hypothesis suggesting that formation of lipid peroxides in the tumour tissue itself is of primary importance in the carcinogenesis.

[The significance of intra-arterial infusion therapy for neoadjuvant chemotherapy]

Arterial infusion therapy with anticancer drugs is now attracting attention as a valuable modality for locally advanced breast cancer. Since 1977, we have used this therapy in 122 patients with primary breast cancer. The present report mainly discusses the clinical and histological response as well as the prognosis. The anticancer drugs were mainly given by two routes, infusion into the internal mammary artery and the subclavian artery. Continuous infusion of 5-FU and intermittent injections of MMC, ADR, 4'-epi-ADR and THP-ADR were jointly or individually made in each artery. Clinical response, defined as CR + PR, was noted in 48.4% of 5-FU group and 72.7% of ADR-MMC group. Histological response according to Shimosato Criteria, defined as grade IIb or better, appeared in 45.2% of main tumors and 25.4% of metastatic lymph nodes in the 5-FU group, and 70.9% main tumors and 46.3% of metastatic lymph nodes in the ADR-MMC group. The non-infusion group contained 27.7% of stage IIIb, against 72.2% in the infusion group. The 5-year overall survival rates were non-infusion group 62%, 5-FU group 34.1% and ADR-MMC group 66.2%. A significant difference was seen between the 5-FU infusion group and the ADR-MMC group (p = 0.03). Administration of high dose medroxy progesterone acetate for two weeks and 4'-epi-ADR infusion chemotherapy resulted in an excellent histological response. This combination therapy is a promising neoadjuvant chemo-endocrine therapy for advanced breast cancer.

Correlation of heat shock protein 70 expression with estrogen receptor levels in invasive human breast cancer

The authors studied the role of 70-Kd heat shock protein (HSP70) in the progression of breast cancer by examining the correlation between the expression of HSP70 and epidermal growth factor receptor, c-erbB-2, p53, and estrogen receptor in 124 cases of invasive primary human breast cancers. Positivity of an anti-HSP70 monoclonal antibody, C92, was closely associated with the elevation of estrogen receptor (P < .008), whereas it inversely correlated with the expression of p53 (P < .01). In addition, the expression of HSP70 correlated inversely with the expression of epidermal growth factor receptor, although the correlation was not statistically significant (P = .06). These results suggest that the expression of HSP70 plays a role in the progression of human breast cancer.

Positive effect of tamoxifen as part of adjuvant chemo-endocrine therapy for breast cancer. Hokkaido Adjuvant Chemo-Endocrine Therapy for Breast Cancer Study Group

A prospective randomised multicentre clinical study was undertaken for 2 years and 3 months from November 1982, with the aim of examining the significance of using a combination of ftorafur (FT) and tamoxifen (TAM) for post-operative adjuvant therapy of breast cancer. Patients had either stage II or stage IIIa disease, were age 75 or below and had undergone radical mastectomy. Patients were divided into two groups and received one of the following treatment protocols: treatment A, intravenous administration of doxorubicin (DOX), 20 mg on the day of surgery and 10 mg the next day, followed by oral FT 50 mg day-1 for 2 years from the 14th day; treatment B, the same pattern of DOX administration for the first 2 days, followed by a combined therapy of FT and TAM 20 mg day-1 for 2 years. The number of patients was 546 (treatment A 274 and treatment B 272), of whom 34 (6%) were ineligible. The remaining 512 patients (treatment A 254 and treatment B 258) were followed up for 5 years for analysis. Significantly higher 5 year disease-free rate and 5 year survival rates were observed with treatment B compared with treatment A. When seen in terms of background factors, node-positive patients appeared to derive more benefit from tamoxifen than node-negative patients, but the oestrogen receptor-negative and premenopausal subgroups appeared to derive about the same benefit as those who were oestrogen receptor positive and post-menopausal. Indeed, survival in the premenopausal group was significantly better with tamoxifen (P = 0.04). No increase in side-effects was seen by combining TAM with FT. The study results demonstrate that concomitant administration of FT and TAM is better than FT alone for post-operative adjuvant therapy for breast cancer.

[Clinical evaluation of CGS16949A in advanced or recurrent breast cancer--a multi-institutional late phase II clinical trial]

A multi-institutional late-phase II clinical trial of CGS 16949A was conducted at the dose of 1 mg twice daily in postmenopausal patients with advanced or recurrent breast cancer. Seventy patients entered into the study; 65 were eligible and 53 were complete cases. There were 3 CR, 11 PR, 10 long-NC, 14 NC and 25 PD with an overall response rate of 22.2% in 63 evaluable cases. The median period of overall duration of responses was 327.5 days. There were 22 cases that drug was found useful or better, and global usefulness rate was 33.8%. Forty six (76.7%) of patients experienced no side effects in this therapy. Grade 2 toxicities included anorexia (1 pt.), feeling of distension of abdomen (1 pt.), vomiting (1 pt.), fatigue (1 pt.), and only one patient experienced Grade 3 toxicity (anorexia). Grade 2 laboratory abnormalities were confirmed in two patients; one with elevated gamma-GTP and another with elevated LDH, and both were in the absence of liver metastasis. From these results, it is concluded that CGS16949A seemed to be a useful hormonal agent in the treatment of postmenopausal breast cancer.

[Phase II study of CGS16949A, a new aromatase inhibitor--a dose finding study]

A dose finding phase II study of a novel aromatase inhibitor CGS16949A was performed in postmenopausal patients with advanced breast cancer. The daily dose of 1 mg (0.5 mg b.i.d.), 2 mg (1 mg b.i.d.) or 4 mg (2 mg b.i.d.) CGS16949A was administered orally for 8 weeks or more on dose escalation schedule. The response rates (CR+PR) in the evaluable cases were 13.6%, 22.0% and 13.3% in 1 mg/day group (1 mg group), 2 mg/day group (2 mg group) and 4 mg/day group (4 mg group), respectively. There was no statistically significant difference in the response rates among the three treatment groups. Median time to the onset of PR was 99, 113 and 114 days in 1 mg, 2 mg and 4 mg group, respectively, and the median duration of response was 276 days, 391 days and 277 days in 1 mg, 2 mg and 4 mg group, respectively. Five patients in each treatment group showed prolonged stabilization of disease ("long NC", lasting > or = 6 months). Median durations of stabilization were 223 and 241 days in 2 and 4 mg group respectively. The incidence of adverse effects were 11.9%, 7.5% and 13.0% in 1 mg, 2 mg and 4 mg group respectively, and 30 out of 33 symptoms (90.9%) were of mild. Laboratory abnormalities were observed in 12.2%, 22.9% and 23.8% in the respective groups of 1, 2 and 4 mg, and no patient experienced clinical symptoms related to these changes. Plasma estradiol concentration at one month after initiation of the treatment decreased significantly in comparison with pretreatment levels, and was slightly exceeding the limit of detection. Plasma cortisol was not changed. As shown in this results, CGS16949A showed sufficient efficacy and good tolerability in postmenopausal patients with advanced breast cancer. It was considered that the optimal dose in clinical use judged as 2 mg/day.

[Nuclear DNA ploidy pattern and cytological atypia in aspiration cytology of breast cancer]

The relationship between nuclear DNA ploidy pattern and cytological atypia in aspiration cytology of breast cancer was studied in 40 cases of primary breast cancers (T1: 14 cases; T2: 26 cases). They were divided into two groups, according to cytological specimens, high degree (H group) and low degree (L group). Twelve of 40 cases were classified into H group and 28 cases into L group. Fresh frozen materials were obtained from mastectomy specimens and nuclear DNA analysis was carried out by flow cytometry (FCM). Estrogen receptor (ER) and progesterone receptor were measured with the DCC method. Lymph node metastases were histologically seen in 17 cases; the ER positive rate was 55.0%, and the PgR positive rate was 42.5%. FCM revealed 21 cases (52.5%) with diploidy pattern and 19 cases (47.5%) with aneuploidy pattern. S-phase fraction in 17 cases (48.6%) exceeded 20%. L group had more diploid cases and ER positive cases than H group (p < 0.05, p < 0.01). No differences in other factors were seen between the two groups. In diploid cases, L group had more ER positive cases than H group (p < 0.02).

[Efficacy and safety of high dose NK 622 (toremifene citrate) in tamoxifen failed patients with breast cancer]

Efficacy and safety of high dose administration of NK 622 (toremifene citrate) were studied in tamoxifen (TAM)--failed patients with breast cancer. The patients included in the study were the following failure cases in TAM therapy: unresponded cases in TAM therapy (TAM unresponded cases), temporary responded (CR, PR) but progressed cases in TAM therapy (TAM temporary responded cases), and those relapsing during TAM adjuvant therapy or within 6 months after the adjuvant therapy (TAM adjuvant failed cases). NK 622 of a 120 mg/day dose were orally given daily once at least for 8 weeks. The response rates in evaluable cases were 6.3% (1/16) in TAM unresponded cases, 11.1% (1/9) in TAM temporary responded cases, 15.4% (4/26) in TAM adjuvant failed cases, and 11.8% (6/51) in total cases including 1 CR and 5 PR cases. Long NC in which duration of NC maintained for more than 6 months was observed in 18.8% (3/16) of TAM unresponded cases, 22.2% (2/9) of TAM temporary responded cases, 11.5% (3/26) of TAM adjuvant failed cases, and 15.7% (8/51) of total cases. Rates of response and long NC were 14.3 and 19.0% in postmenopausal patients with estrogen receptor positive cancer, respectively. A median value of duration to the onset of response was 34 days (15-137). Median duration of response and long NC were 127 days (39-381) and 238.5 days (178-281), respectively. Adverse effects were experienced in 3 (5.1%) of 59 patients: nausea in 1, vertigo in 1 and increase of GOT, GPT, LDH and gamma-GTP in another 1. The side effects were moderate and reversible. From these results, NK 622 seems to become a safe and effective drug for TAM-failed patients with breast cancer by using a 120 mg/day dose.

[Phase I study of NK 622 (toremifene citrate)]

A phase I study of NK 622 (toremifene citrate), a novel antiestrogen, was conducted in female patients with cancer. Patients received a single oral dosing or daily once oral dosing for five consecutive days. Any adverse effects were not experienced in the single dosing of 40 or 60 mg of NK 622. In the daily administration of 10, 20, 40, 60, 120, 240 and 480 mg/day, one of three patients who received 20 mg/day experienced grade 1 anorexia, three of four patients received 240 mg/day experienced adverse effects: Grade 1 leukopenia in one patient, Grade 1 general hot flush in one patient, and Grade 1 nausea, hot flush in the face and vertigo, Grade 2 anorexia, fatigue, dull headache and general hot flush in another one patient. These symptoms recovered to normal levels after treatment. Serum hormone levels were examined in postmenopausal patients, and a significant increase of the sex hormone binding globulin level was observed in the patients received 120 and 240 mg/day doses. Serum levels of NK 622 determined as free base (TOR) reached the peak levels in 2 to 4 hours after administration on the 1st and 5th day in daily treatment, while a metabolite N-demethyltoremifene (TOR-1) reached the peak level in 4 to 170 hours. Maximum serum levels and area under the concentration versus time curves of TOR and TOR-1 increased dose-dependently. These values also increased by repetition of the treatment. Half-lives of TOR and TOR-1 in serum ranged in 74.5 to 148.9 hours and 154.1 to 653.1 hours, respectively. From these results, it was concluded that safety and efficacy of NK 622 should be assessed by using 240 mg or less doses in clinical phase II studies where breast cancer patients received long term treatment with NK 622.

[A case of inflammatory breast cancer treated with medroxyprogesterone acetate (MPA) in combination with intra-arterial infusion chemotherapy]

A 55-year-old female with severe inflammatory breast cancer was treated with the combined use of MPA and the intraarterial infusion chemotherapy. One cycle consisted of 4'-epi-adriamycin; 210 mg (day 1, 4 and 8) and daily administration of MPA; 1,200 mg. A marked shrinkage of the tumor was obtained with this treatment. The regressive change was noted not only in the primary lesion but in lymph nodes of the axillary region. Therefore, the combined use of MPA with intra-arterial infusion chemotherapy may well contribute to the treatment of inflammatory breast cancer.

[A phase II study of DWA2114R, a new platinum complex for breast cancer]

A multi-institutional phase II study of DWA2114R was conducted in breast cancer. DWA2114R at doses of 800-1,000 mg/m2 was administered by 1-hour intravenous infusion every 3-4 weeks on minimal two cycles. Fifty-two patients entered the study; 34 were eligible, 7 ineligible. Eleven patients were dropped from evaluation due to incomplete observations. There were 1CR, 6PR, 1MR, 12 NC, and 14 PD with an overall response rate of 20.6%. A median duration of responses was 11 weeks. Leukopenia and nausea/vomiting were frequently observed but well tolerated and recovery was quick. It is concluded that DWA2114R is a useful drug in the treatment of breast cancer.

[Effect, recurrence and prognosis of intra-arterial infusion chemotherapy with anticancer agents for advanced breast cancer--especially, the significance of tumor blood vessels]

Between January 1977 and March 1991, 86 patients of Stage III and Stage IV breast cancer were treated by intra-arterial infusion chemotherapy (IAIC) in Sapporo Medical College. The 5- and 10-year overall survival rates of Stage III b were: infusion group 53.1% and 53.1%, non infusion group 50.1% and 16.7%, respectively. A significant difference was seen in the 10-year survival rate (p less than 0.05). The 5- and 10-year overall survival rate of Stage III b histologically effective group was 67.3% and non-effective group 31.8%. A significant difference was seen between these two groups (p = 0.0241). A significant difference was seen between n2 positive Stage III b infusion group and non-infusion group in 7-year survival rate (p less than 0.01). The ischemic effect on tumor cells by degeneration changes of the blood vessels was important for the histological effect. Pre-operative angiography helped in the choice of anticancer agents. The sufficient adjuvant chemo-endocrine therapy will assure a good prognosis for IAIC-treated Stage III b breast cancer patients.

Fiberoptic ductoscopy of the breast: a new diagnostic procedure for nipple discharge

A fiberoptic ductoscopy system was successfully developed by means of which we were able to observe the duct cavity of the breast. Two kinds of silicafiberscopes with outer diameters 0.80 and 0.45 mm were used in the present study. Fiberoptic ductoscopy was applied to 52 ducts in 46 patients with nipple discharge for whom no tumor was palpable; the intraductal appearance could be observed in 47 ducts from 41 patients (90.3%). Fourteen ducts from 13 patients were operated upon and were histologically diagnosed as carcinoma (four cases), intraductal papilloma (nine ducts from eight patients) and mastitis (one case). The internal surface of a normal duct was lustrous and smooth. Cancer growing on the surface of a duct wall appeared white and was slightly elevated, forming a bridging structure. The intraductal papillomas formed intraductal solid nodules, being yellow in most cases and red at the site of hemorrhage. Fiberoptic ductoscopy can be used to recognize the growth of minute intraductal lesions in cases of nipple discharge. Clinical endoscopic diagnosis for minute intraductal lesions will make an important contribution to the early detection of cancer and the evaluation of nipple involvement in intraductal carcinoma.

[Clinical evaluation of the hot nodule on 99mTcO4- and 123I thyroid scintigraphy: correlation of scan appearance and histopathology]

Histopathology and scan findings of hot nodule on 99mTcO4- and/or 123I were correlated in 34 patients with thyroid nodules. In a series of 30 hot nodular lesions, 29 were either adenomas or benign nodules; however, one was proved follicular carcinomas histopathologically. And four patients were chronic thyroiditis without nodular lesions in the thyroid lobes, which were diagnosed pathologically and clinically. In 6 patients with palpable thyroid nodules, thyroid scans performed with both 99mTcO4- and 123I were compared. A discrepancy of the two types of scan existed in only one case. Subsequent surgery revealed no malignancy in this patient. From the results of 201T1 imaging of the thyroid gland in 30 patients with cold or hot nodules on either 99mTcO4- or 123I thyroid scanning, we found no distinct difference between the degrees of 201T1 malignant and nonmalignant tumors. It appears that 201T1 accumulation demonstrates only tumor volume and tumor cell viability in these subjects. From these results, it is confirmed that the functional heterogeneities exist in thyroid adenoma tissues as well as in thyroid cancerous tissues. Therefore, the development of the reliable techniques used to distinguish a benign from malignant lesion is indispensable.

[Intra-arterial infusion chemotherapeutic effect of stage III breast cancer by survival rates]

Between January 1977 and December 1989, 140 patients of Stage III breast cancer were treated in Sapporo Medical College. Sixty-six of these patients received intra-arterial infusion chemotherapy. The anticancer drugs were mainly given by two routes, infusion into the internal mammary artery and the subclavian artery. Continuous infusion of 5-FU and intermittent injections of ADR, MMC, 4'-epi-ADR or THP-ADR were jointly or individually made in each artery. The 5-and 10-year overall survival rates were: infusion group 49.2% and 49.2%, non-infusion group 64.0% and 45.0%, respectively. Intra-arterial infusion chemotherapy seems to be useful because non-infusion group contained mostly Stage IIIa and conversely the infusion group contained mostly Stage IIIb. A significant difference was seen between 5-FU infusion group and MMC.ADR group (p=0.026). MMC group, MMC + ADR combination group and 4'-epi-ADR group were marginally significantly different in terms of survival rates of the anticancer drugs of Stage IIIb.

[A case of Hurthle cell carcinoma in the superior mediastinum]

This is a report for an unusual case of oxyphilic cell adenocarcinoma originating from anterior mediastinum in a 36-year-old male who complained of his neck lymphoadenopathy. 201Tl whole body scanning showed increased uptake of the left supraclavicular and upper mediastinal regions. There was no history of prior operation nor irradiation to the thyroid or neck region. Chest CT scanning also demonstrated the tumor in the superior mediastinum, but the mass has no increased 67Ga uptake. No tumor in the thyroid lobes was apparent on thyroid scintiscanning, ultrasonography and neck CT. The mediastinal tumor resection, the right and left thyroid lobectomy and the neck lymphonodectomy were completed. Serial sectioning of the resected thyroid lobes failed to show any tumorous tissue. The light microscopic features of a Hurthle-cell tumor arising in the mediastinal ectopic thyroid and diagnosed by neck lymph node biopsy were presented. The tumor was clinically malignant, having metastasized to the bone and the neck lymph nodes. Non surgical treatment including radioactive iodine (131I) therapy and combination chemotherapy were disappointing. The patient deteriorated progressively and died 16 months after thyroidectomy. We describe here an unusual case of a papillary growing and thyroglobulin producing tumor in the superior mediastinal region without evidence of a primary thyroid gland tumor.

[Intra-arterial infusion chemotherapy of advanced breast cancer--effects and side effects of adriamycin, 4'-epi-adriamycin and THP-adriamycin]

In 34 patients with primary advanced breast cancer, intra-arterial administration of ADR (50 mg X 3, total dose 150 mg, 10 cases), 4' epi ADR (50 mg X 3, 150 mg, 8 cases; 70 mg X 3, 210 mg, 10 cases) and THP-ADR (50 mg X 3, 150 mg, 6 cases) was performed, and its effects and side effect were analyzed. The clinical and histological response rate were superior in the ADR (150 mg) regimen and 4'-epi-ADR (150 mg) regimen. Signs of systemic toxicity such as gastrointestinal disorders, leukocytopenia and thrombocytopenia were the side effects in patients treated with THP-ADR, but the frequency of alopecia was lower. No cardiotoxicity was recorded in any of the patients. These results indicated that 4'-epi-ADR given the total dose of 150 mg in a single dosage of 50 mg was the most effective agent in intra-arterial infusion chemotherapy for advanced breast cancer.

Identification by monoclonal antibody of the tumor antigen of a human autologous breast cancer cell that is involved in cytotoxicity by a cytotoxic T-cell clone

We have already established a pair of human autologous clones, tumor-specific cytotoxic T-lymphocyte clone TcHMC-1 and tumor target clone HMC-1-8, that were derived from the metastatic pleural effusion of a patient with mammary carcinoma. In this paper, we describe the target antigen that was defined by monoclonal antibody 3A2. This monoclonal antibody selectively inhibited the cytotoxic action of TcHMC-1 against HMC1-8 autologous tumor target cells, but not the cytotoxicity of lymphokine-activated killer and possibly natural killer cells against HMC-1-8 cells. Western blot analysis using the 3A2 monoclonal antibody identified a molecule with an approximate molecular weight of 92,000. This antigen was highly expressed on autologous primary cancer cells of breast carcinoma tissue, but not on the normal mammary gland in the same patient. Moreover, this antigen can be detected on approximately 50% of human allogeneic breast carcinomas, but not on other neoplastic tissues such as gastric and colonic carcinomas except for one out of 10 prostatic carcinomas. Nonneoplastic normal cells did not express this antigen. It was also suggested that the antigen is not murine mammary tumor virus-related products. These data suggest that 3A2-defined antigen could participate in the cytotoxicity by human autologous cytotoxic T-lymphocytes as the target molecule expressed on tumor cells.

[Therapeutic effect of stage III breast cancer--comparative study of preoperative intra-arterial infusion chemotherapy and non-infusion therapy]

Between January 1977 and March 1988, 111 patients of stage III breast cancer were treated in Sapporo Medical College. The median age was 51.6 years (range, 26-83 years). Menopausal status was 47 cases of premenopausal, 19 cases of perimenopausal and 45 cases of postomenopausal. Fifty-seven of these patients received intra-arterial infusion chemotherapy. The anticancer drugs were mainly given by two routes, infusion into the internal mammary artery and the subclavian artery. Continuous infusion of 5-FU and intermittent injections of MMC, ADR or 4'-epi-ADR were jointly or individually made in each artery. Clinico-histological response was studied in 53 out of 57 patients. Clinical response, defined as CR + PR, was noted in 33 patients (62.3%). Histological response according to Shimosato Criteria, defined as grade IIb or better, appeared in 31 patients (58.5%). Non-infusion group contained 27.7% of stage IIIb, against 72.2% in infusion group. The 5-year overall survival rates were; non-infusion group 62%, 5-FU infusion group 34.1%, and ADR MMC group 66.2%. A significant difference was seen between 5-FU infusion group and ADR-MMC group (p = 0.03). The median disease-free interval was 22.0 months (range, 1-77 months) in infusion group and 28.2 months (range, 1-124 months) in non-infusion group. MMC + ADR combination group revealed the most excellent results in terms of the 5 year survival rate and clinicohistological effect.

[Intraarterial chemo-embolization with adriamycin containing albumin microspheres]

For local treatment of inflammatory breast cancer and recurrent breast cancers with liver metastasis, we applied intraarterial infusion chemoembolization therapy utilizing albumin microspheres containing adriamycin (ADM-ms), which was developed by Morimoto. In this study, there were 2 cases of inflammatory breast cancer and 3 cases of recurrent breast cancers with liver metastasis. Arterial canulation of primary breast cancer were made through both arteries, the internal mammary artery and lateral thoracic artery, which were feeding arteries of the breast. ADM-ms was injected into both arteries and its tumor effect was evaluated clinically and histologically. Remarkable reduction in tumor size was recognized. Histologic examination of resected specimens revealed extensive fibrosis in the center of the primary tumors. A few cancer cells, degenerated in various degrees, were found remaining in the periphery of the necrotic mass. Local side effects of the microspheres were skin disturbances such as pain, redness and blistering. ADM-ms was injected into the hepatic artery for the liver metastatic cases, and its antitumor effect was evaluated by CT scan or echography. Effective reduction in tumor size was only recognized in one case. No serious systemic side effects, not recognized in any case. Our report reviews the effectiveness of this therapy as a preliminary procedure for surgical treatment of inoperable inflammatory breast cancer.