Abstract P3-13-07: Radiofrequency ablation (RFA) is a promising treatment option for primary breast cancer: Experience in 386 Japanese breast cancer patients

Background. Radiofrequency ablation (RFA) is used for the treatment of various solid tumors. Several small experiences have reported as a primary treatment for breast cancer using RFA. However, the clinical benefits remain uncertain. We retrospectively studied 386 patients and analyzed their RFA-related complications and outcomes.

Methods. A clinical database was constructed from 10 institutions. RFA was performed using an electrical generator connected to a single cooled-tip electrode or multiple electrodes. Adjuvant systemic therapy and whole breast radiation were administered according to the clinicopathological background of each patient. Follow-up periods ranged from 1 to 90 months (mean 45.4 months). RFA-related complications and risk factors for in-breast recurrence after RFA were evaluated. Variables evaluated included patient characteristics, pre- and post-operative imaging modalities, tissue sampling modalities, and RFA-related factors.

Results. Skin burns were observed in 7 patients (1.8 %) and RFA-induced damage to the nipple-areolar complex in 7 patients (1.8 %). Persistent induration of the breast after RFA was observed in 137 patients (35.5 %). Eleven patients (2.8 %) developed in-breast recurrence. In-breast recurrence was more frequent in patients with tumor size >2.0 cm, ER-negative tumor, HER2-positive tumor, positive nodes, no breast irradiation and adjuvant chemotherapy.

Conclusions. Skin burns were a major problem after RFA, but the frequency of burns was relatively low. Breast induration was also developed, but it did not bring harmful effect to the patients with this complication. We conclude that RFA is a promising treatment option for solid T1 breast cancer without malignant potential.

Citation Format: Takahashi M, Ito T, Oura S, Nagamine S, Yamamoto N, Yamamichi N, Earashi M, Doihara H, Imoto S, Mitsuyama S, Akazawa K. Radiofrequency ablation (RFA) is a promising treatment option for primary breast cancer: Experience in 386 Japanese breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-13-07.

Abstract P4-15-05: Long-term outcome of breast cancer patients treated with radiofrequency ablation

Background: Radiofrequency ablation (RFA) is considered to be the most promising non-surgical ablation technique for the treatment of small breast cancer. In feasibility studies, the ablated tumor was surgically removed after RFA, and the tumor cell viability were assessed by histological and/or immunohistological examinations. However, these assessments of tumor viability do not take the place of long-term follow-up in patients treated with RFA alone, because they do not allow for them to be followed up for recurrence after RFA, or to determine if there were any undesirable complications of this procedure. At present, few data are available regarding long-term follow-up of patients treated with this modality.

Methods: Since 2005, we have performed RFA and sentinel lymph node (SLN) biopsy in 19 cases with invasive breast cancer less than 2.0 cm in greatest diameter. After SLN biopsy, a primary electrode (seven-array model 70 Starburst needle electrode; RITA Medical Systems, Mountain View, CA) was inserted into the tumor under real-time US guidance. Then, the prongs of the needle electrode were deployed over a distance of 3 cm in all cases, and the RF generator (RITA model 1500) was activated and set to automatic, with power at 20 W, temperature of 95°C, and an ablation time of 15 min. Axillary lymph node dissection (ALND) was performed in patients with positive SLNs. Several months after RFA therapy, the ablated tumor tissue was excised by multiple mammotome biopsy and examined histologically or immunohistochemically with H&E staining, nicotinamide adenine dinucleotide (NADH)-diaphorase staining, and single-stranded (ss) DNA staining. All cases were followed-up after breast radiation and systemic therapies.

Results: The mean tumor size based on the ultrasonographic maximum dimension was 1.3 cm (range: 0.5–2.0 cm). Although complete response was histologically confirmed in only 8 cases, NADH-diaphorase and ssDNA staining did not demonstrate any viable tumor cells in any of the ablated lesions. At a mean follow-up of 60 months (follow-up range, 37–82 months), there were no cases of in-breast recurrence, although one patient died due to hepatic metastases. Cosmesis of the conserved breast was excellent or good in all of the cases, but a hard lump was persistent after RFA in half of the cases.

Conclusions: The long-term outcome of patients treated with RFA is encouraging with regard to cosmesis and local control. However, a persisted lump can cause patient discomfort, anxiety and fear. Therefore, further studies are needed to establish the optimal technique. Moreover, a prospective study will be required to determine the equivalency in local recurrence rates between the RFA therapy and conventional breast-conserving treatment.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-15-05.

Relationship between nm23 expression and axillary and internal mammary lymph-node metastases in invasive breast-cancer

We examined the relationship between nm23 expression and clinicopathological variables in 144 patients with invasive breast cancer to assess the role of nm23 expression in estimating prognosis. Expression of nm23 was significantly associated with axillary lymph node (AX) metastases (p=0.0359) and internal mammary lymph node (IMN) metastases (p=0.0146), but not with age, menopausal status, histological type or grade, or tumor size. A univariate study revealed that survival significantly correlated with tumor size, AX and IMN metastases, whereas nm23 expression did not appear to be a significant prognostic factor. Among patients with negative AX, however, survival in patients without nm23 expression was lower than in those with nm23 expression (p=0.0778). Survival in patients with IMN metastases was significantly lower than those without IMN metastases among patients with positive AX (p=0.0073). In a multivariate study, AX and IMN metastases, and nm23 expression appeared to be significant prognostic factors for survival. This study suggests that nm23 expression may be an additional prognostic factor in patients with negative AX, while IMN metastases are an additional prognostic factor in those with positive AX.

Nm23 and C-erbb-2 expression in invasive breast-cancer

We investigated whether nm23 and/or c-erbB-2 expression are useful for estimating the prognosis of invasive breast cancer patients. nm23 expression was significantly correlated with axillary (AX) and internal mammary lymph node (IMN) metastases, whereas c-erbB-2 expression was significantly correlated only with AX metastases. However, a univariate study revealed that survival was correlated significantly with tumor size, AX and IMN metastases, and c-erbB-2 expression, whereas nm23 expression was not an important prognostic factor. In a multivariate study, only AX and IMN metastases were significant prognostic factors. When AX and IMN metastases were excluded from the Cox model, only c-erbB-2 expression had independent prognostic value for survival. Therefore, we conclude that nm23 and/or c-erbB-2 expression may reflect the metastatic potential of breast cancer, but their prognostic value in combination is limited.

Radiofrequency ablation treatment for small breast cancer

Abstract #5155

Aims: There is increasing demand for minimally invasive and non-surgical treatment in breast cancer. Although radiofrequency (RF) ablation seems the most promising non-surgical treatment for small breast cancer, its relevance has been controversial. This study was performed to determine the feasibility and the safety of treating small breast cancer with RF ablation. Methods: In this study, all patients had a localized breast cancer of 2.0 cm or less in greatest diameter. The tumors were confirmed to be localized lesions by ultrasonography, mammography, and enhanced MRI or CT. Before treatment, core needle or mammotome biopsy was performed to obtain the tumor tissue for establishing the histological diagnosis and the status of hormonal receptors and HER-2 expression. A model 15000 generator with a seven-array Starbusrt XL needle-electrode Model 70 (RITA Medical System) was used for RF ablation. In the first series, 17 patients underwent RF ablation and sentinel lymph node (SLN) biopsy followed immediately by wide resection (n=13) or total mastectomy (n=4). Axillary dissection was performed in 5 patients with positive SLN. On the other hand, 15 patients underwent RF ablation and SLN biopsy in the second series. Axillary dissection was performed in 3 patients with positive SLN. The ablated lesion was excised by mammotome after several months later. The ablated tumor tissue was examined histologically with H&E staining and NADH-diaphorase staining to assess tumor cell viability. Patients who underwent wide resection or RF ablation alone received breast irradiation, and all of the patients were treated with systemic therapy according to the St. Gallen recommendation. Results: Histological examination with H&E staining revealed a spectrum of changes ranging from complete coagulation necrosis to normal-appearing tumor cells, but NADH-diaphorase staining revealed no viable tumor cells in the either series. No patient developed to local or breast recurrence in the first series with a median follow-up period of 46 months (range: 34-61 months), and in the second series with a median follow-up period of 23 months (range: 12-32 months). However, one patient in the first series and another in the second series developed to the distant metastases, although they are alive with systemic treatment. The cosmesis of conserved breast was excellent in the second series more than in the first series, and no adverse effect such as skin burn or persistent hard lump was observed in the second series. Conclusions: RF ablation is feasible for small breast cancer. To achieve wide acceptance, however, further studies are needed to determine whether the use of RF ablation for small breast cancer can provide local control and survival rates equivalent to those of conventional breast-conserving treatment.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5155.

Cutaneous metastases from gastric adenocarcinoma treated with combination chemotherapy producing complete response with long survival

A case of cutaneous metastases from gastric adenocarcinoma was presented. It was treated with combination chemotherapy producing complete response with prolongation of survival. Skin metastasis will indicate early fatal termination, therefore there has not yet been a reported case of cutaneous metastasis from gastric cancer to have complete response with long survival.

Primary small cell carcinoma of the esophagus: flow cytometric analysis and immunohistochemical staining for the p53 protein and proliferating cell nuclear antigen

BACKGROUND AND OBJECTIVES

The purpose of this study was to determine the clinical course and effects of histopathologic characteristics of specific tumors including DNA contents and immunohistochemical aspects in patients with small cell carcinoma of the esophagus.

METHODS

Medical records of 4 patients who presented with small cell carcinoma of the esophagus were retrospectively reviewed.

RESULTS

DNA aneuploidy was observed in 2 cases. Staining for the p53 product was positive in all cases. The average proliferating cell nuclear antigen (PCNA) labeling rate (LR) was 77.6% (64.0-90.8%). The estimated median survival was 42 days for all patients. Distant metastases were observed in 2 of the 4 patients.

CONCLUSIONS

Higher PCNA LR of small cell carcinoma may be an unfavorable characteristic of biological behavior. Patients with disseminated disease should have symptomatically palliative operation combined with chemotherapy.

Primary leiomyosarcoma arising in the lesser sac: report of a case

We describe herein a very rare case of leiomyosarcoma arising in the lesser sac. A 58-year-old man with a psychiatric disorder was admitted to our department for the investigation of epigastralgia and nausea which he had been suffering since the previous month. A laparotomy revealed that the abdominal mass, found on physical examination, was a primary lesser omental tumor, histological examinations of which confirmed a diagnosis of leiomyosarcoma. The tumor cells showed a DNA diploid pattern. Leiomyosarcoma of the lesser sac is extremely unusual and it is important that it be distinguished from an extraluminal tumor of the abdomen.

Breast conserving treatment versus modified radical mastectomy in Japanese patients with operable breast cancer

From January, 1988 to October, 1995, 96 patients with operable breast cancer were treated by breast conserving treatment (BCT) including wide excision and axillary dissection followed by breast radiation. During the same period, 188 patients were treated by modified radical mastectomy (MRM) with or without breast reconstruction. In order to compare the survival of BCT and MRM groups, univariate and multivariate analyses were performed in this retrospective study. Univariate analysis revealed that the 5-year survival rates in the BCT and MRM groups were 97% +/- 2% and 87% +/- 3%, respectively (p < 0.05 with the Cox-Mantel test). However, the baseline variables were different between the groups. The adjusted Cox regression analysis revealed that the results of BCT were almost equivalent with those of MRM. Moreover, no breast recurrence was found in the BCT group. Therefore, it is suggested that our technique of BCT is as effective as modified radical mastectomy in treating operable breast cancer in Japanese patients.

Early diagnosis of mucosal squamous cell carcinoma of the esophagus: including two interesting cases of superficial spreading-type and multicentric-type squamous cell carcinomas

We reviewed 10 patients with esophageal mucosal carcinoma in order to improve the early diagnosis of the disease. Histologically seven of the 14 lesions were carcinomas in situ (epithelial cancer), and the other seven lesions were carcinomas confined to the mucosa other than epithelial cancer (muscularis mucosae cancer), all 14 lesions were squamous cell carcinomas (SCC). One of these seven mucosal SCC, which demonstrated an extensive spreading-type SCC in which the size of the SCC was 7 cm long while extending entirely around the esophageal lumen in circumferential spread, is described in detail, and multiple epithelial cancers existed separately in one case. Eleven lesions diagnosed before operation showed abnormal findings on conventional endoscopy regardless of the size and depth of transmural invasion. An additional lesion was visible with dye endoscopy as an unstained area, but it was not visible with radiography or conventional endoscopy. Dye endoscopy using Lugol solution is very important because it allows detection and evaluation of the extent of esophageal mucosal cancer.

Hepatocellular carcinoma presenting as extrahepatic mass on computed tomography

The authors describe an extremely rare case of extrahepatic hepatocellular carcinoma. The patient was a 70-year-old man who was examined by a local doctor because of abdominal discomfort. Barium meal examination demonstrated a defect occupying the lesser curvature of the stomach from the middle of the corpus to the fornix. On an abdominal computed tomography (CT) scan, the lesion, 10 cm in diameter, touched the lower surface of the caudate lobe of the liver. Under laparotomy, the tumor was found between the caudate lobe of the liver and posterior wall of the gastric corpus. As the tumor appeared to be connected with the caudate lobe by a pedicle, only the tumor was resected. Histological examination showed the tumor to be hepatocellular carcinoma of Edmondson's grade III-IV, pedunculated type.

The expression of E-cadherin as a prognostic factor in breast cancer

We examined the clinical significance of E-cadherin expression in 98 patients with breast cancer. E-cadherin expression significantly correlated with histologic grade (p=0.0323) and tended to correlate with the absence of axillary lymph node metastases (p=0.0646). The expression of E-cadherin was associated significantly with the recurrence rate (p=0.0334) and marginally associated with disease-free (p=0.0597) but not overall survival, in univariate analysis. The association between E-cadherin expression and disease-free survival was lost in multivariate analysis. The prognostic value of E-cadherin expression in breast cancer appears to be limited. A larger, prospective study with long-term follow-up is needed.

Chemoprevention of DMBA-induced mammary carcinogenesis in rats by low-dose EPA and DHA

We investigated the effects of low-dose eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) on the incidence and growth of 7,12-dimethylbenz(a)anthracene (DMBA)-induced mammary carcinoma in rats fed a high-fat (HF) diet. We also examined the effects of these treatments on the fatty acid composition of tumour and serum. Tumour incidence was significantly decreased by the administration of low-dose EPA and DHA, whereas their inhibitory effects on tumour growth did not reach significance. Serum arachidonic acid (AA) level was decreased by the administration of low-dose EPA and tended to be decreased by the administration of low-dose DHA, whereas tumour AA levels were not changed. The administration of low-dose EPA and DHA may be useful for inhibiting the incidence of breast cancer.

Strangulation ileus resulting from encasement of a loop of the small intestine by the great omentum, caused by abnormal adhesion

We treated a patient with a mechanical ileus resulting from encasement of a loop of the small intestine by the great omentum, caused by abnormal adhesion. Apart from its occurrence postoperatively with laparotomy, strangulation of small intestine into the omentum is very rare, and its occurrence without underlying disease, except in children, has not been documented previously.

Prolapse of the small intestine through a ruptured vagina caused during sexual intercourse: report of a case

We report herein the rare case of a 56-year-old woman who suffered vaginal rupture into the peritoneal cavity during sexual intercourse, through which the small intestine prolapsed out from the vaginal opening. The patient had undergone abdominal hysterectomy 4 years earlier. An emergency laparotomy was performed which revealed rupture in the posterior fornix of the vagina and peritonium through which prolapse of the small intestine had occurred. The prolapsed intestine was pulled back into the pelvic cavity, and the vagina and peritonium were repaired. Macroscopically, the operative findings revealed no inflammatory changes or evidence of malignancy in the abdominal cavity. Thus, although rare, a ruptured vagina caused by sexual intercourse should also be considered in the field of surgery, even when a middle-aged woman presents with acute abdominal symptoms without a history of any other traumatic episode.

Intraoperative assessment of axillary lymph node metastases in operable breast cancer

The diagnostic value of intraoperative histologic examination of frozen sections of axillary lymph nodes was investigated in 243 patients with operable breast cancer. One to six hard or enlarged axillary nodes were sampled from the axillary pad which was derived from a partial axillary dissection (including level 1 and 2 nodes). Half of these nodes were histologically examined using frozen sections during surgery. After a total axillary dissection, both the axillary nodes in the partial axillary dissection and the nodes dissected at level 3 were histologically examined on permanent section. A mean of four nodes were sampled (range: 1 to 6). Axillary dissection yielded a mean of 22 nodes (range: 6 to 60). Axillary sampling detected the presence of metastases in 65 of 84 (77%) patients with positive axillary lymph nodes. In the patients in whom the axillary involvement was not identified by axillary sampling, however, the extent of axillary involvement was limited to levels 1 and 2. Therefore, a partial axillary dissection may be justified for patients in whom axillary involvement is not found on frozen section of nodes from axillary sampling, whereas a total axillary dissection should be performed for patients in whom axillary involvement is found by these procedures.

The effects of high dietary fat and indomethacin on 7,12-dimethylbenz(a)anthracene-induced mammary carcinomas in rats

The effects of high dietary fat and indomethacin (IND) on tumorigenesis, tumor growth, tumor histology, cell kinetics and receptor contents of 7,12-dimethylbenz(a)anthracene (DMBA)-induced mammary carcinomas were investigated in Sprague-Dawley (S-D) rats. Tumorigenesis was stimulated by high dietary fat and inhibited by IND. However, both high dietary fat and IND stimulated tumor growth. Switching the animals from the high-fat diet with or without IND to the low-fat diet suppressed tumor growth and affected the cell kinetics. Histologically, the tumors showed a dense proliferation of ductal cells in the high-fat alone or IND-treated high-fat diet group. Tumors in the low-fat or IND-treated low-fat group, as well as the group switched from a high-fat or IND-treated high-fat diet to a low-fat diet, demonstrated well-developed glandular structures. The estrogen receptor and progesterone receptor contents were not different between the groups either prior to or following switching diets. Therefore, high dietary fat stimulates tumorigenesis and tumor proliferation, while IND has dual effects: a stimulating effect on tumor proliferation, but an inhibiting effect on tumorigenesis. It also appears that hormone-receptor status does not play an important role in the stimulatory effects of high-fat diet or IND on tumor proliferation.

In vitro effects of eicosanoid synthesis inhibitors in the presence of linoleic acid on MDA-MB-231 human breast cancer cells

We investigated the effects of cyclooxygenase and lipoxygenase inhibitors in the presence of linoleic acid (LA), as well as the direct effects of prostaglandin E (PGE) and leukotriene B (LTB) on a human breast cancer cell line (MDA-MB-231) in vitro. Piroxicam, esculetin, and nordihydroguaiaretic acid (NDGA) suppressed cell growth and thymidine incorporation. However, a low concentration (1 microgram/ml) of indomethacin (INDO) stimulated cell growth and thymidine incorporation, while a high concentration of INDO (30 micrograms/ml) inhibited both. Esculetin and NDGA reduced the secretion of LTB, whereas piroxicam reduced the secretion of PGE. INDO reduced the secretion of PGE, but a low concentration of INDO increased the secretion of LTB. Consequently, cell growth was correlated with the PGE and/or LTB concentrations when the cells were treated with these cyclooxygenase or lipoxygenase inhibitors. On the other hand, exogenous PGE2 partially reversed the inhibition of thymidine incorporation caused by INDO, whereas LTB4 exerted a similar effect in the case of esculetin or NDGA. The reversibility of the piroxicam effect with PGE2 is not convincing. Therefore, it is suggested that the growth of MDA-MB-231 cells in vitro is affected by both the lipoxygenase and cyclooxygenase products, probably the other eicosanoids rather than PGE2 and LTB4.

Effects of linoleic acid and eicosanoid synthesis inhibitors on the growth and c-myc oncogene expression of human breast cancer cells

We investigated the effects of linoleic acid and eicosanoid synthesis inhibitors on the growth, DNA synthesis, and c-myc oncogene expression of human breast cancer cell lines. The cell growth of all cell lines examined was stimulated by linoleic acid, although the optimal concentration of linoleic acid for the growth stimulation differed among the cell lines. The growth stimulation of MCF7 and MDA-MB-435 cells was not dependent on the amount of released prostaglandin E(2) but their growth-concentration curve showed the same pattern as that of released leukotriene B-4. Moreover, linoleic acid stimulated the expression of c-myc mRNA in MCF7 cells without the presense of estrogen. Indomethacin as a cyclooxygenase inhibitor did not inhibit the c-myc expression in MCF7, but a lipoxygenase inhibitor, esculetin, markedly inhibited the c-myc expression in MCF7 affected by linoleic acid. These results suggest that linoleic acid has a direct mitogenic effect on breast cancer cells, and its mechanism is distinct from hormonal stimulation, Moreover, metabolites of lipoxygenase rather than those of cyclooxygenase may play an important role in the c-myc oncogene expression affected by linoleic acid.

Intraoperative histologic assessment of surgical margins and lymph node metastasis in breast-conserving surgery

The diagnostic value of intraoperative histologic examination of frozen sections of surgical margins and axillary lymph nodes (AX) was investigated in 95 patients with breast cancer who underwent breast-conserving surgery. The periphery of the excised breast tissue was peeled like an orange and examined histologically by frozen section. The results were compared with examination by permanent section. Evaluation of surgical margins by frozen section resulted in a diagnostic accuracy of 87%, a sensitivity of 96%, and a specificity of 84%. Enlarged or hardened AXs were sampled from the axillary pad which was derived from a complete AX dissection. Histologic examination using frozen section was performed during surgery. After the operation, the remaining AXs were removed from the axillary pad by hand dissection and histologically examined on permanent section. A diagnostic accuracy of 97%, a sensitivity of 77%, and a specificity of 100% were achieved in the diagnosis of AX involvement on frozen section. It was therefore concluded that intraoperative histologic examination of frozen sections may be useful in the determination of involvement of the surgical margins and the AXs in patients with breast cancer.

Effects of piroxicam and esculetin on the MDA-MB-231 human breast cancer cell line

We investigated the effects of piroxicam, esculetin, prostaglandin E2 (PGE2) and leukotriene B4 (LTB4) on a human breast cancer cell line (MDA-MB-231). Both piroxicam and esculetin suppressed cell growth and thymidine incorporation, though esculetin was more active in inhibiting cell growth in the presence of linoleic acid (LA). Esculetin reduced the secretion of LTB independent of LA. Piroxicam reduced the secretion of PGE in the absence of LA but only at higher concentrations in the presence of LA. When the relationship between cell growth and PGE and LTB concentration was evaluated by multivariate regression analysis, cell growth was associated with the PGE and LTB concentration when the cells were treated with esculetin alone or with esculetin and LA. Cell growth was associated only with the PGE concentration when they were treated with piroxicam alone or with piroxicam and LA. Therefore, it appears that the growth of MDA-MB-231 cells in vitro is affected by both lipoxygenase and cyclooxygenase products, though lipoxygenase inhibition is more active than cyclooxygenase inhibition on suppression of cell growth in the presence of LA.

Effects of eicosapentaenoic and docosahexaenoic acid on cell growth and prostaglandin E and leukotriene B production by a human breast cancer cell line (MDA-MB-231)

We investigated the in vitro effects of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), with or without the addition of linoleic acid (LA), on cell growth and prostaglandin E (PGE) and leukotriene B (LTB) secretion by a human breast cancer cell line (MDA-MB-231). With or without the addition of LA, EPA and DHA suppressed cell growth and thymidine incorporation and reduced the secretion of PGE and LTB. In a univariate analysis, cell growth was significantly associated with both LTB and PGE concentrations when cells were treated with DHA or EPA, independent of the addition of LA. However, multivariate regression analysis showed that cell growth was more closely associated with the PGE concentration rather than the LTB concentration. These data suggest that both EPA and DHA suppress cell proliferation in the MDA-MB-231 cell line by inhibition of the cyclooxygenase rather than the lipoxygenase pathways. However, the exact mechanism underlying the antitumor activity of EPA and DHA remains unclear.

Oncologic and cosmetic outcome in patients with breast cancer treated with wide excision, transposition of adipose tissue with latissimus dorsi muscle, and axillary dissection followed by radiotherapy

We evaluated the oncologic and cosmetic outcome in patients with breast cancer treated with wide excision, transposition of adipose tissue with latissimus dorsi muscle (LDM), and axillary dissection followed by radiotherapy. In this study, a wide excision of breast tissue was performed to obtain tumor-free margins. The subsequent breast deformity was not corrected in six patients in the early phase of the study (Group 1), and in 16 patients in the late phase (Group 2) in which the breast deformity was not remarkable at the time of operation. Breast deformity was corrected by transposing adipose tissue with LDM on a vascular pedicle in the remaining 51 patients (Group 3). Five year survival was 100%. Two patients developed distant metastases. None were found to have local recurrence. Fifty percent of the Group 1 patients, 69% of the Group 2 patients, and 67% of the Group 3 patients had an excellent or good cosmetic result. However, when the cosmetic results were evaluated in patients who underwent transposition and had small breasts, the results were excellent or good in 76%, compared to 38% in the patients who had reconstructions who had large breasts. The difference was statistically significant (p = 0.0309). Therefore, it was confirmed that wide excision and axillary dissection followed by breast radiation could provide adequate local control, but frequently resulted in breast deformity. However, transposition of adipose tissue may be useful to correct the breast deformity, especially in women with small breasts.

The role of fatty acids and eicosanoid synthesis inhibitors in breast carcinoma

We have reviewed the literature concerning the role of fatty acids and eicosanoid synthesis inhibitors in breast carcinoma. The omega-6 polyunsaturated fatty acids (PUFAs), primarily linoleic acid, promote breast cancer tumorigenesis and tumor cell proliferation directly and indirectly via increased synthesis of cyclooxygenase- and lipoxygenase-catalyzed products. The omega-3 PUFAs, primarily docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), suppress breast carcinoma tumorigenesis and tumor cell proliferation, although the effect of DHA may be partly ascribed to increased amounts of EPA derived from DHA. Both cyclooxygenase and lipoxygenase inhibitors suppress tumorigenesis and/or tumor proliferation, with the latter being more active. Thus, arachidonic acid-derived eicosanoids play an important role in breast cancer, and the balance of the various eicosanoids may be a critical determinant of cell proliferation. However, the exact mechanism by which fatty acids and eicosanoid synthesis inhibitors exert stimulatory and inhibitory effects on breast carcinoma is still not well understood.

Effects of indomethacin with or without linoleic acid on human breast cancer cells in vitro

The effect of indomethacin (INDO) with or without the addition of linoleic acid (LA) was investigated in a cultured MDA-MB-231 human breast cancer cell line. It was found that INDO without LA suppressed cell growth and thymidine incorporation; however, with the addition of LA, INDO at low concentration promoted these factors, whereas INDO at higher concentrations suppressed them. On the other hand, INDO with or without the addition of LA reduced the secretion of prostaglandin E (PGE). However, INDO at a low concentration (1 microgram/ml) with the addition of LA increased the secretion of leukotriene B (LTB), while INDO without LA had no effect on the secretion of LTB. When the relationship between cell growth and PGE or LTB concentration was investigated, cell growth was associated with the PGE and LTB concentrations when the cells were treated with INDO and LA, whereas it was associated only with the PGE and LTB concentrations when the cells were treated with INDO and LA, whereas it was associated with the PGE concentration when they were treated with INDO alone.

Pathologic Assessment of Surgical Margins on Frozen and Permanent Sections in Breast Conserving Surgery

The diagnostic value of frozen section was evaluated in the histologic assessment of surgical margins obtained by wide excision of breast tumors. There were 87 patients with unilateral breast cancer, and 5 with bilateral breast cancers. The periphery of the excised breast tissue was peeled like an orange and histologically examined by frozen and permanent section. If either in situ or infiltrating microscopic tumor was found at the margin, it was considered positive. Using frozen sections, the margin was judged histologically positive or suspicious in 30 tumors (31%) and negative in 67(69%) tumors. Positive surgical margins were histologically confirmed by permanent section in 20(67%) of the 30 tumors diagnosed as positive or suspicious on frozen section. Another 10 tumors had negative margins. In 4 tumors, however, while the initial or re-excised margin was negative on frozen section, the margins were positive by permanent section. These surgical margins were positive due exclusively to the presence of ductal carcinoma in situ (DCIS). Evaluation of surgical margins in breast cancer by frozen section, thus exhibited a diagnostic accuracy of 86&prtcnt;, a sensitivity of 83%, and a specificity of 86%. It is concluded that frozen sections are useful in the determination of involvement of surgical margins after the wide excision of breast cancer. It must be pointed out that frozen sections will ofter overestimate involvement of the surgical margins.

Recurrence and mortality in patients with differentiated thyroid carcinoma

We examined the factors associated with increased recurrence and/or mortality of 195 patients with primary differentiated thyroid carcinoma. Of 171 patients who underwent at least, resection of the primary macroscopic tumor (curable), 26 patients (15%) developed recurrence and 6 of these patients died from the disease. Sixteen (67%) of 24 patients with initial distant metastasis or grossly malignant tumor residua in the neck after the operation (non-curable patients) died from the disease. In the curable patients, age, sex and tumor size correlated significantly with recurrence and/or mortality. When the characteristics of patients who died after recurrence were compared to those who survived after recurrence, however, only the patient's age correlated significantly with mortality. In the non-curable patients, the histologic subtype correlated significantly with mortality. It may be concluded, therefore, that the risk factors which affect mortality in differentiated thyroid cancer differ between curable and non-curable patients.

Effects of eicosanoid synthesis inhibitors on the in vitro growth and prostaglandin E and leukotriene B secretion of a human breast cancer cell line

We investigated the effects of cyclooxygenase and lipoxygenase inhibitors on a human breast cancer cell line (MDA-MB-231) in culture. Indomethacin (INDO), piroxicam, esculetin, and nordihydroguaiaretic acid (NDGA) significantly suppressed cell growth, although piroxicam caused significant suppression only at high concentrations. Esculetin and NDGA caused significantly reduced secretion of leukotriene B (LTB), while INDO and piroxicam caused significantly reduced secretion of prostaglandin E (PGE). Consequently, cell growth was significantly correlated with the LTB concentration when the cells were treated with esculetin or NDGA, whereas it was significantly correlated with the PGE concentration when they were treated with INDO or piroxicam. Therefore, MDA-MB-231 cell growth in vitro was independently associated with both the PG and LTB concentrations.

A Case with Breast Cancer under the Nipple Who Underwent Breast Conserving Treatment

Although breast conserving treatment (BCT) had become the standard therapy for early breast cancer, breast removal is still recommended for patients with a tumor beneath the nipple or with Paget's disease. We have employed transposition of a latissimus dorsi myocutaneous (LD-MC)flap after wide local excision of a tumor with the nipple-areola complex. A new nipple-areola complex was reconstructed on the LD-MC flap after breast irradiation. Utilizing reconstructive techniques, BCT will likely become the treatment of choice for more patients with early breast cancer.

The prognostic significance of epidermal growth factor receptor expression in breast cancer

The association between epidermal growth factor receptor (EGFR) expression, clinicopathological variables, silver-stained nuclear organizer region (Ag-NOR) counts, and patient survival was determined in 93 patients with operable breast cancer. The EGFR expression was found to be significantly associated with the presence and number of axillary lymph node metastases (P = 0.0429), but not with age, menopausal status, tumor size, histologic type or grade, or Ag-NOR counts. In a univariate analysis, a significant difference was also observed in the survival of patients stratified by tumor size (P = 0.0091), histologic grade (P = 0.0352), axillary lymph node metastases (P = 0.0001), and EGFR expression (P = 0.0263). However, a multivariate analysis revealed that axillary lymph node metastases was the only strong independent predictor of survival (P < 0.0001). When axillary lymph node metastases were excluded from the Cox model, the EGFR expression tended to be an independent prognostic factor (P = 0.0558). The results of this study thus indicate that the prognostic value of EGFR expression is limited because the EGFR expression is significantly associated with axillary lymph node metastases.

Reappraisal of internal mammary lymph node dissection in selected patients with invasive breast cancer

We performed a new type of en bloc extended radical mastectomy (EXT) as a clinical trial in 118 patients from 1980 through 1985. A variety of conventional radical mastectomies (RDL) were also undertaken in 105 patients from 1973 through 1985. In this retrospective study, univariate and multivariate analyses were performed to compare the results of EXT and RDL. The univariate analysis showed that the 10-year survival rates for the EXT and the RDL groups were 86% +/- 3.3% and 77% +/- 4.2%, respectively (P = 0.073 with the Cox-Mantel test). For the subgroups stratified according to the status of axillary lymph node involvement, the EXT was significantly better in patients with one to three metastatic axillary lymph nodes (P = 0.016). The adjusted Cox regression analysis revealed that the favorable results of EXT were most encouraging in the patients with one to three metastatic axillary lymph nodes (P = 0.058). Therefore, it is suggested that an EXT may be more advantageous than RDL in selected patients with resectable invasive breast cancer.

[Reconstructive surgery in breast cancer operation]

We reported our experience with immediate breast reconstruction after partial or total mastectomy. In patients who underwent breast conserving surgery (BCT), an immediate transposition of adipose tissue with latissimus dorsi muscle vascular pedicle was carried out with the aim of improving cosmetics after wide excision. In those who received modified radical mastectomy, immediate breast reconstruction (MIBR) using a transverse abdominomyocutaneous flap or latissimus dorsi myocutaneous flap was carried out. Although either BCT or MIBR was performed at the patient's request, reconstructive surgery thus plays an important role in breast cancer operation.

Inhibitory effects of purified eicosapentaenoic acid and docosahexaenoic acid on growth and metastasis of murine transplantable mammary tumor

We studied the effects of purified linoleic acid, eicosapentaenoic acid(EPA) and docosahexaenoic acid (DHA) on mammary tumor MM48 the transplanted into C3H/He mice. The growth of the primary tumor was significantly inhibited in EPA- and DHA-treated groups as compared with control and/or linoleic acid-treated groups (p < 0.05). The number of metastatic tumors in the lungs tended to be inhibited in the EPA- and DHA-treated groups and promoted in the linoleic acid-treated group, as compared with the control group, but not to a statistically significant extent. The EPA-treated group survived significantly longer than the control group (p = 0.002), while the DHA-treated group survived longer than the control group although the difference was not significant (p = 0.070). However, there was no significant difference between EPA- and DHA-treated groups on primary tumor growth, number of lung metastases or survival time of animals.

Immunohistochemical study of epidermal growth-factor and epidermal growth-factor receptor in breast-carcinoma

We examined the relationship between epidermal growth factor (EGF) and epidermal growth factor receptor (EGFR) with clinicopathologic variables and silver-stained nuclear organizer region (Ag-NOR) counts in 93 patients with breast cancer. EGFR expression was significantly associated with axillary lymph node metastases, whereas EGF expression was not significantly associated with any of the clinicopathologic variables. Ag-NOR counts were not significantly different among groups of tumors categorized by EGF and EGFR expression, but a significant correlation was observed between clinical stage and synchronous expression of EGF and EGFR. However, EGF and EGFR expression did not appear to be independent prognostic factors as determined by multivariate analysis in which axillary lymph node metastases were included. We therefore conclude that EGF and EGFR expression may play a role in tumor progression rather than in tumor proliferation, but their expression was not useful in predicting the prognosis of patients with breast cancer.

Helix-pomatia lectin and C-erbb-2 expression versus axillary and internal mammary lymph-node metastases in prognostic assessment of breast-cancer

The relationship between Helix pomatia lectin (HPA) staining, c-erbB-2 expression, and other prognostic factors in breast cancer, i.e., axillary (AX) and internal mammary lymph node (IMN) metastases was assessed. The prognostic value of HPA staining and c-erbB-2 expression in combination was analyzed. HPA status was found to be significantly correlated with tumor size, and with AX and IMN metastases, whereas c-erbB-2 was significantly correlated only with AX and IMN metastases. A univariate study revealed that disease-free and overall survival were correlated significantly with tumor size, with AX and IMN metastases, and with HPA and c-erbB-2 status. Moreover, c-erbB-2 status was predictive of a poorer prognosis in both HPA+ and HPA- groups, and HPA+/c-erB-2+ patients had the worst prognosis when compared to the other subgroups. In a multivariate study, however, only AX and IMN metastases were significant prognostic factors. A combination of HPA staining and c-erbB-2 expression failed to provide any additional prognostic information. In patients in whom regional lymph node dissection has not been performed, however, one should take into account not only HPA binding status, but also c-erbB-2 oncoprotein status to discriminate more precisely those sub-populations with a high recurrence risk and predicted short survival who would be candidates for more aggressive therapy.

Psychologic and cosmetic self-assessments of breast conserving therapy compared with mastectomy and immediate breast reconstruction

Cosmetic and psychologic morbidity was evaluated by patients' self-assessment in 42 patients who underwent breast conserving therapy (BCT) and 48 patients who underwent mastectomy with immediate breast reconstruction (MIBR). Although sexual adjustment and fear of cancer recurrence were not significantly different between the two groups, body image was rated as significantly better in the BCT group. Additionally, in the MIBR group, nine patients expressed concern about abdominal or back scars and 15 related abdominal or back pain. Eighty-three percent of the BCT group indicated BCT as a future choice of treatment, whereas only 38% of the MIBR group indicated MIBR as a future choice of treatment. Therefore, body image and patients' satisfaction were thought to have been improved by BCT, but psychologic morbidity was the same in both groups.

Mastectomy with and without immediate breast reconstruction using a musculocutaneous flap

We compared surgical cosmetic results in 83 patients who underwent mastectomy with immediate breast reconstruction (MIBR) using a myocutaneous flap with those of 153 patients with breast cancer who underwent mastectomy without breast reconstruction. Cosmetic results were significantly better in patients who underwent MIBR than radical mastectomy or extended MIBR, although no intergroup difference existed in the reconstructive technique. Neither did any difference exist in the incidence of complications between patients undergoing MIBR and mastectomy without breast reconstruction, or between patients undergoing modified mastectomy and radical or extended mastectomy. Finally, MIBR did not appear to adversely effect recurrence or overall survival. We conclude that MIBR using a myocutaneous flap is an acceptable treatment option for patients with breast cancer.

A retrospective study on the clinical and biological prediction of axillary lymph node metastasis in breast cancer

If axillary lymph node metastases were able to be accurately predicted, dissection could be avoided in some patients with breast cancer whose axillary nodes are clinically negative. In this study, we assessed the relationships between histological axillary lymph node metastases and clinical axillary nodal status, tumor size, DNA-ploidy, c-erbB-2 expression, and the score of the argyrophilic nucleolar organizer region. We then attempted to evaluate their predictive values for axillary lymph node metastasis in 173 patients with invasive breast cancer, retrospectively. The clinical and biological variables were significantly correlated with the presence and degree of axillary lymph node metastases. A metastatic index, calculated from the clinical and biological variables, proved especially useful for predicting axillary lymph node metastases in patients whose axillary nodes were clinically negative. However, the predictive abilities were still limited and thus it was concluded that as yet, only axillary dissection can provide accurate information on axillary lymph node metastases.

The prognostic-significance of proliferating cell nuclear antigen in breast-cancer - correlation with DNA ploidy, C-erbb-2 expression, histopathology, lymph-node metastases and patient survival

We have investigated the relationship of PCNA expression with established clinicopathologic and biologic prognostic variables and determined its prognostic value in 91 patients with operable invasive breast cancer. The PCNA index varied within a range of 0-74% with the average in all specimens equal to 17%. When the tumors were separated on the basis of the mean value of the PCNA index, PCNA expression did not correlate with clinical stage, histologic type or grade, tumor size, axillary or internal mammary lymph node metastases, DNA ploidy, or c-erbB-2 expression. Moreover, PCNA expression did not appear to be a significant prognostic factor by univariate or multivariate analyses. Therefore, we conclude that PCNA expression does not correlate with established clinicopathologic and biologic prognostic factors and may not be useful in clinical practice to identify a poor prognostic group of patients with breast cancer.

Internal mammary nodal status is a more reliable prognostic factor than DNA ploidy and c-erb B-2 expression in patients with breast cancer

We evaluated the relationship among DNA ploidy, c-erb B-2 oncoprotein expression, and clinicopathologic prognostic factors, especially axillary and internal mammary node metastases, and their value in estimating the prognosis in 128 patients with operable breast cancer. There were significant correlations between DNA ploidy and clinical stage, tumor size, or axillary or internal mammary lymph node metastases, and between c-erb B-2 expression and clinical stage or axillary lymph node metastases. In a univariate study, overall or disease-free survival was significantly correlated to clinical stage, tumor size, DNA ploidy, c-erb B-2 expression, and axillary and internal mammary node metastases. In a multivariate study, however, only axillary and internal mammary node metastases were recognized as independent factors on overall survival, whereas on disease-free survival, only axillary lymph node metastases were identified as an independent indicator. Since the DNA ploidy status and c-erb B-2 expression were closely correlated with the axillary and/or internal mammary lymph node metastases, they did not appear as independent prognostic factors in this small series.

Clinical and biological prediction of axillary and internal mammary lymph node metastases in breast cancer

We assessed the relationships among histological axillary (AX) or internal mammary (IM) metastases and clinical and biological variables, and then attempted to evaluate their predictive values for AX and IM metastases in 128 patients with invasive breast cancer. As the results, these clinical and biological variables were significantly correlated with AX and IM metastases. However, a metastatic index calculated from clinical and biological variables was not much better in prediction of the AX metastases than axillary nodal status, whereas it was useful to predict the IM metastases. Thus, the predictive ability was still limited. Since accurate prediction of AX and IM metastases is critical to therapeutic choice, however, further study would be required.

A comparison of breast cancers detected by mass screening and those found in out-patient clinics

We evaluated the results of a mass screening study on breast cancer detection by physical examination alone conducted in Ishikawa Prefecture from 1978 to 1990. The number of cases of breast cancer detected by mass screening was then compared with that found in out-patient clinics during the same period. Breast cancer was detected in 88 of 152,969 women by mass screening, the detection rate being 0.06% for the total study: 0.08% at the initial screening and 0.04% at periodic screenings. Early stage breast cancer was more frequently detected during periodic screenings than at the initial screening or in out-patient clinics. Moreover, although the initial screenings may have identified patients with breast cancer at more advanced stages, the survival was not significantly different. The results of this series led us to conclude that mass screening by physical examination alone may have no impact on the mortality rate of breast cancer.

C-erbb-2 oncoprotein expressionversus internal mammary lymph node metastases as additional prognostic factors in patients with axillary lymph node-positive breast cancer

The relationship was assessed between c-erbB-2 oncoprotein expression and other prognostic factors in breast cancer, such as axillary and internal mammary node metastases. The value of these indicators was analyzed in estimating prognosis, especially in patients with axillary node-positive breast cancer. These results showed that c-erbB-2 is significantly related to clinical stage and axillary node metastases. A univariate study revealed that disease-free and overall survival were correlated significantly with clinical stage, tumor size, axillary and internal mammary node metastases, and 21N status. Among the patients with axillary node involvement, however, 21N status did not appear to be a significant additional prognostic factor. Internal mammary node metastases were significant. In a multivariate study, only axillary and internal mammary node metastases were significant prognostic factors for either the entire group of patients or those with positive axillary nodes. Therefore, axillary node dissection and biopsy of the internal mammary nodes may provide important prognostic information for patients with breast cancer.