Decision Making Using Postoperative CEA and CA 15-3 for Detection of Breast Cancer Recurrence

To determine the clinical implications of postoperative levels of serum carcinoembryonic antigen (CEA) and CA 15-3 as follow-up parameters for breast cancer, a retrospective study was conducted on 157 patients who underwent curative surgery for breast cancer. Twenty-three patients had recurrences and 134 patients were without recurrence for more than one year after measuring the tumor marker. The receiver operating characteristic (ROC) curves indicated that CA 15-3 performed more accurately than CEA in discriminating between patients with recurrence (n = 23) and those without (n = 134). Of 23 patients with recurrence, CEA was elevated above the normal range (<2.9 ng/ml) in 32% and CA 15-3 was elevated above the normal range (> 20U/ml) in 67%. The elevation of the markers preceded the clinical appearance of metastases in 2 patients for CEA and in 5 patients for CA 15-3. False positive rates for CEA and CA 15-3 in the 134 patients without recurrence were 4% and 10%, respectively. Nevertheless, these rated became 0% when the cut-off values were doubled. When the postoperative serum level of either CEA or CA 15-3 exceeds twice the upper limit of the normal range or when, in patients with unfavourable prognostic characteristics (node positive or large tumor), either of these values is between the upper limit of the normal range and double the value, recurrent breast cancer must be assumed. For such patients, further investigations with high-sensitivity radiographic modalities are warranted because early treatment may be able to provide survival benefit.

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.

Changing practices in the surgical treatment of breast cancer in Japan: a nationwide survey by the Japanese Breast Cancer Society

A nationwide survey in Japan of the patients with primary breast cancer from 1989 to 1991 revealed marked changes in the surgical treatment of the disease. During this period, there was a significant trend toward fewer instances of radical and extended radical mastectomies, and an increase in modified radical mastectomies and breast-conserving surgery. The percentage of breast-conserving surgery for the early-stage disease increased from 6.8% to 12.7%. Among the types of operations for breast-conserving surgery, quadrantectomy was used for 51.5% of the cases, while either a partial mastectomy or a subcutaneous mastectomy was used for 18.2% and 18.9%, respectively; a lumpectomy was performed in 10.9% of the cases. As for the proportion of patients receiving radiation therapy after breast-conserving surgery, 77% of those undergoing lumpectomy received radiation, in contrast to only 43% of the patients undergoing quadrantectomy. According to the data from 1991, we also found that breast-conserving surgery was performed more often in larger cities and urban areas in Japan. As a result, we found that substantial changes in the treatment of localized breast cancer had taken place from 1989 to 1991. Regarding the details of breast-conserving surgery, however, some variation still remains in spite of the publication of numerous clinical trials.

[An early phase II study of CPT-11 (irinotecan hydrochloride) in patients with advanced breast cancer]

An early phase II study of irinotecan (CPT-11) in patients with advanced or recurrent breast cancer was undertaken by a cooperative study group of 15 institutes in Japan. CPT-11 was administered by intravenous drip-infusion. The administration schedules were 100 mg/m2 weekly (regimen A), 150 mg/m2 biweekly (regimen B), and 200 mg/m2 every 3-4 weeks (regimen C). There were 4 partial responses (PRs), 12 cases with no changes (1 minor response) and 9 cases of progressive diseases with a response rate of 16% (4/25). One out of 7 patients on regimen A and 3 patients out of 15 patients on regimen C achieved PR with a response rate of 14% and 20%, respectively. In three out of 4 PRs, prior chemotherapy, endocrinotherapy or radiotherapy had failed. Major adverse reactions were leukopenia 28/33 (85%), neutropenia 19/25 (76%), anemia 15/33 (46%), nausea/vomiting 28/33 (85%), anorexia 25/33 (76%), diarrhea 22/33 (67%) and alopecia 20/33 (61%). The incidence of leukopenia and thrombocytopenia seemed to be higher in regimen C than regimen A, and diarrhea was also more severe in regimen C than regimen A. The recovery of leukopenia was delayed in some patients on regimen C. The results suggested that CPT-11 was effective against advanced or recurrent breast cancer. The recommended administration schedule for a late phase II study was thought to be 100 mg/m2 weekly, considering efficacy and safety.

Comparison of chemotherapy with or without medroxyprogesterone acetate for advanced or recurrent breast cancer

The usefulness of CAF [cyclophosphamide (CPA)/doxorubicin (ADR)/5-fluorouracil (5-FU)] + medroxyprogesterone acetate (MPA) therapy for advanced/recurrent breast cancer was studied in a randomised trial at 56 institutions. Patients received CAF therapy [CPA: 100 mg, orally, days 1-14; ADR: 30 mg/m2, intravenously (i.v.), days 1 and 8; 5-FU: 500 mg/m2, i.v., days 1 and 8) in arm I, or CAF + MPA therapy (CAF + MPA 1200 mg, daily) in arm II. The response rate was significantly higher (P = 0.041) in arm II (53.5%, 46/86) than arm I (36.6%, 30/82). The response rate by tumour site was significantly higher for lymph node and bone lesions in arm II. Partial response duration and overall response duration were significantly longer in arm II. Incidences of anorexia and nausea/vomiting were significantly higher in arm I but in arm II, moon face, oedema and vaginal bleeding were significantly higher. Many patients in arm II demonstrated improvement in performance status and weight loss, suggesting a beneficial effect of MPA. The chemoendocrine therapy with CAF + MPA appears to be more beneficial than CAF alone in the treatment of advanced/recurrent breast cancer.

[Correlations between estrogen receptor and prognostic factors of patients with breast cancer. The Kanto Cooperative Study Group of Adjuvant Chemoendocrine Therapy for Breast Cancer, Japan]

We investigated possible correlations between estrogen receptor (ER) and prognostic factors in 3,789 patients with stage II or stage IIIa breast cancer in Japan. The patients with ER-positive tumors showed a significantly better prognosis in the 5-year survival rate and the 5-year disease-free survival rate compared with the patients with ER-negative-tumor. Positivities increased with increasing patient age, with increasing tumor size, and lowering degree of cell differentiation, and no relation was observed between the positivities and tumor sites, obesity index, and lymph-node metastasis.

A phase II multi-institutional study of estra-1,3,5(10)-triene-3,17 beta-diol, 3-benzoate, 17[[4-[4-[bis(2-chloroethyl)amino]phenyl]-1- oxobutoxy]acetate] (KM2210), a novel antitumor agent, for advanced and recurrent breast carcinoma

In order to evaluate the efficacy of Estra-1,3,5(10)-Triene-3,17 beta-Diol, 3-Benzoate, 17[[4-[4-[Bis(2-Chloroethyl) Amino]Phenyl]-1-Oxobutoxy] Acetate] (KM2210), a multi-institutional cooperative Phase II study was performed in patients with measurable advanced and recurrent breast cancer. Two hundred miligrams of KM2210, a conjugate of chlorambucil and 17 beta-estradiol, were administered orally daily for more than 4 weeks to each patient. According to the WHO criteria of response, 103 evaluable cases were assessed. Complete response was obtained in 9 cases, partial response in 19, no change in 39 and progressive disease was observed in 36. The overall response rate was 27.2% (28/103). The response rate was higher in patients without prior treatment than in those with prior treatment. However, KM2210 was also effective against breast cancers treated previously with tamoxifen, anthracyclines and their combinations, showing response rates of 25.5%, 22.0% and 29.6% respectively, suggesting that this agent is also effective on breast carcinomas which were insensitive to tamoxifen and anthracyclines. For efficacy classified in terms of metastatic lesions, the response rate was significantly higher in soft tissues than in other involved organs, and the response rate of bone metastasis was limited. Bone marrow suppression, including leukopenia and thrombocytopenia, was thought to be the dose-limiting toxicity of KM2210. Genital bleeding due to the released estrogen was observed as a characteristic side effect. KM2210 is considered to be useful for the treatment of advanced and recurrent breast cancer when administered at a dose level of 200 mg per day for more than 4 weeks.

[Relative lymphopenia in Cushing's syndrome]

The differential white blood cell (WBC) count often reveals relative lymphopenia in Cushing's syndrome and may be a clue to the discovery of the ailment. However, the incidence of this finding has rarely been reported in the literature. We conducted a study on 40 patients with Cushing's syndrome due to adrenocortical adenoma to evaluate the diagnostic implications of relative lymphopenia. Total WBC count, differential WBC count, basal level of plasma cortisol, urinary excretion of free cortisol and thyroid function were evaluated preoperatively. We also investigated the differential WBC count in 40 patients with thyroid tumors matched for age and sex with the Cushing's syndrome patients. The proportion of lymphocytes among WBCs was also compared between the two groups. The proportion of lymphocytes among WBCs was significantly lower in the patients with Cushing's syndrome (19.4 +/- 10.8%) than in those with thyroid tumors (42.3 +/- 9.5%, mean +/- SD, p < 0.05). The incidence of relative lymphopenia was high (82.5%) as well as that of increased urinary excretion of free cortisol (85.3%) in Cushing's syndrome patients. The low T3 syndrome was frequently seen (73.9%), whereas the incidences of leukocytosis and an increased level of basal plasma cortisol were relatively low (42.5% and 47.5%, respectively). Relative lymphopenia provides useful information for diagnosing Cushing's syndrome since it has high sensitivity although it should be kept in mind that its specificity is low.

[Clinical evaluation of NK 622 (toremifene citrate) in advanced or recurrent breast cancer--a comparative study by a double blind method with tamoxifen]

Efficacy and safety of NK 622 (toremifene citrate) were compared with tamoxifen (TAM) by a double blind test in patients with advanced or recurrent breast cancer. NK 622 and TAM were given orally for 12 weeks or more at daily doses of 40 and 20 mg/body, respectively. Eligible cases in NK622 and TAM groups were both 57 patients. No significant difference was observed in patient characteristics between either group. Response rates were 26.3% (8 CR and 7 PR, 15/57) in the NK 622 group and 28.1% (3 CR and 13 PR, 16/57) in the TAM group. Median values of duration to onset of CR were 91 days in the NK 622 group and 169 days in the TAM group. The duration was significantly shorter with the NK 622 group. Median duration of efficacy in CR and PR cases was 155 days in the NK 622 group and 154.5 days in the TAM group. Adverse effects were encountered in 7 patients (12.3%) of each of the 2 groups. The side effects were fatigue, hot flush, WBC decrease, abnormal values in liver function tests, etc. in the NK 622 group and anorexia, nausea, eruption, feeling of warmth, sweating, dry mouth, dizziness, abnormal values in liver function tests, etc. in the TAM group. Administration was discontinued in one patient with eruption and another patient with abnormal values of liver function tests in the TAM group, while there was no such case in the NK 622 group. Including the discontinued cases, the side effects were moderate and reversible in both groups. The patients in whom a drug was determined as useful or more numbered 24/57 (42.1%) in the NK 622 group and 23/57 (40.4%) in the TAM group. There was not significant difference between the 2 groups in the above results except the duration to onset of CR. From these results, NK 622 is expected to show comparable efficacy, safety, and usefulness in patients undergoing TAM treatment for advanced or recurrent breast cancer.

[Phase II study of NK 622 (toremifene citrate) in advanced breast cancer, a multicentral cooperative dose finding study]

In order to determine the usual dose in the first line therapy and a high dose in the second or third line therapy, a dose finding study of a novel antiestrogen NK 622 (toremifene citrate) was performed in patients (pts) with advanced or recurrent breast cancer. NK 622 was orally administered daily once for more than 8 weeks. In pts without previous drug therapy or in pts with cancer relapse after adjuvant therapy, the response rates [(CR + PR)/total] were 24.1% (7/29), 13.8% (4/29), 20.0% (1/5) and 40.0% (2/5) at doses of 40, 60, 120 and 240 mg/day, respectively. A 40 mg/day dose showed an objective response only in postmenopausal pts with estrogen receptor (ER) positive or unknown cancer. At a dose of 60 mg/day, some of the responding cases were premenopausal pts or pts with ER(-) cancer. In pts with cancer relapse during adjuvant therapy or in those with previous therapy and/or radiation, response rates were 25.0% (2/8), 0% (0/4), 13.5% (5/37) and 10.3% (4/39) at doses of 40, 60, 120 and 240 mg/day, respectively. Response was more frequent in pts with ER (+) cancer than with ER (-) cancer. The response rates in pts with previous therapy including tamoxifen (TAM) except medroxyprogesterone (MPA) were 14.3% (4/28) at a 120 mg/day dose and 6.1% (2/33) at a 240 mg/day dose. In pts with previous therapy including TAM, MPA and other antitumor agents, the rate was 18.2% (2/11) at a 120 mg/day dose. Side effects such as elevation of GOT, GPT and serum Ca level, decrease of hemoglobin, anorexia, nausea/vomiting, fatigue, dizziness and hot flush were observed. These side effects were moderate in grade and reversible. Dose dependency of side effects was not clearly observed in grade and incidence. From these results, NK 622 is expected to be a safe drug with efficacy in first line therapy at a dose of 40 mg/day and in second or third line therapy at a dose of 120 mg/day.

[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.

Evaluation of an improved dot-immunobinding assay for carcinoembryonic antigen determination in nipple discharge in early breast cancer: results of a multicenter study

We have previously reported carcinoembryonic antigen (CEA) measurement in nipple discharge to be a useful adjunct in the diagnosis of non-palpable breast cancer. We have now developed a "microdot-immunobinding assay" using a specially constructed device to screen efficiently large numbers of patients with nipple discharge for non-palpable breast cancer. The method is as follows: a sample of nipple discharge is placed on a solid phase monoclonal anti-CEA antibody and, if CEA is present in the discharge, it will be detected by a second monoclonal anti-CEA antibody conjugated with alkaline phosphatase. The use of bromochloroindolyl phosphate as a chromogen results in a stable color reaction that can be semiquantitatively analyzed with the naked eye. CEA levels determined by this microdot assay correlated well with those determined using the earlier Elmotec assay. To determine the accuracy of the method, a collaborative study involving 11 institutes in Japan was organized. The CEA levels in nipple discharges from 77 patients undergoing surgery, 44 of whom were diagnosed as having breast cancer, were assayed. The results were that 17 of the 23 patients with palpable breast cancer, and 16 of the 21 patients with non-palpable breast cancer exhibited CEA values > 400 ng/ml, a cut-off value determined in a previous study. The overall accuracy (78%) of this test for diagnosing non-palpable breast cancer was higher than that obtained from ductography or cytology. The system may thus be of use in the screening of early breast cancer.

[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.

Analysis of thyroid carcinoma based on material registered in Japan during 1977-1986 with special reference to predominance of papillary type

BACKGROUND

As geographic differences have been observed in the characteristics of thyroid carcinoma, an analysis was made on thyroid carcinoma in the iodine rich country of Japan.

METHODS

A total of 10,973 patients with histologically confirmed thyroid carcinoma registered in Japan from 1977-1986 were analyzed. Cases detected incidentally at autopsy and cases of nonepithelial tumor were excluded. This series included approximately 27% of all thyroid carcinoma cases in Japan.

RESULTS AND CONCLUSIONS

Histologic distribution showed that papillary carcinoma accounted for 78.4% of cases, follicular carcinoma accounted for 17.2%, medullary carcinoma for 1.4%, squamous cell carcinoma for 0.3%, and anaplastic carcinoma for 2.7%. There is a tendency in Japan to diagnose papillary carcinoma as follicular carcinoma and to diagnose malignant lymphoma as anaplastic carcinoma. It was considered that the percentage of papillary carcinoma was higher and the percentage of follicular carcinoma and anaplastic carcinoma was lower than foregoing values. The characteristics of thyroid carcinoma in Japan were described, and the low incidence of nonpapillary carcinoma compared with papillary carcinoma was discussed in relation to iodine excess as an etiologic factor.

[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.

[New drugs in endocrine treatment of breast cancer]

Therapeutic access in the treatment of breast cancer with the antiestrogen tamoxifen has been established by world-wide clinical trials since the drug was introduced by Cole et al, in 1971. In recent years, however, a new series of antiestrogens (the derivatives of tamoxifen) such as trioxifene, toremifene and droloxifene have been studied with regard to clinical efficacy as a first-line treatment for postmenopausal patients with breast cancer and occasionally even for patients who previously responded to tamoxifen and then relapsed. Luteinizing hormone releasing hormone (LHRH) agonists are now available for premenopausal patients that will produce a medical castration, when given continuously, by down-regulation of the pituitary LHRH receptors. Four compounds, leuprolide, buserelin, tryptorelin and goserelin have been available for clinical use, but goserelin (Zoladex) is now widely used by long-acting depot preparations, which are given subcutaneously once every 4 weeks. Another series of drugs which inhibit estrogen synthesis in postmenopausal patients and are termed "aromatase inhibitors" have been developed. The pure aromatase inhibitors newly developed include two types of both a steroidal compound (4-hydroxyandrostenedione) and a non-steroidal one which is a tetrahydroimidazopyrimidine derivative (CGS 16949A). This review describes the pharmacological and clinical aspects of these new agents.

The effect of breast self-examination on early detection and survival

To investigate the effect of breast self-examination (BSE), we compared the stages, survival, and the risk of death for 355 patients with breast cancer detected by BSE with those for 1,327 patients with breast cancer detected by chance. The early stages of the disease were found to be more common among the symptomatic breast cancer patients detected by BSE than those by chance. The 5-year overall survival rate was 94.4% for the symptomatic patients detected by BSE, and was significantly higher by 8.7% than that (85.7%) for patients detected by chance (P less than 0.001). The 10-year survival rate was 81.6% for patients detected by BSE, and 76.6% for cases detected by chance (the difference was not significant). The overall difference between the two survival curves was statistically significant by the logrank test (P less than 0.01). A multivariate analysis using the Cox proportional hazards model showed that the risk of death for patients detected by BSE was smaller by 0.570 times than that for patients detected by chance, which was statistically significant (P less than 0.05). The effect of biases inherent to BSE in the survival analysis cannot be controlled completely even after conducting multivariate analysis. These results suggest that BSE may contribute to the reduction of the risk of death through early detection of breast cancer. However, further examination should be conducted by other methods to obtain conclusive evidence.

[Response to rechallenged tamoxifen of metastatic breast cancer relapsed after surgical adjuvant tamoxifen treatment]

Tamoxifen (TAM), an antiestrogen was administered 20 mg b.i.d. to 20 patients with recurrent breast cancer at the time of first relapse who had been treated with the adjuvant therapy including TAM 10 mg b.i.d.. Patients who had been treated with TAM at least 1 year and in which the relapse had occurred after 3 months or more after the cessation of adjuvant treatment were enrolled in the study. Sixteen patients were evaluated, and a complete response was observed in 3 (19%), partial response in 1 (6%), no change in 5 (31%), and progressive disease in 7 (44%). The response rate was shown to be 25% with 95% confidence interval: 3.8-46.2%. The duration of response ranged from 23+ to 32 weeks. Patients who have received postoperative adjuvant therapy including TAM and have relapsed after the cessation of therapy may retain hormone dependency in responding to a further TAM treatment at the time of relapse of malignancy.

Anterior communicating artery aneurysm in early childhood. Report of a case

A case of an aneurysm of the anterior communicating artery in a 13-month-old child is presented. Sixty-six cases of cerebral saccular aneurysm in children under the age of 2 years found in the literature were analyzed. The characteristics that define this group of patients are a high frequency of large or giant aneurysms, a large proportion of aneurysms of the middle cerebral artery and the posterior circulation, and the frequent location at the peripheral site. Only three cases of anterior communicating artery aneurysm were reported in the literature. The authors discuss these characteristics on the basis of development of fetal cerebral vessels.

The effect of mass screening for breast cancer: results of a multivariate analysis

To evaluate the life-prolonging effect of mass screening for breast cancer, we compared the risk of death for the patients detected by mass screening with that for the patients diagnosed in out-patient clinics, after adjusting for other relevant factors simultaneously by using the Cox regression model. A multivariate analysis using the Cox regression model in which clinical staging of disease was taken as one of the independent variables, showed that the risk of death for patients detected by mass screening was smaller by 0.765 times than that for patients found in out-patient clinics although the reduction was not statistically significant. This small reduction might be partly due to the effect of mass screening through early detection even within the same stage, and partly due to length bias, lead time bias and self-selection bias. When clinical staging of disease was removed from the independent variables, the risk of death for patients detected by mass screening was reduced from 0.765 times to 0.677 times that for patients diagnosed in out-patient clinics, which was statistically significant (P greater than 0.01). For asymptomatic patients detected by mass screening, such as reduction of the risk of death was from 0.789 times to 0.555 times that for patients found in out-patient clinics (P less than 0.05). These results suggest that mass screening for breast cancer may contribute to the reduction of the risk of death, although the effect of biases inherent in periodic screening was not removed completely in the present analysis.

[Eleven cases of spindle cell carcinoma of the breast, with special reference to cystic changes in the tumor]

The clinicopathological features of 11 cases of a spindle cell carcinoma handled by our department have been investigated and are presented, with two cases that demonstrated cystic changes. Out of a total of 1,524 breast carcinomas that were treated, 11 (0.72%) were spindle cell carcinomas. The size of the tumor was generally larger than in other more common types of breast carcinomas, but the degree of a lymph node metastasis was low and the prognosis was better. As for the ER status, 4 out of 5 cases were negative. As cystic changes in the tumor were found in 5 of the 11 cases, it would seem that spindle cell carcinomas of the breast tend to show cystic changes in their tumors.

DNA ploidy level and S-phase fraction as prognostic factors in breast cancer

Imprint smears from sixty cases of breast cancer made after mastectomy were stained by the Feulgen method and the nuclear DNA content measured by a cytofluorometer equipped with an incident illumination system. After logarithmic transformation of the fluorescence intensity, the ploidy level and S-phase fraction (SPF) were calculated with a microcomputer and the correlation between the ploidy level or SPF and the clinicopathological prognostic factors studied. Patients with tumors of a larger diameter and more extensive lymph node involvement had higher levels of ploidy and SPF and the ploidy level in the metastatic lymph nodes was higher than that in the primary lesion. Moreover, a significant increase in SPF was observed in the metastatic lymph nodes and a high ploidy level found to be associated with tumors having a negative estrogen receptor. When the tumors were divided into a diploid group and an aneuploid group, the diploid group showed a significantly better prognosis than the aneuploid group, in 6-year survival. Similarly, the groups in which SPF was less than 20.0 per cent had significantly better prognoses than the group in which SPF was 20.1 per cent or more. These prognostic factors were evaluated with Cox's proportional hazard model and a significant correlation observed in lymph node status, ER status, ploidy level and S-phase fraction. It was thus concluded that ploidy level and SPF are important and independent prognostic factors for predicting the postoperative course of breast cancer patients.

Effects of sequential and combined endocrine therapies on the growth of 7,12-dimethylbenz [alpha] anthracene-induced rat mammary carcinoma

Sixty-six female Sprague-Dawley (SD) rats with 7,12-dimethylbenz [alpha] anthracene(DMBA)-induced rat mammary cancer were divided into five groups: tamoxifen (TAM), medroxyprogesterone acetate (MPA), TAM + MPA, ovariectomy (Ovex), control (no treatment). An antitumor effect was shown in each treated group. Thirty-six (72%) out of 50 treated animals responded to the first endocrine therapy. Moreover, tumors disappeared completely from 21 out of the 36 animals, and no new tumors were seen until the 12th week. The facts suggest experimental hormone, when compared to clinical, therapy in DMBA-induced tumors to have a higher response rate. A total of 14 out of 50 tumors failed to respond to the first treatment (resistant tumor). There was no significant difference in the proportion of resistant tumors among the four treated groups. When other endocrine therapies were tried out of resistant tumors, seven out of the 14 responded, the resistant tumors in the TAM group responding significantly well to the other endocrine therapies compared to those in the MPA group (P less than 0.05). These results suggest the possibility of resistant tumors responding to different types of endocrine therapy.

A phase I study of toremifene

A Phase I study of the new antiestrogenic drug toremifene was carried out in 27 Japanese women, using oral doses of 10-480 mg per day for one or five days. Serum concentrations reached a dose-dependent maximum 2-6 hours after each oral administration. Side effects were generally mild.

[Phase I study of FK 435]

We performed phase I study of FK 435, a new antiestrogen, in 30 patients with advanced breast cancer. Slight to moderate adverse reactions were noted as follows. Single-dose study: anorexia, nausea, lassitude in one patient (80 mg), decreased serum calcium in one (160 mg), redness, tenderness in one, facial flushing, hot flushes, headache in one (320 mg). Repeated-dose study: anorexia, nausea in one patient (40 mg/day), anorexia, diarrhea, increased FSH in one, increased PRL in one (80 mg/day). FK 435 was well tolerated. Tmax was 3-5 hours, T1/2 about 25 hours. Most of FK 435 was excreted into urine as glucuronide.

[Role of cancer thermography for detection of breast cancer]

Out of one hundred and sixty-two patients that examined by contact thermography, forty-five cases involving 55 cancers were assessed for malignancy. The sensitivity and the specificity of this method of testing were 81.5% and 83.5%, respectively. False negative cases included early stage, small sized and papillotubular carcinomas. Twenty-five per cent of the fibroadenoma and mastopathy cases showed false positive findings. Further, half of the phyllodes tumor and mastitis cases also showed false positive findings. Two of six T0, Tis cases (33.3%) were diagnosed as malignant tumors by thermography. Contact thermographic examinations will be more widely used in the near future.

[A case of early carcinoma of the remnant stomach that developed from gastritis cystica polyposa]

A 64-year-old man with an early carcinoma of the remnant stomach that developed from a gastritis cystica polyposa (GCP) is presented, and the morphology and histogenesis of this rare condition are discussed. This patient had a Billroth II reconstructed remnant stomach for 25 years, and was referred to our attention because of cholecystocholedocholithiasis. In screening an upper gastrointestinal barium study and an endoscopy revealed an irregular-shaped, flat, polypoid tumor in a stoma of the posterior wall. The resected polypoid lesion measured 4.5 x 3.0 cm. A histological examination revealed it to be a well differentiated adenocarcinoma of the mucosal layer that had developed from a GCP.

Spontaneous regression of esophageal carcinoma with pulmonary metastases: case report

The first description of a spontaneous regression of a primary esophageal carcinoma with progressive growth of multiple pulmonary metastases is reported, and the possible cause of the spontaneous regression is discussed briefly with reference to T cell subsets. A 78-year-old Japanese man underwent an esophageal bypass with gastric substitution for carcinoma of the middle to lower third of the intrathoracic esophagus with aortic invasion. Two months after the operation, multiple pulmonary metastases were documented and were seen to progress gradually over the next six months. Seven months later, all the secondary lesions underwent a complete spontaneous regression. The primary lesion also regressed, but did not disappear completely. It was not possible to establish whether a change in T cell subsets was the cause or an effect of the regression.

Anti-tumor effects of the oral administration of the streptococcal preparation OK-432 (PICIBANIL)--the inhibition of carcinogenesis and growth in rats with ENNG-induced gastrointestinal tumors

We examined whether the Streptococcal preparation OK-432, an immunopotentiating agent, increases immunocompetence of the gut-associated lymphoid system (GALS), inhibits gastrointestinal carcinogenesis, and has an anti-tumor effect. 14C-labelled OK-432 was orally and intraperitoneally administered to rats, and the distribution of the agent in various organs then serially evaluated. The concentration of OK-432 in Peyer's patches and mesenteric lymph nodes was higher after oral administration than after intraperitoneal administration, and showed a biphasic pattern peaking at 30 minutes and 5 hours following administration, in the Peyer's patches. With regard to immunocompetence, PHA- and PWM-stimulated blastogenesis of lymphocytes derived from the mesenteric lymph nodes and peripheral blood enhanced, and the helper/suppressor T-cell ratio was elevated after the oral administration of OK-432. Moreover, chemotactic activity of peritoneal macrophages was also increased. ENNG-induced gastrointestinal carcinogenesis was observed in 60 per cent of the rats orally administered OK-432 as compared with 88 per cent of the controls. The 13-month survival rate of the rats with gastrointestinal cancer was 50 per cent in those administered OK-432 as compared with 25 per cent in those administered OK-432 as compared with 25 per cent in the controls. When administered orally, the agent prevented reduction in immuno-competence in the course of carcinogenesis, suppressed carcinogenesis, and prolonged the survival of animals with cancer without any of the side effects associated with injection. The oral administration of OK-432 is thus considered to be an effective non-specific immunotherapy against gastro-intestinal malignancies.

[An overview of breast cancer mass screening in Japan]

To establish the effective mass screening projects for the breast cancer, our study group cosponsered by the Welfare Ministry was organized by 11 regional groups. From 1968 to 1986, 643, 513 women at the initial screening and 719, 189 women at the subsequent screening were examined by physical examination. Out of them, abnormalities were present in 24, 864 women (3.9%) and 23,880 (3.3%), respectively. A detection of cancer was made in 833 women (detection rate 1.3%) and 428 women (0.6%), respectively. As the examinees increased from year to year, the subsequent examinees were over the initial ones. It was suggested that most of examinees had been fixed year by year and the detection rate of initial screening had been higher than that of the subsequent one. Then more initial examinees are expected to be increased. Women 30 to 59 years of age were mostly screened, but women aged 60 or more should be increased. Of women with abnormal physical findings, women over 90% took the second examination. But more effective, economical and safer screening instruments are expected to be developed and be used at the first examination.

Effects of OK-432 (Picibanil) on estrogen receptor levels and tamoxifen treatment in 7,12-dimethylbenz[a]anthracene-induced rat mammary cancers

The effects of OK-432 (Picibanil) on estrogen receptor (ER) levels and subsequent tamoxifen (TAM) treatment were examined in 189 female Sprague-Dawley rats with 7,12-dimethylbenz[a]anthracene (DMBA)-induced mammary cancers. When OK-432 was administered (0.1 KE/kg i.p. once weekly) for 12 weeks to the rats after DMBA, the average ER level of the TAM-responsive tumors in the OK-432-treated group was significantly higher than that in the control group. The antitumor effect of TAM was significantly greater in the OK-432-treated group. When OK-432 was administered to rats with established DMBA tumors, the average ER levels did not change significantly after 2 or 4 weeks of treatment. ER levels in the control group (no treatment) fell significantly after 2 or 4 weeks. These results suggest that hormone dependence of DMBA-induced rat mammary cancers may be maintained or augmented by the administration of OK-432.

[Relationship of breast cancer and HLA in Japanese females]

One hundred and thirty-seven female breast cancer patients have been HLA-typed by a cytotoxicity test. Over all, no specific HLA antigen was found, though when the patients were divided into two groups, i.e., into those with bilateral or unilateral cancers, A24 and Cw7 was found to be significantly increased in the bilateral group. Further, a haplotype of A24-Cw7 was frequently seen in the bilateral group. No specific HLA antigen, however, was found in patients stratified by a familial history of cancer. It thus was concluded that bilateral breast cancer patients that have developed from patients with a unilateral cancer are detectable by HLA typing.

Evaluation of dot-immunobinding assay for carcinoembryonic antigen determination in nipple discharge as an adjunct in the diagnosis of early breast cancer. Research Group for Carcinoembryonic Antigen in Nipple Discharge

We have previously reported carcinoembryonic antigen (CEA) measurement in nipple discharge to be a useful adjunct in the diagnosis of non-palpable breast cancer. As an extension, a dot-immunobinding assay was developed to screen a large number of patients with nipple discharge for non-palpable breast cancer. The principle is as follows. CEA bound to a solid phase monoclonal anti-CEA antibody is detected by a second monoclonal anti-CEA antibody conjugated with horseradish peroxidase. The use of tetramethylbenzidine as a chromogen results in a stable color reaction that can be semiquantitively analyzed by the naked eye. The CEA levels determined by this dot assay correlated well with CEA levels determined using the former Elmotec assay. To determine whether or not the method could also be feasible in the detection of non-palpable breast cancer, a collaborative study from 12 Japanese institutes was organized. The CEA levels in nipple discharges from 155 patients were assayed. Thirteen of 30 patients with palpable breast cancer and 22 of 30 patients with non-palpable breast cancer exhibited CEA values higher than 400 ng/ml, a cut-off value determined using 89 benign controls. The specificity (91%) and sensitivity (73%) of this test were higher than those of mammography or cytology. The incidence of elevated CEA levels in nipple discharge correlated significantly with the incidence of intratumoral antigen expression. Thus, the system could prove useful in screening for early breast cancer.

Mass screening for breast cancer: comparison of the clinical stages and prognosis of breast cancer detected by mass screening and in out-patient clinics

To establish the criteria for assessing the life-prolonging effect of mass screening for breast cancer, clinical stage and prognosis of breast cancer detected by mass screening in 11 regions of Japan were compared with those for matched patients in out-patient clinics. A total of 728 patients detected by mass screening and 1,450 found in the out-patient clinics were reviewed. The stage of the disease was Tis or I in 40.9% of the patients detected by mass screening, and 28.7% of those found in the out-patient clinics. In contrast, stage III was found in 9.3% and 14.6%, respectively, indicating that early stages were significantly more common in the patients detected by mass screening. The overall survival curve for the patients detected by mass screening was compared with that for those found in the out-patient clinics. The 5-year survival rate was significantly higher in the patients detected by mass screening (91.7% vs. 85.6%; P less than 0.01), while the 10-year survival rate was slightly higher in the same group of patients, but the difference from the other group was not significant (80.5% vs. 78.1%). Women who had conducted breast self-examination (BSE) showed a higher survival rate than those who had not conducted BSE.

[Mass screening for breast cancer in Gunma prefecture--the results for 8 years and future problems]

In Gunma prefecture, mass screening for both breast and thyroid cancer at the same time was conducted between April 1980 and March 1988 with the cooperation of the Gunma Cancer Society. In this paper, the results of mass screening for breast cancer and further problems are reported and discussed. The total number of subjects during these eight years was 191, 603 on the first screening with physical examination alone. Of these, 18,208 (9.5%) examinees were required to attend the second examination. Breast cancer was detected in 159 cases. The detection rate was 0.08% among total subjects. Also thyroid cancer was detected in 244 (0.13%). The detection rate for breast cancer was approximately twice as high at the initial screening (0.11%) than at the subsequent periodic screening (0.06%). Patients with breast cancer detected by mass screening showed an earlier stage and a better prognosis compared with those of our ordinary outpatients. The 8-year disease-free survival rate in mass screening and in outpatient cases was 94.9% and 83.2%, respectively, but there was no significant difference between the two groups. Interval breast cancer was also found in 19 cases (Tis; 1, Stage I; 8 and Stage II; 10) and 5 patients had nodal metastases. This mass screening program is a useful means for early discovery and early treatment of breast cancer. Hereafter, we should intend to increase the number of initial examinees and women aged 60 and over. Also it is important to make and train physicians for such screening, and to educate women about the practice of breast self-examination.

[A case of primary gastric choriocarcinoma]

A 66-year-old man with a primary gastric choriocarcinoma is presented. The pre-operative diagnosis of the gastric barium examination and an endoscopy was an unusual gastric carcinoma in the antrum. At laparotomy, an abscess in the lesser sac that had developed by a tumoral penetrance was found. Thus a total gastrectomy and a lymphadenectomy with a reconstruction was performed. The resected specimen was found to be a Borrmann 1 type tumor, and a histological examination showed it to be a choriocarcinoma with a syncytiotrophoblast, that was immunostained by human chorionic gonadotropin (HCG). The physical findings however, disclosed no tumor in the testis. The serum HCG was found to be 1,380 IU/l on the 7th postoperative day, then a pulmonary metastases appeared and progressed, and the patient died on the 22nd postoperative day.

[Recent trends in breast cancer surgery in Japan]

In the past ten years, extended or conventional radical mastectomies have decreased, being replaced by modified radical mastectomies (muscle-preserving mastectomies) such as Auchinoloss' operation and Patey's operation. Furthermore, limited surgeries for early cases such as partial mastectomy, lumpectomy etc. also have increased in the recent three years. The indications for these operations, the surgical techniques, postoperative functional and cosmetic problems were presented. And future problems as to partial mastectomy were also discussed. In contrast, aggressive surgery such as extensive resection of the chest wall for locally advanced breast cancer is useful as one of the therapeutic measures in the recent multidisciplinary treatments for breast cancer, in order to prolong the patient's survival and improve the quality of life. The techniques including the reconstruction using musculocutaneous flaps were also presented.

[A case of quartet cancer--a carcinoma of the breast followed by three synchronous cancers (kidney, thyroid and colon)]

A case of a surgically treated primary quartet cancer is reported, along with a review of the Japanese literature. A 68-year-old woman, curatively operated for a right breast cancer 6 years previously, was then diagnosed as having a left renal cell carcinoma, a thyroid cancer, and a sigmoid colon cancer as a result of a subsequent screening examination within one year. These synchronous, triple cancers were resected in a curative operation for each. Histopathologically, each neoplasm was proven to be a primary cancer lesion, and two different types (papillary and trabecular) were found in the thyroid gland.

[Surgical procedure and adjuvant therapy in breast cancer]

Modified radical mastectomy (Auchincloss or Patey) have been generally performed for early breast cancer. And this method has shown better prognosis compared with standard (Halsted) or extended radical mastectomy. Also minor conservative surgery (breast or nipple preserving procedure) with or without radiation has been recently tried in small groups of Japan. Postoperative adjuvant chemotherapy (FEMP) has been used in patients proved histologically vascular invasion of cancer cells in our department. Postoperative radiotherapy were undertaken in patients with 4 or more positive axillary nodes or positive parasternal and supraclavicular nodes. Extended radical mastectomy is considered as a favorable method to improve the disease-free survival of the patients with advanced breast cancer, including the combination of chemotherapy, endocrine therapy and radiotherapy. It is important that surgical procedures for breast cancer should be selected and conducted along with a multimodal treatment according to stage for a case by case under the concept of "systemic disease".

Sequential hormone therapy with medroxyprogesterone acetate for 7, 12-dimethylbenz [alpha] anthracene-induced rat mammary tumors

Two types of sequential hormone therapy with medroxyprogesterone acetate (MPA) were examined in female 93 Sprague--Dawley (SD) rats with 7,12-dimethylbenz [alpha] anthracene (DMBA)-induced mammary tumors. Estradiol (E2) priming induced progesterone receptors (PgR) in most cases and, after induction of PgR, MPA often showed an augmented antitumor effect. For this reason, E2 priming + MPA had a more marked antitumor effect on DMBA tumors than MPA alone. Tamoxifen (TAM) (0.1 mg/kg) priming induced PgR more frequently than TAM (0.4 mg/kg) priming. Furthermore, treatment with TAM priming (0.1 mg/kg) + MPA showed a more marked antitumor effect than with TAM priming (0.4 mg/kg) + MPA or MPA alone. In the above two priming therapies with MPA, the latter is more practical for the clinical treatment of breast cancer than the former because the mechanism of action of E2 is usually thought to show tumorigenic activity on breast cancer, while the mechanism of action of TAM is thought to show an antitumor effect. It is suggested that the sequence of administration of MPA after TAM priming may be favorable for the treatment of breast cancer.

[A case of duodenal carcinoid associated with early gastric carcinoma]

This case involves a 51-year-old female. In 1983, a gastroscopic examination disclosed a submucosal tumor in the duodenum. In 1986, during follow-up observation, on her visit to hospital an early gastric carcinoma at the antrum was found. Thus, a distal gastrectomy, which entailed the complete removal of the Group 2 lymph nodes and the hepatoduodenal, intra-mesenteric lymph nodes, and Billroth I reconstructive surgery were both performed. A histopathological examination revealed that the antral lesion was a carcinoma, sig. m. ly0. v0. n(-), and that a lesion at the duodenal bulb was carcinoid, with cell that were positive to Grimelius staining and to somatostatin serotonin by an immunological staining. A metastases to the lymph nodes but only along the upper trunk of the common hepatic artery, also was found.

Effects of trilostane on 7,12-dimethylbenz[a]anthracene-induced rat mammary cancers and body weight of rats in relation to estrogen receptors

Effects of trilostane (TLS) on 7,12-dimethylbenz[a]anthracene (DMBA)-induced mammary cancers and body weight of rats were examined in relation to estrogen receptors (ER) in 103 female Sprague-Dawley rats with DMBA-induced cancers. The inhibitory effects of the treated groups on the growth of DMBA-induced rat mammary cancers were significantly stronger than those of the control group at many points during the treatment, demonstrating a more remarkable inhibitory effect in the high-dose groups of 300 and 500 mg/kg. In the high-dose groups, the inhibitory effects of TLS tended to be slightly stronger in the ER-negative groups than in the ER-positive groups. These results suggest that the mechanisms of action of TLS are not influenced by the presence or absence of ER, but are due to complicated hormonal changes induced by the inhibition of steroid biosynthesis.

Evaluation of mass screening for thyroid cancer

Mass screening for detecting both thyroid and breast cancer in adult women was carried out in Gunma Prefecture, Japan, between 1980 and 1986. The total number of subjects during the seven years was 152,651. The first screening was by inspection and palpation using experienced surgeons. Thyroid abnormalities were found in 5,902 subjects (3.9%) and 3,804 (2.5%) were required to attend a second examination. Thyroid carcinoma was detected in a total of 216 subjects, a detection rate of 0.14%. The detection rate for thyroid cancer was twice as high at the initial screening (0.19%) than that at subsequent periodic screenings (0.09%). Histological classifications of the detected thyroid cancers were: papillary carcinoma, 189 cases (87.5%); follicular carcinoma, 26 (12%); medullary carcinoma, 1 (0.5%). Eighty-seven percent of the thyroid cancers were asymptomatic at the time of screening. The tumor size were 2 cm or less in 126 patients (58.3%). Thyroid cancer detected by mass screening was revealed at an earlier stage and showed a significantly better survival rate compared to that of our usual outpatients. As differentiated carcinoma has been found at a higher incidence by mass screening, the program is useful for the early detection and treatment of thyroid cancer.

[A clinico-pathological study regarding the incidence of intranuclear cytoplasmic inclusions (ICI) in cases of papillary thyroid carcinoma]

Intranuclear cytoplasmic inclusions (ICI) in 38 cases of thyroid papillary carcinomas have been studied as to the relationship between the frequency of ICI and the clinical, histological, and cytological findings of the carcinoma. ICI were present in all cases. The frequency of ICI in the cases studied ranged from +/- (one per several fields) to ¿ (more than ten per one field), using a microscope of 400 magnifications, and from 1.3% to 11.6% (mean value: 3.9%) of the nuclei of the carcinomas. The frequency of ICI was found to be influenced by the state of the nuclear chromatin and pleomorphism, but was not influenced by the papillary or follicular tumor growth. The relationship between the frequency of ICI and the tumor size and the existence of lymph-nodes metastasis, however, was not clarified.

[A clinicopathological study of multiple thyroid carcinomas]

Thyroid cancers associated with multiple cancerous lesions that were detected by clinical and/or histological examination, namely, multiple thyroid carcinomas have been studied clinicopathologically. Of 443 cases of primary thyroid cancers, 111 (25%) had multiple cancerous lesions. Histologically, most multiple cancers consisted of papillary carcinomas. In 66% of the cases, the size of the second cancer was 1.0 cm or less. Fifty-three percent of multiple cancers were located in both the right and left thyroid lobes. Therefore, it is important to examine the contralateral lobe at operation to be certain that there are no other nodular lesions. Since lymph node metastasis was positive in 83% of the cases, it is necessary to perform bilateral neck dissection in multiple cancer cases of not only the bilateral but also of the unilateral type.