Abstract P4-15-03: Patterns of relapse following re-irradiation of the breast using partial breast brachytherapy (PBB)

Purpose: This study is undertaken to evaluate the patterns of relapse among patients with a prior history of irradiation where the RT field included the breast, and who received re-irradiation using PBB for a localized second cancer event in the breast using partial breast.

Materials and Methods: Twenty-seven patients were enrolled in an IRB approved study. Nineteen patients had prior history of breast cancer treated with lumpectomy and external beam therapy (ERT), and 8 patients had prior history of mantle RT. All patients underwent lumpectomy with negative margins and received a median dose of 45Gy PBB. The median time interval between the primary breast cancer diagnosis and the second cancer event in the ipsilateral breast is 94-months (range 28-months to 211-months). The median time between mantle RT and the breast cancer is 245 months.

Results: At a median follow up of 73 months following lumpectomy and PBB 14.8 % (4/27) patients developed a local recurrence and were salvaged by mastectomy. The 5-year Kaplan Meier local disease-free survival and mastectomy-free survival is 100% and 81%, respectively. Remarkably, one third of patients with prior history of mantle RT developed third primary cancers (pancreas, lung and renal). All patients with the third primary cancers died free of any relapse from the breast cancer. None of the patients with prior history of breast cancer developed a second malignancy, and 3/21 developed distant metastases.

Conclusions: In appropriately selected patients with prior history of lumpectomy and ERT for breast cancer we observed a high rate of local control and freedom from mastectomy. Patterns of relapse among patients with prior mantle RT suggest that breast conservation and PBB was appropriate for treating early stage disease. Breast conservation therapy did not have a detrimental effect on breast cancer specific outcome and eventual patient survival. Patients motivated for breast conservation may have an alternative to mastectomy at initial diagnosis.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-15-03.

Breast cancer in patients with residual invasive carcinoma is more accurately staged with additive tumor size assessment

BACKGROUND

Accurate assessment of tumor size for patients with breast cancer undergoing re-excision following breast-conserving therapy is important for appropriate staging and adjuvant treatment. We investigated the accuracy of additive vs. nonadditive size assessment in determining final tumor stage.

METHODS

Patients with infiltrating carcinoma in the initial excision and in at least one additional re-excision (re-excision positive; n = 89) had tumor size assessed with additive and nonadditive techniques. This group was compared with patients undergoing re-excision but without identifiable residual carcinoma (re-excision negative; n = 105) regarding rates of lymph node (LN) metastasis.

RESULTS

The re-excision positive patients had a different median final tumor size depending on the size assessment technique used (nonadditive: 1.8 cm; additive: 3.0 cm; P <.0001). Both groups of patients had a median tumor size consistent with T1c staging in nonadditive size assessment. However, re-excision positive patients had a significantly higher incidence of LN metastasis (P <.05) than did re-excision negative patients. Both groups were then separated into T1 and T2 stages and the LN metastasis rates were assessed. Compared with nonadditive size assessment, additive size assessment distributed re-excision positive patients into T stages whereby the LN metastasis rates more closely approximated those of re-excision negative patients (T1, 3% vs. 6% difference; T2, 4% vs. 13% difference).

CONCLUSIONS

With regard to LN metastasis, staging for patients with residual invasive carcinoma in re-excision specimens is more accurate with additive tumor size assessment.

Methylene blue dye as an alternative to isosulfan blue dye for sentinel lymph node localization

Isosulfan blue dye has been used with increasing frequency in localizing sentinel lymph nodes in breast cancer patients. Few alternative types of dye have been investigated. In a prospective study of 30 patients, methylene blue dye was used instead of isosulfan blue dye to localize the sentinel lymph node. The methylene blue dye localization technique was successful in 90% of patients. These results are similar to those for isosulfan blue dye. This study describes methylene blue dye localization as a successful alternative to isosulfan dye in identifying the sentinel node in breast cancer patients. The methylene blue dye technique offers a substantial cost reduction.

Breast cancer chemoprevention

Chemoprevention of breast cancer is a rapidly growing field. Chemoprevention was initiated with the development of the antiestrogen tamoxifen. A major clinical trial in the United States found that tamoxifen reduced the incidence of breast cancer by almost 50% in women at an increased risk for the disease. Although two European trials did not confirm these findings, the Food and Drug Administration found the American studies significant enough to approve tamoxifen for the delaying of breast cancer in women at high risk for the disease. However, adverse effects associated with tamoxifen include a minimally increased rate of endometrial cancer, cataracts, and strokes. Newer classes of antiestrogens, called selective estrogen receptor modulators (SERMs), are being investigated as potential chemopreventive agents. These SERMS, such as raloxifene, will hopefully provide some of the benefits of estrogen without its inherent risks. In addition, naturally occurring compounds and their analogues are also under investigation.

Comparison of rate of development and rate of change for benign and malignant breast calcifications at the lumpectomy bed

OBJECTIVE

The study purpose was to evaluate the rate of development and the rate of change for benign and malignant breast calcifications at the lumpectomy bed.

MATERIALS AND METHODS

Retrospective review identified 53 new calcifications at the lumpectomy bed in patients with available mammograms and medical records. Breast Imaging Reporting and Data System (BI-RADS) categories were retrospectively assigned on the basis of initial prospective recommendation for yearly follow-up (category 2), 6-month follow-up (category 3), or biopsy (category 4 or 5). Outcomes were defined as benign for no recurrence at the lumpectomy bed on biopsy or follow-up and malignant if biopsy-proven at the lumpectomy bed.

RESULTS

The median rate of development after lumpectomy was 23 months (range, 2-174 months) for benign and 39 months (range, 15-112 months) for malignant calcifications. Fifteen (28%) of 53 calcifications were classified as BI-RADS category 3. Twelve (80%) of 15 were downgraded to BI-RADS category 2 at a median follow-up of 6.5 months (range, 6-16 months); none represented recurrent disease. Three (20%) of 15 were upgraded to BI-RADS category 4 at the 6-month follow-up, one despite stability (benign) and two for increasing pleomorphism (malignant). Nine (17%) of 53 calcifications were classified as BI-RADS category 4 or 5; six (67%) of the nine were malignant and three (33%) were benign at biopsy. Twenty-nine (55%) of 53 calcifications were classified as BI-RADS category 2, none representing recurrent disease.

CONCLUSION

Benign calcifications at the lumpectomy bed usually develop earlier than malignant calcifications, but the rate of development overlaps. Most calcifications initially placed in the probably benign category evolve quickly to more benign or more malignant morphology. Most calcifications heralding recurrence appear suspicious on first presentation.

Skin-sparing mastectomy with immediate breast reconstruction: a critical analysis of local recurrence

PURPOSE

The purpose of this study was to provide follow-up data regarding the incidence of local breast cancer recurrence in patients undergoing skin-sparing mastectomy versus conventional non-skin-sparing mastectomy methods.

PATIENTS AND METHODS

A retrospective follow-up study and analysis were performed of patients who underwent mastectomies for invasive breast cancer at The New York Presbyterian Hospital, Cornell University Medical College and Strang-Cornell Breast Center between 1990 and 1998.

RESULTS

A total of 198 patients were identified in this study, and the mean follow-up was 49 months. This group included 71 patients who underwent skin-sparing mastectomy and 127 who underwent non-skin-sparing mastectomy procedures. No statistical differences in local recurrence rates were demonstrated between patients treated with skin-sparing mastectomy and those who underwent non-skin-sparing mastectomy. Local recurrence was present in four of 71 (5.6%) patients undergoing skin-sparing mastectomy and in five of 127 (3.9%) of those undergoing non-skin-sparing mastectomy.

CONCLUSIONS

The use of skin-sparing mastectomy does not lead to an increase in local recurrence rates when compared with conventional non-sparing mastectomies and provides for improved aesthetic results after immediate reconstruction.

Predictive factors associated with axillary lymph node metastases in T1a and T1b breast carcinomas: analysis in more than 900 patients

BACKGROUND

Axillary lymph node metastasis (ALNM) represents the single most important prognostic indicator in patients diagnosed with breast cancer. The proportion of < or = 1-cm (T1a, T1b) invasive breast carcinomas is increasing. The incidence and predictive factors associated with ALNM in patients with < or = 1-cm tumors remains unclear and the role of axillary lymph node dissection in these patients has been questioned. The purpose of this study was to determine clinical and pathologic factors predictive of ALNM in patients with < or = 1-cm invasive breast carcinomas by univariate and multivariate analyses.

STUDY DESIGN

Review analysis from a prospective database identified patients with < or = 1-cm invasive breast cancers treated at our institution between 1990 and 1996. All patients underwent a resection of the primary tumor and axillary lymph node dissections. Routine patient and tumor characteristics evaluated included: age, race, tumor size, histologic grade, estrogen and progesterone receptor status, and lymphatic and vascular invasion. Univariate and multivariate analyses were performed. Adjusted odds ratios (OR) and 95% confidence intervals (CI) are presented.

RESULTS

A total of 919 patients were identified in this study with tumors < or = 1 cm. These included 199 patients (21.7%) with T1a tumors and 720 patients (78.3%) with T1b tumors. ALNM was detected in 165 patients with an overall incidence of 18.0%. Of the ALNM group, 32 patients (19.4%) had T1a tumors and 133 patients (80.6%) had T1b tumors. Four variables were found to be significant in univariate analysis. These included: increasing tumor size, poor histologic grade, presence of lymphatic or vascular invasion, and younger age of the patient. An increase in tumor size was associated with a significant risk of ALNM (OR = 2.66, 95% CI = 1.28 to 5.75; p = 0.01). Poor tumor grade and the presence of lymphatic or vascular invasion were also associated with an increased risk of ALNM (OR = 2.69, p = 0.003 and OR = 5.52, p = 0.0001, respectively). Patients with ALNM were more likely to have a tumor grade of 3 (25.0% ALNM versus 12.5% node-negative, p = 0.004) and lymphatic or vascular invasion (16.9% ALNM versus 3.5% node-negative, p < 0.0001). In multivariate analysis, an increased risk of ALNM was demonstrated with increasing tumor size (0.1-cm increments), poor histologic grade, and younger age.

CONCLUSIONS

This study investigated clinical and pathologic factors influencing ALNM in patients with T1a and T1b breast carcinomas. We have identified three factors by multivariate analysis as significant independent predictors of ALNM in this group of patients. These include increasing tumor size, poor histologic grade, and younger age. Given the significant amount of ALNM demonstrated in this study (overall 18%) and the inability to identify a subgroup of patients that had an acceptable low risk of ALNM, the complete omission of assessing the axilla for metastatic disease in patients with small breast cancers cannot be advocated. Our recommendation for patients diagnosed with T1a and T1b tumors is to have their axilla investigated for metastatic disease either by traditional axillary lymph node dissections or by intraoperative lymphatic mapping and sentinel lymph node biopsy techniques.

Psychosocial aspects of cancer genetics: women at high risk for breast and ovarian cancer

In the past five years the advent of cancer genetic testing has created concern about the negative psychosocial sequelae of genetic counseling and testing. Research indicates that the women most likely to seek genetic testing are anxious about carrying a gene mutation and developing breast cancer. Women who are at high risk have poor knowledge and the expectation of being a gene-mutation carrier. High levels of distress have been shown to interfere with decision-making about genetic testing. Further, individuals who decline genetic testing may be at increased risk for depressive symptoms even more than those who are found to be gene-mutation carriers. There is great concern that inappropriate candidates will seek genetic testing. Improved education and access to genetic counseling are essential to help women make appropriate decisions about genetic testing. Strategies for the prevention of breast and ovarian cancer are explored, and methods to reduce the adverse psychosocial effects of decision-making about genetic testing and preventive treatment strategies are suggested.

Determination of size in invasive breast carcinoma: pathologic considerations and clinical implications

The widespread use of mammography has made the detection of increasingly small, often impalpable, invasive breast carcinomas possible. An enhanced understanding of morphological factors, among the foremost of which is size of invasive component of carcinoma, is changing the management of breast cancer To the uninitiated, the determination of size of invasive component is seemingly simple but in practical terms is complicated by a number of ambiguous issues. Practical guidelines for the assessment of size of invasive carcinoma are proposed.

Quantifying mammary duct carcinoma in situ: a wild-goose chase?

Duct carcinoma in situ (DCIS) is a malignant neoplasm of the breast that is limited to the glandular component. The introduction of mammographic screening allows for earlier detection of carcinoma, at the stage of DCIS, before it invades the surrounding stroma. Although DCIS has been studied extensively, its quantification remains a dilemma. Several methods for measuring DCIS exist, including clinical measurement, radiographic assessment, and gross pathologic assessment. Other methods have been employedfor this purpose, such as counting the number of tissue sections involved, direct measuring of DCIS from glass slides, and even counting the number of ducts involved. Furthermore, there is no consensus for assessing adequacy of margins. The myriad of techniques for quantifying DCIS has profound implications for treatment and for prognostic evaluation. The inherent difficulties in quantifying DCIS are multifactorial, and the need to establish a standardized approach for reporting the extent of DCIS by correlating radiographic, clinical, gross, and histologic findings is imperative.

A comparison of cell cycle markers in well-differentiated lobular and ductal carcinomas

Infiltrating lobular carcinoma (ILC) and infiltrating ductal carcinoma (IDC) are similar in many respects and their histologic features occasionally overlap. Despite the many similarities, some clinical follow-up data and the patterns of metastasis suggest that ILC and IDC are biologically distinct. Unfortunately, most breast cancer research has focused almost exclusively on the ductal subtype or has not stressed the biologic or molecular genetic distinctions between breast carcinoma subtypes. Several reports have suggested the possibility that ILCs and IDCs differ with respect to expression of antigens involved in proliferation and cell cycle regulation. Therefore, we undertook an immunohistochemical evaluation of cell cycle related antigens in ILCs, including histologic variants thought to represent aggressive neoplasms, and IDCs matched for histologic grade (Modified Bloom-Richardson Grade I). We believe that different antigen expression profiles could elucidate the biological distinctiveness of breast carcinoma subtypes and possibly provide diagnostically relevant information. We studied the expression of the following antigens in 28 archived, formalin-fixed ILCs and 34 well-differentiated IDCs: estrogen receptor (ER), progesterone receptor (PR), Her 2-neu, mib-1, cyclin D1, p27, p53, mdm-2 and bcl-2. 94% of ILCs and 100% of IDCs expressed ER; 75% of ILCs and 76% of IDCs expressed PR; 4% of ILCs and 13% of IDCs expressed c cerb B-2; ILCs and IDCs both expressed mib-1 in approximately 10% of lesional cells; 82% of ILCs and 54% of IDCs expressed cyclin D1; 90% of ILCs and 83% IDCs expressed p27 strongly; 4% of ILCs and 4% of IDCs expressed p53, 25% of ILCs and 33% of IDCs expressed mdm-2; 96% of ILCs and 100% of IDCs expressed bcl-2. None of the apparent differences were statistically significant. The ILC variants demonstrated immunophenotypes that were essentially similar to ILCs of the usual type. We conclude that ILCs and well-differentiated IDCs show similar proliferation and cell cycle control antigen profiles. Despite their unusual histologic features, most ILC variants appear to maintain a characteristic ILC immunophenotype.

Phytochemicals as modulators of cancer risk

These results, describing antitumor activity of some of the phytochemicals that have been actively studied, suggest that dietary changes could play a role in decreasing the incidence of a variety of tumors. 13C and the other compounds discussed may well be only prototypes for other as yet unexplored phytochemicals present in the diet. There have been no attempts to explore the possibilities of synergistic action among the various phytochemicals, 13C, limonene, curcumin, epigallocatechin gallate, sulforaphene, or genistein. Mixtures of these compounds might well show potency at lower doses for each of the compounds and show even greater promise than that already demonstrated.

Multifunctional aspects of the action of indole-3-carbinol as an antitumor agent

Previous studies from this laboratory have suggested that 2-hydroxyestrone is protective against breast cancer, whereas the other principal metabolite, 16 alpha-hydroxyestrone, and the lesser metabolite quantitatively, 4-hydroxyestrone, are potent carcinogens. Attempts to directly decrease the formation of the 16-hydroxylated metabolite were either unsuccessful or required such high levels of the therapeutic agent as to be impractical. On the other hand the concentration of the protective metabolite, 2-hydroxyestrone, proved to be readily modulated by a variety of agents, both in the direction of increased protection and the opposite direction, increased risk by a variety of agents and activities. We have focussed our attention on indole-3-carbinol, a compound found in cruciferous vegetables, and its further metabolites in the body, diindolylmethane (DIM) and indolylcarbazole (ICZ), because of its relative safety and multifaceted activities. It has been shown that it induces CyP4501A1, increasing 2-hydroxylation of estrogens, leading to the protective 2-OHE1, and also decreases CyP1B1 sharply, inhibiting 4-hydroxylation of estradiol, thereby decreasing the formation of the carcinogenic 4-OHE1. In addition to these indirect effects as a result of altered estrogen metabolism, indole-3-carbinol has been shown to have direct effects on apoptosis and cyclin D, resulting in blockage of the cell cycle. In addition to its antitumor activity in animals, it has also been shown to be effective against HPV-mediated tumors in human patients. All of these responses make the study of its behavior as a therapeutic agent of considerable interest.

Breast cancer prevention by antiestrogens

A new era has been entered with the first demonstration that an antiestrogen can prevent breast cancer. In a landmark study tamoxifen was shown to reduce the incidence of breast cancer by approximately 50%. The reduction was observed in pre- and postmenopausal women at increased risk of breast cancer. Invasive cancers were reduced, the reduction being in the estrogen receptor-positive cancers. No preventive effect was observed for estrogen receptor-negative tumors. In situ cancers were also significantly reduced. A collateral benefit was a significant reduction in fractures due to osteoporosis. Adverse effects included a very small increase in the incidence of endometrial cancer, cataracts, and stroke. The benefits appear to outweigh the risks for those at high risk. Preliminary studies of a new selective estrogen receptor modulator (SERM 2), raloxifene, developed for the prevention of osteoporosis, have shown that the breast cancer rate was reduced by more than 50% without any concomitant increase in endometrial cancer. The search for a SERM 3, and beyond, may lead to the development of drugs that have the beneficial effects of estrogen while preventing breast cancer and osteoporosis.

Microinvasive carcinoma (T1mic) of the breast: clinicopathologic profile of 21 cases

Clinicopathologic data on microinvasive carcinoma of the breast (MICB) as defined by the 1997 TNM criteria (T1mic < or = 1 mm) is scarce. Histologic slides of 109 cases from 1993 through 1997, in which microinvasion was either suspected or diagnosed initially, were reviewed. A double immunoenzyme-labeling technique using antismooth muscle actin and anticytokeratin antibody on the same section was used to confirm invasion in equivocal cases. All foci of invasion were measured by ocular micrometer. Twenty-one cases were confirmed to be MICB. The mean age of the patients was 60.9 years. Thirteen patients presented with mammographic abnormalities on routine examination (60.9%). MICB was ductal in 18 patients, including one tubular carcinoma, and was lobular in three patients. The mean number of invasive foci was two per patient (range, one to seven foci). The accompanying duct carcinoma in situ had high-grade nuclei and necrosis in 16 of 18 patients (89%), 13 of which (72%) were comedo-type. Two of the 15 patients had one positive axillary lymph node each (13.3%). Eleven patients underwent mastectomy, nine received radiation therapy, one received chemotherapy, and two underwent lumpectomy only. Median follow up was 28 months (range. 18-63 months). One patient had a chest wall recurrence of infiltrating duct carcinoma and another recurred with duct carcinoma in situ.

Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing mastectomies

BACKGROUND

Skin-sparing mastectomies (SSMs) are being used more frequently to treat many cases of breast cancer. This type of surgery maximizes breast skin preservation and facilitates immediate reconstruction, resulting in a superior cosmetic appearance after mastectomy and a more satisfied patient. Although SSMs are becoming more common, there are few data regarding the local and distant recurrence rates.

METHODS

A total of 231 patients treated with mastectomies from 1990 to 1998 were studied, including 77 SSM and 154 non-skin-sparing (NSSM) mastectomy patients.

RESULTS

The local recurrence rates for SSM and NSSM were 3.90% (3 of 77 patients) and 3.25% (5 of 154 patients), respectively. The local recurrence-free survival at 5 years was 95.3% for SSM patients and 95.2% for NSSM patients (P = .28). The distant recurrence rates of SSM and NSSM were 3.9% (3 of 77 patients) and 3.9% (6 of 154 patients), respectively. The distant recurrence-free actuarial survival at 5 years was 90.2% for SSM patients and 92% for NSSM patients (P = .07).

CONCLUSIONS

Mastectomies using the skin-sparing technique do not appear to result in any increase in local or distant recurrence and improve aesthetic results of the immediate reconstruction.

Chemoprevention of breast cancer

A critical question is, why do the European studies fail to confirm the US study? Clearly, the answers are complex and uncertain. Differences in power, age, risk, compliance, the use of ERT, and follow-up in the European studies may all be relevant. The efficacy of tamoxifen in BRCA 1 or 2 carriers is an important issue; recent data have shown a DNA repair defect in those with BRCA 1 gene alterations. This finding, coupled with the potential genotoxicity of tamoxifen, is of concern, but the NSABP study did show a significant reduction in breast cancer risk in those with first-degree relatives with breast cancer, including those likely to have a hereditary-predisposition gene. The issue will be clarified when the BRCA 1 or 2 status of these individuals is determined from the stored DNA samples of all participants in the NSABP study. The duration of use of an antiestrogen for prevention is uncertain; the adjuvant trial data for up to 5 years of tamoxifen use showed an effect on contralateral breast cancer prevention extending beyond 5 years, but experimental data show that stopping tamoxifen therapy results in the appearance of new tumors. The long-term use of tamoxifen for prevention carries significant risks. If raloxifene can be given long term, then continuing the prevention of tumors may be possible if raloxifene is proven safe. Should tamoxifen be used outside of a clinical trial? The FDA has approved its use to "delay" breast cancer so it can be prescribed for any patient at increased risk for breast cancer. The word prevention has been the subject of polemics. Every day that breast cancer is delayed is a day that it is prevented. Risk reduction is technically a more accurate phrase but lacks meaning to many women. Novel approaches to chemoprevention are being explored. Naturally occurring compounds or their analogues are being assessed. Based on experimental studies, the vitamin A analogue 4-hydroxyphenyl retinamide (4-HPR) was shown to delay and reduce carcinogen-induced breast cancer. A randomized clinical trial of 4-HPR is being tested in women in Italy to reduce contralateral breast cancer, but no results are available. New approaches using substances derived from plants, such as vegetables, are being pursued. Based on epidemiologic studies, investigators have proposed that an estrogen metabolite, C16 alpha-hydroxyesterone (16 alpha-OHE1), may have estrogen-stimulating and DNA-damaging properties of mammary epithelial cells. Strategies to reduce 16 alpha-OHE1 have been explored. Indole-3-carbinol, found in high concentration in cruciferous vegetables (i.e., cabbage, cauliflower, broccoli, rabe, brussels sprouts, kale, and bok choi), has been shown to reduce mammary cancer in rodent models and induces a metabolic pathway competing with 16 alpha-OHE1, which increases C-2 hydroxyesterone and thereby reduces substrate available for the 16 alpha-OHE1 pathway. Indole-3-carbinol has a good short-term safety profile. The minimum effective dose that favorably perturbs the ratio between 16 alpha-OHE1 and 2-OHE1 has been determined, and a pilot feasibility trial is in progress in women at risk for breast cancer at Strang Cancer Prevention Center. Future research will identify single or a combination of agents that may significantly reduce the risk for breast cancer without toxicity. A better understanding of the steps involved in the progression of normal breast cells toward cancer will permit the development of strategies to reduce the incidence of and mortality from breast cancer, with the ultimate goal of prevention.

Local tumor recurrence following breast-conservation therapy: correlation of histopathologic findings with detection method and mammographic findings

PURPOSE

To correlate histopathologic findings with detection method and mammographic appearance in primary and locally recurrent breast carcinoma after breast-conservation therapy.

MATERIALS AND METHODS

Medical records and mammographic findings were retrospectively reviewed; 26 patients with 27 local recurrences after breast-conservation therapy were identified.

RESULTS

Primary histopathologic findings included six in situ and 20 invasive carcinomas. Of the 27 recurrences, 19 (70%) were at or adjacent to the lumpectomy site and eight (30%) were elsewhere in the breast. All primary ductal carcinoma in situ (DCIS) cases manifested mammographically as microcalcifications and recurred as DCIS with microcalcifications. Eleven primary invasive carcinomas (10 masses, one case of microcalcifications) were detected only mammographically, three were detected only with physical examination, and six (six masses) were detected with both. Among these 20 recurrences, 14 (five masses, nine cases of microcalcifications) were detected only mammographically, one was detected only with physical examination, and five (five masses) were detected with both. Seventeen (85%) of 20 primary invasive carcinomas recurred invasively: 16 (94%) with similar histopathologic findings and eight (47%) with similar mammographic findings.

CONCLUSION

In local recurrence after breast-conservation therapy for DCIS, histopathologic findings, detection method, and mammographic findings are usually similar. Histopathologic findings of primary invasive breast carcinoma and local recurrence are usually similar, but the detection method and mammographic findings vary. This is relevant to the interpretation of new clinical or mammographic findings following lumpectomy.

The evaluation of high risk and pre-invasive breast lesions and the decision process for follow up and surgical intervention

Atypical epithelial hyperplasia, lobular carcinoma in situ (lobular neoplasia), radial scar, and ductal carcinoma in situ are considered high-risk lesions that predispose toward the future development of non-invasive or invasive breast cancer. Generally, those women with atypical epithelial hyperplasia, radial scar, or lobular carcinoma in situ can be managed conservatively by close surveillance. The minority of women may consider prophylactic mastectomy. Ductal carcinoma in situ can usually be managed by lumpectomy with or without radiation, with some patients requiring mastectomy due to extensive disease.

Observations on the histopathologic diagnosis of microinvasive carcinoma of the breast

Our histopathologic criteria for diagnosing microinvasive carcinoma of the breast may be enunciated as follows: (1) cytologically malignant cells in the stroma associated with in situ carcinoma, (2) absence of basement membrane and myoepithelial cells around the invasive cells, (3) frequent accompanying stromal alterations in the form of myxomatous change and loosening of connective tissue, and (4) the frequent presence of an inflammatory cell infiltrate composed of lymphocytes and plasma cells. Most or all of these four features are present in cases of ductal microinvasive carcinoma of the breast, but the lobular type is not likely to be accompanied by stromal changes or a lymphoplasmacytic cell infiltrate. The minimum information regarding microinvasive carcinoma of the breast that should be conveyed in the final pathology report includes size as measured by the ocular micrometer or a statement that microinvasion refers to a lesion smaller than 1 mm, the number of foci of invasion, and the spatial distribution of the invasive foci. The nuclear grade of the invasive cells and the size, type, and nuclear grade of the accompanying DCIS should be specified. The status of margins, presence of vascular channel involvement (a rarity in microinvasive carcinoma of the breast), and degree of proliferative changes in adjacent nonneoplastic breast tissue should be reported. Immunostains for basement membrane and myoepithelial cells may be helpful in the diagnosis of microinvasive carcinoma of the breast. Sclerosing lesions such as radial scar and sclerosing adenosis can simulate microinvasive carcinoma of the breast, especially when the latter is associated with in situ carcinoma. Caution should be exercised in cases wherein in situ malignant cells may be dislodged by needling procedures or during dissection of the excised specimen. Cautery-induced artifacts also hinder optimal histologic assessment. In some cases, it is virtually impossible to determine if true invasion is present, and the statement "microinvasive carcinoma of the breast cannot be entirely excluded" may be employed as a last resort. We consider the latter diagnosis to be the last refuge of the diligent pathologist and do not recommend it unless all diagnostic measures, including examination of deeper levels and supplemental stains, have been exhausted. It may be necessary to seek an expert opinion in "difficult" cases, particularly in the event that therapeutic decisions are to be based on the determination of invasion. From a clinical perspective, the management of microinvasive carcinoma of the breast ought to be dictated by the individual circumstances in each case. Based on currently available data, which admittedly suffer from lack of diagnostic uniformity, the vast majority of patients with microinvasive carcinoma of the breast will be node-negative and can look forward to an excellent prognosis. It is hoped that since the UICC has adopted a previously recommended definition of microinvasive carcinoma of the breast, prospective or retrospective studies with uniform diagnostic criteria will be conducted that will enable more definitive conclusions regarding the treatment and prognosis of microinvasive carcinoma of the breast.

Role of estradiol metabolism and CYP1A1 polymorphisms in breast cancer risk

The endogenous metabolism of estrogens is primarily oxidative and involves hydroxylation of the steroid at either C2 (2-OHE1) or C16 (16-OHE1). While the 2-OHE1 metabolites are essentially devoid of peripheral biological activity, 16-OHE1 is an estrogen agonist. There is evidence of an association between the 2-OHE1/16-OHE1 metabolites ratio and breast cancer risk. The CYP1A1 gene may play a role in the 2-hydroxylation (2-OH) of estradiol. African-American women with the wild-type CYP1A1 gene showed a significant increase in the 2-OHE1/16-OHE1 ratio, from 1.35 +/- 0.56 at baseline to 2.39 +/- 0.98 (p = 0.006) after 5 days of treatment with indole-3-carbinol (400 mg/day), a 2-OHE1 inducer. Women with the Msp1 polymorphism showed no significant increase, (0.37% +/- 0.17%). In a case-control study involving 57 women with breast cancer and 312 female controls, the frequency of the homozygous Msp1 polymorphism was 4.2% in African-American controls and 16% in African-American breast cancer cases. The odds ratio of breast cancer with the Msp1 homozygous variant was 8.4 (95% confidence interval: 1.7-41.7). This association was not observed in Caucasian women. The other CYP1A1 polymorphisms were not associated with breast cancer. The CYP1A1 Msp1 polymorphism may be a marker of altered estradiol metabolism and of increased susceptibility to estrogen-related breast cancer in African-Americans.

Inhibition of aberrant proliferation and induction of apoptosis in HER-2/neu oncogene transformed human mammary epithelial cells by N-(4-hydroxyphenyl)retinamide

Epithelial cells from non-cancerous mammary tissue in response to exposure to chemical carcinogens or transfection with oncogenes exhibit hyperproliferation and hyperplasia prior to the development of cancer. Aberrant proliferation may, therefore, represent a modifiable early occurring preneoplastic event that is susceptible to chemoprevention of carcinogenesis. The synthetic retinoid N-(4-hydroxyphenyl)retinamide (HPR), has exhibited preventive efficacy in several in vitro and in vivo breast cancer models, and represents a promising chemopreventive compound for clinical trials. Clinically relevant biochemical and cellular mechanisms responsible for the chemopreventive effects of HPR, however, are not fully understood. Experiments were performed on preneoplastic human mammary epithelial 184-B5/HER cells derived from reduction mammoplasty and initiated for tumorigenic transformation by overexpression of HER-2/neu oncogene, to examine whether HPR inhibits aberrant proliferation of these cells and to identify the possible mechanism(s) responsible for the inhibitory effects of HPR. Continuous 7-day treatment with HPR produced a dose-dependent, reversible growth inhibition. Long-term (21 day) treatment of 184-B5/HER cells with HPR inhibited anchorage-dependent colony formation by approximately 80% (P < 0.01) relative to that observed in the solvent control. A 24 h treatment with cytostatic 400 nM HPR produced a 25% increase (P = 0.01) in G0/G1 phase, and a 36% decrease (P = 0.01) in S phase of the cell cycle. HPR treatment also induced a 10-fold increase (P = 0.02) in the sub-G0 (apoptotic) peak that was down-regulated in the presence of the antioxidant N-acetyl-L-cysteine. Treatment with HPR resulted in a 30% reduction of cellular immunoreactivity to tyrosine kinase, whereas immunoreactivity to p185HER remained essentially unaltered. HPR exposure resulted in time-dependent increase in cellular metabolism of the retinoid as evidenced by increased formation of the inert metabolite N-(4-methoxyphenyl)-retinamide (MPR) and progressive increase in apoptosis. Thus, HPR-induced inhibition of aberrant proliferation may be caused, in part, by its ability to inhibit HER-2/neu-mediated proliferative signal transduction, retard cell cycle progression and upregulate cellular apoptosis.

Application of an improved ELISA assay to the analysis of urinary estrogen metabolites

Work from Strang and other laboratories has established that the 2-/16 alpha-hydroxyestrone ratio is inversely correlated with the risk for breast and cervical cancer. In order to measure these metabolites in urine samples, it is essential to have an assay for these compounds that is both sensitive and reproducible. The present paper describes such an ELISA assay, which overcomes problems that existed in prior approaches to measuring these compounds. The new ELISA procedure supplies greater sensitivity and reproducibility than earlier assay procedures. The ELISA assay has also been found to correlate well with the GC-MS procedure of Adlercreutz.

Retroareolar breast carcinoma: clinical, imaging, and histopathologic features

PURPOSE

To evaluate the clinical, imaging, and histopathologic features of breast carcinoma in the retroareolar tissues and to determine whether there are any characteristics common to this location.

MATERIALS AND METHODS

Thirty-five patients (age range, 38-77 years) with 37 retroareolar carcinomas were identified retrospectively. Retroareolar carcinoma was defined as that within 2 cm of the nipple-areolar complex. Mammographically occult tumors were identified by using histopathologic records (n = 4) or clinical examination findings (n = 6).

RESULTS

Twenty-nine (78%) tumors had clinical findings, including palpable mass (n = 29), associated nipple inversion or retraction (n = 4), and associated nipple discharge (n = 2). Twenty-seven (73%) tumors had mammographic findings of mass (n = 16), mass with calcifications (n = 5), and microcalcifications (n = 6; four of these microcalcifications were associated with a mammographically occult palpable mass). Ultrasound was performed in 17 tumors, all of which were hypoechoic. The stage of 31 carcinomas was known: one was stage 0, 17 were stage I, and 13 were stage II. Histopathologic analysis revealed 35 ductal carcinomas and two invasive lobular carcinomas.

CONCLUSION

Retroareolar carcinoma usually manifests as a palpable mass. Mammography is less sensitive in this area than in other areas of the breast. Ultrasound can be a valuable adjunct in the assessment of retroareolar malignancy.

ErbB-2 protein in sera and tumors of breast cancer patients

We compared levels of erbB-2 oncoprotein among three groups: Group I included 60 asymptomatic women; Group II had 51 women with benign breast biopsies; and Group III had 67 women with node-negative breast cancer. Serological levels of erbB-2 protein were measured in all participants; tumor levels were measured for Groups II and III. Forty-three percent of usable tumors (25/58), including three of seven lobular tumors, were erbB-2 positive. Tumor and blood oncoprotein levels were unrelated. Blood levels, however, were positively related to tumor volume, but only when the tumor had both a ductal carcinoma in situ (DCIS) component and an invasive component, suggesting a role for erbB-2 protein in progression of DCIS to invasive carcinoma. In Groups I and II serological levels of erbB-2 protein were directly related to age, and inversely related to having had a live birth. Therefore, a model that determined the threshold levels of serological erbB-2 positivity in Group III included age and nulliparity as independent variables. Only three of the 67 women (4.5%) in Group III were positive for serological erbB-2. In a multivariate model, with serological erbB-2 as the dependent variable, and in which the independent variables included Study Group, there was a statistical trend for younger women, in which Group III had the highest serological levels of erbB-2, followed by Group II, and then Group I. In women who were over the age of 50 years the trend was reversed; i.e., levels of erbB-2 tended to be lowest in Group III, followed by Group II, and finally Group I.

Dose-ranging study of indole-3-carbinol for breast cancer prevention

Sixty women at increased risk for breast cancer were enrolled in a placebo-controlled, double-blind dose-ranging chemoprevention study of indole-3-carbinol (I3C). Fifty-seven of these women with a mean age of 47 years (range 22-74) completed the study. Each woman took a placebo capsule or an I3C capsule daily for a total of 4 weeks; none of the women experienced any significant toxicity effects. The urinary estrogen metabolite ratio of 2-hydroxyestrone to 16 alpha-hydroxyestrone, as determined by an ELISA assay, served as the surrogate endpoint biomarker (SEB). Perturbation in the levels of SEB from baseline was comparable among women in the control (C) group and the 50, 100, and 200 mg low-dose (LD) group. Similarly, it was comparable among women in the 300 and 400 mg high-dose (HD) group. Regression analysis showed that peak relative change of SEB for women in the HD group was significantly greater than that for women in the C and LD groups by an amount that was inversely related to baseline ratio; the difference at the median baseline ratio was 0.48 with 95% confidence interval (0.30, 0.67). No other factors, such as age and menopausal status, were found to be significant in the regression analysis. The results in this study suggest that I3C at a minimum effective dose schedule of 300 mg per day is a promising chemopreventive agent for breast cancer prevention. A larger study to validate these results and to identify an optimal effective dose schedule of I3C for long-term breast cancer chemoprevention will be necessary.

Alteration of oestradiol metabolism in myc oncogene-transfected mouse mammary epithelial cells

Targeted overexpression of the c-myc oncogene induces neoplastic transformation in immortalized, non-tumorigenic mouse mammary epithelial cells (MMEC). Experiments in the present study were conducted to examine whether cellular transformation induced by c-myc oncogene is associated with altered metabolism of 17beta-oestradiol (E2). The parental, MMEC and the stable c-myc transfectant (MMEC/myc3) cell lines were compared for major oestrogen metabolic pathways, namely E2 and E1 interconversion, and C2- and C16alpha-hydroxylation by both high-pressure liquid chromatography (HPLC) analysis and the 3H release assay using specifically labelled [C2-3H]E2 or [C16alpha-3H]E2. The reductive conversion of E1 to E2 was about 14-fold and 12-fold higher than the oxidative conversion of E2 to E1 in MMEC and MMEC/myc3 cells respectively. However, in MMEC/myc3 cells, both reductive and oxidative reactions were decreased by about 32% and 12% relative to those seen in the parental MMEC cells (P = 0.0028). The extent of C16alpha-hydroxylation was increased by 164.3% (P < 0.001), with a concomitant 48.4% decrease (P < 0.001) in C2-hydroxylation in MMEC/myc3 cells; this resulted in a fourfold increase in the C16alpha/C2 hydroxylation ratio in this cell line. Thus, a persistent c-myc expression, leading to aberrant hyperproliferation in vitro and tumorigenesis in vivo, is associated with an altered oestrogen metabolism. However, it remains unclear whether this represents a result of oncogene expression/activation or is rather a consequence of phenotypic transformation of the cells.

Negative growth regulation of oncogene-transformed mammary epithelial cells by tumor inhibitors

Deregulated expression of Ras and myc oncogenes confers neoplastic transformation in non-tumorigenic mammary epithelial cells. Down-regulation of perturbed biomarkers prior to tumorigenesis may provide a means of effective chemoprevention. In vitro experiments were designed to i) identify specific molecular, endocrine and cellular biomarkers as quantitative end points for preneoplastic transformation, and ii) utilize these end points to evaluate chemopreventive efficacy of selected naturally-occurring and synthetic tumor inhibitors. Stable Ras and myc transfectants exhibited persistent expression of oncogene specific mRNA transcripts, altered estradiol biotransformation and enhanced anchorage-independent growth in vitro prior to tumorigenesis in vivo. Treatment of the transfectants with omega-3-fatty acid, indole-3-carbinol and tamoxifen individually suppressed the perturbed molecular, endocrine and cellular biomarkers in vitro. Thus, suppressed oncogene expression and altered estrogen metabolism may be important determinants for antiproliferative mechanisms in mammary tumor inhibition, providing useful end points for chemopreventive intervention of preneoplasia.

Inhibition of aberrant proliferation and induction of apoptosis in pre-neoplastic human mammary epithelial cells by natural phytochemicals

Aberrant proliferation and modulated apoptosis leading to impaired cellular homeostasis represent crucial early events in the multi-step carcinogenic process. Regulation of these perturbed biomarkers may predict efficacious prevention of cancer development. Present experiments on non-cancerous human mammary epithelial 184-B5 cells were designed to examine whether i) exposure to suspect environmental human carcinogen Benzo (a) pyrene (BP) alters the status of cell proliferation and apoptosis and ii) BP-induced alterations are modulated in response to select natural phytochemicals that inhibit rodent mammary tumorigenesis. Flow cytometric analysis, cellular immunoreactivity to proliferation specific and apoptosis specific gene products and anchorage-dependent colony formation represented quantitative endpoints. Cruciferous glucosinolate indole-3-carbinol (I3C), tea polyphenol (-) epigallo catechin gallate (EGCC) and soy isoflavone genistein (GEN) represented the chemopreventive test compounds. A single 24 h exposure to 39 lM BP resulted in a 50% decrease (P=0.02) in the ratio of quiescent (Q=G0) to proliferative (P=S + M) population in part due to increase in aberrantly proliferative cells. The BP-initiated cells also exhibited an 87.8% inhibition (P=0. 0001) in confluency-associated apoptosis and a concomitant decrease in cellular immunoreactivity to wild-type p53. Simultaneous treatment of cultures with BP + I3C, BP + EGCG and BP + GEN resulted in a 1.8- to 3.4-fold increase (P<0.01) in Q/P ratio and 1.8- to 6. 9-fold increase (P=0.001) in sub G0 (apoptotic) population. The induction of apoptosis was accompanied by enhanced p53 immunoreactivity (P<0.01). In long-term (21 day) experiments, BP treatment induced a 145.3% increase (P=0.001) in anchorage-dependent colony formation. This aberrant proliferation was inhibited by 44.2% to 65.3% (P=0.01) in the presence of the three phytochemicals. Thus, BP-induced aberrant proliferation is inhibited by the natural phytochemicals in part due to regulation of cell cycle progression and induction of p53 dependent apoptosis.

Ototoxicity resulting from intracochlear perfusion of Streptococcus pneumoniae in the guinea pig is modified by cefotaxime or amoxycillin pretreatment

Acute changes in the electrophysiology and ultrastructure of the organ of Corti were studied after microperfusion of c. 5 x 10(6) CFU of serotype 2 Streptococcus pneumoniae D39 or Escherichia coli K-12 directly into the scala tympani of guinea pigs. Hearing loss was assessed by recording the auditory nerve compound action potential response to a 10 kHz tone pip. Mean hearing loss 3 h after pneumococcal perfusion (n = 4) was 44 dB, compared to 6 dB after E. coli perfusion (n = 4) (P<0.001). After pneumococcal perfusion, scanning electron microscopy revealed damage to hair cell stereocilia and cratering of the apical surface of supporting cells. Intraperitoneal injection of 100 mg/kg cefotaxime (n = 4) or 100 mg/kg amoxycillin (n = 4) 30 min before perfusion of pneumococci significantly reduced mean hearing loss to 23 dB (P=0.01) or 20 dB (P=0.01), respectively, and diminished ultrastructural damage. The data suggest that if pneumococci invade the inner ear during meningitis, cochlear deafness may rapidly ensue.

Isolation of two novel WNT genes, WNT14 and WNT15, one of which (WNT15) is closely linked to WNT3 on human chromosome 17q21

The Wnt gene family consists of at least 15 structurally related genes that encode secreted extracellular signaling factors. Wnt proteins function in a range of critical developmental processes in both vertebrates and invertebrates and are implicated in regulation of cell growth and differentiation in certain adult mammalian tissues, including the mammary gland. We have isolated a number of WNT sequences from human genomic DNA, two of which, designated WNT14 and WNT15, represent novel members of the Wnt gene family. We also isolated WNT sequences from human mammary cDNA and present evidence that WNT13 is expressed in human breast tissue, in addition to those previously described. WNT14 and WNT15 appear to have originated from an ancestral branch of the Wnt gene family that also includes the Wnt9 sequences found in jawless and cartilaginous fishes. A Wnt14 cDNA was also isolated from chicken and a partial Wnt15 sequence from mouse. We show that human WNT14 maps to chromosome 1 and that WNT15 maps distal to BRCA1 on chromosome 17q21, where it lies within 125 kb of another WNT family member, WNT3.

Role of the estrogen receptor in the action of organochlorine pesticides on estrogen metabolism in human breast cancer cell lines

As interest in the properties of xenoestrogenic compounds has grown, different in vitro cell culture systems have been proposed as models, against which to gauge relative estrogenic impact. Previous research indicated that some organochlorine-based pesticides elevated the production of 16 alpha-hydroxyestrone relative to 2-hydroxyestrone in ER+ MCF-7 breast cancer cells while phytochemicals like indole-3-carbinol reduced this ratio. That this ratio may be a biological marker of the risk of breast cancer has recently been demonstrated. In this study we have carried out the same paradigm in two ER- cell lines to examine the effect of receptor status. To determine whether the impact of chlorinated pesticides can be modulated by phytochemicals, the ability of indole-3-carbinol or brassinin to reverse the changes in metabolism was examined. Non-persisting phosphorus-based pesticides were also studied and shown not to have an effect on estrogen metabolism. The implications of these findings are examined.

A role for pneumolysin but not neuraminidase in the hearing loss and cochlear damage induced by experimental pneumococcal meningitis in guinea pigs

We investigated the roles of pneumolysin and neuraminidase in the pathogenesis of deafness and cochlear damage during experimental pneumococcal meningitis. Anesthetized guinea pigs were inoculated intracranially with 7.5 log10 CFU of either (i) wild-type Streptococcus pneumoniae D39 (n = 8), (ii) PLN-A, a defined isogenic derivative of D39 deficient in pneumolysin (n = 5), or (iii) deltaNA1, a new derivative of D39 deficient in neuraminidase constructed by insertion-duplication mutagenesis of the nanA gene (n = 5). To quantify hearing loss, the auditory nerve compound action potential evoked by a tone pulse was recorded from the round window membrane of the cochlea every 3 h for 12 h. The organ of Corti was intravitally fixed for subsequent examination by high-resolution scanning and transmission electron microscopy. All animals sustained similar meningeal inflammatory responses. PLN-A induced significantly less hearing loss than D39 over the frequency range of 3 to 10 kHz. Levels of mean hearing loss at 10 kHz 12 h postinoculation were as follows: D39, 50 dB; deltaNA1, 52 dB (P = 0.76 versus D39), and PLN-A, 12 dB (P < 0.0001 versus D39). The mean rates of hearing loss at 10 kHz were 4.4 dB/h for D39, 4.3 dB/h for deltaNA1, and just 1.0 dB/h for PLN-A (P < 0.0001 versus D39). Suppurative labyrinthitis was universal. PLN-A induced the accumulation of less protein in the cerebrospinal fluid (P = 0.04 versus D39). Infection with D39 and deltaNA1 induced significant damage to the reticular lamina, the sensory hair cells, and supporting cells of the organ of Corti. By contrast, after infection with PLN-A, the organ of Corti appeared virtually intact. Pneumolysin seems to be the principal cause of cochlear damage in this model of meningogenic deafness. No clear pathogenic role was demonstrated for neuraminidase.

Inhibition of proliferation and modulation of estradiol metabolism: novel mechanisms for breast cancer prevention by the phytochemical indole-3-carbinol

Aberrant proliferation is an early-occurring intermediate event in carcinogenesis whose inhibition may represent preventive intervention. Indole-3-carbinol (I3C), a glucosinolate metabolite from cruciferous vegetables, inhibits organ site carcinogenesis in rodent models. Clinically relevant biochemical and cellular mechanisms for the anticarcinogenic effects of I3C, however, remain unclear. Experiments were conducted on reduction mammoplasty derived 184-B5 cells initiated with chemical carcinogen (184-B5/BP) or with oncogene (184-B5/HER), and on mammary-carcinoma-derived MDA-MD-231 cells to examine whether (i) I3C inhibits aberrant proliferation in initiated and transformed cells, and (ii) inhibition of aberrant proliferation is associated with altered cell-cycle progression, estradiol (E2) metabolism, and apoptosis. Aberrant proliferation in 184-B5/BP, 184-B5/HER, and MDA-MB-231 cells was evident by a 55%-67% decrease in the ratio of quiescent (Q = G0) to proliferative (P = S + M) phase of the cell cycle, a 72%-90% decrease in apoptosis, and a 76%-106% increase in anchorage-dependent growth. These cells also exhibited a 88%-90% decrease in the ratio of C2 to C16alpha-hydroxylation products of E2. Treatment of 184-B5/BP, 184-B5/HER, and MDA-MB-231 cells to cytostatic dose of 50 microM I3C resulted in an 137%-210% increase in Q/P I3C ratio, a 4- to 18-fold increase in E2 metabolite ratio, a 2-fold increase in cellular apoptosis, and a 54%-61% inhibition of growth. The preventive efficacy of I3C on human mammary carcinogenesis may be due in part to its ability to regulate cell-cycle progression, increase the formation of antiproliferative E2 metabolite, and induce cellular apoptosis.

No effect of timing of biopsy in the menstrual cycle on incidence of bone marrow micrometastasis in patients with breast cancer

BACKGROUND

The timing of breast cancer excision relative to the menstrual cycle has been debated to be of significant prognostic value. The differences in survival relative to the timing in the menstrual cycle have been attributed to the incidence of micrometastasis.

METHODS

All patients underwent bone marrow aspiration after the diagnostic surgical biopsy, immediately before definitive surgery. The timing of the diagnostic surgical biopsy in the menstrual cycle was calculated according to Senie. Monoclonal antibodies to epithelium-specific antigens were used to detect bone marrow micrometastasis (BMM).

RESULTS

This study reports on the effect of the phase of the menstrual cycle on incidence of BMM after surgical biopsy. Ninety-two patients with regular cycles underwent bone marrow aspiration an average of 12 days (range 0-32 days) after biopsy. Thirty-nine patients had undergone biopsy during the follicular phase and 53 patients during the luteal phase. BMM were detected in 31% of patients (29 of 92). We observed BMM in 33% of patients (13 of 39) in the follicular phase and in 30% of patients (16 of 53) in the luteal phase. This difference is not significant (p > 0.70). The mean number of cells detected and the presence of clumps of cells is similar in the two groups.

CONCLUSIONS

The incidence and characteristics of bone marrow micrometastases are independent of the timing of diagnostic excision biopsy in the menstrual cycle.

Possible involvement of nitric oxide in the sensorineural hearing loss of bacterial meningitis

Microperfusion of scala tympani with the NO donors, sodium nitroprusside (SNP) and S-nitroso-N-acetylpenicillamine (SNAP), produced marked depression of the compound action potential (CAP) and cochlear microphonic (CM) together with severe and widespread morphological damage to hair cells and supporting cells in the organ of Corti. In addition, direct perfusion of N-methyl-D-aspartate (NMDA) into scala tympani, which probably induces excess stimulation of NMDA receptors within the cochlea and which is known to lead to the release of NO, was found to elicit similar electrophysiological and structural lesions in the cochlea. Pre-perfusion of scala tympani with L-methyl arginine (L-MA), which inhibits the release of NO, or superoxide dismutase (SOD), an O2-scavenger, conferred marked protection upon the cochlea from the lesions caused by NO donors. These observations indicate that enhanced NO production is likely to be an important factor responsible for pathological insult of the cochlea. The possibility is discussed that this factor is involved in the chain of events leading to hearing loss caused by bacterial meningitis. Such hearing loss is a major sequela of bacterial meningitis in children.

Estradiol metabolism: an endocrine biomarker for modulation of human mammary carcinogenesis

The natural estrogen 17beta-estradiol (E2) has a profound influence on proliferation and neoplastic transformation of mammary epithelium. The role of cellular metabolism of E2 in mammary carcinogenesis, however, remains to be elucidated. Explant culture and cell culture models developed from noncancerous human mammary tissue were used to examine modulation of E2 metabolism in response to treatment with prototype rodent mammary carcinogens and the ability of the naturally occurring phytochemical indole-3-carbinol (13C) to influence E2 metabolism and regulate aberrant proliferation. In the two models, treatment with the chemical carcinogens 7,12-dimethylbenz[a]anthracene and benzo[a]pyrene altered the metabolism of E2 as determined from the radiometric (tritium release) and gas chromatography-mass spectrometry (GC-MS) assays. This alteration in E2 metabolism was accompanied by aberrant proliferation and abrogation of apoptosis as determined by the extent of replicative DNA synthesis, S-phase fraction and Sub G0 (apoptotic) peak. Exposure of carcinogen-initiated cultures to 13C resulted in induction of C2-hydroxylation of E2 and of apoptosis and downregulation of hyperproliferation. Determination of altered cellular metabolism of E2 in response to initiators and modulators of carcinogenesis and evaluation of cell cycle related markers for proliferation and apoptosis may provide a mechanism-oriented approach to validate E2 metabolism as an endocrine biomarker for induction and prevention of human mammary carcinogenesis.

Medical hypothesis: bifunctional genetic-hormonal pathways to breast cancer

As inherited germ line mutations, such as loss of BRCA1 or AT, account for less than 5% of all breast cancer, most cases involve acquired somatic perturbations. Cumulative lifetime exposure to bioavailable estradiol links most known risk factors (except radiation) for breast cancer. Based on a series of recent experimental and epidemiologic findings, we hypothesize that the multistep process of breast carcinogenesis results from exposure to endogenous or exogenous hormones, including phytoestrogens that directly or indirectly alter estrogen metabolism. Xenohormones are defined as xenobiotic materials that modify hormonal production; they can work bifunctionally, through genetic or hormonal paths, depending on the periods and extent of exposure. As for genetic paths, xenohormones can modify DNA structure or function. As for hormonal paths, two distinct mechanisms can influence the potential for aberrant cell growth: compounds can directly bind with endogenous hormone or growth factor receptors affecting cell proliferation or compounds can modify breast cell proliferation altering the formation of hormone metabolites that influence epithelial-stromal interaction and growth regulation. Beneficial xenohormones, such as indole-3-carbinol, genistein, and other bioflavonoids, may reduce aberrant breast cell proliferation, and influence the rate of DNA repair or apoptosis and thereby influence the genetic or hormonal microenvironments. Upon validation with appropriate in vitro and in vivo studies, biologic markers of the risk for breast cancer, such as hormone metabolites, total bioavailable estradiol, and free radical generators can enhance cancer detection and prevention.

Prevention of mammary preneoplastic transformation by naturally-occurring tumor inhibitors

Aberrant hyperproliferation (AH) is a late occurring post-initiational event that precedes mammary tumorigenesis in vivo. Experiments on the spontaneously immortalized, non-tumorigenic murine mammary epithelial C57/MG and MMEC cells were designed to validate AH as an in vitro cellular marker for preneoplastic transformation. Colony forming efficiency (% CFE) in anchorage-independent conditions of growth represented the quantitative parameter for AH. C57/MG and MMEC cells, upon treatment with chemical carcinogens or transfection with oncogenes, exhibited at least a 60-300-fold increase in AH relative to that seen in appropriate untreated controls. Transplantation of mammary epithelial cells initiated either by chemical carcinogens or by oncogenes into mammary fat pads of syngeneic mice produced rapidly growing tumors at the transplant site within 4-6 weeks. The tumor-derived T1/Pr1 and myc3/Pr1 cell lines (positive controls) exhibited at least an 800-900-fold increase in AH. Treatment of initiated cells with naturally occurring tumor inhibitors eicosapentaenoic acid (EPA), indole-3-carbinol (I3C), (-)epigallocatechin gallate (EGCG), squalene (SQE), and perillyl alcohol (PA) at non-toxic doses, resulted in a 70-99% inhibition of AH, depending on the initiator and the chemopreventive test compound. Upregulation of AH in initiated mammary epithelial cells in vitro prior to tumorigenesis in vivo, and persistent inhibition of AH by diverse naturally occurring tumor inhibitors, provides evidence for AH as a cellular surrogate endpoint for induction and modulation of mammary neoplastic transformation.

2-hydroxyestrone: the 'good' estrogen

The issue of the role of 2-hydroxyestrone (2-OHE1) in breast cancer has been the subject of considerable controversy as to whether it is carcinogenic or anticarcinogenic. The expanding data base outlined below is most consistent with the conclusion that 2-OHE1 is anticarcinogenic. In every experimental model in which 2-hydroxylation was increased, protection against tumors was achieved. Correspondingly, when 2-hydroxylation was decreased, an increase in cancer risk was observed. Even more dramatically, in the case of laryngeal papillomas induction of 2-hydroxylation with indole-3-carbinol (I3C) has resulted in inhibition of tumor growth during the time that the patients continue to take 13C or vegetables rich in this compound.

The effects of cisapride on elemental content in neonatal mouse small intestine in vivo

The effects of cisapride on elemental content of enterocytes, smooth muscle cells and lamina propria in neonatal mouse jejunum were studied using electron probe X-ray microanalysis. One hour after injection with cisapride (1.7 or 0.017 mg/kg body weight i.p.), Cl content was significantly reduced in villus base, crypt and smooth muscle cells and Na content decreased in muscle cells. No changes were observed in Na or Cl within villus tip cells. Total Ca content did not change significantly in any cell type following treatment with cisapride. These results confirm that cisapride induces net Cl- secretion in neonatal mouse jejunum.