Sentinel lymph node metastases in cancer: causes, detection and their role in disease progression

Malignant tumors of ectodermal or endodermal origin may metastasize to the sentinel lymph node, the first lymph node encountered by tumor cells that enter lymphatics in the organ of origin. This pathway is enabled by the anatomy of the disease and the causes of metastasis are the result of complex interactions that include mechanical forces within the tumor and host tissues, and molecular factors initiated by tumor cell proliferation, elaboration of cytokines and changes in the tumor microenvironment. Mechanical stresses may influence complex biochemical, genetic and other molecular events and enhance the likelihood of metastasis. This paper summarizes our understanding of interacting molecular, anatomical and mechanical processes which facilitate metastasis to SLNs. Our understanding of these interacting events is based on a combination of clinical and basic science research, in vitro and in vivo, including studies in lymphatic embryology, anatomy, micro-anatomy, pathology, physiology, molecular biology and mechanobiology. The presence of metastatic tumor in the SLN is now more accurately identifiable and, based upon prospective clinical trials, paradigm-changing SLN biopsy has become the standard of clinical practice in breast cancer and melanoma.

Diagnostic value of HMB-45 and anti-Melan A staining of sentinel lymph nodes with isolated positive cells

Numerous immunohistochemical stains have been employed to detect metastatic melanoma in sentinel lymph node (SLN) biopsies. HMB-45 is considered by some as a specific tool to detect early metastatic melanoma (1). Occasionally, one or two isolated HMB-45-positive cells may cause complications in diagnostic interpretation. The goal of this study was to evaluate the reliability of HMB-45 staining of SLNs with sparse isolated positive cells and to compare its staining with anti-Melan A antibody. HMB-45 and anti-Melan A antibody immunostaining was performed on (Group A) 15 histologically negative SLNs excised from patients with malignant melanoma (MM) and on (Group B) 15 histologically negative SLNs excised from patients with breast carcinoma (BC). None of the patients had clinical evidence of systemic metastasis at the time of SLN biopsy. Five cutaneous biopsies with changes of postinflammatory hyperpigmentation (PIHP) were also stained with both antibodies. HMB-45 staining was repeated in all Group B SLNs after blocking endogenous biotins. Electron-microscopic studies were performed on all cases of PIHP. Isolated HMB-45-stained cells were present in 6 of 15 SLNs removed for MM; 8 of 15 for BC; and 3 of 5 cutaneous biopsies of PIHP. HMB-45 reactivity persisted after blocking endogenous biotins in 6 of 8 positive SLNs from Group B. Anti-Melan A antibody was negative in all SLNs of group A and B and in dermal melanophages of all five cases of PIHP. HMB-45 positivity was demonstrated in histologically negative SLNs and cutaneous biopsies, especially in the milieu of aggregated melanophages. Phagocytosis of premelanosomes by macrophages in the draining lymph nodes may account for isolated cell positivity and can hinder correct diagnostic interpretation. HMB-45 may not be a reliable marker for the detection of micro-metastasis of MM and requires correlation with other immunohistochemical markers, such as anti-Melan A antibody, to enhance specificity.

Pathways of lymphatic drainage from the breast

BACKGROUND

The current standard for obtaining accurate sentinel lymph node (SLN) mapping is intraparenchymal lymphophilic dye/radiocolloid injection close to the breast tumor. We hypothesized that common lymphatic trunks drain both a large volume of breast parenchyma and skin and that intradermal or intraparenchymal routes flow to the same axillary node.

METHODS

99mTc-labeled filtered sulfur colloid was injected intradermally directly over the breast tumor in 119 patients. Blue dye was injected intraparenchymally in the same quadrant as the primary tumor (concordant quadrant) in 66 and in a discordant quadrant in 53 patients. During axillary exploration, both blue and gamma-emitting (hot) nodes were found. End points were SLNs that were hot and blue, either the same node or different nodes.

RESULTS

In 62 (93.9%) of 66 of concordant quadrant and in 49 (92.5%) of 53 of discordant quadrant patients, the same SLN was both hot and blue (P = .99; Fisher's exact test). In eight cases in which two distinct nodes were blue and not hot and hot but not blue, the lymph nodes were very close to each other.

CONCLUSIONS

The dermal and parenchymal lymphatics of the breast seemed to drain to the same axillary lymph nodes. Lymph from the entire breast seemed to drain through a small number of lymphatic trunks to one or two lymph nodes.

Microvessels that predict axillary lymph node metastases in patients with breast cancer

HYPOTHESIS

The density of vasoactive endothelial growth factor receptor 3-immunostained microvessels in primary breast cancers correlates with the incidence of axillary lymph node metastasis.

DESIGN

Breast cancer microvessel clusters ("hot spots") were sequentially immunostained for factor VIII, type IV collagen, and vasoactive endothelial growth factor receptor 3. Microvessels were counted under light microscopy at a magnification of x 200. Axillary lymph nodes were evaluated for metastases by light microscopy.

SETTING

A multidisciplinary breast cancer clinic and laboratory.

PATIENTS

Sixty patients with T2 breast cancers treated by lumpectomy (or mastectomy) and axillary lymphadenectomy.

MAIN OUTCOME MEASURES

Putative lymphatic microvessel density compared with axillary metastases.

RESULTS

There were 16% (SE, 1.4%) vs 4% (SE, 0.8%) vasoactive endothelial growth factor receptor 3-immunostained microvessels (P<.001), 38% (SE, 3.9%) vs 65% (SE, 3.1%) type IV collagen-immunostained microvessels (P<.001), and 46% (SE, 4.1%) vs 31% (SE, 3.2%) unstained microvessels (P = .004) in node-positive vs node-negative patients, respectively. A fitted logistic model based on the relative percentage of putative lymphatic microvessels to blood microvessels correctly predicted that 23 (96%) of 24 patients would have a low risk and that 26 (96%) of 27 patients would have a high risk of lymph node metastases. Six (67%) of 9 patients predicted to have an intermediate risk had lymph node metastases.

CONCLUSION

The odds of a patient with breast cancer having axillary lymph node metastasis increased substantially as the proportion of putative lymphatic microvessels increased and the relative proportion of blood microvessels in angiogenic hot spots decreased (log likelihood = 14.6; chi2 = 53.4; P<.001; area under the receiver operation characteristic curve = 0.97).

Comparison of mammographically guided breast biopsy techniques

OBJECTIVE

To determine which mammographically guided breast biopsy technique is the most efficient in making a diagnosis in women with suspicious mammograms.

SUMMARY BACKGROUND DATA

Mammographically guided biopsy techniques include stereotactic 14-gauge core-needle biopsy (SC bx), stereotactic 11-gauge suction-assisted core biopsy (Mammotome [Mbx]), stereotactic coring excisional biopsy (Advanced Breast Biopsy Instrument [ABBI]), and wire-localized biopsy (WL bx). Controversy exists over which technique is best.

METHODS

All patients undergoing any one of these biopsy methods over a 15-month period were reviewed, totaling 245 SC bx, 107 Mbx, 104 ABBI, and 520 WL bx. Information obtained included technical success, pathology, discordant pathology, and need for open biopsy.

RESULTS

Technical success was achieved in 94.3% of SC bx, 96.4% of Mbx, 92.5% of ABBI, and 98.7% of WL bx. The sensitivity and specificity were 87.5% and 98.6% for SC bx, 87.5% and 100% for Mbx, and 100% and 100% for ABBI. Discordant results or need for a repeat biopsy occurred in 25.7% of SC bx, 23.2% of Mbx, and 7.5% of ABBI biopsies. In 63.6% of ABBI and 50.9% of WL bx, positive margins required reexcision; of the cases with positive margins, 71.4% of ABBI and 70.4% of WL bx had residual tumor in the definitive treatment specimen.

CONCLUSION

Although sensitivities and specificities of SC bx and Mbx are good, 20% to 25% of patients will require an open biopsy because a definitive diagnosis could not be reached. This does not occur with the ABBI excisional biopsy specimen. The positive margin rates and residual tumor rates are comparable between the ABBI and WL bx. The ABBI avoids operating room and reexcision costs; therefore, in appropriately selected patients, this appears to be the most efficient method of biopsy.

Racial differences in the presentation and surgical management of breast cancer

BACKGROUND

African American women are seen with more advanced breast cancers, are less likely to be treated with breast-conserving surgery, and generally have poorer prognoses than white women. There are a myriad of potential causes for these phenomena. The purpose of this study was to measure racial differences in the surgical treatment of breast cancer among women with comparable health care access and delivery.

METHODS

The Breast Cancer Registry of the Department of Surgery at Henry Ford Hospital was accessed for all patients between January 1, 1990, and December 31, 1997 for whom data on race, tumor characteristics, stage, and treatment specifics were available. Socioeconomic information was collected with use of 1990 census block data. Proportions of women who received each treatment were compared for African Americans and whites with use of the relative risk (RR) and 95% confidence intervals (CI). We used multiple logistic regression to obtain estimates of the relative risk, controlling for potential confounding factors.

RESULTS

Of the 1699 patients in the database, 1250 had sufficient information for analysis. A total of 8.7% of African American women were diagnosed with late-stage disease (i.e., stage III or IV) compared with 7.9% of whites. Nevertheless, African American women had a lower frequency of stage I disease (30.5% vs 36.2%) and a higher frequency of stage II disease (36.8% vs 31.4%). Overall and adjusted risk estimates for age, tumor stage, marital status, median income, and type of insurance revealed no substantive or statistically significant differences between African American and white patients. The adjusted RR for local excision was 1.39 (95% CI 0.78 to 2.49), for lumpectomy and axillary dissection RR 0.92 (95% CI 0.66 to 1.29), for simple mastectomy RR 0.84 (95% CI 0.41 to 1.72), and for modified radical mastectomy RR 1.00 (95% CI 0.73 to 1.36).

CONCLUSIONS

In this setting of equal access to health care, African American women still have higher frequencies of stage II disease, although the frequencies for late-stage disease are similar. Nevertheless, no surgical differences were found in this population, even after the effects of socioeconomic indicators and stage at diagnosis were controlled for Survival differences between African American and white women are unlikely to be explained by differences in treatment.

A new BRCA1 mutation in a Filipino woman with a family history of breast and ovarian cancer

Mutation of the BRCA1 gene in well-defined breast cancer families has been associated with an 87% lifetime risk for breast cancer and a 44% risk for ovarian cancer. Recent data indicate that the risk associated with these mutations is considerably lower, although still far greater than the risk for disease in the rest of the population. Approximately 81% of the mutations that have been identified have been frameshift (71%) or nonsense (10%) mutations, and either may result in a truncated protein. The protein truncation test (PTT) is often used to screen patients at high risk, because sequencing of this large (100 kb) gene with its 22 coding exons is an arduous task. The PTT was used to analyze genomic DNA and RNA from the peripheral blood of a 31-year-old Filipino woman with a poorly differentiated, stage 2A breast carcinoma and a family history of breast-ovarian cancer. PTT identified the wild-type protein fragment and an additional truncated protein fragment in the patient's sample. Subsequent direct sequencing of the appropriate coding region revealed a point mutation in exon 11 at nucleotide 2178, resulting in a C > T transition that caused a termination (stop codon) in amino acid 687. To our knowledge, this is the first report of mutation of the BRCA1 gene in a Filipino family, and this in-frame stop-codon mutation has not been reported previously.

Multidisciplinary breast cancer clinics. Do they work?

BACKGROUND

In an attempt to improve the care they provide for their patients with breast cancer, the authors' institution developed a multidisciplinary breast cancer clinic (MDBCC) to offer "one-stop shopping" consultation and support for newly diagnosed breast cancer patients.

METHODS

One hundred sixty-two patients, the control group for this study, were evaluated at Henry Ford Hospital during the year prior to the opening of the MDBCC. These patients, who were referred in the traditional sequential consultation manner, were compared with the first 177 patients seen during the first year of the clinic's operation. Retrospective chart reviews were conducted to assess treatment timeliness, and anonymous questionnaires were used to assess patient satisfaction.

RESULTS

The authors found that the MDBCC increased patient satisfaction by encouraging involvement of patients' families and friends and by helping patients make treatment decisions (P < 0.001). The time between diagnosis and the initiation of treatment was also significantly decreased (42.2 days vs. 29.6 days; P < 0.0008).

CONCLUSIONS

Although planning and operating a multidisciplinary clinic is not a new venture, to the best of the authors' knowledge, they have provided the first report demonstrating the benefits described above.

Sentinel lymph node metastasis in experimental melanoma: relationships among primary tumor size, lymphatic vessel diameter and 99mTc-labeled human serum albumin clearance

BACKGROUND

This study was designed to investigate the relationships among primary tumor size, lymphatic vessel diameters, the incidence of sentinel lymph node (SLN) metastasis and lymphatic clearance from murine footpad melanomas.

METHODS

Lymphatic clearance (LC) of [99mTc]HSA from the middle of the footpad of syngeneic C57BL/6 mice, with or without primary melanomas (sizes varying from 1 to 5 mm in anteroposterior diameter), was quantitated using a gamma scintillation detection system. Lymphatic vessel diameters (LD) were measured after injection of aniline blue dye into footpad tumors. The incidence of SLN, femoral lymph node (FLN), and lung metastases was recorded.

RESULTS

Metastasis to SLNs increased as tumor growth progressed (r = 0.976, p = 0.001), and there was a correlation between tumor size and both FLN (p = 0.041) and lung (p = 0.055) metastases. There was also a correlation between lymph node metastasis and LC (r = 0.83, p = 0.04) and LD (r = 0.84, p = 0.04).

CONCLUSIONS

These studies support the hypothesis that lymph flow and LD is increased in experimental murine melanomas and this relates to both primary tumor size and to lymphatic and hematogenous metastasis.

Sentinel lymph node uptake of two different technetium-labeled radiocolloids,

BACKGROUND

The study was designed to compare the uptake of technetium-99m-labeled human serum albumin ([99mTc]HSA) and 99mtechnetium-labeled sulfur colloid ([99mTc]SC) in the sentinel lymph nodes (SLNs).

METHODS

Radiocolloid levels in the SLN, femoral lymph node (FLN), ischial lymph node (ILN), spleen (SP), and right rear footpad (RRF) were quantitated over a period of 240 min after injection of [99mTc]SC or [99mTc]HSA into the rear footpad of C57 BL/6 mice.

RESULTS

There was a significantly greater (p < 0.001) radioactive count in SLNs after [99mTc]SC (mean cpm 211,084.8) compared to [99mTc]HSA (mean cpm 115,640.8). In contrast, the counts in the FLNs were higher after [99mTc]HSA (mean cpm 11,333.4) than after [99mTc]SC injection (mean cpm 5,065.5). The percent uptake in the SP was higher after [99mTc]HSA than after [99mTc]SC injection.

CONCLUSIONS

[99mTc]SC is rapidly and efficiently taken up by lymphatics at the primary injection site, is significantly retained in the SLN, and flows slowly to the next echelon node (FLN or ILN) and to the systemic circulation (SP). [99mTc]HSA tends to accumulate less efficiently in the SLN and to disperse more rapidly to the next echelon nodes and to the systemic circulation. By extrapolation, [99mTc]SC is likely to be a better radiocolloid for the intraoperative detection of SLNs.

Lymphatic diameters and radionuclide clearance in a murine melanoma model

OBJECTIVES

To determine the clearance of a radionuclide from various sizes of footpad melanomas via lymphatics and to measure the diameters of these vessels.

DESIGN

Nonrandomized animal study.

SETTING

A hospital research laboratory.

SUBJECTS

C57BL/6 mice.

INTERVENTIONS

Female mice were injected in the right rear footpad with B16 F10 cells that were allowed to grow to either 1, 2, 3, 4, or 5 mm in anteroposterior diameter. Clearance from feet with or without tumors of injected technetium Tc 99m human serum albumin (99mTcHSA) was assessed for 200 minutes. Calf lymphatic diameters were measured using aniline blue dye.

RESULTS

The clearance of the injected 99mTcHSA from mouse footpads without tumors was 1.26 +/- 0.18 x 10(-4) mL/min x cm3 of tissue. Clearance increased 2.24-fold to 2.82 +/- 0.12 x 10(-4) mL/min x cm3 of tissue from 1-mm tumors and to 6.20 +/- 0.08, 6.11 +/- 0.13, 6.91 +/- 0.58, and 7.23 +/- 0.48 x 10(-4) mL/min x cm3 of tissue from 2-, 3-, 4-, and 5-mm tumors, respectively (P < .05). Calf lymphatic diameters increased from 75.41 +/- 9.72 microns in naive nontumor-bearing mice to 93.51 +/- 7.12, 111.61 +/- 27.07, 126.69 +/- 25.20, 124.43 +/- 24.75, and 127.44 +/- 25.35 microns in mice bearing 1-, 2-, 3-, 4-, and 5-mm tumors, respectively (P < .01).

CONCLUSIONS

There was a size-dependent, direct correlation between increasing tumor size in the footpad and increasing diameter of lymphatics draining the footpad. Clearance of injected 99mTcHSA from these tumors also exhibited a similar positive correlation with tumor size.

Rates of flow of technetium 99m--labeled human serum albumin from peripheral injection sites to sentinel lymph nodes

BACKGROUND

The new technique of sentinel lymphadenectomy for cutaneous melanoma provided us with a unique opportunity to quantitate the rates of lymphatic flow in afferent lymphatics.

METHODS

Seventeen melanoma patients underwent preoperative lymphoscintigraphy with technetium 99m-human serum albumin (HSA). The time and distance between the injection site and the sentinel lymph node (LN) were recorded. By comparison, lymphatic flow rates between footpad, popliteal LN, femoral LN, and systemic blood were measured in 60 female mice (C57BL/6) after footpad injection of 99mTc-HSA.

RESULTS

The rate of lymphatic flow to 14 axillary, four inguinal, one popliteal, and one parotid sentinel LNs averaged 10.4 +/- 7.3 cm/min. In contrast, the lymphatic flow rate between the footpad and the popliteal LN in mice (analogous to the sentinel LN in human beings) averaged 1.33 +/- 0.52 cm/min. There was a marked delay in the passage of radionuclide through the popliteal LN with consequent slowing of the rate of flow between the popliteal and femoral LNs to 0.22 cm/min.

CONCLUSION

Lymphatic flow to the sentinel LN occurs rapidly from both human skin and murine footpads. This information might be helpful in planning the timing of the incision after vital blue dye injection for identifying the sentinel LN.

Lack of correlation between flow cytometric and immunohistologic proliferation measurements of tumors

We compared different means of assaying tumor proliferative activity by either flow cytometric or immunohistologic methods in formalin-fixed, paraffin-embedded blocks. A series of 84 Dukes' stage B colorectal carcinomas were examined to identify high-risk patients who may potentially benefit from adjuvant therapy. Flow cytometric analysis was performed by a modified Hedley method with a combined S+G2/M phase proliferative fraction calculated by means of a rectangular model after debris subtraction. Immunohistologic tumor proliferative activity was analyzed by means of serial step sections from the same blocks used for flow cytometric examination with antibodies to proliferating cell nuclear antigen (PCNA) and Ki-67 (MIB-1). Mean with standard deviation and (range) tumor proliferative activity measurements were: flow cytometric analysis: proliferative fraction = 14.8% +/- 5.3 (5-27%), PCNA = 43.2% +/- 21.2 (4-90%), and MIB-1 = 16.2% +/- 10.8 (2-47%). No correlation was found between flow cytometric proliferative fraction and immunohistologic tumor proliferation measurement or between PCNA and MIB-1 staining indices. Lack of correlation between flow cytometric and immunohistologic findings may be related to the use of archival formalin-fixed paraffin-embedded tissue for flow cytometric evaluation, with resultant increased debris and decreased accuracy of cell cycle calculations. Discordance between PCNA and MIB-1 may reflect inherent problems with anti-PCNA antibody staining of formalin-fixed tissues whereby anti-PCNA clone PC-10 detects non-replicon associated PCNA in formalin-fixed tissues. Prospective studies using fresh tissue with two-color multiparameter flow cytometric analysis and histogram-dependent background fitting may help to clarify the relationship between findings of tumor proliferation as analyzed by flow cytometric and by immunohistologic techniques.

Hematomas following excisional breast biopsies for invasive breast carcinoma: the influence of deep suture approximation of breast parenchyma

The controversy over whether breast parenchyma should be approximated by suture after excisional biopsy is largely unresolved. The major debate is whether suture closure will decrease the incidence of hematomas and perhaps adversely alter the contour of the breast. To focus on the first question, we analyzed 162 patients undergoing mastectomy for breast cancer at Henry Ford Hospital between July 1988 and August 1992. All patients had previous excisional biopsies of breast lumps for diagnostic purposes. The cases were divided into two major groups depending on the placement or lack thereof of deep sutures in breast parenchyma. Of the total number of patients, 105 had deep suture approximation of breast parenchyma, whereas 57 did not. The biopsies were performed by 17 surgeons, although 72 per cent were done by four surgeons. Most of the surgeons varied their technique sporadically, but the number of cases most handled individually were too small for statistical analysis. Macroscopic and microscopic evaluation of the mastectomy specimen by the pathologist was used for definitive diagnosis of hematoma. The majority of these hematomas were of no clinical consequence and were usually not noted by the clinician. None of the hematomas required surgical drainage. Hematomas were determined pathologically in 64/162 patients (39.5%). Hematomas developed in 33/105 patients (31.4%) with deep wound approximation of breast parenchyma by suture compared to the higher rate seen in 31/57 patients (54.4%) without deep wound approximation (P = 0.004). This study supports the use of deep suture approximation after excisional biopsy for breast cancer.

Interstitial fluid pressure in breast cancer, benign breast conditions, and breast parenchyma

BACKGROUND

Interstitial fluid pressure (IFP) in rodent malignant tumors is reportedly much higher than in surrounding normal tissue. We hypothesized the same may be true in human invasive breast tumors.

METHODS

We measured IFP in the operating room in 25 patients undergoing excision breast biopsy under local anesthetic for diagnostic purposes.

RESULTS

In patients with invasive ductal carcinomas IFP was 29 +/- 3 (SE) mm Hg, compared with -0.3 +/- 0.1 mm Hg in those with normal breast parenchyma (p < 0.001), 3.6 +/- 0.8 mm Hg in those with benign tumors (p < 0.003), -0.3 +/- 0.2 mm Hg in those with noninvasive carcinomas (p = 0.034), and 0.4 +/- 0.4 mm Hg in those with other benign breast conditions (p = 0.002). There was a direct correlation between IFP and tumor size (R2 = 0.3977; p = 0.021). No correlation was found between IFP and nuclear grade, angiolymphatic invasion, systemic blood pressure, metastasis to lymph nodes, or estrogen and progesterone receptors.

CONCLUSIONS

IFP measurements may facilitate radiographic or ultrasound localization of small or nonpalpable malignant tumors in those patients undergoing needle aspiration cytology or stereotactic core needle biopsy.

Relationship among p53, stage, and prognosis of large bowel cancer

PURPOSE

We designed a study to determine whether increases in p53 protein in primary carcinomas of the colon or rectum correlate with overall survival. Mutations of the tumor suppressor gene p53 are detectable by immunocytochemical methods in colorectal cancers because of accumulation of nuclear p53 protein.

METHODS

IgG1 monoclonal antibody to human p53 protein (PAb 1801) was used to detect p53 in formalin-fixed, paraffin-embedded archival tumors resected from 84 patients with tumor limited to the bowel wall. A multivariate analysis was performed using five prognostic pathobiologic variables compared with the level of staining of the p53 product.

RESULTS

Nuclear p53 protein was observed in 52 (62 percent) of 84 colorectal cancer patients with Stage T2 or T3, N0, M0 disease. Patients with strong expression (3+ and 4+) of p53 appeared to die from their disease sooner than those with weak expression (1+ and 2+), although this was not statistically significant (P > 0.59). Thirty-two patients did not express nuclear p53 by immunocytochemical methods. When these patients were analyzed in combination with the strong p53 expressors, the trend toward decreased survival increased (P > 0.15).

CONCLUSIONS

This data suggest that lack of p53 expression may also predict an adverse outcome in colorectal cancer. However, before the immunocytochemical method can be used clinically as a prognostic indicator, the colorectal cancer patients with zero expression should be studied further to clarify the functional status of p53 in their tumors.

Is there a role for clinical prognostic factors in staging patients with colorectal cancer?

The clinician treating colorectal cancer (CRC) should be able to predict which patients will live and which will die from their tumor. Many prognostic variables, significant in retrospective analyses, are never formally used in staging. The resultant imperfection of clinical predictions of survival are probably directly related to the relative inaccuracy of the staging system, a system inevitably dependent entirely on pathologic criteria. Potentially valuable clinical variables, sometimes associated with better or worse outcome despite the pathologic stage of disease, could improve the accuracy of prediction. Evolution to better clinico-pathologic staging systems would also help to better stratify patients in prospective randomized trials of new adjuvant therapeutic modalities.

Irrigation does not dislodge or destroy tumor cells adherent to the tumor bed

Local recurrences in the surgical bed after tumor resection may be due to residual tumor cells "dropping" into the wound. Irrigation with water is often used to remove these cells. We designed experiments to determine whether irrigation would prevent tumor recurrence. Surgical wounds of uniform size in C57BL/6 mice were seeded with 5 x 10(2), 5 x 10(3), 5 x 10(4), 5 x 10(5), or 5 x 10(6) viable syngeneic B16-F10 melanoma cells to test the hypothesis that irrigation with water would decrease local tumor recurrence. The tumor-contaminated wounds were irrigated with distilled water or with saline (0.9% NaCl) immediately or 5, 30, 60, 120, or 240 min after seeding. Control wounds were seeded but not irrigated. The technique of irrigation was altered in a second group of experiments such that the amount of time the tumor cells were exposed to the water or saline was 5, 10, or 15 min. To determine the rapidity and durability of tumor cell attachment to host tissue, 1 x 10(4) viable B16-F10 tumor cells were seeded in vitro onto freshly cut disks of syngeneic mouse dermis. The tissue was irrigated with saline or distilled water 0, 2, 5, 10, 15, 30, 60, 120, or 240 min later. Tumor growth was observed in all the mice and neither the mechanical action of irrigation nor the hypotonic effect of distilled water changed the rate of growth. Scanning electron microscopy (SEM) demonstrated stable and firm attachment to mouse tissue within seconds of seeding with no noticeable dislodgement or cytotoxicity by either saline or water irrigation. The data suggest that the commonly used technique of irrigating the bed of the resected tumor may not be of value in preventing local recurrences.

A spontaneous subcutaneous tumor in C57BL/6 mice that metastasizes to the liver

A malignant tumor that arose spontaneously in the subcutaneous tissue of the back of a C57BL/6 female mouse was found to metastasize spontaneously to the liver. The primary and metastatic tumors, SML (spontaneous metastasis to the liver) 1 and SML 2, were established in vitro in long-term cell suspension culture and were passaged 10 times in vivo for 18 months. When 100,000 cells were injected subcutaneously in the orthotopic position, tumor growth appeared in 60% of the SML 1 mice and 100% of the SML 2 mice. SML 1 did not grow when injected in the footpad, while SML 2 did. The median survival was 47 days for SML 1 and 48.5 days for SML 2 (P = 0.013). The pattern of metastasis was similar for both tumor cell lines, irrespective of intravenous or subcutaneous injection routes. Spontaneous metastasis of the SML 2 line occurred from both the orthotopic and heterotopic sites, while the SML 1 metastasized spontaneously from the orthotopic site only. Liver metastasis appeared in > 90% of the mice for both SML 1 and SML 2. Metastasis to the spleen occurred in about half the mice. Other sites of metastasis were the ovaries (36% and 52%, respectively, for SML 1 and SML 2), the kidneys (approximately 15%) and the small bowel (very rarely). Metastasis to the lungs did not occur except very rarely in the later passages of the SML 2 line. Histologic, immunohistochemical and electron microscopic studies showed a histiocytic tumor with macrophage characteristics. The cells exhibited chemotaxis toward liver extracellular matrix and reduced motility toward collagen IV, laminin and fibronectin compared to the B16-F10 melanoma line. This spontaneously occurring tumor should prove useful for the study of organ-specific metastasis to the liver.

Lymph flow from murine footpad tumors before and after sublethal hyperthermia

The effect of local hyperthermia (43.5 degrees C for 1 h) on lymph flow from B16-F10 tumor-bearing foot pads of C57BL/6 mice was measured by monitoring the clearance of 99mTc-labeled human serum albumin. The foot was represented by a single-compartment model enabling a quantitative computation of lymphatic flow from the tumor to regional lymph nodes. Lymphatic flow from untreated tumors was 0.0059 +/- 0.0011 ml/min cm3 compared to 0.0118 +/- 0.0027 ml/min cm3 lymphatic flow from tumors immediately following heating. Morphological alterations in tumor blood vessels result in their high vascular permeability. The increase in lymphatic clearance from tumors after sublethal hyperthermia is compatible with the increase in interstitial fluid formation in tumors based on Starling's Law.

Metachronous second primary malignant fibrous histiocytoma in two skeletal muscles

The first recorded case of a metachronous second primary malignant fibrous histiocytoma (MFH) of soft tissue is presented. The patient, who has been followed every two months since the treatment of his buttock sarcoma by neoadjuvant therapy, is free of disease 24 months later. The clinical presentations, different histologies, and DNA contents of these two MFHs are consistent with metachronous primary sarcomas. The literature on second primary neoplasms is discussed.

Use of polypropylene mesh to stabilize the "floating humerus" after total scapulectomy

Total scapulectomy for malignant disease is a rarely performed procedure that presents a significant challenge for shoulder reconstruction. Failure to stabilize the resulting "floating humerus" may result in significant esthetic and functional problems. Current techniques of reconstruction and stabilization may yield suboptimal results and significant morbidity. We report a case of Ewing's sarcoma of the scapula, which required total scapulectomy. Polypropylene mesh was used in an attempt to prevent migration of the head of the humerus. The result was a stable shoulder with satisfactory motion and no additional morbidity. We believe that polypropylene mesh offers an advantage in shoulder reconstruction after total scapulectomy and should be considered as an option for stabilization of the humerus.

Development of lymph node and pulmonary metastases after local irradiation and hyperthermia of footpad melanomas

C57BL/6 mice with syngeneic B16-F10 melanomas were treated 7 days after tumor inoculation into the footpad with local hyperthermia (HT) of 43.5 degrees C for 90 min. A combination of local 30 Gy X-irradiation (XRT) given 2, 4 or 12 h after HT cured the primary tumor in 34/35 mice, with irreversible damage to normal foot tissues in most of the animals. When 7.5, 10 or 15 Gy XRT were delivered 4, 18 or 24 h after HT, there were only a small number of cures and also a much smaller incidence of irreversible normal tissue damage. HT alone resulted in a significant (P less than 0.001) increase in metastases to regional lymph nodes (RLN) and the lungs. The 'curative' doses of combined XRT and HT resulted in a significant (P less than 0.001) decrease in metastasis to RLN and to the lungs. Conversely, subcurative doses of combined therapy resulted in an increase in RLN and lung metastasis (P less than 0.001). Abdominal lymph node metastasis, not usually seen in control mice, is markedly increased after HT alone or in combination with subcurative XRT (P less than 0.001). The overall survival of mice treated with HT alone is decreased (P less than 0.0028). The survival of mice treated with HT followed 4, 18 or 24 h later with 10 Gy XRT is further decreased (P less than 0.0025). These data show that subcurative HT, or XRT plus HT, increases the incidence of spontaneous metastasis in this syngeneic mouse melanoma model. Curative doses prevent this effect on metastasis, but there is an unacceptable incidence of irreversible damage to the tumor-bearing foot. The cause(s) of this phenomenon are not known.

Chemotactic activity present in liver extracellular matrix

A selective pattern of metastasis, not accountable by a simple mechanical trapping mechanism, is exhibited by many primary tumors and appears to be controlled by properties of both the tumor cell and the host organ. This organotropism may be regulated, in part, by the migration of an invading tumor cell toward chemotactic factors present in the extracellular matrix which may be released as a result of proteolytic digestion. To test this hypothesis we have examined 4 M guanidine extracts of liver extracellular matrix, prepared by high salt extraction, for organ-specific chemotactic activity. The murine cell lines B16-L4b and M5076, which preferentially metastasize to the liver in an experimental metastasis model, demonstrated preferential motility toward the liver matrix extract while the lung-colonizing lines B16, B16-F10 and B16-BL6 did not. The liver specific chemotactic activity eluted as four fractions of Mr much less than 250,000, Mr approximately 245,000, Mr approximately 120,000 and Mr approximately 30,000 by gel filtration chromatography.

Changes associated with metastasis in B16-F1 melanoma cells surviving heat

Metastasis to distant sites is mediated by various receptors on the surface of tumor cells. B16-F1 melanomas surviving 43.5 degrees C heat in vitro for 15 minutes and cultured for 10 days bind significantly increased amounts of the basement membrane protein laminin. Motility of heat-resistant B16-F1 cells in vitro toward the chemoattractant laminin is significantly increased. The increased expression of putative laminin receptors may be associated with increased metastasis of melanomas after subcurative hyperthermia.

Primary malignant giant cell tumor of bone: "dedifferentiated" giant cell tumor

Well documented examples of primary malignant giant cell tumor of bone (giant cell tumor and concurrent sarcoma arising de novo) are exceedingly rare in the literature. We report a case arising in the left ischium of a 44-yr-old man. He had no previous history of radiation therapy or multiple resections. Histologically, the tumor was a typical giant cell tumor of bone juxtaposed to a malignant fibrous histiocytoma (MFH). The juxtaposition of a high grade sarcoma (MFH) and a locally aggressive nonmalignant neoplasm such as giant cell tumor is analogous to several other tumors of bone and soft tissue in which a low grade malignant or locally aggressive tumor can be associated with MFH or fibrosarcoma de novo, namely chondrosarcoma, chordoma, liposarcoma, and well differentiated intraosseous and parosteal osteosarcoma. The presence of a high grade malignant component in each of the aforementioned neoplasms generally portends a more ominous prognosis, although this is not invariably true. Recognition of the phenomenon of "dedifferentiation" (or tumor progression) in some bone tumors and sarcomas is important to ensure appropriate treatment. Distinction from secondary malignant giant cell tumors which are usually radiation induced is also important, since the latter have a much worse prognosis than those with dedifferentiation occurring de novo.

Relationship of spontaneous regional lymph node metastases to dose of local irradiation of primary B16 melanomas

We evaluated the effects of local X-irradiation on microscopic or small macroscopic primary melanomas in the feet of C57BL/6 mice and the subsequent development of spontaneous femoral lymph node (LN) metastases. Doses of 30, 40, 55, 62.5, or 72.5 Gy often cured the foot tumor and metastases to regional femoral lymph nodes were relatively uncommon. Doses of 3.75, 7.5, 10, 15, and 20 Gy were associated with a dose-dependent regrowth delay of the foot tumor treated at microscopic size. Foot melanomas that were not cured spread to regional femoral LNs more frequently (P less than 0.001). The relative risk of developing femoral LN metastasis increased 2.55 times for each 1-mm increase in the anteroposterior diameter of the primary foot tumor in mice with 20 days of primary tumor exposure and increased 4.87 times for each 1-mm increase in mice with 100 days of primary tumor exposure. Although tumors treated with subcurative doses of irradiation had a longer period of time to metastasize to regional LNs for each 1-mm increase in primary tumor size, this variable alone did not account for the increased incidence of metastasis seen with irradiation.

Lung metastases after curative or noncurative irradiation of microscopic primary melanomas

Melanomas growing in the feet of syngeneic C57BL/6 mice were treated with a single dose of X-irradiation. After doses of 0, 3.75, 7.5, 10, 20, or 30 Gy the tumor-bearing limb was amputated at tumor sizes 1, 2, 3, 4, or 5 mm. After doses of 40, 50, 62.5, or 72.5 Gy, progressive tumor growth did not occur, and amputation of tumor-bearing limbs was done when controls were 1, 2, 3, 4, or 5 mm in size. Eighteen days after amputation the mice were killed, and pulmonary metastases were documented at autopsy. None of the mice developed pulmonary metastases after curative irradiation of the primary foot tumor. After subcurative irradiation there was a significant increase (P less than .003) in pulmonary metastases. The size of the primary melanoma is important in the prediction of these metastases. In this model melanomas can be cured by an adequate dose of irradiation, but in those not cured the incidence of lung metastases is increased. The impact of this biologic phenomenon on survival is unclear.

Organ-specific chemotactic factors present in lung extracellular matrix

The preferential colonization of a distant organ by a circulating tumor cell (organ specific metastasis) may be regulated by chemotactic factors present within the extracellular matrix of the host organ. Organ-specific extracellular matrix was prepared from murine kidney and lung by high salt extraction and DNAase/RNAase digestion. A soluble protein fraction (S2) from each of the matricies was obtained by 4 M guanidine extraction and was tested for organ-specific chemotactic activity in a modified Boyden chamber. The lung colonizing B16-F10 and B16-BL6 tumor cell lines demonstrated organ-specific motility only toward the lung extract. The low metastasizing B16 parental line and liver colonizing B16-L4b line showed no preference for either lung or kidney. The lung activity resolves into five fractions by gel filtration chromatography, with the highest activity eluting at Mr approximately 71,000. Chemotactic factors present in lung extracellular matrix may regulate the preferential colonization of an organ by stimulating the migration of tumor cells in a specific manner. These factors may be released during the degradation of the extracellular matrix.

An anatomic approach to tumors of the psoas major muscle

The technique of excision of the entire psoas major muscle via the retroperitoneal route is described. This approach prevents direct seeding of the peritoneal cavity with tumor cells and provides relatively easy access to the entire psoas major muscle and its blood supply. The anatomic characteristics of the retroperitoneal space preclude wide surgical margins in whatever approach is used, and in this regard the retroperitoneal approach is probably no more difficult than the transperitoneal approach. The relative ease with which a primary tumor in the psoas major muscle can be excised makes the retroperitoneal approach desirable from the surgeon's point of view.

Regional lymph node and pulmonary metastases after local hyperthermia of melanomas in C57BL/6 mice

The effects of local tumor hyperthermia on regional lymph node metastases are inconclusive. We studied the effects of hyperthermia on the incidence of popliteal, femoral, and abdominal lymph node metastases in C57BL/6 mice with primary B16 melanomas (F10 variant) growing subcutaneously in the left foot. Tumors were heated to 42.3, 43.5, and 44.2 degrees C for 90 minutes either 7 days after inoculation of 5 X 10(4) viable cells (microscopic tumor = mic) or when the tumors were approximately 3 mm in diameter (macroscopic tumor = mac). Femoral lymph node metastases occurred in 0/21 control animals and in 8/22 (36%), 11/19 (58%), and 11/17 (65%) animals whose primary tumors were heated to 42.3, 43.5, and 44.2 degrees C, respectively. For all three treatments, the increase in metastases as compared to controls was statistically significant (p less than 0.004, Fisher's exact test). The incidence of abdominal lymph node metastasis was slightly higher in the treated groups than controls. Twenty of 21 (95%) control mice developed popliteal lymph node metastases and hyperthermia-induced increases could not be demonstrated. Fifteen of 21 control mice killed 3 weeks after amputation of tumor-containing leg had pulmonary metastases with an average of 6 +/- 4 (standard deviation) lesions per affected mouse. Pulmonary metastases occurred in 22/22 (100%), 17/19 (89%), and 13/17 (76%) of mice whose tumors were heated to 42.3, 43.5, and 44.2 degrees C, respectively. The numbers of metastases for affected mice were significantly increased compared to controls for tumors heated to 43.5 and 44.2 degrees C (28 +/- 43, 43 +/- 52, 119 +/- 121, p greater than 0.02, p less than 0.006, p less than 0.002, for two sample T-test). While 0/8 mic tumors were cured 5/9 mac tumors heated to 44.2 degrees C disappeared (p less than 0.03, Fisher's exact test) and there was a growth delay in the remaining mice. Mic tumors, heated to 43.5 degrees C, had an accelerated onset of growth while mac tumors heated to this temperature had a slight growth delay. Growth of both mic and mac primary tumors heated to 42.3 degrees C was similar to controls. These results show that therapeutic and subtherapeutic local hyperthermia increases metastases to regional lymph nodes and to lungs even when primary tumor growth rate is partially or totally controlled.

Spontaneous regional lymph node metastases of three variants of the B16 melanoma: relationship to primary tumor size and pulmonary metastases

We studied the patterns of spontaneous regional lymph node metastases of three variants (F1, F10, and BL6) of the B16 melanoma in C57BL/6 mice and related the incidence to primary tumor size and pulmonary metastases. The incidence of regional lymph node and pulmonary metastases correlated with increasing primary tumor size (p less than or equal to 0.0001). The incidence of pulmonary metastases in mice whose regional lymph nodes did not contain tumor also correlated with increasing primary tumor size (p less than or equal to 0.0001). This propensity for direct hematogenous spread was more apparent in BL6 tumors than in F1 and F10 tumors (p less than or equal to 0.0001). BL6 tumors also metastasized to regional nodes at smaller primary tumor sizes (p less than or equal to 0.04). Heterogeneous variants that metastasize earlier to regional lymphatic and hematogenous sites dictates the natural history of the primary tumor. Whether prophylactic lymphadenectomy for melanomas is therapeutic may depend on dissemination-related phenotypic characteristics.

Carcinomas of the colon and rectum. A comparison of staging classifications

Five staging methods for colorectal cancer were compared to the Dukes method in order to assess which methods were most sensitive and specific. Three hundred fifty-two patients with resected carcinomas of the colon and rectum were followed from 6 to 11 years or until death. All patients were staged by intraoperative and pathological criteria. Survival curves were constructed for each stage. The pTNM system was most sensitive at predicting death. The Gastrointestinal Tumor Study Group (GITSG) system was the most specific at predicting survival. However, the Dukes system did no worse than either of these staging systems and predicted relatively few false-positive and false-negative cases. The sensitivity and correctness of the Dukes system was improved by adding information regarding percent of lymph node metastases, ulceration of the primary tumor, and adjacent organ invasion.

Kinetics of the MLR response following single donor-specific allogeneic blood transfusions

Prior blood transfusion (BT) confers a significant improvement in transplant survival in recipients (1). However, increased survival across major histocompatibility barriers generally requires the administration of immunosuppressive agents (2-5). The mechanisms by which BT prolongs graft survival have not been fully elucidated. Experimental evidence suggests that suppressor cells (6,7), soluble suppressor factors (8), and blocking antibodies (9) may play a role.

Perioperative allogeneic blood transfusions. Survival in patients with resected carcinomas of the colon and rectum

Blood transfusion (BT) is reported to cause immunosuppression. We postulated that BT might therefore adversely affect the prognosis of carcinomas of the colon and rectum. We analyzed the overall and recurrence-free survival of 366 patients whose colorectal carcinomas were resected. The 199 patients who received perioperative BTs appeared to survive less well than the 167 patients who received no blood products. However, Cox analysis, which adjusts for other prognostic variables, shows that the difference was not statistically significant. Although 43% of transfused patients survived, as compared with 56.5% of nontransfused patients, this difference was due to variables other than transfusion. This study did not support the hypothesis that BT has an adverse effect on survival of patients with colorectal cancer.

Prophylactic lymphadenectomy for B16 melanoma in C57/BL6 mice: survival based on size and heterogeneous variant of the primary

Survival following prophylactic lymphadenectomy by hip disarticulation in mice with three B16 melanoma variants was studied. C57/BL6 mice inoculated with viable tumor cells (F1, F10, and BL6) into the left hind foot pad were randomized to wide excision (WE) of the primary tumor alone or wide excision plus prophylactic lymphadenectomy (WE plus PL) at 1-, 2-, 3-, 4-, and 5-mm primary tumor sizes (each group, N = 6). Overall survival time was improved by WE plus PL. A significant survival advantage and cure was apparent for the F1 and F10 variants with primary tumor sizes of 2 and 3 mm (F1, 2 and 3 mm, P less than 0.001; F10, 2 mm, P less than 0.006; 3 mm, P less than 0.001), but not for the BL6 variant. Prophylactic lymphadenectomy provides a therapeutic advantage in mouse melanomas of intermediate size in two of the three variants of B16.

Factors prognostic for survival in patients with malignant melanoma spread to the regional lymph nodes

To establish clinical and histologic determinants of survival, records of all UCLA patients with resectable melanoma metastatic to the lymph nodes during the years 1954-1976 were reviewed. These 150 patients were treated first with wide excision, lymphadenectomy, and with radiation/chemotherapy and/or additional surgery only if further recurrences developed. None received adjuvant immunotherapy or chemotherapy. In 97 of 139 patients with identified primary tumors, slides of the primary lesion were reviewed. Putative prognostic factors included age, sex, parity, site of primary tumor, presence of satellitosis, clinical status of nodes, histologic characteristics of primary lesion (Clark's level, thickness of tumor, presence/width of ulceration, and number of mitoses/HPF), time from biopsy of primary tumor to lymphadenectomy, and number of positive nodes. kaplan-Meier estimates of survival for the entire group at one, two, five, and ten years were 73, 55, 37, and 33%, respectively. Median follow-up period of survivors was four years. Univariate analyses using the log-rank test showed that thickness of the primary lesion (p less than 0.001), width of ulceration (p = 0.003), absence of ulceration (p = 0.024), and number of positive nodes (p = 0,.033) were prognostic for survival. In multivariate analysis by the Cox procedure, thickness of the primary (p = 0.001) and number of melanoma-containing nodes (p = 0.043) were prognostic for survival. Location of the primary tumor became marginally significant (p = 0.12) in the multrivariate model. These findings demonstrate the prognostic importance of characteristics of both the primary lesion and extent of regional dissemination. Future prospective randomized trials for (adjuvant) therapy of Stage II melanoma should be stratified by these variables.

Acute effects of orally administered levamisole on random monocyte motility and chemotaxis in man

Cellular immune functions were studied in patients with early bladder cancer 2 hours after ingestion of either levamisole or a placebo. Random monocyte motility was significantly increased (P less than 0.025) in 13 of 17 patients receiving levamisole. Monocyte chemotaxis was significantly increased (P less than 0.025) in 16 of the 17 patients. Random monocyte motility and monocyte chemotaxis did not change in either 8 patients on the placebo or in 15 normal controls. Monocytes from normal donors showed increased random motility and chemotaxis after incubation with levamisole in vitro. These results indicated that increases in peripheral blood monocyte motility followed oral administration of levamisole. Kinetic studies indicated that these effects were rapid in onset and short lived.

Two-step separation of human peripheral blood monocytes on discontinuous density gradients of colloidal silica-polyvinylpyrrolidinone

Normal human peripheral blood monocytes were purified by a two-step separation. The first step, the standard Ficoll--Hypaque (F--H) buoyant density centrifugation, yielded mainly mononuclear cells, of which 24 +/- 9% were monocytes. Isopycnic centrifugation on discontinuous gradients of colloidal silica polyvinylpyrrolidinone (CS-PVP) further separated these mononuclear cells. The density interface between 1.070 and 1.060 g/ml yielded 82 +/- 7% monocytes, 5 +/- 4% granulocytes and 13 +/- 8% lymphocytes. Sixty-six percent of the monocytes obtained after F--H separation were recovered in this layer. The monocytes were intact and viable and retained their ability to phagocytose and kill Candida pseudotropicalis and to spread on glass coverslips. Motility (both random and towards a chemoattractant) was retained but was quantitatively less than after F--H separation alone. The relative purity of the monocyte population allowed assessment of major histocompatibility surface antigens by serotyping. This confirmed the presence of HLA and Ia-like antigens on monocytes.