Response of intraductal carcinoma of the prostate to androgen deprivation therapy predicts prostate cancer prognosis in radical prostatectomy patients

BACKGROUND

Intraductal carcinoma of the prostate (IDC-P) has a poor prognosis and is thought to be completely resistant to current therapies, including androgen deprivation therapy (ADT). However, to date, there are no data showing direct evidence of such resistance.

METHODS

We retrospectively evaluated 145 patients with high-risk prostate cancer who underwent radical prostatectomy (RP) with neoadjuvant ADT between 1991 and 2005. All patient data were collected from slides prepared from needle biopsy (NB) samples of prostate tissue and RP specimens. Data were analyzed in terms of serum level of prostate specific antigen (PSA), Gleason score of NB samples, clinical T stage, the positive cancer core rate, maximum cancer extension rate, presence of Gleason pattern 5, and presence of IDC-P in both NB samples and RP specimens.

RESULTS

The median initial PSA was 33.2 ng/mL (range, 2.4-296 ng/mL), and the median follow-up period was 109 months (range, 11-257 months). The preoperative median ADT period was 4 months (range, 1-20 months). IDC-P was present in 53 patients (37%) in NB samples and 65 (45%) in RP. The patients were divided into three groups based on the presence or absence of IDC-P in NB/RP samples (IDC-P-negative at biopsy: 92 cases, IDC-P-positive at biopsy with IDC-P disappearance: 15 cases, and IDC-P-positive at biopsy with IDC-P persistence: 38 cases). Overall, 28% of IDC-P-positive cases in NB samples showed the disappearance of IDC-P at RP. IDC-P persistence cases showed the poorest prognosis, while IDC-P disappearance cases had a similar prognosis to that of IDC-P-negative at biopsy cases in terms of disease-free survival, cancer-specific survival, and overall survival (P = .0018, P = .0087, and P = .0034, respectively).

CONCLUSIONS

Some cases with IDC-P responded to ADT and demonstrated favorable clinical outcomes similar to those of cases without IDC-P. These findings indicate that cases with IDC-P are heterogeneous.

The influence of the presence of intraductal carcinoma of the prostate on the grade group system's prognostic performance

BACKGROUND

Although the presence of intraductal carcinoma of the prostate (IDC-P) influences biochemical failure in radical prostatectomy patients, no data are available regarding the impact of its integration into the classification grade group system. Thus, the aim of this study was to enhance the utility of the grade group system by integrating the presence of IDC-P.

METHODS

This study was a retrospective evaluation of 1019 patients with prostate cancer who underwent radical prostatectomy between 2005 and 2013 without neoadjuvant or adjuvant therapy. The data on age, prostate-specific antigen (PSA) level at diagnosis, pathological T stage (pT), presence of Gleason pattern 5 (GP5), presence of IDC-P, and surgical margin status were analyzed to predict PSA recurrence after prostatectomy.

RESULTS

The median patient age was 67 (range, 45-80) years and the median initial PSA level was 6.8 (range, 0.4-82) ng/mL. The median follow-up period was 82 (range, 0.7-148) months. IDC-P was detected in 157 patients (15.4%). Among these patients, the increase in the positive rate of IDC-P correlated with tumor upgrading. The grade groups (GGs) were as follows: GG1 without IDC-P, 16.0% (n = 163); GG2 without IDC-P, 46.1% (n = 470); GG3 without IDC-P, 15.7% (n = 160); GG4 without IDC-P, 2.6% (n = 27); GG5 without IDC-P, 4.1% (n = 42); any GG with IDC-P, 15.4% [n = 157; GG 2 (n = 29); GG3 (n = 60); GG4 (n = 13); GG5 (n = 55)]. Any grade Group with IDC-P showed significantly worse prognosis than any other group without IDC-P (P < 0.0001). In a multivariate analysis, integration of the IDC-P into the Grade Groups, the PSA level at diagnosis, and the surgical margin status were significant prognostic predictors (P < 0.0001, < 0.0001 and < 0.0001, respectively).

CONCLUSIONS

Integrating the presence of IDC-P into the grade group system will result in more accurate predictions of patient outcome.

Relationship Between Hematogenous Tumor Cell Dissemination and Cellular Immunity in DCIS Patients

BACKGROUND/AIM

By definition, tumor cells do not pass the epithelial basement membrane in pre-invasive lesions. However, recently, it was shown that hematogenous tumor cell dissemination already takes place in patients with ductal carcinoma in situ (DCIS), giving disseminated tumor cells (DTCs) in the bone marrow the opportunity to interact with the peripheral immune system. We, therefore, investigated the relationship between DTCs and the peripheral innate and adaptive immune system of DCIS patients, as immunosurveillance might also be impaired in pre-invasive lesions.

MATERIALS AND METHODS

We analyzed the peripheral immune status of 115 DCIS patients by flow cytometry. Results were correlated with presence of DTCs, that were detected in the bone marrow by immunocytochemistry (pan-cytokeratin antibody A45-B/B3) using the automated cellular imaging system (ACIS) according to the international society of hematotherapy and graft engineering (ISHAGE) evaluation criteria. Apoptotic DTCs were characterized by positive M30 staining and cytomorphological criteria.

RESULTS

In contrast to breast cancer, we found no significant correlation between appearance of DTCs and quantitative distribution of T-cell sub-populations, B and NK-cells neither in the bone marrow nor in the peripheral blood. Moreover, DTCs did not affect the expression of important immunomodulatory antigens for functional integrity of specific immune response such as, TCR-ζ, CD28 or CD95. Interestingly, 39% of DTCs were positive for M30 expression and showed cytomorphological signs of apoptosis.

CONCLUSION

In contrast to breast cancer, DTCs of DCIS seem to be less immunogenic, which might result in a diverging way to evade immunosurveillance.

Calponin-h2: a potential serum marker for the early detection of human breast cancer?

Early diagnosis is the key for the successful treatment of breast cancer. A serum marker for the early detection of breast cancer could significantly reduce breast cancer morbidity and mortality by bringing the time of diagnosis at an earlier and therefore still curable stage. So far, no biomarker for the early detection is available for the clinical routine. The aim of the present study was to evaluate the use of calponin-h2 as a blood-based biomarker for the early diagnosis of this disease. Using two monoclonal antibodies against calponin-h2, we developed a sandwich ELISA to analyze the serum levels of calponin-h2. In order to evaluate the diagnostic potential of this biomarker, patients with breast cancer (n = 76), benign diseases of the breast (n = 51) and healthy females (n = 24) were analyzed. Serum levels above 10 ng/ml were only observed in patients with breast cancer (n = 8; 10.5%). Further large-scale studies and preanalytic evaluations are necessary to clarify the definite role of calponin-h2 as a biomarker in breast cancer management.

Metformin decreases circulating androgen and estrogen levels in nondiabetic women with breast cancer

INTRODUCTION

Diabetic patients treated with metformin have a lower risk of developing BC or a better BC prognosis. Metformin might reduce cancer growth through direct antiproliferative effects or through indirect mechanisms, particularly the reduction of insulin. In a randomized study on nondiabetic BC patients in natural menopause with high testosterone levels, we observed a significant decrease in insulin and in testosterone levels with metformin 1500 mg/d compared with 1000 mg/d. We present the results of a new analysis of our study on the effect of metformin on the bioavailability of sex hormones.

PATIENTS AND METHODS

One hundred twenty-four eligible women were initially invited to take metformin 500 mg/d for 3 months. The 108 women who completed the first 3 months continued the study using 1000 mg/d for 1 month. The women were then randomized into 2 groups, and, for the subsequent 5 months, 1 group increased the dose to 1500 mg/d, and the other group continued with 1000 mg/d.

RESULTS

Ninety-six women completed the study, 43 receiving metformin 1500 mg/day, and 53 receiving 1000 mg/day. The women receiving 1500 mg/d showed a greater and significant reduction of free testosterone (-29%) and estradiol (-38%), a borderline significant reduction of estrone and insulin-like growth factor-1, and a nonsignificant reduction of androstenedione. They also showed a nonsignificant increase of dehydroepiandrosterone sulfate.

CONCLUSION

Metformin does not interfere with the production of dehydroepiandrosterone sulfate. Besides, it decreases estradiol levels, basically through the reduction of testosterone. These hormonal changes might have clinical relevance.

Heterogeneous clinicopathological features of intraductal carcinoma of the prostate: a comparison between "precursor-like" and "regular type" lesions

Intraductal carcinoma of the prostate (IDC-P) has been described as a lesion associated with intraductal spread of invasive carcinoma and consequently aggressive disease. However, there are a few reported cases of pure IDC-P without an associated invasive component, strongly suggesting that this subset of IDC-P may represent a precursor lesion. We compared the clinicopathological features between the morphologically "regular type" IDC-P and "precursor-like" IDC-P. IDC-P was defined as follows; 1) solid/dense cribriform lesions or 2) loose cribriform/micropapillary lesions with prominent nuclear pleomorphism and/or non-focal comedonecrosis. We defined precursor-like IDC-P as follows; 1) IDC-P without adjoining invasive adenocarcinoma but carcinoma present distant from the IDC-P or 2) IDC-P having adjoining invasive microcarcinoma (less than 0.05 ml) and showing a morphologic transition from high-grade prostatic intraepithelial neoplasia (HGPIN) to the IDC-P. IDC-P lacking the features of precursor-like IDC-P was categorized as regular type IDC-P. Of 901 radical prostatectomies performed at our hospital, 141 and 14 showed regular type IDC-P and precursor-like IDC-P in whole-mounted specimens, respectively. Regular type IDC-P cases had significantly higher Gleason score, more frequent extraprostatic extension and seminal vesicle invasion, more advanced pathological T stage, and lower 5-year biochemical recurrence-free rate than precursor-like IDC-P cases. Multivariate analysis revealed nodal metastasis and the presence of regular type IDC-P as independent predictors for biochemical recurrence. Our data suggest that IDC-P may be heterogeneous with variable clinicopathological features. We also suggest that not all IDC-P cases represent intraductal spread of pre-existing invasive cancer, and a subset of IDC-P may be a precursor lesion.

Relationship between circulating tumor cells and peripheral T-cells in patients with primary breast cancer

BACKGROUND

Detection of circulating tumor cells (CTCs) in the peripheral blood of patients with primary breast cancer is associated with poor clinical outcome. Recent studies have found evidence for immunological influence on tumor cell dormancy. We therefore investigated the relationship between peripheral T-cells and CTCs, as immunological factors may contribute to the fate of CTCs.

MATERIALS AND METHODS

The peripheral blood immune status of 116 patients with primary breast cancer was analyzed by flow cytometry. Results were correlated with the presence of CTCs and clinicopathological parameters of these patients.

RESULTS

Appearance of CTCs was significantly associated with grade III tumors (p<0.05). Interestingly, CTC-positive patients presented with a significant increase of peripheral CD95(FAS)-positive T-helper cells. As immune response is regulated by CD95(APO-1/FAS)-CD95ligand interaction and tumor cells induce apoptosis via the CD95/CD95L (ligand) pathway, this might lead to tumor cell escape by apoptotic T-helper cells.

CONCLUSION

Absence of T-cell help at the time of priming may result in a loss of long-term antigen-activation of CD8 lymphocytes and could lead to an ineffective anti-tumor cell response. This might contribute to systemic immunosuppression and open the door for tumor cell dormancy.

Usefulness of serum CA-15.3 in the management of benign breast lesion

Benign breast lesion is an important risk factor for breast cancer and elevated CA-15.3 in serum is a well established marker of breast cancer. Core-needle biopsy is now the method of choice to sample non-palpable mammographic abnormality and as well as clinically palpable lesion. To asses relationship of serum CA-15.3 with different histologic entities of benign breast lesion and usefulness of this marker in predicting breast cancer in this high risk group, a study was conducted among 140 patients who had a diagnosis of benign breast lesion and malignancy following fine needle aspiration cytology (FNAC) at department of surgery, Medical College, Kolkata between 2007 and 2009. We prospectively estimated serum CA-15.3 level in all patients. Different histologic entities of benign breast lesion, who showed serum CA-15.3 level >30U/ml underwent tru-cut biopsy to detect malignancy. Of 140 patients studied, 50 were stamped as malignancy and 90 as benign after FNAC of which 20 patients had fibroadenoma, 25 had fibro-adenoma with fibrocystic disease, 20 had fibrocystic disease with epitheliosis and 25 had fibrocystic disease with atypia. All breast cancer patients and 10 each from fibro-adenoma with fibrocystic disease, fibrocystic disease with epitheliosis and fibrocystic disease with atypia had serum CA -15.3 level>30U/ml. Thirty patients with benign breast lesion who had raised CA-15.3 underwent core-needle biopsy. Fifteen patients were detected to have intraductal carcinoma, mostly with fibrocystic disease with atypia. Clinical applicability of serum CA-15.3 to detect breast cancer should be strongly considered in management of patients with benign breast lesion and tru-cut biopsy than FNAC be done before benign breast lesion being stamped as benign. Biopsy results that are not concordant with the targeted lesion require surgical biopsy.

Premenopausal serum androgens and breast cancer risk: a nested case-control study

INTRODUCTION

Prospective epidemiologic studies have consistently shown that levels of circulating androgens in postmenopausal women are positively associated with breast cancer risk. However, data in premenopausal women are limited.

METHODS

A case-control study nested within the New York University Women's Health Study was conducted. A total of 356 cases (276 invasive and 80 in situ) and 683 individually-matched controls were included. Matching variables included age and date, phase, and day of menstrual cycle at blood donation. Testosterone, androstenedione, dehydroandrosterone sulfate (DHEAS) and sex hormone-binding globulin (SHBG) were measured using direct immunoassays. Free testosterone was calculated.

RESULTS

Premenopausal serum testosterone and free testosterone concentrations were positively associated with breast cancer risk. In models adjusted for known risk factors of breast cancer, the odds ratios for increasing quintiles of testosterone were 1.0 (reference), 1.5 (95% confidence interval (CI), 0.9 to 2.3), 1.2 (95% CI, 0.7 to 1.9), 1.4 (95% CI, 0.9 to 2.3) and 1.8 (95% CI, 1.1 to 2.9; Ptrend = 0.04), and for free testosterone were 1.0 (reference), 1.2 (95% CI, 0.7 to 1.8), 1.5 (95% CI, 0.9 to 2.3), 1.5 (95% CI, 0.9 to 2.3), and 1.8 (95% CI, 1.1 to 2.8, Ptrend = 0.01). A marginally significant positive association was observed with androstenedione (P = 0.07), but no association with DHEAS or SHBG. Results were consistent in analyses stratified by tumor type (invasive, in situ), estrogen receptor status, age at blood donation, and menopausal status at diagnosis. Intra-class correlation coefficients for samples collected from 0.8 to 5.3 years apart (median 2 years) in 138 cases and 268 controls were greater than 0.7 for all biomarkers except for androstenedione (0.57 in controls).

CONCLUSIONS

Premenopausal concentrations of testosterone and free testosterone are associated with breast cancer risk. Testosterone and free testosterone measurements are also highly reliable (that is, a single measurement is reflective of a woman's average level over time). Results from other prospective studies are consistent with our results. The impact of including testosterone or free testosterone in breast cancer risk prediction models for women between the ages of 40 and 50 years should be assessed. Improving risk prediction models for this age group could help decision making regarding both screening and chemoprevention of breast cancer.

[Prognostic factors in breast cancer]

Survival in breast cancer is determined by many factors, their influence is different. The aim of the study is to assess the impact on survival of various prognostic factors.

MATERIAL AND METHODS

We studied a total of 198 cases of histologically confirmed breast cancer patients, and we evaluated the impact of prognostic factors on survival.

RESULTS

The most important factor influencing survival is the preset of axillary metastasis(p: 0.0001). Other important prognostic factors are: tumor size (p: 0.003), tumor grading (p: 0.0025), N stage (p: 0.0001.) lymphovascular invasion (p 0.0005) and Nottingham Prognostic Index (p: 0.0109). The factors with no impact on survival were: histological type (p: 0.82), number of lymph nodes affected(p: 0.23), tumor necrosis(p: 0.49) and inflammatory infiltration (p: 0.2).

CONCLUSIONS

The most important prognostic factors are: axillary metastasis followed by tumor grading, NPI and lymphovascular invasion.

Serum levels of HSP90 in the continuum of breast ductal and lobular lesions

BACKGROUND

Heat-shock protein 90 (HSP90) is an abundant protein in mammalian cells. It interacts with a variety of proteins that play key roles in breast neoplasia. This is the first study to assess serum levels of HSP90 in atypical ductal hyperplasia (ADH), lobular neoplasia (LN), ductal carcinoma in situ (DCIS), invasive ductal carcinoma (IDC) and infiltrative lobular carcinoma (ILC).

PATIENTS AND METHODS

Serum concentrations of HSP90 in women with benign (n=34), ADH (n=26), DCIS (n=30), IDC (n=29), LN (n=20) and ILC (n=9) lesions were determined with immunoenzymatic assays. For the evaluation of serum concentrations along the transition from benign through precursor and preinvasive to invasive lesion, the severity of diagnosis was treated as an ordinal variable.

RESULTS

No significant association was demonstrated between serum HSP90 levels and the severity of the lesion in ductal and lobular series. The post hoc comparison between the lobular and ductal precursor lesions (i.e. ADH vs. LN) did not yield a statistically significant difference. Similarly, the post hoc comparison between the lobular and ductal invasive carcinomas (i.e. IDC vs. ILC) did not point to a statistically significant difference.

CONCLUSION

This is the first study evaluating HSP90 serum levels in both lobular and ductal lesions of the breast. Contrary to published pathological findings according to which HSP90 exhibits significant variability along both series, such a finding was not replicated for the level of serum HSP90 concentrations.

Autoantibodies in breast cancer: their use as an aid to early diagnosis

BACKGROUND

There is increasing evidence that the immune system produces a humoral response to cancer-derived antigens. This study assessed the diagnostic potential of autoantibodies to multiple known tumour-associated proteins.

PATIENTS AND METHODS

Sera from normal controls (n = 94), primary breast cancer patients (n = 97) and patients with ductal carcinoma in situ (DCIS) (n = 40) were investigated for the presence of autoantibodies to p53, c-myc, HER2, NY-ESO-1, BRCA1, BRCA2 and MUC1 antigens by enzyme-linked immunosorbent assay.

RESULTS

Reproducibly elevated levels of autoantibodies were seen in at least one of the six antigens in 64% of primary breast cancer patient sera and 45% of patients with DCIS at a specificity of 85%. No significant differences were seen when patients were subdivided by age, tumour size, histological grade, lymph node status or detection methodology.

CONCLUSIONS

Autoantibodies against one or more of these tumour-associated antigens appears to indicate the presence of early-stage breast cancers. Autoantibody assays against a panel of antigens could be used as an aid to mammography in the detection and diagnosis of early primary breast cancer, especially in younger women at increased risk of breast cancer where mammography is known to have reduced sensitivity and specificity.

Effects of Raloxifene on Circulating Prolactin and Estradiol Levels in Premenopausal Women at High Risk for Developing Breast Cancer

BACKGROUND

Prolactin is a peptide hormone necessary for normal breast development that may contribute to breast tumorigenesis. Estrogen is a significant positive regulator of prolactin synthesis; therefore, raloxifene, a selective estrogen receptor modulator under study as a breast cancer prevention agent, may modulate both estradiol and prolactin levels by inhibiting estradiol from binding to its receptor.

METHODS

Premenopausal women at increased risk for invasive breast cancer participated in a pilot chemoprevention trial and were given 60 mg raloxifene daily for 24 months. Fasting serum samples collected at baseline and after 12 months on drug were used to measure circulating prolactin, estradiol, and sex hormone binding globulin (SHBG) levels.

RESULTS

Of the 27 subjects who completed 12 months of raloxifene, 23 had paired prolactin samples, and 20 had paired estradiol and SHBG samples. Prolactin levels did not significantly change with raloxifene treatment, but SHBG levels increased (mean change = 7.3 nmol/L; P = 0.0001; 95% confidence interval, 3.9-10.7). Estradiol (mean change = 42 pg/mL; P = 0.048; 95% confidence interval, 1-84 pg/mL) levels were elevated when comparing 15 of the 20 women with paired estradiol measurements who also had both of these samples taken during the early follicular phase of the menstrual cycle.

CONCLUSIONS

This report is the first to examine the long-term effects of raloxifene on prolactin, estradiol, and SHBG levels in premenopausal women who are also at increased risk for developing invasive breast cancer. Raloxifene had no significant effect on prolactin levels but did increase estradiol and SHBG measurements.

Detection of micrometastatic breast cancer by means of real time quantitative RT-PCR and immunostaining in perioperative blood samples and sentinel nodes

The aim of our study was to detect micrometastatic breast cancer by epithelial glycoprotein-2 (EGP-2) and cytokeratin 19 (CK19), using immunostaining and real time quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR). Fifty-eight breast cancer patients, 52 primary tumors, 75 sentinel nodes (SN) and 149 peripheral blood (PB) samples (from before, during and 4 days after operation) were examined. Immunostaining was performed with antibodies directed against EGP-2 and CK19. Detection limits were one Michigan Cancer Foundation-7 (MCF-7) breast cancer cell line cell/2.10(6) leukocytes (immunostaining) and one MCF-7 cell/10(6) leukocytes qRT-PCR. Control noncancer lymph nodes (n = 10) showed nonspecific CK19 staining, but were qRT-PCR negative; control healthy volunteer PB (n = 11) was always negative. Primary tumor samples, all positive with immunostaining, showed a wide variation of EGP-2 (>10(4) fold) and CK19 mRNA expression (>10(3) fold). SN (n = 19) from 16 patients were tumor-positive with routine haematoxylin-eosin (H&E) and/or immunostaining. SN tumor presence was positively correlated to qRT-PCR expression, but 3 tumor-positive SN were false negative with qRT-PCR. Three SN were qRT-PCR positive, while tumor negative with H&E and/or immunostaining. No immunostaining positive PB was observed, but 19 patients (33%) had one or more qRT-PCR positive PB samples. We concluded that primary tumors have varying expressions of EGP-2 and CK19 mRNA. Both markers can be used in qRT-PCR to obtain adequate sensitivity for single tumor cell detection. In SN, immunostaining appears more sensitive/specific than H&E or qRT-PCR for tumor detection. No immunostaining positivity was found in PB, while 33% of patients had qRT-PCR positive PB. The clinical value of these findings will have to be clarified.

Association between the ras p21 oncoprotein in blood samples and breast cancer

To assess the potential of using oncoprotein levels in blood as a marker of breast cancer status, we measured ras p21 in blood samples taken from 34 breast cancer cases and 60 non-cancer controls including 26 women with benign breast disease (BBD) and 34 healthy women. Plasma samples drawn before surgery or at routine office visit were analyzed for ras p21 by Western blot with computer aided image analysis to measure staining intensity in integrated pixel units (IPU). We found detectable levels of ras p21 in 53% of the blood samples of cases, in 27% of the BBD controls and 26% of the healthy controls. Comparing cases to the combined control group (n=60) and controlling for known breast cancer risk factors, ras p21 was associated with breast cancer status (odds ratio=5.22, 95% CI=1.58-17.23). The median levels of ras p21 staining were higher in cases (7.04 IPU, P=0.03) compared to BBD controls (0.00 IPU) or healthy controls (0.00 IPU). The sensitivity of the assay for detecting breast cancer was 50% which compares favorably with that seen for erbB-2 ( approximately 10%), a more extensively studied blood-borne tumor marker. Ras p21 may be useful in the early detection of breast tumors and in post-surgical follow-up of patients, giving patients and physicians new tools for managing breast cancer.

Elevated preoperative serum ICTP is a prognostic factor for overall and disease-free survival in breast cancer

The aim of this study was to evaluate the prognostic value of preoperative concentrations of the serum markers of type I collagen synthesis (PINP, PICP) and degradation (ICTP) in breast cancer. One hundred and eighty-four breast cancer patients without advanced disease were enrolled. Preoperative serum markers of type I collagen were assessed with specific radioimmunoassays. Elevated preoperative serum concentrations of ICTP (>4.9 microg/l) correlated statistically significantly with a poor prognosis for the breast cancer (P=0.0004) and shorter disease-free survival (P=0.02), and multivariate regression analysis likewise showed an elevated ICTP concentration (P=0.008), high grade (P=0.03) and high pathological stage (P=0.02) to be risk factors for poor survival. Sixty-five out of the 184 patients developed metastatic disease during the follow-up. The median follow-up time was 62 months (range 6-111 months). High ICTP (P=0.02) and large numbers of metastatic nodules (P=0.002) were prognostic factors for shorter disease-free survival in multivariate regression analysis. PINP and PICP had no significant prognostic value with respect to either overall or disease-free survival in this analysis. Our results indicate that preoperatively elevated serum ICTP is a prognostic factor in breast cancer, the measurement of which should improve the accuracy of predictions of the clinical outcome.

Relationship between serum prolactin levels and histology of benign and malignant breast lesions: a detailed study of 153 consecutive cases

This study was aimed at investigating the relationship between serum prolactin levels and the morphology of operable female breast lesions. One hundred fifty-three consecutive patients with operable benign and malignant breast lesions in whom preoperative serum prolactin levels had been determined were stratified into five groups according to their serum prolactin levels. The histologic findings in these groups were analyzed and compared. Most patients (93%) had serum prolactin levels within the normal limits. Of the 54 patients with benign lesions, only 4(7%) had slightly elevated serum prolactin levels. Two of these patients had fibroadenomas, one had a phyllodes tumor and one had fibrocystic change. Of the 99 patients with carcinoma, 7 (7%) had hyperprolactinemia. Five of the seven tumors were invasive and two were in situ. All seven tumors were of low or intermediate grade of malignancy. The two cases with the highest prolactin levels (3057 and 1822 mU/L) were both intermediate-grade ductal carcinoma in situ (DCIS). It is concluded that the great majority of patients presenting with operable breast lesions have normal serum prolactin levels, and that elevated levels, when present, occur with equal frequency in patients with benign and malignant breast lesions. Hyperprolactinemic patients presenting with carcinoma in this study, none of whom had a history of recent pregnancy or lactation, tended to have histologically low- or intermediate-grade tumors, but this needs to be confirmed by investigating more cases.

Apoptosis-related proteins (Fas, Fas ligand, bcl-2 and p53) in different types of human breast tumors

The aim of this study was to evaluate the possible role of apoptosis-related proteins (ARP: Fas and Fas ligand, bcl-2, p53) in the progress of tumorigenesis in breast cancer. Epithelial tumor cells and lymphocytes were analyzed immunohistochemically for the rate of lymphoid infiltration and presence of ARP in 50 human breast tumors of different types. The tumors included: i) fibrocystic disease (n=12); ii) benign fibroadenoma (n=11); iii) carcinoma in situ (n=8); iv) invasive ductal carcinoma with high lymphoid infiltration (n=12); and v) invasive ductal carcinoma with lymphoid depletion (n=7). Both fibrocystic disease and fibroadenomas had low amounts of lymphocytes and very little lymphoid infiltration. In cancer in situ, expansion of lymphoid infiltrates and increased density of lymphocytes resulted in a rise in the total number of lymphocytes, reflecting intensification of the immune response. In carcinomas with high lymphoid infiltration, a significant increase in the number of Fas and FasL and p53-positive cells was found. The number of bcl-2-positive tumor cells in these tumors was not changed, whereas the number of bcl-2-positive lymphocytes decreased. In carcinomas with lymphoid depletion, the opposite picture was found as a result of deep subcompensation of the lymph system. ARP are present in a significantly higher number of lymphocytes than of the epithelial tumor cells. This indicates that the cells initiating apoptosis in tumors are themselves damaged by the process. The intense apoptosis in lymphocytes in malignant tumors may be one of the reasons for the progress of breast tumors.

Plasma D-dimer levels in operable breast cancer patients correlate with clinical stage and axillary lymph node status

PURPOSE

To investigate the relationship between preoperative plasma D-dimer levels and extent of tumor involvement in operable breast cancer patients.

PATIENTS AND METHODS

A total of 140 preoperative plasma specimens were obtained from women scheduled to undergo diagnostic breast biopsies. Ninety-five patients in the initial group went on to undergo axillary lymph node dissection. Of the 140 patients from whom plasma samples were obtained, 102 were subsequently diagnosed with invasive breast carcinoma, nine were subsequently diagnosed with ductal carcinoma-in-situ, and 20 were subsequently diagnosed with benign breast disease. Plasma D-dimer levels were quantitated using a commercially available immunoassay kit (DIMERTEST; American Diagnostica, Greenwich, CT). The relationships between plasma D-dimer and other prognostic variables (tumor size, estrogen receptor, progesterone receptor, nuclear grade, histologic grade, lymphovascular invasion, and clinical stage grouping) were then examined using univariate and multivariate linear and logistic regression analyses.

RESULTS

Median plasma D-dimer levels were significantly higher in patients with invasive carcinoma than those patients with either benign breast disease or carcinoma-in-situ (P =.0001). A significant relationship existed between the presence of elevated D-dimer (> 100 ng/mL) and involved axillary lymph nodes (chi(2) test; P =.001). Elevated D-dimer levels predicted positive lymph node involvement in both univariate regression (P =.0035) and multivariate linear regression (P =.012) models. In addition, elevated D-dimer levels predicted the presence of lymphovascular invasion in univariate logistic regression (P =. 0025) and multivariate logistic regression analysis (P =.0053). Quantitative D-dimer levels were highly correlated with clinical stage grouping (analysis of variance test; P =.002).

CONCLUSION

Plasma D-dimer levels were markers of lymphovascular invasion, clinical stage, and lymph node involvement in operable breast cancer. This correlation suggests that detectable fibrin degradation, as measured by plasma D-dimer, is a clinically important marker for lymphovascular invasion and early tumor metastasis in operable breast cancer.

Polyamines in human breast cancer and its relations to classical prognostic features: clinical implications

Experimental evidence suggest an important role of polyamines in breast cancer development. Polyamines have been determined in tissue and erythrocyte samples from 100 patients with primary invasive breast cancer and 30 patients with fibroadenomas. Statistical analysis was performed in order to determine the prognostic value of the polyamine patterns of tumor tissues and erythrocytes in comparison with clinical and histological prognostic factors. In malignant tissues, polyamine levels were significantly higher than in benign tissues. They correlated with markers of tumor aggressivity (axillary node involvement and especially with markers of high mitotic rate as Ki-67 staining, histological grade). No correlation was found between estrogen and progesterone status, tumor size and polyamine concentrations. Erythrocyte polyamines levels were identical between cancer patients and controls. The knowledge of the polyamine pattern in breast cancer could become useful in clinical practice particularly if polyamine metabolism is targeted as a therapeutic approach.

High frequency of germ-line BRCA2 mutations among Hungarian male breast cancer patients without family history

To determine the contribution of BRCA1 and BRCA2 mutations to the pathogenesis of male breast cancer in Hungary, the country with the highest male breast cancer mortality rates in continental Europe, a series of 18 male breast cancer patients and three patients with gynecomastia was analyzed for germ-line mutations in both BRCA1 and BRCA2. Although no germ-line BRCA1 mutation was observed, 6 of the 18 male breast cancer cases (33%) carried truncating mutations in the BRCA2 gene. Unexpectedly, none of them reported a family history for breast/ovarian cancer. Four of six truncating mutations were novel, and two mutations were recurrent. Four patients (22%) had a family history of breast/ovarian cancer in at least one first- or second-degree relative; however, no BRCA2 mutation was identified among them. No mutation was identified in either of the genes in the gynecomastias. These results provide evidence for a strong genetic component of male breast cancer in Hungary.

[A densitometric analysis of the chromatin structural characteristics of the nuclei in the peripheral blood lymphocytes of breast cancer patients]

Alterations in optical structural characteristics of nuclear chromatin, in comparison with healthy individuals (10) and patients with fibroadenoma (29), were detected in 57 patients with a breast cancer by densitometric investigation of peripheral blood lymphocytes. The degree of these alterations are closely associated with the level of malignancy in the initial neoplasia and the aggregation of oncopathology in pedigrees.

Intraductal carcinoma of the breast associated with high levels of circulating tumor-associated antigens (CA 15-3 and NCC-ST-439)

BACKGROUND

A remarkable elevation of serum tumor-associated antigen levels usually occurs in advanced or metastatic cancer and has not been reported previously in the setting of noninvasive carcinoma of the breast.

METHODS

An immunohistochemical and histopathologic study is presented on a specimen taken from a 43-year-old Japanese woman with micropapillary intraductal carcinoma of the breast with significantly high levels of preoperative circulating tumor-associated antigens, CA 15-3 (198.5 U/ml) and NCC-ST-439 (1400 U/ml).

RESULTS

A histologic specimen consisted of numerous cysts lined by slightly stratified, monotonous columnar cells producing foci of micropapillary intraductal carcinoma. Extensive sampling of the specimen demonstrated no invasive foci although faintly eosinophilic secretory material occasionally leaked from disrupted cysts into the surrounding stroma. The cancerous and normal epithelium showed intense apical reactivity with monoclonal antibodies 115D8, DF3, and NCC-ST-439; intraluminal and spilled secretion also showed positive reaction with these antibodies. Serum levels of CA 15-3 and NCC-ST-439 were within normal limits after subcutaneous mastectomy. No carcinoembryonic antigen was demonstrated either in the sera, the neoplastic epithelium, or the secretory material.

CONCLUSIONS

These histopathologic and immunohistochemical studies showed that the leaked secretion from the disrupted cysts into the surrounding connective tissue stroma may be responsible for the marked elevation of circulating tumor-associated antigen levels in this micropapillary intraductal carcinoma.

Carcinocythemia. A terminal manifestation of metastatic breast cancer

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Purification and analysis of glycoproteins bearing blood group-A determinants from hamster pancreatic ductal adenocarcinomas

Although the hamster pancreas does not express A, B or H blood group antigens, all hamster pancreatic ductal adenocarcinomas induced by treatment with N-nitrosobis(2-oxopropyl)amine express blood group-A antigen. Thus, the acquisition of blood group-A antigen expression in this system is a cancer-associated alteration. We have purified three major blood group-A antigen bearing glycoproteins (gp120, gp135 and gp150) from hamster pancreatic cancer cell membrane preparations using affinity chromatography on DBA (Dolichos biflorus) agglutinin-agarose. When assayed by immunoblotting, gp120 and gp135 showed strong blood group-A reactivity, which was removed by treating membrane samples with peptide-N-glycosidase F. Blood group-A reactivity was unchanged by treatment of the membrane fractions with endoglycosidases F and H. In addition, these two glycoproteins bearing blood group-A antigen also bound L-PHA (Phaseolus vulgaris leucoagglutinin). These results demonstrate that gp120 and gp135 express blood group-A antigen on Asn-linked multi-antennary complex type glycan structures. The gp150 showed weak blood group-A expression. This is the first demonstration of the neoexpression of cancer-associated blood group-A determinants which reside on Asn-linked glycan structures.

Elevation of free beta subunit of human choriogonadotropin and core beta fragment of human choriogonadotropin in the serum and urine of patients with malignant pancreatic and biliary disease

Human choriogonadotropin (hCG), its free beta subunit (beta hCG), and the core beta hCG fragment (c beta hCG) were measured by highly sensitive time-resolved immunofluorometric assays in the serum and urine of 29 patients with pancreatic cancer, 7 patients with biliary cancer, and 45 patients with benign pancreatic or biliary diseases. The results were compared with those of an age- and sex-matched reference population of nonpregnant women and men. Of the various forms of hCG assayed in serum, beta hCG showed the best diagnostic accuracy, and c beta hCG was the best marker in urine. Elevated serum concentrations of beta hCG were observed in 72% of the patients with pancreatic cancer, in 6 of 7 patients with biliary cancer, and in 9% of those with benign disorders. The serum concentrations of c beta hCG were elevated in 45%, 57%, and 2%, respectively, and those in urine in 55%, 71%, and 11%, respectively. The molar concentrations of c beta hCG in serum were mostly lower than those of beta hCG. Thus beta hCG secreted into serum appears to be the main source of c beta hCG in urine. Provided that they are measured by sufficiently sensitive and specific assays, beta hCG in serum and c beta hCG in urine appear to be useful markers for pancreatic and biliary cancer.

Peritumoral lymphatic invasion in patients with node-negative mammary duct carcinoma

Five hundred six consecutive cases of ductal infiltrating carcinoma of the breast (T1-T2,N0,M0) were evaluated to define the frequency of peritumoral lymphatic invasion (PLI) and verify its possible prognostic significance. Histologically, PLI was characterized by the presence of neoplastic emboli within vascular lumina lined by recognizable endothelial cells, adjacent to but outside the margins of the carcinoma. In routine histopathologic assessment the frequency of PLI was 68% whereas in a randomly selected group of 234 reviewed cases the frequency rose to 20%. Patients with routinely evaluated PLI had a worse prognosis than those without PLI with reference both to disease-free survival (P = 0.0001) and total survival rates (P = 0.0001). The difference for local recurrences was prognostically highly significant (P = 0.0001) and also significant for the development of metastases (P = 0.0576). In the reviewed material the difference in prognosis between PLI-positive and PLI-negative cases was not confirmed for total survival whereas the significance for the disease-free interval persisted. The assessment of PLI, carried out following strict histopathologic criteria, appears to select a group of node-negative breast cancer patients who have an increased risk of recurrences and might benefit from a treatment different from that reserved for node-negative and PLI-negative patients.

Generation of superoxide anion and candidacidal activity by lipopolysaccharide-treated macrophages from patients affected by neoplasia

Macrophages, derived from in vitro cultured monocytes from both healthy donors and patients affected by metastatic breast cancer, treated or not with Escherichia coli lipopolysaccharide (LPS), were tested for phagocytosis and intracellular killing of Candida albicans and superoxide anion release. We found a marked impairment in intracellular killing closely linked to the lack of superoxide production in macrophages from patients affected by neoplasia treated or not with LPS. On the other hand, the LPS treatment significantly enhanced the phagocytic activity of all the macrophage populations tested, except for phagocytes obtained from patients affected by neoplasia and differentiated in autologous serum.

Platelet-derived growth factor (PDGF) in plasma of breast cancer patients: correlation with stage and rate of progression

Plasma levels of platelet-derived growth factor (PDGF) were measured in 58 female patients with breast cancer and in 9 normal female control subjects by means of a specific radioimmunoassay. Levels in normal control subjects were all below the lower limits of detection by the assay (1.56 fmol/100 microliters plasma). Two of 17 (12%) patients with stage 2 breast cancer had detectable plasma levels. Among patients with Stage 4 breast cancer 13/41 (32%) had significantly elevated levels (greater than 2 times the lower limit of sensitivity of the assay). Patients with elevated PDGF levels had a significantly greater degree of metastatic involvement and significantly shorter survival. Apart from being a marker of aggressive high bulk breast cancer, PDGF may be involved in the acceleration of growth of some metastatic breast tumors.

Effect of chemotherapy on circulating steroid hormone levels in postoperative premenopausal breast cancer patients

Serum levels of 17-beta oestradiol, testosterone and progesterone were determined in postoperative premenopausal breast cancer patients. In patients receiving chemotherapy circulating 17-beta oestradiol values decreased significantly compared to control group during the sampling/drug regimens employed. Among the control group, however, the oestradiol levels remained high throughout the sampling period. Testosterone levels in patients were also significantly low compared to control group throughout the sampling regimen up to 28 days. In contrast the levels of progesterone in patients were elevated and remained high compared to the corresponding controls. A positive correlation was found between the drop in serum oestradiol and testosterone levels following the initiation of chemotherapy and the regression of the tumour size. Steroid hormone levels in the serum of breast cancer patients receiving chemotherapy can serve as clinical tools to monitor the progress of the disease and response to therapy.

Lewis blood group antigens (a and b) in human breast tissues. Loss of Lewis-b in breast cancer cells and correlation with tumor grade

The Lewis blood group antigens (Lewis-a [Lea] and Lewis-b [Leb]) and their precursors are present on various normal human epithelial cell surfaces. The authors examined 35 benign and malignant human breast lesions using mouse monoclonal antibodies to synthetic Lea and Leb carbohydrate antigens. Normal breast lobular and ductal epithelium and benign breast lesions showed Leb staining but only occasional Lea staining. In invasive ductal carcinomas of breast, of all grades, a loss of Leb antigen staining was found in 80% of the breast cancer cases. This reduced Leb antigen expression increased with the grade of malignancy. Therefore, the loss of Leb blood group antigens on breast cancer cell surfaces may suggest altered fucosylation patterns in malignant cells and reflect the degree of malignancy and/or invasiveness.

[Platelet aggregation during adjuvant chemotherapy with CMF]

We have studied platelet aggregation in fourteen pre- and post-menopausal women treated with cyclic adjuvant CMF chemotherapy for mammary cancer with positive axillary nodes, previously operated. Aim of the investigation is to evaluate the effect of chemotherapy on platelet aggregation. The obtained results demonstrate that CMF therapy does not modify platelet aggregation in both pre- and post-menopausal patients.

Carcinoma of the male breast: a review of 41 cases

We reviewed the cases of 41 consecutive men treated for breast carcinoma from 1950 through 1987 at Vanderbilt University Affiliated Hospitals to examine controversies in and methods of therapy for this disease. Twenty-two patients (52%) had stage I or II lesions potentially curable by operative therapy. The overall 5-year survival rates were 100% for stage I, 65% for stage II, 56% for stage III, and 0% for stage IV. Radical mastectomy offered no advantage over modified radical mastectomy in terms of survival or rate of recurrence. Diagnosis at an early clinical stage and no finding of disease in axillary lymph nodes were important factors in survival in this series of patients. All tumors evaluated for hormone receptors were positive. Although experience was limited, encouraging results were obtained with the use of tamoxifen citrate in adjuvant as well as palliative roles. With the exception of a predominance of centrally located lesions and a uniquely high frequency of positive hormone receptor status, carcinoma of the male breast appears biologically similar to the disease in women, and treatment should be guided by similar principles.

Individual and combined usefulness of lipid associated sialic acid, mucoid proteins and hexoses as tumor markers in breast carcinoma

Serum levels of lipid associated sialic acid (LASA), mucoid proteins (MP) and hexoses (galactose + mannose) were measured in 41 breast cancer patients, 14 patients with benign breast diseases and 36 healthy age matched female individuals. In breast carcinoma patients, we have observed significant increase in the levels of the three markers compared with the controls (P less than 0.001) and in MP and hexoses compared to the patients with benign breast diseases (P less than 0.001). LASA and hexoses levels were significantly higher in benign breast diseases with respect to controls (P less than 0.001 and P less than 0.01, respectively). We evaluated the sensitivity and specificity of the markers individually and in combination. MP were most sensitive (71.8%) and specific (71.4%). Both sensitivity and specificity were increased when combinations of the markers were studied. Combination of MP with LASA was most sensitive (97.4%) while the combination of MP and hexoses was most specific (92.9%). LASA was significantly elevated in infiltrating duct carcinoma compared to lobular carcinoma (P less than 0.001). MP and hexoses also showed higher mean value in infiltrating duct carcinoma than lobular carcinoma. The present study suggests that the combination of the markers investigated might be useful for diagnosis and classification of breast carcinoma.

Carcinocythemia. Report of two cases, one simulating a Burkitt lymphoma

Carcinocythemia is a rare complication of metastatic carcinoma, characterized by the presence of carcinoma cells in the peripheral blood, which may mimic acute leukemia. Two cases are reported in which the patients developed carcinocythemia several years after being treated for carcinoma of the breast. Cytologic examination of peripheral blood smears in both cases showed the presence of numerous large abnormal cells; in one case the cells simulated those of a Burkitt lymphoma. Cytochemical and/or immunologic marker studies ruled out a hematopoietic origin of the malignant cells in both cases and confirmed a diagnosis of carcinocythemia. The rapidly fatal outcome observed in these two cases was in accordance with the poor prognosis usually encountered with this rare phenomenon.

Lack of Changes in Soluble Interleukin-2 Receptor Serum Levels during Chemotherapy-induced Lymphocyte Damage

The biological significance of soluble IL-2 receptors (sIL-2R) is still unknown; in particular, it is not yet clear whether their increase in the blood may reflect activation of immune cells, or whether it is related to an immune dysfunction. To investigate this problem, we evaluated serum levels of sIL-2R before and after administration of a highly lymphocytolitic chemotherapy (FEC: fluorouracil, epirubicin, cyclophosphamide) in a group of 6 patients with advanced breast cancer. SIL-2R were analyzed in relation to lymphocyte number. Absolute mean number of lymphocytes was significantly lower after than before chemotherapy. On the contrary, no significant difference was seen in sIL-2R mean levels, and no significant correlation was observed between changes in sIL-2R and in lymphocyte number following chemotherapy. These results would exclude that sIL-2R may simply be due to a passive release following lymphocytic damage.

Procoagulant activity of human tumours: existence of Xa and thrombin-like activities

We have analysed 15 infiltrating duct carcinomas of the breast, 10 gastrointestinal adenocarcinomas, one each of the thyroid and larynx, and four mesenchymal tumours for the presence and the nature of procoagulant activity (PCA). The metastatic tumours had a significantly higher PCA (P = 0.01-0.001) as compared to the non-metastatic tumours in the respective groups, and almost 20-25 times the activity as compared to normal tissue (P = 0.001). Although the majority of the tumours had FVII-dependent tissue thromboplastin-like activity, some of the tumour homogenates revealed the presence of an FVII-independent PCA. Unlike the known alternate PCA, which acts via factor X activation, this PCA was factor X independent. It caused clot formation in FX-deficient plasma (six cases) and purified fibrinogen solution (four cases), indicating the presence of a Xa-like enzyme or a thrombin-like activity respectively.

Surgical treatment for ductal adenocarcinoma of the pancreas

A ten year community hospital experience of 124 patients with ductal adenocarcinoma of the pancreas proved at biopsy is reported. All patients underwent a celiotomy, and 94 per cent were observed until death. All of the patients were stratified by stage (I, 9 per cent; II, 30 per cent; III, 18 per cent, and IV, 43 per cent). Nine of the patients with Stage I disease underwent resection with a high postoperative mortality rate of 44 per cent and only one five year survivor. Fifty-nine patients with Stages II and III disease underwent biliary bypass with a low postoperative mortality rate of 2 per cent. Bypass of the common bile duct (N = 24) provided more permanent palliation against recurrent jaundice or cholangitis (p less than 0.05), but did not improve the survival time when compared with bypass of the gallbladder (N = 20). This was not true for those with Stage IV disease in whom recurrent jaundice did not develop in those with either bypass of the gallbladder or common duct. Adding prophylactic gastroenterostomy (GE) to biliary bypass (N = 25) conferred no survival benefit, but did protect against subsequent duodenal obstruction (p less than 0.05). Thirty-seven per cent of the 38 patients in whom a GE was not performed had duodenal obstruction develop. Adjuvant radiation and chemotherapy in 22 patients with unresectable Stages II and III disease resulted in a significant prolongation of survival time compared with 15 untreated patients in the control group (p less than 0.05). Fifty-one patients with Stage IV disease underwent biliary bypass or biopsy of the tumor resulting in a 14 per cent postoperative mortality rate and a median survival time of four months. Nine per cent of the 44 survivors with Stage IV disease lived at least one year. The implications of these findings to clinical practice are discussed.

Level of plasma fibronectin in patients with breast cancer

Plasma fibronectin was determined by laser nephelometric immunoassay in two populations: healthy individuals and patients with metastatic or non-metastatic breast cancer. The results showed that the fibronectin concentration was higher in the patient group than in the healthy controls of similar age, with a significant difference (p less than 0.05). The patients who had metastatic breast cancer tended to show higher levels than those with no detectable metastasis, but such a difference was not statistically significant. Since fibronectin is sensitive to clinical events unrelated to the malignancy status, it does not seem suitable as a tumor marker.

Anticoagulant activity in cell-free peritoneal fluid of an experimental pancreatic ascites tumor

The ascitic form of a chemically-induced pancreatic ductal adenocarcinoma in the Syrian golden hamster was very bloody and indistinguishable from blood macroscopically. Unlike blood, the bloody fluid remained unclotted at room temperature. To explore the possibility of presence of anticoagulants, we mixed 40% cell-free fluid with 60% normal human plasma and tested the clottability of the mixture with standard techniques. Plasma containing the fluid showed markedly prolonged activated partial thromboplastin time (APTT), thrombin time (TT) and recalcification time (RCT), and normal prothrombin time (PT) and reptilase time (RT). Comparing the prolongation of APTT of samples containing the fluid to those containing a commercial heparin, the fluid contained an anticoagulant activity equivalent to 0.436 +/- 0.03 unit heparin per ml (mean +/- SEM, n = 14). In addition to prolonging the APTT, TT and RCT, the fluid also inhibited the clotting and amidolytic activities of thrombin. "Heparsorb" had nearly completely neutralized the anticoagulant activity in fluid samples, while protamine sulfate was only partially effective. Incubation of fluid with pronase or phospholipase did not affect its anticoagulant activity; incubation with heparinase had only a minimal effect. Electrophoresis of an alkali digested fluid on cellulose acetate revealed the presence of heparan sulfate. The native ascitic fluid also contained other hemostatic components including platelets, fibrinogen and antithrombin III, but their concentrations were much lower than in blood. Apparently, heparan sulfate in the neoplastic effusion is largely responsible for the bloody ascites tumor remaining unclotted.

Can plasma human pancreatic polypeptide be used to detect diseases of the exocrine pancreas?

Plasma concentrations of human pancreatic polypeptide (HPP) parallel exocrine pancreatic secretion in response to stimulation with cholecystokinin. We determined prospectively the relationships among fasting HPP level, integrated HPP response to infusion of cholecystokinin, and output of trypsin and also the sensitivity, specificity, and predictive values of the fasting HPP level in the diagnosis of exocrine pancreatic disease. Our study group consisted of 19 patients with acute pancreatitis, 17 with chronic pancreatitis, and 25 with ductal adenocarcinoma of the pancreas and 27 control subjects. In the control patients and those with chronic pancreatitis, significant correlations were detected between HPP level and output of trypsin (P less than 0.001) in response to infusion of cholecystokinin and between fasting HPP and integrated HPP levels (P less than 0.004); no correlation was detected between HPP level and steatorrhea. The sensitivity, specificity, and negative and positive predictive values of the fasting HPP level for detection of either chronic pancreatitis or pancreatic cancer were similar and approximated 0.88, 0.67, 0.88, and 0.66, respectively. The HPP concentration had no value in detecting acute pancreatitis. Because the fasting HPP level has a high degree of negative predictability and is simpler to measure than the integrated HPP level or the output of trypsin, it may be a useful test in patients suspected of having either chronic pancreatitis or pancreatic cancer. A fasting HPP level of 125 pg/ml or greater could be used to exclude chronic pancreatitis or pancreatic cancer, but the finding of a value of less than 125 pg/ml necessitates use of other diagnostic tests for reliable determination of the presence of these diseases.

Carcinoma of the prostate of ductal origin

Thirty-nine patients with ductal prostatic carcinoma have been reviewed. Their mode of presentation, initial stage, plasma phosphatase levels and response to hormone therapy were found to be similar to those in a group of 124 patients with the common acinar prostatic cancer. Histochemical examination demonstrated prostate-specific antigen in all ductal carcinomas.

Hematologic parameters in the adjustment of chemotherapy doses in combined modality treatments involving radiation

The differential white blood cell count of a group of patients with Stages I and II infiltrating ductal carcinoma who underwent treatment in the preadjuvant chemotherapy era have been evaluated. All patients received a modified radical mastectomy followed by postoperative radiation therapy to the chest wall and draining regional lymph node chains (ipsilateral internal mammary, axillary,and supraclavicular regions). When the levels of circulating neutrophils, band cells, and lymphocytes were compared for the period beginning prior to surgery and ending 1 year after the completion of radiotherapy, it was found that radiation induced a significant lymphopenia. However, all patients maintained a neutrophil count at least twice that needed for full-dose conventional chemotherapy. Based on these observations and related preclinical and clinical information, it is proposed that future clinical trials utilizing even local radiotherapy as a component of therapy must have their chemotherapy doses based on appropriate hematologic parameters (neutrophil + band count) in order to avoid spurious and quite possibly erroneous results.

Plasma hormone responses to tamoxifen therapy and oophorectomy

The effect of tamoxifen therapy on plasma hormones in the pre- and postmenopausal state was studied in a young patient with breast cancer. Tamoxifen therapy was carried out for metastatic disease prior to (premenopausal) and after oophorectomy (surgical menopause). Changes in luteinizing hormone, follicle-stimulating hormone, prolactin, and estrogen were noted and were corroborated with the therapy or oophorectomy. The findings support some of the previously reported changes in those hormones that were noted in conjunction with tamoxifen therapy.

The relationship of dietary selenium and breast cancer

An inverse relationship exists between dietary selenium (Se) concentrations and the incidence of human breast cancer. The addition of Se to the diet has been shown to decrease the incidence of spontaneous murine mammary tumors. We compared the serum Se concentrations in breast cancer patients with those of women without breast cancer. Serum was collected from 35 women with breast cancer. Nineteen of these women had infiltrating ductal carcinoma and two had Paget disease of the nipple. Nine women had lymph nodal metastases at the time of mastectomy, four had definite evidence of metastatic disease when the blood samples were drawn, and the disease process of one patient was unclassified. Samples from 27 women known to be free of breast cancer were used as controls. The difference noted between the mean serum Se concentrations of breast cancer patients and controls were found to be significant.

Study of secretory component in patients with metastatic breast cancer

A radioimmunoassay was developed for secretory component, a glandular epithelial cell product secreted as an accessory protein with dimeric immunoglobulins A and M. Forty-four normal women between the ages of 40 and 70 had plasma concentrations of secretory component of 7.195 microgram/ml +/- 3.590 (+/-2 SD). Of the patients with metastic breast cancer of epithelial origin, 34 (91.9%) had plasma concentrations greater than 8.990 microgram/ml; 29 (78.1%) had plasma concentrations greater than 10.785 microgram/ml; 10 (27%) had concentrations greater than 15.000 microgram/ml; and 3 (8.1%) had concentrations greater than 22.710 microgram/ml. Serial plasma concentrations (averaging 3.48 per patient) of 35 (94.6%) of these patients reflected the clinical course of the disease. All patients had some combination of surgery, radiation therapy, and chemotherapy. No direct correlation was noted between the type of therapy and concentration of secretory component. However, plasma secretory component served as a marker in the systemic circulation of a change in the status of the metastatic breast cancer. The impact of this research may lie in its incorporation into clinical management.

Prostaglandin E and hypercalcemia in breast carcinoma: only a tumor marker? A need for perspective

Prostaglandin E concentrations were measured in a patiet with breast carcinoma, hypercalcemia, undetectable parathyroid hormone (PTH) and no evidence of bone metastases. Catheterization of the drainage bed of her tumor documented production of E series prostaglandins. Treatment with the largest recommended doses of indomethacin for 10 days failed to lower her plasma prostaglandin E (PGE) concentrations or to correct the hypercalcemia, but it normalized urinary excretion of PGE. Subsequent chemotherapy reduced prostaglandin concentrations toward normal values concomitant with a reduction of clinically estimated tumor burden. During this period of time, serum calcium concentrations had no consistent relationship to the plasma PGE levels. We suggest that PGE merely reflected the tumor burden of this patient and did not directly contribute to the genesis of her hypercalcemia. The pertinent literature relating PGE and hypercalcemia is reviewed.