A Case of Brachial Lymph Node Recurrences after the Resection of Locally Advanced Breast Cancer

We present a case of two recurrences in the brachial lymph nodes after initial resection, which was performed for radical cure. A 66-year-old woman was diagnosed with left breast cancer T4bN3cM0 Stage IIIC and an immunohistochemistry assay showed estrogen receptor (ER) positivity (5%), progesterone-receptor (PgR) positivity (1%), human epidermal growth factor receptor-2 (HER2) positivity (3+), and low Ki-67 (15%). After four courses of adriamycin and cyclophosphamide, followed by four courses of trastuzumab plus docetaxel, the patient underwent left mastectomy and axillary dissection. Postoperatively, she was diagnosed with breast cancer ypT1cN0M0, and trastuzumab and anastrozole were started. Postoperative irradiation was performed. Three years and 5 months after the initial breast cancer surgery, she had left brachial lymph node recurrence. It was resected, and tamoxifen was administered postoperatively. One year and 9 months after, she had another left brachial lymph node recurrence, and it was resected. She received radiation therapy to her upper limb and started taking exemestane. After 1 year and 3 months since the second recurrence surgery, there has been no recurrence. Our case suggests that the replacement of regional lymph nodes with tumor cells may result in the reconstruction of lymph flow to the upper arm and the development of brachial lymph node metastasis. There are no reports of resection of the recurrent tumor in the brachial lymph node for curative treatment. Therefore, careful follow-up is important in the future.

A pathologic method for extracting good prognosis group in triple negative breast cancer after neoadjuvant chemotherapy

The area of residual tumor (ART) is a prognostic factor in patients treated with neoadjuvant chemotherapy (NAC) for lung, pancreatic, and rectal cancers. This study aimed to evaluate the usefulness of ART as a method for predicting the prognosis of triple-negative breast cancer (TNBC) patients after neoadjuvant chemotherapy. We included 143 patients with TNBC treated with NAC. The ART at the maximum cut surface of the residual tumor was measured. We divided the patients into three groups: ART-0 (ART=0 mm² ), ART-low (0 mm² < ART ≤ 136mm² ), and ART-high (ART > 136 mm² ), and compared their clinicopathological factors and prognosis. There were no significant differences in both recurrence-free survival (RFS) and overall survival (OS) between ART-0 and ART-low; however, the ART-high group had significantly shorter RFS and OS than the ART-0 and ART-low groups. Multivariate analysis showed that ART-0, and -low and ypN (-) were independent favorable prognostic factors for RFS. Groups with both ART-low and ypN(-) as well as those with ART-0 and ypN(-) showed significantly longer OS and RFS than the other groups (p<0.05). Moreover, there was no significant difference in the RFS and OS between the ART-0 and ypN(-) groups and the ART-low and ypN(-) groups (p=0.249 and p=0.554, respectively). We concluded that ART is a candidate histopathological evaluation method for predicting the prognosis of TNBC patients treated with NAC. Furthermore, postoperative chemotherapy could be omitted in patients with ART-0 and ypN(-) (pathological complete response) and those with ART-low and ypN(-).

Assessment of Upper Limb Physiological Features in Patients with Lymphedema After Breast Surgery Using Multiple Instruments

Background: Objective assessment of upper limb physiological features may allow for early detection and proper intervention for lymphedema after breast surgery. However, the development of diagnostic instruments and standard measurement procedures are required. Methods and Results: Four instruments (Venustron, Softmeasure, Myoton Pro, and iBDent), tape measurement, and water volumetry were investigated in this study. Inter-limb differences in physiological data were obtained from 40 patients with lymphedema after breast surgery and 38 control subjects. Four instruments and tape measurements were performed at four points. Inter-limb differences between patients with lymphedema and control subjects were determined. All measurements took <20 minutes with minimal pain reported. Inter-limb differences in water volumetry and tape measurements, especially when measured at 5 cm distal to the cubital fossa, were increased in International Society of Lymphology (ISL) stage II cases. All four instruments showed high reproducibility in standard silicon sample measurement. On the other hand, data from human samples were varied, and the utility for assessment of lymphedema was not determined. Conclusion: Water volumetry and tape measurement at 5 cm distal to the cubital fossa were useful to assess lymphedema in ISL stage II cases. Four instruments used in this study were feasible in clinical practice. In addition, inconsistent data from human tissue were not due to sensor limitations, rather, acquisition of accurate data from human tissue seemed to be difficult due to anatomical factors. In addition to high-quality sensor, development of system that produce accurate and reproducible results from human tissue is required.

High expression of post-treatment Ki-67 status is a risk factor for locoregional recurrence following breast-conserving surgery after neoadjuvant chemotherapy

INTRODUCTION

During the past decade, neoadjuvant chemotherapy (NAC) has been increasingly used in patients to reduce large tumors to a size eligible for breast-conserving therapy (BCT). However, the association between NAC and Ki-67 has not yet been fully elucidated. The aim of this study was to evaluate the prognostic significance of Ki-67, specifically after NAC followed by BCT, particularly in terms of locoregional recurrence (LRR).

METHODS

A total 217 patients who received BCT after NAC were retrospectively analyzed. In these patients, immunohistochemistry analyses defined four tumor subtypes, Luminal A, Luminal B, Triple negative, and HER2 type. Ki-67 was examined by immunohistochemistry in both pretreatment core needle samples and post-treatment surgical excision specimens. High Ki-67 expression was defined as >20%. The prognostic factors LRR, locoregional relapse-free survival (LRRFS), and overall survival (OS) were analyzed.

RESULTS

In total, LRR developed in 14 patients, and the 5 year-LRRFS was 94.2%. Post-treatment high Ki-67 expression, triple negative, the presence of lymphovascular invasion, and histological grade 3 were significantly high in LRR for prognostic factors (P < 0.05). There were significant differences in Kaplan-Meier method for LRRFS curves according to these three factors for patients receiving BCT following NAC (P < 0.05). There was a significant difference in the 5 year-OS for patients with and without LRR (41.7% vs. 93.9%, P < 0.001).

CONCLUSION

Post-treatment high Ki-67 expression could be one of the important prognostic factors of LRR, and require careful follow-up on LRR at the time of surveillance.

High Mobility Group Box1 (HMGB1) released from cancer cells induces the expression of pro-inflammatory cytokines in peritoneal fibroblasts

High Mobility Group Box1 protein (HMGB1), one of the mediators of inflammation, is associated with tumorigenesis. The HMGB1-Receptor for advanced glycation end-products (RAGE) in gastric adenocarcinoma tissues promoted gastric cancer growth, however, there are no reports concerning the relationship between the expression of HMGB1 in gastric cancer and cancer-related inflammation. Fibroblasts exist most abundantly on cancer tissue where inflammation occurs. So, we studied the effects of HMGB1 released from cancer cells on the fibroblasts. The expression of HMGB1 in cancer cells and nuclear factor-kappa B (NF-kB) in fibroblasts were evaluated immunohistochemically in human gastric cancer specimens. Cytoplasmic HMGB1 expression in the cancer cells and nuclear translocation of NF-kB in fibroblasts were detected at deeper invasion. To determine whether HMGB1 released from cancer cells induces the expression of pro-inflammatory cytokines in fibroblasts, we analyzed the activation of Toll-like receptor (TLR) signaling. Fibroblasts stimulated by recombinant HMGB1 and the HSC44PE-conditioned medium showed the phosphorylation of Interleukin-1 receptor associated-kinase 4 (IRAK4), nuclear translocation of NF-kB, and enhanced pro-inflammatory cytokine expression. Treatment with HSC44PE-conditioned-medium transfected with siRNA-HMGB1 reduced the expressions of pro-inflammatory cytokines in the fibroblasts. We propose that HMGB1 released from cancer cells induces the expression of pro-inflammatory cytokines in peritoneal fibroblasts through the HMGB1-TLR2/4 pathway.

Does dopamine block the spawning of the acroporid coral Acropora tenuis?

Most corals undergo spawning after a particular moon phase, but how moon-related spawning is endogenously regulated in corals remains unknown. The objective of the present study was to evaluate whether dopamine (DA) affects spawning in Acropora tenuis. When pieces of four A. tenuis colonies were reared under a natural photoperiod and water temperature, spawning was observed after the predicted moon phase. After exposure to water containing DA at 0.1 μM, pieces of the same colonies only released 5 to 10 bundles. Co-treatment with DA and pimozide (D1 and D2 receptors antagonist), but not domperidone (D2 receptor antagonist), induced mass release of bundles from the colonies. A cross-experiment revealed high fertilization rates between the control colonies (95%) and between the control and DA-treated colonies (90%), suggesting that gametes developed normally in coral tissue. Therefore, DA appears to have an inhibitory effect on the spawning of A. tenuis.

Remarkable tumor lysis in a hepatocellular carcinoma patient immediately following glypican-3-derived peptide vaccination: an autopsy case

We recently reported the safety, immunological and clinical responses to a GPC3-derived peptide vaccine in a phase I clinical trial of patients with advanced hepatocellular carcinoma (HCC). We conducted a subsequent trial in advanced HCC to assess the histopathological findings before and after vaccination with the GPC3 peptide. Here, we present the clinical course and the pathological study including the autopsy of a patient with advanced HCC in the ongoing clinical trial. A 62-year old patient suffering from HCC refractory to sorafenib therapy received the GPC3 peptide vaccine. The patient had fever and remarkably impaired liver function twice after vaccination. Contrast-enhanced CT after the second vaccination showed multiple low-density areas in the liver tumor, indicating tumor necrosis. In contrast, the tumor thrombus in the right atrium increased. The patient discontinued protocol treatment due to disease progression and died 30 days after the second vaccination. An autopsy was performed to determine the main cause of death and to evaluate the antitumor effect of the vaccination. A histological examination showed central necrosis in most of the intrahepatic tumor. The main cause of death was circulatory failure due to tumor thrombus, which occupied most of the right atrium. An immunohistochemical analysis revealed infiltration of CD8-positive T cells in the residual carcinoma, but not within the cirrhotic area. Ex vivo IFN-γ enzyme-linked immunospot analysis revealed vaccine-induced immune-reactivity against the GPC3 peptide. A histopathological examination at the estimated time of a strong immunological response demonstrated a GPC3 peptide vaccination-induced cytotoxic T-lymphocyte response with an anti-tumor effect.

Forkhead box P3 regulatory T cells coexisting with cancer associated fibroblasts are correlated with a poor outcome in lung adenocarcinoma

Recently, an association between tumor infiltrating Forkhead box P3 regulatory T cells (Treg ) and an unfavorable prognosis has been clinically shown in some cancers, but the mechanism of Treg induction in the tumor microenvironment remains uncertain. The aims of the present study were to examine the relationship between Treg and patient outcome and to investigate whether Treg induction is influenced by the characteristics of cancer-associated fibroblasts (CAF) in lung adenocarcinoma. The numbers of Treg in both the tumor stroma and the tumor nest were counted in 200 consecutive pathological stage I lung invasive adenocarcinoma specimens. To examine whether the characteristics of CAF influence Treg induction, we selected and cultured CAF from low Treg and high Treg adenocarcinoma. The number of Treg was much higher in the stroma than in the nest (P < 0.01). Patients with high Treg had a significantly poorer prognosis than those with low Treg (overall survival: P = 0.03; recurrence-free survival: P = 0.02; 5-year overall survival: 85.4% vs 93.0%). Compared with the CAF from low Treg adenocarcinoma, culture supernatant of the CAF from high Treg adenocarcinoma induced more Treg (P = 0.01). Also, CAF from high Treg adenocarcinoma expressed significantly higher mRNA levels of transforming growth factor-β (P = 0.01) and vascular endothelial growth factor (P = 0.01), both of which are involved in Treg induction. Our studies suggest the possibility that CAF expressing immunoregulatory cytokines may induce Treg in the stroma, creating a tumor-promoting microenvironment in lung adenocarcinoma that leads to a poor outcome.

E-cadherin expression on human carcinoma cell affects trastuzumab-mediated antibody-dependent cellular cytotoxicity through killer cell lectin-like receptor G1 on natural killer cells

Trastuzumab is a recombinant antibody drug that is widely used for the treatment of HER2-overexpressing breast carcinoma. Despite encouraging clinical results, many HER2-overexpressing carcinomas are primarily resistant to trastuzumab. We attempted to explain trastuzumab resistance and search for solutions. Since the killer cell lectin-like receptor G1 (KLRG1), an inhibitory receptor expressed on subsets of natural killer (NK) cells recognizes E-cadherin as ligands and may inhibit immune responses by regulating the effector function of NK cells, we used HER2-overexpressing carcinoma cells which were expressing E-cadherin to investigate the role of antibody-dependent cellular cytotoxicity (ADCC) through KLRG1 on NK cells in vitro and vivo. The results indicated that HER2-overexpressing carcinoma cells were killed by trastuzumab-mediated ADCC and the ADCC activity was reflected the degree of E-cadherin expression on carcinoma cells. We found that expression of E-cadherin was shown to be a predictor of response to trastuzumab-based treatment for HER2-overexpressing carcinomas, furthermore, trastuzumab-mediated ADCC was markedly enhanced by KLRG1-negative peripheral blood mononuclear cells (PBMCs(KLRG1(-))).

Abstract P3-10-28: Breast Cancer Patients with Neoadjuvant Chemotherapy Have a Different Clinical Significance of the Ki-67 Expression before and after the Treatment

Background: Reliable predictive and prognostic markers for routine diagnostic purposes are needed for breast cancer patients treated with neoadjuvant chemotherapy (NAC). Ki-67 is a marker for proliferating cells and is overexpressed in many breast cancers. Aim of this analysis was to evaluate the potential role of Ki-67 as a biomarker for the breast cancer patients with NAC.

Patients and Methods: A retrospective search of a prospectively maintained clinical breast cancer database was performed to identify patients treated with NAC at the National Cancer Center Hospital East. The expression of Ki-67 was assessed using immunohistochemistry (MIB-1) in pretherapy core-needle biopsy and post-therapy surgical excision specimens. Levels of Ki-67 index (percentage of Ki-67 positive cancer nuclei) were dichotomized as high (over 10%) and low (less or equal 10%). Survival curve was calculated using Kaplan-Meier method. Log-Rank test was used to detect differences.

Results: Records were available for 296 patients who were received NAC (anthracycline and/or taxane based) between Nov 2001 and Nov 2009. High and low Ki-67 index in pre-therapy were 173 and 123 cases, respectively. 51 cases (17%) of all achieved a pathological complete response (pCR: no residual invasive disease in the breast). pCR rate (23%) in high Ki-67 was significantly different from that (9%) in low Ki-67. 5-year overall survival estimates were 69% and 75%, respectively. However, there was not difference between the groups in overall survival curve at a median follow-up time of 31 months. Of 245 cases with residual invasive, high and low Ki-67 index in post-therapy were 80 and 165 cases, respectively. 62 cases maintained high Ki-67 index before and after NAC, 94 cases maintained low Ki-67 index. There was significantly difference between high and low Ki-67 indexes of post-therapy in overall survival curve (P&lt;0.01), 5-year overall survival estimates were 51% and 81%, respectively. Moreover, there was not significant different between 51 cases with pCR and low Ki-67 index in overall survival curve.

Conclusions: Although Ki-67 index in pre-therapy is a useful predictor for the therapeutic response to NAC, high Ki-67 index in pre-therapy dose not imply that the patients have a worse prognosis. Ki-67 index in post-therapy is useful to predict outcomes for patients with residual invasive disease.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-28.

Targeting of bone-derived insulin-like growth factor-II by a human neutralizing antibody suppresses the growth of prostate cancer cells in a human bone environment

PURPOSE

Advanced prostate cancer frequently involves the bone, where the insulin-like growth factor (IGF)-II is abundant. However, the importance of IGF-II in bone metastasis from prostate cancer is uncertain. The present study was aimed at examining the therapeutic importance of targeting IGF-II in bone metastases from prostate cancer.

EXPERIMENTAL DESIGN

We investigated whether inhibiting IGF-II using a human neutralizing antibody (m610) suppresses the growth of prostate cancer cells in a human bone environment. Human MDA PCa 2b prostate cancer cells were inoculated into human adult bone implanted into mammary fat pad of nonobese diabetic/severe combined immunodeficient mice or inoculated into mammary fat pad of the mice without human bone implantation. The mice were treated with m610 or a control antibody (m102.4) once weekly for 4 weeks immediately after inoculation with MDA PCa 2b cells.

RESULTS

Histomorphologic examination indicated that m610 treatment significantly decreased the MDA PCa 2b tumor area in the human bone compared with the control. Ki-67 immunostaining revealed that the percentage of proliferating cancer cells in the m610-treated bone tumor sections was significantly lower than that in the control. m610 had no effect on MDA PCa 2b tumor growth in the absence of implanted human bone. m610 prevented the in vitro IGF-II-induced proliferation of MDA PCa 2b cells.

CONCLUSIONS

Our results indicate that IGF-II plays an important role in the prostate cancer cell growth in human bone, suggesting that targeting it by neutralizing antibodies offers a new therapeutic strategy for bone metastasis from prostate cancer.

Effects of ATP on the intracellular calcium level in the osteoblastic TBR31-2 cell line

We investigated the effects of extracellular ATP on TBR31-2 cells established from the bone marrow of transgenic mice harboring the temperature-sensitive simian virus (SV) 40 T-antigen gene. These cells showed the capacity to differentiate toward osteoblasts and could be enhanced by bone morphogenetic protein (BMP)-2, an inducer of osteoblasts. The intracellular calcium ion level ([Ca(2+)](i)) in differentiating TBR31-2 cells was measured by fluorescence confocal microscopic imaging using the Ca(2+)-sensitive probe, Calcium Green 1/AM. P2 receptor agonists, such as ATP (1 microM), uridine 5'-triphosphate (1 microM), and ADP (1 microM), significantly increased the [Ca(2+)](i) of TBR31-2 cells in 2-d and 5-d cultures, but a potent P2X receptor agonist, alpha,beta-methylene ATP (10 microM), did not increase [Ca(2+)](i). The increase in [Ca(2+)](i) induced by ATP in the 2-d culture tended to be higher than in the 5-d culture. The increase in [Ca(2+)](i) of both cultures was inhibited by pyridoxalphosphate-6-azophenyl-2',4'-disulphonic acid, a P2 receptor antagonist. However, in an external Ca(2+)-free condition ATP-induced increase in [Ca(2+)](i) was unchanged at either stage. U73122, phospholipase C inhibitor and Thapsigargin, a calcium-pump inhibitor, significantly inhibited the increase in [Ca(2+)](i) at both stages. Reverse transcription-polymerase chain reaction analysis showed that the expression of P2Y receptor mRNA was higher in the 2-d culture than in the 5-d culture. These results indicate that ATP induces the increase in [Ca(2+)](i) from the calcium store through activating P2Y receptors in TBR31-2 cells and that the 2-d culture can respond to ATP more than the 5-d culture due to the higher expression of P2Y receptors. This suggests that the physiological role of ATP in osteoblasts is altered during differentiation.

Grading system for lymph vessel tumor emboli for prediction of the outcome of invasive ductal carcinoma of the breast

There are no suitable histologic diagnostic clues for determining the true biological malignancy of invasive ductal carcinomas associated with lymph vessel tumor emboli. The purpose of this study was to devise a grading system for lymph vessel tumor emboli in invasive ductal carcinomas that would allow accurate prediction of the outcome of invasive ductal carcinoma patients with lymph vessel invasion. We classified 393 invasive ductal carcinomas into the following 4 grades according to the number of mitotic and apoptotic figures in tumor cells in lymph vessels at 1 high-power field: grade 0, no lymph vessel invasion; grade 1, absence of mitotic and apoptotic figures, presence of any number of mitotic figures and absence of apoptotic figures, or absence of mitotic figures and presence of any number of apoptotic figures; grade 2, 1 to 4 mitotic figures and 1 or more of apoptotic figures, or 1 or more of mitotic figures and 1 to 6 apoptotic figures; and grade 3, more than 4 mitotic figures and more than 6 apoptotic figures. The mortality rate increased with the grade, and the mortality rate of patients with grade 3 lymph vessel tumor emboli was more than 70%. Multivariate analyses with well-known prognostic factors demonstrated that grade 3 lymph vessel tumor emboli significantly increased the hazard rates for tumor recurrence, and tumor death independent of adjuvant therapy status, nodal status, or invasive tumor size. The grading system for lymph vessel tumor emboli is the best histologic grading system for accurately predicting the outcome of patients with invasive ductal carcinoma of the breast.

Dengue hemorrhagic shock and disseminated candidiasis

Dengue fever, one of the common endemic viral fevers, often presents with fever, rash, and mild liver dysfunction. However, plasma leakage induced by dengue virus infection can lead to dengue hemorrhagic fever and dengue shock syndrome, and it can cause severe complications including liver failure and encephalopathy. Infection of dengue virus with other pathogens is an unusual but serious complication. We report a case of dengue shock syndrome with liver failure and impaired consciousness. The patient developed a disseminated Candida tropicalis infection, which may have been due to translocation of the fungus from the intestine damaged by the dengue virus.

Accurate assessment of lymph vessel tumor emboli in invasive ductal carcinoma of the breast according to tumor areas, and their prognostic significance

Lymph vessel tumor emboli (LVTEs) within tumors are difficult to distinguish from stroma-invasive tumor foci. The purpose of this study was to evaluate staining of LVTEs with hematoxylin-eosin (HE) and with D2-40 to determine whether LVTEs identified by HE staining alone are D2-40-positive LVTE and whether the presence of LVTE identified by HE or D2-40 staining is an accurate predictor of outcome in 151 patients with invasive ductal carcinoma (IDC) of the breast. We first attempted to identify LVTE in the stroma-invasive tumor area (intratumor area), the advance area, and the nontumor area by HE staining alone, and then LVTE identified by HE staining was confirmed by D2-40 staining. The number of LVTE identified by HE staining and D2-40 staining successively increased from the intratumor area to the nontumor area. Although D2-40 staining detected larger numbers of LVTE than HE staining in all tumor areas, the highest positive predictive value of LVTE was observed in the intratumor area, and the next was in the advance area, and then the nontumor area, and significant correlations were found between the numbers of LVTE stained by HE and D2-40 in the same tumor areas. LVTE identified by HE staining or D2-40 staining in the intratumor area or nontumor area significantly increased the risk for tumor recurrence or death of patients with IDC, independent of hormone receptor status or nodal status. The results of this study demonstrate that the existence of intratumoral LVTE and that the presence of intratumoral LVTE identified by HE staining or D2-40 staining are accurate predictors of the outcome of patients with IDC of the breast.

A multi-institutional study of radiation therapy for isolated para-aortic lymph node recurrence in uterine cervical carcinoma: 84 subjects out of over 5,000 population

5052

Background: Most patient who had any recurrent sites of cancer, have been considered to be last-stage of life. However, recent advances of clinical research reveal some patients achieve long-term survival even in recurrence cases. Furthermore, patients who had only one recurrent region, even radiation therapy could play an important role. As for uterine cervical carcinoma, the most common recurrent site other than pelvis is para-aortic lymph node. Furthermore, improvement of diagnostic imaging enables us to detect more frequently isolated para-aortic lymph node recurrence. Thus, we conducted the current study. Methods: Between 1994 and 2003, over 5000 uterine cervical carcinoma patients treated with curative intended treatments at sixteen Japanese major hospitals. Out of them, 84 patients developed para-arotic lymph node recurrence as the only site of initial tumor progression. Seventy-four patitents had squamous cell carcinoma and 5 had adenosquamous cell carcinoma and 5 had adenocarcinoma. These patients were treated with external beam radiation therapy prescribing 1.7–2.0 Gy per fraction, 5 fractions per week and median total dose was 50 Gy (25–60 Gy). Thirty-two patients received adjuvant systemic chemotherapy. Results: Median follow-up time of all patients was 20 months (2–92 months). Three- and 5-year overall survival rates of all patients were 49.5% and 31.3%, respectively. Stratified by patients with or without chemotherapy, 3-year overall survival rate of patients with chemotherapy group was 37.7% and those without group was 56.7% (p = 0.69). Moreover, stratified by symptom sign, 3-year overall survival rate of symptom positive group was 27.6% and those of negative group was 56.1% (p = 0.018). Three-year overall survival rates of the total dose ≥ 51Gy and that of ≤ 50 Gy were 58.0% and 42.8%, respectively (p = 0.07). AS for morbidity, no patients received G3 or greater late toxicity (CTCAE ver. 3.0). Conclusions: The current study suggested that radiation therapy for isolated para-aortic lymph node recurrence in uterine cervical carcinoma could have significant impact on overall survival. Furthermore, no symptom group and over 51Gy irradiation group could achieve better prognosis.

No significant financial relationships to disclose.

Predictors of tumour involvement in remaining axillary lymph nodes of breast cancer patients with positive sentinel lymph node

AIMS

To characterize the various clinicopathologic features in cases of breast cancer with positive sentinel lymph nodes (SLNs), in order to determine factors that might help in predicting the involvement of the non-SLNs.

METHODS

A retrospective database review was performed of 726 breast cancer patients with stage 0-II, in whom SLNs were successfully identified. One hundred eighty-five of these patients showed positive SLNs, and subsequently underwent axillary lymph node dissection (ALND). These cases were divided into two groups based on the presence or absence of metastases in the non-SLNs, i.e. positive non-SLNs (NSLN+; 81 cases) and negative non-SLNs (NSLN-; 104 cases).

RESULTS

Multivariate analysis revealed that a larger size of the primary tumour (>2.0cm), presence of lymphatic invasion, larger size of the largest SLN metastasis (>2mm), and a 100% metastatic rate in the SLNs (number of positive SLNs/number of harvested SLNs) were significantly associated with NSLN+. Among the cases in which all the four factors were present, 73% (30/41) were found to have NSLN+.

CONCLUSION

We found four independent predictors in relation to non-SLN metastasis. Although these factors might be useful for determining the need of additional ALND, it would seem that even the presence of all of these four factors in combination may be insufficient to safely omit ALND. Thus, until further evidence is accumulated from the results of large clinical trials, ALND would still be recommended for patients with SLN metastasis.

Correlation between concordance of tracers, order of harvest, and presence of metastases in sentinel lymph nodes with breast cancer

BACKGROUND

There are various methods for the detection of sentinel lymph nodes (SLNs) in breast cancer by using a combined method with blue dye and radioisotope (RI) tracers. The purpose of the study was to reveal any correlation between concordance of the tracers and the order of harvest with the presence of metastases in SLNs.

METHODS

The outcomes were reviewed in 408 cases with stage 0 to II breast cancer; the combined method was used in which blue dye and RI were injected subcutaneously around the tumor. The radioactivity and blue staining in each harvested SLN were checked.

RESULTS

In 330 cases (81%), SLNs contained both blue dye and RI tracers (blue-hot cases), and in 42 (10%) and 31 (8%) cases, the SLNs contained only the blue stain (blue-only cases) and only RI (hot-only cases), respectively. The overall metastatic rate was 25% on a patient basis. Blue-only cases had a higher rate (42%) of metastasis than hot-only cases (14%). The rate of nodes containing both blue dye and RI gradually decreased from the first SLNs harvested to the third SLNs harvested. The rate of nodes containing RI only increased with the number harvested, and there was not so much change in the rate of nodes containing blue only.

CONCLUSIONS

These data suggest that RI tracer could detect a wide range of SLNs and that the blue dye tracer could efficiently detect SLNs with metastasis. The combined methods compensates for the deficiencies of each method and thus will probably help to prevent missing SLNs.

Clinicopathological study of intrapelvic cancer spread to the iliac area in lower rectal adenocarcinoma by serial sectioning

BACKGROUND

The role of iliac lymphadenectomy in surgery for rectal cancer remains unknown. Detailed clinicopathological data on lateral cancer extension may be needed to determine the true role of this procedure.

METHODS

Seventy consecutive patients with low rectal cancer who underwent systematic iliac lymphadenectomy between 1991 and 1995 were reviewed. The iliac area was divided into five regions: (1) middle rectal root, (2) internal iliac, (3) obturator, (4) common iliac and (5) external iliac. Iliac lymph nodes that were cancer-free based on conventional pathological examination were serially sectioned at 100-microm intervals and re-examined for occult microscopic involvement.

RESULTS

Occult microscopic foci were detected in five (7 per cent) of the 70 patients, and the overall incidence of lateral cancer spread was 24 per cent (17 of 70). Among patients without other sites of distant metastasis or circumferential involvement of the margin, the 5-year survival rate of those with lateral spread was 35 per cent. Although the prognosis of patients with cancer involving multiple iliac regions was poor, three of six patients with metastasis to only a single region were alive without disease at 3 years.

CONCLUSION

Surgeons should be aware of the possibility of localized lateral spread, including microscopic metastasis, when determining the optimum procedure for iliac lymphadenectomy in patients with rectal cancer.

Relationship between SCL-90, Maudsley Personality Inventory and CCK4-induced intracellular calcium response in T cells

This study examined the relationship between the Symptom Checklist 90 (SCL-90), Maudsley Personality Inventory (MPI) and cholecystokinin 4 (CCK4)-induced intracellular calcium response in T cells. Fifty-two normal volunteers were 37 males and 15 females; they ranged in age from 23 to 44 years. Measures included CCK4-induced intracellular calcium response in T cells, SCL-90 scores, and MPI. Paranoid ideation and interpersonal sensitivity in SCL-90 showed a significant negative association with CCK4-induced intracellular calcium response. Absent were sex differences and extroversion and neuroticism correlations. There were no significant differences between men and women in SCL-90 or MPI scores. There was no correlation among extroversion and neuroticism and CCK4-induced intracellular calcium response. CCKB receptor function might play a role in paranoid ideation and interpersonal sensitivity.

Allergy to laboratory animals: an epidemiological study

A large cross sectional survey was carried out using a self administered questionnaire to examine the prevalence of laboratory animal allergy (LAA) and the factors associated with its development. Out of 5641 workers who were exposed to animals at 137 laboratory animal facilities in Japan, 23.1% had one or more allergic symptoms related to laboratory animals. The commonest symptom as rhinitis. About 70% of LAA subjects developed symptoms during their first three years of exposure. Atopy (past and family history), the number of animal species handled, and the time spent in handling correlated significantly with the development of LAA as did some types of job. A close relation between nasal symptoms and exposure to rabbits and between skin symptoms and exposure to rats were found. LAA subjects developed symptoms most quickly to rabbits.

Evaluation of a one-way airflow system in an animal room based on counts of airborne dust particles and bacteria and measurements of ammonia levels

Air cleanliness in the working area of an animal room equipped with a conventional turbulent flow air distribution systems was compared with that in a similar room fitted with a one-way-flow air distribution system; in this, the supply air flowed from the working area through the racks of cages and was removed from the exhaust side. Before the introduction of animals, the air in the working and exhaust areas of both rooms was ascertained to be Class 100. With animals in situ, however, whereas in the turbulent airflow room both the workspace and exhaust air reached about Class 10,000 (with particle counts, bacterial counts and ammonia levels being almost the same) in the one-way-flow room, the air in the work space only went up to about Class 1000. With the addition of sliding doors or curtains in front of the rack in the one-way-flow room the work space air was maintained at Class 100 with almost no dust particles over 1 microns in size, airborne bacteria or ammonia being detectable. A comparison of all factors measured showed that whereas in the turbulent flow room the contamination of the work space air was 91% of that of the exhaust air, in the one-way-flow room it was only 47%, with curtains added this was reduced to 7% and with sliding doors to only 2%. In the latter case, contamination levels increased markedly on both sides during and immediately after cage changing, but recovered to the pre-cage changing levels within 30 min in the personnel working area and within 60 min on the exhaust side.

[Air-borne dust and its protein in laboratory animal facilities]

Atopic individuals who were exposed to dust in animal rooms for a long time were more likely than non-atopics to have animal-related symptoms. Standard skin prick tests were performed using crude antigens from dander and urine, and 75 to 100% of atopic persons had positive skin reactions. It seems that allergens in animal rooms result from air-borne dust and the dust originates in animal urine and dander. The protein content occurs as dust particles both below and above 10 micron in diameter. The dust particles above 10 micron cannot pass through face masks, so half of the dust protein is arrested under the mask, but smaller particles pass through. In order to minimize the symptoms, we need to improve the design of cages, animal rooms, experimental rooms, ventilation systems and other protective equipment.

[Effects of environmental temperature on thymus and spleen weights and lymphocytes in mice]

Thymus and spleen weights and lymphocytes in the blood were examined in mice transferred from 22 degrees C to 12 degrees C or 32 degrees C environments. After the exposure to either environment, organ weights tended to decrease. In mice exposed to 12 degrees C, the number of WBCs and mononuclear cells and the ratio and the number of T cells decreased on day 1 and/or 3 after the exposure. The number of B cells also declined on day 3, but the ratio of B cells increased on days 3 and 7. In mice exposed to 32 degrees C, the number of WBCs and mononuclear cells and the number of T cells decreased on day 1 and increased on day 7 and/or 14. The ratio of T cells declined on days 1, 3 and 7, while that of B cells increased on day 3, and the number of B cells increased on day 7. These results show that wide variations in environmental temperature affect the weights of organs and the number of cells which act on immune responses in mice.

Canine storage disease characterized by hereditary progressive neurogenic muscular atrophy: breeding experiments and clinical manifestation

Progressive neurogenic muscular atrophy due to storage of a compound lipid in the lower motor neurons was diagnosed in 3 English Pointers that were littermates. Using 2 clinically normal littermates of these 3 affected dogs and 2 clinically normal dogs of the 2nd litter from the parents of the original 3 affected dogs as the initial breeding stock, a breeding experiment was performed, resulting in a breeding line of 26 dogs, 4 of which had the disease and 6 of which died before 3 months of age. Results indicated that the disease may have an autosomal recessive mode of inheritance. The clinical manifestation and electrophysiologic findings indicated lower motor neuron involvement in the affected dogs produced by breeding consistent with findings in the original 3 affected dogs. Upper motor neurons or the sensory system was not involved. The disease appeared to be distinct from other canine storage diseases previously reported.

[Circadian rhythm of air-borne bacteria and dust particles in a mouse breeding room]

The circadian rhythm of air-borne bacteria and dust particles in a mice breeding room was studied at 1-hour intervals on the first, third and fifth day after accommodation of the animals. The numbers of air-borne bacteria in the room increased day by day after accommodation, and showed a circadian rhythm which went down at about noon and rose with three peaks at about 20:00, 1:00 and 8:00. The numbers of dust particles tended to decrease from day to day, and they showed almost the same circadian rhythm as the air-borne bacteria. Correlations between air-borne bacteria and dust particles were not significant for each particle level on the first day, but were significant for all the particle levels of 0.3, 1, 2, and 5 microns at the third day, and were also significant at particles levels of 0.5 micron or more on the fifth day.

[Filter efficiency of commercial face masks in capturing particles and airborne bacteria]

The filter efficiency of seven kinds of commercial face mask for particles and airborne bacteria was tested in the wash room of a laboratory animal facility. The filter efficiency of the masks was 19 to 50%, as measured by the weight of particles with diameters below 10 micron, 22 to 71% for particles of the 0.3 micron level, 47 to 90% for the 1 micron level, and 90 to 99.6% for the 5 micron level. The filter efficiency for airborne bacteria was 35 to 81%. Among these even masks tested, glasswool surgery masks, three-sheet synthetic fiber masks with and without charcoal, and 28-sheet gauze masks with glass filter showed generally high efficiency, and single-sheet synthetic fiber masks, 18-sheet of gauze masks and gas masks showed low efficiency.

[The effects of fur on the thermal regulation of mice (Mus musculus)]

In order to ascertain the thermal insulation function of fur in mice, food and water intakes and rectal and skin temperatures were observed in Jcl: ICR mice and a group of the same species with their fur clipped, as well as BALB/C nu/+ and nu/nu mice. Food and water intakes increased as the ambient temperature dropped. The rectal temperature remained almost unchanged at ambient temperatures of from 18 to 30 degrees C. Skin temperatures were highest at side of the abdomen, lower at the neck, and lowest at the head. There was a tendency for skin temperatures to increase as the ambient temperature rose. The skin temperatures of mice with fur were higher than those of mice without fur. The thermal insulation of fur was 0.25, 0.14 and -0.06 clo at 18, 22, 26 and 30 degrees C in ICR mice, and 0.36, 0.01, 0.01 and -0.03 clo at 18, 22, 26 and 30 degrees C in BALB/C mice, respectively. These results confirm that heat loss from the skin at low temperatures could be prevented by the presence of fur. It also appeared that the hairless mice mutant had a lower metabolic rate than the animals with their fur clipped.

[Influence of blood pressure control on delivery in pregnant rats in a warm environment]

The relation between blood pressure and delivery in pregnant rats was investigated when the blood pressure of pregnant rats was controlled by a pressor or antihypertensive drug in the middle or final stage of pregnancy. All of the pregnant rats studied delivered in a 23 degrees C environment in spite of blood pressure control by a pressor or antihypertensive drug. At 33 degrees C, the pregnant rats were divided into two groups whose blood pressure was increased severely (160-175 mm Hg) or moderately (145-155 mm Hg) at 10 days of pregnancy. Those in the former group delivered, but those in the latter died in the final stage of pregnancy. When the pregnant rats in the group with high blood pressure on day 10 were treated with a antihypertensive drug in the middle stage of pregnancy or with a pressor drug in the final stage, the mortality rate was 100 per cent in both cases. The delivery rate was 57 per cent when the pregnant rats were treated with a antihypertensive drug from the middle to the final stage of pregnancy. In the group with low blood pressure on day 10, all of the pregnant rats delivered when they were treated with a pressor drug in the middle stage of pregnancy. However, the delivery rate was 89 per cent when the pregnant rats were treated with antihypertensive drug in the final stage of pregnancy.

[Influence of hot environment on body temperature, heart rate and blood pressure of pregnant rats]

Twenty-six out of fifty pregnant rats died on days 18-20 of gestation at 33 degrees C environment. The death generally occurred in the dark period around 1-5 a.m. Shortly prior to the death, very high body temperature of 42.0-43.7 degrees C were recorded and the blood pressure was undetectably low. In autopsy, the finding in the main was the congestion in lungs and liver. In temporal changes of body temperature and heart rate, influences of hot environment were observed, but there was no significant difference between dead pregnant group and delivered pregnant group at 33 degrees C environment. At 23 degrees C, the blood pressure of pregnant rats starting at about 140 mmHg level, reached 160-168 mmHg on day 12 of gestation and maintained the level to day 16. On day 18, the pressure returned to 140-145 mmHg and unchanged to term. At 33 degrees C, significant differences were obviously observed between dead group and delivered group in temporal changes of blood pressure. The blood pressure of rats delivered sharply increased to 170 mmHg or more in the middle stage of pregnancy and decreased to about 140 mmHg in the final stage. However, these of dead group increased to 160 mmHg or less in the middle stage of pregnancy, and maintained the level until the final stage.

Effects of room temperature on reproduction, body and organ weights, food and water intakes, and hematology in mice

Two consecutive generations of mice were raised at graded room temperatures ranging from 12 to 32 degrees C at intervals of 2 degrees C. The delivery rate decreased at 30 and 32 degrees C, and the litter size and weaning rate decreased above 28 degrees C. No significant difference was demonstrated within the 12-26 degrees C range for any reproduction parameters observed. The body weights of the first-generation mice born at 22 degrees C and transferred to rooms at assigned temperature did not significantly differ within the 14-28 degrees C range after 8 and 16 weeks of exposure. The second-generation mice born and reared at various temperature levels did not show significant inter-group difference in weight within the 20-26 degrees C range at any age in the growth period. No significant inter-group difference was observed within the 20-26 degrees C range in respect of food and water intakes in the second-generation mice. Hematological values and organ weights in the first and second generation mice of both sexes did not significantly differ in any parameter within the 20-26 degrees C range. The results suggest the temperature range of 20-26 degrees C to be optimal for laboratory mouse rooms.

Morphological study on the hereditary neurogenic amyotrophic dogs: accumulation of lipid compound-like structures in the lower motor neuron

A morphological study was performed on hereditary neurogenic amyotrophic dogs, the clinical features of which especially resembled spinal progressive muscular atrophy (SPMA), a human motor neuron disease. The skeletal muscles showed obvious neurogenic atrophy with endomysial fibrosis. The peripheral nerves revealed axonal degeneration mainly limited to the motor nerve. In the spinal cord, the number of anterior horn cells seemed normal but, interestingly enough, numerous accumulated granules were detected in these anterior horn cells. Histochemically, these granules were interpreted as a lipid compound. Under the electron microscope, the granules were disclosed as multi-lamellar structures, arranged concentrically or in parallel, resembling membranous cytoplasmic bodies (MCBs) or zebra bodies. This finding strongly suggests that hereditary abnormality of lipid metabolism may underlie SPMA in these dogs. However, unlike other metabolic disorders where accumulations of granules are diffusely distributed, in the dogs we examined accumulations were found only in the anterior horn cells of the spinal cord and in the hypoglossal and spinal accessory nuclei. We are unable to explain this occurrence at the present time. Further investigations should be made on dogs because they serve as an important animal model of human motor neuron disease.

Effects of room temperature on reproduction, body and organ weights, food and water intake, and hematology in rats

Two generations of rats were raised at animal room temperature ranging from 12 to 32 degrees C at steps of 2 degrees C. The body weight of rats born in 22 degrees C environment and exposed to each temperature did not significantly differ within the range of 16-28 degrees C. The delivery rate, litter size, and weaning rate decreased at 30 degrees C and 32 degrees C, and only the weaning rate had a tendency to decrease at 12 degrees C. No significant difference was demonstrated within the 14-28 degrees C range for any reproduction parameter observed. The body weight of sucklings did not differ at birth within the 12-32 degrees C range; and at 3 weeks of age, there were no differences within the range of 18-28 degrees C. The body weight gain in both sexes after weaning was generally small when the temperature was below 18 degrees C or above 30 degrees C. There were no significant differences in food intake within the 20-26 degrees C range, in water intake within the 12-26 degrees C range, in hematological and serum biochemical values within the 20-26 degrees C range, and in organ weights within the 18-28 degrees C range. Therefore, the range of 20-26 degrees C (68-78 degrees F) was the optimum temperature range in rat rooms.

[Distribution of environmental temperature and relative humidity according to the number of conditioned air changes in laboratory animals rooms]

The relation of the rate of circulating air change to room temperature and relative humidity in animal quarters with a central air-conditioning system during heating and cooling seasons was investigated, with the results as follows: During the period of heating, the ambient temperature generally rose with a fall of relative humidity as the number of conditioned air changes per hour was increased. Vertical differences in temperature and humidity between levels of 0.5 and 1.5 m above the floor also diminished with increasing air change rate. This tendency was more conspicuous in small animals rooms with outer walls facing north and west. With increasing rate of air changes, the room temperature was prone to decline and the relative humidity to rise during the period of cooling. There were less vertical differences in temperature and humidity during this period. The velocity of air circulation within the animal quarters and its variations tended to increase progressively with increasing rate of ventilation, though the changes were modest.

[Observation on the air-borne bacteria and ammonia (NS3) gas in laboratory animal facility with rotary heat exchanger]

The number of air-borne bacteria in air ducts and barrierred laboratory animal rooms with the so-called econovent rotary heat exchanger, were checked monthly during a year by the pin-hole sumpler method for air ducts and Koch method for animal rooms. Also, concentration of ammonia was checked with the same samples by gas impinger. No significantly difference in number of air-borne bacteria was seen between before and after passing the econovent. Those passing through HEPA filter was not detected. There were more air-borne bacteria in animal rooms, outside locker room and shower room than in the corridor, utensil storage, inside locker room and pass box. No ammonia were detected in the outdoor, but exhaust air duct after passing the econovent contained very small amount of ammonia. On the other hand, high concentration of ammonia were preserved in the supplying air duct, exhaust air duct and mice and rats rooms, about 86% of ammonia in exhaust air duct returned back into the supplying air duct. No influences on reproduction in mice and rats were recognized.