Prediction of outcome of early ER+ breast cancer is improved using a biomarker panel, which includes Ki-67 and p53

Background:

The aim of this study is to determine whether immunohistochemical (IHC) assessment of Ki67 and p53 improves prognostication of oestrogen receptor-positive (ER+) breast cancer after breast-conserving therapy (BCT). In all, 498 patients with invasive breast cancer from a randomised trial of BCT with or without tumour bed radiation boost were assessed using IHC.

Methods:

The ER+ tumours were classified as ‘luminal A’ (LA): ER+ and/or PR+, Ki-67 low, p53−, HER2− or ‘luminal B’ (LB): ER+ and/or PR+and/or Ki-67 high and/or p53+ and/or HER2+. Kaplan–Meier and Cox proportional hazards methodology were used to ascertain relationships to ispilateral breast tumour recurrence (IBTR), locoregional recurrence (LRR), distant metastasis-free survival (DMFS) and breast cancer-specific survival (BCSS).

Results:

In all, 73 patients previously LA were re-classified as LB: a greater than four-fold increase (4.6–19.3%) compared with ER, PR, HER2 alone. In multivariate analysis, the LB signature independently predicted LRR (hazard ratio (HR) 3.612, 95% CI 1.555–8.340, P=0.003), DMFS (HR 3.023, 95% CI 1.501–6.087, P=0.002) and BCSS (HR 3.617, 95% CI 1.629–8.031, P=0.002) but not IBTR.

Conclusion:

The prognostic evaluation of ER+ breast cancer is improved using a marker panel, which includes Ki-67 and p53. This may help better define a group of poor prognosis ER+ patients with a greater probability of failure with endocrine therapy.

ATM induction insufficiency in a radiosensitive breast-cancer patient

The ataxia telangiectasia (A-T) gene (ATM) is a dominant breast cancer gene with tumour suppressor activity. ATM also regulates cellular sensitivity to ionising radiation (IR) presumably through its role as a facilitator of DNA repair. In normal cells and tissues the ATM protein is rapidly induced by IR to threshold/maximum levels. The kinase function of the ATM protein is also rapidly activated in response to IR. The fact that women carriers of ATM mutations can have an increased risk of developing breast cancer and that many sporadic breast tumours have reduced levels of the ATM protein broadens the scope of ATM's tumour suppressor within the breast. This report describes the downregulation of ATM protein levels in a radiosensitive breast cancer patient. Postinduction ATM levels were up to tenfold lower in the patient's fresh tissues compared to normal controls. These results might indicate a much broader role for ATM anomalies in breast cancer aetiology.

Rapid radiation-induction of ATM protein levels in situ

Ataxia-telangiectasia (A-T) is characterised by hypersensitivity to ionising radiation (IR), immunodeficiency, neurodegeneration and predisposition to malignancy. Mutations in the A-T gene (ATM) often result in reduced levels of ATM protein and/or compromise ATM function. IR induced DNA damage is known to rapidly upregulate ATM kinase activity/phosphorylation events in the control of cell cycle progression and other processes. Variable expression of ATM levels in different tissues and its upregulation during cellular proliferation indicate that the level of ATM is also regulated by mechanisms other than gene mutation. Here, we report on the IR induction of ATM protein levels within a number of different cell types and tissues. Induction had begun within 5 min and peaked within 2 h of exposure to 2 Gy of IR, suggesting a rapid post-translational mechanism. Low basal levels of ATM protein were more responsive to IR induction compared to high ATM levels in the same cell type. Irradiation of fresh skin biopsies led to an average three-fold increase in ATM levels while immunohistochemical analyses indicated "low expressing" cells within the basal layer with ten-fold increases in ATM levels following IR. ATM "high expressing" lymphoblastoid cell lines (LCLs) which were initially resistant to the radiation-induction of ATM levels also became responsive to IR after ATM antisense expression was used to reduce the basal levels of the protein. These results demonstrate that ATM is present in variable amounts in different tissue/cell types and where basal levels are low ATM levels can be rapidly induced by IR to saturable levels specific for different cell types. ATM radiation-induction is a sensitive and rapid radioprotective response that complements the IR mediated activation of ATM.

ATM protein synthesis patterns in sporadic breast cancer

AIMS

The gene mutated in ataxia-telangiectasia (A-T), designated ATM (for "A-T mutated"), is believed to be associated with an increased risk of developing breast cancer. Most patients with A-T have null mutations of the ATM gene that appear to give rise to a truncated nonfunctional ATM protein. Therefore, the increased risk of breast cancer reported in A-T heterozygotes appears to be the result of haplo-insufficiency of ATM in breast tissues. This study aimed to determine whether reduced synthesis of ATM was also an important factor in sporadic breast cancer.

METHODS

Paraffin wax embedded tissues from patients with breast invasive ductal carcinoma (IDC) (n = 42), patients with ductal carcinoma in situ (DCIS) (n = 17), and others with lymph node metastases (n = 14) were studied. A streptavidin-biotin-peroxidase system was used to stain tissue sections for the ATM protein using the ATM-4BA and CT-1 polyclonal and monoclonal antibodies, respectively. The protein truncation test was used to screen for mutations in the ATM gene in those patients who had greatly reduced ATM protein immunoreactivity in the primary carcinoma (n = 3).

RESULTS

Most metastatic breast carcinomas in lymph nodes (71%) had greatly reduced or absent ATM protein synthesis, which was significant when compared with that observed in non-metastatic invasive breast carcinomas (p = 0.029; chi 2 test). Although not significant (p = 0.045; chi 2 test), some sporadic breast carcinomas (14 of 42) also had reduced or absent ATM protein immunoreactivity. The protein truncation test did not reveal any gross ATM gene abnormality in the cases tested, indicating that the patients were not A-T heterozygotes, who are predisposed to breast cancer.

CONCLUSIONS

A reduction in immunohistochemically detectable ATM protein in sporadic breast carcinoma implicates ATM in the progression of the disease.

Malignant phyllodes tumours of the breast display increased stromal p53 protein expression

AIMS

To determine the variation in p53 protein expression in phyllodes tumours and fibroadenomas of the breast.

METHODS AND RESULTS

Fifteen phyllodes tumours (six malignant, nine benign) and 20 fibroadenomas were examined for p53 expression by immunohistochemistry. Five of the six malignant phyllodes tumours showed moderate or strong p53 positivity at sites of peri-epithelial stromal condensation and atypia. All 20 fibroadenomas, nine benign phyllodes tumours and one malignant phyllodes tumour showed either negativity or focal weak nuclear positivity of scattered stromal cells.

CONCLUSIONS

Increased p53 immunoreactivity is present in malignant phyllodes tumours in contrast to benign phyllodes tumours and fibroadenomas. Malignant phyllodes tumours display a distinctive pattern of p53 immunostaining which may be of diagnostic value. These findings suggest that p53 protein may be important in the progression of benign to malignant phyllodes tumours.

nm23 protein expression and p53 immunoreactivity in cutaneous fibrohistiocytic tumors

Recent data indicate that reduced expression of the 17-kD protein encoded by the nm23 gene may be important in the pathogenesis of several types of human tumors. Immunohistochemistry was performed using a murine monoclonal antibody, NCL-nm23 (Novocastra, 1:150 dilution) to investigate nm23 protein immunoreactivity in a group of locally aggressive cutaneous fibrohistiocytic tumors; dermatofibrosarcoma protuberans (DFSP) (n = 14) and atypical fibroxanthoma (AFX) (n = 7). Cases of dermatofibroma (DF) (n = 17) formed the benign control group. Comparison with p53 protein immunoreactivity in the same cases studied previously was made. Strong immunohistological expression of the nm23 protein was seen in most of the cases of DF (n = 15; 88%) in the form of strong cytoplasmic immunolabelling without nuclear staining. However, strong nm23 immunoreactivity was observed in only a minority of the cases of DFSP (n = 5; 36%) and AFX (n = 2; 29%). Statistically significant differences in nm23 immunoreactivity were found between DFSP and DF (p = 0.008, chi 2 test with continuity correction) and between AFX and DF (p = 0.015; chi 2 test with continuity correction). No significant difference was seen between DFSP and AFX (p = 0.87, chi 2 test with continuity correction). There was inverse correlation between nm23 and p53 immunoreactivity (r = 0.331; r2 = 0.109; p = 0.046; simple regression analysis). In summary, nm23 protein immunoreactivity is reduced in DFSP and AFX but not in dermatofibroma suggesting that reduced expression of the protein may be important in influencing the behavior of fibrohistiocytic tumors, although this is not well characterised. nm23 protein expression is also found to be inversely related to p53 immunohistological expression in these tumors.

Heterogeneity in Klippel-Feil syndrome: a new classification

BACKGROUND

Klippel-Feil syndrome (KFS) is characterised by congenital vertebral fusion of the cervical spine and a wide spectrum of associated anomalies. KFS has often been considered a sporadic syndrome. However, since the publication of the original KFS classification early this century, a number of KFS families have indicated heterogeneity complicated by a broad range of variable expression.

OBJECTIVE

The two major objectives of this study were (1) to identify differences and similarities in the postnatal appearance, morphology, position and inheritance of vertebral fusions within and between KFS families and (2) to establish a new KFS classification focussed on KFS aetiology.

MATERIALS AND METHODS

Vertebral fusions were assessed via spinal radiography. Chromosomal karyotypes were performed using routine cytogenetics.

RESULTS

The medical histories of three KFS families are presented. The postnatal time, position and appearance of vertebral fusions, associated anomalies and mode of inheritance were different for the three KFS families. Four classes of KFS are described in a comprehensive classification table that allays much of the uncertainty arising from KFS heterogeneity and variable expression.

CONCLUSION

We have described four different KFS classes (KF1-4) within a comprehensive classification that addresses KFS genetic heterogeneity. The position of vertebral fusions in the cervical spine and their incidence within affected families are delineating features of KFS.

Quality-of-life assessment during palliative radiotherapy

A total of 164 consecutive patients with a range of biopsy-proven locally advanced or metastatic cancers were interviewed to assess quality of life using the Rotterdam Symptom Check List (RSCL) at three longitudinal time intervals during a course of palliative radiotherapy. Of the 164 patients, 120 were able to complete all 3 questionnaires. Paired t-tests were used to assess the significance of changes in the patients' mean scores over time. Of the 33 symptoms assessed in the RSCL, changes in the degree of symptomatology were highly consistent with changes expected in clinical practice, as a result of either disease progression or side effects of treatment. It is concluded that the RSCL provides a practical assessment of various symptoms in patients receiving palliative radiotherapy, and that the changes in symptom profile over time are relevant to clinical practice. The RSCL has never been previously used in the assessment of palliative radiotherapy, and the present study validates this instrument.

Liver metastases from transitional cell carcinoma are lipiodol avid

A case of transitional cell carcinoma of the bladder with symptomatic liver metastases is presented. When conventional chemotherapy failed, a lipiodol CT scan demonstrated avid uptake by the tumours, which has implications for targeted cancer therapy.

Upregulation of ATM in sclerosing adenosis of the breast

The gene mutated in ataxia telangiectasia (ATM) has an established tumour suppressor role in breast cancer. ATM appears to be expressed in most normal cells, including breast epithelium, where it has been postulated to have a nuclear role in cell cycle regulation following DNA damage. However, ATM is not upregulated after DNA damage. In this study, we demonstrate an absence of immunohistologically detectable levels of ATM in the normally quiescent myoepithelial cells that line normal breast ducts. This contrasts dramatically with the significant expression of ATM in the proliferative myoepithelium of sclerosing adenosis (n = 7). This upregulation of ATM suggests that ATM expression is coupled to the proliferative status of the myoepithelium. Our results also indicate that there are factors other than ATM gene mutations that can dramatically influence ATM expression in the breast and that these factors should be considered for their possible implications in carcinogenesis.

Clinical radiohypersensitivity screening using radiation-induced chromosomal aberrations

Severe acute toxicity to radiotherapy (radiohypersensitivity) can limit the effective use of radiotherapy and it is not usually possible to identify such individuals before treatment commences. Five patients with acute radiohypersensitivity (RH) were detected over a 3-year period. All five RH subjects demonstrated a significantly higher degree of radiation-induced chromosomal aberrations (ICA) in fresh blood lymphocytes when compared to normal controls. Results indicate the feasibility of using the ICA assay in conjunction with other tests to screen for radiosensitivity.

Delayed presentation of primary testicular seminoma

A case is reported here of delayed presentation of primary testicular seminoma, 9 years after initial presentation with retroperitoneal disease. The diagnostic difficulty associated with primary extragonadal germ cell tumour is emphasized.

Absence of ATM truncations in patients with severe acute radiation reactions

PURPOSE

Severe acute toxicity limits the effective use of radiotherapy in patients who are radiosensitive, and it is not usually possible to identify these radiohypersensitive (R-H) individuals before treatment commences. Five such R-H patients were detected over a 3-year period. We undertook this study to determine whether the severe acute radiohypersensitivity of these five individuals showed any correlation with cellular and molecular parameters known to be abnormal in radiosensitivity-related syndromes such as ataxia-telangiectasia (A-T).

METHODS AND MATERIALS

Lymphoblastoid cells were isolated from fresh blood from the 5 R-H individuals who had previously demonstrated clinical R-H at least 9 months prior to sampling. Lymphoblastoid cell lines (LCLs) were established to determine the extent of postradiation chromosomal aberrations, cell cycle delay, cell proliferation, and tumor suppressor p53 protein stabilization. The polymerase chain reaction (PCR) and protein truncation (PTT) assays were used to test for the possibility of mutations in the gene mutated in A-T, termed ATM.

RESULTS

LCLs derived from R-H subjects retained a significantly higher degree of radiation-induced chromosomal aberrations when compared to normal control LCLs. p53 stabilization by ionizing radiation appeared normal in all but one R-H subject. There was no evidence of A-T gene truncation mutations in any of the R-H subjects tested.

CONCLUSIONS

All R-H subjects in this study had their cellular radiosensitivity confirmed by the chromosomal aberration assay. Delayed p53 stabilization at 4 hours postirradiation in one R-H subject suggested that different etiologies may apply in the radiohypersensitivity investigated in this study.

Production and verification of an anti-ovine IgE monoclonal antibody

Recombinant mouse/sheep IgE was used in the production of an anti-IgE monoclonal using conventional hybridoma techniques. The specificity of hybridomas secreting anti sheep IgE monoclonal antibodies was verified using a number of assays including competitive ELISAs, ability to induce mediator release from mast cells, and IgE binding using western blotting. Immunohistochemical staining demonstrated the binding of putative anti-IgE monoclonals to the sheep mast cell surface. The isotype of the antibody was IgG1:K.

Loss of heterozygosity studies in squamous cell carcinomas of the head and neck

BACKGROUND

Loss of heterozygosity (LOH) studies have been pivotal in identifying tumor suppressor genes involved in the pathogenesis of a number of cancers. In squamous cell carcinomas of the head and neck region (SCCHN), LOH studies using the Southern blot technique are scarce.

METHODS

SCCHNs were obtained immediately after surgical resection from 78 patients. Histologic confirmation was made by frozen section and tumors with less than 50% malignant cells were excluded. DNA was digested with restriction enzymes, and after Southern blotting the membranes were hybridized with radio-labeled probes. Chromosome arms analyzed included 1p, 3p, 4p, Sq, 8p, lOp, 11p, 11q, 13q, 17p, 17q, 18q, 21q, and 22q.

RESULTS

The average rate LOH was 25% per chromosome arm. Significantly higher rates of LOH were observed for chromosome arms 5q (56%) and 17p (45%). Other investigators have reported high rates of LOH for the H- ras-1 locus, and chromosome arms 11p, 11q, and 13q. However, these results were not confirmed in this study. For patients with stage 1 or 2 tumors, the overall LOH rate was 13%, and for patients with stage 3 or 4 disease the rate was 23%. This difference was statistically significant (p < 0.025).

CONCLUSIONS

tumors progress to higher stages, they appear to accumulate an increasing number of genetic abnormalities. Chromosome arms 5q and 17p contain tumor suppressor genes which are likely to be involved in the pathogenesis of SCCHN:

An open multicentre study of tropisetron for cisplatin-induced nausea and vomiting

OBJECTIVES

(i) To assess the efficacy and tolerability of tropisetron when used for acute and delayed cisplatin-induced emesis. (ii) To investigate whether dexamethasone added to tropisetron improves the control of emesis for patients who do not achieve a complete response to tropisetron alone. (iii) To assess sex of the patient and alcohol intake as prognostic factors for nausea and vomiting.

DESIGN

A prospective open label phase II trial over one or two cycles of chemotherapy. Data collection was based on observed response and patients' self-reporting.

SETTING

Twenty Australian tertiary care hospitals in 1994.

PATIENTS

102 male and female patients from 18 to 75 years with histologically confirmed malignancy receiving their first chemotherapy containing > or = 50 mg/m2 cisplatin.

INTERVENTION

In Cycle 1 tropisetron 5 mg was given intravenously before chemotherapy on Day 1, then 5 mg orally before breakfast on Days 2 to 6. In Cycle 2, dexamethasone 20 mg intravenously on Day 1, then 8 mg orally on Days 2 to 6 could be added to tropisetron if a complete antiemetic response had not been achieved in Cycle 1.

MAIN OUTCOME MEASURES

Number of vomiting episodes and severity of nausea for 6 days after chemotherapy; severity of side effects; patient satisfaction with chemotherapy treatment; oestradiol levels in women; and past alcohol consumption in men and women.

RESULTS

(i) The complete response rate (CR) for acute emesis in Cycle 1 was 64% (95% confidence interval [CI], 54%-72%), with 84% (95% CI, 76%-90%) having < or = 2 vomits. The CR for delayed emesis was 24% (95% CI, 17%-32%). The CR for acute nausea was 56% (95% CI, 47%-66%), with 97% (95% CI, 91%-99%) having < or = 2 nausea episodes. The CR for delayed nausea was 21% (95% CI, 14%-30%). Seventy-one patients received Cycle 2. The main side effects were headache (20 patients) and constipation (16 patients). The control of acute emesis was rated as "good" or "very good" by 68% of investigators; 85% rated the tolerability of treatment as "good" or "very good". Treatment was rated as "very satisfactory" or "satisfactory" by 52% of patients. (ii) The CR for acute emesis with dexamethasone added was 78% (95% CI, 64%-88%). (iii) Women with lower oestradiol levels had better control of emesis, although this difference was not statistically significant. Chronic alcohol intake and binge drinking were strongly associated with a complete acute antiemetic response.

CONCLUSIONS

Tropisetron was effective for acute cisplatin-induced emesis; adding dexamethasone enhanced this response. Both single and combined therapy had less effect on delayed emesis. The impact of alcohol on control of emesis is a chronic rather than acute phenomenon which requires prospective testing.

Patterned expression in familial Klippel-Feil syndrome

Klippel-Feil syndrome (KFS) is characterised by congenital fusion of vertebrae within the rostral spine. The first KFS gene (SGM1) locus identified on chromosome 8 segregates with vertebral fusions and associated vocal impairment within the KF2-01 family (Clarke et al., '94, '95). Here, we describe the unique pattern of variable phenotypic expression within the KF2-01 family. The pattern of anomalies revealed a cumulative, rostrocaudal graded sequence of skipped vertebral fusions. This fusion pattern presents striking similarities with the mutant phenotype and gene expression profile of the Drosophila segment polarity gene engrailed.

Familial Klippel-Feil syndrome and paracentric inversion inv(8)(q22.2q23.3)

Klippel-Feil Syndrome (KFS) is characterized by congenital vertebral fusion believed to result from faulty segmentation along the embryo's developing axis. KFS appears to be a heterogeneous disease often associated with craniofacial malformation. Here we provide the first evidence of a familial KFS gene locus on 8q, where an inv(8)(q22.2q23.3) has been found segregating with congenital vertebral fusion. The four-generation KF2-01 family present with dominant form of the KFS where the sequence of vertebral fusion was confined to the cervical spine (always including the C2-3 fusion and reduced expression of the C4-5 and C6-7 fusions) in association with malformation of laryngeal cartilages and mild-to-severe vocal impairment.

Radiation sensitivity of Merkel cell carcinoma cell lines

PURPOSE

Merkel cell carcinoma (MCC), being a small cell carcinoma, would be expected to be sensitive to radiation. Clinical analysis of patients at our center, especially those with macroscopic disease, would suggest the response is quite variable. We have recently established a number of MCC cell lines from patients prior to radiotherapy, and for the first time are in a position to determine their sensitivity under controlled conditions.

METHODS AND MATERIALS

Some of the MCC lines grew as suspension cultures and could not be single cell cloned; therefore, it was not possible to use clonogenic survival for all cell lines. A tetrazolium based (MTT) assay was used for these lines, to estimate cell growth after gamma irradiation. Control experiments were conducted on lymphoblastoid cell lines (LCL) and the adherent MCC line, MCC13, to demonstrate that the two assays were comparable under the conditions used.

RESULTS

We have examined cell lines from MCC, small cell lung cancer (SCLC), malignant melanomas, Epstein Barr virus (EBV) transformed lymphocytes (LCL), and skin fibroblasts for their sensitivity to gamma irradiation using both clonogenic cell survival and MTT assays. The results show that the tumor cell lines have a range of sensitivities, with melanoma being more resistant (surviving fraction at 2 Gy (SF2) 0.57 and 0.56) than the small cell carcinoma lines, MCC (SF2 range 0.21-0.45, mean SF2 0.30, n = 8) and SCLC (SF2 0.31). Fibroblasts were the most sensitive (SF2 0.13-0.20, mean 0.16, n = 5). The MTT assay, when compared to clonogenic assay for the MCC13 adherent line and the LCL, gave comparable results under the conditions used.

CONCLUSION

Both assays gave a range of SF2 values for the MCC cell lines, suggesting that these cancers would give a heterogeneous response in vivo. The results with the two derivative clones of MCC14 (SF2 for MCC14/1 0.38, MCC14/2 0.45) would further suggest that some of them may develop resistance during clonogenic evolution.

Post-orchidectomy radiation therapy alone for patients with early stage non-seminomatous germ cell tumours of the testis

The aim of this study was to review the patterns of disease relapse and survival outcomes for patients treated post-orchidectomy with radiotherapy for early stage (I and IIA) non-seminomatous germ cell tumors of the testis (NSGCT). The clinical records were reviewed of 117 men consecutively treated at the Queensland Radium Institute from 1960-90 (inclusive) for stage I or IIA NSGCT. A total of 108 patients received radiotherapy to the para-aortic nodes and ipsilateral hemipelvis following orchidectomy; nine patients received radiotherapy to the para-aortic nodes and whole pelvis. Twenty-two of 99 (22.2%) stage I and eight of 18 (44.4%) stage IIA patients relapsed following definitive radiotherapy. The 5 year overall and recurrence-free survivals were 84 and 75%, respectively. Factors associated with a significantly worse outcome included: (i) patients with stage IIA disease; (ii) the presence of undifferentiated elements in the operative specimen; (iii) a primary tumor < 5 cm size; and (iv) treatment given prior to 1979. Given the unsatisfactory recurrence rate following radiation therapy alone and the availability of cisplatin-based chemotherapy regimens, it is recommended that radiation therapy alone for patients with early stage NSGCT be abandoned in favour of other management strategies.

The importance of postoperative radiation therapy in the treatment of Merkel cell carcinoma

PURPOSE

To determine the role of postoperative radiation therapy in the treatment of Merkel cell carcinoma (MCC).

METHODS AND MATERIALS

Eighty patients with MCC of the skin were treated with curative intent at the Queensland Radium Institute between 1981 and 1991. Fifty-one patients (63.7%) were referred after initial biopsy for further treatment and 29 patients (36.3%) were referred with locally recurrent disease following primary surgery elsewhere. Thirteen patients (16.3%) presented with nodal disease without a clinically definable primary skin lesion.

RESULTS

Of the 80 patients, 38 had undergone surgery (S) alone, 34 surgery plus radiotherapy (S + RT), 7 RT after incomplete S, and 1 patient had chemotherapy (CT) plus RT. Overall survival at 36 months for all patients was 68%. All of the 38 patients treated with S alone relapsed. The median time to recurrence was 5.5 months. Ten of the 34 patients treated with S + RT relapsed. The median time to recurrence was 16.5 months. Of the 80 patients, 55 have relapsed after primary treatment, 25 have developed systemic metastases, and 26 patients have died as a direct result of MCC.

CONCLUSION

Our large series confirms earlier reports from this Institute and highlights the importance of S + RT over S alone in preventing local recurrence of this highly malignant skin cancer.

Characterisation of four Merkel cell carcinoma adherent cell lines

We have previously described the establishment of a number of cell lines from Merkel cell carcinoma (MCC), also known as small cell cancer of the skin or neuroendocrine carcinoma of the skin. These cells, all of which grew as suspension cultures, were found to resemble small cell lung cancer (SCLC) lines types 1, 2 and 3 by their morphology and growth characteristics. We now report 4 more MCC cell lines which resemble the SCLC type 4 cell lines in that they grow as adherent monolayers. These MCC lines would belong to the variant subgroup as they no longer express most neuroendocrine markers, grow at low cell density and have population doubling times of 1-5 days in contrast to the MCC suspension lines which have doubling times of 6-12 days. MCC14/1 and MCC14/2 were established from the same metastatic node and would appear to represent 2 clones of the tumour which differ in morphology, histochemical markers and DNA content. We present details of the morphology, DNA content and immunohistochemistry of these 4 lines and compare their growth patterns with those of SCLC and MCC lines which grow in suspension.

Molecular biology and the radiation oncologist

An overview is provided of several recent advances in our understanding of the molecular events that occur when cells are exposed to ionizing radiation. A basic knowledge of molecular radiobiology is necessary so that the radiation oncologist can (i) screen cancer patients for an abnormally reduced or exaggerated response to radiotherapy; and (ii) devise novel ways to counter the molecular pathways that sustain malignant progression.

Post-orchidectomy radiation therapy for patients with stage I seminoma of the testis

The outcome of radiotherapy in patients with stage I testicular seminoma was evaluated. During the period 1960-89 (inclusive) 270 patients with stage I seminoma of the testis received radiotherapy to the para-aortic nodes and ipsilateral hemipelvis following radical orchidectomy. Two hundred and fifty seven patients (95.2%) received a minimum tumour dose of 30Gy in 20 daily fractions using 4-6 MV photons. The 5 year overall and recurrence-free survival rates were 97 and 95%, respectively. Only eight of the 270 patients relapsed and three were cured with 'salvage' therapies. Of the 11 patients who died, four deaths (36%) were the result of uncontrolled testicular cancer, six (55%) intercurrent illness and one (9%) the result of attempted salvage. Patients staged and treated prior to 1979 had a significantly worse disease-free survival compared to patients treated during and after 1979. As side effects were negligible, it was concluded that radiotherapy for stage I seminoma provides excellent cure rates. The difficulties arranging a 'surveillance' programme in so large a State as Queensland are discussed.

Some basic guidelines in the use of chemotherapy for patients with incurable malignancy

The increasing use of cytotoxic chemotherapy for patients with incurable malignancy has raised a number of practical and ethical dilemmas for health care workers in the fields of oncology and palliative medicine. This paper addresses some of these issues and attempts to suggest basic principles which may contribute to the successful use of palliative chemotherapy.

Characterization of cell lines established from Merkel-cell ("small-cell") carcinoma of the skin

Six cell lines have been established from different biopsies of the rare small-cell skin cancer of neuro-endocrine origin known as Merkel-cell carcinoma (MCC). These were established from metastatic lesions and have now been in culture for periods varying from 1 to 3 years. All lines grow as suspension cultures and exhibit typical MCC cytological features of small round cells with little cytoplasm, round nuclei and tight junctions. There was variation in the number and size of nucleoli and dense-core granules. We present details of their immunohistochemistry and growth characteristics in culture. The latter were similar to small-cell lung-cancer (SCLC) lines and can be subdivided, by their appearance, into type I, type II and type III in the same way as SCLC lines. This classification may be of significance for the prognosis and management of MCC.

Chemosensitivity testing of primary cultures of Merkel cell cancer

Twenty-seven tumor specimens from patients with Merkel cell carcinoma (MCC) were tested for chemosensitivity against a battery of nine cytotoxic drugs in a short-term antimetabolic assay measuring inhibition of thymidine incorporation. Dose-response curves were constructed by plotting drug concentration in micrograms/ml versus % control [3H]thymidine incorporation. Specimens were considered 'sensitive' to a drug if, at the approximate peak plasma concentration (PPC), the inhibition of [3H]thymidine was greater than 50% when compared with untreated control primary cultures. The assay revealed a 'sensitive' tumor in 19 of 20 specimens and 16 of 17 patients had a tumor that was 'sensitive' to at least one drug tested in the assay system. The highest sensitivity in order of frequency was found with doxorubicin, epirubicin, cyclophosphamide, etoposide and cisplatin. At least 40% of the tumors were 'sensitive' to these five drugs. Cyclophosphamide was chosen as the most active drug (at PPC) in 10 of 19 assays (53%), etoposide in seven of 17 (41%), doxorubicin in four of 19 (21%), chlorambucil in one of 12 (8%) and cisplatin in one of 18 (5%) of assays. Though our results are preliminary, we have identified for the first time a range of cytotoxic drugs which appear effective against MCC in vitro. Our main task now is to determine whether our in vitro predictive assay will correlate with clinical benefit to the patient.

Prognostic markers in cancers of the head and neck region

Increasing research initiatives in head and neck cancer over the past 5 years have resulted in the identification of several 'new' biologic parameters which may be of prognostic importance. This review discusses the limitations of traditional parameters and outlines several promising developments in the study of proliferation markers, molecular biology, immunobiology and flow cytometry as they relate to head and neck cancer.

Chromosomes 1, 11, and 13 are frequently involved in karyotypic abnormalities in metastatic Merkel cell carcinoma

We report a cytogenetic study of six Merkel cell carcinomas (MCC) in which rearrangement of chromosome 1 was noted in four cases: two cases were trisomic, in one case there was a reciprocal translocation between chromosomes 1 and 5 [t(1;5)(p36;p13)], and in the fourth case all cells had a normal chromosome 1 and three derivatives, a del(1)(p22) and del(1)(q21), and a translocation involving material of unknown origin to the long arm, t(1;?)(q21;?). Four cases demonstrated loss of chromosome 13; in two of these, both copies were lost, and the survival for these two patients was much longer than is common for MCC patients. Partial trisomy of chromosome 11 was noted in two cases, and two patients demonstrated loss of chromosome 22 in all cells examined. Although no consistent chromosome change was noted in our cases, our data and those of previously published reports, show that abnormalities of chromosomes 1, 11, and 13 occur in 30-47% of cytogenetic reports of this rare malignancy.

HPV DNA in oropharyngeal squamous cell cancers: comparison of results from four DNA detection methods

Oropharyngeal squamous cell cancers (SCCs) were examined for human papillomavirus (HPV) related DNA sequences. The techniques employed were Southern blotting under stringent and non stringent conditions, dot blotting, primer directed gene amplification using the polymerase chain reaction (PCR), and in-situ hybridization. HPV 16 DNA was found in 4 of 30 tumor samples using PCR. HPV 16 DNA was found in 2 further tumors using in-situ hybridization. No HPV DNA could be found by Southern blot or dot blot in any tumor sample. The Southern blot assays were sensitive enough to detect clonally integrated HPV 16 DNA of length greater than 250 bp in the tumors. While HPV DNA is present in some oropharyngeal SCCs, there is no molecular evidence to support a causal association of HPV 16 gene products with continued tumor growth in oropharyngeal cancer.

A comparison of epidermal growth factor receptor (EGFR) and c-erbB-2 oncogene expression in head and neck squamous cell carcinomas

The proto-oncogenes c-erbB-2 and epidermal growth factor (EGF) receptor which encode 2 closely homologous transmembrane glycoproteins have been found amplified and/or overexpressed in a range of epithelial malignancies. In a series of 46 head and neck squamous cell cancers (SCCs), immunohistochemical reactivity for the EGF receptor was detected in all cases, particularly at the invading edge of cellular islands of SCC and in the basal cells of normal adjacent squamous epithelium. Southern blot analysis demonstrated EGF receptor gene amplification in 3 cases. In contrast, strong membrane staining for the c-erbB-2 oncoprotein was not detected in any sample, and there were no cases of c-erbB-2 gene amplification. Despite a close structural and (presumed) functional homology between these 2 receptor-oncoproteins in the development of malignancy, we report that their expression in SCCs is markedly different. Furthermore, unlike the situation for breast cancer, quantitation of the c-erbB-2 or EGF receptor oncoproteins is unlikely to yield important prognostic information in this group of patients.

Loss of allelic heterozygosity on distal chromosome 1p in Merkel cell carcinoma. A marker of neural crest origins?

The location of genes involved in tumor evolution has been inferred from experiments in which loss of constitutional heterozygosity has been detected in tumor DNA at high frequency in specific chromosome regions. For example, cytogenetic and molecular abnormalities on chromosome 1p have been reported in tumors such as malignant melanoma and neuroblastoma which arise in cells derived from embryonic neural crest tissue. To extend these observations, we have examined tumor DNA from three cases of Merkel cell carcinoma for evidence of loss of constitutional heterozygosity on the short arm of chromosome 1. In all three cases, heterozygous allelic deletions of varying extent on distal chromosome 1p were detected in tumor DNA. Comparisons with neural crest tumors suggest that loss of heterozygosity on distal chromosome 1p in Merkel cell tumors may be a marker of neural crest origin.

Analysis of gene amplification in head-and-neck squamous-cell carcinoma

The presence of gene amplification was determined in 66 fresh head-and-neck SCC specimens using a battery of 9 different probes. Amplification of at least one gene was found in 12 samples (18%), of which 7 were amplified at multiple loci (58%). We observed amplifications for EGFR (10% of samples) and c-myc (9%), as well as co-amplification of bcl-1/int-2 (7%). No amplifications were demonstrated for c-Ha-ras-1, TGF alpha, c-mos, c-erbB-2, or c-erbA-2. The incidence of proto-oncogene amplification in head-and-neck SCC patients is comparable to that reported for other solid tumours. There was no statistically significant difference in survival between patients with or without gene amplification. However, the presence of multiple amplifications in several patients with advanced primary tumours suggests that the accumulation of genetic changes may correlate more closely with tumour size than with inherent biologic aggression.

Characterization of a novel monoclonal antibody, 3H-1, reactive with squamoproliferative lesions and squamous-cell cancers

Immunization of mice with membranes from a virus-transformed human keratinocyte cell line (KJD-I/SV40) yielded an IgM monoclonal antibody (MAb 3H-I) which reacted with the membrane and cytoplasm of KJD-I/SV40 cells and in the perinuclear region of a squamous-cell carcinoma line (Colo-16). Immunohistochemistry of formalin-fixed, paraffin-embedded sections using MAb 3H-I gave intense staining of proliferating squamous epithelium in several characteristic patterns. Acanthotic squamous epithelium and well-differentiated squamous-cell carcinomas (SCC) demonstrated a membranous staining pattern whereas psoriatic skin and undifferentiated SCC of the head and neck exhibited diffuse cytoplasmic, focal cytoplasmic or, in some tumours, no staining. Simple squamous epithelium was unreactive. Western blotting revealed an antigen of 55 kDa. The epitope recognized by MAb 3H-I may be a marker for particular stages of squamous proliferation and differentiation.

Prognostic significance of monoclonal antibody 3H-1 reactivity with squamous-cell head-and-neck cancers

We report the reactivity of a novel murine IgM monoclonal antibody (MAb), 3H-1, in formalin-fixed tissue from a series of 44 patients with squamous-cell cancers (SCCs) of the upper aerodigestive tract. The antigen detected by 3H-1 MAb is not expressed in simple squamous epithelia and only rarely in non-squamous malignancies. The following staining patterns were found to be associated with a progressively unfavourable prognosis: membranous, diffuse cytoplasmic and focal cytoplasmic/nil staining. There were no statistically-significant associations between focal cytoplasmic/nil staining and traditionally used prognostic parameters such as tumour size, nodal involvement or pathologic grade. However, multivariate analyses demonstrated that focal or nil staining was a significant independent prognostic factor for survival (p less than 0.001) and was the only significant prognostic factor for relapse (p less than 0.001). The converse applied to tumours with predominantly membranous staining (p = 0.004). 3H-1 MAb, with the advantage of relying on the pattern rather than the intensity of staining, makes it possible to identify different cellular phenotypic sub-populations more accurately than by conventional means, and may ultimately improve our understanding of the mechanisms underlying transformation from a benign or proliferative state to a malignant one.

Prognostic importance of cellular DNA content in head-and-neck squamous-cell cancers. A comparison of retrospective and prospective series

Flow cytometric DNA-ploidy measurements were performed on formalin-fixed tumour specimens from 172 patients with squamous-cell cancers (SCCs) of the head and neck region. One hundred and two samples were chosen retrospectively and a further 70 consecutive patients were analysed prospectively in order to assess the prognostic significance of DNA ploidy and DNA index (DI). There were no statistically significant differences between retrospective and prospective groups in regard to age, sex, TNM stage, ploidy or DI. Sixty-seven percent of patients were aneuploid (65% retrospective; 71% prospective). The proportion of aneuploid tumours was significantly higher among poorly differentiated tumours. Survival analysis using Cox multivariate regression modelling revealed that DNA aneuploidy and increasing DI were significant independent prognostic factors for both relapse-free and overall survival. The relapse and death rates among aneuploid subjects were approximately 3 times as high as those for diploid subjects. Patients with a DI greater than 2.11 (hypertetraploidy) experienced a 6.6-fold higher death rate than diploid subjects. These results provide strong support for the incorporation of DNA ploidy profiles into the clinical management of patients with head and neck cancer.

A clinical and flow cytometric analysis of patients with nasopharyngeal cancer

Abnormal cellular DNA content, a hallmark of malignancy, is known to be an important prognostic factor in many human solid tumors; however, no data have been published on whether cellular DNA content carries prognostic significance for patients with nasopharyngeal cancer (NPC). Archival, formalin-fixed, paraffin-embedded pathology specimens representing pretreatment tissue biopsies from 55 patients (41 men and 14 women) with NPC were analyzed for cellular DNA content in a retrospective fashion from 1968 to 1988. Individual tumors were classified as either lymphoepithelioma, squamous cell, or anaplastic carcinoma, and were staged according to International Union Against Cancer (UICC) criteria. All patients were treated with curative intent using a 4 to 6 MeV linear accelerator to total doses ranging from 50 to 60 Gy in 4 to 6 weeks. The overall 5-year actuarial survival for all 55 patients was 44.4% (men, 41%; women, 52%). Survival by T stage was as follows: T1, 65%; T2, 51%; T3, 36%; and T4, 27%. Similarly, the 5-year survival rate declined as the bulk of nodal metastases increased: N0, 62%; N2, 50%; N3, 37%; and N1, 25%. Patients who had anaplastic carcinoma had a 5-year survival of 73%, those with lymphoepithelioma had a 60% survival, and those with squamous cell cancer (SCC) had a 30% survival. There was a statistically significant difference in 5-year survival between patients with SCC and those with nonkeratinizing histologies (P less than 0.05). In addition, there was a significant association between patients older than 40 years of age with SCC and patients younger than 40 years of age with nonkeratinizing malignancies (P less than 0.01). Of the 55 tumors successfully analyzed, 22 (40%) were diploid and 33 (60%) were aneuploid. The mean coefficient of variation (CV) of all 55 samples was 6.17%. There was no significant difference in 5-year survival between patients with diploid and those with aneuploid tumors (48% versus 42%). Furthermore, there was no statistically significant survival difference between aneuploid and diploid tumors within any one histologic subgroup. There was also no significant survival difference related to the DNA index. The results indicate that the extent of local tumor spread is still the most important prognostic factor for patients treated with radiotherapy for NPC. The data support the conclusion that patients with lymphoepithelioma and anaplastic carcinomas have a superior survival to patients with squamous cell carcinoma.(ABSTRACT TRUNCATED AT 400 WORDS)

An immunohistochemical assessment of cellular proliferation markers in head and neck squamous cell cancers

Prognostic information is essential for the evaluation, judgement and optimal treatment of patients with squamous cell cancers (SCCs) of the upper aerodigestive tract. Using immunohistochemical and flow cytometric techniques, we have studied the significance of cellular expression of the Ki-67 antigen, epidermal growth factor receptor (EGFR), the transferrin receptor (TFR) and DNA ploidy status in a prospective analysis of patients with SCCs of the head and neck region. All 42 fresh tumour samples (five well differentiated; 28 moderately differentiated; nine poorly differentiated) expressed both EGFR and TFR to varying degrees. Receptor expression was most marked on the peripheral invading margin of cancer cell islands although staining was also demonstrated in a random fashion within cellular islands and consistently along the basal cell layer of overlying stratified squamous epithelium. The percentage of cancer cells that reacted with the Ki-67 monoclonal antibody was assessed as low (less than 10%) in 15 samples (35.8%), intermediate (10-30%) in 19 samples (45.2%) and high (greater than 30%) in eight samples (19.0%). Eleven of 15 samples (73%) with a low percentage reactivity were DNA diploid, whereas seven of eight samples (87.5%) with a high percentage reactivity were DNA aneuploid. Poorly differentiated SCCs were significantly more often aneuploid than were either moderately or well differentiated tumours. Our results suggest that EGFR and TFR are widely distributed on SCCs, especially on proliferating cells at the invading tumour margin. In addition, there is a close spatial correlation between cells expressing EGFR, TFR and those expressing the Ki-67 antigen. Tumours in which the staining intensity for both EGFR and TFR was intense invariably expressed the Ki-67 antigen in a high proportion of cells. Further patient follow-up will be important in determining whether intense EGFR and TFR staining, combined with a high percentage reactivity with Ki-67 antibody and DNA aneuploidy, will ultimately define a subset of head and neck cancer patients with a poor clinical outcome.