Topical protection of human esophageal mucosal integrity

Patients with nonerosive reflux disease exhibit impaired esophageal mucosal integrity, which may underlie enhanced reflux perception. In vitro topical application of an alginate solution can protect mucosal biopsies against acid-induced changes in transepithelial electrical resistance (TER). We aimed to confirm this finding in a second model using 3D cell cultures and to assess prolonged protection in a biopsy model. We assessed the protective effect of a topically applied alginate solution 1 h after application. 3D cell cultures were grown by using an air-liquid interface and were studied in Ussing chambers. The apical surface was "protected" with 200 μl of either alginate or viscous control or was unprotected. The tissue was exposed to pH 3 + bile acid solution for 30 min and TER change was calculated. Distal esophageal mucosal biopsies were taken from 12 patients and studied in Ussing chambers. The biopsies were coated with either alginate or viscous control solution. The biopsies were then bathed in pH 7.4 solution for 1 h. The luminal chamber solution was replaced with pH 2 solution for 30 min. Percentage changes in TER were recorded. In five biopsies fluorescein-labeled alginate solution was used to allow immunohistological localization of the alginate after 1 h. In the cell culture model, alginate solution protected tissue against acid-induced change in TER. In biopsies, 60 min after protection with alginate solution, the acidic exposure caused a -8.3 ± 2.2% change in TER compared with -25.1 ± 4.5% change after protection with the viscous control (P < 0.05). Labeled alginate could be seen coating the luminal surface in all cases. In vitro, alginate solutions can adhere to the esophageal mucosa for up to 1 h and exert a topical protectant effect. Durable topical protectants can be further explored as first-line/add-on therapies for gastroesophageal reflux disease.

Post-prandial reflux suppression by a raft-forming alginate (Gaviscon Advance) compared to a simple antacid documented by magnetic resonance imaging and pH-impedance monitoring: mechanistic assessment in healthy volunteers and randomised, controlled, double-blind study in reflux patients

BACKGROUND

Alginates form a raft above the gastric contents, which may suppress gastro-oesophageal reflux; however, inconsistent effects have been reported in mechanistic and clinical studies.

AIMS

To visualise reflux suppression by an alginate-antacid [Gaviscon Advance (GA), Reckitt Benckiser, UK] compared with a nonraft-forming antacid using magnetic resonance imaging (MRI), and to determine the feasibility of pH-impedance monitoring for assessment of reflux suppression by alginates.

METHODS

Two studies were performed: (i) GA and antacid (Alucol, Wander Ltd, Switzerland) were visualised in the stomach after ingestion in 12 healthy volunteers over 30 min after a meal by MRI, with reflux events documented by manometry. (ii) A randomised controlled, double-blind cross-over trial of post-prandial reflux suppression documented by pH-impedance in 20 patients randomised to GA or antacid (Milk of Magnesia; Boots, UK) after two meals taken 24 h apart.

RESULTS

MRI visualized a "mass" of GA form at the oesophago-gastric junction (OGJ); simple antacid sank to the distal stomach. The number of post-prandial common cavity reflux events was less with GA than antacid [median 2 (0-5) vs. 5 (1-11); P < 0.035]. Distal reflux events and acid exposure measured by pH-impedance were similar after GA and antacid. There was a trend to reduced proximal reflux events with GA compared with antacid [10.5 (8.9) vs. 13.9 (8.3); P = 0.070].

CONCLUSIONS

Gaviscon Advance forms a 'mass' close to the OGJ and significantly suppresses reflux compared with a nonraft-forming antacid. Standard pH-impedance monitoring is suitable for clinical studies of GA in gastro-oesophageal reflux disease patients where proximal reflux is the primary outcome.

Model system for isolation of competent ovarian-carcinoma cells from fresh tumor-tissue by a magnetic separation technique (macs)

Flow cytometric analysis of tumor cells in carcinomas is hampered by the presence of a variety of different cells in the tumor tissue and the surrounding stroma. To obtain single competent tumor cells, we have established a model system which can be applied to separate living cells from fresh ovarian carcinoma tissue. Due to the lack of tumor-cell surface specific antibodies, we isolated tumor cells by a procedure called 'negative tumor cell selection'. For this purpose, fresh ovarian carcinoma tissue, immediately after surgery, was subjected to mechanical disintegration using an automated mincing device to obtain a single-cell suspension (approximately 10(7) cells/g). Collagenase D (0.005%) was added to prevent further aggregation. Cells other than tumor cells were then labeled with a set of monoclonal antibodies directed to cell surface antigens: CD3 (T-cells), CD14 (monocytes), CD15 (granulocytes), CD45R (T-/B-cells) and 5B5 (fibroblasts). Anti-isotype antibodies coupled to ferrit microbeads were then reacted with the cell suspension and those cells reacting with the microbeads retained on a steel wool matrix in a magnetic field (1). Tumor cells not reacting with the microbeads were recovered by a simple wash of the steel wool matrix. All incubation steps were at 4 degrees C. This procedure, which takes about 2 hours, enables fast and simple isolation of single, living competent tumor cells from fresh tumor tissue and also from ascitic or pleuritic effusions. In a model system with cultured ovarian carcinoma cells and human leukocytes, tumor cell purity was about 93% and about 97% when re-subjected to the same procedure (respective recovery rates 75% and 50%). The still unlabeled tumor cells can subsequently be analyzed by flow cytometry or by central laser scanning microscopy for the presence of various surface antigens including receptors for proteases or growth factors. Moreover, after detergent treatment and fixation, flow cytometric multiparameter analysis such as simultaneous labeling of intracellular and surface antigens as well as nuclear DNA staining for ploidy and S-phase determination becomes possible.

Prepregnancy body mass index and dietary intake in the first trimester of pregnancy

OBJECTIVES

Adequate maternal nutrition is of paramount importance in pregnancy, particularly in the first trimester when fetal development is crucial. It has been reported that heavier women are most likely to fear weight gain associated with pregnancy. Few studies have, however, investigated associations between prepregnancy body mass index (BMI) and nutrient intakes in the first trimester of gestation using detailed, prospective methodologies. The aim of this study was to investigate possible associations between prepregnancy BMI and nutrient intakes in the first trimester of gestation.

DESIGN

Seventy-two Caucasian, primiparous nonsmokers of mean age 33.1 years (SD 4.6) were recruited from three London teaching hospitals and they completed a background information questionnaire and a 4- to 7-day weighed inventory food diary during the first trimester of pregnancy. Prepregnancy anthropometric data were extracted from General Practitioner records.

RESULTS

Prepregnancy BMI was inversely associated with dietary energy (P = 0.04), Southgate and Englyst fibre (P < 0.01), and iron and folate (P < 0.01). After excluding under-reporters [individual energy intake:basal metabolic rate (estimated) ratio < 1.2], prepregnancy BMI was inversely associated with folate intake (P =0.04). Dietary intakes of Englyst fibre (P = 0.03) were statistically significantly lower than average dietary recommendations in this group.

CONCLUSIONS

This study identified that women with a high prepregnancy BMI are more likely to under-report nutrient intakes. The finding that folate intake was significantly lower in heavier women accurately reporting dietary intake is of particular concern.

An oral carcinogenicity and toxicity study of senna (Tinnevelly senna fruits) in the rat

Senna (Tinnevelly senna fruits), a known laxative derived from plants, was administered by gavage to Sprague-Dawley (Crl:CD (SD) BR) rats once daily at dose levels of 0, 25, 100 and 300 mg/kg/day for up to 104 consecutive weeks. Based upon clinical signs related to the laxation effect of senna, the highest dose (300 mg/kg/day) was considered to be a maximum tolerated dose. Sixty animals per sex were assigned to the control and dose groups. Assessments included clinical chemistry, hematology, full histology (control and high-dose groups; in addition, low and mid dose: intestinal tract, adrenals, liver, kidneys, brain and gross lesions) and toxicokinetics. The primary treatment-related clinical observation was mucoid feces seen at 300 mg/kg/day. When compared to controls, animals administered 300 mg/kg/day had slightly reduced body weights, increased water consumption and notable changes in electrolytes in serum (increases in potassium and chloride) and urine (decreases in sodium, potassium and chloride). The changes in electrolytes are most likely physiologic adaptations to the laxative effect of senna. At necropsy, dark discoloration of the kidneys was observed in animals in all treated groups. Histological changes were seen in the kidneys of animals from all treated groups and included slight to moderate tubular basophilia and tubular pigment deposits. In addition, for all treated groups, minimal to slight hyperplasia was evident in the colon and cecum. These histological changes, together with the changes seen in the evaluation of clinical chemistry and urine parameters, have been shown to be reversible in a previous 13-week rat study of senna. No treatment-related neoplastic changes were observed in any of the examined organs. Based upon these data, it is concluded that senna is not carcinogenic even after daily administration for 2 years at dosages of up to 300 mg/kg/day in Sprague-Dawley rats.

Vergleich des Plasminogenaktivators vom Urokinasetyp (uPA) und des Plasminogenaktivator-Inhibitors (PAI-1) mit klinischen Parametern beim resezierten Plattenepithelkarzinom der Mundh�hle

This article examines the distribution and prognostic importance of urinase type plasminogen activators (uPA) and of plasminogen activator inhibitors (PAI-1) in cases of primary oral squamous cell carcinoma. Tissue from the primary tumor was taken from 79 patients. In order to make an intra-individual comparison, tissue from the healthy mucous membrane of the mouth was taken from 50 patients and metastatic tissue from lymph glands in the neck from 16 patients. The content of uPA and PAI-1 was determined using ELISA. After follow-up, 58 patients with primary surgical therapy were included. Statistical evaluation was carried out using the Kruskal-Wallis test, the Mann-Whitney U-test and the Wilcoxon test. Pearson's product moment correlation was used to determine the relationship between uPA and PAI-1 levels. The median uPA value was 3.43 ng/mg in primary tumor, and for PAI-1 47.1 ng/mg ( n=79). There was a significant correlation between uPA and PAI-1 both in the cancerous as well as the healthy tissue ( P<0.01). The intra-individual comparisons showed uPA and PAI-1 differed significantly between cancerous and healthy tissue ( P<0.0001) with the mean uPA and PAI-1 values being nine times higher in the cancerous tissue ( n=58). The correlation for between uPA and PAI-1 in tumors, healthy tissue and metastatic lymph node tissue ( n=16) showed highly significant values in the tumors ( P<0.001). The comparison between cancerous tissue in the primary tumor and the lymph nodes was not significant for PAI-1. For uPA, the values in the lymph nodes were significantly lower ( P<0.049). There were also significantly higher levels in metastatic lymph node tissue compared with healthy mucous membrane ( P=0.005 for uPA and P=0.003 for PAI-1). There was no significant correlation of PAI-1 and uPA ( n=79) with the patient's sex, size of the tumor (T stage), nodal status (N stage), differentiation (grade), or residual tumor status. If the patients were divided into two groups (< or =58 years and >58 years), the older patients had higher uPA ( P<0.017) and PAI-1 ( P<0.02) levels. The was no significant association between tumor localisation and uPA content in the tumor; for PAI-1 the association was significant ( P<0.02) in the individual areas of the mouth. A total of 23 (40%) patients relapsed (local n=13, lymph node n=3, local and lymph node n=1, lymph node and skin n=1, other locations n=5). Such patients had raised uPA ( P=0.012) and PAI-1 ( P=0.014) levels in the primary tumor. The high variability of the normal clinical parameters in tumors only has a limited prognostic value because it is not taken into account in individual cases. Thus determination of the PAI-1 level directly after surgery could provide an indication of the likelihood of a relapse and thus aid in determining the adjuvant therapy. This confirms a trend in that tumor associated proteases can also play a key role in oral squamous cell carcinoma as new, independent, prognostic factors. Whether or not uPA and PAI-1 will play such a role will be determined in additional multicentre clinical studies.

[The prognostic importance of urinase type plasminogen activators (uPA) and plasminogen activator inhibitors (PAI-1) in the primary resection of oral squamous cell carcinoma]

This article examines the prognostic importance of urinase type plasminogen activators (uPA) and of plasminogen activator inhibitors (PAI-1) in cases of primary oral squamous cell carcinoma. Tissue samples were taken from the core of the tumour in 58 such primary surgical patients. The levels of uPA and PAI-1 were determined using ELISA. Statistical significance was calculated using the chi2- and log-rank tests. The mean follow-up (n=58) was 23 months. In order to determine prognostic value, the time before relapse was used. The mean time before relapse was 19 months. A total of 28 (40%) patients relapsed (local n=13, lymph node n=3, local and lymph node n=1, lymph node and skin n=1, other locations n=5). Such patients had significantly raised uPA (P<0.012) and PAI-1 (P<0.014) levels in the primary tumour. A optimal cutoff value for uPA (4.58 ng/mg) and PAI-1 (106.3 ng/mg) was determined using the multiple log-rank test. There was no significant correlation for patients with low or high levels (i.e. lower or higher than the cutoff value, respectively) with the usual clinical parameters such as localisation, N-stage, T-stage, differentiation and residual tumor status. Older patients (>58 years) had significantly higher levels of uPA and PAI-1 (P<0.017 and P<0.02, respectively). The likelihood of relapse was significantly higher in patients with high levels (uPA P<0.009, PAI-1 P<0.008). If the patients were divided into three groups depending on uPA and PAI-1 levels (group 1: uPA and PAI-1 low, n=35; group 2: uPA or PAI-1 high, n=12; group 3: uPA and PAI-1 high, n=11), relapses were more common in group 3 than in groups 1 or 2 (P<0.023). Patients with only surgical therapy (n=29) and those with postoperative radiotherapy (n=29) were used to evaluate postoperative follow-up. Cutoff levels were calculated for both groups. In the surgical therapy group this was uPA=5.63 ng/mg and PAI-1=106.3 ng/ml and in the surgical therapy plus radiotherapy group uPA=4.13 ng/mg and PAI-1=97.02 ng/mg. Kaplan-Meier curves showed a marked tendency for patients with higher levels to relapse more often. This is significant for surgical patients for PAI-1 (P<0.01) and for radiotherapy patients for uPA (P<0.04)

[Significance of endorectal nuclear magnetic resonance tomography and transrectal ultrasound diagnosis in local staging of prostatic carcinoma]

METHODS

We assessed the staging accuracy of endorectal magnetic resonance imaging (eMRI) and transrectal ultrasonography (TRUS) for localized prostate cancer. 54 patients with biopsy proven prostate cancer underwent TRUS and eMRI prior to radical retropubic prostatectomy. The MR images were prospectively interpreted by two radiologists. These findings were compared with the histopathological results.

RESULTS

Overall accuracy of eMRI in defining local tumor stage was 93% by radiologist A and 56% by radiologist B. Overall accuracy by TRUS was 63%. Analysis of interobserver agreement showed a poor correlation regarding MRI studies. Endorectal MRI was more sensitive than TRUS for detecting capsular penetration and seminal vesicle involvement. TRUS revealed a relatively high specificity and was superior to eMRI in this regard.

CONCLUSION

This series shows the current limited value of TRUS and eMRI for planning treatment in patients with clinically localized prostate cancer.

On-Coupling and Off-Coupling of Neocortical Areas in Chess Experts and Novices

Abstract This paper presents a pilot study on the differences in evoked EEG coherence measures (computed as zero-lagged cross-correlation, “EC”) between chess experts and novices while solving chess problems. One of our earlier investigations ( Volke, 1999 ) had shown that both location and direction of EC changes in task processing (compared with a resting condition) depend on the degree of task performance. As a result we postulated that when solving the same tasks experts and novices would show different EC. The results of the recent study confirmed this supposition. Chess tasks of varying difficulty were presented to 25 chess players of different performance levels. The EEG was recorded from 29 positions (enhanced 10:20-system). EC were computed for post-stimulus intervals of 1.6s. A special averaging procedure (considering Fisher's Z transformation) was applied for summarizing the single EC of each type of task. These subject- and task-related EC-values (29 × 28/2 = 406 values per frequency band) were subjected to a MANOVA after a two-staged principal component analysis. Significant differences between experts and novices, compared with the resting condition, were found in the delta frequency range. The relevant cortical areas of experts, defined by a topological analysis of the differentiating principal components, were located rather posterior and more in the right hemisphere, compared with those of the novices. Furthermore, the essential EC of the experts showed higher values in the task situation (“on-coupling”), compared with the resting condition, whereas those of the novices were lower (“off-coupling”). The results are interpreted as a higher task-related functional integration of the cortical areas in experts.

Limited value of endorectal magnetic resonance imaging and transrectal ultrasonography in the staging of clinically localized prostate cancer

OBJECTIVE

To examine the role of endorectal magnetic resonance imaging (eMRI) and transrectal ultrasonography (TRUS) for clinically localized prostate cancer and to assess interobserver agreement in interpreting MRI studies.

PATIENTS AND METHODS

Fifty-four patients with biopsy-confirmed prostate cancer underwent TRUS and eMRI before radical retropubic prostatectomy. The MR images were prospectively interpreted by two radiologists with special expertise in this field. The criteria evaluated prospectively in each patient were extracapsular extension (ECE) and seminal vesicle invasion (SVI). The results were correlated with the histopathological findings after radical prostatectomy.

RESULTS

At pathology, 27 patients had stage pT2, 15 had stage pT3a and 12 had stage pT3b lesions. The overall accuracy of eMRI in defining local tumour stage was 93% by radiologist A and 56% by radiologist B; the overall accuracy by TRUS was 63%. There was a poor correlation for the MRI studies between observers. The eMRI was more sensitive than TRUS for detecting ECE and SVI in organ-confined prostate cancer. TRUS had a relatively high specificity for ECE and SVI, and was better than eMRI in this regard.

CONCLUSION

Whereas MRI tended to over-stage, TRUS under-staged prostate cancer. This series shows the current limited value of TRUS and eMRI for planning treatment in patients with clinically localized prostate cancer. Treatment decisions should not be altered based on TRUS or eMRI findings alone.

[No association between p53 overexpression and polarographically measured tumor oxygenation in patients with head and neck carcinomas]

PURPOSE

Clinical investigation of a potential relationship between the polarographically measured tumor oxygenation and the p53 status in patients with squamous cell carcinoma of the head and neck.

PATIENTS AND METHODS

In 99 patients with mostly advanced, histologically proven squamous cell carcinoma of the head and neck we estimated the classical tumor parameters (TNM stage, histological grading) the immunohistochemical p53-overexpression (DO-7) and the tumor oxygenation status (Eppendorf pO2 Histograph). The tumor volume and the hemoglobin concentration were evaluated simultaneously.

RESULTS

No statistically significant difference could be detected between immunohistological p53-positive (p53 > or = 10% stained cells) and p53-negative tumors (p53 < 10% stained cells) regarding both the median pO2 and the relative frequency of values < or = 5 mm Hg. Moreover, no statistically relevant differences could be seen between both p53-groups considering the hemoglobin concentration, the TNM stage, the histological grading and the tumor volume.

CONCLUSION

Our data imply that there is no association between p53-overexpression and tumor hypoxia in head and neck carcinomas. However, this is not necessarily in contradiction to experimental or clinical data that confirmed a relationship between hypoxia and p53-mediated increased malignancy of tumor cells in other tumor entities. The comparable oxygenation status of p53-positive and p53-negative tumors in our study is associated with an analogous clinical tumor aggressiveness of both groups. That could be caused by a hypoxia related but p53-independent selection of tumor cells with a more malignant phenotype in head and neck carcinomas. However, further research is needed to prove this possible relationship.

Risk-group discrimination in node-negative breast cancer using invasion and proliferation markers: 6-year median follow-up

Factors reflecting two major aspects of tumour biology, invasion (urokinase-type plasminogen activator (uPA), plasminogen activator inhibiter (PAI-1), cathepsin D) and proliferation (S-phase fraction (SPF), Ki-67, p53, HER-2/neu), were assessed in 125 node-negative breast cancer patients without adjuvant systemic therapy. Median follow-up time was 76 months. Antigen levels of uPA, PAI-1 and cathepsin D were immunoenzymatically determined in tumour tissue extracts. SPF and ploidy were determined flow-cytometrically, Ki"'-67, p53, and HER-2/neu immunohistochemically in adjacent paraffin sections. Their prognostic impact on disease-free (DFS) and overall survival (OS) was compared to that of traditional factors (tumour size, grading, hormone receptor status). Univariate analysis determined PAI-1 (P < 0.001), uPA (P = 0.008), cathepsin D (P = 0.004) and SPF (P = 0.023) as significant for DFS. All other factors failed to be of significant prognostic value. In a Cox model, only PAI-1 was significant for DFS (P < 0.001, relative risk (RR) 6.2). In CART analysis for DFS, the combination of PAI-1 and uPA gave the best risk group discrimination. For OS, PAI-1, cathepsin D, tumour size and ploidy were statistically significant in univariate, but PAI-1 was the only independently significant factor in Cox analysis (P < 0.001, RR 8.9). In particular, this analysis shows that PAI-1 is still a strong and independent prognostic factor in node-negative breast cancer after extended 6-year median follow-up.

Prognostic significance of urokinase (uPA) and its inhibitor PAI-1 for survival in advanced ovarian carcinoma stage FIGO IIIc

Strong evidence has accumulated on the prognostic value of tumour-associated proteolytic factors in patients afflicted with solid malignant tumours, including advanced ovarian cancer. We evaluated the prognostic impact of the protease urokinase plasminogen activator (uPA) and its inhibitor PAI-1 on overall survival in patients with advanced ovarian cancer stage FIGO IIIc in order to select patients at risk. uPA and PAI-1 antigen were determined by ELISA in primary tumour tissue extracts of 86 ovarian cancer patients FIGO stage IIIc enrolled in a prospective study. Univariate and multivariate analyses were performed using the Cox proportional hazard model. The time-varying coefficient model of Gray was used to assess the time-dependent strength of prognostic factors tumour mass, uPA and PAI-1 on overall survival. In all patients, uPA and PAI-1 (optimized cut-offs of 2.0 and 27.5 ng mg(-1) protein respectively), in addition to the traditional prognostic parameters of residual tumour mass, nodal status, grading and ascites volume, were of prognostic significance in univariate analysis for overall survival. Even in patients with residual tumour mass (n = 43), the statistically independent prognostic impact of PAI-1 persisted, allowing further discrimination between low- and high-risk patients. In multivariate analysis, residual tumour mass (P < 0.001, relative risk (RR) 4.5), PAI-1 (P < 0.001; RR 3.1) and nodal status (P = 0.022, RR 2.6) turned out to be strong, statistically independent prognostic parameters. Evaluation of the time-dependent prognostic impact of residual tumour mass and PAI-1 on overall survival (n = 86, 50 months) revealed that the prognostic power of these factors increased with time. In patients with advanced ovarian cancer, both residual tumour mass and PAI-1 are statistically independent strong prognostic factors. Even within patient subgroups with or without residual tumour mass, PAI-1 allowed selection of patients at risk who might benefit from individualized therapy protocols.

HER-2/neu gene amplification by fluorescence in situ hybridization allows risk-group assessment in node-negative breast cancer

In a collective of 112 node-negative breast cancer patients, we compared the prognostic impact of HER-2/neu gene amplification (AMP) determined by fluorescence in situ hybridization (FISH) and HER-2/neu protein overexpression (EXP) measured by immunohistochemistry (IHC) with traditional prognostic factors (tumor size, grade, steroid hormone receptor status, menopausal status) and tumor invasion markers uPA (urokinase-type plasminogen activator) and its inhibitor PAI-1 determined by enzyme immunoassay (ELISA). Median follow-up in patients still alive at time of analysis was 7 years. Automated FISH and IHC were performed on parallel-cut formalin-fixed paraffin-embedded tissue sections. HER-2/neu AMP was detected by FISH in 31% and HER-2/neu EXP was measured by IHC in 41% of the cases. In 13% of the tumors, both AMP and EXP were found. FISH and IHC results were concordant in 56% of all analyzed cases. In univariate analysis, HER-2/neu AMP significantly predicted both disease-free (DFS) and overall survival (OS). HER-2/neu EXP was significant for OS, only. In multivariate analysis of all analyzed prognostic factors, HER-2/neu AMP was the only independent predictive factor for both DFS and OS. CART analysis revealed that HER-2/neu AMP together with the combination uPA/PAI-1 allowed optimal risk-group assessment after a 7-year median follow-up: patients with low levels of both uPA and PAI-1 and no HER-2/neu AMP had a significantly lower relapse rate (4.6%) than the remaining patients (32%). In conclusion, HER-2/neu gene AMP determined by FISH allowed a more accurate risk-group assessment than HER-2/neu protein EXP measured by IHC. Combining the HER-2/neu gene status measured by FISH with levels of tumor invasion markers uPA and PAI-1 improves clinically relevant risk-group assessment. In addition to its prognostic strength, the significant impact of HER-2/neu AMP on OS may reflect its ability to predict resistance to systemic therapy.

Prognostic impact of tumor biological factors on survival in node-negative breast cancer

Tumor biological factors uPA, PAI-1, cathepsin D, S-phase fraction (SPF), MIB1 (Ki-67), p53, and HER-2/neu were assessed in 100 node-negative breast cancer patients. Their prognostic impact on disease-free (DFS) as well as overall survival (OS) was compared to that of traditional factors tumor size, grading, and steroid hormone receptor status. Antigen levels of uPA, its inhibitor PAI-1, and cathepsin D were determined in tumor tissue extracts by immunoenzymatic methods. SPF was determined by flow cytofluorometry, MIB1, p53, and HER-2/neu by immunohistochemistry in adjacent routinely formalin-fixed paraffin sections. Median follow-up in all patients still alive at time of analysis was 76 months. Univariate analysis determined PAI-1 (p = 0.0001), uPA (p = 0.0437), MIB1 (p = 0.0214), and SPF (p = 0.0248) as statistically significant prognostic factors for DFS. In contrast, tumor size, steroid hormone receptor status, grading, p53, HER-2/neu, and cathepsin. D failed to be of prognostic value. In multivariate analysis, including the statistically significant prognostic factors PAI-1, uPA, MIB1, and SPF, only PAI-1 (p = 0.0003, relative risk: 4.7) proved to be of independent statistical significance for DFS. Regarding OS, PAI-1 was the only statistically significant prognostic factor in univariate (p = 0.0001) as well as multivariate analysis (p = 0.0000, relative risk: 7.1). Thus, factors describing the invasive and metastatic capacity of tumor cells (uPA, PAI-1) and factors related to their proliferative activity (SPF, MIB1) provide valuable prognostic information in node-negative breast cancer patients.

Prognostic impact of proliferation-associated factors MIB1 (Ki-67) and S-phase in node-negative breast cancer

MIB1 proliferation rate (MIB1-PR) and total S-phase fraction (SPF) were retrospectively determined in formalin-fixed, paraffin-embedded sections of 90 primary node-negative breast carcinomas. None of the patients had received adjuvant systemic therapy. Median follow-up in patients still alive at the time of analysis was 37.5 months (16-72 months). Immunostaining of Ki-67 antigen was performed using the monoclonal antibody MIB1 and the APAAP technique. An adjacent 50-microm paraffin section was used for flow cytometric S-phase determination. Results were compared to established clinicopathological prognostic factors. MIB1-PR was significantly correlated to grading (P = 0.018); SPF was significantly correlated with tumour size (P = 0.041) and inversely with steroid hormone receptor status (P = 0.03). A significant correlation between MIB1-PR and SPF was found in aneuploid (P = 0.025) but not in diploid tumours (P = 0.164). In univariate analysis, both MIB1-PR (optimized cut-off of 25%) and SPF (optimized cut-off of 8%) were significant prognostic factors for disease-free survival (DFS) (MIB1-PR, P = 0.0224; SPF, P = 0.0028). In multivariate analysis, however, only SPF remained significant; it was the strongest prognostic factor for DFS (P = 0.0073), stronger than MIB1-PR or established clinicopathological prognostic factors. We thus conclude that MIB1-PR and SPF provide additional prognostic information in node-negative breast cancer. However, in our study, flow cytometrically determined SPF had the greater prognostic impact.

Primary tumor and metastasis in ovarian cancer differ in their content of urokinase-type plasminogen activator, its receptor, and inhibitors types 1 and 2

The relevance of urokinase-type plasminogen activator (uPA) and plasminogen activator inhibitor (PAI) type 1 in predicting the survival probability of patients with advanced ovarian cancer after radical surgery and adjuvant chemotherapy by assessing the patients' primary tumors has recently been shown by us (W. Kuhn et al., Gynecol. Oncol., 55: 401-409, 1994). In the present study, we determined uPA, uPA receptor, PAI-1, and PAI-2 concentrations in primary tumors and tumor-infiltrated omentum and retroperitoneal lymph nodes of ovarian cancer patients. The group consisted of 39 patients with advanced ovarian carcinoma stages Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) IIIc or IV; for comparison 7 patients with early carcinoma stage FIGO I were also included. In metastases of the omentum from ovarian cancer stage FIGO IIIc or IV patients, we noted a 4-fold elevated uPA content, a 2-fold increase in PAI-1, and also a significant increase in uPA receptor and PAI-2 over primary tumors. In metastases of the lymph nodes the levels of the respective antigens were also increased when compared to primary tumors. These data may indicate that elevated levels of components of the fibrinolytic system at sites of metastases may contribute to the aggressive potential of cancer cells by favoring their reimplantation and/or the consolidation of a new tumor stroma.

Time-resolved infrared ATR measurements of liposome transport kinetics in human keratinocyte cultures and skin reveals a dependence on liposome size and phase state

A novel in vitro method for studying the permeation kinetics of superficially applied liposomes or vesicles through layers of human skin or keratinocytes on a solid support is presented, employing attenuated total reflection infrared spectroscopy. The method is applied to investigate transport kinetics of unilamellar vesicles of dimyristoylphosphatidylcholine (DMPC) through cultured human keratinocyte layers and through human skin. We find a strong resemblance of the qualitative features of the permeation kinetics of small unilamellar DMPC vesicles for skin and keratinocytes. Detailed studies of the vesicles transport through keratinocyte layers show that DMPC vesicles with an average diameter of 55 nm can readily permeate through the layer at 37 degrees C with a diffusion constant of D = (4.0 +/- 0.8) x 10(-15) m2/second, whereas larger vesicles of twice that diameter do not permeate at all. In contrast, liposomes containing a chemical permeation enhancer permeate through the layer significantly faster [D = (7.0 +/- 0.5) x 10(-15) m2/second] than the small DMPC vesicles despite their five-times-larger diameter. Moreover, the transport of the DMPC vesicles depends drastically on their phase state. No permeation was observed for small DMPC vesicles at a temperature of 10 degrees C when the lipid is in the crystalline phase state. Our results indicate that keratinocyte culture layers can pose a significant permeation barrier for vesicles. The permeation mechanism can be explained by diffusion of the vesicles through small pores and gaps in the layer, presumably driven by transdermal osmotic gradients.

Prognostic value of the cysteine proteases cathepsins B and cathepsin L in human breast cancer

The lysosomal cysteine proteases cathepsin B and cathepsin L have been implicated in tumor spread and metastasis. To evaluate the prognostic impact of these proteases for disease-free survival and overall survival in breast cancer, the antigen content of cathepsin B and cathepsin L was determined using ELISA in tumor cytosol fractions of 167 breast cancer patients and in cytosols of 29 benign breast tissue specimens. Median values of 856 ng versus 76 ng cathepsin B/mg protein and of 428 ng versus 56 ng cathepsin L/mg protein were found in tumor versus benign cytosol fractions. A positive correlation between cathepsin B and cathepsin L (r = 0.32, P = 0.0000, Spearman test) was found. Cathepsin L was inversely correlated to hormone receptor status (P = 0.0014, Mann-Whitney U test) and to the presence of tumor necrosis (P = 0.009, Mann-Whitney U test). There were no correlations of cathepsin B or cathepsin L to tumor size, axillary lymph node status, age, menopausal status, tumor grading, and vessel invasion. To perform univariate analyses of disease-free survival, optimal cutoff points were determined by isotonic regression and classification and regression trees analysis. Patients with a high content of cathepsin B (>1092 ng/mg protein) or cathepsin L (>376 ng/mg protein) in their primary tumors had a statistically significantly higher risk of recurrence than patients with a low content of cathepsin B or cathepsin L (5-year disease-free survival: cathepsin B, 70% versus 52%, P = 0.04; cathepsin L, 83% versus 52%, P = 0.0002). Median follow-up was 39 (range, 6-73) months. Multivariate analysis for disease-free survival showed that cathepsin L is a strong and independent prognostic factor with a prognostic impact comparable to that of axillary lymph node status and grading. We conclude that both cathepsin B and cathepsin L may serve as prognostic factors for tumor recurrence in human breast cancer. These data underline the significance of tumor-associated proteolysis for invasion and metastasis.

[Prognostic significance of the S-phase and MIB1 (Ki-67) proliferation parameters in node-negative breast carcinoma]

OBJECTIVE

In 90 patients with primary node-negative breast carcinomas we compared the prognostic impact of total S-phase fraction (SPF) and MIB1 proliferation rate (MIB1-PR) after a median follow-up of 34 months (9-72 months).

METHODS

SPF was determined flow cytometrically and MIB1 (Ki-67) immunohistochemically in parallel-cut, paraffin-embedded tissue sections.

RESULTS

SPF was significantly correlated to tumor size and steroid hormone receptor status, MIB1-PR to grading. In univariate analysis both SPF and MIB1-PR were significant prognostic factors for disease-free survival. In multivariate analysis however, S-phase fraction was the only significant prognostic factor when compared to MIB1-PR, tumor size, steroid hormone receptor status, menopausal status, grading, lymph vessel invasion, and tumor necrosis.

CONCLUSIONS

In our study SPF was of higher prognostic strength and may therefore be better suited for clinical application than MIB1-PR in node-negative breast cancer.

Urokinase (uPA) and PAI-1 predict survival in advanced ovarian cancer patients (FIGO III) after radical surgery and platinum-based chemotherapy

Fifty-one patients with advanced ovarian cancer FIGO III were studied to determine new tumor biology-oriented prognostic factors. The tumor-associated protease urokinase-type plasminogen activator (uPA) and its inhibitor PAI-1 were detected in malignant ovarian cancer tissue extracts. The concentration of both factors was significantly higher in malignant tissue compared with benign ovarian tissue specimens (P < 0.01). According to a cutoff value for uPA and PAI-1, patients could be subdivided into risk groups: patients with low uPA and PAI-1 (uPA < 0.9 ng/mg protein and PAI-1 < 13.5 ng/mg protein) had a statistically significant better prognosis than patients with high uPA and/or high PAI-1 (P = 0.01). Especially in patients without residual tumor, uPA and PAI-1 were strong prognostic parameters (P = 0.03). In multivariate analysis the residual tumor was the most powerful prognostic indicator (P = 0.013) closely followed by uPA and PAI-1 (P = 0.047). Moreover, there is a strong correlation between uPA levels and lymph node involvement (P = 0.004) and a trend to higher uPA-levels in poorly differentiated (G3 + G4) cancers (P = 0.059) and in tumors with increased ascites production (P = 0.09). A trend to higher PAI-1 levels was also noted in the above-mentioned tumor situations. The differences, however, were of no statistical significance. From these data it can be concluded that the pattern of tumor spread (mainly intraabdominally versus additional extensive lymph node involvement) and tumor biological appearance (ascites production, differentiation) are reflected by the expression of the tumor-associated proteolytic factors uPA and PAI-1. Adjuvant therapy might be adjusted to uPA and PAI-1 not only in advanced ovarian cancer but also in carcinoma of low malignant potential or early-stage ovarian carcinoma.

[D-dimer and plasminogen activator of the urokinase type: personal experiences with breast cancer]

Plasma values of d-dimer, a stable end product of plasmin-induced fibrinolysis, were ascertained in 128 female patients with mammary carcinoma. These patients demonstrated significantly increased d-dimers in comparison with the control group with benign mammary disease (p < 0.01). The sensitivity and specificity of d-dimer were slightly higher than those of the established tumour marker CA 15-3 and CEA. There was no correlation between d-dimers in the plasma and increased expression of urokinase plasminogen activator (UPA) in the tissue. Increased d-dimers in the plasma of female patients with mammary carcinoma reflect multi-factoral interactions between carcinoma growth and the haemostatic-fibrinolytic system, and may be used as tumour markers.

[Developments in the therapy of advanced FIGO III ovarian cancer]

From 1982 to 1992 103 patients with ovarian cancer stage FIGO III have been treated. In 38% of the patients there was no residual tumour postoperatively, in 40.8% the residual tumour was smaller than 2 cm. In 51.5% bowel resections were necessary, a stoma was unavoidable in just one case. A lymphadenectomy (pelvic, paraaortic or combined) was done in 46.6% of the patients. Postoperatively, 54.4% of the patients received a platinum-based chemotherapy, in the other patients other kinds of chemotherapy were applied. A radiation of the whole abdomen was done only in 3.9%. A median survival time for more than 60 months could be achieved in tumour-free patients due to the increased radical operations in combination with the platinum based chemotherapy. The lymphadenectomy seems to prolong the survival time of the patients. The positive nodal status is definitely unfavourable for the prognosis. By this therapeutic approach, an increased survival time with a good life quality can be achieved.