Predictors of positive axillary lymph nodes after sentinel lymph node biopsy in breast cancer

OBJECTIVE

The purpose of this study was to determine the factors that predict the presence of metastasis in nonsentinel lymph nodes (SLN) when the SLN is positive.

METHODS

A prospective database was analyzed and included patients who underwent SLN biopsy for invasive breast cancer from July 1997 to August 2000 (n = 442). One hundred (22.6%) patients had one or more positive SLNs, and were analyzed to determine factors that predicted additional positive axillary nodes.

RESULTS

Of the 100 patients with a positive SLN, 40 patients (40%) had additional metastasis in non-SLNs. The only significant variables that predicted non-SLN metastasis were tumor lymphovascular invasion (P = 0.004), extranodal extension (P < 0.001), and increasing size of the metastasis within the SLN (P = 0.011). In analyzing just those patients who had lymphovascular invasion, extranodal extension, and a SLN metastasis > 2mm, 92% were found to have additional positive nodes.

CONCLUSIONS

In patients with invasive breast cancer and a positive sentinel lymph node, lymphovascular invasion, extranodal extension, and increasing size of the metastasis all significantly increase the frequency of additional positive nodes.

Selective analysis of the sentinel node in breast cancer

BACKGROUND

This study was designed to determine the minimum number of sentinel nodes necessary to accurately stage patients with breast cancer.

METHODS

Between August 1997 and February 2001, 509 consecutive patients were enrolled in a prospective sentinel node database. Nodes were characterized as either blue or hot (>2 times background), or both, and ranked based on the order harvested. Predictive value of the sentinel node based on these characteristics was evaluated to determine the minimum number necessary to stage the basin.

RESULTS

In all, 990 sentinel nodes were harvested from 465 basins. Pathologic stage in 126 of 128 positive basins was predicted by the first or second node harvested. The remaining 2 patients were positive by immunohistochemistry only. The hottest node predicted the status in 114 of 128 basins.

CONCLUSIONS

Although all nodes should be examined, these data suggest that limiting frozen section analysis to the first two sentinel nodes identified will not compromise the accuracy of staging and may provide a vehicle for resource savings.

Tamoxifen and chemotherapy for axillary node-negative, estrogen receptor-negative breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-23

PURPOSE

Uncertainty about the relative worth of doxorubicin/cyclophosphamide (AC) and cyclophosphamide/methotrexate/fluorouracil (CMF), as well as doubt about the propriety of giving tamoxifen (TAM) with chemotherapy to patients with estrogen receptor-negative tumors and negative axillary nodes, prompted the National Surgical Adjuvant Breast and Bowel Project to initiate the B-23 study.

PATIENTS AND METHODS

Patients (n = 2,008) were randomly assigned to CMF plus placebo, CMF plus TAM, AC plus placebo, or AC plus TAM. Six cycles of CMF were given for 6 months; four cycles of AC were administered for 63 days. TAM was given daily for 5 years. Relapse-free survival (RFS), event-free survival (EFS), and survival (S) were determined by using life-table estimates. Tests for heterogeneity of outcome used log-rank statistics and Cox proportional hazards models to detect differences across all groups and according to chemotherapy and hormonal therapy status.

RESULTS

No significant difference in RFS, EFS, or S was observed among the four groups through 5 years (P =.96,.8, and.8, respectively), for those aged < or = 49 years (P =.97,.5, and.9, respectively), or for those aged > or = 50 years (P =.7,.6, and.6, respectively). A comparison between all CMF- and all AC-treated patients demonstrated no significant differences in RFS (87% at 5 years in both groups, P =.9), EFS (83% and 82%, P =.6), or S (89% and 90%, P =.4). There were no significant differences in RFS, EFS, or S between CMF and AC in patients aged < or = 49 or > or = 50 years. No significant difference in any outcome was observed when chemotherapy-treated patients who received placebo were compared with those given TAM. RFS in both groups was 87% (P =.6), 87% in patients aged < or = 49 (P =.9), and 88% and 87%, respectively (P =.4), in those aged > or = 50 years.

CONCLUSION

There was no significant difference in the outcome of patients who received AC or CMF. TAM with either regimen resulted in no significant advantage over that achieved from chemotherapy alone.

NCCN Practice Guidelines for Breast Cancer

The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. In many situations, the patient and physician have the responsibility to jointly explore and ultimately select the most appropriate option from among the available alternatives. With rare exception, the evaluation, treatment, and follow-up recommendations contained within these guidelines were based largely on the results of past and present clinical trials. However, there is not a single clinical situation in which the treatment of breast cancer has been optimized with respect to either maximizing cure or minimizing toxicity and disfigurement. Therefore, patient and physician participation in prospective clinical trials allows patients not only to receive state-of-the-art cancer treatment but also to contribute to the improvement of treatment of future patients.

Variation in axillary node dissection influences the degree of nodal involvement in breast cancer patients

BACKGROUND AND OBJECTIVES

The number of positive axillary lymph nodes predicts prognosis and is often important in determining adjuvant chemotherapy in breast cancer patients. This study was undertaken to determine if differences in the extent of axillary node dissection would alter the number of reported positive nodes.

METHODS

The study population consisted of 302 patients with invasive breast cancer who underwent complete (level I/II/III) axillary lymph node dissection. Assuming that all patients had undergone a level I/II dissection, it was determined how frequently a patient's nodal category (0, 1-3, 4-9, >10 positive nodes) would have been altered if a level I or level I/II/III dissection were performed.

RESULTS

Assuming that all 302 patients had undergone a level I/II dissection, performing only level I dissection would have resulted in a change in nodal category in 15.9% of all patients and 36.1% of patients with positive nodes. The corresponding changes for a level I/II/III dissection would have been 4.3% and 9.5%, respectively.

CONCLUSIONS

Variations in the level of axillary node dissection for breast cancer can result in significant changes in the number of positive axillary nodes. This can potentially bias adjuvant chemotherapy recommendations if treatment decisions are based on this prognostic factor.

Routine preoperative lymphoscintigraphy is not necessary prior to sentinel node biopsy for breast cancer

BACKGROUND

This prospective study was performed to ascertain the added benefit of lymphoscintigraphy to a standard method of intraoperative lymphatic mapping and sentinel node biopsy for breast cancer.

METHODS

Patients with invasive breast cancer were injected with 99mTc sulfur colloid prior to sentinel node biopsy; preoperative lymphoscintigraphy was then performed in half of the patient population.

RESULTS

Sentinel node identification was possible in 45 of 50 patients (90%). All 14 patients (31%) with axillary nodal metastases had at least one histologically positive sentinel node (0% false negative rate). Lymphoscintigraphy revealed sentinel nodes in 17 of the 24 patients (70.8%) imaged. All 17 of these patients had one or more axillary sentinel nodes identified using intraoperative lymphatic mapping. In addition, 5 of 7 patients with a negative preoperative lymphoscintogram had an axillary sentinel lymph node(s) identified intraoperatively. None of the tumors showed drainage to the internal mammary lymph node chain by lymphoscintigraphy despite the fact that there were 5 patients with inner quadrant tumors. There was no significant advantage with respect to sentinel lymph node localization (91.7% versus 88.5%, P = not significant) or false negative rate (0%, both groups, P = not significant) in the group undergoing preoperative lymphoscintigraphy when compared with the patients in whom lymphoscintigraphy was not performed.

CONCLUSIONS

Preoperative lymphoscintigraphy adds little additional information to intraoperative lymphatic mapping, and its routine use is not justified.

Genetic induction and upregulation of cyclooxygenase (COX) and aromatase (CYP19): an extension of the dietary fat hypothesis of breast cancer

A novel model of mammary carcinogenesis is proposed involving sequential induction and upregulation of cyclooxygenase and aromatase genes by essential fatty acids prominent in the US diet. The basic carcinogenic processes are: (1) constitutive prostaglandin biosynthesis and formation of mutagenic oxygen and nitrogen free radicals responsible for tumor initiation; (2) PGE-2-induced expression of aromatase and constitutive estrogen biosynthesis which sustains mitogenesis and tumor promotion; and (3) PGE-2-induced expression of vascular endothelial growth factor which stimulates angiogenesis and tumor metastasis.

Prospective study of nonsteroidal anti-inflammatory drugs and breast cancer

We conducted a prospective cohort study of Nonsteroidal anti-inflammatory drugs (NSAIDs) and breast cancer among 32,505 women in central Ohio, USA. After 5 years of follow-up, a total of 393 cases have been detected. The annual incidence of breast cancer per 100,00 women varied inversely with increasing intake of NSAIDs, declining from 323 among non-users to 183 among heavy users (p<0.01). Breast cancer rates decreased by about 50% with regular ibuprofen intake (p<0.01), and by about 40% with regular aspirin intake (p<0.05). The results suggest that specific NSAIDs may be effective chemopreventive agents against breast cancer.

Biodistribution and localization of radiolabeled NR-LU-10 Fab fragment in human breast cancer xenografts

Radioimmunodetection, which takes advantage of tumor-specific or tumor-associated radio-labeled monoclonal antibodies or other biologic molecules to diagnose the extent of disease in cancer patients, has been of limited use in studies to date in patients with breast cancer. The difficulty is in finding an antibody that is both sensitive and specific enough to localize in breast tumors. This study undertook immunohistochemical and in vivo evaluation of tumor localization and biodistribution of NR-LU-10 Fab (antibody fragment) in breast tumors to determine its ability to bind selectively to malignant tissue. NR-LU-10 Fab recognizes a pancarcinoma glycoprotein antigen found on tumors of epithelial cell origin. NR-LU-10 Fab reacted with 6/6 (100%) breast cancer cell lines and 14/16 (87.5%) breast tumors with varying degrees of immunostaining intensities. Athymic mice bearing ZR-75-1 breast cancer xenografts were injected with 125I-labeled NR-LU-10 Fab (12 microg/5 microCi) and sacrificed at fixed time intervals. These studies demonstrated the highest tumor uptake of labeled Fab at 12 h postinjection (4.58+/-1.59% of injected dose/gram [% ID/g] of tissue); this gradually decreased to 0.13+/-0.05% ID/g of tissue by 72 h postinjection of the radiolabeled Fab. Biolocalization to normal tissues was as predicted for a Fab fragment; i.e., initially high in clearance organs (kidney), followed by rapid clearance over the 72-h test period. NR-LU-10 Fab displays adequate breast tumor localization with minimal biolocalization to normal tissues, thus supporting its potential use in radioimmunoscintigraphy and the RIGS system (radioimmunoguided surgery).

Keratinocyte growth factor (KGF) induces aromatase activity in cultured MCF-7 human breast cancer cells

Estrogen is the major hormonal stimulus for growth of the hormonal-dependent type of breast cancer. The rate-limiting step in the conversion of androgens to estrogens in breast tumors is catalyzed by aromatase, one of a series of related P-450 enzymes involved in the production of steroid hormones. An interesting correlation has been found between KGF mRNA and aromatase mRNA expression in human breast tumors. Tumors that express aromatase mRNA exhibit strong KGF expression, while tumors that do not express aromatase are weak or negative for KGF expression. Thus, it is reasonable to theorize that a possible association between KGF and aromatase in controlling human breast tumor growth exists. The purpose of the current study was to establish whether there is any interaction between KGF, which is known to have epithelial-specific mitogenic activity on breast cancer cells in vitro, and the synthesis of estradiol within the hormone-dependent breast cancer epithelial cells. In the present study, we have demonstrated that KGF stimulates aromatase activity in human breast cancer cells (MCF-7) in a dose-dependent manner. Our data shows that recombinant human KGF, at a dose as low as 10 ng/ml, can significantly increase aromatase activity 2-fold over controls. In agreement with this observation, we also found that aromatase mRNA levels were increased after 10 ng/ml KGF treatment in MCF-7 cells. These results indicate that the stimulatory effect of KGF on aromatase activity may be mediated by alterations in aromatase mRNA levels or in the efficiency of the translation of the message in MCF-7 cells. In addition, our results have demonstrated that modulation of aromatase activity appears to correlate with the stimulation of proliferative activity by KGF in MCF-7 cells. These results are consistent with our previous observations that estradiol-17 beta stimulates KGF expression in human breast cancer stromal cells, leading to the speculation that breast malignant transformation is associated with a positive feedback stimulation, whereby estradiol-17 beta stimulates breast cancer stromal cell production of KGF, and KGF subsequently stimulates aromatase activity in breast cancer cells, consequently raising levels of estradiol-17 beta, in turn acts on breast stromal cells to yield more KGF. Such a positive feedback loop could play an important role in the loss of growth control in human breast cancer cells.

Estrogen-induced keratinocyte growth factor mRNA expression in normal and cancerous human breast cells

The local recurrence rate of breast cancer has been reported to be unusually high at the surgical scar. Such breast cancer recurrence is believed to be triggered by the release of growth factors into the healing wound. Observations from an animal model have also demonstrated that KGF expression is dramatically induced by creation of full thickness wounds in mouse skin. Since KGF is an epithelial cell-specific mitogen in rat mammary epithelium, it is reasonable to speculate that KGF may be also involved in regulating human breast cancer cell growth. The purpose of the present study was to determine the effect of estradiol-17 on KGF gene expression in normal human breast stromal cells, as well as in human breast cancer stromal cells, and the mechanisms by which estradiol-17 regulates breast epithelial proliferation. Our results show that KGF expression was not effected by estradiol-17 treatment in normal human breast stromal cells. In contrast, KGF expression was stimulated by estradiol-17 in human breast cancer stromal cells. KGF mRNA levels have also been examined in normal human breast stromal cells and human breast cancer stromal cells. An interesting correlation was found between KGF expression and estradiol-17 regulation in these cell types. Normal human breast stromal cells which do not response to estradiol-17 have lower KGF mRNA level than the cancer cells which KGF expression is stimulated by estradiol-17. Our data also demonstrate that recombinant human KGF significantly stimulate normal human breast and human breast cancer epithelial cell proliferation in a dose-dependent manner. Since we have shown that estradiol-17 induces KGF mRNA expression in human breast cancer stromal cells, KGF may be involved at least in part in the stimulatory pathway that is initiated by estradiol-17 in human breast cancer epithelial cells.

Stress and immune responses after surgical treatment for regional breast cancer

BACKGROUND

Adults who undergo chronic stress, such as the diagnosis and surgical treatment of breast cancer, often experience adjustment difficulties and important biologic effects. This stress can affect the immune system, possibly reducing the ability of individuals with cancer to resist disease progression and metastatic spread. We examined whether stress influences cellular immune responses in patients following breast cancer diagnosis and surgery.

METHODS

We studied 116 patients recently treated surgically for invasive breast cancer. Before beginning their adjuvant therapy, all subjects completed a validated questionnaire assessing the stress of being cancer patients. A 60-mL blood sample taken from each patient was subjected to a panel of natural killer (NK) cell and T-lymphocyte assays. We then developed multiple regression models to test the contribution of psychologic stress in predicting immune function. All regression equations controlled for variables that might exert short- or long-term effects on these responses, and we also ruled out other potentially confounding variables.

RESULTS

We found, reproducibly between and within assays, the following: 1) Stress level significantly predicted lower NK cell lysis, 2) stress level significantly predicted diminished response of NK cells to recombinant interferon gamma, and 3) stress level significantly predicted decreased proliferative response of peripheral blood lymphocytes to plant lectins and to a monoclonal antibody directed against the T-cell receptor.

CONCLUSIONS

The data show that the physiologic effects of stress inhibit cellular immune responses that are relevant to cancer prognosis, including NK cell toxicity and T-cell responses. Additional, longitudinal studies are needed to determine the duration of these effects, their health consequences, and their biologic and/or behavioral mechanisms.

Androgens influence estrogen-induced responses in human breast carcinoma cells through cytochrome P450 aromatase

The aromatase cytochrome P450 complex is responsible for the in vivo conversion of androgens to estrogens. Although breast cancer epithelial cells have been reported to have appreciable aromatase activity, its biologic significance remains uncertain. To address this, the effect of androgens on the expression of the estrogen-regulated gene pS2 in hormone-dependent human breast carcinoma cells in vitro was examined. Steroid-deprived MCF-7 cells were exposed to varying concentrations (1 nM, 10 nM, and 100 nM of androstenedione or testosterone for 2,4, and 6 days. Baseline aromatase activity was 4.9 (+/-3.1) fmol 3H2O/hour/microgram DNA [34.3 (+/-21.3) fmol/hr/10(6) cells] and was not influenced by the androgens. As an indication of estrogen biosynthesis, northern analysis was performed to quantitate pS2 mRNA expression. Although no significant pS2 induction was observed at 2 days, both 4 and 6 day exposure to 100 nM testosterone resulted in a 3-fold increase in pS2 mRNA expression. 5 alpha-dihydrotestosterone (5 alpha-DHT) failed to elicit a similar pS2 response. This testosterone-induced response was inhibited with the aromatase inhibitor 7 alpha (4'-amino) phenylthio-1,4-androstadiene-3,17-dione (7 alpha-APTADD) and with 10 microM tamoxifen. MCF-7 breast cancer cells possess endogenous aromatase activity at high enough levels to convert androgens to estrogens and elicit an estrogen-induced response. The expression of aromatase may offer a potential advantage to hormone-responsive cells, providing an additional autocrine growth pathway which may be exploited.

Seroma formation following axillary dissection for breast cancer: risk factors and lack of influence of bovine thrombin

BACKGROUND

Seromas of the axillary space following breast surgery can lead to significant morbidity and delay in the initiation of adjuvant therapy. A prospective, randomized study was undertaken to evaluate the effect of bovine spray thrombin on seroma formation following either modified radical mastectomy (MRM) or lumpectomy with axillary dissection (LAD). In addition, risk factors for seroma formation were analyzed and identified.

METHODS

A total of 101 patients were randomized to receive either bovine thrombin (20,000 units) (treatment group) or no thrombin (control group) applied to their axilla following either MRM or LAD. Drains were left in place until the preceding 24-hour drainage was < 40 milliliters. The number of days the drains were in place and wound complications (including seroma formation) were recorded.

RESULTS

Forty-nine (n = 49) patients were assigned to the treatment gorup and 52 (n = 52) to the control group. MRM was performed on 60 patients (59%) and LAD oN 41 (41%). Eighteen of the 49 patients (37%) in the thrombin group developed a seroma in comparison to 21 of the 52 control patients (40%) (P = 0.71). Significant risk factors for seroma formation included increased age, patient weight, initial 72-hour wound drainage, and LAD. No statistically significant differences were observed between treatment and control groups with respect to time to drain removal, or the incidence of other wound complications.

CONCLUSION

Although thrombin by itself appears to have no effect on subsequent seroma development following axillary dissection, the identification of predictive variables will be helpful in designing future trials aimed at reducing the incidence of this common complication of breast surgery.

Nonsteroidal antiinflammatory drugs and breast cancer

We examined the association of nonsteroidal antiinflammatory drugs and breast cancer risk in a case-control study of 511 breast cancer patients and 1,534 population control subjects. The relative risk of breast cancer was reduced in women using these compounds at least 3 times per week for > or = 1 year [odds ratio (OR) = 0.66; 95% confidence interval (CI) = 0.52-0.83]. Odds ratios were similar for use of ibuprofen (0.57) or aspirin per se (0.69). Breast cancer risk declined with increasing exposure, and the greatest risk reduction (40%; odds ratio = 0.60; 95% CI = 0.40-0.91) occurred at the highest level of use (daily intake for > or = 5 years). These results indicate that nonsteroidal antiinflammatory drugs may have chemopreventive potential against the development of breast cancer.

Adjuvant CMFVP versus adjuvant CMFVP plus ovariectomy for premenopausal, node-positive, and estrogen receptor-positive breast cancer patients: a Southwest Oncology Group study

PURPOSE

To determine whether the addition of surgical ovariectomy to standard chemotherapy prolongs disease-free survival (DFS) and overall survival in premenopausal patients with estrogen receptor (ER)-positive operable breast cancer with positive axillary nodes.

PATIENTS AND METHODS

Three hundred fourteen premenopausal patients with ER-positive, node-positive breast cancer were enrolled between July 1979 and July 1989. Patients were stratified according to number of involved nodes and type of primary surgery and randomized to receive either of the following: (1) cyclophosphamide 60 mg/m2/d by mouth for 1 year, methotrexate 15 mg/m2 intravenously (i.v.) weekly for 1 year, fluorouracil (5-FU) 400 mg/m2 i.v. weekly for 1 year, vincristine .625 mg/m2 i.v. weekly for the first 10 weeks, and prednisone weeks 1 to 10 with doses decreasing from 30 mg/m2 to 2.5 mg/m2 (CMFVP); or (2) bilateral ovariectomy followed by CMFVP.

RESULTS

The median follow-up time is 7.7 years and the maximum 13.2 years. Treatment arms are not significantly different with respect to either survival or DFS (one-sided log-rank, P = .55 and .70, respectively). The 7-year survival rate is 71% on the CMFVP arm and 73% on CMFVP plus ovariectomy. No significant differences were observed in node or receptor level subsets.

CONCLUSION

We conclude that, in this study, the addition of ovariectomy did not improve results over chemotherapy alone in the treatment of premenopausal women with node-positive, ER-positive, operable breast cancer. Our sample size was too small to detect a small improvement. The death hazards ratio of CMFVP/CMFVP plus ovariectomy was 1.22 (95% confidence interval [CI], .79 to 1.89).

The natural history of breast cancer with more than 10 positive nodes

BACKGROUND

Experimental protocols are being used increasingly to treat breast cancer with > 10 positive nodes. An appreciation of the natural history of this disease is crucial for choosing the optimal therapeutic approach.

PATIENTS AND METHODS

We retrospectively reviewed the records of 141 patients who had breast cancer with > 10 positive nodes and received definitive therapy at our institution in the years 1969 through 1991. Because therapy evolved during this period, we compared the results from 1969 through 1981 to those from 1982 through 1991.

RESULTS

Ninety-one patients (65%) were > or = 50 years of age. Fifty-four (38%) were estrogen receptor (ER) positive, the remainder were ER negative or ER status unknown. Fifty-seven (40%) had 10 to 15 positive nodes, 63 (45%) had 16 to 25, and 21 (15%) had > 25. The ratio of positive nodes to total nodes was < 50% in 22 patients, 50% to 75% in 49, and > 75% in 70. One hundred thirty-four patients (95%) underwent modified or radical mastectomy. Forty (28%) received adjuvant chemotherapy, including 16 (11%) of 58 patients treated prior to 1981. Eleven patients (8%) were treated with adjuvant radiation therapy. The median survival for all patients was 52 months, with an actuarial survival of 29% at 10 years. Patients treated after 1981 had significantly improved survival. They lived a median of 68 months postoperatively, as compared to 41 months among patients treated earlier.

CONCLUSIONS

This is a high-risk group of patients, yet there is a small subset who can obtain a long survival with standard treatment modalities.

Adjuvant CMFVP versus tamoxifen versus concurrent CMFVP and tamoxifen for postmenopausal, node-positive, and estrogen receptor-positive breast cancer patients: a Southwest Oncology Group study

PURPOSE

To compare chemohormonal therapy, chemotherapy alone, and hormonal therapy alone in postmenopausal patients with estrogen receptor (ER)-positive operable breast cancer and positive axillary nodes with respect to survival and disease-free survival (DFS).

PATIENTS AND METHODS

Eight hundred ninety-two postmenopausal women with ER-positive, node-positive breast cancer were enrolled by the Southwest Oncology Group (SWOG) from July 1979 to March 1989 and 74 by the Eastern Cooperative Oncology Group (ECOG) between June 1987 and March 1989. Patients were stratified according to number of involved nodes and type of primary surgery and randomized to receive the following: (1) tamoxifen 10 mg twice daily by mouth for 1 year; (2) cyclophosphamide 60 mg/m2/d by mouth for 1 year, methotrexate 15 mg/m2 intravenously (IV) weekly for 1 year, fluorouracil (5-FU) 400 mg/m2 IV weekly for 1 year, vincristine .625 mg/m2 IV weekly for the first 10 weeks, and prednisone during weeks 1 to 10 with doses decreasing from 30 mg/m2 to 2.5 mg/m2 (CMFVP); or (3) the combination of tamoxifen and CMFVP.

RESULTS

The median follow-up duration is 6.5 years, with a maximum of 12.8 years. Treatment arms are not significantly different with respect to either survival or DFS (log-rank, 2 df, P = .82 and .23, respectively). The 5-year survival rate is 77% for the tamoxifen arm, 78% for CMFVP, and 75% for the combination. No significant differences were observed in node or receptor level subsets. Severe or worse toxicity was experienced by 56% of patients on CMFVP and 61% on CMFVP plus tamoxifen, compared with 5% on tamoxifen alone.

CONCLUSION

CMFVP chemotherapy, either alone or in combination with tamoxifen, has not been shown to be superior to tamoxifen alone in the treatment of postmenopausal women with node-positive, ER-positive, operable breast cancer.

The regional treatment of liver metastases from breast cancer

To determine the effect of aggressive regional therapy for liver metastasis from breast cancer, we retrospectively reviewed data on 74 patients identified with liver metastases. Forty had only liver metastases. In this group of 40 patients, 18 were treated with regional therapy only, i.e., surgical resection and/or regional chemotherapy via hepatic artery or portal vein catheters whereas 22 patients had systemic chemotherapy. The two groups were comparable. The regional chemotherapy regimen was 5-FU, Adriamycin, methotrexate, and cytoxan. Median survival (27 months) for those patients treated with regional therapy (N = 18) was significantly longer than for those (N = 22) treated with systemic therapy (5 months) (P = 0.001). Only 45% of the regional treatment group failed in the liver. Our data, although retrospective and selective, suggest that certain subgroups of breast cancer patients with metastatic liver disease may benefit from aggressive regional therapy.

Clinical trials. Access and reimbursement

Clinical trials continue to play an extremely important role in clinical oncology, but of the nearly 1 million cancer patients diagnosed in the United States each year, only 2.5% (25,000) participate in such trials. Access to clinical trials has been enhanced by the adoption by the NCI of a promotional campaign that involves seminars, dissemination of information to national and local news media, and assisting in making information about clinical trials available to patients and physicians. Factors that hinder accrual of patients to clinical trials include: (1) physicians' concern about losing contact with patients, (2) physicians who feel that "experimental therapy" is not as good as "standard therapy," and (3) the time it takes to discuss and implement clinical trials. Reimbursement for clinical trials has also become a major concern. Who should pay for clinical research? Many insurance companies have been reluctant to pay for "experimental therapy" but will pay for "standard therapy." If this trend continues, the whole concept and organization of clinical trials, i.e., Phase I, II, and III trials, will be greatly hindered. Solutions must be found, and third party payers need to realize that an investment in clinical trials today will decrease the long term costs of state-of-the-art care.

Prospective evaluation of clinical and pathologic detection of axillary metastases in patients with carcinoma of the breast

Complete axillary dissection was performed in 287 patients undergoing modified radical mastectomy between 1984 and 1987 to identify patterns of axillary node metastases, as well as discontinuous axillary node ("skip") metastases. Positive pathologic findings were compared with preoperative clinical examinations in 266 patients and showed only 60 cases (22.6%) clinically suspicious for tumor, in contrast to 131 (45.6%) with pathologically confirmed positive lymph nodes. Axillary contents were classified level I, II, or III based on their relationship to the pectoralis minor muscle. An average of 24.2 nodes was resected per patient (level I, 10; level II, 8.1; and level III, 5.3). Tumors ranged in size from 0.5 to 12.0 cm (mean, 2.6 cm), and increasing tumor size was associated with an increased likelihood of positive nodes. The data on 204 patients with complete clinical and pathologic data show that of 119 patients with negative level I nodes a limited axillary dissection (level I only) would fail to identify 6 with positive level II and 2 with positive level III nodes, whereas of 85 patients with positive level I nodes limited axillary dissection would fail to identify 17 with positive level II nodes, 7 with positive level III nodes, and 27 with positive levels II and III nodes. Complete axillary dissection (levels I, II, and III) should be performed to stage patients accurately, as well as to remove tumor-involved nodes and diminish local axillary recurrences. Clinical examination of the axilla appears to be a poor means of identifying axillary metastatic cancer.

Is DNA ploidy an independent prognostic indicator in infiltrative node-negative breast adenocarcinoma?

To evaluate DNA content as an independent, long-term prognostic indicator in infiltrative, node-negative adenocarcinoma of the breast, flow cytometric DNA analyses were performed retrospectively in 165 patients. The exclusive use of paraffin-embedded tissue permitted the study of patients for whom 3 to 15 years' follow-up was available. Other investigators have shown a relationship between DNA nuclear content and well-known prognostic indicators of breast carcinoma, such as estrogen receptors, age, menopausal status, and stage of tumor. However, very few of these studies were based on patients with long-term clinical follow-up and investigated the independent prognostic value of DNA nuclear content. The frequency of aneuploidy in the patients in this study was 57%, with DNA indices ranging from 0.73 to 2.59. Survival in patients with localized breast carcinoma with DNA aneuploid tumors was 84.1% at 5 years and 75.5% at 10 years. Those with diploid tumors showed survival of 87.8% at 5 years and 73.4% at 10 years. These data show no independent prognostic value for DNA nuclear content. The relationship between DNA content, tumor histologic type, and age was also investigated. High-grade tumors were more often aneuploid. There was no association between DNA content and age. Of 165 patients, information regarding estrogen receptor status was available in only 77; 45% of those with aneuploid tumors and 35% with diploid tumors were estrogen receptor-negative. This difference was not significant. The authors conclude that simple determination of DNA ploidy fails to indicate prognosis for infiltrative, node-negative breast carcinoma.

Heterotopic pancreas

Heterotopic pancreas will be encountered infrequently by the surgeon causing symptoms or incidentally at laparotomy. To avoid confusion with carcinoma at laparotomy, local excision with frozen section diagnosis is recommended. Because frozen section diagnosis will not always be correct, clinical awareness of this condition at operation is also important.

Radioimmunoguided surgery in recurrent colorectal cancer: the role of carcinoembryonic antigen, computerized tomography, and physical examination

From January 1986 to December 1987, 32 patients with recurrent colorectal cancer had second-look radioimmunoguided surgery (RIGS system). All patients had pathologic confirmation of recurrence. The RIGS system identified 81% of recurrences, and in six patients recurrent tumor was identified only by RIGS. All patients had physical examination, carcinoembryonic antigen (CEA) assay, and computerized tomography of the abdomen and pelvis. Detection of recurrence was based on symptoms in six, elevated CEA value in 25, and physical examination in one. The CEA was elevated preoperatively in 30 patients; two false-negative results occurred in symptomatic patients who had pelvic recurrence. The median CEA value in those with liver recurrence was 30 ng/ml (range 5.2 to 298) and for pelvic recurrence 13 ng/ml (range 1.9 to 31) (P less than .05). The overall sensitivity of CT was 41% (abdomen other than liver 37%, liver 56%, and pelvis 22%). The combination of elevated CEA, symptoms, and physical findings identified 100% of recurrences. We conclude that a rising CEA remains the most accurate indicator of recurrence. CT should not be done routinely to detect recurrent colorectal cancer unless CEA is elevated or the patient is symptomatic. In our study the intraoperative use of the RIGS system aided the surgeon in identifying occult tumors.

Staging of carcinoma of the breast using a hand-held gamma detecting probe and monoclonal antibody B72.3

Radioimmunoguided Surgery (RIGS) uses a hand-held gamma detecting probe to identify radiolabeled monoclonal antibodies (Mab). Fourteen patients with carcinoma of the breast proved at biopsy received Mab B72.3 (5 millicuries of 125I per 1 milligram, Iodo-Gen method) intravenously six to 26 days before exploration. Probe counts were measured intraoperatively in mammary tissue and axillary lymph nodes. In the mammary tissue, the RIGS system identified tumor that was histologically confirmed in seven of eight patients and confirmed the absence in four of six patients. Probe counts were suspicious for tumor that was not proved histologically in two of 14 patients. Unsuspected tumor was identified in three of 14 patients. In axillary tissue, probe counts identified one of two tumors that were confirmed histologically and verified the absence of tumor in eight of 12 patients. Probe counts in axillary tissue were suspicious for tumor that could not be documented histologically in four of 14 patients. RIGS appears to be able to identify residual, subclinical and multicentric carcinoma of the breast and accurately delineate the pattern of antigenic drainage of tumor into adjacent lymph nodes.

Follow-up on flow cytometric DNA analysis of squamous cell carcinoma of the tongue

Preliminary data from this institution suggested that flow cytometric DNA analysis was an objective prognostic indicator in archival localized squamous cell carcinoma of the tongue. Technical improvements were made, including analysis of tumor, normal tissue, and a combination of the two; standardized cursor placement; mathematic determination of tetraploid populations; and development of a statistical analysis. A larger number of patients (60) with this disease were reviewed. DNA content was related to disease-free survival, local recurrence, regional metastasis, and incidence of second primary tumors. There was no significant difference between aneuploid and diploid tumors with respect to the variables analyzed. We believe these technical improvements will enhance flow cytometric DNA analysis of paraffin-embedded tissues. However, in this retrospective review of localized squamous cell carcinoma of the tongue, DNA analysis was not a valuable prognostic indicator. Only prospective studies will address this issue.

Eliminating the dog-ear in modified radical mastectomy

Inadequate attention has been paid to optimal closure of the postmastectomy incision in patients not desirous of breast reconstruction. Herein, we describe the use of a basic plastic surgical technique at the time of mastectomy to eliminate the dog-ear deformity at the axillary end of the incision. The technique is conceptually simple and expedient, and gives an excellent cosmetic result.

Technical and statistical improvements for flow cytometric DNA analysis of paraffin-embedded tissue

Flow cytometric DNA analysis of paraffin-embedded solid tumors has permitted review of large series of archival tissue in attempts to relate abnormal DNA content to prognosis. Limitations of the technique include: 1) a laborious, time-consuming procedure; 2) variation in technique between laboratories; and 3) lack of an objective method of computing DNA indices. Critical evaluation of our technique has shortened the time involved in dewaxing and rehydration, selectively utilized patient's own normal tissue as the internal standard, proved reproducibility of stored specimens, standardized DNA index computation, and developed a statistical analysis to confirm aneuploidy. These technical improvements and the development of a statistical analysis provide a way to shorten the procedure time and standardize the data generated from flow cytometric DNA analysis so as to improve the quality of retrospective reviews of paraffin-embedded tumors and accelerate the definition of flow cytometry's role as a prognostic indicator.

Radical neck dissection: is it enough?

This series of 307 patients who underwent radical neck dissection showed an overall recurrence rate of 19 percent. Clinical staging of disease was an accurate predictor of both recurrence and survival. Extranodal disease dramatically increased recurrence and decreased survival. Although our recurrence rate after radical neck dissection was lower than that previously reported for surgery alone, it was still significantly higher than that after adjuvant radiotherapy. We conclude that histologically proved neck disease should be treated by radical neck dissection, followed by adjuvant radiotherapy to decrease recurrence and, it is hoped, improve survival.

Reoperation directed by carcinoembryonic antigen level: the importance of a thorough preoperative evaluation

Many asymptomatic patients suspected to have recurrent colorectal cancer based on an elevated carcinoembryonic antigen level will be spared unnecessary operation if strict attention is paid to their preoperative evaluation. Liver and renal function should be assessed. Unresectable extraabdominal and intraabdominal recurrence or metastases should be excluded. Patients being evaluated for recurrence after curative resection of a rectosigmoid cancer should undergo a bone scan. Having satisfactorily ensured normal results for these investigations, the surgeon should then proceed to search for an intraabdominal source of tumor recurrence.

Needle localization of mammographically detected lesions in perspective

Needle localization of mammographically detected lesions has been shown to detect early breast cancer. One hundred seven patients who underwent needle localized biopsy from June 1977 to September 1985 were reviewed. Eighty percent of the biopsies were benign and 20 percent were cancers (22 patients). In patients undergoing modified radical mastectomy, 80 percent of the axillary specimens were node-negative. During the same 8 year period, 570 breast cancers were diagnosed. Needle localization was responsible for only 4 percent of all cancers found. Though needle localization represents an advance in the detection of early breast cancer, the majority of cancers are found by physical examination. The importance of routine examination by a physician and self-breast examination remains paramount.

Variation in recognition of recurrent colonic cancer by different CEA assays

Forty-six patients were followed with serial CEA determinations by two CEA assays after curative resection of a primary or recurrent colonic cancer. Thirteen have had a histologically proven recurrence, of which only six (46 percent) were predicted by both assays, while seven (54 percent) were predicted by one assay only. The assays appear complementary in indicating tumor recurrence, and preliminary findings suggest that it may be beneficial to follow patients with more than one CEA assay after resection of a primary or recurrent colonic cancer.

Intraoperative probe-directed immunodetection using a monoclonal antibody

To assess monoclonal antibody (MAb) 17-1A and its F(ab')2 fragment in intraoperative radioimmunodetection and to evaluate further the clinical usefulness of a hand-held gamma-detecting probe (GDP), we injected radiolabeled monoclonal antibody 17-1A three to six days preoperatively or its F(ab')2 fragment two to three days preoperatively into 18 patients with colorectal cancer. Intraoperative GDP counts with tumor-tissue ratios of 1.5:1 or greater were obtained from 15 (75%) of 20 tumor sites, with ratios averaging 2.3:1 for fragments and 3.4:1 for whole antibody. The GDP counts contributed to intraoperative decision making in three patients, either by localization of tumor not identified by inspection or palpation or by mapping margins of resection with histologic confirmation of a local/regional recurrence. These preliminary data demonstrate that probe-directed, intraoperative radioimmunodetection can assist the surgeon in detecting subclinical tumor deposits and thus better evaluate the extent of primary or recurrent colorectal cancers intraoperatively.

Facial nerve sacrifice and tumor recurrence in primary and recurrent benign parotid tumors

Three hundred eight patients underwent parotidectomy for a benign parotid tumor between 1948 and 1979. Two hundred seventy-four had operation for primary tumor, and 34, for recurrent tumor. Ninety-eight percent of those with primary tumors had superficial or total parotidectomy, and 2 percent had local excision with a wide margin of normal tissue. In those with recurrent tumor, 91 percent had superficial or total parotidectomy and 9 percent had local excision with a wide margin of normal tissue. There were nine recurrences in the primary group (3.2 percent) and 10 in the recurrent group (29 percent), at an average follow-up of 10 and 13 years, respectively. The time to recurrence in the primary group was between 5 and 20 years, whereas, second recurrences in the recurrent group generally took place within 5 years. Seven patients in the primary group (2.5 percent) and 9 in the recurrent group (26 percent) had sacrifice of the facial nerve. Most facial nerve sacrifices in the primary group were minor, involving a branch of the nerve only. Facial nerve sacrifice in the recurrent group, however, usually involved division of the nerve or the nerve trunk. These findings demonstrate that the major morbidity associated with managing benign parotid tumors occurs in dealing with recurrent tumors. Recurrence is uncommon if superficial or total parotidectomy is performed for a primary tumor.

Flow cytometric analysis of DNA content as a prognostic indicator in squamous cell carcinoma of the tongue

The mortality of squamous cell carcinoma of the tongue has not significantly improved in decades. Much of the information that has been gathered to date has been based on retrospective analyses. There is little consensus on treatment of the disease. In an attempt to define an objective prognostic indicator of aggressiveness of these tumors, a retrospective analysis of 15 paraffin-embedded specimens using flow cytometry was performed. Ten patients (67 percent) had aneuploid tumors and had a 5 year disease-free survival rate of 33 percent, whereas patients with diploid tumors (33 percent) had a 5 year disease-free survival rate of 80 percent. Although the number of patients was small, it appears that flow cytometry may be an objective prognostic indicator in patients with squamous cell carcinoma of the tongue. Larger series of archival paraffin-embedded flow cytometry analyses are recommended, as well as examination of variables other than the disease-free survival rate.

Needle aspiration biopsy of major salivary gland tumors. Its value

Three hundred forty-one needle aspiration biopsies (NAB) of major salivary gland tumors were performed over a 32-year period. Eighty percent of tumors were benign, and 20% were malignant. Preoperative NAB findings were compared with pathologic diagnosis of the surgically resected specimen in all cases. Forty-six of 63 aspirates from malignant tumors were correctly diagnosed by NAB, establishing a sensitivity at 73%. Two hundred forty-nine of 265 aspirates from benign tumors were correctly diagnosed by NAB, establishing a specificity at 94%. Overall accuracy was 90%. Diagnostic error or difficulty in clinically localizing the tumor to the salivary gland was encountered in 64 patients with parotid tumors and 12 patients with submandibular tumors. NAB correctly localized over 85% of these tumors to the salivary gland, thus enabling both immediate and correct decision-making concerning subsequent management to be undertaken.

Clinical and pathologic correlations in disease metastatic to the thyroid gland

Findings in our series of patients and a review of the literature seem to suggest that metastatic cancer to the thyroid is much more common that is clinically evident. The clinical presentation of an asymptomatic mass, normal thyroid functions, and a cold nodule on thyroid scan can occur months to years after treatment of a primary cancer and thus often produces a clinical dilemma. Workup should include ruling out other metastatic cancer and fine-needle aspiration of the thyroid mass. If isolated metastatic cancer to the thyroid is found, surgical resection should be performed, usually by lobectomy and isthmusectomy. Unfortunately, the prognosis is poor, but surgery often prolongs the disease-free interval and occasionally will be curative.

A method for intraoperative identification of the recurrent laryngeal nerve

Thyroid and parathyroid surgery is associated with a 1 to 6 percent incidence of injury to the recurrent laryngeal nerve. Electrical stimulation of the recurrent laryngeal nerve produces vocal cord motion that can be monitored by means of a double-cuffed endotracheal tube. Twelve patients underwent prospective evaluation with this monitoring system, and in all 12, the recurrent laryngeal nerve was accurately identified and localized. The nerve could be stimulated from a mean distance of 1.7 cm by a mean amperage of 1.3 mA. Postoperative indirect laryngoscopy demonstrated normal vocal cord function in all patients.

Surgical management of papillary and follicular carcinoma of the thyroid

The clinical outcome in 155 patients with papillary or follicular carcinoma of the thyroid gland operated on over a 25-year period demonstrated no difference in survival rates or incidence of recurrent tumor between those treated by total thyroidectomy and those undergoing less than total thyroidectomy. However, the complication rate was statistically significantly higher in those undergoing total thyroidectomy. Partial thyroidectomy with lobectomy on the side of the tumor, resection of the thyroid isthmus, and simple excision of enlarged cervical lymph nodes, if present, appears to be equally effective and safer.