Ductal lavage for detection of cellular atypia in women at high risk for breast cancer

BACKGROUND

Breast cancer originates in breast epithelium and is associated with progressive molecular and morphologic changes. Women with atypical breast ductal epithelial cells have an increased relative risk of breast cancer. In this study, ductal lavage, a new procedure for collecting ductal cells with a microcatheter, was compared with nipple aspiration with regard to safety, tolerability, and the ability to detect abnormal breast epithelial cells.

METHODS

Women at high risk for breast cancer who had nonsuspicious mammograms and clinical breast examinations underwent nipple aspiration followed by lavage of fluid-yielding ducts. All statistical tests were two-sided.

RESULTS

The 507 women enrolled included 291 (57%) with a history of breast cancer and 199 (39%) with a 5-year Gail risk for breast cancer of 1.7% or more. Nipple aspirate fluid (NAF) samples were evaluated cytologically for 417 women, and ductal lavage samples were evaluated for 383 women. Adequate samples for diagnosis were collected from 111 (27%) and 299 (78%) women, respectively. A median of 13,500 epithelial cells per duct (range, 43-492,000 cells) was collected by ductal lavage compared with a median of 120 epithelial cells per breast (range, 10-74,300) collected by nipple aspiration. For ductal lavage, 92 (24%) subjects had abnormal cells that were mildly (17%) or markedly (6%) atypical or malignant (<1%). For NAF, corresponding percentages were 6%, 3%, and fewer than 1%. Ductal lavage detected abnormal intraductal breast cells 3.2 times more often than nipple aspiration (79 versus 25 breasts; McNemar's test, P<.001). No serious procedure-related adverse events were reported.

CONCLUSIONS

Large numbers of ductal cells can be collected by ductal lavage to detect atypical cellular changes within the breast. Ductal lavage is a safe and well-tolerated procedure and is a more sensitive method of detecting cellular atypia than nipple aspiration.

Expression of pp32 gene family members in breast cancer

The pp32 gene family consists of at least three closely related members, pp32, pp32r1 and pp32r2. In spite of a high degree of identity at the nucleotide level, pp32 functionally behaves as a tumor suppressor where as pp32r1 and pp32r2 are pro-oncogenic. The purpose of this pilot study was to determine pp32-related expression and whether alternative gene use among the pp32 family members occurred in human breast cancer. As a first step, in situ hybridization with a riboprobe capable of hybridizing with all the three members showed abundant pp32-related mRNA in benign ducts and acini and in infiltrating ductal carcinomas. A total of 100/102 cases were positive. Further, a detailed molecular analysis by RT-PCR, cloning, and sequencing was performed in five frozen infiltrating breast carcinomas and matched benign breast tissues. Oncogenic pp32r1 (5/5) and pp32r2 (3/5) expression was observed in carcinomas where as benign breast tissues expressed pp32. 4/5 carcinomas continued to express pp32 but one was devoid of pp32 expression. These results suggest that alternative expression of pp32 family members may be common in human breast cancer and the analysis of the profile of pp32-related expression might be helpful in understanding the role of these genes in breast cancer pathogenesis.

Detection of breast cancer cells in ductal lavage fluid by methylation-specific PCR

If detected early, breast cancer is curable. We tested cells collected from the breast ducts by methylation-specific PCR (MSP). Methylated alleles of Cyclin D2, RAR-beta, and Twist genes were frequently detected in fluid from mammary ducts containing endoscopically visualised carcinomas (17 cases of 20), and ductal carcinoma in situ (two of seven), but rarely in ductal lavage fluid from healthy ducts (five of 45). Two of the women with healthy mammograms whose ductal lavage fluid contained methylated markers and cytologically abnormal cells were subsequently diagnosed with breast cancer. Carrying out MSP in these fluid samples may provide a sensitive and powerful addition to mammographic screening for early detection of breast cancer.

Surgery in breast cancer

This year (1999) has been filled with new information on the prevention of breast cancer and new literature trying to address some of the long-term adverse consequences of our surgical therapies. As the complexities of our therapies continue to increase at exponential rates, we now also have the ability to more accurately predict the consequences of both our therapeutic actions and our failure to act. Nowhere is this more evident than in the literature devoted to long-term consequences of treatment for breast cancer. As we are more successful in achieving our goals of increased survival from this dreaded disease, the future needs of these long-term survivors must play an ever-increasing role in our current management. Advances reported this year are laying down a new basis for efforts to improve the quality of life for breast cancer survivors.

Significance of axillary lymph node extranodal soft tissue extension and indications for postmastectomy irradiation

BACKGROUND

Extranodal soft tissue extension of axillary lymph node metastases (ETE) has been considered an indication for postmastectomy radiotherapy, including the axilla. However, it is unclear whether patients with ETE are at an increased risk of axillary recurrence.

METHODS

From a single institutional database of 2362 patients with breast carcinoma treated between 1974-1994, a total of 487 patients who underwent mastectomy for lymph node positive, infiltrating (T1-T3) breast carcinoma was found. All the patients had pathologically confirmed axillary lymph node metastases and negative surgical margins; none had received postoperative irradiation. Of these patients, 50 had histologically documented axillary ETE. Forty-three patients had a minimum follow-up of at least 1 year and comprise the study population. The median follow-up time of surviving ETE positive patients was 79 months. Twenty-five patients (58.1%) received adjuvant systemic therapy. Sites of first failure were local or distant. Local failure was categorized further as chest wall failure, axillary failure, supraclavicular lymph node failure, or internal mammary lymph node failure.

RESULTS

For the 43 patients with ETE, the median patient age was 59.5 years (range, 38-81 years) and the median tumor size was 3.6 cm (range, 0.5-12.0 cm). The median number of positive axillary lymph nodes was 6 (range, 1-36 lymph nodes) versus 2 (range, 1-30 lymph nodes) for all T1-T3 ETE positive patients compared with ETE negative patients (P < 0. 001). The risk of ETE increased significantly with increasing numbers of axillary lymph node metastases (P < 0.001). Of the patients with ETE, 16 (37.2%) developed recurrent disease. ETE positive patients with disease recurrence had significantly greater numbers of positive axillary lymph nodes (median, 10 lymph nodes) than those patients who were recurrence free (median, 4 lymph nodes) (P = 0.02). The site of first failure was local in 7 patients (16. 3%) and distant in 9 patients (20.9%). All patients with local recurrence had chest wall failures; there were no isolated lymph node recurrences. The only simultaneous local and distant failure was in one patient presenting with supraclavicular and intraabdominal metastases.

CONCLUSIONS

The risk of axillary recurrence, either as an isolated event or as part of simultaneous failure, is extremely low, even in patients with ETE. These data suggest that patients with ETE frequently have higher numbers of positive axillary lymph nodes and on that basis are at risk for local recurrence and as a rule would be considered for postmastectomy irradiation. However, these data suggest that the presence of ETE is not an indication for routine postmastectomy axillary lymph node irradiation.

Telomerase activity and prognosis in primary breast cancers

PURPOSE

Recent studies associate telomerase activity with prognostic factors and survival. We compared quantitative telomerase activity in primary tumors with traditional prognostic factors and outcome in a group of invasive but nonmetastatic breast cancers.

PATIENTS AND METHODS

Telomerase activity was measured in 203 invasive breast cancers by the quantitative telomeric repeat amplification protocol method. Telomerase expression was compared with 28S rRNA level, tumor content, and clinical variables, including outcome. For clinical correlations, telomerase activity was standardized by two methods: (1) a correction for cellularity using 28S rRNA levels, and (2) a correction for the histologically determined invasive proportion of the specimen.

RESULTS

Telomerase activity was found in 82% of breast cancers with measurable 28S rRNA levels. Telomerase activity was associated with the proliferative index (P <.01) of the tumor but not with any other prognostic variable. Neither uncorrected nor corrected telomerase activity was associated with relapse-free or overall survival in this study.

CONCLUSION

Telomerase activity level was associated with the proliferative index of invasive breast cancers, but its measurement in samples from this group of nonmetastatic breast cancer patients did not predict survival.

Surgery for breast cancer

Women with breast cancer today have many more therapeutic options available to them for their surgical therapy. Almost all patients with breast cancer have some options for breast conservation. Active patient involvement in analyzing and understanding the pros and cons of each of these options seems extremely important to the long-term emotional and psychological outcome of their breast cancer therapy. Several reports this year have reintroduced the issue of adequate local control. The common philosophy a decade ago was that because systematic therapy (adjuvant chemotherapy) was improving, local therapy would become of lesser importance. Several studies this year have indicated the extreme importance of local control in maximizing survival advantage because of the relationship of increasing local failure and deteriorating survival from systemic disease. Despite significant improvements in treatment, our screening and diagnostic approaches have still failed to identify the majority of lesions prior to the patient's own palpation of the tumor. Using new diagnostic modalities that do not involve surgery, the biopsy of lower probability lesions with great accuracy is expected to improve the efficacy of the current screening measures. Despite all the improvements, the most important therapeutic step in the management of breast cancer remains earlier diagnosis and earlier extirpation of the initial invasive focus of malignancy.

Hürthle cell neoplasms of the thyroid: are there factors predictive of malignancy?

OBJECTIVE

To determine if any preoperative or intraoperative factors can reliably predict malignancy in patients with Hürthle cell neoplasms.

SUMMARY BACKGROUND DATA

Most experienced surgeons recommend total thyroidectomy for Hürthle cell carcinomas and reserve thyroid lobectomy for Hürthle cell adenomas. However, delineation between Hürthle cell adenoma versus carcinoma often cannot reliably be made either before or during surgery.

METHODS

Medical records from 57 consecutive patients who underwent thyroid resections for Hürthle cell neoplasms between October 1984 and April 1995 at The Johns Hopkins Hospital were analyzed to determine if any factors were predictive of malignancy.

RESULTS

Of the 57 patients with Hürthle cell neoplasms, 37 had adenomas and 20 had carcinomas, resulting in a 35% prevalence of malignancy. Patients with adenomas did not differ from those with carcinoma with respect to age, sex, or history of head and neck irradiation. However, patients with Hürthle cell carcinomas had significantly larger tumors (4.0 +/- 0.4 cm vs. 2.4 +/- 0.2 cm, p < 0.005). Furthermore, although the incidence of malignancy was only 17% for tumors 1 cm or less and 23% for tumors 1 to 4 cm, tumors 4 cm or greater were malignant 65% of the time (p < 0.05). Both fine-needle aspiration and intraoperative frozen section analysis had low sensitivities in the detection of cancer (16% and 23%, respectively). With up to 9 years of follow-up, there has been no tumor-related mortality.

CONCLUSIONS

These data demonstrate that the size of a Hürthle cell neoplasm is predictive of malignancy. Therefore, at the time of initial exploration for large Hürthle cell neoplasms (>4 cm), definitive resection involving both thyroid lobes should be considered because of the higher probability of malignancy.

Association between extent of axillary lymph node dissection and survival in patients with stage I breast cancer

BACKGROUND

The role of axillary lymph node dissection for stage I (T1N0) breast cancer remains controversial because patients can receive adjuvant chemotherapy regardless of their nodal status and because its therapeutic benefit is in question. The purpose of this study was to determine whether extent of axillary dissection in patients with T1N0 disease is associated with survival.

METHODS

Data from 464 patients with T1N0 breast cancer who underwent axillary dissection from 1973 to 1994 were examined retrospectively. Kaplan-Meier estimates of overall survival, disease-free survival, and recurrence were calculated for patients according to the number of lymph nodes removed (<10 or > or = 10; <15 or > or = 15), and survival curves compared using the Wilcoxon-Gehan statistic. Cox proportional hazards regression modelling was used to adjust for confounding prognostic variables.

RESULTS

Median follow-up time was 6.4 years. Patient groups were similar in age, menopausal status, tumor size, hormonal receptor status, type of surgery, and adjuvant therapy. There was a statistically significant improvement in disease-free survival in the > or = 10 versus <10 nodal groups (P <.01). Five-year estimates of survival were 75.7% and 86.2% for <10 nodes and > or = 10 nodes, respectively; 10-year estimates were 66.1% and 74.3%. There also was a notable improvement in the survival comparison of patients with <15 versus > or = 15 nodes (P < or = .05). These findings were confirmed in the multivariate analysis.

CONCLUSIONS

These results may reflect a potential for misclassification of tumor stage among patients who had fewer nodes removed. The data, however, suggest that in patients with Stage I breast cancer, improved survival is associated with a more complete axillary lymph node dissection.

DNA content and other factors associated with ten-year survival after resection of pancreatic carcinoma

BACKGROUND AND OBJECTIVES

The 5-year survival rates after resection of pancreatic carcinoma have recently increased and are predicted by tumor size, DNA content, and lymph node metastases at the time of resection. However, whether the 10-year survival rates have also increased and are similarly predicted by these factors is not known.

METHODS

The influence of preoperative imaging tests, alcohol consumption, cigarette smoking, K-ras mutations, anatomic location, details of surgical resection, pathologic findings, and tumor DNA content on survival was tested for 96 patients after a successful resection of a pancreatic carcinoma with 17 patients being followed for more than 5 years.

RESULTS

The 5- and 10-year patient survival rates were 18% and 3%, respectively. Univariate and multivariable analyses showed that tumor DNA content, pathologic tumor size, and lymph node metastases were the strongest prognostic indicators for long-term patient survival, although the importance of tumor size may diminish 2 or more years after resection. Surprisingly, the 11 patients with diploid carcinomas > or = 4 cm had an estimated 10-year survival rate of 36%.

CONCLUSION

These results show that the 10-year survival rate for pancreatic carcinoma remains very low, although the subset of patients with biologically favorable tumors has a prolonged survival and possible cure after resection.

Thyroid-specific expression of cholera toxin A1 subunit causes thyroid hyperplasia and hyperthyroidism in transgenic mice

Thyroid cell growth and function are regulated by hormones and growth factors binding to cell surface receptors that are coupled via G proteins, Gs and Gq, to the adenylyl cyclase and phospholipase C signal transduction systems, respectively. Activating mutations of the TSH receptor and G alpha s have been documented in subsets of thyroid neoplasms. To test the oncogenic potential of activated G alpha s in transgenic mice, we used the cholera toxin A1 subunit that constitutively activates G alpha s and used the rat thyroglobulin gene promoter for targeting this transgene (TGCT) to thyroid follicular cells. Three (M1392, F1358, and F1286) of six founders identified were able to transmit the transgene to their offspring and thyroid glands from these mice contained elevated levels of cAMP. Concentrations of serum thyroxine were elevated as early as 2 months of age (M 1392 and F 1286). F1358 mice were euthyroid until 8 months of age, at which time they developed hyperthyroidism. All three TGCT lines developed thyroid hyperplasia independent of their thyroxine levels. DNA image analysis of thyroid follicular cells from both the hyper and euthyroid mice showed that DNA index and "S+G2/M" phase were increased compared with normal, changes similar to that seen in poor prognosis human carcinomas. These data suggest that the G alpha s-adenylyl cyclase-cAMP pathway has an important role in thyroid hyperplasia and the transgenic mouse models reported herein will allow further examination of the role of this pathway in thyroid oncogenesis.

Pancreaticoduodenectomy for pancreatic adenocarcinoma: postoperative adjuvant chemoradiation improves survival. A prospective, single-institution experience

OBJECTIVE

This study was designed to evaluate prospectively survival after pancreaticoduodenectomy for pancreatic adenocarcinoma, comparing two different postoperative adjuvant chemoradiation protocol to those of no adjuvant therapy.

SUMMARY BACKGROUND DATA

Based on limited data from the Gastrointestinal Tumor Study Group, adjuvant chemoradiation therapy has been recommended after pancreaticoduodenectomy for adenocarcinoma of the head, neck, or uncinate process of the pancrease. However, many patients continue to receive no such therapy.

METHODS

From October 1991 through September 1995, all patients with resected, pathologically confirmed adenocarcinoma of the head, neck, or uncinate process of the pancreas were reviewed by a multidisciplinary group (surgery, radiation oncology, medical oncology, and pathology) and were offered three options for postoperative treatment after pancreaticoduodenectomy: 1) standard therapy: external beam radiation therapy to the pancreatic bed (4000-4500 cGy) given with two 3-day fluorouracil (5-FU) courses and followed by weekly bolus 5-FU (500 mg/m2 per day) for 4 months; 2) intensive therapy: external beam radiation therapy to the pancreatic bed (5040-5760 cGy) with prophylactic hepatic irradiation (2340-2700 cGy) given with and followed by infusional 5-FU (200 mg/m2 per day) plus leucovorin (5 mg/m2 per day) for 5 of 7 days for 4 months; or 3) no therapy: no postoperative radiation therapy or chemotherapy.

RESULTS

Pancreaticoduodenectomy was performed in 174 patients, with 1 in-hospital death (0.6%). Ninety-nine patients elected standard therapy, 21 elected intensive therapy, and 53 patients declined therapy. The three groups were comparable with respect to race, gender, intraoperative blood loss, tumor differentiation, lymph node status, tumor diameter, and resection margin status. Univariate analyses indicated that tumor diameter < 3 cm, intraoperative blood loss < 700 mL, absence of intraoperative blood transfusions, and use of adjuvant chemoradiation therapy were associated with significantly longer survival (p < 0.05). By Cox proportional hazards survival analysis, the most powerful predictors of outcome were tumor diameter, intraoperative blood loss, status of resection margins, and use of postoperative adjuvant therapy. The use of postoperative adjuvant chemoradiation therapy was a predictor of improved survival (median survival, 19.5 months compared to 13.5 months without therapy; p = 0.003). The intensive therapy group had no survival advantage when compared to that of the standard therapy group (median survival, 17.5 months vs. 21 months, p = not significant).

CONCLUSIONS

Adjuvant chemoradiation therapy significantly improves survival after pancreaticoduodenectomy for adenocarcinoma of the head, neck, or uncinate process of the pancreas. Based on these survival data, standard adjuvant chemoradiation therapy appears to be indicated for patients treated by pancreaticoduodenectomy for adenocarcinoma of the head, neck, or uncinate process of the pancreas. Intensive therapy conferred no survival advantage over standard therapy in this analysis.

pp32 overexpression induces nuclear pleomorphism in rat prostatic carcinoma cells

Nuclear pleomorphism is an important diagnostic factor in tumour pathology. Traditionally, nuclear pleomorphism is evaluated qualitatively or semiquantitatively, often as a component of tumour grade; the molecular basis of nuclear pleomorphism, however, remains unclear. In this study, we investigated the quantitative effects on nuclear morphology of overexpressing pp32, a recently described nuclear phosphoprotein highly expressed in self-renewing and neoplastic cell populations. Assessment of Feulgen-stained transfected and control lines of AT3.1, a rat prostatic carcinoma cell line, using a computerized Cellular Image Analysis System (BD CAS-200) showed that stable overexpression of human pp32 in AT3.1 cells is accompanied by marked increases in the coefficient of variation of nuclear shape, nuclear size and chromatin textures but not in DNA content. In contrast, stable transfection with control vector, with ras, or with bcl-2 failed to affect nuclear morphology. Cell cycle analysis further showed that pp32-related increases in variation of nuclear structure manifested principally in G1. These studies suggest that pp32 plays a role either directly or indirectly in the control of nuclear shape of G1 cells.

Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients

OBJECTIVE

This single-institution study examined the outcome after pancreaticoduodenectomy in patients with adenocarcinoma of the head of the pancreas.

SUMMARY OF BACKGROUND DATA

In recent years, pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas has been associated with decreased morbidity and mortality and, in some centers, 5-year survival rates in excess of 20%.

METHODS

Two hundred one patients with pathologically verified adenocarcinoma of the head of the pancreas undergoing pancreaticoduodenectomy at The Johns Hopkins Hospital between 1970 and 1994 were analyzed (the last 100 resections were performed between March 1991 and April 1994). This is the largest single-institution experience reported to date.

RESULTS

The overall postoperative in-hospital mortality rate was 5%, but has been 0.7% for the last 149 patients. The actuarial 5-year survival for all 201 patients was 21%, with a median survival of 15.5 months. There were 11 5-year survivors. Patients resected with negative margins (curative resections: n = 143) had an actuarial 5-year survival rate of 26%, with a median survival of 18 months, whereas those with positive margins (palliative resections; n = 58) fared significantly worse, with an actuarial 5-year survival rate of 8% and a median survival of 10 months (p < 0.0001). Survival has improved significantly from decade to decade (p < 0.002), with the 3-year actuarial survival of 14% in the 1970s, 21% in the 1980s, and 36% in the 1990s. Factors significantly favoring long-term survival by univariate analyses included tumor diameter < 3 cm, negative nodal status, diploid tumor DNA content, tumor S phase fraction < 18%, pylorus-preserving resection, < 800 mL intraoperative blood loss, < 2 units of blood transfused, negative resection margins, and use of postoperative adjuvant chemotherapy and radiation therapy. Multivariate analyses indicated the strongest predictors of long-term survival were diploid tumor DNA content, tumor diameter < 3 cm, negative nodal status, negative resection margins, and decade of resection.

CONCLUSIONS

The survival of patients with pancreatic adenocarcinoma treated by pancreaticoduodenectomy is improving. Aspects of tumor biology, such as DNA content, tumor diameter, nodal status and margin status, are the strongest predictors of outcome.

P-glycoprotein status of favorable-histology Wilms' tumor predicts treatment outcome

Patients with advanced-stage favorable-histology (FH) Wilms' tumor have a 4-year relapse-free survival rate of 70% to 90% after resection and chemotherapy of actinomycin D, vincristine, and doxorubicin. These three agents are actively pumped out of cells by P-glycoprotein (Pgp). The authors studied whether Wilms' tumor expresses Pgp and if the degree of Pgp expression correlates with treatment outcome. At the time of diagnosis, eight blinded paraffin-embedded FH and four anaplastic (ANA) Wilms' tumor sections were immunogold-labeled with a Pgp monoclonal antibody (17F9). Four of the FH-tumor patients had had relapse (FH+) according to the National Wilms' Tumor Study-3 protocol. Negative-relapse FH-tumor patients (FH-) had at least 6 years of follow-up. All 12 Wilms' tumors stained positive for Pgp. Both differentiated tubular structures and blastemal elements expressed Pgp. By the pathologist's score and the computerized cell image analysis, the degree of Pgp staining was greater at the time of diagnosis in FH+ tumors than in FH- tumors (P < .03; Mann-Whitney test). There was no statistically significant difference between ANA and FH+ or FH- tumors. These results show that both FH and ANA Wilms' tumors express Pgp, with higher levels of Pgp expression found in FH patients who had relapse. Current chemotherapeutic protocols, using Pgp-sensitive agents, may not be optimal for all FH Wilms' tumor patients.

Unresectable hilar cholangiocarcinoma: percutaneous versus operative palliation

BACKGROUND

Several nonoperative and operative options are available for palliation of patients with unresectable hilar cholangiocarcinoma. This retrospective analysis compares the results of nonoperative percutaneous stenting and operative palliation in 65 patients.

METHODS

Twenty-one patients were managed with percutaneous biliary stents (group A), and 44 patients underwent laparotomy (group B) with placement of large-bore silicone rubber transhepatic stents in 33. The two groups were similar with respect to age, gender, mean laboratory data, and cholangiographic extent of tumor.

RESULTS

Group A and group B patients were comparable in hospital morbidity (67% vs 61%), hospital mortality (14% vs 7%), and mean initial hospital stay (27 vs 31 days). Survival was greater in group B laparotomy patients at 1, 3, and 6 months (p < 0.01), and median survival was 5 months for group A compared with 8 months for group B patients (p = 0.06). Group A patients who were managed with percutaneous stents required more stent changes per month of survival (0.5 vs 0.3, p = 0.06). However, group B patients who underwent operative palliation were more likely to undergo a second operation (0% vs 21%, p = 0.05), most often for duodenal or small-bowel obstruction.

CONCLUSIONS

Operative placement of large-bore transhepatic stents may reduce cholangitis, delay hepatic failure, and prolong survival. We conclude that patients with unresectable hilar cholangiocarcinoma who are fit for surgery may benefit from operative palliation.

Impact of axillary lymph node dissection on the therapy of breast cancer patients

PURPOSE

We studied a series of 283 breast cancer patients retrospectively to determine the actual benefits of axillary lymph node dissection (ALND) for these patients.

PATIENTS AND METHODS

The records of 283 women with invasive breast cancer treated between 1988 and 1990 were reviewed for histologic status of the axillary lymph nodes, tumor size, DNA content, hormone-receptor values, and actual adjuvant treatments received.

RESULTS

ALND was of possible therapeutic benefit for the 15% (43 of 283) of patients who had clinically positive nodes. Nodal metastases were found in 86% (37 of 43) of patients in this subgroup. ALND alone determined the indication for standard adjuvant therapy for a group of 31% (88 of 283) of patients who had favorable primary biopsy findings and clinically negative axillary nodes; ALND proved that 13% (11 of 88) of these latter patients had positive nodes. For 54% (152 of 283) of patients who had clinically negative nodes and unfavorable biopsies, ALND played no role in the decision as to whether standard adjuvant therapy was indicated. Only 5% (seven of 152) and 3% (four of 152) of these latter patients received radiation therapy and/or high-dose adjuvant chemotherapy, respectively, because of ALND.

CONCLUSION

The benefits of ALND vary greatly for different groups of breast cancer patients, and controlled studies may be needed to determine whether ALND is necessary for all breast cancer patients.

Evidence for altered cell-cycle traverse of the non-modal cells of the heteroploid MCa-11 line

Classic stem cell theory states that the growth of heteroploid cell populations is due to the proliferation of 'main stemline' cells with modal DNA content and chromosome number. Cells with non-modal DNA content and chromosome number are thought to be blocked and/or destroyed at mitosis. To test this, we studied two chromosomally stable cell populations (mouse bone marrow and WCHE-5 cells) and one heteroploid, chromosomally diverse cell line (MCa-11). The heteroploid MCa-11 cells showed significant [3H]dT labelling for cells with DNA contents below the modal G0/G1 peak and above the modal G2 peaks (P < 0.001). This was consistent with the presence of cells with the non-modal DNA content that were engaged in replicative DNA synthesis. A percentage labelled mitosis analysis showed that MCa-11 cells with non-modal DNA content and chromosome number were able to complete mitosis, although with prolonged pre-karyokinetic time. These results suggest that many non-modal cells present in heteroploid cell populations are capable of continued proliferation.

Experience with ambulatory preoperative bowel preparation at the Johns Hopkins Hospital

A transition to ambulatory preoperative antibiotic bowel preparation was carried out. The protocol included a liquid diet for 40 hours preceding surgery and coordination of purging with buffered oral saline laxative, 45 mL containing 8 g sodium phosphate and 22 g sodium biphosphate (Fleet Phospho-Soda, C.B. Fleet Co, Lynchburg, Va) and bisacodyl preparation with an oral erythromycin base-neomycin routine. Enemas were omitted. Personnel in the preoperative evaluation center had the responsibility of instructing patients, distributing directions and drugs, and reviewing for compliance and possible problems during the preoperative period. All patients scheduled for any of a variety of gastrointestinal procedures, as well as some other complex operations, were included in this study. Follow-up data were obtained. Surgeons' comments regarding efficacy were highly favorable. In only five cases was there comment regarding liquid stool, and this was no impediment to surgery. This incidence was comparable with that of the inpatient experience, as was the spectrum of postoperative complications. Transfer of responsibility to the department proceeded with ease. Results were entirely comparable with those of the former inpatient experience.

A comparison of flow cytometric and absorption cytometric DNA values as prognostic indicators for pancreatic carcinoma

BACKGROUND

The DNA content of 30 adenocarcinomas of the head of the pancreas was measured by flow and absorption cytometric analysis.

METHODS

Each of the patients in this study had curative pancreatoduodenectomy. The absorption cytometric measurements were done in a research laboratory, and the flow cytometric measurements were performed in a commercial laboratory. The DNA measurements were done on nuclei disaggregated from pancreatic cancer tissue blocks without the examiner knowing whether the patient had survived.

RESULTS

Twenty-one of the 30 cancers were found to be aneuploid by absorption cytometric analysis, whereas only 1 of the 30 cancers was aneuploid by flow cytometric analysis. This difference was statistically significant (P < 0.001).

CONCLUSIONS

Univariate and multivariate analyses showed that the absorption cytometric DNA measurements were stronger prognostic determinants for patient survival than were the flow cytometric DNA measurements, indicating that some caution may be warranted in the interpretation of commercially obtained DNA distributions of pancreatic carcinomas.

Non-random distribution of abnormal mitoses in heteroploid cell lines

We have performed absorption-cytometric DNA measurements of the DNA contents of the G0/G1, G2, metaphase, and telophase cells of the heteroploid MCa-11 and HL-60 lines, as well as the WCHE-5 line which has a narrowly restricted number of chromosomes. We found that morphologically unbalanced mitoses occurred much more frequently in telophase-cell pairs of the heteroploid MCa-11 and HL-60 lines than in those of the chromosomally stable WCHE-5 line. Furthermore, the morphologically unbalanced mitoses represented unequal segregation of DNA into each of the daughter telophase nuclei. Such mitotic segregation errors (MSE) occurred almost exclusively in telophase cells with DNA contents which were above, or below, the DNA content of the modal telophase population. The net effect of these non-random, unblanced divisions of heteroploid cells with non-modal DNA contents is to produce one daughter cell with a DNA content that tends to return to the modal DNA content peak.

Pancreatic cancer cell DNA content correlates with long-term survival after pancreatoduodenectomy

The DNA content of 47 adenocarcinomas arising in the head of the pancreas from patients who had undergone successful pancreatoduodenectomy was measured. The DNA measurements of each tumor were made without knowledge of the clinical course by absorption cytometry performed on Feulgen-stained nuclei that had been disaggregated from pancreatic cancer tissue blocks. Forty-seven evaluable DNA distributions were obtained from specimens taken between 1975 and 1988. Of the 47 tumors, 19 (40%) were diploid and 28 (60%) were aneuploid cancers. The 19 patients with diploid cancers had a median survival time of 25 months. Median survival of the 28 patients with aneuploid cancers was 10.5 months. This difference was statistically significant (p = 0.003). A multivariate life table regression analysis demonstrated that the ploidy and proliferative index as determined by absorption cytometry were independent prognostic factors, as strong as or stronger than the number of positive nodes and tumor size. Thus cellular DNA content appears to be one of the most important predictors of survival in patients with adenocarcinoma of the head of the pancreas who have successfully undergone a pancreaticoduodenectomy.

Use of immediate postoperative mastectomy prostheses

From materials readily available in the operating room, a temporary breast prosthesis can be fashioned for use in the immediate postoperative period. These materials yield a prosthesis with good shape and form, filling a brassiere cup and providing the general pressure needed on skin flaps in the immediate postoperative period. Psychologically, filling the absent breast cup helps patients adjust to their new body image and eliminates the shock of gross asymmetry.

Discrepancies among the metaphase, telophase, and the G0/G1 and G2 DNA peaks of heteroploid cell lines

Heteroploid cell populations often show narrow peaks of G0/G1 and G2/M DNA content and broadly distributed chromosome numbers. This was originally explained by the selective metaphase arrest of the cells that have non-modal chromosome numbers. To test whether this explanation applies, we have measured the chromosome number distributions, as well as the G0/G1, G2, metaphase (M), and telophase (T) DNA distributions, of the cell lines WCHE-5, MCa-11, and HL-60. The WCHE-5 cells had narrowly distributed chromosome numbers and G0/G1 G2, M, and T DNA peaks. The MCa-11 and HL-60 cells also had narrowly distributed G0/G1 and G2 DNA peaks, but broadly distributed chromosome numbers and M and T DNA peaks. The widths of the MCa-11 and HL-60 M- and T-cell DNA peaks were similar to those of their chromosome number peaks, suggesting that all cells were completing mitosis, regardless of chromosome number or DNA content. Thus, selective metaphase arrest does not seem to be the cause of the narrow G0/G1 and G2 DNA peaks of heteroploid cell populations.

Is preoperative angiography useful in patients with periampullary tumors?

Ninety patients with periampullary tumors, staged by CT scan and believed to be resectable, were staged further by visceral angiography. Most of these patients (78) had carcinoma of the head of the pancreas. Visceral angiography was normal in 62 patients. Major vessel encasement (17 patients) or occlusion (11 patients) was identified in 28 patients. There were no complications related to angiography. Among the 62 patients with normal angiograms, 48 underwent a pancreaticoduodenectomy, for a resectability rate of 77%. Among the 17 patients with vessel encasement, the resectability rate was 35%. For the 11 patients with vessel occlusion, the resectability rate was 0%. Combined with CT scan, visceral angiography is a useful adjunct in the staging of patients with periampullary tumors. Major vessel occlusion precludes resection, and major vessel encasement makes resection unlikely. If visceral angiography is normal, it is very likely that the tumor will be resectable.

Acid giemsa technique for rapid identification of mitotic cells

We developed a rapid technique for differential staining of compacted chromatin as a tool for screening of large tissue culture cell populations for mitotic cells. With a combination of acid Giemsa staining and counterstaining, differential staining of mitotic cells and classification according to stage of mitosis can be accomplished at magnifications as low as x 50-100 (objectives of x 5-10). The mapped and classified cells can then be de-stained and re-studied for DNA content by Feulgen staining and/or for uptake of radioactive DNA precursors by autoradiography. The staining and de-staining procedures outlined do not affect the reproducibility and accuracy of DNA content measurements or measurements of radioactive uptake. Therefore, this technique can be used for cell kinetic analysis by the percentage labeled mitoses method and for cytophotometric studies of mitotic segregation.