The clinical value of immunohistochemically demonstrable CEA in breast cancer: a possible method of selecting patients for adjuvant chemotherapy

The production of carcinoembryonic antigen (CEA) by human breast cancer tissue has been studied in relation to the prognosis of patients with breast cancer. All of the patients were in a controlled trial of adjuvant chemotherapy for the treatment of operable breast cancer. CEA was studied in primary tumours and axillary node metastases from these patients using an immunoperoxidase (PAP) method. Sections of 290 primary carcinomas and 217 axillary metastases were examined for CEA. The CEA status of the primary tumours was of no value as a prognostic indicator nor in the selection of patients for chemotherapy. In contrast, patients could be divided into 3 groups on the basis of the CEA results in the axillary nodes. In one group, in which cases were strongly positive for CEA (24% of the total) the prognosis, as reflected by recurrence free survival, was relatively good and chemotherapy produced no further advantage. In another group in which cases were weakly positive for CEA (18% of the total) the prognosis was poor but chemotherapy produced significant improvement. In a third group, in which cases were negative for CEA (58% of the total) the prognosis was poor and was not improved by chemotherapy, at least in the short term. Thus, the CEA status of axillary metastases may be clinically useful.

Indications for mediastinal lymph node evaluation

Successful surgical therapy for bronchogenic carcinoma depends upon an accurate lymph node assessment. Criteria were developed and reported to identify patients who would benefit from mediastinoscopy prior to thoracotomy. This report summarizes the prospective use of the criteria between 1974 and 1977 and the total experience from 1970 to 1977. Selection of patients for prethoracotomy mediastinal evaluation is primarily based on chest roentgenogram and cell type. Left upper lobe lesions meeting the criteria were submitted to mediastinotomy if mediastinoscopy was negative. Eighty-seven potentially resectable lesions were evaluated prospectively, and the total experience included 202 patients. Mediastinal metastasis occurred in 39 patients of the current and 82 patients of the total series. When metastases to the mediastinum were documented, roentgenographic evidence of metastasis was seen in 20 of 39 (51 percent) of the current and 44 of 82 (54 percent) of the total series. There was roentgenographic evidence of metastasis in central lesions, peripheral masses, and small peripheral lesions with mediastinal metastases in 50 percent, 25 percent, and 78 percent of the cases, respectively. Mediastinal metastases were reported 80 percent of the time before thoracotomy using these criteria. The use of mediastinotomy on left upper lobe lesions identified six of seven of the unresectable cases missed by the mediastinoscopy. The criteria will identify patients at high risk for mediastinal metastases who benefit from prethoracotomy surgical evaluation.

The effect of surgical drainage materials on colonic healing

The effect of surgical drainage materials on rat colonic healing has been investigated in a prospective randomized and controlled study. Latex, silicone rubber (Silastic), polyvinylchloride (PVC) and polytetrafluoroethylene (Teflon) tubes were implanted alongside a colonic anastomosis and compared with a 'no drain' group using mechanical and histological assessments. There was a significant increase in anastomotic leakage in the latex group in which there appears to be a local inhibition of healing. Silastic, PVC and Teflon were not found to interfere with healing. The continued use of latex drains in colonic surgery is therefore questioned.

An innovative family medicine clerkship

A clinical clerkship in family medicine at Brown University has been developed utilizing many innovative educational modalities. These include games, simulations, group problem solving, research projects, videotaping, case presentations, field trips, sensitivity sessions, computer assisted instruction, patient management problems, slide-tape shows, and direct clinical experiences. These modalities are described together with a new approach to evaluation. Students' evaluations of the clerkship have been excellent, providing evidence that this clerkship offers a model of learning that is both effective and enjoyable.

Severe hypertriglyceridaemia responding to insulin and nicotinic acid therapy

A patient with unusually severe hypertriglyceridaemia (serum concentration initially 258 mmol/l or 22600 mg/dl) and hypercholesterolaemia is reported and discussed. The triglyceride elevation was found to reside within the very low density lipoprotein fraction and was probably attributable to the combination of diabetes mellitus and familial hypertriglyceridaemia. Treatment with insulin and restriction of dietary carbohydrate led to a 50% reduction in the triglyceride concentration, and the addition of nicotinic acid in modest doses led ultimately to a complete normalization of the patient's lipid values. A close correlation was noted between the falling triglyceride concentration and the rising serum sodium concentration during the course of successful therapy. Overall, it is felt likely that this patient's severe and reversible hypertriglyceridaemia was on the basis of excessively rapid lipolysis leading to high concentrations of very low density lipoprotein production. Combined therapy with insulin and nicotinic acid is recommended for other patients of this nature.

Comparative effects of azathioprine, cyclophosphamide and frentizole on cellular immunity in mice

This report extends previous observations on the immunosuppressive properties of cyclophosphamide (CPA), azathioprine and frentizole (15) to include murine models of cellular immunity. Systemic and local graft vs host reactions (GVHR) were most effectively suppressed by CPA. In contrast to frentizole, both CPA and azathioprine were found to inhibit the proliferation of parental T-cells in a systemic GVHR. However, CPA was the only agent capable of inhibiting the proliferation of T-cells following contact sensitization with oxazolone. Mice pretreated with a high dose of CPA or frentizole prior to inoculation with the murine sarcoma virus exhibited accelerated tumor growth. However, there was no accelerated growth of murine sarcoma virus induced tumors or an SaI spindle cell fibrosarcoma during rather prolonged therapy with immunosuppressive doses of CPA, azathioprine or frentizole. Normal mice treated with CPA showed a more drastic reduction in lymphoid elements of the spleen and thymus than mice treated with azathioprine or frentizole. Studies on the mitogenic responsiveness of spleen cells obtained from normal mice after an eight day course of therapy suggested that CPA has some selectivity of action on B-cells and azathioprine on T-cells.

Parity and breast cancer: evidence of a dual effect

Epidemiological studies have shown that early first pregnancy reduces the risk of developing breast cancer, which indicates that initiation of the disease occurs at an early age. Thus the subclinical lesion of breast cancer might already be present in the breast before childbearing begins and the growth of any such focus might be modified by the endocrine changes of pregnancy. To test this hypothesis the relation between parity and age at presentation was studied in 341 unselected patients with breast cancer presenting to a single clinic. The mean age at presentation was 5.2 years lower in parous than nulliparous women (p < 0.001) and fell with increasing parity. It is concluded that reproductive history influences not only the risk of breast cancer but also the latent interval of a proportion of breast carcinomas.

Patient management by telephone: a training exercise for medical students

An instructional exercise in telephone management of medical problems using experimental and didactic techniques was designed for medical students taking a family medicine clerkship. The effectiveness of this curriculum was evaluated by comparing the students' proficiency against a standard established through the use of a Delphi group opinion technique. This study indicates that formal training experiences for medical students in managing telephone complaints in a family practice setting can improve the students' performance.

Levels of serum thyroid-stimulating hormone in hyperthyroidism

A modified thyroid-stimulating hormone (TSH) radioimmunoassay with particular sensitivity at the bottom end of the normal range was developed using dog serum in standard tubes and reduced quantities of TSH labeled with radioactive iodine (125I) and antiserum. The standard deviation of B0 points was 1%, implying an assay sensitivity of less than 0.1 microU/mL. This procedure was used to measure serum TSH levels in 32 normal subjects, 18 patients with hyperthyroidism, and seven patients with elevation of serum triiodothyronine (T3) levels. The range of values obtained from normal subjects was less than 0.1 to 4.1 microU/mL, with 97% of the subjects' values greater than 0.2 microU/mL. All of the hyperthyroid patients had values less than or equal to 0.2 microU/mL. Hence, the modified TSH assay was thought to be of use in distinguishing hyperthyroid from normal subjects. The TSH levels in subjects with elevated T3 levels ranged from less than 0.1 to 1.8 microU/mL. These results were thought to indicate heterogeneity within this group and suggest that only certain of these individuals merit the diagnosis of "T3 toxicosis."

Comparative effects of azathioprine, cyclophosphamide and frentizole on humoral immunity in mice

Data is presented comparing the activities of three immunosuppressive agents, cyclosphosphamide, frentizole and azathioprine in models of humoral immunity in mice. Cyclophosphamide and frentizole suppressed the primary and secondary plaque forming cell responses to sheep erythrocytes at lower doses than did azathioprine. Prolonged suppression of serum antibody titers occurred following short-term therapy with cyclophosphamide or frentizole, but not azathioprine. Azathioprine was also the least effective agent in suppressing a primary response to the T-independent antigen, trinitrophenylated lipopolysaccharide. All three agents were found to inhibit the induction and activity of suppressor cells at immunosuppressive doses.

IgE production in five inbred rat strains following immunization with alum-precipitated egg albumin

Five inbred rat strains were assessed for their ability to mount IgE responses to alum-precipitated egg albumin (alum EA). Fischer (FI) and Lewis (LE) rats which possess the B1 at the major histocompatibility (Ag-G) locus exhibited weak IgE responses to this antigen. High titer IgE responses were obtained in rats possessing the B3 allele at the Ag-B locus. In some instances the anti-EA IgE response was enhanced following an infection with Nippostrongylus brasiliensis. An effort was also made in these studies to determine whether or not there is some correlation between high IgE production and a depressed capacity for cellular immunity. The basis of these experiments was twofold: (a) recent reports have shown elevated serum levels of IgE in some clinical diseases where cellular immunity is depressed, and (b) in the studies reported here, high titers of IgE were obtained in one rat strain known to be somewhat deficient in its capacity for cellular immunity, whereas very low titers were produced by a strain which is much stronger in this respect. From the results obtained, there appears to be no correlation between IgE production and an inherently weaker capacity for cellular immunity.

Reciprocal changes in serum concentrations of 3,3',5-triiodothyronine (T3) in systemic illnesses

Serum concentrations of 3,3',5'-triiodothyronine (reverse T3, rT3) were measured in adult patients with several systemic illnesses whose serum total and/or free T3 were low, serum total T4 was low or normal, and free T4 was either normal or elevated. The mean serum rT3 was 76, 46, and 77 ng per 100 ml in patients with hepatic cirrhosis, chronic renal failure, and acute febrile illnesses, respectively; the values in patients with hepatic cirrhosis and acute febrile illness were significantly higher than, and values in patients with renal failure did not differ significantly from, the mean serum rT3 (41 ng per 100 ml) in normal subjects. The mean serum rT3 in another group of patients from Calcutta, India, who had severe protein calorie malnutrition (PCM), was 53 ng per 100 ml; it was significantly higher than the corresponding value, 22 ng per 100 ml, in the same patients after feeding treatment. Mean serum rT3 in patients with systemic illnesses was not so high as that (151 ng per 100 ml) in the normal newborn, who also has low serum T3 and normal or high T4. High serum rT3 in patients with systemic illness could not be attributed to increased serum protein binding of rT3; whenever studied, the dialyzable fraction of rT3 was not decreased but actually increased. The mean serum-free rT3 was 450,207, and 366 pg per 100 per 100 ml in patients with hepatic cirrhosis, chronic renal failure, and acute febrile illnesses, respectively; each of these values was significantly higher than the corresponding value, 98 pg per 100 ml, in normal subjects. The mean serum free rT3, 516 pg per 100 ml, in newborn cord sera was similar to that in patients with hepatic cirrhosis but was higher than that observed in patients with chronic renal failure and acute febrile illnesses. High serum rT3 and low serum T3 in patients with PCM improved to normal or towards normal after feeding treatment. Since the peripheral metabolism of T4 is normally the predominant source of T3 as well as rT3 in man, our data, demonstrating reciprocal changes in serum rT3 and T3 and no consistent change in serum T4, suggest that body metabolism of T4 may be so altered in systemic illness that the conversion of T4 to rT3 may be increased while that to T3 is decreased. The mechanism or the biological significance of such a diversion of T4, from the normally occurring conversion to highly potent T3, to the generation of poorly calorigenic rT3 in systemic illness, is not clear at this time. The data in patients with PCM demonstrate, however, that such a change in the metabolism of T4 can be reversible.