Immunohistologic localization of estrogen receptors in breast cancer with monoclonal antibodies. Correlation with biochemistry and clinical endocrine response

Breast cancer specimens from 114 patients were assayed for the presence of estrogen receptors (ER) utilizing highly specific, monoclonal antiestrophilin antibodies and the peroxidase-antiperoxidase technique. Results were compared with conventional ER determinations by the dextran-coated charcoal method (DCC) and were in agreement as to positivity and negativity in 86%. Semiquantified immunocytologic assay results were in accord with the level of ER as measured by DCC in 66%. The tumors studied included 43 from patients with Stage IV disease where clinical response to hormonal manipulation was known. In the latter group, the immunohistologic method had a sensitivity similar to that of DCC but showed a superior positive predictive value and a significantly better specificity. These results indicate that this new method is a valuable laboratory tool, enabling prediction of hormone responsiveness in advanced mammary carcinoma and capable of performance at the community hospital level.

Characteristics of a specific radioimmunoassay for measurement of ferritin on the surface of peripheral mononuclear white blood cells in cancer patients

Using 125I-labeled rabbit anti-Hodgkin's spleen ferritin antibody (RHF), a simple radioimmunoassay has been developed for quantitation of ferritin on the surface of peripheral blood mononuclear white blood cells (PBM). This method makes use of a % specific binding determination (%SP) by measuring the amount of 125I-labeled RHF bound to 1 X 10(6) PBM in the presence and absence of soluble ferritin. To standardize this procedure, artificial ferritin positive control cells were prepared by covalently coupling ferritin to cultured acute lymphoblastic leukemia cells. These cells were tested on a daily basis in parallel with patient PBM's to ensure inter and intra-assay precision and remained stable for over two years. Characteristics of 125I-labeled RHF binding to control and patient PBM's were evaluated to determine the specificity of interaction and optimum binding parameters. %SP was linear in the range of 1 X 10(5) - 1 X 10(6) PBM's and was progressively inhibited by graded concentrations of soluble ferritin. F(ab')2 preparations of RHF were equally as effective as intact RHF in blocking 125I-labeled RHF binding confirming that 125I-labeled RHF was not binding non-specifically to PBM Fc receptors. Additional experiments describing kinetics and methods of standardization of new lots of 125I-labeled RHF are also described.

Measurement of ferritin-bearing peripheral mononuclear blood cells in cancer patients by radioimmunoassay

A radioimmunoassay has been developed to measure ferritin bound to the surface of isolated human peripheral blood mononuclear white blood cells (PBMs) in order to investigate the possible relationship of this phenomenon to breast and other forms of cancer. The assay measures the specific binding (%SP) of affinity-purified 125I-labeled rabbit anti-Hodgkin's spleen ferritin antibody to isolated patient PBMs. A preliminary prospective, preclinical trial on 300 patients was run which included: (a) normals, benign breast disease, and medical/surgical patients as non-cancer controls; (b) postoperative primary cancer and advanced cancer in clinical remission as post cancer controls; and (c) both early preoperative breast cancer patients and cancer patients with localized recurrences or active disseminated disease as test groups. The mean %SP for the non-cancer control groups was in the range of 4.3 to 5.1 (n = 187), which was identical to that for inactive cancer or postoperative cancer, which was no evidence of recurrence. Using a %SP normal cutoff level of 6.5, which resulted in a false-positive rate of approximately 10% for both non-cancer and post-cancer control groups, only 27% of early preoperative cancers (n = 22) gave elevated %SP values. These results suggest that measurement of ferritin-PBM is inappropriate for early disease diagnosis. In contrast, 91% of patients with advanced active breast cancer and 73% of those patients with other types of advanced cancers, including tumors of ovarian, lung, colon or esophageal origin, showed elevated %SP values more than double those of post-cancer controls. The mean %SP value in active advanced cancer was 10.8 for breast (n = 12) and 10.6 for all other solid tumors investigated (n = 34). Paired patient comparisons of ferritin-PBM and plasma carcinoembryonic antigen in breast cancer showed elevations in 91% of the patients for ferritin-PBM and 67% for carcinoembryonic antigen. Overall, these results suggest that patients with advanced cancer display elevated levels of ferritin on the surface of their PBMs and that this measurement may be a useful adjunct in monitoring and evaluating the clinical status of cancer patients.

Pulmonary cryptococcosis and Cushing's syndrome

Pulmonary cryptococcosis occurred in two patients with Cushing's syndrome, both of whom were successfully treated with amphotericin B and flucytosine. Excessive endogenous production of corticosteroids may have predisposed these patients to the development of opportunistic infection. Persons with Cushing's syndrome and a pulmonary infiltrate should be examined for infection with Cryptococcus neoformans in addition to an examination for ectopic adrenocorticotropic hormone production.

Five-day storage of platelet concentrates. II. In-vivo studies

Following in-vitro tests it was concluded that platelet concentrates stored for 5 days at 22 degrees C in polyolefin containers, coded PL732, should be as effective in clinical practice as similar concentrates stored in the standard PVC containers, coded PL146. These predictions have been confirmed by the following in-vivo tests; autologous survival studies in volunteers, determination of recovery, platelet increment calculations 1 and 24 h after transfusion and clinical appraisal after transfusion of haemorrhagic thrombocytopenic patients. Bacteriological cultures of the platelet concentrates were sterile after storage for more than 5 days. It can be concluded that the 5-day storage of platelet concentrates in these containers is a practical proposition.

The effects of patient delay and symptoms other than a lump on survival in breast cancer

This study examined the relationship of survival in breast cancer to delay in treatment and the presence of symptoms. Data were analyzed for 664 patients diagnosed from 1975-1979 at 15 hospitals in Brooklyn, New York. Pathologic risk factors were defined to classify breast cancer into less (Class I) or more aggressive (Class III) disease. Delay and survival were not significantly associated among women diagnosed with Class I disease. Delay was associated with poor survival for patients with Class III disease (P less than 0.001). The presence of symptoms other than a lump was associated with longer delay and poorer survival in patients with Class II and III disease. These findings suggest that the contradictory relationship between delay and survival reported by others may be due to variations in the proportions of slow and fast growing tumors and that fast growing tumors must be treated promptly for a successful result.

Immunohistologic and histochemical methods for detection of steroid binding in breast cancer: a reappraisal

A review of the current literature on immunohistologic and histochemical methods for the detection of steroid hormone binding sites in breast cancer, reveals that many, but not all of the criteria for establishing hormone-receptor binding interactions have been met. These include tissue specificity, binding between labeled ligands and soluble receptor in vitro, correlations between histochemical and biochemical assays, as well as between histologic procedures and tumor hormone responsiveness. However, histochemical binding phenomena do not appear to follow classical receptor dogma in regard to the concentration of ligand required, or specificity of binding as determined by competitive binding assays. It is concluded that these histologic techniques may be detecting classical receptor that may be reacting differently than would be expected from biochemical analyses, Types II and III binding sites, and/or organelle and membrane-bound receptors. Certainly no current method should presently be promoted as a laboratory method for the detection of classical receptor. New immunocytologic procedures employing specific, antireceptor sera currently under development, may obviate many of the criticisms leveled against earlier methods.

CEA (carcinoembryonic antigen): its role as a marker in the management of cancer

A consensus Development Conference was held at the National Institutes of Health from September 29-October 1, 1980, to address issues concerning the role of carcinoembryonic antigen (CEA) as a marker in the management of cancer. The panel met following formal presentations and discussions to assess the issues based on the evidence presented. These issues included: Should CEA be used in cancer screening? Is CEA helpful in cancer diagnosis? What does CEA tell about the extent and outcome of cancer? Is CEA helpful in monitoring cancer treatment? This paper constitutes the panel's findings.

Breast self-examination, relationship to stage of breast cancer at diagnosis

Data from 996 newly diagnosed breast cancer patients indicated a highly significant association (P less than 0.001) between periodic breast self-examination (BSE) and pathologic stage of disease. Among women reporting periodic BSE, only small differences were noted between those who practiced monthly and those who practiced several times annually. Average maximum tumor diameter and frequency of tumors 4 cm or large were significantly greater (P less than 0.01) among women who rarely or never practiced BSE. The relationship between the periodic practice of BSE and the diagnosis of breast cancer before nodal involvement was present even after controlling for a wide variety of variables. The regular practice of BSE was associated with a one-third reduction in the likelihood of diagnosis of disease with positive nodes. This difference translated to a 10% decline in five-year mortality for whites and a 17% decline for nonwhites.

Histochemical assay of estrogen and progesterone receptors in breast cancer: correlation with biochemical assays and patients' response to endocrine therapies

Estrogen (ER) and progesterone (PgR) receptors were assayed by histochemistry in primary, recurrent, and metastatic breast cancer. Ligand-conjugates composed of 17 beta-estradiol and 11 alpha-hydroxyprogesterone covalently linked to bovine serum albumin and labelled with fluorescein isothiocyanate were employed. Results were compared with those of conventional biochemical receptor assays and correlated for ER in 92% of 314 tumors and for PgR in 86% of 86 specimens. ER and PgR determinations by both assay systems were correlated with clinical response to various endocrine therapies in 40 women with Stage IV disease. The histochemical assay enabled successful prediction of response in 80% of cases including eight which could not be fully analyzed biochemically.

Identification of breast cancer patients with high risk of early recurrence after radical mastectomy: III. Steroid hormones measured in urine

The relationship of the levels of selected urinary steroid metabolites to breast cancer recurrence after radical mastectomy was studied. An analysis of variance of the steroid measurements suggested that the measurements standardized to per gram of creatinine were the appropriate measure to use in exploring these relationships. No significant associations were found for premenopausal patients; however, for postmenopausal patients, low levels of total 17-ketosteroids were associated with a reduced two-year recurrence-free rate whereas low and high levels of OHA and high levels of total estrogens were associated a relatively low high two-year recurrence-free rate. Because of the large number of significance tests performed and the lack of consistent patterns, it is questionable whether the observed associations are of any importance. Including these steroid quantities in a multivariate regression model along with previously determined clinical prognostic factors indicated that the steroid determinations were the least important variables and did not make a significant contribution to the fit of the model.

Histochemical analyses of steroid hormone receptors in breast and prostatic carcinoma

Histochemical analyses estrogen (ER) and progesterone (PgR) receptors in breast cancer were statistically correlated with results of dextran-coated charcoal (DDC) and sucrose gradient assays. Correlated for ER was 91% of 363 cases, and for PgR 88% of 255 specimens. Breast cancer ER/PgR positivity by histochemistry correlated with a favorable clinical response to endocrine therapies in 72% of 25 cases, while ER/PgR negativity correlated with a lack of response in 96% of 22 cases with Stage IV disease. Nuclear ER/PgR correlated with a poor response to therapy in 8 of 12 patients. An in vitro technique to detect nuclear translocation of ER revealed two groups of ER positive cases, with 11 of 17 exhibiting translocation and 6 not displaying translocation. In prostatic carcinoma, 72% of 65 men were positive for ER and/or androgen receptor. Comparison of specimens obtained without and with electrocautery revealed a preponderance of nuclear binding in the latter, suggesting heat-induced nuclear translocation of receptor. coumestrol, a naturally fluorescent, entirely unaltered estrogen was also used for histochemical detection of ER. Results correlated with ER by DCC in 87% of 61 breast cancers. Coumestrol was additionally used to visually observe receptor and nuclear translocation of ER in intact whole cells in culture.

An improved histochemical method for detection of estrogen receptors in mammary cancer. Comparison with biochemical assay

Unselected, consecutive surgical specimens from 120 women with cancer of the breast were subjected to histochemical assay for the presence of estrogen receptor. A fluoresceinated bovine serum albumin--estradiol conjugate was used that linked estradiol at position 17 and contained 5 mol fluorescein and 4 mol estradiol per mole albumin. Simultaneous competitive binding studies with excess unlabeled estradiol, diethylstilbestrol, and the antiestrogen nitromifene citrate were regularly performed. Results were compared to those obtained by the dextran-coated charcoal receptor assay. Three specimens were necrotic, two others thawed, and two lacked sufficient protein for biochemical analysis. One specimen did not contain tumor, and 11 others showed a predominant nuclear staining pattern. Nuclear receptor was not assayed biochemically. Comparison of results in the remaining 101 cases showed agreement in 92%. The precedure is uncomplicated, economical, and could be performed and interpreted in any pathology laboratory.

Histochemistry of steroid receptors in breast cancer: an overview

Immunofluorescence and a new histochemical technique were employed to assay 226 breast cancer specimens for estrogen receptor. Results showed an overall correlation of 91 percent when compared to those of biochemical assays. The histochemical technique is rapid, easy to perform and reveals the same parameters as does immunofluorescence without the need for antiserum. Tumor cell receptor heterogeneity and location of receptor in cytoplasm or nucleus is readily defined by both methods. These histologic tests should prove to be useful in extending the availability of estrogen receptor analysis to all patients with breast cancer.

A histochemical technique for evaluation of progesterone receptors in breast cancer

A histochemical method for the detection and localization of progesterone receptors in human breast cancer has been developed employing a fluorescein labeled conjugate of bovine serum albumin linked to a progestin as the binding hormone. Considerable tumor cell receptor heterogeneity was apparent and nuclear binding was frequently noted. The results of the new assay correlated with those obtained by dextran-coated charcoal assay in 91 per cent of specimens.

Relationship of race to functional status among breast cancer patients after curative surgery

Analysis of functional status of 197 breast cancer patients three years after curative radical mastectomy indicated a cumulative probability of disability of 25%, whereas the probability of death regardless of prior disability was 40.5%. Analysis of functional status by patient characteristics indicated that nonwhites were three times more likely than whites to experience disability (P less than 0.01) as defined in terms of their ability to carry on normal activities without assistance. Although whites and nonwhites were diagnosed at similar stages of disease, nonwhites were, on average, eight years younger than whites. They younger age may reflect a larger proportion of premenopausal breast cancer cases among nonwhites, which if associated with more rapidly progressing disease could account for their poorer prognosis. Alternatively there may exist factors in the nonwhites' social or economic environment that limited the ability of the family to care for the patient at home. These data reaffirm the need to monitor closely breast cancer patients to diagnose acute complications, and they indicate that most patients can resume normal activities shortly after curative surgery.

Relationship of plasma lipids to renal function and length of time on maintenance hemodialysis

Significant hypertriglyceridemia, the most common lipid abnormality in renal failure, first occurs when the creatinine clearance falls to 50 ml/min. The prevalence of hypertriglyceridemia continues to rise as creatinine clearance falls further with the highest rate developing at a creatinine clearance less than 10 ml/min. Hypertriglyceridemia is correlated with plasma glucagon levels but not growth hormone or insulin. Plasma cholesterol values remain normal in the face of deteriorating renal function and show no correlation with any of the hormones measured. Although all three hormones became elevated as renal function diminished, none were directly correlated with glomerular filtration rate. There was a distinct decrease in the prevalence of hyperlipidemia after 5 years of maintenance hemodialysis therapy. Plasma growth hormone and glucagon through an effect on plasma triglyceride and plasma insulin by effecting plasma cholesterol may play a role in this decline of hyperlipidemia with duration of hemodialysis.

Effects of halofenate on glucose tolerance in patients with hyperlipoproteinemia

Halofenate, a triglyceride- and uric acid-lowering drug, potentiated the effect of oral hypoglycemics. Its effect on serial glucose tolerance was evaluated in ten patients with hypertriglyceridemia without overt diabetes. Six-hour oral glucose tolerance tests were done during a control period and every 24 weeks over two years of halofenate treatment. Abnormal glucose tolerance (chemical diabetes) was observed during the control period in six of ten patients. The number of abnormal tests gradually decreased to none by 48 weeks. Plasma glucose, insulin, and free fatty acid values during the glucose tolerance tests were reduced significantly. Halofenate induced significant serum uric acid reduction. No significant regressions were observed among levels of lipids, hormones, glucose, and uric acid. The mechanisms by which lipid-lowering drugs improve glucose tolerance are as yet unexplained.

Immunofluorescent detection of estrogen receptors in breast cancer. Comparison with dextran-coated charcoal and sucrose gradient assays

Biopsy specimens from 106 women with primary operable, recurrent or metastatic breast cancer were analyzed in a double blind study designed to compare the results of a new fluorescent antibody method for detection of estrogen receptors with estrogen receptors measured biochemically with dextran-coated charcoal and sucrose gradient assay techniques. Assay results correlated in 89.4% of tumors analyzed, and molecular receptor forms (8S and 4S) were accurately predicted in 94.7% of neoplasms studied. Divergent results most often occurred in specimens sparsely populated with malignant cells. The new technique permitted recognition of possible sources of false negative results such as necrosis, absence of tumor and, on occasion, estrogen bound in vivo. It was possible to analyze by the immunofluorescence method two specimens of insufficient size for biochemical assay.