The risk of premature menopause induced by chemotherapy for early breast cancer

The objectives of this retrospective case series were to determine the prevalence and timing of menstrual abnormalities in early-stage breast cancer patients undergoing adjuvant methotrexate or anthracycline-based chemotherapy and to more fully assess the possible mechanism of the amenorrhea reported after chemotherapy. One hundred forty-two premenopausal patients undergoing adjuvant chemotherapy were analyzed for patient age, breast cancer stage, type of chemotherapy, and menstrual abnormalities before, during, and after chemotherapy completion. A 24-month minimum follow-up after chemotherapy completion was available for all patients. One hundred nine of 142 patients were evaluable. Sixty-nine patients (46 node negative, 23 node positive) received methotrexate-based chemotherapy, 33 patients (3 node negative, 30 node positive) received anthracycline-based chemotherapy, and 7 patients received both treatments (all node positive). Amenorrhea occurred in about a third of patients during chemotherapy (methotrexate groups 31%, anthracycline group 33%), and a higher proportion were amenorrheic 1 year after chemotherapy was completed (methotrexate group 45%, anthracycline group 46%). Abnormalities were more likely to occur in older premenopausal patients (Chi square = 6.18, p < 0.05), although 28% of patients under age 35 developed persistent abnormal menses. In some amenorrheic patients, follicle-stimulating hormone (FSH) levels were decreased within 6 months of chemotherapy (24.4 IU). The levels tended to be higher after chemotherapy (59.1 IU), suggesting ovarian failure. Menstrual abnormalities and menopause will frequently occur in premenopausal early-stage breast cancer patients, with 30% of all patients amenorrheic 1 year after chemotherapy.

Overexpression of transforming growth factor-alpha and epidermal growth factor-receptor in idiopathic pulmonary fibrosis

BACKGROUND AND AIM

A recent transgenic mouse model overexpressing transforming growth factor alpha (TGF-alpha) led to a phenotype of pulmonary fibrosis. In order to validate this mouse as a model for idiopathic pulmonary fibrosis in humans, we studied the expression of TGF-alpha in lung tissue of patients with idiopathic pulmonary fibrosis compared to control lung tissue.

METHODS

Tissue from both groups was obtained from operative specimens and immediately formalin-fixed and paraffin embedded. Contiguous four micron sections were prepared for conventional histochemical staining and staining with antibodies to either TGF-alpha or the epidermal growth factor-receptor (EGF-R). Immunostaining was performed using the Ventana ES automated immunohistochemistry system. Four cell types were examined (vascular endothelium, bronchial epithelium, type 2 pneumocytes, and fibroblasts) and stain activity was scored on a six point scale.

RESULTS

Eleven patients with IPF were compared to seven control subjects. TGF-alpha immunoreactivity was significantly higher in the IPF patients than in controls in the vascular endothelium, type 2 pneumocytes, and fibroblasts (P < 0.005). [IPF (4(2-4) Median (Range)) than the controls (0.5(0-2), p < 0.0005).] The differences in EGF-R, one of the receptors for TGF-alpha, between these two patient populations were not as striking. There was a small but significantly greater expression of EGF-R in the bronchial epithelium and type 2 pneumocytes of the IPF patients.

CONCLUSIONS

TGF-alpha is overexpressed in patients with IPF, especially in the vascular endothelial cells.

Prevalence of digital clubbing in bronchogenic carcinoma by a new digital index

OBJECTIVE

Clubbing can be a paraneoplastic manifestation of bronchogenic carcinoma. We assessed a new digital index of clubbing and used it to determine the prevalence of clubbing for different cell types of lung cancer.

METHODS

Clubbing was assessed by measurement of the thickness of both the base of the nailbed (distal phalangeal depth--DPD) and the distal interphalangeal depth (IPD) of the index finger in a control group compared to patient groups with either chronic obstructive lung disease, or lung cancer.

RESULTS

Of the 55 normal subjects, no patient had a DPD/IPD ratio of more than 1.05 on either hand, while 11% of the patients with COPD had a ratio of more than one. For the cancer patients, 33% had a ratio greater than one, with 30 of 109 (37%) having a ratio > 1.05 (chi(2) = 17.6, p < 0.0001). There was no difference in the prevalence of clubbing between the 33 squamous cell patients, the 43 adenocarcinoma patients, and the 33 small cell lung carcinoma patients included.

CONCLUSIONS

Measurement of the interphalangeal and distal phalangeal distance demonstrated that one-third of patients with lung cancer had evidence of clubbing. The type of bronchogenic carcinoma did not appear to affect the proportion of patients with clubbing.

Steroid-sparing alternative treatments for sarcoidosis

Alternatives to corticosteroids for the treatment of sarcoidosis are reviewed. These include cytotoxic agents such as methotrexate, azathioprine, and cyclophosphamide. In addition, agents such as hydroxychloroquine and cyclosporine are reviewed. The efficacy, toxicity, and timing of these drugs in the management of sarcoidosis is discussed.

Diagnosis and management of neurological sarcoidosis

BACKGROUND

Neurological involvement is a significant cause of morbidity and mortality in patients with sarcoidosis. Detection and management of neurosarcoidosis remains problematic. Our interest in immunosuppressive agents for chronic sarcoidosis has given us experience with various agents for the treatment of sarcoidosis, including cyclophosphamide and methotrexate.

METHODS

We analyzed all patients with sarcoidosis seen in our clinic during a 10-year period. Evaluation for neurological disease included routine physical examination. Magnetic resonance imaging, cerebral spinal fluid analysis, and neural tissue biopsy were performed where clinically indicated. Patients were treated with corticosteroids, methotrexate, or cyclophosphamide.

RESULTS

Neurological disease was identified in 71 of 554 patients with sarcoidosis. Seventh (facial) cranial nerve paralysis was the most common manifestation identified in 39 patients. This included 24 patients with facial nerve palsy as the only manifestation of neurological sarcoidosis in whom complete recovery was seen in all but 1 patient. Forty-eight patients with disease other than facial nerve palsy received corticosteroids or other therapies. Corticosteroids benefited only 14 patients (29%). Methotrexate successfully treated 17 (61%) of 28 patients and cyclophosphamide controlled disease in 9 (90%) of 10 assessable patients. Methotrexate and cyclophosphamide were each associated with a higher response rate than corticosteroids alone (chi 2, 14.6; P < .001).

CONCLUSIONS

Neurological symptoms can be significant manifestations of sarcoidosis. Facial nerve paralysis is a common, but usually self-limited form of disease. Other manifestations are usually chronic and agents other than corticosteroids appear to have increased efficacy with lower morbidity.

Predicting respiratory failure in sarcoidosis patients

BACKGROUND AND AIM OF WORK

Although sarcoidosis is a multisystem disease, mortality from sarcoidosis is usually due to respiratory failure. In order to identify those patients at risk of death from respiratory failure from sarcoidosis, we analyzed a seven-year experience of patients seen at the University of Cincinnati Interstitial Lung Disease clinic.

RESULTS

A total of 479 patients were seen during that time. Of these, 22 (4.6%) died. Thirteen patients died from respiratory failure, three died from cardiac disease, and two each from neurologic or hepatic disease. Two patients died from unrelated disease. Analysis of the patients who died from respiratory failure was compared to the other patients. All patients who died from respiratory failure had fibrotic changes demonstrated by chest roentgenogram. All patients who died had at least one vital capacity less than 2.5 liters, with the majority of patients who died of respiratory failure having a vital capacity of less than 1.5 liters.

CONCLUSIONS

Patients who die from respiratory failure from their sarcoidosis have fibrosis demonstrated on chest roentgenogram and a reduced vital capacity, usually less than 1.5 liters.

Sleep apnea in sarcoidosis

BACKGROUND AND AIM OF WORK

Sleep apnea is reported to occur in 2-4% of the general population. Patients with sarcoidosis are at increased risk for sleep apnea, possibly due to factors such as steroid use, neurosarcoid, or upper airway obstruction.

METHODS

In order to determine the prevalence and risk factors for sleep apnea in sarcoidosis patients, we studied 83 consecutive patients with sarcoidosis seen over a six-week time period. Patients were screened using the Epworth Sleepiness Scale questionnaire and the age, sex, race, weight, and medications were recorded. The presence of previously diagnosed sleep apnea, neurosarcoid, lupus pernio, and sinus disease were also noted. A control group of 91 patients seen in general pulmonary clinics were similarly screened. Patients with a positive sleep questionnaire were referred for sleep studies.

RESULTS

A total of 14 sarcoid patients (17%) were found to have sleep apnea, which was significantly higher than our control group with 3/91 (3%, p < 0.001). The presence of lupus pernio was significantly more frequent in the sleep apnea group. Although 5/51 (10%) female sarcoid patients had sleep apnea, overall it was more frequent in male sarcoid patients.

CONCLUSIONS

Sleep apnea was frequent in sarcoid patients and was associated with lupus pernio.

Quantitation of vascular endothelial growth factor mRNA levels in human breast tumors and metastatic lymph nodes

In situ hybridization analysis provides a means to qualitatively study the heterogeneity of primary tumors and metastases based on the types of genes transcribed. In this study, we have tested some parameters for quantitative analysis of in situ hybridizations with paraffin-embedded human breast tumors and measured mRNA levels for the angiogenic protein, vascular endothelial growth factor (VEGF). VEGF mRNAs were highly tumor specific, with the highest levels near necrotic regions within the tissues (0.1 to 2.7 dpm/mm2). Normal cells within the tissue sections did not have detectable levels of VEGF mRNA. For comparison, tumor levels of c-myc (4 to 46 dpm/mm2) and glyceraldehyde-3-phosphate dehydrogenase mRNAs (48 to 214 dpm/mm2) were measured. The mRNAs for both of these genes were more broadly expressed across the tissue sections. The hybridization pattern for VEGF mRNAs was consistent with hypoxia-induced VEGF mRNA steady-state levels and supports the hypothesis that oxidative stress regulates VEGF expression in breast tumors.

Plasma membrane phosphotyrosine, Her2-NEU, and epidermal growth factor receptor in human breast cancer. A comparative study

Experimental therapeutic regimens for breast cancer include strategies to block the activity of specific oncogenes. Because oncogenesis is a multistep process, specific oncogenes may drive tumor production at one stage yet not function in another. Since the effectiveness of therapy targeted against oncogenes depends on their function in the tumor, correlation of oncogene function to specific stages of tumor development has therapeutic implications. Among the oncogenes known to be important in breast cancer production are two cell surface growth factor receptors, epidermal growth factor receptor (EGFR) and Her2-NEU (NEU). These proteins are receptor tyrosine kinases that autophosphorylate specific tyrosine residues on activation. The oncogenic potential of these receptors depends on this autophosphorylation. We examined 86 primary formalin-fixed, paraffin-embedded breast tumors for overexpression of EGFR and NEU and correlated our findings with the presence of cell surface phosphotyrosine as an indicator of tyrosine kinase activity at the plasma membrane. Our data indicate that only 34% of tumors that overexpress EGFR or NEU show plasma membrane phosphotyrosine, indicating that in the majority of these tumors, the overexpressed oncogene may not be active at this stage.

Increased phosphotyrosine in breast cancer tissue is associated with a worse prognosis

We have previously demonstrated that phosphotyrosine can be identified in breast cancer cells using an immunohistochemical stain. We have subsequently used this technique to characterize 106 women with breast cancer (46 with Stage 1 and 60 with Stage 2) who have been followed for at least four years by one oncologist. We analyzed all primary breast cancer tissue using immunohistochemical staining and the amount of phosphotyrosine (PT) was scored on a 0 to 3 range. The PT score of the primary tumor was unrelated to either breast cancer stage or estrogen and progesterone receptor analysis, as high PT scores were noted in both disease stages and all receptor categories. We did find that patients with either no or trace (1+) amounts of PT survived longer than those patients with higher amounts of PT. The patients with low PT had significantly lower chance of relapse (Chi Square = 15.8, p < 0.001) and a lower mortality (Chi Square = 13.1, p = 0.001). We conclude that immunohistochemical methods to determine the PT score may identify patients at higher risk for disease relapse independent of tumor stage or hormonal status.

Prolonged use of methotrexate for sarcoidosis

BACKGROUND

To determine the safety and efficacy of methotrexate as a steroid-sparing agent in patients with symptomatic sarcoidosis, a nonrandomized interventional study of patients with chronic sarcoidosis treated with methotrexate for at least 2 years was performed. Efficacy was assessed for all patients after 2 years of treatment. Toxicity was assessed for all patients receiving therapy for the entire time (a total of 150 patient-years).

METHODS

Patients were treated in a subspecialty ambulatory clinic at a university hospital. Patients with biopsy-confirmed sarcoidosis who had persistent symptoms and who were eager to avoid or reduce corticosteroid therapy were selected for study. A total of 50 patients completed at least 2 years of methotrexate therapy. Patients were treated with oral methotrexate once a week. Dosage was adjusted based on the patient's white blood cell count. Clinical response was measured in the affected organ, including the lung (measurement of vital capacity), skin (regression of skin lesions), and central nervous system (magnetic resonance imaging). Also noted was the initial and subsequent dosage of prednisone used as therapy for sarcoidosis.

RESULTS

Improvement in vital capacity or other affected symptomatic organ was noted in 33 of 50 treated patients. Corticosteroids were discontinued in an additional six patients who remained stable with clinical or symptomatic improvement. The major toxic effects noted in 150 patient-years of therapy were hepatic (six patients), leukopenia requiring hospitalization (one patient), and cough (one patient). Forty-one liver biopsy procedures were performed in 33 patients. Of these, six demonstrated significant changes related to methotrexate that led to drug discontinuation.

CONCLUSION

Methotrexate is a well-tolerated therapeutic agent with significant steroid sparing and efficacy for the treatment of chronic symptomatic sarcoidosis.

Paranoid psychosis due to neurosarcoidosis

We present two patients with known sarcoidosis who developed neurosarcoidosis manifested by paranoid psychosis and clinical diabetes insipidus with hypernatremia. Both had gadolinium enhanced magnetic resonance imaging which demonstrated leptomeningeal and hypothalamic enhancement. Both had elevated protein and a lymphocytosis in their cerebrospinal fluid, which improved after corticosteroid therapy. The patients improved clinically with this therapy as well. We suggest that new onset psychosis in a sarcoid patient, particularly with symptoms of hypothalamic/pituitary involvement, should be evaluated for neurosarcoidosis with an MRI and CSF examination. If the results are consistent with neurosarcoidosis, the patient should be treated promptly with corticosteroids.

Thrombocytopenia in the intensive care unit

STUDY OBJECTIVE

To determine the prevalence of thrombocytopenia in an ICU and assess which factors were associated with thrombocytopenia.

DESIGN

A review of the medical records of patients admitted during 3 separate months during 1 academic year. Patients must have survived at least 12 h in the ICU.

SETTING

A medical ICU at a university hospital.

PATIENTS

General medicine patients admitted to the ICU.

INTERVENTIONS

All medical records were reviewed. During the ICU stay, daily medications, events, and platelet count were noted. All patients were followed up until death or hospital discharge. In 22 patients, including 18 who had thrombocytopenia, bone marrow aspirates were performed.

MEASUREMENTS AND RESULTS

One hundred sixty-two admissions were evaluated. Thirty-eight (23 percent) had platelet counts less than 100,000/mm3 at least once, and 17 (10 percent) patients had platelet counts less than 50,000/mm3. Several factors were associated with thrombocytopenia; however, only sepsis, use of antineoplastic chemotherapy, elevated creatinine level, or elevated bilirubin value were independent risk factors for severe thrombocytopenia. In only one patient were the bone marrow findings different from those expected by the clinical presentation. Thrombocytopenia was associated with longer hospital stay (p < 0.001) and higher mortality (p < 0.001).

CONCLUSION

Thrombocytopenia is a common occurrence in the ICU, usually due to the underlying disease, and is associated with an increased mortality.

Enzymatic and immunohistochemical evaluation of tyrosine phosphorylation in breast cancer specimens

Using a synthetic peptide substrate, tyrosine protein kinase (TPK) activity was measured in 21 tumors from patients with histologically confirmed breast cancer and in five normal breast tissues from patients undergoing reduction mammoplasty. In 20 of 21 cancer specimens, tumor was available to assess phosphotyrosine (PT) immunohistochemically. Breast cancer specimens possessed significantly more TPK activity than normal breast tissues (Cancer = 43.9 +/- 3.1 pm/mg protein/min, [Mean +/- S.E.M.]; Normal = 3.4 +/- 0.9, p < 0.001). TPK activity was higher in the clinically more aggressive infiltrating ductal cancers compared to the less aggressive intraductal cancers (Infiltrating = 55.9 +/- 5.8; Intraductal = 17.2 +/- 3.4, p < 0.01). TPK activity in tumors with both infiltrating and intraductal histology was intermediate (34.0 +/- 7.2). Significant correlation existed between membrane TPK enzymatic activity and PT expression by immunohistochemistry. There was no relationship between estrogen or progesterone receptor status and TPK activity or PT; however, TPK activity from node negative breast cancer tissue was significantly less than from node positive specimens (p < 0.01). We conclude that breast cancer specimens possess elevated amounts of TPK which correlate with PT expression, and that increased tyrosine phosphorylation appears to correlate with the biologic aggressiveness of the malignant tumor.

Use of intermittent, intravenous cyclophosphamide for idiopathic pulmonary fibrosis

STUDY OBJECTIVE

To determine the safety and efficacy of intravenous cyclophosphamide for patients with idiopathic pulmonary fibrosis.

DESIGN

Nonrandomized, open-labeled study of efficacy in symptomatic patients.

SETTING

Patients were treated as outpatients in a referral clinic.

PATIENTS

All patients had idiopathic pulmonary fibrosis with symptoms of dyspnea on exertion. Patients had either worsening disease or contraindication to corticosteroids.

INTERVENTION

Thirty-three patients were treated with intravenous cyclophosphamide every two weeks. Initial dosage was 500 mg, and the dose was escalated provided the total white blood cell count remained > 3,000 cells per cubic millimeter. The maximum dose administered was 1,000 to 1,800 mg of cyclophosphamide. Corticosteroid therapy was tapered as tolerated by the patient.

MEASUREMENTS AND RESULTS

Patients were treated for at least six months or until death. For the 33 patients, 18-month probability of survival was > 50 percent. For those patients surviving six months, there was a significant rise in the vital capacity (from 1.6 +/- .61 L [mean +/- SD] to 1.8 +/- .52 L, p < 0.01) which persisted for at least 18 months of treatment. This was associated with a significant fall in the average prednisone dosage from 32 +/- 13.0 mg/day to 4 +/- 10.4 mg/day (p < 0.01) by 12 months. Only one patient required hospitalization for possible drug-related toxic reaction.

CONCLUSIONS

Intermittent, intravenous cyclophosphamide therapy was associated with improved pulmonary function and reduced corticosteroid dosage in patients with idiopathic pulmonary fibrosis who survived at least six months after institution of therapy.

Pulmonary lymphangitic metastasis from breast cancer. Lymphocytic alveolitis is associated with favorable prognosis

BACKGROUND

More than 20 percent of patients with breast cancer have pulmonary lymphangitic spread at death. Previous reports have indicated that some patients may respond to aggressive chemotherapy that includes corticosteroids.

METHODS

Bronchoscopy with bronchoalveolar lavage (BAL) was used to assess pulmonary infiltrates in 14 patients with infiltrating ductal breast cancer. All patients had received prior cytotoxic or hormonal therapy. Following a diagnosis of pulmonary metastasis by BAL or biopsy specimen, all patients received prednisone and chemotherapy.

RESULTS

BAL confirmed the diagnosis of metastatic tumor in 10 of 14 patients. The conditions of the remaining patients were diagnosed by one or more other bronchoscopy specimens. Patients were divided into two groups based on BAL lymphocyte percentage (10 percent is the upper limit of normal in our laboratory). Seven patients had > 10 percent lymphocytes (high lymphs: 26 +/- 11.6 percent [mean +/- SD]) compared with seven patients with normal lymphocyte percentage (low lymphs: 4 +/- 1.9 percent, p < 0.01). Six of seven patients with low lymphs died within three months of BAL compared with one in seven patients with high lymphs (p < 0.01). Within six months, all patients with low lymphs were dead whereas five of seven patients with high lymphs were alive, (p < 0.01). Comparing the two groups, there was no significant difference in percentage of BAL neutrophils, patient age, duration of disease prior to diagnosis, or arterial-alveolar oxygen gradient.

CONCLUSION

In breast cancer patients with pulmonary lymphangitic metastasis, a lymphocytic alveolitis is associated with a better overall prognosis.

Increased tyrosine protein kinase activity in hairy cell and monocytic leukemias

Tyrosine protein kinases (TPK) help regulate cellular growth and differentiation. Several proto-oncogenes encode for protein products with associated tyrosine kinase activity. An assay for TPK activity was performed in cell extracts using a synthetic peptide substrate and [32P] adenosine triphosphate (ATP). TPK activity was elevated in K-562 cells, which possess an amplified c-abl oncogene, compared to normal blood mononuclear cells (K-562 = 9.37 +/- 1.72 [mean +/- standard deviation] pmol ATP/10(6) cells/min; normal = 1.14 +/- 0.46, p less than 0.01). TPK activity was measured in peripheral blood mononuclear cells from patients with hairy cell leukemia (HCL), myelomonocytic leukemia (MOL), acute myeloblastic leukemia (AML), and chronic lymphocytic leukemia (CLL). In patients with clinically active disease, elevated TPK activity was measured in mononuclear cells from five HCL patients (range 3.76-24.15) and from seven MOL patients. These elevated levels appeared to parallel disease activity, as low levels of TPK activity were measured in patients with inactive (treated) disease. Low levels of TPK were measured in mononuclear cells from active AML and CLL patients. Elevated TPK levels in patients with HCL and MOL may reflect the overexpression of a proto-oncogene or increased growth factor activity in immature or rapidly dividing leukemic cells. Serial TPK levels in HCL and MOL patients correlated with change in disease activity.

c-myc, c-erbB-2, and Ki-67 expression in normal breast tissue and in invasive and noninvasive breast carcinoma

c-myc, c-erbB-2, and Ki-67 expression was examined by immunohistochemistry in 11 normal breast tissues and 42 invasive and 14 noninvasive breast carcinomas. The c-myc product was detected in all breast carcinoma specimens and in 7 of 11 normal breast tissues. Invasive tumors stained more frequently with the anti-myc monoclonal antibody than did noninvasive tumors, while the level of expression in normal breast tissue was much less than that in breast cancer. Membrane staining of the c-erbB-2 protein was demonstrated in 29% (4 of 14) of noninvasive ductal carcinomas and in 45% (19 of 42) of invasive breast carcinomas. None of the 11 normal breast tissue samples was positive. The mean value of Ki-67-positive cells was 0.91 +/- 0.31% for normal breast tissue, 4.57 +/- 1.36% for noninvasive ductal carcinoma, and 12.76 +/- 2.18% for invasive breast cancer. In 42 invasive breast carcinomas, the expression of c-myc, c-erbB-2, and Ki-67 proliferation marker were compared with lymph node status, estrogen receptor status, progesterone receptor status, and age of patients at diagnosis. c-erbB-2 overexpression and Ki-67 overexpression were identified as the only factors associated with lymph node status. We concluded that they might be additional prognostic factors for breast carcinoma.

An inhibitor of tumor necrosis factor found in pleural effusions

Tumor necrosis factor (TNF) has significant biologic effects. Inhibitors of TNF have been isolated from urine and blood. We studied pleural fluid from 22 patients with benign or malignant effusions. Pleural macrophages from these effusions were capable of releasing TNF, especially when stimulated with lipopolysaccharide. The cell-free supernatant from some of these pleural effusions contained an inhibitor of TNF. Fluid from 12 malignant effusions contained an inhibitor of 17% +/- 15.4% (mean +/- SD) of 500 U/ml of TNF activity, whereas the mean inhibition in 10 benign effusions was 2% +/- 5.6% (p less than 0.05). Only one of 10 benign effusions had more than 10% inhibitory activity. This inhibitor was found to be heat sensitive and unaffected by dialysis, and the molecular weight of at least one of the inhibitors was 60 to 80,000 daltons. Enzyme digestion studies were consistent with a protein portion being the major determinant of activity. We conclude that some malignant effusions contain an inhibitor of TNF activity.