Pathologic findings from the national surgical adjuvant breast project (protocol no. 4). II. The significance of regional node histology other than sinus histiocytosis in invasive mammary cancer

The morphologic appearances of regional lymph nodes in radical mastectomy specimens obtained from 303 women entered into a prospective study of invasive breast cancer were categorized into patterns that have been considered to reflect immunologic function. An attempt was made to correlate these with 31 other histological and 8 clinical features, including short-term treatment failure (3 months to 4 years, average 24 months). No significant relationship to the latter was encountered. However, a lymphocyte predominance pattern was significantly associated with a stellate tumor border, absent cell reaction within the dominant tumor, absent sinus histocytosis of lymph nodes, combination tumor types, and a patient age of 55 years or more. A similar relationship between age of patient and sinus histiocytosis was found with the germinal center predominance pattern. In addition, this histologic appearance was associated with circumscribed tumors, severe cell reaction, and the infiltrating ductal carcinoma NOS and medullary types. Nodes with an unstimulated appearance were also found to be related to an absent cell reaction but marked sinus histiocytosis and a patient age of 45-54 years. Possible reasons for the differences between these findings and those of others relating prognostic value to such assessment of nodal histology is discussed, as are the findings of studies relevant to the identity of immunologic function with the morphologic appearance of nodal structure. The findings from this study fail to indicate any value of such nodal assessments as prognostic discriminants for breast cancer. Although longer periods of observation might alter this conclusion, such an event is regarded as unlikely.

Metastasizing plasma cell tumor of the small bowel

An 81-year old man who had a plasmacytoma of the ileum presented with melena for which no bleeding site could be established before surgery. He developed intussusception and the tumor was located at laparotomy. Metastases to the skin and axillary lymph nodes were documented prior to his operation, to mesenteric lymph nodes at surgery and to intrathoracic lymph nodes and a substernal goiter at autopsy. The liver, spleen, bones and marrow were not involved by myeloma or amyloid. Immunoelectrophoresis demonstrated an Ig-A (lambda) monoclonal protein in the serum (with nondiagnostic serum zone electrophoresis patterns) and lambda light chains in the urine. Immunoflourescense of Ig-A (lambda) globulin was present in imprint preparations from the bowel tumor.

Further observations on the inhibition of tumor growth by Corynebacterium parvum with cyclophosphamide. I. Variation in administration of both agents

Studies from this laboratory have indicated that the administration of cyclophosphamide (CY) and Corynebacterium parvum (CP) over a prolonged time to C3H mice with established measurable tumors resulted in complete arrest of tumor growth as well as partial and complete regressions in many instances. The present investigations on optimal dosage, route, frequency, and sequence of administration of CY and CP in the model system were performed to obtain information that could be useful in the design of chemotherapeutic and immunotherapeutic regimens for the treatment of human tumors. Findings have suggested the need for administration of CP in more than one instance. Although a single dose of CP in combination with weekly injections of CY had a significantly prolonged inhibitory effect, weekly doses of CP and CY were more effective. We also concluded that the time between doses of an immunostimulating agent (I-I interval) as well as between administration of chemotherapy (C-C interval) may be critical for an optimal result. In this model system, C-C and I-I intervals of 7 days inhibited tumor growth most effectively. The time between administration of chemotherapy and immunotherapy (C-I interval) has been considered critical. Whereas slightly better results were achieved in these studies when the immunotherapy was administered 4 days after the CY or when the C-I interval was +4 days, almost equally good results were obtained when both agents were given on the same day, which signified that the C-I interval may not be as critical as other investigators have reported. The present findings confirmed and extended our prior observations and indicated that the iv and ip routes of administration were superior to the im and sc routes in our model. The observed tumor growth inhibition was a result of both chemotherapeutic and immunotherapeutic modalities; also, the inhibitory properties of the regimen were more related to the chemotherapeutic component. Finally, almost identical tumor growth inhibition was observed when CP obtained from two different laboratories was used in conjunction with CY.

Studies concerning the regional lymph node in cancer. VIII. Effect of two asynchronous tumor foci on lymph node cell cytotoxicity

Results suggest that cytotoxicity by cells from nodes regional to a primary tumor is unique. While a primary tumor was present, A) cytotoxicity was displayed by cells from lymph nodes (RLNs) to that tumor, B) cells from nonregional lymph nodes regional (NRLNs) possessed lesser cytotoxicity which failed to increase in response to a second tumor focus in an area drained by those nodes, and C) the second focus attenuated cytotoxicity of cells from LNs regional to the primary tumor. Following removal of the primary tumor, cells from RLNs rapidly lost cytotoxicity and with passage of time were unable to regain that function in response to a second tumor focus. In contrast, cells from NRLNs demonstrated increased cytotoxicity at any time following removal of the primary tumor when exposed to a second focus. These observations suggest that nodes regional to a distant metastatic focus may be unable to react to it and thus contribute little to the host response generated by the primary tumor. In addition, since nodes regional to a primary tumor manifest diminished cytotoxicity in the presence of a distant tumor focus, tumor cells gaining access and lodging in those nodes subsequent to the development of other metastatic foci are likely to proliferate, resulting in the "positive" lymph node. The findings are in keeping with our contention that host factors responsible for metastases, and perhaps metastases themselves, are at least in part responsible for growth of tumor in RLNs. They also have relevance to the site of administration of specific immunotherapeutic agents and to the significance of the removal of RLNs with a primary tumor.

The pathology of invasive breast cancer. A syllabus derived from findings of the National Surgical Adjuvant Breast Project (protocol no. 4)

The inter-relationships of 32 pathologic and 7 clinical parameters encountered in the study of 1000 examples of invasive breast carcinoma have been presented. In some instances the biological significance of these associations is at present unclear. In others it is to be noted that there is no information provided as to the rank of their significance. Nevertheless, the associations that were encountered not only help further characterize the various forms of breast cancer but also provide information regarding the possible biological significance of some of their features. Although it is not our intention to minimize the possible significance of the inter-relationships of pathologic parameters, most emphasis in the summarizing statements which follow has been placed upon those correlations which may relate to prognosis. In this regard reference has been made to short-term treatment failure, vis a vis local recurrence and/or metastases, which may not necessarily accurately reflect patient survival, although generally such a relationship exists. Information in this regard as well as to the rank of the significance of these pathologic features shall be forthcoming when sufficient time has elapsed since the inception of this study to allow for such conclusions, i.e. survival or long-term treatment failure rates. Lastly, it becomes evident that the guidelines followed in the examination of these specimens appear to represent at least the minimum requirements necessary for a meaningful pathologic evaluation of breast carcinoma.

Ten year follow-up results of patients with carcinoma of the breast in a co-operative clinical trial evaluating surgical adjuvant chemotherapy

In 1958, a co-operative clinical trial, involving 23 institutions, was begun to evaluate the efficacy of a short course of triethylenethiophosphoramide as an adjuvant to radical mastectomy in the treatment of patients with primary carcinoma of the breast. Of 826 women prospectively randomized so that they received either a placebo or triethylenethiophosphoramide, 99.3 per cent were available for five years of follow-up study, and 95.3 per cent have been observed for ten or more years. Results have indicated the inadequacy of standard operative therapy in effecting a permanent tumor-free state in a majority of patients. Particularly distressing was the finding that 76 per cent of all patients with positive axillary nodes--65 per cent with one to three and 86 per cent of those with more than or equal to four positive--demonstrated a treatment failure by ten years and that only 24.9 per cent survived. The survival rate of those with one to three positive nodes was 37.5 per cent and only 13.4 per cent if more than or equal to four nodes contained tumor. Also disturbing was the observation that one of four patients with negative axillary nodes displayed a treatment failure by ten years. Such findings mandate the urgency for immediate evaluation of available systemic therapeutic agents postoperatively. That systemic chemotherapy can enhance the disease-free state as well as survival rate of at least some patients with carcinoma of the breast is supported by the finding that the original observation at 18 months indicating an advantage for premenopausal women with more than or equal to four positive nodes who received triethylenethiophosphoramide persisted for as long as ten years. At that time, 21 per cent fewer patients in the triethylenethiophosphoramide group had treatment failures and 21 per cent more survived, an indication that the initial delay in treatment failure was reflected in patient survival rate. Data suggesting that the limited chemotherapy used was more effective in patients having smaller tumors are in keeping with the concept that adjuvant therapy is likely to be most effective in a host with minimal residual tumor burden. Of importance was the observation that 80 per cent of treatment failures occurring in ten years were apparent by five years of observation. Strikingly, 86 per cent of ten year treatment failures in patients with positive nodes occurred by five years. In patients with more than or equal to four positive nodes, this was so in 92 per cent of the instances. Such findings tend to discredit the claim that the worth of an alternative treatment for carcinoma of the breast can be ascertained only by a period of observation much longer than five years.

L-Phenylalanine mustard (L-PAM) in the management of primary breast cancer. A report of early findings

Prolonged l-phenylalanine mustard (L-PAM) administration as an adjuvant to mastectomy in the management of patients with primary breast cancer and pathologically positive axillary nodes was evaluated by a prospective, randomized, clinical trial. Treatment failures occurred in 22 per cent of 108 patients receiving placebo and 9.7 per cent of 103 women given L-PAM (p = 0.01). A statistically significant difference (p = 0.02) existed in favor of L-PAM relative to disease-free interval. In premenopausal women, the difference with respect to disease-free interval of treated and control groups was highly significant (p = 0.008). A treatment failure occurred in 30 per cent of premenopausal patients receiving placebo and 3 per cent of those treated with L-PAM (p = 0.008). Whereas a similar trend was observed in postmenopausal patients, the difference is not statistically significant. Thus, L-PAM has been demonstrated to be effective in the treatment of women with primary breast cancer, particularly those who are premenopausal. Results were achieved with minimal undesirable side effects.

Pathologic findings from the National Surgical Adjuvant Breast Project (protocol no. 4). I. Observations concerning the multicentricity of mammary cancer

Microscopic foci of multicentric cancer were detected in 121 of 904 breasts surgically removed for a clinically overt, invasive cancer. This incidence of 13.4% is regarded as a conservative estimate since examples of such lesions occurring in the same quadrant as the dominant mass, except in those instances in which the latter was present within the tail of the breast or beneath the nipple, were excluded from the analysis. Further, this data was obtained from only one randomly selected block of the quadrants, and in 41% of the cases only one or two were available for study. Multiple multicentric cancers were found in the same breast in two and three quadrants in 11.6% and 5.8% of the cases respectively. In 9.3% of the cases the multicentric cancers were designated as noninvasive (lobular in situ and/or intraductal) and in 4.1% invasive. An attempt to correlate the occurrence of multicentric cancers with a large number of pathologic and some clinical features disclosed a statistically significant association between multicentricity and grossly nonencapsulated dominant cancers with maximum diameters greater than 5 cm, the presence of a moderate or marked intraductal component and noninvasive cancer in its vicinity, and tumor involvement of the nipple. In addition, it was noted that there was a greater likelihood that the primary tumor was of the lobular invasive type and that the overlying skin was involved when the multicentric cancer was invasive rather than noninvasive. Lymphatic tumor emboli were observed in quadrants in 18 or 2.0% of the cases. Although the number of examples is small, nevertheless positive associations were noted with the occurrence of primary tumors that were in the left breast or beneath the nipple and were not grossly circumscribed, but exhibited a nuclear grade of 1, intralymphatic and blood vessel invasion, calcium, and involvement of the overlying skin as well as nipple. In addition, patients with such intralymphatic extension were more likely to have clinically detectable lymph nodes of which four or more contained metastases. The relationship of these findings to the rationale of such procedures as segmental resection in the surgical treatment of breast cancer is discussed.

Inhibitory effect of prolonged Corynebacterium parvum and cyclophosphamide administration on the growth of established tumors

The present study was carried out to investigate the effects of prolonged administration of C. parvum alone and in combination with cyclophosphamide for the treatment of established, measurable C3H tumors. The continued weekly administration of C. parvum by itself provided a limited but significant inhibitory effect on tumor growth and significantly prolonged survival. Intraperitoneal and intravenous administration was found to be more effective than the subcutaneous route. When C. parvum was administered asynchronously in combination with cyclophosphamide at weekly intervals a tumor growth inhibitory effect was achieved which was greater than that resulting from either agent along. Such an effect was consistently obtained and was seemingly independent of the sequence of drug administration. When cyclophosphamide preceded the initial C. parvum administration, arrest in the rate of tumor growth occurred, resulting in infinite tumor doubling time for the duration of observation (greater than 90 days). The combination of C. parvum and cyclophosphamide produced a more effective inhibition of tumor growth than did BCG and cyclophosphamide similarly employed. The importance of these findings relative to clinical application is considered. While the significance and genesis of the marked desmoplastic reaction characterizing tumors from animals treated with C. parvum and cyclophosphamide is at present speculative, consideration is given to the possibility that this could signify a host response against tumor growth.