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.

Diethylstilbestrol: recommended dosages for different categories of breast cancer patients. Report of the Cooperative Breast Cancer Group

A total of 523 postmenopausal breast cancer patients with progressive disease were entered in a radomized, double-blind study of four dosages of diethylstibestrol (DES): 1.5, 15, 150, OR 1,500 MG/DAY. Higher dosages produced significantly (p less than .05) higher regression rates: 21% for the 1,500 mg dosage, 17% for the 150 mg dosage, 15% for the 15 mg dosage, and 10% for 1.5 mg dosage. Durations of regressions were similar regardless of the dosages used to induce them. Although the highest dosage produced the highest regression rate overall, selecting the best dosage or treatment of choice for each type of patient based on menopausal age and on dominant metastatic site would result in more regressions.

Cardiac tamponade in primary myxedema and review of the literature

A case of cardiac tamponade secondary to primary myxedema is described. The nature of the patient's pericardial fluid and clinical course compared with other cases in the literature is reviewed. The patient had no recurrence of cardiac tamponade. Complete resolution of the pericardial effusion occurred 10 months followint initial pericardiocentesis and L-thyroxine therapy.

Primary hyperparathyroidism and breast cancer

Three cases demonstrating the coexistence of primary hyperparathyroidism and breast carcinoma with the disappearance of hypercalcemia following removal of parathyroid adenomas are presented. In these cases, the patients had the typical diagnostic findings of primary hyperparathyroidism. Reluctance to perform neck explorations in such patients does not appear warranted.

Interaction between thyroid hormones and erythrocyte membranes: competitive inhibition of binding 131 I-L-triiodothyronine and 131 I-L-thyroxine by their analogs

Molecular structural characteristics of thyroid hormones which influence binding to the erythrocyte membranes were investigated by competitive binding experiments. The ability of thyroid hormone analogs to displace 131 I-L-thyroxine and 131 I-L-triiodothyronine from the membranes was considered evidence of their competitive binding. The diphenyl ether linkage (thyronine) was essential as compounds with a single aromatic ring were weakly competitive. The presence of three iodine atoms at 3, 5 and 3' positions on thyronine was optimal for maximal competitive binding. There was weak competitive binding of analogs if chlorine or bromine was substituted for iodine. The alanine side chain was required for optimal binding as N-acetyl-l-thyroxine and various deaminated analogs were poor competitors compared to T4 and T3. L-isomers of T4 and T3 showed greater competitive binding to erythrocyte membranes than the corresponding d-isomers.

Metabolic parameters in women with metastatic breast cancer

The metabolic mechanism for increased circulating free fatty acids in post-menopausal women with metastatic breast cancer was investigated. Hormone and metabolic response to glucose and growth hormone were compared to cancer patients and control subjects; thyroid, adrenal and pituitary function were evaluated. The results of these studies indicated that breast cancer patients had glucose intolerance and delayed and prolonged insulin secretion, increased basal growth hormone levels and insensitivity of adipose tissue to growth hormone. Cortisol and protein-bound iodine levels were normal and there was no lipolytic factor in the sera of breast cancer patients. The changes observed in breast cancer patients were not attributable to age, obesity, inanition or stress. These metabolic abnormalities may characterize host susceptibility to breast cancer or be effects of tumor.