The effect of raloxifene on risk of breast cancer in postmenopausal women: results from the MORE randomized trial. Multiple Outcomes of Raloxifene Evaluation

CONTEXT

Raloxifene hydrochloride is a selective estrogen receptor modulator that has antiestrogenic effects on breast and endometrial tissue and estrogenic effects on bone, lipid metabolism, and blood clotting.

OBJECTIVE

To determine whether women taking raloxifene have a lower risk of invasive breast cancer.

DESIGN AND SETTING

The Multiple Outcomes of Raloxifene Evaluation (MORE), a multicenter, randomized, double-blind trial, in which women taking raloxifene or placebo were followed up for a median of 40 months (SD, 3 years), from 1994 through 1998, at 180 clinical centers composed of community settings and medical practices in 25 countries, mainly in the United States and Europe.

PARTICIPANTS

A total of 7705 postmenopausal women, younger than 81 (mean age, 66.5) years, with osteoporosis, defined by the presence of vertebral fractures or a femoral neck or spine T-score of at least 2.5 SDs below the mean for young healthy women. Almost all participants (96%) were white. Women who had a history of breast cancer or who were taking estrogen were excluded.

INTERVENTION

Raloxifene, 60 mg, 2 tablets daily; or raloxifene, 60 mg, 1 tablet daily and 1 placebo tablet; or 2 placebo tablets.

MAIN OUTCOME MEASURES

New cases of breast cancer, confirmed by histopathology. Transvaginal ultrasonography was used to assess the endometrial effects of raloxifene in 1781 women. Deep vein thrombosis or pulmonary embolism were determined by chart review.

RESULTS

Thirteen cases of breast cancer were confirmed among the 5129 women assigned to raloxifene vs 27 among the 2576 women assigned to placebo (relative risk [RR], 0.24; 95% confidence interval [CI], 0.13-0.44; P<.001). To prevent 1 case of breast cancer, 126 women would need to be treated. Raloxifene decreased the risk of estrogen receptor-positive breast cancer by 90% (RR, 0.10; 95% CI, 0.04-0.24), but not estrogen receptor-negative invasive breast cancer (RR, 0.88; 95% CI, 0.26-3.0). Raloxifene increased the risk of venous thromboembolic disease (RR, 3.1; 95% CI, 1.5-6.2), but did not increase the risk of endometrial cancer (RR, 0.8; 95% CI, 0.2-2.7).

CONCLUSION

Among postmenopausal women with osteoporosis, the risk of invasive breast cancer was decreased by 76% during 3 years of treatment with raloxifene.

De-escalating and escalating treatments for early-stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017

The 15th St. Gallen International Breast Cancer Conference 2017 in Vienna, Austria reviewed substantial new evidence on loco-regional and systemic therapies for early breast cancer. Treatments were assessed in light of their intensity, duration and side-effects, seeking where appropriate to escalate or de-escalate therapies based on likely benefits as predicted by tumor stage and tumor biology. The Panel favored several interventions that may reduce surgical morbidity, including acceptance of 2 mm margins for DCIS, the resection of residual cancer (but not baseline extent of cancer) in women undergoing neoadjuvant therapy, acceptance of sentinel node biopsy following neoadjuvant treatment of many patients, and the preference for neoadjuvant therapy in HER2 positive and triple-negative, stage II and III breast cancer. The Panel favored escalating radiation therapy with regional nodal irradiation in high-risk patients, while encouraging omission of boost in low-risk patients. The Panel endorsed gene expression signatures that permit avoidance of chemotherapy in many patients with ER positive breast cancer. For women with higher risk tumors, the Panel escalated recommendations for adjuvant endocrine treatment to include ovarian suppression in premenopausal women, and extended therapy for postmenopausal women. However, low-risk patients can avoid these treatments. Finally, the Panel recommended bisphosphonate use in postmenopausal women to prevent breast cancer recurrence. The Panel recognized that recommendations are not intended for all patients, but rather to address the clinical needs of the majority of common presentations. Individualization of adjuvant therapy means adjusting to the tumor characteristics, patient comorbidities and preferences, and managing constraints of treatment cost and access that may affect care in both the developed and developing world.

Continued breast cancer risk reduction in postmenopausal women treated with raloxifene: 4-year results from the MORE trial. Multiple outcomes of raloxifene evaluation

Raloxifene, a selective estrogen receptor modulator approved for the prevention and treatment of postmenopausal osteoporosis, has shown a significant reduction in breast cancer incidence after 3 years in this placebo-controlled, randomized clinical trial in postmenopausal women with osteoporosis. This article includes results from an additional annual mammogram at 4 years and represents 3,004 additional patient-years of follow-up in this trial. Breast cancers were ascertained through annual screening mammograms and adjudicated by an independent oncology review board. A total of 7,705 women were enrolled in the 4-year trial; 2,576 received placebo, 2,557 raloxifene 60 mg/day, and 2,572 raloxifene 120 mg/day. Women were a mean of 66.5-years old at trial entry, 19 years postmenopause, and osteoporotic (low bone mineral density and/or prevalent vertebral fractures). As of 1 November 1999, 61 invasive breast cancers had been reported and were confirmed by the adjudication board, resulting in a 72% risk reduction with raloxifene (relative risk (RR) 0.28, 95% confidence interval (CI) 0.17, 0.46). These data indicate that 93 osteoporotic women would need to be treated with raloxifene for 4 years to prevent one case of invasive breast cancer. Raloxifene reduced the risk of estrogen receptor-positive invasive breast cancer by 84% (RR 0.16, 95% CI 0.09, 0.30). Raloxifene was generally safe and well-tolerated, however, thromboembolic disease occurred more frequently with raloxifene compared with placebo (p=0.003). We conclude that raloxifene continues to reduce the risk of breast cancer in women with osteoporosis after 4 years of treatment, through prevention of new cancers or suppression of subclinical tumors, or both. Additional randomized clinical trials continue to evaluate this effect in postmenopausal women with osteoporosis, at risk for cardiovascular disease, and at high risk for breast cancer.

Factors predicting the use of breast-conserving therapy in stage I and II breast carcinoma

PURPOSE

To define patterns of care for the local therapy of stage I and II breast cancer and to identify factors used to select patients for breast-conserving therapy (BCT).

PATIENTS AND METHODS

A convenience sample of 16,643 patients with stage I and II breast cancer treated in 1994 was obtained from hospital-based tumor registries. Histologic variables were determined from original pathology reports.

RESULTS

BCT was performed in 42.6% of patients. Multivariate analysis demonstrated that living in the Northeast United States (odds ratio [OR], 2.48; 95% confidence interval [CI], 2.16 to 2.84), having a clinical T1 tumor (OR, 2.51; 95% CI, 2.27 to 2.78), and having a tumor without an extensive intraductal component (OR, 2.07; 95% CI, 1.81 to 2.37) were the strongest predictors of breast-conserving surgery. Radiation therapy was given to 86% of patients who had breast-conserving surgery. Age less than 70 years was the most significant predictor of receiving radiation (OR, 2.11; 95% CI, 1.77 to 2.25). Tumor variables did not correlate with the use of radiation, but favorable tumor characteristics were associated with the use of breast-conserving surgery.

CONCLUSION

Despite strong evidence supporting the use of BCT, the majority of women continue to be treated with mastectomy. Predictors of the use of BCT do not correspond to those suggested in guidelines.

Factors influencing the use of breast reconstruction postmastectomy: a National Cancer Database study

BACKGROUND

Advances in surgical techniques and changes in our understanding of the biology of breast cancer have made immediate or early breast reconstruction a viable option for the majority of women with breast cancer. Little is known about national patterns of use of reconstruction. This study was undertaken to determine national patterns of care and factors that influence the use of breast reconstruction.

STUDY DESIGN

A large convenience sample reported to the National Cancer Data Base was studied. Patients coded as undergoing mastectomy between 1985 and 1990 (n = 155,463) and between 1994 and 1995 (n = 68,348) were evaluated. The use of reconstruction in the two time periods was compared, and patient and tumor factors influencing the use of the procedure were compared.

RESULTS

Between 1985 and 1990, 3.4% of mastectomy patients had early or immediate reconstruction, increasing to 8.3% in 1994-5. Patient age, income, geographic location, type of hospital where treatment occurred, and tumor stage all influenced the use of reconstruction in univariate analysis. In multivariate analysis, patients age 50 or under had a 4.3-fold greater likelihood of having reconstruction than their older counterparts. Patients with ductal carcinoma in situ were twice as likely as those with invasive cancer to have reconstruction. Family income of $40,000 or more (Odds Ratio 2.0), ethnicity other than African-American (Odds Ratio 1.6), surgery in a National Cancer Institute-designated cancer center (Odds Ratio 1.4), and surgery in a geographic region other than the Midwest or South (Odds Ratio 1.3) remained significant predictors of the use of reconstruction in multivariate analysis.

CONCLUSIONS

Breast reconstruction is an underused option in breast cancer management. Predictors of the use of reconstruction do not reflect contraindications to the procedure, and indicate the need for both physician and patient education.

The National Cancer Data Base 10-year survey of breast carcinoma treatment at hospitals in the United States

BACKGROUND

The National Cancer Data Base (NCDB), a joint project of the American College of Surgeons Commission on Cancer and the American Cancer Society, is a cancer management and outcome data base for health care organizations. It provides a comparative summary of patient care that is used by participating hospitals and communities for self-assessment. The most current (1995) data are described herein.

METHODS

Since 1989, seven calls for data have been issued, yielding reports on a total of 240,031 breast carcinoma patients for the years included in this analysis. A total of 1849 hospital cancer registries responded to at least 1 of the calls for data.

RESULTS

A continuous improvement in care was reported. By 1995, 45.8% (nearly one-half) of breast carcinoma patients were diagnosed early as Stage 0 or I, and early stage patients (Stage 0 or I) were most often treated with partial mastectomy (in 58% of cases). Favorable 10-year relative survival rates for Stage 0 (95%) and Stage I (88%) breast carcinoma patients were reported. Patients who were presumed to be Stage I and were not selected for axillary dissection had poorer survival. Survival differences were reported for different treatment groups within individual stage strata. Over the 10-year observation period, fewer patients from lower-income neighborhoods were diagnosed with early stage breast carcinoma. In general, the annual relative survival rate remained constant over the 10-year observation period (with no plateau after 5 years) within each stage and for all stages combined.

CONCLUSIONS

Improvements in diagnosis and treatment during the period 1985-1995 were demonstrated by these data. The NCDB breast carcinoma data are appropriate norms for formal quality assurance purposes, such as those specified by the Standards of the Commission on Cancer published by the American College of Surgeons Commission on Cancer. Cancer committees and other clinicians working within the hospital setting should assess and compare stage distribution, stage specific treatment patterns, and the correlations between the outcomes of patients and both disease stage and treatment.

Hormone replacement therapy and risk of breast cancer with a favorable histology: results of the Iowa Women's Health Study

CONTEXT

Long-term, postmenopausal use of hormone replacement therapy (HRT) appears to increase breast cancer risk. Whether the effect of HRT use on risk of breast cancer varies among histological types of invasive carcinoma is unknown.

OBJECTIVE

To determine associations between HRT use and risk of ductal carcinoma in situ (DCIS), invasive carcinoma with favorable histology, and invasive ductal or lobular carcinoma.

DESIGN

Prospective cohort study whose participants were followed up continuously for 11 years from January 1986 to December 1996.

SETTING AND PARTICIPANTS

Iowa Women's Health Study, a population-based random sample of postmenopausal women aged 55 to 69 years in 1986. A total of 1520 incident breast cancer cases occurred in the at-risk cohort of 37 105 women.

MAIN OUTCOME MEASURES

Multivariate-adjusted relative risk (RR) of tumor-specific breast cancers associated with duration of ever, current, or past HRT use.

RESULTS

Duration of ever HRT use was associated with risk of invasive carcinoma with a favorable histology, with an RR of 1.81 (95% confidence interval [CI], 1.07-3.07) for those who used HRT 5 or fewer years vs an RR of 2.65 (95% CI, 1.34-5.23) for those who used HRT for more than 5 years (P for trend = .005) after adjustment for age and other breast cancer risk factors. There was no association between ever HRT use and the incidence of DCIS or invasive ductal or lobular carcinoma. Among current hormone users, after adjusting for age and other breast cancer risk factors, the RRs (95% CIs) of invasive carcinoma with a favorable histology were 4.42 (2.00-9.76) and 2.63 (1.18-5.89) for 5 or fewer years of use and for more than 5 years of use, respectively. Risk of invasive ductal or lobular carcinoma was associated with current use (< or =5 years) of HRT with an RR of 1.38 (95% CI, 1.03-1.85).

CONCLUSIONS

Exposure to HRT was associated most strongly with an increased risk of invasive breast cancer with a favorable prognosis. These data add important clinical information for assessing the risks and benefits of HRT use.

Selective estrogen receptor modulation and reduction in risk of breast cancer, osteoporosis, and coronary heart disease

The recognition of selective estrogen receptor modulation in the laboratory has resulted in the development of two selective estrogen receptor modulators (SERMs), tamoxifen and raloxifene, for clinical application in healthy women. SERMs are antiestrogenic in the breast but estrogen-like in the bones and reduce circulating cholesterol levels. SERMs also have different degrees of estrogenicity in the uterus. Tamoxifen is used specifically to reduce the incidence of breast cancer in premenopausal and postmenopausal women at risk for the disease. In contrast, raloxifene is used specifically to reduce the risk of osteoporosis in postmenopausal women at high risk for osteoporosis. The study of tamoxifen and raloxifene (STAR) trial is currently comparing the ability of these SERMs to reduce breast cancer incidence in high-risk postmenopausal women. There is intense interest in understanding the molecular mechanism(s) of action of SERMs at target sites in a woman's body. An understanding of the targeted actions of this novel drug group will potentially result in the introduction of new multifunctional medicines with applications as preventive agents or treatments of breast cancer and endometrial cancer, coronary heart disease, and osteoporosis.

Environmental factors and the risk of salivary gland cancer

Cancer of the major salivary glands is rare, and little is known about its etiology. We conducted a population-based case-control study to elucidate the risk factors for these tumors. Of 199 cases diagnosed with salivary gland tumors between 1989 and 1993, 150 (75%) were interviewed. We subsequently excluded nine cases based on review of pathology specimens. We identified 271 controls through random-digit dialing and the Health Care Finance Administration files; 191 (70%) were interviewed. Therapeutic medical radiation treatment to the head or neck [odds ratio (OR) = 2.6; 95% confidence interval (CI) = 0.84-8.1], full mouth dental x-rays (OR = 1.6; 95% CI = 1.0-2.7), and ultraviolet light treatment to the head or neck (OR = 1.9; 95% CI = 0.89-4.3) were associated with increased risk. These elevations in risk were largely limited to those exposed before 1955, when the exposure dose was substantially higher. Occupational exposure to radiation/radioactive materials (OR = 2.4; 95% CI = 1.0-5.4) and nickel compounds/alloys (OR = 6.0; 95% CI = 1.6-22.0), as well as employment in the rubber industry (OR = 7.0; 95% CI = 0.80-60.3), increased risk. In men, current smoking (OR = 2.1; 95% CI = 0.98-4.7) and heavy alcohol consumption (OR = 2.5; 95% CI = 1.1-5.7) were associated with risk, but these factors were not strongly related to salivary gland cancer in women.

Medical contraindications are not a major factor in the underutilization of breast conserving therapy

BACKGROUND

Multiple randomized trials have demonstrated that survival after breast conserving therapy (BCT) is equal to survival after mastectomy, but large population-based studies indicate that > 50% of patients with early stage breast cancer continue to undergo mastectomy. This study was undertaken to determine whether medical contraindications to BCT or patient choice are responsible for high mastectomy rates.

STUDY DESIGN

Four hundred thirty-two patients with stage 0, I, or II breast carcinoma were prospectively evaluated by a multidisciplinary team for eligibility for BCT. Standard criteria developed by a joint committee of the American College of Surgeons, American College of Radiologists, College of American Pathologists, and Society of Surgical Oncology were used. Eligible patients were offered a choice among BCT, mastectomy, or mastectomy and immediate reconstruction.

RESULTS

Only 97 of the 432 patients had contraindications to BCT. The incidence of contraindications varied by stage: 10% for stage I, 28% for stage II, and 33% for stage 0 (p < 0.01). The type of contraindications also varied with stage. Age, histologic tumor type, and axillary node status (when controlled for tumor size) did not influence rates of BCT. Of eligible patients, 81% chose BCT, independent of age or race.

CONCLUSIONS

Medical contraindications to BCT are not major factors resulting in high mastectomy rates. Strategies like neoadjuvant chemotherapy, which addresses medical contraindications, are unlikely to have a major impact on national rates of BCT.

Assessment of the biological and pharmacological effects of the ανβ3 and ανβ5 integrin receptor antagonist, cilengitide (EMD 121974), in patients with advanced solid tumors

BACKGROUND

Cilengitide, an antiangiogenic agent that inhibits the binding of integrins alpha(nu)beta(3) and alpha(nu)beta(5) to the extracellular matrix, was studied at two dose levels in cancer patients to determine the optimal biological dose.

PATIENTS AND METHODS

The doses of cilengitide were 600 or 1200 mg/m(2) as a 1-h infusion twice weekly every 28 days. A novel dose escalation scheme was utilized that relied upon the biological activity rate.

RESULTS

Twenty patients received 50 courses of cilengitide with no dose-limiting toxic effects. The pharmacokinetic (PK) profile revealed a short elimination half-life of 4 h, supporting twice weekly dosing. Of the six soluble angiogenic molecules assessed, only E-selectin increased significantly from baseline. Analysis of tumor microvessel density and gene expression was not informative due to intrapatient tumor heterogeneity. Although several patients with evaluable tumor biopsy pairs did reveal posttreatment increases in tumor and endothelial cell apoptosis, these results did not reach statistical significance due to the aforementioned heterogeneity.

CONCLUSIONS

Cilengitide is a well-tolerated antiangiogenic agent. The biomarkers chosen in this study underscore the difficulty in assessing the biological activity of antiangiogenic agents in the absence of validated biological assays.

Antibody levels to hepatitis E virus in North Carolina swine workers, non-swine workers, swine, and murids

In a cross-sectional serosurvey, eastern North Carolina swine workers (n = 165) were compared with non-swine workers (127) for the presence of antibodies to hepatitis E virus as measured by a quantitative immunoglobulin enzyme-linked immunosorbent assay. Using a cutoff of 20 Walter Reed U/ml, swine-exposed subjects had a 4.5-fold higher antibody prevalence (10.9%) than unexposed subjects (2.4%). No evidence of past clinical hepatitis E or unexplained jaundice could be elicited. Swine (84) and mice (61), from farm sites in the same region as exposed subjects, were also tested. Antibody prevalence in swine (overall = 34.5%) varied widely (10.0-91.7%) according to site, but no antibody was detected in mice. Our data contribute to the accumulating evidence that hepatitis E may be a zoonosis and specifically to the concept of it as an occupational infection of livestock workers.

Stereotactic core-needle biopsy of the breast: a report of the Joint Task Force of the American College of Radiology, American College of Surgeons, and College of American Pathologists

A national task force consisting of members from the American College of Radiology, the American College of Surgeons, and the College of American Pathologists examined the issues surrounding stereotactic core-needle biopsy for occult breast lesions. Their report includes indications and contraindications, informed consent, specimen handling, and management of indeterminate, atypical, or discordant lesions.

Staging of breast cancer: a new rationale for internal mammary node biopsy

Metastases to the axillary nodes, the internal mammary nodes, or both, define a group of patients at very high risk of having systemic micrometastases leading to recurrent disease and death if surgical therapy alone is used. In our review of 7,070 patients with breast cancer in whom both axillary nodes and internal mammary nodes were examined histologically, 5% to 10% had internal mammary node metastases in the absence of axillary node metastases. With the availability of effective systemic therapy that can improve the survival of patients with operable breast cancer who have lymph node metastases, information obtained from internal mammary node biopsies assumes practical significance. Our current policy is to perform internal mammary node biopsies on patients with operable breast cancer who have medial and central primary tumors of any size and lateral primary tumors 2 cm or greater in diameter if a frozen section of the most suspicious node in the axillary dissection shows no histologic evidence of metastasis.

The Effect of Multiple Reexcisions on the Risk of Local Recurrence After Breast Conserving Surgery

BACKGROUND

Guidelines for breast conserving surgery (BCS) advise mastectomy if negative margins cannot be obtained after reasonable surgical attempts. This study examined the effect of multiple reexcisions on local recurrence (LR) and identified factors predictive of the need for multiple reexcisions.

METHODS

2,770 patients undergoing BCS over 25 years were analyzed; 137 patients (group A) with two or more reexcisions, 1514 patients with one reexcision (group B), and 1119 patients who had no reexcision (group C). The median follow-up was 73 months.

RESULTS

The five and ten-year actuarial LR rates for groups A, B, and C were 5.5%, 1.9%, 2.5%, and 10%, 5.7%, and 5.6%, respectively. The number of reexcisions did not predict for LR on multivariate analysis. Women <40 years underwent reexcision more frequently than other age groups. Patients with tumors detected by palpation alone made up 14% of the reexcision group versus 8% of the no reexcision group (p < 0.001). Patients with ductal carcinoma in situ and lobular carcinoma were more likely to require reexcision than those with ductal carcinoma. On multivariate analysis, younger age, detection by physical exam only, lobular histology, smaller tumor size, and the presence of extensive intraductal component (EIC) were highly significant predictors of the need for reexcision.

CONCLUSIONS

Multiple reexcisions do not impact on LR rates if negative margins are ultimately obtained. Conversion to mastectomy based solely on the number of excisions performed is not indicated. Subsets of patients more likely to require reexcision, who may be candidates for a larger initial resection, can be identified.

Ductography for nipple discharge: no replacement for ductal excision

BACKGROUND

Current management of nipple discharge depends on clinical history to distinguish pathologic from physiologic discharge. We investigated whether ductography supplied additional information in the decision for surgery and/or the localization of pathologic lesion.

METHODS

A retrospective review of patients with a presenting complaint of nipple discharge seen at the Lynn Sage Breast Center was conducted from January 1995 to June 1996. Medical records, pathology, and ductograms were reviewed.

RESULTS

Of 91 patients with nipple discharge, 49 met the criteria for physiologic discharge and 42 had pathologic discharge. Eleven with physiologic discharge had ductograms; none were abnormal. Four of 20 preoperative ductograms were normal but showed intraductal papillomas at the time of surgery; 6 of 20 (30%) had multiple lesions. Four lesions on ductograms did not demonstrate corresponding lesions in the surgical specimen. It is uncertain whether this is due to a missed lesion or a false-positive ductogram.

CONCLUSIONS

Modern ductography does not reliably exclude intraductal pathology and is not a substitute for surgery in patients with pathologic discharge. Its utility is in identifying multiple lesions or those with lesions in the periphery of the breast.

Late ovarian metastases in carcinoma of the colon and rectum

We reviewed 63 patients with metachronous ovarian metastases from colorectal carcinoma to determine the natural history of this problem, and whether aggressive surgical treatment is beneficial. Ovarian metastases usually occurred in younger patients (mean age, 51 years) and in 55.5% of the patients, the metastases were part of diffuse intra-abdominal disease. The mean survival rate for all patients following surgery was 16.6 months. The survival rate did not correlate with menstrual status, interval to recurrence, or Dukes' stage of the original cancer. Ability to remove all gross disease at the time of oophorectomy was the major determinant of survival. Surviving patients who were rendered disease free surgically (n = 15) lived a mean of 48 months compared with 9.6 months for patients with localized, but unresectable disease (n = 9), and eight months for patients with diffuse disease (n = 35). Surgical attempts to remove all gross disease seem to result in significantly improved survival rates even though a cure is rare. Bilateral oophorectomy is warranted as part of the palliative treatment of women who are seen with stage D cancers to prevent the development of large symptomatic metastases that require further therapy.

The woman at increased risk for breast cancer: evaluation and management strategies

Increased understanding of risk factors for breast cancer, especially the identification of genes associated with a predisposition to breast cancer, has focused attention on the issue of breast cancer prevention. At present, the only clinically available method of breast cancer prevention is prophylactic mastectomy. However, there are no absolute indications for its use, and it is not often appropriate in relation to actual risk for disease. This article reviews what is known about major breast cancer risk factors, reviews the available data on prophylactic mastectomy, and discusses current strategies for the management of the woman at increased risk for breast cancer.

Comparison of conventional surgical resection, radioactive implantation, and bypass procedures for exocrine carcinoma of the pancreas 1975-1980

To examine the efficacy of a variety of procedures for treatment of biopsy proven exocrine adenocarcinoma of the pancreas, a retrospective review of 231 patients surgically treated at a single institution from January 1975 through December 1980 was performed. Thirty-nine patients underwent resection for cure, of which 19 were conventional resection, 33 I125 implantation, 76 biliary or GI bypass, and 83 biopsy alone, a resectability rate of 16.9%. There was one pancreatic fistula in the implant group. Median survival following implant was 8 months (0%, 30-day mortality) and, for conventional resection (n = 19), 17 months with an inhospital mortality of 16%. Median survival excluding inhospital mortality was 17 months for the conventional resection group. For bypass, median survival was 4 months (p = 0.0001 vs. conventional resection) with an inhospital mortality of 14%. Of patients discharged from hospital, 5 of 16 (31%) survived 2 years in the conventional resection group, while 4 of 132 (3%) survived 2 years in the nonresected groups. Only one patient (5% of resected) has survived 4 years in the conventional resection group, although eight others are alive and at risk in this group. Resectability rate for patients referred with adenocarcinoma of the pancreas remains low. The only long-term survivors are in those patients undergoing resection. Local implantation with I125 requires prospective evaluation because of an apparent influence on palliation without significant morbidity.

Phase I and pharmacologic study of the specific matrix metalloproteinase inhibitor BAY 12-9566 on a protracted oral daily dosing schedule in patients with solid malignancies

PURPOSE

To evaluate the feasibility of administering BAY 12-9566, a matrix metalloproteinase (MMP) inhibitor with relative specificity against MMP-2, MMP-3, and MMP-9, on a protracted oral daily dosing schedule in patients with advanced solid malignancies. The study also sought to determine the principal toxicities of BAY 12-9566, whether plasma BAY 12-9566 steady state concentrations (C(ss)) of biologic relevance could be sustained for prolonged periods, and whether BAY 12-9566 affected plasma concentrations of MMP-2, MMP-9, and tissue inhibitor of MMP-2 (TIMP-2).

PATIENTS AND METHODS

Patients with solid malignancies were treated with BAY 12-9566 at daily oral doses ranging from 100 to 1,600 mg. BAY 12-9566 dose schedules included 100 mg once daily, 400 mg once daily, 400 mg twice daily, 400 mg three times daily, 400 mg four times daily, and 800 mg twice daily. Plasma was collected to study the range of BAY 12-9566 C(ss) values achieved, and exploratory studies were performed to assess the effects of BAY 12-9566 on plasma concentrations of MMP-2, MMP-9, and TIMP-2.

RESULTS

Twenty-one patients were treated with 47 28-day courses of BAY 12-9566. The most common side effects were headache, nausea, vomiting, abnormalities in hepatic functions, and thrombocytopenia, which were rarely clinically significant. BAY 12-9566 was well tolerated on all dose schedules, and there was no consistent dose-limiting toxicity that precluded treatment in the range of dose schedules evaluated. Instead, dose escalation was terminated because BAY 12-9566 plasma C(ss) values increased less than proportionately and plateaued as the daily dose was increased within the dose range of 100 to 1,600 mg/d, suggesting saturable drug absorption. Mean plasma C(ss) values achieved with all dose schedules exceeded BAY 12-9566 concentrations required to inhibit MMPs in vitro and in vascular invasion and tumor proliferation in vivo models. There were no consistent effects of BAY 12-9566 on the plasma concentrations of MMP-2 and MMP-9 over the continuous dosing period at any dose schedule level. However, plasma levels of TIMP-2 seemed to increase in a dose-dependent manner (r(2) =.50, P =.046).

CONCLUSIONS

The recommended dose of BAY 12-9566 for subsequent disease directed studies is 800 mg twice daily, which resulted in biologically relevant plasma C(ss) values and an acceptable toxicity profile. Although exploratory studies of MMPs in plasma were not revealing, it is conceivable that some tumor types and disease settings are more likely to produce more readily quantifiable levels of activated MMPs than others. Therefore, attempts to identify and quantify surrogate markers of MMP inhibitory effects should continue to be performed in disease-directed studies in more homogenous patient populations.

Management of complex breast cysts

OBJECTIVE

This study was undertaken to evaluate the various strategies currently in use to manage complex cysts and specifically address the need for intervention.

MATERIALS AND METHODS

A review of 4562 breast sonograms obtained during an 18-month period revealed 308 complex cysts in 252 women. Data collected from review of patient records included the patient's age and risk factors for breast cancer, aspiration or biopsy results (or both), follow-up imaging studies, and management recommendations.

RESULTS

Management recommendations for complex cysts were 1-year follow-up in 13 patients, 6-month follow-up in 148, sonographically guided aspiration in 82, aspiration with possible core biopsy in 62, and excisional biopsy in three. No malignancies were diagnosed in the group treated with follow-up imaging, sonographically guided aspiration, or excisional biopsy. One malignancy, a papilloma with a 3-mm focus of ductal carcinoma in situ, was diagnosed in one of the patients who underwent core biopsy.

CONCLUSION

Of the lesions classified as complex cysts, the malignancy rate was 0.3% (1/308). This malignancy rate is lower than that for lesions classified as probably benign using mammographic criteria (i.e., for lesions classified as category 3 lesions using the Breast Imaging Reporting and Data System). Because the accepted standard practice for management of probably benign lesions is follow-up studies, the low yield of malignancy in this series suggests that complex cysts can be managed with follow-up imaging studies instead of intervention.

Does clearing of axillary lymph nodes contribute to accurate staging of breast carcinoma?

The major prognostic indicator in carcinoma of the breast is the presence of metastases in axillary lymph nodes. However, 25% of patients with negative axilliary nodes by standard pathologic techniques are dead of metastatic breast carcinoma within 10 years. "Clearing" of the axillary fat has been shown to increase the yield of lymph nodes. Forty-two pathologic Stage I and II breast carcinoma specimens were cleared following routine pathologic examination to determine whether stage was changed by the clearing procedure. A total of 857 lymph nodes were recovered from 42 patients by routine techniques. Clearing increased the number of nodes found by 30%, to 1114. In the 31 node-negative patients an additional 178 nodes were identified, increasing the mean number of nodes per patient from 20 to 26. The number of additional nodes found per specimen ranged from 0 to 19. None of the additional nodes identified contained metastases. In the node-positive patients, 79 additional nodes were found by clearing, including 33 with metastases. No change in stage resulted, although the mean number of nodes per patient was increased from 22 to 30. Although an occasional positive lymph node may be overlooked by manual dissection, the rarity of this event makes routine clearing of the axillary contents impractical for carcinoma of the breast except in a research setting. Whether this conclusion applies equally to other tumors and other lymph node groups requires further study.

Clinical highlights from the National Cancer Data Base, 2000

The National Cancer Data Base (NCDB) is the empirical data collection and analysis arm of the American College of Surgeons Commission on Cancer, and is supported in part by the American Cancer Society. The NCDB collects oncology patient demographic information, diagnostic and treatment information, and outcomes data from a broad spectrum of hospital-based cancer registries throughout the US, ranging from large research and teaching facilities to small community hospitals. Through this unique network, data are aggregated and reported back to participating hospitals to allow individual facilities to evaluate local patient care practices and outcomes. This article highlights the principal findings of articles published in 1999 and early 2000 that used NCDB data as the empirical basis of their analyses. Included among these are articles on breast cancer, gastric carcinoma, head and neck cancers, leukemia, liver carcinoma, lung cancer, parathyroid tumors, prostate carcinoma, small bowel adenocarcinoma, testicular malignancies, and vulvar melanoma. These articles are based on cases diagnosed between 1985 and 1996. The NCDB has accrued more than 6.4 million cancer cases for this time period. Sufficient numbers of rare cancers are reported to the NCDB to permit some types of clinical evaluation not possible using other data sources.