Telomerase activity of sarcoma cell lines and fibroblasts is independent of p53 status

Telomerase activity is necessary for the stabilization of telomeres, which function to overcome cellular senescence and are linked to unlimited cell proliferation. Activation of telomerase is characteristic of immortalized cell lines and most tumors. The p53 gene has been implicated as a crucial barrier to unlimited cell proliferation, and its absence has been shown to allow direct immortalization of cells by certain oncogenes. The p53 gene may have an additional function of signaling cell growth arrest in response to telomere shortening, which occurs with repeated cellular divisions and ultimately threatens chromosomal stability. This prompted us to consider whether the enzyme telomerase, responsible for adding new telomeres to chromosomal ends, may be affected by the p53 status of normal and malignant cells. We investigated whether a relationship between telomerase and p53 could be demonstrated in a human sarcoma cell line containing a missense p53 mutation and several stable transfectants that express the wild-type p53 gene or a temperature-sensitive mutant of p53. All cell lines had readily detectable telomerase activity regardless of p53 status. In addition, murine fibroblast cell strains established from tissues of p53+/+ and p53-/- (p53 knockout) mice expressed telomerase regardless of the p53 status of their tissue of origin. Levels of telomerase subunit mRNA (hEST2) were comparable among cell lines and tissues with different p53 status. These results imply that p53 status is not associated with telomerase activity per se and that activation of telomerase can occur either in cells completely devoid of p53 or in cells that have functional p53.

Infrequent mutation of the p16/MTS1 gene and overexpression of cyclin-dependent kinase 4 in human primary soft-tissue sarcoma

The pl6INK4a/MTS1 (p16) gene encodes a specific inhibitor of cyclin-dependent kinase (CDK)4 and CDK6. The p16 gene is frequently mutated or deleted in many types of cancer cell lines as well as in certain types of primary tumors. p16 knockout mice are viable but predisposed to sarcoma and B-cell lymphoma. To investigate the role of p16 in human soft-tissue sarcoma tumor progression, we examined the p16 gene by Southern blot analysis and PCR sequencing in 30 pairs of primary soft-tissue sarcomas and autologous normal tissue. Only one tumor sample showed possible rearrangement of the p16 gene. In contrast, Western blot analysis of the p16 protein in 20 pairs of samples showed decreased p16 expression in only 20% of the tumors but elevated p16 expression in 40% of the tumors when compared with the autologous normal controls. Overexpression of p16 was not concomitant with loss of the RB protein as is found in several other types of cancers, because more than one-half of the tumors with increased p16 expression also had high levels of RB protein. On the other hand, the p16 target protein CDK4 was overexpressed in at least 60% of the tumors. In the majority of cases, CDK4 overexpression accompanied elevated p16 and/or RB levels. Our results suggest that: (a) alteration of the p16 gene is infrequent in primary soft-tissue sarcoma; (b) Cdk4 may act as an oncogene in soft-tissue sarcoma; and (c) elevated p16 and RB levels might be the result of compensatory up-regulation of these proteins to counteract CDK4 overexpression in these tumors. Our results also suggest that it is more informative to examine aberrations in the "p16-CDK4/cyclin D-RB" pathway than to selectively examine individual components in this pathway when investigating genetic changes involved in human malignancy.

Epidermal growth factor receptor and insulin-like growth factor-I receptor expression and function in human soft-tissue sarcoma cells

Epidermal growth factor (EGF) and insulin-like growth factor-I (IGF-I) receptors are implicated in the development and progression of several malignancies including osteogenic and soft tissue sarcomas (STS). To determine a role for ligand-mediated receptor activation in sarcoma progression, the relative expression and function of EGF-R, IGF-I-R, and several other molecular determinants implicated in the progression of mesenchymal neoplasms were evaluated in human sarcoma cells established from surgical specimens of primary and metastatic tumors. mRNA blot analyses demonstrated the expression of c-Met, p53, and MDM2-specific transcripts. Western blot analyses confirmed the production of high levels of p53 protein; however, minimal levels of MDM2 and c-Met proteins were detected. Analysis of STS cells #23, #26, and #50 originating from an unclassified sarcoma lung metastasis, a malignant fibrous histiocytoma lung metastasis, and a dedifferentiated chondrosarcoma, respectively demonstrated high steady-state levels of EGF-R and IGF-I-R mRNA transcripts and protein correlating with receptor-specific tyrosine kinase activity and autophosphorylation in response to ligand. Treatment of these STS cells with EGF resulted in a >5 fold increase in DNA synthesis and mitogenesis compared with untreated controls. In contrast, treatment with IGF-I showed a variable STS growth response correlating with the origin of the tumor. These data support the involvement of EGF-R and IGF-I-R in the growth and metastasis of human soft tissue sarcoma and may offer new targets for therapeutic intervention in the management of this disease.

Preoperative chemotherapy for stage IIIB extremity soft tissue sarcoma: long-term results from a single institution

PURPOSE

To review a single institution's long-term results with doxorubicin-based preoperative chemotherapy for American Joint Committee on Cancer (AJCC) stage IIIB extremity soft tissue sarcoma (STS).

PATIENTS AND METHODS

The records of all patients with AJCC stage IIIB extremity STS treated with preoperative chemotherapy between 1986 and 1990 at The University of Texas M.D. Anderson Cancer Center were reviewed to assess rates of response, local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS).

RESULTS

Seventy-six patients with stage IIIB disease received preoperative chemotherapy. The median sarcoma size was 10 cm. Seventy-two patients (95%) had tumors located deep to the muscular fascia. Most patients received a median of three preoperative cycles of doxorubicin and dacarbazine (ADIC), cyclophosphamide and ADIC (CyADIC), or other doxorubicin-based regimens. Radiographic response rates were as follows: complete response (CR), 9%; partial response (PR), 19%; minor response, 13%; stable disease, 30%; and progression, 30%. The overall objective major response rate (CRs plus PRs) was 27%. At a median follow-up time of 85 months, 5-year actuarial rates of LRFS, DMFS, DFS, and OS with 95% confidence intervals (CIs) were 83% (CI, 73% to 94%), 52% (CI, 41% to 66%), 46% (CI, 35% to 60%), and 59% (CI, 48% to 72%), respectively. Comparison of responding patients (CRs plus PRs) and nonresponding patients did not show any significant differences in LRFS, DMFS, DFS, or OS.

CONCLUSION

Preoperative doxorubicin-based chemotherapy was associated with response, DFS, and OS rates similar to those observed in randomized postoperative chemotherapy trials. Responding patients had rates of LRFS, DMFS, DFS, and OS comparable to those of nonresponders.

Lower extremity salvage after radical resection of malignant tumors in the groin and lower abdominal wall

BACKGROUND

Resection of a large malignant tumor in the groin often leaves a substantial soft-tissue defect that makes wound closure difficult. Nevertheless, palliation and lower extremity salvage is frequently possible if the tumor is widely excised and the wound closed with well-vascularized tissue; however, few data are available on patients undergoing such procedures.

STUDY DESIGN

We retrospectively examined our experience with limb salvage in 25 patients undergoing radical groin resection for metastatic or recurrent malignant tumors between April 1, 1991 and April 8, 1996.

RESULTS

Defect size ranged from 15 to 735 cm2 (mean, 238.5 cm2). Tumor resection included part of the abdominal wall in 14 patients and the femoral vessels in 5 patients. Defects were most commonly repaired with a vertical rectus abdominis myocutaneous flap (56%). Mean hospital stay was 10.4 days, and mean followup was 15.5 months. Although the complication rate was 68%, the limb salvage rate was 100%, and normal ambulation was achieved in 88% of patients. The most frequent complications were chronic lymphedema (42%) and seroma (29%). There was one perioperative death (4%).

CONCLUSIONS

Functional limb salvage after radical resection of the groin and lower abdominal wall is very successful, has an acceptable morbidity rate, does not prolong hospital stay, and contributes significantly to the patient's quality of life. Chronic lymphedema is a frequent complication after this treatment but can be managed successfully with conservative techniques.

Role of splenectomy in chronic lymphocytic leukemia

BACKGROUND

The benefit of splenectomy, performed for complications of chronic lymphocytic leukemia (CLL) including autoimmune hemolytic anemia, thrombocytopenia, hypersplenism, and symptomatic splenomegaly, has not been clearly demonstrated. The objective of this study was to determine if splenectomy achieves a predictable hematologic and survival advantage over conventional chemotherapy in patients with CLL.

STUDY DESIGN

A retrospective review was performed of 77 consecutive patients with CLL who underwent splenectomy between 1970 and 1994 at the University of Texas M. D. Anderson Cancer Center. Indications for splenectomy, pre- and postoperative hematologic profiles, response to splenectomy, and time to progression and death were recorded. Kaplan-Meier life tables were constructed, and a comparison to an age- and gender-matched cohort of CLL patients treated with fludarabine and no splenectomy was performed using log rank statistical analysis.

RESULTS

Seventy-six percent of the patients studied were Rai stage III/IV. Twenty of 29 patients with hemoglobin counts (Hb) < or = 10 g/dL and 11 of 18 patients with platelet counts (plt) < 50 x 10(9)/L achieved an excellent hematologic response to splenectomy. Splenectomy significantly improved survival in patients with Hb < or = 10 g/dL or plt < or = 50 x 10(9)/L (p = 0.025). Thrombocytopenia did not significantly increase postoperative morbidity, and mortality rate was not significantly different between treatment groups.

CONCLUSIONS

Splenectomy significantly improves survival in selected subgroups of patients with advanced-stage CLL over that achieved with conventional chemotherapy. Based on these results, splenectomy should be performed early in the course of the disease in CLL patients with either an Hb < or = 10 g/dL or plt < or = 50 x 10(9)/L.

Purification and characterization of human lung fibroblast motility-stimulating factor for human soft tissue sarcoma cells: identification as an NH2-terminal fragment of human fibronectin

Paracrine motogenic factors, including motility cytokines and extracellular matrix molecules secreted by normal cells, can stimulate metastatic cell invasion. Both intact extracellular matrix molecules and their degradative products may exhibit these activities. We have found that human lung fibroblasts produce paracrine motility-stimulating factors for recently established human sarcoma cell strains. We purified the major fibroblast motility-stimulating factor (FMSF) from human lung fibroblast-conditioned medium by sequential heparin affinity chromatography and DEAE anion exchange chromatography. Lysylendopeptidase C digestion of FMSF and sequencing of peptides purified by reverse-phase high-pressure liquid chromatography identified FMSF as an NH2-terminal fragment of human fibronectin. Using SYN-1 sarcoma cells, FMSF predominantly stimulated chemotaxis and some chemokinesis, and it was chemotactic for a variety of human sarcoma cells, including fibrosarcoma, leiomyosarcoma, liposarcoma, synovial sarcoma, and neurofibrosarcoma cells. The FMSF activity present in human lung fibroblast-conditioned medium was completely eliminated by either neutralization or immunodepletion with a rabbit antihuman-fibronectin antibody, thus further confirming that the NH2-terminal fibronectin fragment was the FMSF responsible for the motility stimulation of human soft tissue sarcoma cells. Because human soft tissue sarcomas have a distinctive hematogenous metastatic pattern (predominantly lung), and lung-derived fibroblasts secrete large amounts of FMSF, FMSF and fibronectin may play a role in stimulating sarcoma invasion into lung tissue.

Splenectomy in the accelerated or blastic phase of chronic myelogenous leukemia: a single-institution, 25-year experience

BACKGROUND

Patients in the accelerated or blastic phases of chronic myelogenous leukemia (CML) often have painful splenomegaly and secondary thrombocytopenia. We tested the hypothesis that splenectomy can be performed with minimal complications in advanced CML, thereby alleviating pain, reversing thrombocytopenia, and minimizing transfusion requirements.

METHODS

We reviewed the records of 53 patients in the accelerated or blastic phases of CML who underwent splenectomy between 1970 and 1995 at the U. T. M. D. Anderson Cancer Center.

RESULTS

Twenty-eight patients were in accelerated phase and 25 in blastic phase at the time of splenectomy. The most common indications for splenectomy were symptomatic splenomegaly (median splenic weight, 1000 gm; range, 120 to 6700 gm) or thrombocytopenia (platelet count less than 100,000/microliter) or both. There was 1 death within 30 days of splenectomy. The preoperative platelet count increased 3.72-fold +/- 0.53-fold (mean +/- SEM) by postoperative day 7 (p < 0.001; paired t test). Patients with transfusion-dependent thrombocytopenia had significantly fewer platelet and red blood cell transfusions in the 6 months after splenectomy than in the 6 months before splenectomy (p = 0.016; sign test).

CONCLUSIONS

Splenectomy can be performed with minimal morbidity and mortality in advanced CML, thereby relieving symptomatic splenomegaly, reversing thrombocytopenia, and minimizing transfusion requirements.

Case/control study of the role of splenectomy in chronic lymphocytic leukemia

PURPOSE

This retrospective analysis was performed to evaluate critically the morbidity and mortality of splenectomy in patients with chronic lymphocytic leukemia and to determine the probability of hematologic response. Further, using a case/control format based on multivariate analysis-derived predictors of survival, we evaluated the influence of splenectomy on survival.

PATIENTS AND METHODS

Between 1971 and 1993, 55 patients with chronic lymphocytic leukemia underwent splenectomy. They were compared with 55 fludarabine-treated patients who had been matched for age, serum albumin level, sex, hemoglobin level, Rai stage, number of prior therapies, and time from diagnosis.

RESULTS

In the perioperative period, blood-product usage was modest, and common morbidities were limited to minor infections in 18% of the patients and pneumonia/atelectasis in 25%. Perioperative mortality was 9%. Deaths were related to septic complications in all cases and associated with a preoperative performance status > or = 2 (P = .05). The only predictor identified for hemoglobin and neutrophil increments was spleen weight (P < .05). No factors predictive of platelet increment were identified. The early death rate (within 30 days) and overall survival of splenectomy and control patients were not significantly different (P > .2). Among Rai stage IV patients, those who were splenectomized displayed a strong trend for improved overall survival (P = .15 by log-rank test). The 2-year actuarial survival rate of Rai stage IV patients was 51% +/- 9% in the splenectomy group and 28% +/- 9% in the control group.

CONCLUSION

Splenectomy can be performed with modest morbidity, mortality, and resource utilization in patients with advanced chronic lymphocytic leukemia and significant cytopenias. The procedure results in major hematologic benefits in most patients, with hemoglobin and neutrophil increments correlated with spleen weight. Overall, the survival of splenectomized patients is equivalent to control patients. Thrombocytopenic patients (< 100 x 10(9)/L) are most likely to obtain hematologic benefit, and potentially enjoy improved survival. These patients would be suitable for a randomized study to establish definitively the role of splenectomy in chronic lymphocytic leukemia.

The National Cancer Data Base report on soft tissue sarcoma

BACKGROUND

Discernible improvements have taken place in soft tissue sarcoma patient survivorship and quality of life over the past 20 years, with overall 5-year survival currently at approximately 50%. Shifts in treatment have taken place over the past decade, from single-modality treatment involving radical surgery to sophisticated limb-salvage strategies combined with radiation therapy and protocol-administered chemotherapy.

METHODS

To identify patterns of treatment and outcome, all soft tissue sarcoma cases diagnosed in 1988 and 1993 as recorded in the National Cancer Data Base were analyzed on the basis of histology and anatomic site.

RESULTS

There was an increase in sarcomas originating in the pleura with a concurrent increase in mesotheliomas. A shift toward more advanced disease was also noted. Limb-sparing surgical procedures are now standard. However, it appears from stage subset analysis that many Stage II and III patients are undertreated due to lack of multimodality therapy usage.

CONCLUSIONS

Use of pretreatment multimodality planning conferences will increase the likelihood that stage-appropriate combinations of surgery, radiation therapy, and chemotherapy will be used. In turn, election of multimodality approaches should increase the possibility of improved overall and disease free survival in the future.

Malignant fibrous histiocytoma in children

Because malignant fibrous histiocytoma (MFH) rarely occurs in children, the natural history of this tumor and prognostic factors predictive of outcome have not been well described. The charts of all pediatric patients with MFH seen at M.D. Anderson Cancer Center were reviewed with respect presentation, treatment, and outcome, in an attempt to determine prognostic factors that are predictive of survival. Forty-four pediatric patients were identified. Extremities were the most common tumor site (31 of 44 patients). Five patients presented with angiomatoid histology subtype; all subsequently survived. The estimated 5-year survival rate was 85% for clinical group I patients, 87% for clinical group II, 53% for clinical group III, and 0% for clinical group IV. The estimated 5-year survival rate was 95% for patients with tumors of less than 5 cm in diameter and 45% for those with larger tumors. Overall, the estimated 5-year survival rate was 71%. Significant prognostic factors found to affect survival (by univariate analysis) were clinical group, tumor size, and recurrence. Gender and race were not significant predictors. The use of chemotherapy and radiation was not found to improve the chance of survival, but this most likely reflected the more frequent use of adjuvant therapy in patients with unresectable or high-grade tumors. Although adequate surgical resection continues to be the most effective treatment, investigation of adjuvant chemotherapy and radiation therapy on protocol is warranted.

Soft tissue sarcoma metastasis from clonal expansion of p53 mutated tumor cells

Although soft tissue sarcoma has a high incidence of p53 mutations, it is not clear if such alterations facilitate tumor growth and metastasis. In this study, fresh autologous normal lymphocytes, normal muscle, primary and metastatic sarcoma tissues from a single synovial sarcoma patient were examined for p53-related alterations that potentially associated with sarcoma tumor development and metastasis. Normal tissues contain two wild-type p53 alleles. Primary sarcoma had one chromosome 17p p53 allelic deletion without apparent p53 mutation in the other allele. However, metastatic tumor had deletion of one p53 allele with an exon 5 codon 135 missense mutation in the other allele. This p53 gene point mutation in the metastasis was associated with the production of mutated p53 protein. A small clone of cells harboring the identical p53 gene point mutation was identified in the primary tumor using mutant allele specific PCR amplification, albeit at levels much less than in the metastatic sarcoma. This single patient example indicate that soft tissue sarcoma metastasis can develop from clonal expansion of primary tumor cells bearing p53 mutations.

Expression of 72 kDa and 92 kDa type IV collagenases from human giant-cell tumor of bone

Basement membrane forms widespread barriers to tumor invasion. It has been shown that tumor-secreted, basement membrane-degrading enzymes, namely metalloproteinases (MMPs) play an important role in tumor invasion and metastasis. In this study, we determined the enzymatic activity, content, and mRNA of both the 72 kDa (MMP-2) and 92 kDa (MMP-9) MMPs in primary cultures of human giant-cell tumor of bone (GCT) in vitro and in tissue extracts (in vivo). Gelatin zymography showed the presence of lytic bands at M(r) 121,000, 92,000, and 72,000, and these enzymatic activities were inhibited by EDTA, an inhibitor of MMPs. Western blots with antibodies specific for MMP-2 and MMP-9 confirmed the presence of MMP-2 and MMP-9 both in vitro and in vivo, but GCT cells at late passage showed only MMP-2. Northern blots using labeled cDNA probes specific for these molecules revealed the presence of 3.1 kb transcript for MMP-2 and a 2.9 kb transcript for MMP-9. Using specific antibodies to 72 kDa and 92 kDa type IV collagenases, we studied their cellular distribution by immunohistochemical means. Stronger immunoreactivity was found for 92 kDa type IV collagenase than 72 kDa type IV collagenase in the giant cells. It appears, therefore, that MMP-9 may play an important role in the malignant behavior of GCTs and suggests a potential therapeutic role for protease inhibitors in attempting to minimize the invasive behavior of GCTs.

Soft-tissue sarcomas of the shoulder girdle: factors influencing local recurrence distant metastases, and survival

BACKGROUND

Prognostic factors and the role of radiotherapy have not been well characterized for soft-tissue sarcomas (STS) of the shoulder girdle.

METHODS

The cases of 70 patients with primary shoulder STS were reviewed for the following information: size, grade and histology of tumors, extent of resection, and use of adjuvant radiotherapy. The influence of these factors on local disease-free survival (LDFS), distant disease-free survival (DDFS), and overall survival (OS) rates was analyzed using univariate analysis.

RESULTS

With a median follow-up of 108 months, the overall 5- and 10-year survival rates for patients with shoulder girdle STS were 82% and 80%, respectively, whereas the 5-year disease-free survival rate was 63%. There were 25 (35%) tumor recurrences: 12 (17%) distant and 13 (18%) local regional. Tumors > 5 cm in size were associated with a significantly decreased 5-year OS rate compared with lesions < 5 cm, and high-grade tumors were associated with significantly decreased DDFS and OS rates. Because most of the patients who underwent amputation had large, high-grade tumors, they had significantly decreased 5-year DDFS and OS rates compared with wide local excision. Radiotherapy produced a significant improvement in LDFS rates, particularly in patients with tumors > 5 cm in size.

CONCLUSIONS

The results indicate that both tumor size and grade are important prognostic factors in shoulder girdle STS. Adjuvant radiotherapy should be considered in large tumors to improve the LDFS and to decrease the need for radical ablative surgery.

Soft-tissue sarcoma of the extremities. MR appearance of post-treatment changes and local recurrences

MR imaging has the potential to provide valuable insights into intratumoral changes following preoperative therapy and has proven beneficial in the diagnosis of recurrent soft-tissue sarcoma of the extremities and differentiation of recurrence from postsurgical/postradiation changes. As advances occur in surgical and adjuvant treatment programs, further refinements of qualitative and quantitative MR imaging parameters should continue to enhance the role of MR imaging in the post-treatment evaluation of patients with soft-tissue sarcoma of the extremities.

Human peri-tumoral and lung fibroblasts produce paracrine motility factors for recently established human sarcoma cell strains

Paracrine motogenic cytokines secreted by normal cells can stimulate metastatic cell invasion. For example, human fibroblasts secrete hepatocyte growth factor/scatter factor (HGF/SF), which stimulates paracrine migration of epithelial and certain carcinoma cells, and migration-stimulating factor (MSF), which stimulates autocrine migration of fibroblasts from certain breast carcinomas. We found that human peri-tumoral and lung fibroblasts secrete motility-stimulating activity for several recently established human sarcoma cell strains. Motility of lung metastasis-derived SYN-I sarcoma cells was preferentially stimulated by human lung and peri-tumoral fibroblast motility-stimulating factors (FMSFs). FMSFs were non-dialyzable, susceptible to trypsin and sensitive to dithiothreitol. Cycloheximide inhibited accumulation of FMSF activity in conditioned medium; however, addition of cycloheximide to the migration assay did not significantly affect motility-stimulating activity. Purified HGF/SF, rabbit anti-hHGF and RT-PCR analysis of peri-tumoral and lung fibroblast HGF/SF mRNA expression indicated that FMSF activity was unrelated to HGF/SF. Partial purification of FMSF by gel exclusion chromatography revealed several peaks of activity, suggesting multiple FMSF molecules or complexes. Since human soft tissue sarcomas have a distinctive hematogenous metastatic pattern (predominantly lung), FMSF may play a role in this process independent of HGF/SF.

Surgical management of primary soft tissue sarcoma

Few areas in oncology more clearly illustrate the need for multidisciplinary management than the soft tissue sarcoma problem. Using this approach has led to limb preservation with survival results at least equivalent to those for amputations. This achievement has dramatically improved the quality of life and overall clinical outcome for patients with this disease. In the future, improved understanding of the biology of this disease may broaden our therapeutic options. Meanwhile, a detailed understanding of the surgical possibilities will enhance the multimodality care that can be offered by the teams of clinicians managing patients suffering from this disease.

Myofibroblastoma of the axilla

A mass in the axilla of a 47-year-old woman was biopsied and resected. The mass was composed of a loosely distributed population of spindle cells that were immunoreactive for smooth-muscle actin. Ultrastructurally, the cells possessed abundant endoplasmic reticulum, and some contained peripheral smooth muscle myofilaments, establishing that they were myofibroblasts. Mitotic activity was sparse, there was no cytologic atypia, and by flow cytometry the tumor was diploid with a low S phase. A diagnosis of myofibroblastoma was favored, although the possibility of a low-grade sarcoma could not be excluded. There has not been any indication of recurrence over a 4-month period of follow-up.

Vascular access by physician assistants: evaluation of an implantable peripheral port system in cancer patients

PURPOSE

To determine the ability of a physician assistant (PA) to insert, in an ambulatory setting, a peripheral subcutaneous implanted vascular-access device (VAD) and to evaluate the ability to transfer this training to a second PA. We also evaluated the performance and complications associated with this new device.

PATIENTS AND METHODS

The Peripheral Access System (PAS) Port catheter system (Sims-Deltec Inc, St Paul, MN) was inserted in patients who required long-term (> 3 months) vascular access for infusion therapy.

RESULTS

The first PA (PA-1) successfully inserted 57 of 62 devices (92%) after gaining experience with the technique in 10 patients (success rate, five of 10 [50%]; P = .003). The second PA (PA-2) was successful in eight of 10 initial attempts (80%) and 25 of 30 overall (83%). Complications were few and limited to phlebitis, thrombosis, and a low infection rate (0.2 per 1,000 catheter days).

CONCLUSION

PAs can be taught to insert a peripheral subcutaneous implanted VAD. This technique is transferable from one PA to another, and the device studied is appropriate for outpatient VAD programs.

Ethics of research training for NIH T32 surgical investigators

As part of the revised curriculum of the NIH T32 Training Grant mechanism, 6 hr of formal instruction in ethics of research are now required. We therefore implemented a four-session seminar (6 hr total time) structured around assigned readings, didactic presentations, and group discussions. The objective of this research project was to assess whether this new program provided our trainees with a framework for ethical conduct in research. Twelve trainees completed the ethics course; 8 trainees who had not yet taken the ethics course served as a control group. All trainees answered a 72-item questionnaire of our own design that examined a variety of issues in research ethics. We compared the responses of seminar participant and nonparticipant groups using the Fisher exact test and Student t test for nominal and ordinal data, respectively. Both groups of trainees perceived that too much emphasis was placed on quantity rather than quality of publications. Both groups felt that this pressure emanated from department chairmen rather than laboratory mentors (P < 0.0001). In contrast to these shared perceptions, the two groups demonstrated many differences in their comprehension of research ethics. For example, compared to the controls, trainees who participated in the ethics course believed that they could define potential NIH standards for data storage and research mentorship (P < 0.05), understood gratuitous manuscript authorship (P < 0.05), were comfortable in dealing with outlier or discordant data (P < 0.10), and, most pertinently, were fully prepared to seek third-party input into an ethical dilemma involving their own work (P < 0.006).(ABSTRACT TRUNCATED AT 250 WORDS)

Biologic distinctions and therapeutic implications of sarcomatoid metaplasia of epithelial carcinoma of the breast

BACKGROUND

Malignant sarcomatoid metaplasia of epithelial carcinoma of the breast (carcinosarcoma) is diagnosed at an annual rate of two cases per 107 women in the United States of America. It seems that these tumors behave differently than other carcinomas or sarcomas of the breast.

STUDY DESIGN

The University of Texas M. D. Anderson Cancer Center experience (1947 to 1991) treating 50 patients (mean age of 50 years, range of 25 to 76 years) was retrospectively reviewed. The five-year overall survival and disease-free survival rates were compared and prognostic factors were identified.

RESULTS

The overall survival rate of 43 percent was lower than had been expected for carcinoma of the breast. No patient with stage IV disease survived five years. Tumor size and stage at diagnosis had the strongest impact on outcome. The impact of axillary lymph node status on prognosis was less than expected. Hormonal receptor levels were positive in only 12.5 percent of the tumors tested. Mastectomy with adjuvant chemotherapy or radiotherapy, or both, was superior to mastectomy alone and to wide local excision with or without adjuvant therapy, particularly for patients with stage II disease. If complete surgical resection is possible, the surgical approach for treatment of recurrent disease is better than any other modality.

CONCLUSIONS

Carcinosarcoma behave biologically differently than conventional carcinoma of the breast in that sarcomatoid characteristics dominate the clinical course. These biologic distinctions should direct the treatment toward a multimodality approach that includes mastectomy and sarcoma-oriented adjuvant chemotherapy and radiotherapy.