Combination chemoendocrine therapy containing vindesine for refractory metastatic breast cancer

Metastatic breast cancer has ultimately failed to respond to the multiple prior therapies, and thus new therapeutic regimens are required. Nine patients with metastatic breast cancer previously treated with multiple therapeutic regimens were enrolled. The treatment schedule was as follows: vindesine was given intravenously at a dose of 2 mg/m(2) every four weeks. Etoposide and medroxyprogesterone acetate was orally administered at a dose of 25 mg/day for 14 consecutive days and 600 mg/day every day. Only one patient with exclusive bone metastasis showed partial response and the objective response rate for the combination of agents was 11%. Pain derived from the metastatic lesions was reduced in four (80%) among five patients with bone metastasis. For patients with refractory breast cancer, especially with bone metastasis, chemoendocrine therapy containing vindesine might have therapeutic efficacy with low toxicity and favorable quality of life.

HLA antigen as predictive index for the outcome of breast cancer patients with adjuvant immunochemotherapy with PSK

We demonstrated that the prognosis of breast cancer patients who received adjuvant immunochemotherapy with Krestin (PSK) showed a tendency to be better than that of breast cancer patients receiving chemotherapy only. We retrospectively investigated the usefulness of HLA typing for selecting patients to receive adjuvant immuno-chemotherapy with PSK. One hundred and thirty-four patients with operable breast cancer were typed as HLA-A, -B, -C by a lymphocytotoxicity test. Patients without vascular invasion had no adjuvant therapy (NA group). Patients with vascular invasion in the tumor and/or in the metastatic lymph node were randomized into two groups. In group 1 (FEMP only), a combination chemotherapy of 100 mg of 5-fluorouracil (F), 50 mg of cyclophosphamide (E), 2 mg of mitomycin C (M), and 5 mg of predonisolone (P) was orally administered daily for 28 days (one course). In group 2 (FEMP+PSK), FEMP and 3.0 g of PSK were orally administered for 28 days (one course). Two courses a year of these agents were given for five years in both groups. Each group (NA, FEMP, FEMP+PSK) was stratified by the presence of HLA B40 type (B40(+)) or not (B40(-)). Five- and 10-year disease-free survival (DFS) rates (93%, 80%, respectively) of patients with B40(+) seemed to be better than those (83% and 51%) of patients with B40(-). In the NA group, 5- and 10-year DFS were 100% and 71% in patients with B40(+), 92% and 76% in those with B40(-), respectively. In the FEMP group (chemotherapy only), 5- and 10-year DFS of patients with B40(+) were both 84%. These were not statistically significant compared with those (82% and 33%) of patients with B40(-). On the other hand, in the FEMP+PSK group, 5- and 10-year DFS of patients with B40(+) were both 100%, and those of patients with B40(-) were 76% and 55%, respectively. DFS of patients with B40(+) was significantly better than that of patients with B40(-). It is concluded that HLA typing may be a predictive index in determining the use of immunochemotherapy combined with PSK for patients with operable breast cancer.

Spindle cell carcinoma of the breast

Spindle cell carcinoma is a rare breast tumor. We present herein three cases of spindle cell carcinoma of the breast and review its characteristics from the literature. Spindle cell carcinoma frequently forms a large and well-circumscribed tumor with gross cyst formation. Histologically, its dominant component is of sheets of spindle shaped cells, and it includes such contiguous carcinoma components as squamous differentiation or invasive ductal carcinoma. Estrogen receptor expression and lymph node metastasis tend to be low. Despite the sarcomatous features, spindle cells are likely to be derived from epithelial cells of mammary glands. Immunohistochemical and ultrastructural examination demonstrated the expression of keratin and the desmosome-like junctional structure in the spindle cell components. Relatively favorable prognosis is expected in spindle cell carcinoma of the breast compared to common breast carcinoma.

Changes of cytokines and thyroid function in patients with recurrent breast cancer

The hypothyroid state or nonthyroidal illness is often observed in patients with recurrent cancer. High levels of cytokines are frequently observed in critically ill patients. Recent studies have shown that interleukin (IL)-6 may be a cause of nonthyroidal illness. We reported the relationship between thyroid function and the prognosis of the patients with recurrent breast cancer. In this study, we measured the serum level of cytokines (IL-2, IL-6, IL-8) and thyroid function (free T3, free T4, and thyrotropin (TSH)) in 38 patients with recurrent breast cancer. All patients had received three or more different courses of therapy before they were entered the study. The patients were divided into three groups according to their response to therapy. There were 16 partial response (PR), 10 no change (NC) and 11 progressive disease (PD) patients. They did not receive any medication that influenced the thyroid hormone level other than medication for cancer. The IL-2 level was under the detectable limit in all groups. No abnormal levels of cytokines were observed in the PR group. IL-6 and IL-8 levels in the PD group were significantly higher than that in the NC group (p < 0.05). Significant negative correlation was observed between IL-6 and thyroid hormones (free T3, free T4). Patients whose IL-6 level was 20 pg/ml or more died within four months after the beginning of the treatment. We concluded that IL-6 may lead to a hypothyroid state in patients with recurrent breast cancer. A high level of IL-6 and IL-8 means the confusion of the defense system in hosts. Therefore, these cytokines will be predictive indicators of the therapeutic response and the prognosis of the patients with recurrent breast cancer.

Low and high molecular weight cytokeratins in invasive breast carcinoma

Low molecular weight cytokeratin (LCK) and high molecular weight cytokeratin (HCK) were analyzed by immunohistochemistry using two monoclonal antibodies in 90 patients with operable invasive breast carcinoma (IBC). Fifty-nine (65.6%) of 90 tumors were LCK-positive, and 19 (21.1%) were HCK-positive. The incidence of LCK positivity was inversely correlated with nuclear or histological grade, however, the incidence of HCK positivity was positively correlated. The positive correlation of the incidence of LCK positivity with estrogen receptor (ER) status was observed, however, the inverse correlation was found between the incidence of HCK positivity and ER status. The mean of ER content (101.9 fmol/mg protein) in LCK-positive tumors was significantly higher than that (20.8 fmol/mg protein) in LCK-negative tumors. To the contrary, the mean of ER content (10.1 fmol/mg protein) in HCK-positive tumors was significantly lower than that (91.3 fmol/mg protein) in HCK-negative tumors. Overall survival (OS) and relapse-free survival (RFS) of patients with LCK-positive tumors tended to be better than those of patients with LCK-negative tumors. No difference was demonstrated between OS and RFS of patients with HCK-positive tumors and those of patients with HCK-negative tumors. LCK-positive IBC can be well differentiated and HCK-positive IBC poorly differentiated. The immunohistochemical analysis for LCK and HCK can be utilized to evaluate the differentiation of IBC. Furthermore, LCK immunoreactivity might be one of the prognostic factors of IBC, and HCK immunoreactivity could be useful for the histological diagnosis for carcinoma with metaplasia, such as squamous cell or spindle cell carcinoma.

Breast conserving surgery with nipple resection

Breast conserving surgery with nipple resection was carried out on 4 patients with early breast cancer because location of each tumor was very close to nipple. These consisted of 3 patients with state I invasive ductal carcinoma and 1 patient with stage II invasive ductal carcinoma. Cancer cells were not recognized histopathologically in the resection margins of each case and all cases underwent a curative resection with axillary dissection (up to level III). The rested areola in each case was made to be round-shaped by skin suture and the edge of the wound located in the center of areola looked like a small nipple. The cosmetic result of this operation were excellent in all patients. This operation may be effective both for these patients with early breast cancer locating under the nipple or areola and for those whose tumor was very close to nipple.

Multidisciplinary treatment with anthracyclines in inflammatory breast cancer

Twenty-two patients with inflammatory breast cancer treated between 1962 and 1994 were analyzed. Before the introduction of multidisciplinary treatment with anthracycline agents between 1962 and 1981, 11 patients out of 14 were resected, however, a curative operation was performed for only 3 of these patients (29.3%). Ablative endocrine therapy, intraarterial infusion of anticancer drugs (mitomycin C or 5-fluorouracil), and radiation were carried out as the preoperative induction therapy for inflammatory breast cancer. All 14 patients died within 36 months. After the introduction of multi-disciplinary treatment with anthracycline agents between 1981 and 1994, preoperative induction chemotherapy or chemoendocrine therapy using anthracyclines was carried out on 7 out of 8 patients and the remaining patient received radiation. Of the former 7 patients, 6 (85.7%) underwent a curative operation. There was approximately a 35 percent cumulative survival rate observed 60 months after operation, and 3 patients out of the 7 lived for more than 5 years. To conclude, multidisciplinary treatment including systemic induction chemotherapy with anthracyclines was an effective treatment for inflammatory breast cancer.

Relationship between thyroid-pituitary function and response to therapy in patients with recurrent breast cancer

In this study, thyroid (T3, T4, free T3, free T4) and pituitary function (thyrotropin (TSH), growth hormone (GH), prolactin (PRL)) in 38 patients with recurrent breast cancer were examined. The patients were divided into three groups according to their response to the therapy. There were 16 partial response (PR), 10 no change (NC) and 11 progressive disease (PD) patients. The maximum and the minimum value for each hormone throughout the course of treatment were compared between three groups. The PD group showed significantly lower minimum T3 levels than the other two groups (p < 0.05). The maximum TSH level in the PD group was significantly higher than that of the other groups. The minimum TSH level in the PD group was significantly lower than that in the PR group (p < 0.05). The minimum TSH level in the NC group was also lower than that in the PR group. The maximum PRL level in the NC and the PD group was higher than that in the PR group (p < 0.05, p < 0.01, respectively). The tumors of the patients with temporal increase of TSH level were resistant to all subsequent therapies. These five patients died within four months followed by decreasing of the TSH level. It is concluded that thyroid and pituitary function, especially free T4, TSH and PRL, are predictive indicators of therapeutic response and the prognosis of the patients with recurrent breast cancer.

Malignant rhabdoid tumor of the breast: a case report

A 66-year-old woman developed a malignant rhabdoid tumor of the breast, with a tumor doubling time of 10 days. One month after radical mastectomy, there was local recurrence, followed by multiple pulmonary metastases, and the patient died of respiratory failure 5 months after surgery. The gray-white-colored tumor measured 13 x 12 x 10 cm, and its border was well defined. The tumor was composed of diffusely growing round or polygonal cells with vesicular nuclei, prominent nucleoli, and ample cytoplasm containing eosinophilic inclusions. Lymph node involvement was widespread. Both vimentin and keratin were clearly demonstrated by immunohistochemical staining. Ultrastructural studies revealed that the MRT cells contained cytoplasmic whorls of intermediate filaments.

Immunochemotherapies versus chemotherapy as adjuvant treatment after curative resection of operable breast cancer

In our previous study, oral adjuvant combination chemotherapy of 5-fluorouracil, cyclophosphamide, mitomycin C, and predonisolone (FEMP) after curative resection of operable breast cancer with vascular invasion in the tumor and/or in the metastatic lymph node was found to be more effective than one course of mitomycin C or cyclic course of mitomycin C. In the present study, we have assessed the efficacy of protein-bound polysaccharide (PSK) or levamisole (LMS) in addition to FEMP. Between January 1980 and December 1990, 227 operable breast cancer patients with vascular invasion in the tumor and/or in the metastatic lymph node were randomized into FEMP, FEMP + LMS, or FEMP + PSK. The risk ratio was lower in the FEMP + PSK group compared to the FEMP group. In disease-free survival or overall survival, there was no significant difference between the three groups, however, the survival curve of the FEMP + PSK group tended to be better than that of the FEMP group(logrank, P = 0.0706; generalized Wilcoxon, P = 0.0739). Side effects were observed at a low incidence, but they were mild and tolerable. Immunochemotherapy using PSK improved the prognosis of patients with operable breast cancer with vascular invasion.

Sudden hemorrhage of the breast caused by breast cancer without skin invasion: report of a case

A rare case of sudden hemorrhage caused by breast cancer is herein presented. A 65-year-old woman was admitted to our hospital because of bleeding from her left breast. On physical examination, a continuous hemorrhage accompanied by an open cavity formation was observed in her left breast. She had no history of breast trauma. Her bleeding profile studies and liver function were both normal. In addition, no anticoagulation medication had been administered. The histological findings of the cavity wall indicated invasive ductal carcinoma without skin invasion. After carrying out chemotherapy, a standard radical mastectomy was performed.

Pneumocystis carinii pneumonia during treatment for recurrent breast cancer: a case report

We describe a case of Pneumocystis carinii pneumonia (PCP) in a woman with recurrent breast cancer without human immunodeficiency virus (HIV) infection. The PCP was associated with severe lymphocytopenia due to treatment with anticancer agents in combination with granulocyte colony-stimulating factor (G-CSF). Despite the severe lymphocytopenia, the total leucocyte count never fell below 3000/mm3 during the treatment. It was difficult to determine whether the patient's respiratory failure was caused by severe infectious pneumonia, hypersensitivity pneumonia or pneumonitis carcinomatosis. She was treated with steroid for suspected drug-induced hypersensitivity pneumonia. However, as her condition did not improve, PCP was suspected, and sulfamethoxazole-trimethoprim was administered. At the same time, anticancer drugs were administered to half the progression of the cancer, since lymphangitis carcinomatosa was also suspected. The severe respiratory failure did not improve, and the patient died on day 23 after admission. At autopsy, the cause of death was confirmed to respiratory failure due to PCP.

Phase II trial of mitoxantrone, doxifluridine and medroxyprogesterone acetate as second-line treatment for anthracycline-resistant metastatic breast cancer

Sixteen patients with anthracycline resistant metastatic breast cancer were treated with a combination of mitoxantrone (MIT), doxifuridine (5'-DFUR) and medroxyprogesterone acetate (MPA). The median dose of anthracyclines was 360 mg (range 20-540 mg). Eligible patients received 7.0 mg/m2 of MIT every four weeks 600 mg of 5'DFUR were given orally every day. Eight (50.0%) out of 16 patients showed partial response. Six (54.5%) out of 11 bone lesions, 4 (80.0%) out of 5 lung lesions and 1 (20.0%) out of 5 soft tissue lesions responded to this treatment. The median response duration was 26 weeks (range 4-52). Hematological and gastrointestinal toxicity were tolerable. Alopecia was not observed. Tachycardia was noted in patients receiving more than 80 mg of MIT; however, digitalis controlled the symptom. The combined treatment with MIT is useful for anthracycline-resistant metastatic breast cancer.

Subcutaneous mastectomy with axillary dissection plus breast reconstruction using latissimus dorsi myocutaneous flap (or latissimus dorsi muscle) for breast cancer

Subcutaneous mastectomy with axillary dissection plus breast reconstruction using latissimus dorsi myocutaneous flap (or latissimus dorsi muscle) was carried out for 8 patients with breast cancer. These consisted of 1 patient with non-invasive ductal carcinoma, 5 with stage I (4 invasive ductal carcinomas and 1 invasive lobular carcinoma) and 2 with stage II (1 invasive ductal carcinoma and 1 invasive lobular carcinoma). Cancer cells were recognized histopathologically in the resection margins of the small mammary gland resting under the nipple in only 1 case, and the remaining 7 cases underwent a curative resection. In the prognosis, 7 patients were disease-free and 1 showed a local recurrence. The patient with local recurrence showed no metastasis after the resection of the local lesion. The cosmetic results of this operation were excellent in all patients. This operation was effective both for these patients with breast cancer who did not want to undergo breast conserving surgery or modified radical mastectomy and for those who were excluded from the criteria of breast conserving surgery from the prognostic and cosmetic points of view.

Screening for abdominal aortic aneurysm and occlusive peripheral vascular disease in Japanese residents

To evaluate the prevalence of abdominal aortic aneurysm (AAA) and occlusive peripheral vascular disease (PVD) in Japanese residents, and to examine the correlations between these diseases and the risk factors of atherosclerosis, 348 residents of a village in central Japan aged between 60 and 79 years were screened. The screening for AAA was performed using ultrasonography (US) and that for PVD was performed by palpation and Doppler US. No AAA was found, and a right common iliac arterial aneurysm was detected in a 79-year-old man (0.3%). The mean diameter of the infrarenal abdominal aorta was 18.7 mm and an abdominal aorta of 25 mm or greater in diameter was seen in 16 participants (4.6%), all of whom need to be followed up. PVD was suspected in two patients (0.6%) with a low ankle brachial pressure index. Of a total of five patients diagnosed or suspected of having a common iliac arterial aneurysm or PVD, four (80%) had at least one risk factor for atherosclerosis. Thus, we conclude that Japanese residents with risk factors predisposing them to atherosclerosis such as hypertension, obesity, abnormal serum lipid levels, and a history of smoking should be selectively screened for AAA and PVD due to the low prevalence of these diseases and from the viewpoint of cost-effectiveness.

Oral high-dose medroxyprogesterone acetate treatment for recurrent breast cancer

Oral high-dose medroxyprogesterone acetate (MPA) treatment (600, 800, 1200 mg/day or changed dosage) was given to 49 patients with recurrent breast cancer from January 1979 to December 1992. The overall response rate to MPA was 38.8% (19/49). The response rate in the soft tissue was significantly higher compared with that in bone metastases or in visceral metastases. MPA was effective on patients both with or without previous treatment. Several side effects were recognized, but they were mild and tolerable. These results demonstrate that MPA is effective when used as first line or second line treatment.

Immunohistochemical fibronectin staining pattern and prognosis in invasive breast carcinoma

Fibronectin (FN) in 99 female patients with invasive breast carcinomas (IBCs) was studied by immunohistochemistry using a monoclonal antibody to human plasma FN. Sixty-five (65.7%) of 99 IBCs were FN-positive and 34 (34.3%) were FN-negative. The FN staining pattern was not correlated with patient characteristics, such as age, tumor size, nodal involvement and estrogen receptor status. Relapse-free survival (RFS) of patients with FN-positive tumors was significantly better than that of patients with FN-negative tumors. A multivariate analysis using the Cox proportional hazards model showed that the FN staining pattern was independently correlated with RFS as well as nodal status. The results show that FN staining pattern may be an independent prognostic factor in IBCs. It is suggested that patients with FN-negative tumors should be carefully followed up, even if axillary nodal invasion is absent.

Fibromatosis of the breast: a case report

Fibromatosis of the female breast is rare. We dealt with a recurrent case of fibromatosis four months after a wide excision of the tumor. It was difficult to differentiate the tumor from carcinoma and only a pathological examination could lead to the final diagnosis. Ultrasonographic findings are so characteristic that we would like to emphasize the usefulness of ultrasonography not only in distinguishing between recurrence and operative scar but also in defining the diagnosis as fibromatosis of the breast.

Clinical significance of first line treatment in recurrent breast cancer

From 1962 to 1992, 279 patients with recurrent breast cancer were treated. Of these, the cases with resected lesions, imperfectly evaluated cases and cases where information was lacking were excluded, and 185 recurrent breast cancers were evaluable at the first line or subsequent treatment. Sixty-seven (36.2%) out of 185 cases responded to first line treatment, while the remaining 118 cases did not respond. In the 67 responder cases at the first line treatments, 16 (23.9%) responded to second line or third line, however, in the 118 nonresponder cases, only 13 (11.0%) responded to next or subsequent treatment. The incidence of responder in the second line or third line treatment was significantly higher in the first line responder group than in the first line nonresponder group. Furthermore, overall survival of first line responders was significantly better than that of first line nonresponders. There was no significant difference in the survival after recurrence between responders and nonresponders in the first line chemotherapy, chemoendocrine treatment or radiotherapy, however, a significant difference was seen between the two groups in the first line endocrine treatment. These results suggest that first line treatment may select the treatment sensitive (especially, truly hormone-dependent) recurrent breast cancers which show a better prognosis.

[A case of recurrent breast cancer responding to combination therapy with mitoxantrone (MIT), 5'-deoxy-5-fluorouridine (5'-DFUR) and medroxyprogesterone acetate (MPA)]

The patient was a 50-year-old woman who had undergone left standard radical mastectomy who had undergone left standard radical mastectomy on June 1, 1986. She showed multiple liver metastases with elevation of CEA level in July, 1991, and 5'-DFUR plus MPA combination therapy was started. The daily dosages were: 800 mg/body and 1,200 mg/body, respectively. After intra-arterial infusion of pirarubicin and Lipiodol, bilateral oophorectomy was performed and an implantable reservoir for intra-arterial infusion chemotherapy was implanted via the proper hepatic artery. Then she was treated by arterial-infusion of mitoxantrone 10mg/body intermittently every two weeks. The metastatic foci responded to this therapy and her CEA level decreased.

Nonpalpable breast cancer

Thirty-seven patients with nonpalpable breast cancer treated between 1981 and 1992 were analysed. Twenty-five (68%) of the patients were detected by microcalcification of mammogram, 8 by nipple discharge and 4 by other means. Biopsy was carried out in all patients to get a final diagnosis and histopathological examinations were performed using continuous sections (especially the section with microcalcification). The incidence of noninvasive carcinoma was 59% (22 cases) and the remaining invasive carcinomas were 3 minimal lesions less than 0.5 cm, 3 lesions from 0.5 to 1.0 cm, 3 diseases more than 1.0 cm, and 6 invasive carcinomas with noninvasive ductal carcinoma predominant. Modified radical mastectomy was performed in 16 cases, partial glandectomy in 10 and other surgery including subcutaneous mastectomy in 11. All of the patients with nonpalpabl breast cancer showed a good prognosis because of early detection and early treatment. Mammography was useful to detect nonpalpable breast cancers with microcalcification.

[Advanced breast cancer with remarkable response to the combination therapy of mitoxantrone (MIT) and medroxyprogesteron acetate (MPA) after failure of anthracycline therapy: a case report]

A 67-year-old advanced breast cancer patient with multiple bone metastases showed a remarkable response to the combination therapy of mitoxantrone (MIT) and medroxyprogesteron acetate (MPA) after failure of anthracycline therapy. Eight course of CTF (cyclophosphamide, THP-adriamycin, 5-fluorouracil) and subsequent 4'-epi-adriamycin were performed for locally advanced breast cancer and multiple bone metastases, but the ulcerated breast cancer enlarged. Then the combination therapy of MIT (10 mg/day) and MPA (1,200 mg/day) was carried out. Seven months after treatment, the ulcerated breast cancer disappeared completely and the serum levels of CA 15-3, TPA and CEA decreased within the normal range. These results suggest that combination therapy with mitoxantrone may well be effective against the anthracycline-resistant breast cancer.

A new triphenylethylene derivative, TAT-59; hormone receptors; insulin-like growth factor 1; and growth suppression of hormone-dependent MCF-7 tumors in athymic mice

TAT-59 ((E)-4-[1-[4-[2-(dimethylamino)ethoxy]-phenyl]-2-(4- isopropyl)phenyl-1-butenyl]-phenyl-monophosphate) treatment was performed on hormone-dependent MCF-7 tumors in athymic mice. TAT-59 given at 1, 5, and 20 mg/kg inhibited the estrogen-stimulated growth of MCF-7 tumors in athymic mice in a dose-dependent fashion. The most clear decrease in tumor growth was shown in the TAT-59 alone group, although it was not dramatic. Average serum concentrations of DP-TAT-59((Z)-[1-[4-[2-(dimethylamino)- ethoxy]phenyl]-2-(4-isopropyl)phenyl-1-butenyl]-4-hydroxybenzene) and DM-DP-TAT-59(desmethyl-DP-TAT-59), metabolites of TAT-59, increased in a dose-dependent manner. Much higher levels of DP-TAT-59 and DM-DP-TAT-59 were shown in tumors (target tissues of estrogen) as compared with muscles (nontarget tissues of estrogen) or serum. A serum concentration of DP-TAT-59 or DM-DP-TAT-59 corresponding to the physiologic levels of serum estradiol in premenopausal women was sufficient to inhibit the estrogen-stimulated growth of MCF-7 tumors in mice. TAT-59 induced a dose-dependent increase in estrogen receptor levels in the MCF-7 tumors. In contrast, it prevented the estradiol (E2)-induced increase in progesterone receptor levels in a dose-dependent manner. Insulin-like growth factor 1 levels measured in the MCF-7 tumors significantly decreased in the TAT-59 alone group and in the no treatment group as compared with the E2 alone group. These results show the pronounced antiestrogenic action of TAT-59 on hormone-dependent MCF-7 tumors in athymic mice.