Oral contraceptive use and the prognosis of breast cancer

In 471 breast cancer patients the influence of a positive history of oral contraceptive (OC) use on survival was investigated. 297 (63%) patients used OCs during any period of their life and 92 (20%) used them still at the time of diagnosis. Sixty months after diagnosis OC users had a significantly increased overall survival (p = 0.037). Survival rates amounted to 79.5% and 70.3% for OC users and non-users, respectively. The effect persisted after adjustment for other prognostic factors and was mainly attributed to women who had taken OCs four years or longer (p = 0.025). Comparing the survival after a 56 months median follow-up dependent on duration of OC use (never, 1-48 months, > or = 49 months) in subgroups of prognostic factors, the most significant influence on survival was observed among long-term users with tumors more than 2 cm in diameter (p = 0.005), with axillary node-positive tumors (1-3 nodes, p = 0.055/ > or = 4 nodes, p = 0.019), and with tumors of low estrogen receptor (p = 0.015) or progesterone receptor content (p = 0.04). The difference in survival between OC users and non-users cannot be explained by the distribution of prognostic factors investigated (histological type, histological grade, tumor size, lymph node involvement, hormonal receptor content). OC users had an even higher percentage of poorly differentiated tumors (p = 0.003). These results suggest an effect of OC use on tumor biology during the preclinical phase of the disease.

The results of modified use of chemotherapy for patients with metastatic breast cancer

We investigated whether modifying standard chemotherapy with 5-fluorouracil, doxorubicin and cyclophosphamide (FAC) could improve the outcome of patients with advanced breast carcinoma. We changed the conventional FAC treatment as follows: firstly, we administered oestrogens during the delivery of chemotherapy. Secondly, we administered 5-fluorouracil by continuous infusion. Thirdly, we limited chemotherapy treatment to 12 cycles and did not continue treatment during remissions. We evaluated this modified treatment in 63 patients and compared its results to other treatments results given at this institution. We found that the modified treatment improved the quality of life and survival of premenopausal breast cancer patients.

Characterization of tamoxifen stimulated MCF-7 tumor variants grown in athymic mice

The non-steroidal antiestrogen tamoxifen (TAM) is successfully used to treat all stages of breast cancer in both pre- and postmenopausal women. Unfortunately, most women treated with TAM eventually develop resistant tumor recurrences which require intervention with a second-line endocrine therapy, or cytotoxic chemotherapy if the recurrence is completely endocrine insensitive. There is evidence that some recurrences may in fact be TAM stimulated. MCF-7 human breast cancer cells grown as solid tumors in athymic mice chronically treated with TAM reproducibly develop a TAM stimulated phenotype (Osborne et al., Eur J Cancer Clin Oncol 23:1189-1196, 1987; Gottardis and Jordan, Cancer Res 48: 5183-5187, 1988; Osborne et al., J Natl Cancer Inst 83:1477-1482, 1991; Wolf et al., J Natl Cancer Inst 85:806-812, 1993). Tumors of this type may provide a useful model for a subset of therapeutic failures in the clinic. Therefore, we have extensively studied this model in an attempt to define the mechanism or mechanisms leading to TAM stimulated growth. In this paper we describe the characteristics of 4 TAM stimulated MCF-7 tumor variants. All of these tumors are growth stimulated by TAM, but vary in their response to estradiol (E2) treatment, and grow poorly in placebo treated hosts. All tumor variants express estrogen receptor (ER) RNA and protein, which at the RNA level appear to be down regulated by TAM, and to a greater extent by E2. All tumors also express epidermal growth factor receptor (EGFR) RNA, which is down regulated by TAM, and further down regulated by E2. However, among the tumor variants analyzed, ER and EGFR levels appear to be inversely related. Further, despite the expression of ER by all 4 TAM stimulated tumor variants, E2 induction of progesterone receptor expression is very weak or entirely absent.

History of lactation and breast cancer risk

A self-administered questionnaire was completed by 1,018 women diagnosed with breast cancer during 1988-1989 identified through the British Columbia Cancer Registry and by 1,025 controls selected at random from the Provincial Voters List. Parous premenopausal women who had never nursed (odds ratio (OR) = 1.3, 95% confidence interval (CI) 0.9-2.0) or who had lactated for 1 month or less (OR = 1.8, 95% CI 1.3-2.5) had an increased risk of breast cancer adjusted for age and parity, compared with women who had breast-fed 2 months or longer. The risk was particularly elevated (OR = 3.0, 95% CI 1.6-5.4) among women who reported having tried to nurse, but who were unsuccessful. Among women who nursed for at least 2 months, there was an indication of decreasing risk with increasing duration of nursing. Among postmenopausal parous women, no relation between lactation history and breast cancer risk was evident.

Relationship between quadriceps strength and bone mineral density of the proximal tibia and distal forearm in women

It is well known that there is a relationship between muscle strength and bone density, but it is uncertain whether this relationship is site specific. The aim of this study was to assess the relationship of quadriceps strength to site-specific bone mineral density (BMD) of the tibia and to BMD of the forearm. In 66 healthy women, aged 21-78 years, BMD was measured in the proximal tibia and the distal forearm by dual-photon absorptiometry. Isometric and isokinetic strength of the quadriceps was measured using an isokinetic dynamometer (Cybex II). Highly significant correlations between BMD of the proximal tibia and quadriceps strength were found (RS ranging from 0.79 to 0.84, p < 0.0001). Also, BMD of the distal forearm was correlated with quadriceps strength (RS ranging from 0.59 to 0.62, p < 0.0001). In a stepwise multiple regression analysis, quadriceps strength was a better predictor of tibial BMD than age, body height, or weight. However, age, height, and weight were more predictive of forearm BMD than quadriceps strength. When studying the pre- and postmenopausal women separately, quadriceps strength was correlated with BMD of the proximal tibia but not to forearm BMD. In conclusion, the study provides support for a site-specific relationship between muscle and bone.

Rational use of oral contraceptives in the perimenopausal woman

Oral contraceptives have undergone extensive revision in their labeling over the past 10 years to remove warnings about cardiovascular and other risks and to highlight their noncontraceptive benefits. While these changes are becoming better known, the potential bone-sparing effects of oral contraceptives in the premenopausal and perimenopausal woman remain under-appreciated. Osteoporosis is a major health care problem worldwide in terms of both its associated morbidity and mortality and its economic impact. Although the benefits of postmenopausal hormone replacement therapy for the prevention and treatment of osteoporosis are generally recognized, little attention has been paid to strategies that might be used to maintain bone mass up to the time of menopause, at which time bone loss accelerates. An additional noncontraceptive benefit of oral contraceptives may be to maintain and build bone mass up to the time of menopause.

Analysis of time to response to chemotherapy in 316 metastatic breast cancer patients

Chemotherapy is a major tool for metastatic breast cancer treatment. In this study, a series of 316 patients have been analyzed to evaluate the time needed to reach tumor response by means of combination chemotherapy. Twenty-five percent of patients responded within 3 months and virtually all responses occurred within 7.5 months. The time curves of response (any) and best response are superimposable. A subset analysis has shown that the following pretreatment characteristics predict a significantly longer time to response: prior exposure to adjuvant chemotherapy, nodal positivity at diagnosis, no previous endocrine treatment and osseous metastases.

Bone metabolism in obesity: changes related to severe overweight and dietary weight reduction

A non-invasive evaluation of bone metabolism was performed in 44 morbidly obese patients before and after a mean weight loss of 22.4 kg (range 7.9-43.4 kg) after 2 months and a further weight loss of 7.3 kg after 8 months (0.8-20.0 kg). This weight reduction was obtained by a nutritionally adequate very-low-calorie diet. Before treatment the bone mineral content of the distal forearm was increased compared to normals (51.9 U vs. 43.7 U, p < 0.001). Bone formation was evaluated by serum alkaline phosphatase and serum osteocalcin. Serum alkaline phosphatase was increased (187.8 U/l vs 147.4 U/l, p < 0.001) while serum osteocalcin was lower than in the controls (0.67 nmol/l vs 0.98 nmol/l, p < 0.01). Bone resorption, as measured by the urinary hydroxyproline/creatinine ratio, was not increased in the obese patients (19.2 molar ratio x 10(-3) vs 16.7 molar ratio x 10(-3), NS). After 2 months, the bone mineral content had declined by 3.3%. Serum alkaline phosphatase remained unchanged (187.8 U/l vs 186.9 U/l, NS) but serum osteocalcin demonstrated a significant rise (3.94 nmol/l vs 10.53 nmol/l, p < 0.001), parallel to changes in the hydroxyproline/creatinine ratio (19.2 molar ratio x 10(-3) vs 25.2 molar ratio x 10(-3), p < 0.001). At 8 months, no further change in the bone mineral content was seen. The hydroxyproline/creatinine ratio did still increase (from 25.8 molar ratio x 10(-3) to 30.1 molar ratio x 10(-3), p < 0.05), while serum alkaline phosphatase and serum osteocalcin remained unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

The efficiency of transvaginal ultrasonography in the diagnosis of endometrioma

OBJECTIVE

To assess the efficiency of transvaginal ultrasonography in the screening of endometriomas and in differentiating endometriomas from other ovarian masses.

DESIGN

Prospective study with surgical and pathological confirmation of the sonographic diagnosis.

SETTING

Department of Obstetrics and Gynecology at the University of Cagliari, Cagliari, Italy.

PATIENTS

All premenopausal nonpregnant women (n = 236) submitted to laparotomy or laparoscopy from May 1991 to December 1992.

INTERVENTIONS

Transvaginal ultrasonographic examinations were done within 1 week before surgery. Ultrasonographic diagnosis was compared with surgical and histopathological findings.

MAIN OUTCOME MEASURE

The visualization of round-shaped homogeneous hypoechoic "tissue" of low-level echoes within the ovary was chosen as characteristic ultrasonographic finding of endometrioma. Sensitivity, specificity, and predicted values were calculated for each visualized ovary (group A) to assess the efficiency in the screening, and for each visualized cyst (group B) to assess the efficiency in differentiating endometriomas from other ovarian masses.

RESULTS

Four hundred twenty-three of 466 ovaries were visualized. Of the 82 visualized cysts, 27 were suspected to be endometriomas, and the diagnosis was confirmed by pathology in 21. The sensitivity and the specificity were 75% and 99%, respectively, in group A, and 84% and 90%, respectively, in group B.

CONCLUSION

The study demonstrates that transvaginal ultrasonography has an efficiency of 88% in differentiating endometriomas from other ovarian masses with a specificity of 90%.

Cathepsin-D in human breast cancer: correlation with vascular invasion and other clinical and histopathological characteristics

The relationship between the Cathepsin-D concentration in breast cancer cytosols and clinical and histopathological characteristics of the tumours was investigated, including vascular invasion, histological type, histological grade, lymph node involvement and tumour size. The median cathepsin-D concentration of a series of 738 primary breast carcinomas was used to define "low" and "high" cathepsin-D. High cathepsin-D concentration was associated with peritumoral vascular invasion, with high grade infiltrating duct carcinomas, with tumours of > or = 2 diameter, and with metastases in the axillary lymph nodes. Low cathepsin-D concentration was associated with in-situ carcinomas.

Genetic alterations in c-erbB-2 protooncogene as prognostic markers in human primary breast tumors

c-erbB-2 DNA amplification and mRNA expression were analyzed by dot and Southern blots in 65 human primary breast tumors. Gene amplification was observed in 21 of 65 (32.3%) and elevated levels of c-erbB-2 transcript in 14 of 60 (23.3%) of the tumors analyzed. Only 55% of the tumors with c-erbB-2 gene amplification presented gene overexpression, showing an incomplete correlation between gene amplification and overexpression. No statistically significant correlation was observed between c-erbB-2 genetic alterations and other prognostic factors in breast cancer. However, patients with tumors presenting c-erbB-2 gene amplification and/or overexpression appeared to have a shorter disease-free interval than patients without c-erbB-2 genetic alterations. High levels of c-erbB-2 gene amplification were more powerful predictors of risk of recurrence than was overexpression of the gene. Cox univariate-bivariate analyses suggested that gene amplification was independent of nodal status to predict recurrence in breast cancer.

Linkage analysis of DRD2, a marker linked to the ataxia-telangiectasia gene, in 64 families with premenopausal bilateral breast cancer

Recent reports suggest that subjects who are heterozygous for the ataxia-telangiectasia gene are at increased risk of breast cancer. We conducted linkage analyses of 64 families with premenopausal bilateral breast cancer using DRD2, a marker linked to the ataxia-telangiectasia locus at 11q22-23. We assumed a model with dominant transmission of breast cancer. Lod scores summed over all families provided strong evidence against tight linkage (e.g., a lod score of -6.08 at theta = 0.00001), although a single family provides suggestive evidence of tight linkage to DRD2. Evidence against linkage to 11q was strongest among families that may involve the BRCA1 breast cancer susceptibility gene on 17q21. However, we did not observe evidence of linkage to 11q among the remaining subgroup with neither a family history of ovarian cancer nor the appearance of linkage to 17q21.

Women with a pelvic mass--when to perform an ultrasound

A retrospective study of 264 patients with a pelvic mass who had a preoperative serum CA 125 level performed was undertaken to compare the sensitivity, specificity and predictive values of this test as a predictor of malignancy, compared with clinical impression and ultrasonography (USG). The values were calculated for each parameter alone and in combination, and the effect of menopausal status, histological type and stage of disease was also assessed. The results indicate that in postmenopausal women with a pelvic mass, a CA 125 level should be performed and the patient referred to a gynaecological oncologist if the value is raised. In contrast both CA 125 and USG should be performed in the premenopausal woman to allow appropriate referral. In this study a CA 125 level of 35 u/ml or more correctly identified malignancy in 90% of postmenopausal women.

Influence of disease activity on steroid hormone levels in peripheral blood of patients with rheumatoid arthritis

The steroid hormone status of 27 female patients (15 premenopausal and 12 postmenopausal) and 11 male patients with rheumatoid arthritis (RA) was investigated before and after a clinically significant deterioration in disease activity. In postmenopausal patients the serum level of cortisol decreased significantly with the progression of disease activity. No significant change in the serum levels of oestrone, oestradiol, androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulfate or prolactin was found within the groups. In premenopausal patients serum cortisol levels also decreased, with progression of disease activity, but this difference did not reach statistical significance. In male patients with RA none of the measured steroid hormone levels changed significantly after exacerbation of disease activity. Our data indicate that the synthesis and/or utilization of cortisol might be abnormal in female patients with active rheumatoid arthritis.

The impact of female hormone usage on the lipid profile. The Framingham Offspring Study

BACKGROUND

Exogenous female hormone use appears to affect cardiovascular disease risk in both premenopausal and postmenopausal women. The purpose of this study was to evaluate the impact of exogenous female hormone usage on the lipid profile among premenopausal and postmenopausal women.

METHODS

One thousand nine hundred thirty female participants of the Framingham Offspring study comprised the study population. Of the 992 premenopausal subjects, 57 were current oral contraceptive users; among the 938 postmenopausal subjects, 80 were current hormone users. The influence of hormone use on lipid and lipoprotein levels was determined using multivariable linear regression models that adjusted for age, body mass index, smoking, alcohol intake, beta-blocker, and diuretic therapy. Adjusted least-squares means were calculated for each lipid and lipoprotein according to female hormone usage and menopausal status.

RESULTS

In the premenopausal analysis, pooled oral contraceptive use was significantly related to increased levels of total cholesterol, triglycerides, high-density lipoprotein cholesterol and apolipoprotein A-I. Increased estrogen content was inversely associated with low-density lipoprotein cholesterol, and apolipoprotein B levels, while increased progestin content was inversely related to high-density lipoprotein cholesterol and apolipoprotein A-I levels. Among postmenopausal women, use of premarin only was significantly associated with increased high-density lipoprotein cholesterol and apolipoprotein A-I levels. Combination use of premarin and provera was significantly associated with increased apolipoprotein A-I levels; less powerful but still significant associations with increased high-density lipoprotein cholesterol and decreased low-density lipoprotein cholesterol were also observed.

CONCLUSION

In this cross-sectional analysis, oral contraceptive use is associated with both favorable and unfavorable lipid alterations with respect to atherogenic risk. Among postmenopausal women, hormone replacement therapy (both premarin only and combined premarin and provera) appears to be associated with favorable effects on the lipid profile.

Interleukin-1 and tumor necrosis factor stimulate arachidonic acid release and phospholipid metabolism in human myometrial cells

OBJECTIVE

Our aim was to evaluate the effects of the cytokines interleukin-1 and tumor necrosis factor on arachidonic acid release in human myometrial cells.

STUDY DESIGN

Primary monolayer cultures of human myometrial cells prelabeled with tritiated arachidonic acid were exposed to interleukin-1 or tumor necrosis factor for varying periods and the release of tritiated arachidonic acid and its loss from phospholipids were measured by radiochromatography. To gain some information on the biologic action of interleukin-1 the contractile response to oxytocin was measured in myometrial strips preincubated with this cytokine. Data were statistically evaluated with analysis of variance or Student's test.

RESULTS

Both cytokines caused a dose-dependent increase in tritiated arachidonate release that was suppressed by the protein synthesis inhibitor cycloheximide. Tritiated arachidonic acid release was maximal after 24 hours of stimulation with interleukin-1. Both interleukin-1 and tumor necrosis factor stimulated the release of the isotopically labeled fatty acid from phosphatidylcholine. In addition, interleukin-1 also increased the loss of arachidonic acid from phosphatidic acid and significantly potentiated the oxytocin-evoked myometrial contractility.

CONCLUSIONS

Both interleukin-1 and tumor necrosis factor enhance arachidonic acid release, probably by inducing the synthesis of phospholipase A2 and possibly other enzymes involved in the metabolism of phospholipids. In turn, arachidonic acid itself may act as a second messenger, synergizing with other uterotonic agents, as well as serving as the precursor for prostaglandins and various other bioactive eicosanoids.

Prognostic significance of plasma prolactin in breast cancer: comparison with the expression of c erb B-2 oncoprotein

Having established prolactin to be an indicator of disease progression and hyperprolactinemia as an independent predictor of short term prognostication, we have in this report compared plasma prolactin with the expression of c erb B-2 oncoprotein, ER and PR. c erb B-2 oncoprotein, ER and PR are determinants of breast cancer biology. This is a retrospective study of 47 breast cancer patients. When patients were grouped according to the stage of the disease, plasma prolactin was higher in patients with advanced disease than those with stage II disease. The patients were sub-grouped according to prolactin < 20.0 ng/ml and > 20.0 ng/ml. The expression of c erb B-2, ER and PR did not differ in these two sub-groups. The overall survival differed significantly between the two sub-groups of prolactin. The patients were sub-grouped according to c erb B-2 positivity or negativity, there was no significant difference in survival. c erb B-2 expression did not differ between the three grades of the tumor, nodal and receptor positivity or negativity. Hence, the present study reinforces the positive association between hyperprolactinemia and unfavourable prognosis and finds c erb B-2 expression as a weak prognosticator in advanced breast cancer patients.

Effects of nomegestrol acetate on carbohydrate metabolism

The effects of nomegestrol acetate on carbohydrate metabolism were investigated in 20 premenopausal women presenting with menstrual disturbances. The progestogen was administered from day 5 to day 24 of the cycle, over six consecutive cycles, at a dosage (5 mg/d) known to inhibit ovulation. A 3 hour oral glucose tolerance test (OGTT) was performed prior to the hormonal intake and at 3 months and 6 months of therapy. Blood glucose and insulin were measured before and for 3 hours after a 75 g glucose load, and the glucose and insulin areas under the curves (AUC) were calculated. The fasting glycosylated hemoglobin and fructosamine were also determined. Treatment did not induce any significant changes in plasma glucose or insulin glucose values during the oral glucose tolerance test, in glucose and insulin areas under the curves or in glycosylated protein levels. Two women with impaired glucose tolerance were not worsened during therapy. These data suggest that nomegestrol acetate is free from adverse effects on glucose tolerance after 6 months treatment.

Epithelial ovarian tumors of borderline malignancy: long-term follow-up

Thirty-nine patients underwent primary surgery for epithelial ovarian tumors of low malignant potential at the Massachusetts General Hospital between 1970 and 1980. Eighty-five percent of patients were found to have Stage I disease and 15% were found to have Stage III disease. Fifty-four percent of patients had a tumor with serous histology, 39% had a tumor with mucinous histology, and the remainder of patients had tumors with an endometrioid or mixed-cell type. Second malignancies and benign ovarian tumors were frequently found concomitantly with the borderline tumors or in follow-up. Gastrointestinal and endometrial adenocarcinomas were the most common second malignancies and were frequently found associated with a borderline tumor of serous histology. Follow-up was available in all 39 patients (100%). Mean time of follow-up was 11.8 years. Sixty-nine percent of patients are clinically without evidence of disease with a mean follow-up of 14.7 years, 23% died of other causes, 5% died of disease, and 3% died with disease and sepsis. All patients dying with disease did so within 7.3 years of their primary surgery. Seven patients underwent conservative surgery, defined as preservation of some ovarian tissue. Six of 7 patients are clinically free of disease with a mean follow-up of 14.6 years; 1 patient died of other causes. No patients treated conservatively had a recurrence of their disease.

[The role of echography in the determination and monitoring of ductal ectasia in nipple discharge]

In this study a good sensibility of ultrasound in identifying ductal disease was demonstrated. We evaluated the relationship between nipple discharge and ductal ectasia and the importance of the ectasia in maintaining nipple discharge. From our data the hypothesis of a possible role of oestroprogestinic hormones in the genesis or maintaining of ductal ectasia emerged.

Osteoporosis risk factors, gynaecological history and fractures in perimenopausal women--the results of the baseline postal enquiry of the Kuopio Osteoporosis Risk Factor and Prevention Study

The Kuopio Osteoporosis Risk Factor and Prevention (OSTPRE) Study examines the risk factors of osteoporosis, the relationship of risk factors to bone density and fractures, as well as the possibility to prevent bone loss by administering certain hormones. The baseline postal enquiry in 1989 was sent to all the 14,220 women aged 47-56 years residing in the Kuopio Province, Finland. The questionnaire included questions about their gynaecological history, physical exercise and smoking habits, calcium intake, body weight and height, history of bone fractures, health disorders, their current and previous use of drugs, as well as their willingness to participate in bone densitometry and in a clinical hormone trial. The response rate was 92.8%. In all, 56% reported some previous use of female hormones. Strong contraindications for oestrogen replacement therapy were found in 9.3% of the women. Almost half of the respondents reported lack of regular physical exercise, 11.9% were smokers, and 17.0% reported a calcium intake from milk products of less than 500 mg daily. The incidence of fractures increased steadily with age. The incidence of premenopausal fractures within the last 10 years was 7.65 per 1000 person/years and that of postmenopausal fractures was 17.40 per 1000 person/years (P = 0.000). The effect of menopause on fracture incidence was stronger than the effect of a 5-year age increase. Of the respondents, 84.4% were willing to participate in bone densitometry and 68.3% for long-term prevention of osteoporosis with oestrogen.

Expression of ras p21 oncoprotein in normal and neoplastic human endometrium

The ras-encoded p21 protein expression was investigated in 18 normal endometrial tissues and in 37 human primary endometrial carcinomas by Western blotting analysis. Scattered p21 levels were found in normal specimens (mean = 1.29 OD; median = 1.10 OD; range = 0.33-2.65). The p21 levels were significantly higher in secretory (mean = 1.99 OD; median = 2.16 OD; range = 0.71-2.65) than in proliferative (mean = 0.97 OD; median = 1.07 OD; range 0.38-1.73) endometrium (P = 0.009) and higher in primary endometrial carcinomas (mean = 2.05 OD; median = 2.04 OD; range 0.21-4.36) than in normal proliferative tissues (P = 0.004). Immunohistochemical analysis showed that most of the tumor cells expressed p21 oncoprotein while the stromal component was unreactive. No correlation between p21 expression and histopathological characteristics of the tumors was observed. Moreover, estrogen receptor (ER)-positive tumors expressed higher p21 levels than did ER-negative tumors (77% vs 33%; P = 0.009). A similar trend, although not statistically significant, was found between p21 values and progesterone receptor expression (74% vs 44%; P = 0.060). On the other side, p21 levels were unrelated to epidermal growth factor receptor levels. Further studies should verify the possible significance of p21 expression in the prognostic characterization of patients with endometrial cancer.

Revisable criteria for vertebral deformity

In order to study vertebral fractures in various study populations, we earlier prepared a database of vertebral dimensions derived from spinal radiographs of 191 normal women seen regularly over 25 years. In this report we have expanded the range of measurements to include vertebral levels T3 to L5. We report means and standard deviations on anterior and posterior heights, on wedge shape and on heights relative to adjacent vertebrae. When one or both of the latter two quantities are 'far' below the mean, a vertebra is called deformed. We also describe a more flexible way of expressing damage using the number of deformed vertebrae, the degree of deformity of individual vertebrae, or the total damage to the entire spine. In assessing damage we use criteria for deformity adjusted to the limits detected by an experienced diagnostician, replacing an earlier approach based on 95% probability limits of normal variation. The normal women from whom these variations are ascertained are a low-prevalence group with respect to vertebral deformity, with prevalence of 2.8%. When the criteria developed from these women were applied to a moderate-prevalence group (37%) the model had a sensitivity of 97%, a specificity of 89% and an accuracy of 92% as regards the identification of subjects with damaged vertebrae. When used epidemiologically for a moderate-prevalence group the model has a known overestimation of 15%. the model is compared with other schemes for identifying vertebral deformities.

Influence of the climacteric on the bone mass of the spine and femur

OBJECTIVE

To determine the correlation between the bone mass of the lumbar spine and the neck of the femur in Spanish climacteric women.

METHOD

Bone mass was measured using quantitative digital radiology in 200 climacteric women who had no record of receiving hormone replacement therapy.

RESULT

A statistically significant correlation (P < 0.05) is observed between the bone mineral density and content of the lumbar spine and the femur in all the groups of climacteric women, although only in the postmenopausal women does it approach 70%. A direct relationship is observed between the loss of bone mass and the onset of the menopause, as well as with the patients' body mass index.

CONCLUSION

When the different parameters are analyzed, the results show that measurement of the lumbar spine is essential, and measurement of the femur should not be used as a substitute, but rather in addition to it.

Evidence for the in-vitro de-novo synthesis of immunoglobulin and a previously undescribed 17 kDa protein (TEP-2) by the mucosa of the fallopian tube

De-novo synthesis and secretion of proteins by short-term explants of matched Fallopian tube mucosa and endometrium were studied using radiolabelled L-[35S]methionine and [3H]glucosamine. To compare directly each anatomical site of the Fallopian tube and endometrium from the same source, newly synthesized proteins were separated on one-dimensional polyacrylamide gel electrophoresis and examined by auto-radiography. De-novo synthesis of two protein bands provisionally designated as tubal epithelial protein 1 (TEP-1) and tubal epithelial protein 2 (TEP-2), was observed in explants of the Fallopian tube mucosa obtained from each anatomical site throughout the ovarian cycle (n = 20). TEP-2 was not apparent in tubal mucosa obtained from post-menopausal women (n = 5). De-novo synthesis of TEP-1 and TEP-2 was not apparent in autoradiographs of radiolabelled proteins from short-term explants of endometrium. From the autoradiographs the molecular mass of TEP-1 and TEP-2 was calculated to be 25 kDa and 17 kDa, respectively. Incorporation of glucosamine into newly synthesized protein occurred in TEP-2 but not TEP-1. TEP-1 was observed to be immunochemically identical to immunoglobulin kappa light chains.

Tamoxifen: a review of pharmacoeconomic and quality-of-life considerations for its use as adjuvant therapy in women with breast cancer

Extensive clinical experience, summarised in the recent overview of the Early Breast Cancer Trialists' Collaborative Group (EBCTCG), have confirmed that tamoxifen reduces the rate of both disease recurrence and mortality when administered as adjuvant therapy in women with early breast cancer. Tamoxifen is now established as the preferred adjuvant agent in postmenopausal women; in particular, patients with node-positive, estrogen receptor-positive breast cancer have the most to gain from tamoxifen therapy. Data from a decision-analysis model indicated that tamoxifen monotherapy had a cost-utility ration {$US6000 per additional quality-adjusted life-year (QALY), in 1989 dollars} 5 to 6 times lower than that cited as the cost-acceptability cut-off point in the US. While tamoxifen monotherapy is effective in postmenopausal women, the EBCTCG overview findings indicate that a combined regimen of tamoxifen and antineoplastic chemotherapy has superior efficacy in the same patient group. An issue of current interest is whether the added benefit offered by such a regimen can be justified in terms of added toxicity and cost. Data from a decision-analysis model indicate that combined therapy has a high incremental cost-utility ratio ($US58 000 per additional QALY, in 1989 dollars) compared with no therapy in postmenopausal women. However, the quality-of-life measures TWiST (Time Without Symptoms and Toxicity) and Q-TWiST (quality-adjusted TWiST) indicate that the early toxicity associated with a combined regimen appears to be justified given the superior long term benefits. Patient preference data from 1 study further indicate that the degree of benefit offered by a combined regimen would be acceptable to the majority (73%) of patients. Other areas where pharmacoeconomic analyses may help define more closely the optimal use of adjuvant tamoxifen is in patients at low risk of developing metastatic disease and in determining the optimal duration of therapy. Both areas require further clinical data. In conclusion, tamoxifen adjuvant monotherapy has a low cost-utility ratio in postmenopausal women with node-positive, estrogen receptor-positive breast cancer. Combined therapy in the same patient group has a high cost-utility ratio compared with no therapy but quality-of-life and patient preference data suggest that the costs may be justified. Firm conclusions relating to the use of the drug in other patient subgroups and the optimal duration of therapy await further research.

Immunohistochemical analysis of p53 protein over-expression in endometrial carcinomas: inverse correlation with sex steroid receptor status

Mutations of the tumour suppressor p53 gene have been reported in a variety of human malignant tumours, and are frequently associated with over-expression of p53 protein. To examine the significance of p53 gene alteration in endometrial carcinomas, we studied the immunohistochemical reactivity with a monoclonal antibody against p53 (PAb 1801) in 30 endometrial carcinomas as well as in 64 normal endometria. The presence or absence of correlation of p53 over-expression with the clinicopathological features and with the immunohistochemical expression of sex steroid receptors (oestrogen receptors; ER, progesterone receptors; PR) was also analysed. Expression of p53 was found in none of 64 normal endometria, but was identified in 5 of the 30 (16.7%) endometrial carcinomas. All 5 of the p53-positive tumours developed in women more than 3 years post-menopause, whereas the carcinomas in 5 pre-menopausal women and 3 women less than 3 years post-menopause were p53-negative. None of the 5 p53-positive carcinomas was associated with adjacent endometrial hyperplasia. Two of the 5 p53-positive tumours showed non-endometrioid histology: serous papillary and clear cell carcinomas. In contrast, 6 carcinomas accompanied by adjacent hyperplasia were p53-negative. In addition, ER and/or PR expression was found in none of the 5 p53-positive tumours, but was present in 21 of the 25 p53-negative tumours (p < 0.01). These clinicopathological features of p53-positive carcinomas and the inverse correlation of p53 immunoreactivity with sex steroid receptor status suggest that p53 over-expression is frequent in a specific category of endometrial carcinoma, presumably oestrogen-unrelated tumours.

Effects of acute exercise on insulin and non-insulin-dependent glucose uptake in normal and moderately obese women

OBJECTIVES

To investigate the effectiveness of exercise on the regulation of insulin sensitivity.

METHODS

Eleven premenopausal women, with body fat mass from the normal range to moderate obesity, were examined with glucose clamp at 10 mmol/L glucose concentration to determine insulin-dependent and non-insulin-dependent (after somatostatin inhibition of endogenous insulin production) glucose uptake (= IDGU and NIDGU respectively) before and 24 hrs after a glycogen-decreasing exercise.

RESULTS

IDGU, but not NIDGU, increased after exercise. The degree of increase of IDGU after exercise showed negative correlations with body mass index (borderline, significance), the waist to hip circumference ratio, fasting free testosterone and free fatty acid concentrations, as well as diastolic blood pressure (borderline significance), and a positive relationship to sex hormone binding globulin concentration and IDGU before exercise.

CONCLUSION

It is concluded that only IDGU contributes to the augmentation of insulin sensitivity after a glycogen-decreasing exercise in women. Additionally, the increase of IDGU is less in abdominal obesity, and negatively dependent on free fatty acid concentrations, hyperandrogenism and hyperinsulinaemia, all putative pathogenetic factors for insulin resistance.

[Ovarian cysts: strategy and prognosis]

The management of an adnexal masses involves several steps: establish the diagnosis of organic ovarian cyst, avoiding a useless and iatrogenic surgery of a functional cyst, knowing that functional cysts may persist more than 3 months and may occur even on low-dose oral contraceptives; cure painful cysts, by ultrasound guided aspiration of some functional cysts or laparoscopic detorsion of twisted adnexae; exclude malignancy, with the help of ultrasound, Doppler and Ca-125 preoperatively, then laparoscopic examination and pathology; failed diagnosis of cancer becomes rare (1 out of 300 laparoscopic surgeries for ovarian cyst); the association of a benign ultrasound and Doppler pattern and of a Ca-125 lower than 35 mUI/ml is almost pathognomonic of a benign cyst; cure benign ovarian cysts with a minimum of surgical trauma; in our series, 84.4% of ovarian cysts are managed laparoscopically, 11.1% by elective laparotomy, 4.5% by laparotomy after an attempt at laparoscopic surgery (that implies that the patient must be informed of the risk of laparotomy); adapt the surgical technique to the pathologic type and size of the cyst, with a high rate of laparotomy in large dermoid cysts, and a high rate of (salpingo-)oophorectomy in peri or postmenopausal cysts; ensure an adequate therapy of early ovarian carcinomas, avoiding understadification and undertreatment; prevent ovarian cancer by a careful long-term follow-up of patients with benign ovarian cysts and by the use of bilateral oophorectomy in postmenopausal patients.

Premenopausal patients with node-positive resectable breast cancer. Preliminary results of a randomised trial comparing 3 adjuvant regimens: FEC 50 x 6 cycles vs FEC 50 x 3 cycles vs FEC 75 x 3 cycles. The French Adjuvant Study Group

Anthracyclines are among the most active drugs for the treatment of advanced breast cancer. Epirubicin has been found to be as effective as doxorubicin at equimolar doses but significantly better tolerated, especially in terms of alopecia, leucopenia, and cardiac toxicity. The role of anthracycline-containing regimens in adjuvant treatment of breast cancer has been studied by only a few clinical trial teams. In 1986, the French Adjuvant Study Group (FASG) began a randomised trial aimed to investigate the concept of dose intensity as well as the optimal duration of treatment in patients with early breast cancer. Between 1986 and 1990, 621 patients were included in the trial, of whom 595 were evaluable. Patients were randomised to 1 of 3 treatment groups: Group A (n = 207) received FEC 50 (fluorouracil 500 mg/m2, epirubicin 50 mg/m2 plus cyclophosphamide 500 mg/m2) every 21 days for 6 cycles; Group B (n = 193) received FEC 50 every 21 days for 3 cycles; Group C (n = 195) received FEC 75 (fluorouracil 500 mg/m2, epirubicin 75 mg/m2 plus cyclophosphamide 500 mg/m2) every 21 days for 3 cycles. Locoregional radiotherapy was administered after the third cycle of chemotherapy in all treatment arms. Clinical prognostic factors were similar between treatment groups. Approximately 62% of all patients had 1 to 3 positive lymph nodes; 50% of patients were hormone receptor positive and 73% were Scarff-Bloom Richardson (SBR) grade 2 to 3. Toxicity was evaluated in 595 patients (207, 193 and 195 patients in Groups A, B and C, respectively), who received a total of 2301 chemotherapy cycles.(ABSTRACT TRUNCATED AT 250 WORDS)

High serum HDL-cholesterol in pre- and post-menopausal women with breast cancer in southern Italy

Up until now, conflicting results have been reported on the association between serum cholesterol and risk of breast cancer in women. In this study, the serum concentrations of cholesterol, HDL-cholesterol, triglycerides and total lipids in women with breast cancer (BC) have been compared to those of women with benign breast disease (BBD). BC women had higher serum concentration of HDL-cholesterol both in pre- and in post-menopausal age. No difference was observed in the serum concentration of total cholesterol, triglycerides and total lipids. These findings could be explained by an increased estrogen activity which is believed to be involved in the development of breast cancer, and in the modulation of lipid metabolism (lowering LDL-cholesterol and increasing HDL-cholesterol). High serum HDL-cholesterol could be a biochemical index of increased risk of having breast cancer.

Risk factors and the prevention of breast cancer with tamoxifen

Oestrogen is intimately involved in the growth and development of breast cancer. Tamoxifen, a non-steroidal anti-oestrogen, not only is an effective adjuvant therapy for node positive and node negative disease, but also has several attractive pharmacological features that have enhanced interest in testing it as a preventive drug for breast cancer in high risk women. Tamoxifen is known to prevent contralateral breast cancer, but it also has significant oestrogenicity for reducing circulating cholesterol and preventing bone loss in the lumbar spine of postmenopausal women. Several clinical trials have been initiated around the world; however, there has been increasing concern about the safety of tamoxifen. Nevertheless, current reports indicate that there is little risk of developing endometrial and liver cancer, although further clinical studies must be planned. Concerns about retinal and thromboembolic problems remain anecdotal, and again additional research is essential. The prevention trials with tamoxifen are necessary to establish the worth and feasibility of a pharmacological intervention. If tamoxifen is found to be of value to prevent breast cancer in a broad population, then the future ability to predict breast cancer through molecular markers will provide the physician for the first time with a therapeutic option to treat the targeted patient.

Prognostic significance of the CaMBr1 antigen on breast carcinoma: relevance of the type of recognised glycoconjugate

An extensive study of the expression of the blood group-related antigen CaMBr1 has been performed by immunohistochemistry, immunoblotting and high performance thin layer chromatography both on frozen and paraffin-embedded (paraffin) samples from normal and neoplastic breast tissues. The glycolipid antigenic fraction (from frozen samples) was preferentially expressed on functioning breast epithelium. In a prospective series of 143 breast cancer cases CaMBr1 expression was associate, on frozen sections, with the transferrin receptor (P = 0.01), the positivity with oestrogen receptor immunochemical assay (P = 0.06), premenopausal status (P = 0.06) and node negativity (P = 0.07). Non-significant correlation with longer disease-free survival (DFS) was observed. In a retrospective series of 862 cases on paraffin sections the glycoproteic antigenic fraction was significantly associated with premenopausal status (P < 0.05) and lobular histotype (P < 0.01), but failed to predict survival, although a trend for longer DFS was observed for positive cases.

Urinary testosterone as a marker of risk of recurrence in operable breast cancer

We investigated the role of urinary testosterone levels as a marker of risk of recurrent disease in 113 operable breast cancer patients (70 premenopausal, 43 postmenopausal). Twenty-four-hour urine collections for testosterone measurement were obtained before surgical treatment, between 20-40 days thereafter, and then every 6 months for 5 years. The cutoff values to separate 'high testosterone (A+)' from 'normal testosterone (A-)' were 8.0 micrograms/24 h in premenopause and 4.9 micrograms/24 h in postmenopause. Urinary testosterone levels were considered high when they exceeded the cutoff value in at least 2 of the first 3 measurements (pretreatment, post-treatment, 6 months) of each patient. According to the aforementioned criterion, 33 patients (29.2%) had high testosterone levels, which were associated to axillary node involvement in 16 patients. Thirteen of the latter relapsed during the 5-year follow-up period (5/7 in premenopause, 8/9 in postmenopause). Relapse-free survival (RFS) curves were drawn only for node-positive patients owning to the small number of recurrences observed in the node-negative group. In premenopausal node-positive patients, RFS was significantly different for patients presenting high and normal urinary testosterone levels (77% vs 28%, respectively; logrank test, p < 0.006). In postmenopausal node-positive patients, RFS was also different between the two groups (54% vs 11% in 'high' and 'normal' excretors, respectively) but the difference was not statistically significant. The present findings suggest that urinary testosterone is a prognostic indicator of early breast cancer recurrence in node-positive patients.

William L. McGuire Memorial Symposium. Drug resistance to tamoxifen during breast cancer therapy

Breast cancer is the most common malignancy occurring in Western women, and is one of the leading causes of cancer mortality. The nonsteroidal antiestrogen tamoxifen has been shown to be an effective treatment for pre and postmenopausal women with all stages of the disease. Tamoxifen provides effective palliation when used to treat patients with advanced disease, and adjuvant tamoxifen therapy produces significant increases in both disease-free and overall survival (Early Breast Cancer Trialists Collaborative Group. Lancet 339:1-15, 71-85, 1992). Data from the laboratory have shown that the primary action of tamoxifen is tumoristatic rather than tumoricidal, and long-term therapy is therefore recommended. Unfortunately, many patients experience disease progression while taking tamoxifen. Some tamoxifen resistant tumors may remain sensitive to alternative endocrine therapies, while others may become refractory to any hormonal manipulation. Many models have been developed in vitro and in vivo to study the progression of breast cancer growth from tamoxifen sensitive to tamoxifen resistant. We and others have used long-term estrogen deprivation and long-term tamoxifen exposure to develop cell lines and tumors capable of growth in the presence of clinically relevant tamoxifen concentrations. Recently our laboratory has also shown that mutations in the estrogen receptor can cause an antiestrogen-occupied receptor to behave as though it were occupied by an estrogen. Breast cancer is a highly heterogeneous disease and it is likely that the mechanisms which cause tamoxifen resistant growth are equally heterogeneous. Several of the models from our laboratory and others which may contribute to an understanding of this complex phenomenon are discussed here.

The total incidence of loco-regional recurrence in a randomized trial of breast cancer TNM stage II. The South Sweden Breast Cancer Trial

We studied loco-regional recurrence during follow-up (median observation time 8 years) in 1,153 patients, who underwent modified mastectomy and were randomly assigned to one of the following postoperative treatments; Premenopausal patients: radiotherapy, cyclophosphamide, or both; Post-menopausal patients: radiotherapy, tamoxifen, or both. Recurrence occurred in a total of 419 patients, 123 of whom had loco-regional recurrence with or without distant metastasis. The loco-regional recurrence rate was 7% in the irradiated subgroups and 17% in the non-irradiated subgroups, the corresponding cure rates being 43% and 58%. Complete remission of all local recurrence was obtained after the first treatment in 67% of the cases, and was persistent in 67% of them (44% overall). Complete remission was obtained in all patients with local recurrence who received local treatment only, and was persistent in 65%. Of local recurrences treated with a combination of surgery, radiotherapy and hormone therapy, complete response was obtained in 94% of the patients, and was persistent in 94% of them (88% overall). Complete remission of all regional recurrence was obtained after the first treatment in 58% of the patients and was persistent in 67% of them (39% overall). Postoperative radiotherapy reduced not only the total number of loco-regional recurrences but also the number of uncontrolled loco-regional recurrences. Aggressive local treatment would appear to yield both satisfactory initial control and, when combined with the hormone therapy, a high rate of persistent loco-regional control.

Design and rationale of a randomised comparison of cyclophosphamide, methotrexate and fluorouracil vs fluorouracil, epirubicin and cyclophosphamide in node-positive premenopausal women with operable breast cancer. A trial of the International Collaborative Cancer Group (ICCG)

In 1984, the International Collaborative Cancer Group (ICCG) started a randomised trial comparing adjuvant treatment with cyclophosphamide 100 mg/m2 orally on days 1 to 14, methotrexate 40 mg/m2 intravenously on days 1 and 8 plus fluorouracil 600 mg/m2 intravenously on days 1 and 8 every 4 weeks for 6 cycles (CMF) vs fluorouracil 600 mg/m2, epirubicin 50 mg/m2 and cyclophosphamide 600 mg/m2 (FEC), all given intravenously on day 1 for 8 cycles at 3-week intervals in premenopausal patients with node-positive breast cancer. However, a large French institution that joined the ICCG shortly after the trial was initiated utilised different schedules of both CMF and FEC. Because different dose intensities were also employed, particularly of FEC, both patient groups, the French and non-French, will be analysed separately. A total of 761 patients were randomised as of March 1992. Patients were well balanced for prognostic factors. The median follow-up is now 3.5 years. Preliminary data have previously been reported in abstract form. Final data will be presented pending further follow-up.