Predictive value of nuclear DNA content in breast cancer in relation to clinical and morphologic factors. A retrospective study of 227 consecutive cases

Interactive cytometry, chance or evil of bias?

Interactive selection of a limited number of cells in imaging cytometry for determining the DNA histogram of breast cancer cells as the best known prognosticator at the moment, implies statistical and systematic sampling problems. Analysis of histograms of 361 breast cancer aspirate specimens measured in two laboratories demonstrate the expected high statistical variations in view of the only 100 cells measured per case but also slight systematic differences. Controlled systematic sampling without pathological bias results in a somewhat higher malignancy grading than selective biased sampling. For this finding we have no explanation. The main result is, however, that we did not find the expected contrary which makes the argument for at least this application invalid that expert pathologists are needed for reliable interactive sampling.

Methodologic sources of errors in image and flow cytometric DNA assessments of the malignancy potential of prostatic carcinoma

Considerable controversy exists about the value of using cytometric assessments of nuclear DNA ploidy patterns from neoplastic parenchymal cells of prostatic carcinomas as a supplement to conventional clinicopathologic data in an assessment of malignancy potential in neoplastic disease. To a great extent, the controversy is of methodologic origin. By revealing common pitfalls in this kind of DNA cytometry and by suggesting means to avoid or at least to reduce them, a realistic assessment can ultimately be made of the prognostic values of this technique: (1) the results of DNA assessments using flow cytometry and image cytometry should be combined (advantages and disadvantages with the two techniques outbalance each other); (2) the cytometric DNA ploidy pattern must always be correlated with results of histopathologic assessments and clinical data; (3) a standardization of DNA histograms obtained by means of both flow DNA cytometry and image DNA cytometry must be made with precise definitions of "diploidy," "tetraploidy," and "aneuploidy"; (4) the subjective component in classifying DNA histograms can be reduced by means of a computerized evaluation technique; (5) the degree of intratumoral variation in DNA ploidy patterns of neoplastic cell nuclei must be established by means of assessments of multiple biopsy specimens from widely different parts of a carcinoma; and (6) foci of a previously poor recognized neuroendocrine phenotype of neoplastic parenchymal cells are ubiquitous in prostatic carcinomas, particularly in anaplastic adenocarcinomas. Today, the DNA ploidy pattern of this phenotype can be assessed by means of a new image DNA cytometry technique.

Comparison between flow cytometry and image cytometry in ploidy distribution assessments in gynecologic cancer

The DNA content in 37 tumors from 34 women with gynecological cancer was measured by flow cytometry (FCM) and interactive image cytometry (ICM). Agreement was obtained in 81% of cases as regards ploidy levels, but seven tumors (19%) showed different ploidies. Of these, five were classified as diploid by FCM but either aneuploid (three cases) or polyploid (two cases) by ICM. Two other tumors were aneuploid by ICM but polyploid (one case) and unclassifiable (one case) by FCM. All tumors classified as aneuploid by FCM were also aneuploid by ICM, and all tumors classified diploid by ICM were also diploid by FCM. Of six patients whose tumors were classified as euploid (five diploid and one polyploid) by FCM but classified as aneuploid by ICM, five relapsed, and three of these have died of disease. On the basis of these findings, it is concluded that ICM must be performed in cases classified as diploid by FCM to ensure that small subpopulations of aneuploid tumor cells are not overlooked.

Prognostic potential of flow cytometric S-phase and ploidy prospectively determined in primary breast carcinomas

In a prospective study of a consecutive breast cancer series accumulated in the period 1978-82, the S-phase fraction (SPF) and ploidy status were determined by flow cytometry performed on cell nuclei derived from samples of 580 primary tumors. Sixty percent of the tumors were non-diploid. After correction for debris the median SPF values were 7.3% overall, 12% for non-diploid tumors, and 2.9% for diploid tumors (2.6% when nodal subsets N2 and N3 and cases with metastases at presentation were excluded). The SPF values correlated both to tumor size (p = 0.008) and to the number of positive axillary lymph nodes (p = 0.03). At clinical follow-up in 1986, 467 unilateral breast cancer patients who had undergone radical treatment for cure could be evaluated with respect to the prognostic value of both the SPF value and ploidy status. The median duration of follow-up was then 59 months (range 2-90), and the median time-to-recurrence 24 months (range 2-69, n = 137). At follow-up in 1991, 201/467 of the patients had died, the median duration of follow-up being 50 months (range 2-126) for the decreased, and 119 (range 6-148) for the survivors. In multivariate analysis (Cox's proportional hazards models), the strongest independent predictors of distant recurrence-free survival (DRFS) were the number of positive axillary lymph nodes (p less than 0.0001), the debris-corrected SPF value alone (p = 0.003, versus p = 0.05 for uncorrected value), and ploidy status combined with the corrected SPF value (p = 0.0002). When age was taken into account, both the corrected SPF value and the ploidy-SPF combination were predictors of crude survival (p = 0.006 and p = 0.002, respectively). In univariate life-table analysis, the 5-year DRFS rate was 93% in node-negative (N0) cases with an SPF less than 7.3%, as compared to 80% in those with an SPF greater than or equal to 7.3% (p = 0.005). Among node-positive cases, the prognostic value of the SPF was confined to those with 1-3 positive nodes, the 5-year DRFS rate being 68% in cases with an SPF less than 7.3%, as compared to 40% in cases with an SPF greater than or equal to 7.3% (p = 0.01).(ABSTRACT TRUNCATED AT 400 WORDS)

A meta-analysis of reported correlations between prognostic factors in breast cancer: does axillary lymph node metastasis represent biology or chronology?

A statistical overview of published results on correlations between various prognostic factors in breast cancer was undertaken. A distinction was made between clinical (or anatomical) prognostic factors--namely, axillary lymph node status and tumour size--and eight different biological prognostic factors. The latter included: tumour grade, oestrogen and progesterone receptor status, thymidine labelling index, DNA ploidy, S-phase fraction, epidermal growth factor receptor expression and c-erbB-2 gene amplification (or overexpression). 139 articles were eligible for review which reported a total of 432 individual correlations. A simple form of meta-analysis was employed: the counting method, in which the number of studies achieving a statistically significant correlation or not were counted. For each possible correlation examined, the proportion of studies showing a statistically significant correlation was calculated and an exact binomial 99% confidence interval determined for that proportion. If the 99% confidence interval included 5% (the proportion of correlations that would be expected to be statistically significant if the null hypothesis was true), it was taken as failing to exclude the null hypothesis of a zero correlation, while if it excluded 5% it was taken as rejecting the null hypothesis of a zero correlation. A broad agreement was found among published reports on the existence of a statistically significant correlation between the various biological prognostic factors in breast cancer. Of the 20 correlations examined, 18 had a 99% confidence interval excluding 5%, thus rejecting the null hypothesis of a zero correlation. On the other hand, a completely different result was obtained when reports on possible correlations between lymph node status and tumour size on the one hand and the eight biological prognostic factors on the other were analysed. Of the 16 correlations examined, 13 had a 99% confidence interval including 5%, failing to reject the null hypothesis of a zero correlation. These observations suggest the hypothesis that the prognostic influence of node status and tumour size cannot be explained by an analysis of the biology of breast cancer; and is compatible with the contention that axillary node status is merely a reflection of the relative chronological age of breast cancer.

Cytologic assessment of tumor cell kinetics: applications of monoclonal antibody Ki-67 to fine-needle aspiration smears

Rates of tumor-cell proliferation often provide prognostic information about a given neoplasm. Previously available methods for accessing cell kinetics are time consuming and expensive, and often require special equipment or radioactive reagents. Monoclonal antibody Ki-67 binds a nuclear antigen expressed in proliferating but not in resting cells. We studied Ki-67 immunostaining of fine-needle aspiration smears from 40 benign and malignant masses. Labeling indices ranged from 0 (thyroid follicular adenoma) to 75 percent (pulmonary oat-cell carcinoma). Frozen section immunostaining (11 cases) and flow cytometric assessment of cell proliferation (8 cases) were in good agreement with Ki-67 labeling indices on smear material. We suggest that this method provides a rapid, inexpensive, and dependable means of assessing tumor-cell kinetics in cytologic preparations.

DNA content flow cytometry as a prognostic factor for node-positive breast cancer. The role of multiparameter ploidy analysis and specimen sonication

The DNA content was analyzed in paraffin-embedded material from 167 patients with node-positive breast cancer to learn whether specimen sonication and multiparameter ploidy analysis (MPPA) (using DNA content and light scatter) could improve the strength of ploidy as a prognostic variable. Sonicated specimens were found to have fewer aggregates, a lower percentage of cells in S-phase (%S) and G2M phase than the corresponding nonsonicated specimens. The results using MPPA predicted the prognosis better because they allowed detection of small aneuploid peaks in histograms classified as diploid or tetraploid using DNA content alone. Ploidy was a significant univariate factor, and patients with tetraploid tumors had the best survival. In the multivariate analysis, if other routine factors were examined preferentially, ploidy and %S did not provide additional prognostic information for survival. This study of paraffin-embedded breast cancers suggested that sonication and MPPA may improve the ploidy analysis in certain cases and that tetraploidy may be a favorable ploidy pattern in this group.

DNA flow cytometric analysis of primary operable breast cancer. Relation of ploidy and S-phase fraction to outcome of patients in NSABP B-04

Between 1971 and 1974, 1665 women with primary operable breast cancer were randomized into a National Surgical Adjuvant Breast and Bowel Project (NSABP) trial (B-04) conducted to evaluate the effectiveness of several different regimens of surgical and radiation therapy. No systemic therapy was given. Cells from archival paraffin-embedded tumor tissue taken from 398 patients were analyzed for ploidy and S-phase fraction (SPF) using flow cytometry. Characteristics and outcome of patients with satisfactory DNA histograms were comparable to those from whom no satisfactory cytometric studies were available. In patients with diploid tumors (43%), the mean SPF was 3.4% +/- 2.3%; in the aneuploid population (57%), the SPF was 7.9% +/- 6.3%. Only 29.9% +/- 17.3% of cells in aneuploid tumors were aneuploid. Diploid tumors were more likely than aneuploid tumors to be of good nuclear grade (P less than 0.001) and smaller size (P equals 0.03). More tumors with high SPF were of poor nuclear grade than were tumors with low SPF (P equals 0.002). No significant difference in 10-year disease-free survival (P equals 0.3) or survival (P equals 0.1) was found between women with diploid or aneuploid tumors. Patients with low SPF tumors had a 13% better disease-free survival (P equals 0.0006) than those with a high SPF and a 14% better survival (P equals 0.007) at 10 years than patients with high SPF tumors. After adjustment for clinical tumor size, the difference in both disease-free survival and survival between patients with high and low SPF tumors was only 10% (P equals 0.04 and 0.08, respectively). Although SPF was found to be of independent prognostic significance for disease-free survival and marginal significance for survival, it did not detect patients with such a good prognosis as to preclude their receiving chemotherapy. The overall survival of patients with low SPF was only 53% at 10 years. These findings and those of others indicate that additional studies are necessary before tumor ploidy and SPF can be used to select patients who should or should not receive systemic therapy.

Adjuvant systemic therapy of stage I and II breast cancer

The value of adjuvant systemic therapy has been clearly demonstrated in both node-positive and node-negative patients. However, there are many women with favorable prognoses whose breast cancer recurs. It has been possible only recently to identify subsets of patients who are at definite risk for recurrence. Advances both in selection and treatment of patients with early-stage breast cancer are being made as critical research questions are delineated and examined in prospective randomized trials.

Two-dimensional polyacrylamide gel electrophoresis of human lung cancer: qualitative aspects of tissue preparation in relation to histopathology

It is of great importance to identify new objective markers significant for the diagnosis, treatment, and prognosis of human cancers. Cytometric assessment of the DNA content has been shown to be one parameter which correlates excellently with the clinical course of patients with solid cancers of the breast, prostate, and thyroid. However, additional specific marker polypeptides are needed in order to further improve the diagnostic and prognostic sensitivity. Two-dimensional polyacrylamide gel electrophoresis (2-DE) is a unique tool in this field of cancer research, but serious problems concerning intersample variations in the 2-DE pattern must be solved because quantitative variations of potential marker polypeptides are expected to occur at low levels. In this study we examined a modified preparation method for tumor tissues, focusing on the relation between histopathological properties and 2-DE gel quality. We selected a group of human lung cancers sharing similar prognosis; nevertheless, the 2-DE patterns showed significant intersample but low intrasample variations. It is concluded that histopathological features, such as a local homogeneity, and the amounts of connective tissue and serum proteins are critical factors for the successful preparation and high quality of 2-DE-gels.

Medical management of early-stage breast cancer

With improved screening and education, a greater proportion of breast cancer is detected at an early stage. Although the prognosis for many of these patients is excellent following definitive local therapy alone, some subsets of node-negative patients have a 30% chance of eventually developing metastatic disease that will be incurable with current therapy. Thus, an increasing proportion of early-stage patients are being offered some form of adjuvant therapy, with the expectation of improved relapse-free survival, and possibly improved overall survival. Efforts have been made to base the selection of patients for adjuvant therapy on specific prognostic factors. Meanwhile, the scope and complexity of putative prognostic factors continues to widen, and now includes such items as the presence of occult microscopic metastases, DNA ploidy and proliferative fraction, cytogenetic abnormalities, oncogene expression, growth factor receptors, and expression of hormonally regulated proteins. In addition, there is now a considerable range of options with regard to the composition, dose intensity, and sequence of multimodality therapy. Data regarding the classification, significance, and interpretation of prognostic factors is reviewed together with the development, current status, and recommendations regarding adjuvant therapy for patients with early-stage breast cancer. For 1991, the National Cancer Institute (NCI) has estimated that 175,000 new cases of breast cancer will be diagnosed in American women. It is also estimated that 44,500 women will die of breast cancer. Unfortunately, the age-adjusted death rate from breast cancer has shown no overall change from 1930 through 1987. However, effective screening techniques continue to identify an increasing percentage of early-stage tumors, which should exceed 50% of all new tumors in 1991. Ultimately, our understanding of environmental and genetic risk factors may identify new ways to reduce the impact of this disease. In the interim, development and application of effective systemic adjuvant chemotherapy and hormonal therapy has become increasingly important. There is no question that a greater proportion of patients with less extensive disease are now being offered some form of adjuvant therapy. Meanwhile, selection of patients for adjuvant therapy, and choice among specific adjuvant regimens, has remained controversial. Analysis of multiple prognostic factors is performed not only in the context of cooperative investigational trials, but more often in the offices of individual physicians caring for individual patients. Tumor biopsies can now be routinely sent to specialized laboratories for performance of complex assays with potential prognostic information, although interpretation of these results with reference to a specific patient is often uncertain.(ABSTRACT TRUNCATED AT 400 WORDS)

Regional heterogeneity in breast carcinoma: thymidine labelling index, steroid hormone receptors, DNA ploidy

We examined multiple samples of 65 primary breast carcinomas larger than 1 cm in diameter for thymidine labelling index (TLI), DNA index (DNAI, a measure of cellular DNA content by flow cytometry), and estrogen (ER) and progesterone (PgR) receptors by radioligand-binding. One or more axillary metastases were also assayed in 11 patients. Two to 15 samples were successfully assayed for TLI from 59 tumors, 2-31 samples for DNAI from 61 tumors, and 2-15 samples from 55 tumors for ER and PgR. Criteria for heterogeneity were excess inter-sample variance in comparison with intrasample variance at the p less than 0.05 level for TLI and DNAI, and variation of clinically significant magnitude in assay results for ER and PgR. Sixty-one percent of tumors were heterogeneous for TLI, 26% for DNAI, 24% for ER and 40% for PgR. High TLI disposed toward heterogeneity for TLI itself (p = 0.06), for ER (p = 0.04), and for PgR (p = 0.007). Young age favored heterogeneity for TLI (p = 0.12), ER (p = 0.002), and PgR (p = 0.04). Heterogeneity for DNAI was not related to age and TLI status but was more common in larger tumors (p = 0.08). After consideration of relationships between TLI, age, size, ER and PgR, TLI rather than age appears to be the more important determinant of heterogeneity for receptors. High TLI could lead to heterogeneity through increased numbers of cell divisions that favor emergence of variant stemlines, or by causing local vascular and humoral disparities through rapid growth. Regional heterogeneity can explain erroneous prognostic predictions in approximately 10% to 20% of breast carcinoma patients. We recommend multiple sampling of large breast carcinomas and analysis of axillary metastases for study of tumor markers.

Chromosome numbers and DNA-content in intracerebrally transplanted experimental gliomas

Serially transplanted experimental tumors of the central and peripheral nervous system can be used as models to investigate open questions in human neurooncology. Altered susceptibility of higher passages to chemotherapy might be correlated with chromosome number and DNA-content variations which would be partly expressed as changes in proliferation behaviour. Karyotypes therefore were analysed in the 73rd to 90th generations of transplanted experimental gliomas. Wide variation of chromosome number was observed; 2 major types of distribution occurred, the one presenting with, the other without stemlines. Large chromosomes # 1 and # 4 were often monosomic, while small chromosomes of ## 8 to 20 were increased up to the fivefold. Lines with prominent and few markers were observed. On the whole, cells of the proliferating pool of the tumor had to be considered as hypotetraploid. Comparison of chromosome numbers and DNA content gave good correlation; differences between the 2 were explained by the fact that only the number of chromosomes was taken into account, regardless of whether small or large chromosomes were lacking or in excess. When intracerebrally transplanted tumors had been previously treated by administration of BCNU, the DNA content was altered, indicating an increased share of diploid cells in the proliferation pool. Results are at variance with earlier findings in tissue cultures of directly induced malignant gliomas and neurinomas in rats. The findings in transplanted tumors can be interpreted as a result of increased malignancy in transplantation tumors, documented by rapid growth in the animal and dedifferentiated histologic morphology.

DNA ploidy and cell-cycle analysis: tools for assessment of cancer prognosis

DNA ploidy and cell cycle analysis as measured by flow cytometry (FC) and image analysis (IA) have moved out of the realm of the research laboratory to become valid clinical tests used in the assessment of prognosis of the cancer patient. Although much information on the relationship of DNA ploidy/%S-phase analysis to patient prognosis is available in the literature, the data are not presented in such a way as to be helpful in clinical decision making. Because predictive values and confidence intervals, which measure the likelihood that a given clinical test will rule in or rule out a clinical outcome, were not calculated in previous reviews, conclusions about the clinical utility of these analyses were not possible. Using the available raw data on DNA ploidy and %S-phase analysis from previously published papers, predictive values and confidence limits were calculated for specific clinical presentations. In several such clinical situations (tumor type, stage, etc.), predictive value of greater than 90% was derived. We conclude that in these situations DNA ploidy and %S-phase analysis can be used to predict clinical outcome, to design treatment, and to guide patient management. The evaluation of the clinical utility of these tests must ultimately rest on prospective trials which show that randomized arms respond to treatment regimens dependent upon the DNA ploidy and %S-phase status.

Histological grading of breast cancer. Interobserver, reproducibility and prognostic significance

A study was conducted to assess the reproducibility and prognostic significance of the histopathological grading by using the criteria of Bloom and Richardson. 166 breast carcinomas of the invasive ductal type (NOS - not otherwise specified) according to the WHO criteria, selected from the biopsy material of the years 1980 to 1988 were investigated. 85 of the patients presented axillary lymph node metastases in the mastectomy specimens. A satisfactory correlation of histopathological grades assessed by three pathologists was found in 72.3% of all cases. Fifteen cases (9%) were over- and 31 cases (18.7%) were underestimated compared with an expert's grade. A disagreement of two grades occurred in one case only. In comparison of grade 1 and grade 3 tumours as well as of grade 2 and grade 3 tumours significant differences in the overall survival could be found. Irrespective of statistically significant differences between the three grades in actuarial survival, the histopathological grading is of rather low value for the prediction of prognosis of individual patients.

DNA measurements in chronic hepatitis, cirrhosis and hepatocellular carcinoma

It has been documented that chronic hepatitis may progress to cirrhosis and then develop hepatocellular carcinoma (HCC). To test whether abnormal cellular DNA increases along this line of development, liver tissues from 48 patients with chronic hepatitis, 17 with cirrhosis, and 8 with HCC were investigated for cellular DNA content with a scanning microdensitometer. Seven of 8 HCCs and 2 cirrhotic livers adjacent to HCC had abnormally increased cellular DNA content. Only 4 livers from patients with chronic liver diseases other than HCC had abnormal cellular DNA content. The cellular DNA content in livers not accompanying HCC was not related to the patient's age, histological diagnosis, and hepatitis inflammatory activity. The results confirmed the increase of cellular DNA content in HCC, but did not provide evidence of a progressively increasing DNA content from chronic hepatitis to liver cirrhosis. However, cirrhotic livers with abnormal hepatocytic DNA content deserve careful follow-up for the early detection of HCC.

Prognostic indicators in invasive breast cancer

Tumor size and axillary lymph node involvement are the primary determinants of clinical course for most patients. Receptors for estrogen and progesterone are important additional prognostic factors for disease-free survival, overall survival, survival time after initial disease recurrence, and the likelihood of response to hormonal therapy. Histologic grading has merit as a prognostic factor, although poor reproducibility limits its broad application. Promising data have been emerging from the use of flow cytometry to analyze DNA content and proliferative rate. Patients with aneuploid tumors are more likely to have a shorter survival time than patients with diploid tumors. A high S-phase fraction also identifies a subset of patients at increased risk for early relapse. A combined index of ploidy and S-phase may be a more useful guide; together, diploidy and low S-phase identify a subgroup of node-negative patients at very low risk for disease recurrence. A number of oncogenes have been identified in breast cancer; amplification of the HER-2/neu gene or overexpression of the gene product may be an important prognostic indicator for node-positive patients.

DNA ploidy level and S-phase fraction as prognostic factors in breast cancer

Imprint smears from sixty cases of breast cancer made after mastectomy were stained by the Feulgen method and the nuclear DNA content measured by a cytofluorometer equipped with an incident illumination system. After logarithmic transformation of the fluorescence intensity, the ploidy level and S-phase fraction (SPF) were calculated with a microcomputer and the correlation between the ploidy level or SPF and the clinicopathological prognostic factors studied. Patients with tumors of a larger diameter and more extensive lymph node involvement had higher levels of ploidy and SPF and the ploidy level in the metastatic lymph nodes was higher than that in the primary lesion. Moreover, a significant increase in SPF was observed in the metastatic lymph nodes and a high ploidy level found to be associated with tumors having a negative estrogen receptor. When the tumors were divided into a diploid group and an aneuploid group, the diploid group showed a significantly better prognosis than the aneuploid group, in 6-year survival. Similarly, the groups in which SPF was less than 20.0 per cent had significantly better prognoses than the group in which SPF was 20.1 per cent or more. These prognostic factors were evaluated with Cox's proportional hazard model and a significant correlation observed in lymph node status, ER status, ploidy level and S-phase fraction. It was thus concluded that ploidy level and SPF are important and independent prognostic factors for predicting the postoperative course of breast cancer patients.

The future anatomic pathology laboratory for molecular diagnosis and prognosis: circa 1990-95

Molecular biology provides analytical tools for the study of human disease. These clinical assays can help make a diagnosis, predict a prognosis, or elucidate the pathogenesis of poorly understood diseases. The detection and/or quantitation of specific genes, messenger RNA's, and their protein products provide diagnostic and prognostic information for physicians. Illustrative applications of some of these techniques in human virus infection and breast cancer will suggest the future direction that an anatomic pathology laboratory should consider if it is to provide optimal and competitive service to physicians.

Mitotic rate, DNA distribution, and chromatin in situ sensitivity to heparin in breast cancer

The purpose of this study was to characterize breast carcinomas by cell kinetic parameters. Mitotic rate (MR) and flow cytometrically (FCM) measured cell cycle distribution as well as chromatin testing in situ employing heparin for determination of activated chromatin, provided the following results: MR counted in 73 unselected carcinomas showed an increase up to a tumor size of 4.2 cm (p less than 0.05); beyond this diameter, the MR was found to decrease. In T1-T2 carcinomas, cell cycle stage analysis yielded higher percentages of cells in S and G2M phase for ductal (13% and 12%, N = 22) than for lobular (8% and 7%, N = 8) node-negative carcinomas (p less than 0.002). In ductal carcinomas, lymph node involvement was reflected by higher % G2M values (15%, N = 26) compared with negative cases (12%, N = 22) (p less than 0.05). Ductal node-positive T3-T4 carcinomas (N = 10) revealed a higher % S value (16%) than their T1-T2 counterparts. A correlation between MR and % G2M was established only up to a tumor size of 4.2 cm (r = 0.39, p less than 0.05). A highly sensitive ('H') and a poorly sensitive ('P') subgroup of carcinomas with respect to heparin-induced changes in fluorescence intensity of the G1/0 peak of the DNA aneuploid cell line were identified, as previously shown. These subgroups were here updated with a larger number of carcinomas and were limited to T1-T2 cancers (N = 57). Group 'H' included more younger patients (p less than 0.005), less cases with nodal involvement in ductal carcinomas (p less than 0.05), and lower % G2M values in lobular node-negative cases (p less than 0.05), than group 'P'. DNA diploid cells always existing in DNA aneuploid carcinomas are more sensitive than their aneuploid counterparts (p less than 0.01); however, they strengthen the stratification to 'H' and 'P'. We suggest 'H' carcinomas to be less aggressive than 'P' carcinomas. Small breast carcinomas are recommended to cell kinetic investigations for individualizing adjuvant therapy.

Pathologic findings from the National Surgical Adjuvant Breast and Bowel Projects (NSABP). Prognostic discriminants for 8-year survival for node-negative invasive breast cancer patients

Twenty-two pathologic features (including estrogen and progesterone receptors) and four clinical features observed in 950 women with node-negative Stage I invasive breast cancer who enrolled in the National Surgical Adjuvant Breast and Bowel Projects (NSABP) protocol B-06 were evaluated for their possible prognostic significance. Preliminary univariate analysis revealed ten characteristics that were significant in this regard at the 1% level. Their assessment in a Cox regression model demonstrated only three to be prognostically important; notable among these were nuclear grade, histologic tumor type, and race. Life-table plots revealed that 86% of patients whose cancers exhibited good nuclear grade survived for 8 years as opposed to 64% in whom the nuclear grade was scored as poor. Analyses demonstrated three prognostic categories for histologic tumor type. Patients with either mucinous, tubular, or papillary cancers fared significantly better than those having not otherwise specific (NOS) or atypical medullary tumors. Survival for those with typical medullary, NOS combinations, or lobular invasive cancers was intermediate. Blacks fared worse than whites. Survival was correspondingly better or worse when two favorable or unfavorable characteristics were detected. The number of black women in this cohort was considered too small for further subset analysis although generally the pattern of findings suggested that survival was worse for blacks than for whites in all subsets. A review, as well as our own experience, suggested that nuclear grade is as good if not better as a predictor of survival in node negative patients as information derived from DNA analyses, immunohistochemical demonstration of erb-B2 overexpression, and, possibly, the tumor labeling index at predicting survival in node-negative patients.

Indicators of prognosis in node-negative breast cancer

Measures of the proliferative activity of tumor cells have prognostic value in patients with node-negative breast cancer. We studied 367 women in southern Sweden who had undergone surgical resection for such cancer. Tumor specimens were analyzed with DNA flow cytometry in order to estimate both the DNA content (ploidy) and the fraction of cells in the synthetic phase of the cell cycle (S phase). The median duration of follow-up was four years; 28 percent of the patients received adjuvant therapy, usually with tamoxifen (n = 83). A multivariate analysis based on complete data on 250 patients included the following covariates: age (greater than or equal to 75, 50 to 74, and less than or equal to 49 years), tumor size (less than or equal to 20 vs. greater than 20 mm), concentration of estrogen and progesterone receptors (less than 10 vs. greater than or equal to 10 fmol per milligram of protein), ploidy (diploid vs. nondiploid), and S-phase category (fraction of cells in S phase: less than 7.0 percent, 7.0 to 11.9 percent, and greater than or equal to 12 percent). The S-phase fraction yielded the most prognostic information, followed by progesterone-receptor status and tumor size. A prognostic model based on these three variables identified 37 percent of the patients as constituting a high-risk group with a fourfold increased risk of distant recurrence. In the remaining 63 percent of the patients, the five-year overall survival rate (92 +/- 4 [+/- SE] percent) did not differ from the expected age-adjusted rate for Swedish women. We conclude that a prognostic index that includes indicators of the proliferative activity of tumor cells may be able to identify women with node-negative breast cancer in whom the risk of recurrence is sufficiently low that adjuvant chemotherapy can be avoided.

Nuclear DNA content and survival in medullary thyroid carcinoma. Swedish Medullary Thyroid Cancer Study Group

In a nationwide study of medullary thyroid carcinoma, the relation between nuclear DNA content and survival was studied in 211 patients with complete follow-up of up to 27 years. Morphologically identified tumor cells were analyzed by an image cytometric method. The DNA histograms were classified (1) by an objective method in which the degree of aneuploidy was defined as the percentage number of tumor cells with DNA values exceeding the 90th percentile of diploid control cells (P90), and (2) according to a subjective evaluation of whether the DNA profiles represented a euploid or an aneuploid DNA pattern. Both classifications separated groups with marked differences (P less than 0.001) in survival. A multivariate proportional hazards analysis indicated that each method provided additional information when the other one was taken into account. In patients whose tumors were classified according to the objective P90 method 1, the relative hazards (with 95% confidence interval) in the groups with P90 values of 36% to 69% and greater than or equal to 70% were 1.6 (0.9-2.8) and 2.1 (1.1-4.0) respectively, compared with the reference group. With the subjective method 2 the corresponding figure for the group with aneuploid tumors was 1.7 (1.0-2.0) compared with the group with euploid tumors.

Variations in Feulgen stainability of epithelial parenchymal cells extracted from paraffin-embedded salivary gland specimens

The variations of Feulgen stainability of cells extracted from paraffin-embedded archival specimens for DNA assessment by means of image cytometry (ICM) were investigated in normal salivary gland parenchyma. The Feulgen stainability of the deparaffinized, rehydrated, and disaggregated preparations was found to exhibit variations of up to 300%, expressed by the mean of integrated optical density (IOD), when a routine procedure was applied to a first series of Cytospin preparations of disaggregated specimens. When measured in nondisaggregated tissue sections, only negligible variations were observed. After minimization of the mechanical strains to the cellular material in the Cytospin preparations in a second series, the variations in Feulgen stainability were found to be considerably lower. The findings indicate that the main reason for variations in the Feulgen stainability of extracted cells is, most likely, the disaggregation procedure itself. Factors such as initial treatment of the specimens, duration and kind of formalin fixation, and length of storage time periods seem to be of minor importance. Retrospective studies on paraffin-embedded specimens require a carefully controlled tissue type-adapted disaggregation procedure. In addition, we concluded that the interpretation of histograms, obtained by means of ICM DNA assessments in Cytospin preparations of archival material, requires a well-defined internal specific standard.

Partition of protein and DNA during cytokinesis in human breast cancer cell lines

Three human breast cancer cell lines (HTB-126, MDA-231, and HTB-122) with DNA index (DI) values between 1.26 and 1.72 were analysed together with a diploid mouse embryonal carcinoma cell line (PCC3) by a TV-video time-lapse technique (pedigree analysis). Cytochemical parameters (DNA and proteins) were studied in individual cells in a rapid scanning microspectrophotometer. Post-mitotic sister cell pairs were analysed after Feulgen-naphthol-yellow staining. The DI values of the cell lines were selected to reflect various well-known clinical ploidy entities differing in malignancy potentials. A mitotic disturbance of the partition of DNA and protein to daughter cells was found in particular in MDA-231 closest to the triploid DNA modal value (DI = 1.37). Duration of mitosis was considerably longer in the near triploid line compared to the other lines. The MDA-231 line was also least sensitive to suboptimal growth conditions. This report calls attention to a possible causality between mitotic error and intraclonal genotype and cell mass heterogeneity.

Prognostic value of S-phase fraction and DNA ploidy studied with in vivo administration of bromodeoxyuridine on human gastric cancers

The authors studied the prognostic values of DNA ploidy pattern and proliferative activity with in vivo administration of bromodeoxyuridine in human gastric cancers. Fresh specimens surgically removed from 117 patients with gastric cancer were investigated by flow cytometric study using a monoclonal antibody to bromodeoxyuridine. DNA ploidy patterns were classified into four types according to the bivariate BrdUrd/DNA distribution: D1, tumors with single diploid population; D2, tumors which showed mosaic of diploid and aneuploid population; A1, tumors with single aneuploid population; and A2, several aneuploid populations without diploid population. The numbers of cases of each ploidy pattern were as follows: D1, 36 cases (30.8%); D2, 38 cases (32.5%); A1, 15 cases (12.8%); and A2, 27 cases (23.1%). DNA ploidy pattern and S-phase fraction (SPF) showed no relation with clinicopathologic findings, except for type A2. In type A2, lymph node metastasis and lymphatic vessel invasion were observed more often than type D1. The SPF calculated from the bivariate BrdUrd/DNA distribution was higher in aneuploidy (D2, A1, and A2) than in diploidy (D1) (P less than 0.01). Also, A2 exhibited a higher SPF than A1 (P less than 0.01). Furthermore, SPF correlated with DNA index significantly (P less than 0.01). Patients who showed aneuploid tumors, DNA ploidy type A2, or SPF of more than 10% survived 3 years less than those with diploid tumors, DNA ploidy type D1, or SPF of less than 10%, respectively (P less than 0.05). By analyzing with the Cox's proportional hazard's model, it is revealed that DNA ploidy and SPF are one of the independent factors of prognostic significance. The results indicated that the patients with aneuploid tumors or highly proliferative tumors had a poor prognosis and that DNA ploidy pattern and SPF were useful prognostic factors for gastric cancers.

The prognostic significance of growth pattern and its relation to tumor cell nuclear DNA content in endometrial carcinoma

Hysterectomy specimens from 21 endometrial carcinoma patients, who died from their disease, and 23 patients selected at random from 307 survivors, were analysed for tumor growth pattern and tumor cell nuclear DNA content. The results indicate that tumor growth pattern, reflected by the mode of infiltration, is significantly correlated to the clinical course of the disease. Patients with carcinomas exhibiting contiguous growth pattern had a better outcome than patients with discontiguously growing carcinomas. It was also found that tumor growth pattern correlated well with tumor nuclear DNA content. It is suggested that the pattern of infiltration of the tumors is a sensitive predictor of prognosis and that this prognostic information, which only can be obtained postoperatively, to a large extent is reflected by tumor cell nuclear DNA content in curetted diagnostic material, obtained prior to treatment.

Inflammatory symptoms in breast cancer. Correlations with growth rate, clinicopathologic variables, and evolution

Based on two pretreatment evaluations, doubling time (DT) was calculated in 75 cases of invasive breast cancer (BC). The cases studied were more or less equally distributed between three DT groups: fast-growing tumors (DT less than 90 days), intermediate cases (DT between 90 and 180 days), and slow-growing tumors (DT greater than 180 days. A correlation was found to exist between DT and patient age and, to an even greater extent, between DT and pathologic prognostic indicators such as histologic grading and nuclear grade. Inflammatory symptoms were not associated with DT, but were closely related to the size of the tumor and regional lymph node involvement. The date of detection of distant metastases depended heavily on the DT of the BC:BC with shorter DT = earlier metastatic spread. The presence of inflammatory signs was also decisive: within each DT category, inflammatory BC metastases were both more frequent and precocious.

DNA cytometry of soft tissue tumours with TV image-analysis system

We examined 69 soft tissue tumours for DNA content. Altogether 42 aspiration cytology and 27 imprint Feulgen-stained smears, each verified by histology, were analysed and the results evaluated with Böckings's algorithm. Except one false negative case (extramedullary ependymoma) 43 malignant and 25 benign soft tissue tumours could clearly be separated on the basis of their DNA content. The sensitivity of the positive cases (suspicious and malignant) came up to 97.7% with a false negative ratio of 2.2% while the sensitivity of the negative cases (benign) proved to be 75% with a 0% false positivity ratio. Cytometry is a useful aid in aspiration cytology diagnostics of soft tissue tumours particularly when their benign or malignant character is to be determined because the primary surgical therapy and consequently the further fate of patient, too, depend on the precise cytological diagnosis.

Aneuploidy as a prognostic factor in breast cancer

The predictive value of nuclear DNA content in mammary carcinoma is still under debate in spite of several reports indicating a relationship between DNA ploidy and prognosis. The impact of differences in methodology on the evaluation of DNA data is discussed, and a recent study demonstrating DNA ploidy as a statistically significant prognostic variable on a prospective material of breast cancer patients is presented.

Prediction of relapse or survival in patients with node-negative breast cancer by DNA flow cytometry

More accurate prediction of the prognosis in women with node-negative breast cancer may improve physicians' ability to identify the patients most likely to benefit from systematic adjuvant therapy. With this in mind, we performed DNA flow-cytometric measurements of ploidy and the fraction of cells in the synthesis phase of the cell cycle (S-phase fraction) on 395 specimens of node-negative breast cancer from our bank of frozen tumors, using the aliquots of pulverized frozen tissue from steroid-receptor assays. The median duration of follow-up in patients still alive at the time of analysis was 59 months. Thirty-two percent of the 345 specimens that could be evaluated were diploid, and 68 percent were aneuploid. The probability of disease-free survival at five years was 88 +/- 3 percent in patients with diploid tumors and 74 +/- 3 percent in those with aneuploid tumors (P = 0.02). The S-phase fraction was not a significant additional predictor of disease-free survival in patients with aneuploid tumors. However, the probability of disease-free survival in patients with diploid tumors and low S-phase fractions was 90 +/- 3 percent at five years, as compared with 70 +/- 13 percent in those with diploid tumors and high S-phase fractions (P = 0.007). Similar differences in overall survival were noted. We conclude that DNA flow-cytometric measurements of ploidy and S-phase fraction can be performed on frozen specimens of tumors and are potentially important predictors of disease-free and overall survival in patients with node-negative breast cancer.

Flow cytometry DNA ploidy and number of cell populations in the primary breast cancer and their correlation to the prognosis

In a prospective study on 516 breast cancer patients flow cytometry DNA ploidy and number of cell populations (defined as number of DNA stem lines) detected in the primary tumor were evaluated for prognostic purposes. The median follow-up time was about 5 years. In the 241 node negative cases, those patients with three or more cell populations had the worst prognosis, with a distant recurrence-free survival rate of about 60% at five years compared to 90% in cases with only one cell population detected in the primary tumor. The number of tumor involved axillary lymph nodes was the outstanding prognostic indicator which was confirmed in 275 node positive patients; DNA ploidy and number of cell populations did not give any significant prognostic information in this group of patients.

Non-palpable invasive breast carcinomas from the Stockholm screening project

Sixty-six non-palpable, invasive mammary adenocarcinomas from the Stockholm mammography screening project were studied with respect to histopathology. In 53 of these tumors estrogen receptor (ER) content was estimated and in 30 of them also the DNA distribution pattern. The tumors were predominantly of low or intermediate histological malignancy grade and ER-rich, whereas the distribution of DNA ploidy equalled that found in a non-selected tumor material. Only 2 tumors recurred during follow-up (median 51 months), indicating that non-palpable breast carcinomas represent a prognostically favourable subset in spite of a relatively high proportion of aneuploid tumors.

Prognostic value of nuclear DNA content in breast cancer in relation to tumor size, nodal status, and estrogen receptor content

The prognostic value of nuclear DNA distribution pattern in relation to tumor size, axillary lymph node status, and estrogen receptor (ER) content was studied in 464 patients with primary, operable mammary adenocarcinoma. The median follow-up time was 3 1/2 years. Slide cytophotometric DNA analysis was performed on morphologically identified Feulgen-stained tumor cells. The tumors were classified into four subgroups according to their DNA histogram type. DNA content was significantly related to tumor size and ER level but not to nodal status. When all variables were stimultaneously introduced into Cox's proportional hazards model, tumor size, nodal status, and DNA profile remained as significant predictors of recurrence. Restricting the analysis to node-negative patients, both DNA profile and tumor size showed a significant prognostic value. DNA did not contribute significant prognostic information in node-positive patients. However, the trends in recurrence-free survival were similar to those in the node-negative subgroup: patients with aneuploid tumors tended to fare worse than those with euploid carcinomas.