Intraductal biopsy for diagnosis and treatment of intraductal lesions of the breast

BACKGROUND

Bloody nipple discharge is a significant clue in the detection of ductal carcinoma of the breast. In the past, pathologic diagnoses were obtained exclusively via excision, but recently developed mammoscopic techniques have been found to yield valuable information relating to the diagnosis of intraductal lesions.

METHODS

Mammary duct endoscopy (i.e., mammoscopy) was performed a combined total of 407 times for 295 patients who experienced nipple discharge. Intraductal breast biopsy (IDBB) under mammoscopic observation was performed in 193 intraductal papillomas (from a total of 107 patients) and 30 ductal carcinomas (from a total of 27 patients); IDBB was performed a combined total of 36 times in the 27 patients who had breast carcinoma and yielded 21 diagnostic specimens (58.3%). In addition, the therapeutic value of IDBB was assessed in 70 patients with intraductal papilloma who had undergone more than 3 years of follow-up; these 70 patients harbored a combined total of 75 intraductal papillomas.

RESULTS

IDBB correctly identified the presence of carcinoma in 9 of 27 patients (33.3%); 7 other lesions (25.9%) were placed in the suspected carcinoma (i.e., atypical papillary lesion) category, and 5 (18.5%) were identified as intraductal papillomas. Using IDBB, it was difficult to collect diagnostic specimens from patients with breast carcinoma, because of the location and weak tissue cohesiveness of these lesions compared with intraductal papillomas. The 193 intraductal biopsies performed on intraductal papillomas yielded only 20 specimens that were insufficient for diagnosis. IDBB exhibited therapeutic efficacy in 54 of 70 patients with intraductal papilloma (77.6%) who had more than 3 years of clinical follow-up. Therapeutic results tended to be less favorable for patients who had intraductal lesions in multiple duct lobular units.

CONCLUSIONS

Mammoscopy can contribute not only to the diagnosis of cases of nipple discharge but also to the treatment of intraductal papilloma.

Utility of cytologic specimens in the evaluation of prognostic and predictive factors of breast cancer: Current issues and future directions

Although numerous biological and molecular markers of breast cancer have been identified over the past two decades, traditional factors such as estrogen receptor (ER), progesterone receptor (PR), and HER-2 remain among the most useful indicators of prognosis and therapeutic response to treatment. These markers can be reliably evaluated in cytologic specimens, particularly in fine-needle aspirates (FNA) of primary or metastatic breast cancer. Accurate assessment of ER, PR, and HER-2 is critical in the treatment of breast cancer patients. A review of the literature, however, shows considerable interlaboratory variability in the detection of these markers and reporting of the test results. Because therapies are now being directed toward individual molecular targets, there is a need for increased standardization of such analyses. Current practices should follow consensus recommendations set by the College of American Pathologists and the American Society for Clinical Oncology, and the results should be monitored through quality-assurance programs. The utility of cytologic specimens of breast lesions is also not limited to evaluation of individual prognostic and predictive factors. Cytologic specimens have been used successfully for genomic and proteomic studies. Such investigational studies are under way and offer great potential for revolutionizing the prediction of patient outcomes and disease response to therapy, as well as assessment of risk of developing breast cancer.

Ductoscopic cytology and image analysis to detect breast carcinoma

BACKGROUND

The goal of the prospective study was to determine whether 1) image analysis (IA; including DNA index [DI], S-phase fraction, and the presence or absence of aneuploidy or hypertetraploidy [HT]) of fiberoptic ductoscopy (FD) breast specimens was feasible, 2) IA findings from FD specimens predicted histopathologic evidence of disease, and 3) a combination of IA, cytology, and clinical factors provided complementary information in the diagnosis of breast carcinoma.

METHODS

IA and cytologic evaluation were performed on 106 consecutively collected ductoscopic specimens from 88 subjects.

RESULTS

IA was successful in 73 (71%) FD specimens. HT (P = 0.03) was related to intraductal visual observations. The proportion of atypical papillomas with aneuploidy was greater (P = 0.05) than in any other class. The HT index was higher in atypical papilloma (P = 0.02) and in breast carcinoma (P = 0.05) than with other diagnoses. The proportion of papilloma cases with HT was greater (P = 0.04) than benign papillomas. Malignant cytology was associated with a higher DI (P = 0.02) and a higher HT index (P = 0.001) than nonmalignant (benign or atypical) cytology. HT (P = 0.002) was less common with cytology containing few epithelial cells, and the HT index was higher with malignant versus nonmalignant FD cytology (P = 0.001). The percentage of cells containing HT was greater in FD specimens that were suspicious for malignancy (P = 0.006) than in those with benign cytology or mild atypia. Considering all samples and combining IA, cytologic, and visual findings in a stepwise linear discriminant analysis optimized the sensitivity (61%) and specificity (90%) of breast carcinoma prediction. Excluding spontaneous nipple discharge (SND) samples and adding epithelial cell quantity in samples improved the model (sensitivity, 85%; specificity, 80%).

CONCLUSIONS

IA was feasible in FD specimens whenever adequate epithelial cells were present. IA and cytologic findings were associated. Adding IA results to cytology and visual findings and excluding samples with SND improved diagnostic sensitivity.

Cell cycle genes in a mouse mammary hyperplasia model

Human mammary epithelial cells emerge spontaneously from senescence, exhibiting eroding telomeric sequences, and ultimately enter crisis to generate the type of chromosomal abnormalities seen in early stages of breast cancer. In a mouse mammary tumor model, the spontaneous escape of senescence can be observed as an increase in DNA synthesis that is reflected by alterations in the cell cycle profile and increases in the expression levels and activities of cell cycle molecular components. This review provides an overview of gene alterations in the cell cycle components in mouse mammary hyperplasia.

Estimation of an optimal radiotherapy utilization rate for gastrointestinal carcinoma

BACKGROUND

Radiotherapy utilization rates for cancer vary widely, both within and between countries. The optimal proportion of patients with gastrointestinal malignancies who should receive at least one course of radiotherapy at some time during their illness is an important benchmark.

METHODS

The authors studied treatment guidelines and treatment reviews to identify the indications for radiotherapy for patients with gastrointestinal malignancies. Optimal radiotherapy utilization trees were constructed to show the clinical attributes of patients with gastrointestinal carcinomas who will benefit from radiotherapy. Epidemiologic incidence data for each of these clinical attributes were obtained to calculate the optimal proportion of all patients with gastrointestinal malignancies for whom radiotherapy was considered appropriate. Optimal rates of radiotherapy use were compared with actual rates in population-based studies to assess any discrepancies between actual and optimal radiotherapy utilization rates.

RESULTS

Radiotherapy was indicated in 80% of patients with esophageal carcinoma, 68% of patients with gastric carcinoma, 57% of patients with pancreatic carcinoma, 13% of patients with carcinoma of the gallbladder, 0% of patients with hepatic carcinoma, 14% of patients with colon carcinoma, and 61% of patients with rectal carcinoma. The actual radiotherapy utilization rates for most of these gastrointestinal malignancies fell well short of optimal rates, which were derived from evidence-based treatment guidelines.

CONCLUSIONS

It is possible to model optimal radiotherapy utilization using published treatment guidelines and existing incidence data. There was a discrepancy between the optimal and actual rates of radiotherapy utilization for patients with carcinomas of the esophagus, stomach, pancreas, and rectum. Strategies to implement evidence-based clinical guidelines are recommended.

Breast magnetic resonance image screening and ductal lavage in women at high genetic risk for breast carcinoma

BACKGROUND

Intensive screening is an alternative to prophylactic mastectomy in women at high risk for developing breast carcinoma. The current article reports preliminary results from a screening protocol using high-quality magnetic resonance imaging (MRI), ductal lavage (DL), clinical breast examination, and mammography to identify early malignancy and high-risk lesions in women at increased genetic risk of breast carcinoma.

METHODS

Women with inherited BRCA1 or BRCA2 mutations or women with a >10% risk of developing breast carcinoma at 10 years, as estimated by the Claus model, were eligible. Patients were accrued from September 2001 to May 2003. Enrolled patients underwent biannual clinical breast examinations and annual mammography, breast MRI, and DL.

RESULTS

Forty-one women underwent an initial screen. Fifteen of 41 enrolled women (36.6%) either had undergone previous bilateral oophorectomy and/or were on tamoxifen at the time of the initial screen. One patient who was a BRCA1 carrier had high-grade ductal carcinoma in situ (DCIS) that was screen detected by MRI but that was missed on mammography. High-risk lesions that were screen detected by MRI in three women included radial scars and atypical lobular hyperplasia. DL detected seven women with cellular atypia, including one woman who had a normal MRI and mammogram.

CONCLUSIONS

Breast MRI identified high-grade DCIS and high-risk lesions that were missed by mammography. DL detected cytologic atypia in a high-risk cohort. A larger screening trial is needed to determine which subgroups of high-risk women will benefit and whether the identification of malignant and high-risk lesions at an early stage will impact breast carcinoma incidence and mortality.

The replication error phenotype is associated with the development of distant metastases in hormonally treated patients with breast carcinoma

BACKGROUND

The positive replication error (RER+) phenotype defines a distinct subgroup of tumors with specific clinical, pathologic, and molecular features that have been documented well in hereditary nonpolyposis colon carcinoma (HNPCC). More recently, this phenotype also has been described in breast carcinoma.

METHODS

To determine the effect of RER phenotype on prognosis in patients with breast carcinoma, the authors examined matched archival tumor and normal tissue from 100 women with Stage I and Stage II breast carcinoma, all of whom were treated with hormonal therapy. Patients had been followed for a minimum of 5 years or until death. Seven microsatellite loci were examined, including hMLH1 (3p22, D3S1611), hMSH2 (2p16, D2S123), NM23-H1 (17q21), TP53-Dint (17p13), TP53-Penta (17p13), APC (5q21, D5S346), and HPC1 (1q24, D1S2883). The RER+ phenotype was defined as the presence of allelic shifts at three of the seven loci examined.

RESULTS

Twenty-five percent of patients were classified with the RER+ phenotype based on these criteria. The two groups, women with positive RER status and women with negative RER status, were comparable in terms of other factors that may influence prognosis: age, tumor size, lymph node status, disease stage, and estrogen receptor status. The development of distant metastases to the lung, liver, or brain was correlated significantly with the positive RER phenotype, with a relative risk of 2.625 (95% confidence interval, 1.059-6.057).

CONCLUSIONS

The presence of high-frequency RER+ may predict for the development of distant metastatic disease in patients with early-stage breast carcinoma who are treated with hormonal therapy.

Ductal lavage and its histopathologic basis: A cautionary tale

Ductal lavage has been touted as a possible screening tool for patients with a high risk for the development of breast cancer. This article examines the fundamental concepts underlying the procedure and critically evaluates its possible utility in light of the known molecular and surgical pathologic data. It highlights the fact that risk assessment in breast cancer is far from an exact science, since most women who develop breast cancers are not identified as high-risk by the Gail model. The utility of ductal lavage has as yet not been proven, and even if it were useful, it is likely to benefit only a subset of all breast cancer patients. Further studies, preferably controlled clinical trials, are necessary before routine use of the procedure can be recommended.

Acceptance of tamoxifen chemoprevention by physicians and women at risk

BACKGROUND

In the National Surgical Adjuvant Breast and Bowel Project (NSABP) P-1 trial, tamoxifen was shown to reduce breast carcinoma risk by 49% in high-risk women. The purpose of the current study was to identify factors associated with being offered, and accepting, tamoxifen chemoprevention.

METHODS

The records of 219 women who sought risk evaluation after the publication of the NSABP P-1 trial between September 1998 and October 2002 were reviewed. Risk was calculated using the model of either Gail et al. or Claus et al. The impact of individual risk factors on the offering and acceptance of tamoxifen was compared using the Fisher exact test and logistic regression analysis.

RESULTS

Tamoxifen was offered to 137 women (63%) in the current study. The magnitude of Gail risk, age, menopausal status, hysterectomy, and history of lobular carcinoma in situ (LCIS) or atypical hyperplasia (AH) were all found to be significant predictors of a patient being offered tamoxifen. On multivariate analysis, only a history of AH or LCIS and hysterectomy were found to be significant, with odds ratios of 20.3 and 3.4, respectively. Fifty-seven of the women who were offered tamoxifen (42%) took the drug. Only a history of LCIS or AH and older age were found to be predictive of tamoxifen acceptance.

CONCLUSIONS

In the current study, risk due to AH or LCIS was found to be the main predictor of being offered and accepting tamoxifen chemoprevention.

Atypia in the assessment of breast cancer risk: Implications for management

Proliferative disease accounts for as much as one-third of all biopsies for benign disease and 5-10% of proliferative lesions show atypia ductal or lobular hyperplasia. Nearly 40% of women with a family history of breast cancer and atypical hyperplasia subsequently develop breast cancer. A quantitative model developed by Gail and colleagues estimates the probability of developing breast cancer over time. Risk factors in the model include current age, ages at menarche and first live birth, number of previous biopsies, the presence of cellular atypia, and the number of first-degree relatives with breast cancer. Atypical hyperplasia approximately doubles the risk of developing invasive breast cancer within any quantitative risk profile. Ductal lavage provides a minimally invasive method of collecting breast epithelial cells. The procedure opens the possibility of repeatable tracking of breast cytology over time, but its role as a risk assessment tool remains to be fully defined.

Ductoscopic Cytology to Detect Breast Cancer

PURPOSE

Fiberoptic ductoscopy allows direct visualization of the breast ductal lumen, providing a targeted approach to the diagnosis of intraductal disease. The purpose of this prospective study was to determine whether (1) endoscopic evaluation of the breast could be reliably performed, and (2) ductoscopic data (intraductal distance traveled, visual observations, epithelial and foam cell quantity, cytology) predict whether a woman has breast cancer.

PATIENTS AND METHODS

Ductoscopic information was collected on intraductal distance traveled, visual observations, epithelial and foam cell quantity, and cytology.

RESULTS

Ductoscopic samples were successfully collected in 106/108 attempts. The first six specimens collected were acellular. Of the 100 remaining ductoscopic specimens, 37 were from breasts with ductal carcinoma in situ or invasive breast cancer, 10 from breasts with precancerous lesions, 37 duct hyperplasia/papilloma, 11 histologically normal specimens, and five specimens from breasts that did not undergo subsequent surgical excision. The ability to travel intraductally > or = 10 cm was greater in women with hyperplasia and papilloma (with and without atypia) lesions. Intraductal lesions that were visually considered tumors were more often hyperplasia/papilloma and malignant than other lesions. Extrinsic duct occlusion was observed only in malignant lesions. Excluding learning curve samples, 67/100 (45% of normal, 68% of hyperplastic, 90% of precancerous, 82% of ductal carcinoma in situ, and 70% of invasive) fiberoptic ductoscopy specimens had adequate epithelial cells, and all duct cannulation attempts except two were successful. There was one false-positive cytologic result in a woman found to have a papilloma. Foam cell quantity was significantly related to epithelial cell quantity.

CONCLUSION

Fiberoptic ductoscopy is feasible in the vast majority of subjects. Fiberoptic ductoscopy is a specific but not sufficiently sensitive method to be used alone to diagnose breast cancer. The presence of highly atypical epithelial cells in specimens from breasts containing papillomas is a pitfall of this method. Caution must be exercised to avoid a false-positive diagnosis in patients with spontaneous nipple discharge.

Ductal lavage in the screening of high-risk women

Due to the high incidence of breast cancer and the excessively high false-positive rate of current screening technologies, adjunctive risk assessment measures are needed. Nipple aspiration cytologic analysis and random fine-needle aspirations have been proposed; however, ductal lavage and cytologic analysis of the effluent is a more sensitive and specific test. The dilemma lies in what should be done subsequent to a ductal lavage yielding malignant or atypical cells. The procedures and potential management strategies are discussed.

Anaesthesia, surgery, and challenges in postoperative recovery

Surgical injury can be followed by pain, nausea, vomiting and ileus, stress-induced catabolism, impaired pulmonary function, increased cardiac demands, and risk of thromboembolism. These problems can lead to complications, need for treatment in hospital, postoperative fatigue, and delayed convalescence. Development of safe and short-acting anaesthetics, improved pain relief by early intervention with multimodal analgesia, and stress reduction by regional anaesthetic techniques, beta-blockade, or glucocorticoids have provided important possibilities for enhanced recovery. When these techniques are combined with a change in perioperative care a pronounced enhancement of recovery and decrease in hospital stay can be achieved, even in major operations. The anaesthetist has an important role in facilitating early postoperative recovery by provision of minimally-invasive anaesthesia and pain relief, and by collaborating with surgeons, surgical nurses, and physiotherapists to reduce risk and pain.

Chemoradiotherapy in the Treatment of Regional Pancreatic Carcinoma

In locally advanced pancreatic cancer, the utilization of chemotherapy and radiotherapy is increasing, although in view of the reported long-term results of several contemporary trials, further improvements are certainly needed. Encouraging results using the combination of cisplatin, cytarabine, caffeine, and continuous infusion (CI) 5-fluorouracil (5-FU) (PACE) for the treatment of advanced pancreatic carcinoma prompted a phase II study using PACE followed by external beam radiotherapy with CI of 5-FU (PACE-RT) for localized disease. Forty-one patients were treated with PACE-RT as adjuvant therapy after surgical resection (21 patients), or as primary therapy for locally advanced, unresectable disease (20 patients), with reevaluation for resection after completion of treatment. PACE consisted of cisplatin 100 mg/m2 IV on day 1, cytarabine 2 g/m2 IV every 12 hours x 2 doses, and caffeine 400 mg/m2 subcutaneously after each cytarabine dose; and days 3 to 21, 5-FU 250 mg/m2/d given by CI. Cycles were repeated every 28 days. After 2 cycles of PACE, radiation therapy was given concurrently with 5-FU at 200 mg/m2/d. In the adjuvant setting, the tumor bed and the draining lymph node basin received 50.4 Gy and 45 Gy, respectively. In the neoadjuvant setting, the primary and regional lymph nodes were to receive 39.6 Gy followed by a neutron boost of 8 NGy to the gross tumor volume. Photon therapy was delivered at 1.8 Gy per fraction and neutron therapy at 0.8 NGy per fraction, 5 days a week. All patients were evaluable for toxicity and survival. The most common toxicity was myelosuppression, with grade III to IV neutropenia occurring in 59% of the patients. The median survival times in the locally advanced and adjuvant patients were 13.4 and 18.1 months, with 1-year survival rates of 52% and 65%, respectively. Nine of 20 patients receiving PACE-RT for unresectable carcinoma had sufficient tumor regression to meet clinical criteria for exploration; three were resected with curative intent. The survival of these three patients undergoing resection after neo-adjuvant therapy was 22.4, 24.3 and 40 months. The treatment program was active, but only moderately well tolerated. Modification of this regimen with newer, less toxic drugs may provide better results and reduced toxicity.

Preinvasive and invasive ductal pancreatic cancer and its early detection in the mouse

To evaluate the role of oncogenic RAS mutations in pancreatic tumorigenesis, we directed endogenous expression of KRAS(G12D) to progenitor cells of the mouse pancreas. We find that physiological levels of Kras(G12D) induce ductal lesions that recapitulate the full spectrum of human pancreatic intraepithelial neoplasias (PanINs), putative precursors to invasive pancreatic cancer. The PanINs are highly proliferative, show evidence of histological progression, and activate signaling pathways normally quiescent in ductal epithelium, suggesting potential therapeutic and chemopreventive targets for the cognate human condition. At low frequency, these lesions also progress spontaneously to invasive and metastatic adenocarcinomas, establishing PanINs as definitive precursors to the invasive disease. Finally, mice with PanINs have an identifiable serum proteomic signature, suggesting a means of detecting the preinvasive state in patients.

Review article: chemotherapy for pancreatic cancer

Pancreatic cancer is a common, highly lethal disease that is rising in incidence. Chemotherapy based on 5-fluorouracil (5-FU) has been shown to prolong survival in advanced pancreatic cancer. Gemcitabine improves major symptoms and survival outcomes compared with bolus 5-FU. Many novel small molecules are being widely and actively researched. These compounds are based on classical mechanisms of action as well as biological therapies targeting novel cellular survival pathways, and include fluoropyrimidines, nucleoside cytidine analogues, platinum analogues, topoisomerase-inhibitors, antimicrotubule agents, proteasome inhibitors, vitamin D analogues, arachidonic acid pathway inhibitors, histone deacytylator inhibitors, farnesyltransferase inhibitors and epidermal growth factor receptor therapies. Adjuvant chemotherapy has also demonstrated the best survival outcomes following resection compared to other adjuvant or neo-adjuvant strategies such as radiation-based treatments. These benefits are superimposed on the dramatic increase in resectability rates and reduction in post-operative mortality achieved by centralisation of treatment in high-volume speciality centres. Newer 'small-molecule' drugs as well as the latest 'large-molecule' biological agents hold considerable promise for the future. Real advances are anticipated over the next five years but are dependent on large randomised controlled trials for success.

Is extended resection for adenocarcinoma of the body or tail of the pancreas justified?

Patients with body or tail tumors of the pancreas often have contiguous organ involvement or portal-splenic confluence adherence requiring extensive resection in order to obtain grossly negative margins. The aim of this study was to determine whether long-term survival is possible after contiguous organ or portal vein resection in patients with adenocarcinoma of the body or tail of the pancreas. Between 1983 and 2000, a total of 513 patients with adenocarcinoma of the body or tail of the pancreas were identified from a prospective database. Distal pancreatectomy with or without splenectomy was performed in 57 patients (11%). Extended resection was necessary in 22 patients (39%): 14 (64%) for contiguous organ involvement and eight (36%) for portal vein resection Estimated blood loss, blood transfused, and length of hospital stay were significantly greater in patients requiring extended resection compared to standard resection (P=0.02, P=0.01, and P=0.02, respectively). Median follow-up for patients still alive was 84 months (range 40 to 189 months). Median survival following resection was 15.9 months compared to 5.8 months in patients who were not resected (P<0.0001). Actual 5- and 10-year survival rates were 22% and 18%, respectively, following extended resection, 8% and 8% following standard resection, and 0% and 0% if no resection was attempted because of locally unresectable disease. Patients undergoing extended resection for adenocarcinoma of the pancreatic body or tail have long-term survival rates similar to those for patients undergoing standard resection; they also have markedly improved long-term survival compared to those who are not considered resectable because of locally advanced disease. Extended distal pancreatectomy is justified in this group of patients.

DNA methylation patterns in cancer: novel prognostic indicators?

DNA methylation is an epigenetic phenomenon influencing the normal function of DNA and its scaffolding proteins. Especially in cancer, aberrant methylation patterns may contribute to the disease process by the induction of point mutations, activation of inactive genes through hypomethylation of promoters, and transcriptional inactivation through a complex interplay with histone acetylation and other inhibitory mechanisms. Aberrant methylation patterns have been evaluated as tools in the management of patients with cancer. The predictive value, the therapeutic manipulation and the prognostic significance of aberrantly methylated gene loci have been tested in hematological as well as in solid neoplasias in adults and children. A seemingly insurmountable wealth of data has been generated, however, data on clinical associations are sometimes presented in an almost incautious fashion. Nevertheless, some genes like p15INK4B in myelodysplastic syndrome (MDS) and p16INK4A in some lung cancer subtypes have been shown to confer a certain prognosis. In selected cases the data have been confirmed by independent studies. Assays have been developed that can be used by almost any clinical laboratory (e.g. methylation-specific PCR) for the rapid and affordable screening of tumors for aberrant methylation. The study of aberrant methylation patterns has successfully entered the arena of relevant clinical applications. Importantly, methylation does not only hold the potential for being 'just another' biomarker, but also, as it can be reverted chemically, it is a phenomenon that holds great promise for therapeutic exploitation.

Quality control and peak finding for proteomics data collected from nipple aspirate fluid by surface-enhanced laser desorption and ionization

BACKGROUND

Recently, researchers have been using mass spectroscopy to study cancer. For use of proteomics spectra in a clinical setting, stringent quality-control procedures will be needed.

METHODS

We pooled samples of nipple aspirate fluid from healthy breasts and breasts with cancer to prepare a control sample. Aliquots of the control sample were used on two spots on each of three IMAC ProteinChip arrays (Ciphergen Biosystems, Inc.) on 4 successive days to generate 24 SELDI spectra. In 36 subsequent experiments, the control sample was applied to two spots of each ProteinChip array, and the resulting spectra were analyzed to determine how closely they agreed with the original 24 spectra.

RESULTS

We describe novel algorithms that (a) locate peaks in unprocessed proteomics spectra and (b) iteratively combine peak detection with baseline correction. These algorithms detected approximately 200 peaks per spectrum, 68 of which are detected in all 24 original spectra. The peaks were highly correlated across samples. Moreover, we could explain 80% of the variance, using only six principal components. Using a criterion that rejects a chip if the Mahalanobis distance from both control spectra to the center of the six-dimensional principal component space exceeds the 95% confidence limit threshold, we rejected 5 of the 36 chips.

CONCLUSIONS

Mahalanobis distance in principal component space provides a method for assessing the reproducibility of proteomics spectra that is robust, effective, easily computed, and statistically sound.

Aberrant methylation of the cyclin D2 promoter in primary small cell, nonsmall cell lung and breast cancers

DNA methylation alteration of several genes contributes to human tumorigenesis. Cyclin D2, a member of the D-type cyclins, is implicated in cell cycle regulation and malignant transformation. In our study, we examined the methylation status of the cyclin D2 promoter in small cell lung cancer (SCLC), nonsmall cell lung cancer (NSCLC), breast tumors and tumor cell lines. We observed that aberrant methylation of cyclin D2 was present in 32 of 56 (57%) SCLC cell lines, 7 of 32 (22%) SCLC tumor tissues; 25 of 61 (47%) NSCLC cell lines, 19 of 48 (40%) NSCLC tumor tissues; 18 of 30 (60%) breast tumor cell lines and 19 of 63 (30%) breast tumor tissues. Methylation was more frequent in the tumor cell lines compared to the primary breast and SCLC tumors (p = 0.007 and p = 0.001, respectively). Methylation was rare in the control tissue samples; 0 of 12 peripheral blood lymphocytes; 0 of 12 buccal epithelial cells; 0 of 18 nonmalignant lung tissues and 3 of 28 (11%) nonmalignant breast tissues. Promoter methylation correlated with loss of transcript by reverse transcription PCR (RT-PCR) in 9 of 11 (6 lung, 5 breast) tumor cell lines tested. Two cell lines that were not methylated also lacked expression, suggesting that other mechanisms of inactivation may be involved. Expression was restored by treatment with the demethylating agent, 5 aza 2' deoxycytidine, in all 9 methylated cell lines. Our results confirm earlier reports in breast cancer and indicate that aberrant methylation of cyclin D2 may contribute to the pathogenesis of the 2 major types of lung cancers.

Chromosomal variations within aneuploid cancer lines

Aneuploid cancers exhibit a wide spectrum of clinical aggressiveness, possibly because of varying chromosome compositions. To test this, karyotypes from the diploid CCD-34Lu fibroblast and the aneuploid A549 and SUIT-2 cancer lines underwent fluorescence in situ hybridization (FISH) and DAPI counterstaining. The number of DAPI-stained and FISH-identified chromosomes, 1-22, X,Y, as well as structural abnormalities, were counted and compared using the chi(2), Mann-Whitney rank sum test and the Levene's equality of variance. Virtually all of the evaluable diploid CCD-34Lu karyotypes had 46 chromosomes with two normal-appearing homologues. The aneuploid chromosome numbers per karyotype were highly variable, averaging 62 and 72 for the A549 and SUIT-2 lines, respectively. However, the A549 chromosome numbers were more narrowly distributed than the SUIT-2 karyotype chromosome numbers. Furthermore, 25% of the A549 chromosomes had structural abnormalities compared to only 7% of the SUIT-2 chromosomes. The chromosomal compositions of the aneuploid A549 and SUIT-2 cancer lines are widely divergent, suggesting that diverse genetic alterations, rather than chance, may govern the chromosome makeups of aneuploid cancers.

Risk of Malignancy in Follicular Neoplasms without Nuclear Atypia: Statistical Analysis of 397 Thyroidectomies

OBJECTIVE

To determine how to triage patients with a follicular neoplasm (FN), without nuclear atypia reported by fine-needle aspiration, on the basis of risk factors.

METHODS

The age, sex, tumor size, and cell type of 397 patients who underwent thyroidectomy for follicular carcinoma (FC) or follicular adenoma between 1991 and 2001 were analyzed statistically. The likelihood ratio and probability of FC for various combinations of tumor size, sex, and cell type were estimated with use of Bayes' theorem.

RESULTS

FC was significantly associated with tumor size >2.1 cm (P = 0.048), male sex (P = 0.0007), and Hürthle cell type (P<0.0001). The mean size of minimally invasive FC was significantly smaller (2.9 cm versus 4.8 cm; P = 0.004) and the mean patient age was significantly younger (47.6 years versus 61.0 years; P = 0.003) than for widely invasive FC. The lowest probability (0.31%) for FC was in female patients with a small (< or = 2.1 cm) micro-follicular FN reported by a cytopathology practice with 10% accuracy of true FN at surgical intervention, whereas the highest probability (29.5%) for FC was in male patients with a large (>2.1 cm) Hürthle cell neoplasm reported by a cytopathology practice with 70% accuracy of true FN at surgical intervention.

CONCLUSION

Although an estimate of probability for FC based on age, sex, thyroid nodule size, and cell type is provided in this study for patients diagnosed with FN without nuclear atypia on fine-needle aspiration, the variability of the accuracy in cytopathology practice makes it difficult to change the current treatment paradigm, which requires carefully planned prospective studies with long-term follow-up.

Butyrate inhibits pancreatic cancer invasion

Pancreatic cancer is the most deadly gastrointestinal malignancy because of its propensity for local invasion and early metastasis. Integrin chains, in particular beta4, can promote invasion in other cancers. The effect of sodium butyrate (NaBT), which induces differentiation in transformed cells, on integrin expression is unknown. The purpose of this study was to determine patterns of integrin expression in pancreatic cancer cells and investigate the effect of NaBT on integrin expression and invasion. Integrin expression was assessed in the less invasive MIA-PaCa-2 and PANC-1 and more invasive L3.6, AsPC-1, and SUIT-2 human pancreatic cancer cell lines by ribonuclease (RNase) protection assay. Western blotting and immunofluorescent staining for beta4 expression was determined after NaBT treatment. Matrigel invasion chambers were used to assess pancreatic cancer cell invasion. beta4 and beta7 integrin expression was highest in L3.6, AsPC-1, and SUIT-2 cells. NaBT reduced the expression of beta4 integrin in AsPC-1 cells including less cell surface beta4. Invasion of AsPC-1 cells was also reduced by NaBT. Expression of beta4 is higher in more aggressive pancreatic cancer cells; NaBT inhibits beta4 expression and invasion. NaBT may represent a novel strategy to inhibit pancreatic cancer invasion and improve the prognosis of this deadly disease.

Ductal lavage in patients undergoing mastectomy for mammary carcinoma

BACKGROUND

Ductal lavage (DL) is a new method for the sampling of breast epithelium. Data regarding its sensitivity in the detection of epithelial abnormalities, including carcinoma in situ (CIS), remains limited.

METHODS

DL was performed in the affected breasts of 26 women undergoing mastectomy for mammary carcinoma and in the clinically normal breast of 4 additional women undergoing risk-reducing mastectomy. After surgery, dye was injected through the microcatheter used for DL. Three cytopathologists independently reviewed all DL slides and the data reflect consensus by at least two reviewers. Interobserver agreement was assessed. The findings in DL samples were correlated with the features of CIS in the mastectomy specimens.

RESULTS

Four (14%) of 29 DL samples satisfactory for evaluation showed marked atypia, 10 (34%) showed mild atypia, and 15 (52%) were benign. No DL sample was clearly malignant. Interobserver agreement was good (average kappa = 0.52). Of the DL samples satisfactory for evaluation, 27 had been obtained from 24 breasts containing CIS, which included 18 ductal CIS (DCIS), 3 lobular CIS (LCIS), 2 DCIS and LCIS, and 1 solid CIS with mixed ductal and lobular features. Invasive carcinoma was present in 20 samples. Two DL samples from breasts with extensive LCIS showed mild atypia and injected dye was identified in ducts and lobules involved by LCIS.

CONCLUSIONS

DL had low sensitivity for CIS in breasts that also contained invasive carcinoma. The use of DL remains investigational, and close follow-up should be continued for all patients undergoing DL, including those with benign diagnoses.

DNA methylation ofRASSF1A, HIN-1, RAR-?, Cyclin D2 andTwist inin situ and invasive lobular breast carcinoma

Little is known about epigenetic silencing of genes by promoter hypermethylation in lobular breast cancers. The promoter methylation status of 5 cancer-related genes (RASSF1A, HIN-1, RAR-beta, Cyclin D2 and Twist) was evaluated in 2 types of lobular cancers, in situ (LCIS) and invasive lobular carcinomas (ILC) (n = 32), and compared to ductal in situ (DCIS) and invasive (IDC) breast cancers (n = 71). By using methylation-specific PCR (MSP), 100% of ILC and 69% of LCIS cases were found to have 1 or more hypermethylated genes among the panel of 5 genes (compared to 100% IDC and 95% of DCIS). Two or more hypermethylated genes were detected per tumor in 79% of invasive and 61% of in situ lobular carcinomas compared to 81% of IDC and 77% of DCIS. By contrast, DNA from nearly all normal reduction mammoplasty tissues (n = 8) was unmethylated for the 5 genes. The methylation profiles of lobular vs. ductal carcinomas with respect to RASSF1A, Cyclin D2, RARbeta, and Hin-1 genes were similar, suggesting that gene silencing by promoter hypermethylation is likely to be important in both groups of diseases. Distinctly different, Twist was hyper- methylated less often in ILC (16%, 3/19 cases) than in IDC (56%, 15/27 cases) (p = 0.01). These results suggest that these 2 types of tumors share many common methylation patterns and some molecular differences. Additional studies might lend further understanding into the etiology and clinical behavior of this tumor type.

Differential gene expression induced by insulin and insulin-like growth factor-II through the insulin receptor isoform A

The human insulin receptor (IR) exists in two isoforms (IR-A and IR-B). IR-A is a short isoform, generated by the skipping of exon 11, a small exon encoding for 12 amino acid residues at the carboxyl terminus of the IR alpha-subunit. Recently, we found that IR-A is the predominant isoform in fetal tissues and malignant cells and binds with a high affinity not only insulin but also insulin-like growth factor-II (IGF-II). To investigate whether the activation of IR-A by the two ligands differentially activate post-receptor molecular mechanisms, we studied gene expression in response to IR-A activation by either insulin or IGF-II, using microarray technology. To avoid the interfering effect of the IGF-IR, IGF-II binding to the IR-A was studied in IGF-IR-deficient murine fibroblasts (R- cells) transfected with the human IR-A cDNA (R-/IR-A cells). Gene expression was studied at 0.5, 3, and 8 h. We found that 214 transcripts were similarly regulated by insulin and IGF-II, whereas 45 genes were differentially transcribed. Eighteen of these differentially regulated genes were responsive to only one of the two ligands (12 to insulin and 6 to IGF-II). Twenty-seven transcripts were regulated by both insulin and IGF-II, but a significant difference between the two ligands was present at least in one time point. Interestingly, IGF-II was a more potent and/or persistent regulator than insulin for these genes. Results were validated by measuring the expression of 12 genes by quantitative real-time reverse transcriptase-PCR. In conclusion, we show that insulin and IGF-II, acting via the same receptor, may differentially affect gene expression in cells. These studies provide a molecular basis for understanding some of the biological differences between the two ligands and may help to clarify the biological role of IR-A in embryonic/fetal growth and the selective biological advantage that malignant cells producing IGF-II may acquire via IR-A overexpression.

Gene expression profile in thyroid of transgenic mice overexpressing the adenosine receptor 2a

Mutations of the TSH receptor leading to constitutive activation of the cAMP cascade are responsible for the development of hot nodules, if arising in a somatic cell, and nonautoimmune hyperthyroidism, when occurring in a germinal cell. An animal model of constitutive activation of the thyroid cAMP cascade has been obtained by generating transgenic mice expressing the adenosine receptor (Tg-A2aR) under the control of the thyroglobulin promoter. These mice develop huge goiters and die prematurely due to hyperthyroidism induced cardiac failure. To identify new genes involved in the tumorigenic pathway of the thyroid, we designed a protocol using microarray technology to study the differential expression, between normal and transgenic thyroid, of +/-13,000 genes. A total of 360 genes or expressed sequence tags showed a strong modulation with background corrected values of fluorescence superior to 2-fold change. The modulated genes were classified according to their proposed gene ontology functions. Approximately half of them were up-regulated. The function of the majority of these genes in thyroid physiology is still to be determined. Some of them, like IGF-I or IGF binding protein 3 or 5, may play an important role in the development of thyroid nodules through paracrine mechanisms. This study demonstrates the feasibility of sequentially following the cascade of events leading to the formation of benign tumors such as hot thyroid nodule or hyperfunctional goiter.

Sentinel node biopsy in breast cancer: validation study and comparison of blue dye alone with triple modality localization

BACKGROUND

Sentinel node biopsy (SNB) for breast cancer patients is a new technique with the potential to provide an accurate staging of the axillary nodal status while avoiding the morbidity of an axillary dissection. The objective of the present study is to validate the use of sentinel node biopsy in a New Zealand hospital and to compare the ability of patent blue dye (PB) alone with triple modality (TM) (preoperative lymphoscintigraphy, intraoperative gamma probe and intraoperative blue dye) to identify the sentinel node.

METHODS

A total of 104 patients who had a palpable breast lump that was confirmed to be malignant by radiology and cytology and a clinical diagnosis of stage I or stage II breast cancer, were enrolled for SNB and randomly assigned to triple modality or blue dye alone for the localization of the sentinel node. Axillary dissection was performed after the sentinel node(s) had been removed.

RESULTS

There were 63 patients in the PB group and 41 patients in the TM group. Both groups are comparable, with a similar mean age and primary tumour size. A sentinel node was identified in 57 (90%) of the PB group patients and 40 (98%) of the TM group patients. Of these 23 (37%) of the PB group and 23 (56%) in the TM group had axillary nodes positive for malignancy. There was one false negative SNB in the PB group and two false negative results in the TM group. Therefore, the PB group had an accuracy of 98% and a sensitivity of 96% compared to an accuracy of 95% and a sensitivity of 91% for the TM group.

CONCLUSION

The results of the present study validate the use of SNB in suitable breast cancer patients. Identification and the accuracy of the sentinel node localization were similar between the two groups. Therefore, in hospital centres without adequate access to a nuclear medical facility, it would be feasible to conduct SNB using blue dye alone.

The diagnosis and management of pre-invasive breast disease: the role of new diagnostic techniques

In recent years we have seen significantly increased use of minimally invasive diagnostic techniques in the management of breast disease. There is wide recognition of fine needle aspiration and core biopsy as the principal diagnostic methods. However, concerns exist regarding their reliability. This article provides a brief overview of the major diagnostic issues related to use of fine needle aspiration, core biopsy and ductal lavage. It summarizes areas of use for each technique, outlines the main diagnostic pitfalls and their causes, and provides a perspective on future developments in the field.

Do pre-operative abdominal exercises prevent post-operative donor site complications for women undergoing DIEP flap breast reconstruction? A two-centre, prospective randomised controlled trial

The deep inferior epigastric perforator (DIEP) flap is the gold standard for breast reconstruction using abdominal tissue. Unlike the transverse rectus abdominis myocutaneous (TRAM) flap, no rectus abdominis muscle is removed with the flap, but intra-muscular scarring can still cause post-operative complications. Strong abdominal muscles have been advocated as a prerequisite for surgery, but without any evidence as to the potential benefits. This study aimed to investigate the effect of pre-operative abdominal exercises on inpatient pain levels, length of hospital stay, post-operative abdominal muscle strength and function following a DIEP flap.Ninety-three women undergoing delayed breast reconstruction with a DIEP flap between October 1999 and November 2000 were randomly allocated to either a control or exercise group. The exercise group performed pre-operative exercises using the Abdotrim abdominal exerciser. Pre-operatively, outcome measures included trunk muscle strength measured on an isokinetic dynamometer, SF-36, rectus muscle thickness measured using ultrasound, and submaximal fitness. Post-operative pain and length of hospital stay were recorded. Subjects were reassessed using the same outcome measures 1 year post-operatively. There was a statistically significant increase in static (isometric) muscle strength and thickness pre-operatively for the exercise group. One year following surgery, there was a significant decrease in dynamic (concentric and eccentric) flexion strength for both groups, although the clinical significance of this is questionable as the majority of women had returned to pre-operative fitness and the surgery had no impact on functional activities. The static flexion strength of the control group was reduced at 1 year, whereas it was maintained in the exercise group, although this was not statistically significant. One third of women in the control group complained of functional problems or abdominal pain post-operatively compared to one fifth of the exercise group. Overall, the DIEP flap had no major impact on abdominal muscle strength for either group, demonstrating its superiority over the TRAM flap. There was no statistically significant benefit to the exercise group of the pre-operative exercises 1 year following surgery. However, there was a subjective benefit, albeit statistically nonsignificant, in terms of reduced functional problems post-operatively and improved well-being prior to surgery.

Treatment of pancreatic cancer: challenge of the facts

Adenocarcinoma of the pancreas is associated with the worst survival of any form of gastrointestinal malignancy. In spite of the progress in surgical treatment, resulting in increasing resection rates and a decrease in treatment-related morbidity and mortality, the true figures of cure are even today below 3%. The dissemination of pancreatic cancer behind the local tissue compartments restricts the short-term (< 3 years) and long-term outcome for patients who have undergone resection. By histological evaluation, less than 15% of the patients undergoing R(0) resection have a pN(0) status, more than 60% suffer from lymph angiosis carcinomatosa, and more than 50% suffer extrapancreatic nerve plexus infiltration. Hematoxylin and eosin-negative lymph nodes were found to be cancer positive when reverse transcriptase polymerase chain reaction (RT- PCR) or immunostaining was applied to the HE-negative lymph nodes. Cancer of the uncinate process has a very poor prognosis because there are no early symptoms; vessel wall involvement occurs early and frequently; a high association of liver metastasis exists as well. Surgery offers a low success rate, but it provides the only chance of cure. Ductal pancreatic cancer is diagnosed in more than 95% of the cases in an advanced stage; potentially curative resection can be performed only in about 10%-15% of these patients. Major contributions of surgery to improved treatment results are the reduction of surgical morbidity--e.g., early postoperative local and systemic complications--and a decrease of hospital mortality below 3%-5%. In most recently published prospective trials, R(0) resection has been reported to result in an increase in short-term survival beyond that recorded for patients with residual tumor. However, R(0) resection fails to improve long-term survival. In many published R(0) series, standard tissue resection of pancreatic head cancer with the Kausch-Whipple procedure failed to include remote cancer cell-positive tissues in the operative specimen; e.g., N(2)-lymph nodes, nerve plexus, and perivascular extrapancreatic and retropancreatic tissues were not excised. Cancer recurrence after so-called R(0) resection with curative intent is frequently the consequence of cancer left behind. Thus, long-term survival (> 5 years) is observed in a very small group of patients, contradicting the published 5-year actuarial survival rates of 20%-45% for resected patients. The assessment of clinical benefit from surgical or medical cancer treatment should therefore be based on several end points, not only on actuarial survival. Publication of actuarial survival figures must include the number of observed (actual) survivals, the definition of the subset of patients followed after resection, and the total number of patients in the study group; anything less is misleading. In reporting pancreatic cancer treatment trial results after oncological resections, more convincing primary end points to evaluate treatment efficacy are median survival (in months), actual survival at 1-5 years, and progression-free survival (in months). In series with multimodality treatment, clinical benefit response as well as quality of life measurements using the EORTC Quality of Life index C30 (QLQ-C30) are of importance in evaluating survival data. Adjuvant treatment improves survival after oncological resection; however, the short-term and long-term benefit after adjuvant chemotherapy in R(0) as well as in R(1)-(2) resected patients has not yet been underscored by data from controlled clinical trials. The survival benefit (median survival time) of adjuvant chemotherapy or radiochemotherapy has been demonstrated to be 6-10 months. Therefore, after oncological resection of pancreatic cancer each patient should be offered adjuvant treatment. A neoadjuvant treatment protocol for pancreatic cancer, however, has not been established.

Docetaxel and radiotherapy and pancreatic cancer

PURPOSE

We conducted a phase 1 trial to determine the maximum tolerated dose (MTD) of weekly docetaxel delivered concurrently with radiation therapy for the treatment of locally advanced adenocarcinoma of the pancreas.

PATIENTS AND METHODS

Thirteen patients with histologically proven locally non-resectable advanced adenocarcinoma of the pancreas were enrolled in this study. Patients received 4 weekly doses of docetaxel by 1-hour intravenous (IV) infusion with 40 Gy of external beam radiation therapy during 4 weeks. Patients who were stabilized or in response, received 2 additional cycles of docetaxel with a 10 Gy boost of radiotherapy. Doses were escalated at 10 mg/m2 increments in successive cohorts of 3 new patients until MTD was observed.

RESULTS

Four patients received docetaxel at 20 mg/m2/week, 3 at 25 mg/m2/week, 3 at 30 mg/m2/week, and 3 at 35 mg/m2/week. All patients, except 2, were given the treatment in its integrity. The most common toxicities were nausea, vomiting, asthenia, and abdominal pains. Except for 1 patient, all toxicity was reversible and did not exceed grade 3. Hematologic toxicity was mild and has not required treatment interruption. 28% of the patients had to be rehospitalized. A total of 73 cycles was administered with a mean of 4 cycles per patient (2-6).

CONCLUSION

Even the MTD was not reached, dose escalation was stopped at 35 mg/m2/week. This dose is comparable to the ones previously published using docetaxel in combination with radiotherapy in other tumors. Three patients achieved stable disease and 1 patient an objective response. This combination of weekly docetaxel and radiotherapy shows a feasible and well-tolerated regimen, with, nonetheless, a significant rate of rehospitalization, for patients with locally advanced pancreatic cancer.

Evidence of progenitor cells of glandular and myoepithelial cell lineages in the human adult female breast epithelium: a new progenitor (adult stem) cell concept

Although experimental data clearly confirm the existence of self-renewing mammary stem cells, the characteristics of such progenitor cells have never been satisfactorily defined. Using a double immunofluorescence technique for simultaneous detection of the basal cytokeratin 5, the glandular cytokeratins 8/18 and the myoepithelial differentiation marker smooth muscle actin (SMA), we were able to demonstrate the presence of CK5+ cells in human adult breast epithelium. These cells have the potential to differentiate to either glandular (CK8/18+) or myoepithelial cells (SMA+) through intermediary cells (CK5+ and CK8/18+ or SMA+). We therefore proceeded on the assumption that the CK5+ cells are phenotypically and behaviourally progenitor (committed adult stem) cells of human breast epithelium. Furthermore, we furnish evidence that most of these progenitor cells are located in the luminal epithelium of the ductal lobular tree. Based on data obtained in extensive analyses of proliferative breast disease lesions, we have come to regard usual ductal hyperplasia as a progenitor cell-derived lesion, whereas most breast cancers seem to evolve from differentiated glandular cells. Double immunofluorescence experiments provide a new tool to characterize phenotypically progenitor (adult stem) cells and their progenies. This model has been shown to be of great value for a better understanding not only of normal tissue regeneration but also of proliferative breast disease. Furthermore, this model provides a new tool for unravelling further the regulatory mechanisms that govern normal and pathological cell growth.

Mapmodulin/leucine-rich acidic nuclear protein binds the light chain of microtubule-associated protein 1B and modulates neuritogenesis

We had previously described the leucine-rich acidic nuclear protein (LANP) as a candidate mediator of toxicity in the polyglutamine disease, spinocerebellar ataxia type 1 (SCA1). This was based on the observation that LANP binds ataxin-1, the protein involved in this disease, in a glutamine repeat-dependent manner. Furthermore, LANP is expressed abundantly in purkinje cells, the primary site of ataxin-1 pathology. Here we focused our efforts on understanding the neuronal properties of LANP. In undifferentiated neuronal cells LANP is predominantly a nuclear protein, requiring a bona fide nuclear localization signal to be imported into the nucleus. LANP translocates from the nucleus to the cytoplasm during the process of neuritogenesis, interacts with the light chain of the microtubule-associated protein 1B (MAP1B), and modulates the effects of MAP1B on neurite extension. LANP thus could play a key role in neuronal development and/or neurodegeneration by its interactions with microtubule associated proteins.

The specificity of amylin for the diagnosis of pancreatic adenocarcinoma

BACKGROUND

Diabetes mellitus or impaired glucose tolerance occurs in up to 80% of patients with pancreatic cancer at the time of cancer diagnosis. It has been reported that plasma amylin (islet amyloid polypeptide [IAPP]) levels are elevated in all patients with pancreatic cancer who are diabetic, and even moderately elevated in pancreatic cancer patients with normal glucose tolerance.

AIM

To determine the specificity of elevated amylin levels for pancreatic cancer.

METHODS

Plasma amylin levels were determined in 168 patients with one or more of the following medical conditions: benign and malignant biliary obstruction, pancreatic cancer, chronic pancreatitis, acute pancreatitis, other gastrointestinal (GI) malignancies, and newly diagnosed type II diabetes.

RESULTS

Elevated levels of plasma amylin were detected in several disorders other than pancreatic cancer--particularly chronic pancreatitis, other GI malignancies, and biliary obstruction from benign causes. No statistical differences in amylin levels were detected for any of the tested medical conditions when compared to pancreatic adenocarcinoma.

CONCLUSION

These results suggest that elevated plasma amylin is not specific for pancreatic cancer, thereby limiting its role as a tumor marker. Further studies are needed to determine whether amylin, if used in conjunction with other biological markers, could be useful for the diagnosis of pancreatic cancer.

Telomerase, p53 and PCNA activity in osteosarcoma

AIMS

The aim of this study was to investigate telomerase activity and to assess the correlation between telomerase activity, tumor proliferative activity and p53 overexpression in osteosarcoma tumor samples.

METHODS

Using a telomerase polymerase chain reaction-enzyme-linked immunoassay based on the telomeric repeat amplification protocol method, we examined telomerase activity in 26 primary osteosarcoma specimens. P53 overexpression was identified using immunohistochemical staining, and tumor proliferative activity was assessed by immunohistochemical staining of PCNA.

RESULTS

Telomerase activity was detected at a relatively low level in five of 26 osteosarcoma tissue specimens. P53 was detected in eight of 21 cases. There was no significant correlation between telomerase activity and p53 overexpression (p=0.325). There was a significant correlation between PCNA staining and telomerase activity (p=0.0075).

CONCLUSION

Difference between the telomerase activity and p53 overexpression in osteosarcoma suggests that p53 and telomerase may not cooperate in tumor proliferation. Correlation of telomerase activity to PCNA expression suggests that telomerase activity may also useful for evaluate proliferative activity in osteosarcoma.

Concurrent methylation of multiple genes in childhood ALL: Correlation with phenotype and molecular subgroup

Multiple genes have been shown to be independently hypermethylated in lymphoid malignancies. We report here on the extent of concurrent methylation of E-cadherin, Dap-kinase, O(6)MGMT, p73, p16, p15 and p14 in 129 pediatric ALL cases. While most of these genes demonstrated methylation in a proportion of cases, O(6)MGMT, p16 and p14 were infrequently methylated (11, 7 and 3%, respectively). Methylation of at least one gene was found in the vast majority (83%) of cases. To determine the extent and concordance of methylation we calculated a methylation index (MI=number of methylated genes/number of studied genes) for each sample. The average MI was 0.28, corresponding to 2/7 methylated genes. MI was correlated with standard prognostic factors, including immunophenotype, age, sex, WBC and presence of specific translocations (TEL-AML1, BCR-ABL, E2A-PBX1 or MLL-AF4). We determined that children >/=10 years old and children presenting with high WBC (>/=50 x 10(9)/l) both associated with a higher MI (P<0.01 and <0.05, respectively). T-ALLs demonstrated a lower MI (median=0.17) than precursor B ALLs (median=0.28). Among the different molecular subgroups, MLL-ALLs had the highest MI (mean=0.35), while ALLs carrying the t(1;19) had the lowest MI (mean=0.07). The most common epigenetic lesion in childhood ALL was methylation of E-cadherin (72%) independent of the molecular subtype or other clinicopathological factors.

Surgical resection following radiation therapy with concurrent gemcitabine in patients with previously unresectable adenocarcinoma of the pancreas

The combination of gemcitabine with concurrent radiation therapy (Gem/RT) is a promising new approach that is being investigated in patients with unresectable pancreatic cancer. However, substantial toxicity with this combination has also been observed. This review was conducted to determine whether Gem/RT could be safely delivered in the neoadjuvant setting, based on our experience with this combined therapy in a cohort of patients with previously unresectable pancreatic cancer, who subsequently underwent surgical resection. Between July 1996 and June 2001, a total of 67 patients with locally unresectable pancreatic cancer, without distant metastatic disease, received Gem/RT at our institution. Seventeen patients (25%) underwent exploratory surgery following Gem/RT, and nine underwent standard Whipple resection. Thus 9 (52%) of 17 patients who had exploratory operations or 9 (13%) of 67 patients, underwent surgical resection. Thirty-day mortality after resection was 0%, and there were no major surgical complications. Median length of hospital stay was 14 days (range 11 to 19 days). With a median follow-up of 32 months, median survival for the resected patients was 17.6 months (95% confidence interval 12.6 to 37.3 months). Median survival for the remaining 58 patients was 11.9 months (95% confidence interval 9.6 to 14.7 months, P=0.013). We conclude that surgical resection may be safely performed after Gem/RT in a select group of patients initially considered to have unresectable pancreatic cancer. The use of Gem/RT in a neoadjuvant setting is currently being investigated in a multi-institutional phase II trial.

The multiple promoter methylation profile of PR gene and ERalpha gene in tumor cell lines

The changes of methylation status of various gene promoters are a common feature of malignant cells and these changes can occur early in the progression process. Therefore, abnormal methylation can be used as cancer marker. Such studies will first require the development of a panel of methylated markers that are methylated in cancer tissues but unmethylated in normal tissues or methylated status is different between cancer tissues and normal tissues. By using methylation-specific PCR (MSP) assay method, we observed alterations in DNA methylation at the double promoter regions of the progesterone receptor (PR) gene and estrogen receptor (ERalpha) gene in various tumor cell lines. Compared with normal white blood cell, the methylation status of PRA promoter in various cancer cell lines changed from unmethylation pattern to methylation pattern. That of PRB promoter changed from both unmethylated and methylated alleles to only methylated allele. The methylation status of ERalpha-A and ERalpha-B promoter in various cancer cell lines are cell -specific. This study indicates that PR promoter methylation may be a molecular marker in various cancer detections. And the methylation status of ERalpha-A and ERalpha-B is cell-specific.

Activation of conventional PKC isoforms increases expression of the pro-apoptotic protein Bad and TRAIL receptors

BACKGROUND

Pancreatic cancer is a leading cause of cancer death worldwide; current treatment options have been ineffective in prolonging survival. Agents that target specific signaling pathways (e.g., protein kinase C [PKC]) may regulate apoptotic gene expression rendering resistant cancers sensitive to the effects of other chemotherapeutic drugs. The purpose of our study was to assess the effect of PKC stimulation on apoptotic gene expression in pancreatic cancer cells.

METHODS

The human pancreatic cancer cell line, PANC-1, was treated with PKC-stimulating agents, phorbol 12-myristate 13-acetate (PMA) or bryostatin-1, and analyzed for expression of apoptosis-related genes.

RESULTS

Both PMA and bryostatin-1 induced expression of the pro-apoptotic gene Bad in a dose dependent fashion. The expression of Bad was blocked by the PKC inhibitors GF109203x, Gö6983, and Ro-31-8220, suggesting a role for the conventional isoforms of PKC. In addition, treatment with the MEK inhibitors PD98059 or UO126 reduced PMA-mediated induction of Bad gene expression. PMA also increased the expression of TRAIL receptors DR4 and DR5; this expression was inhibited by the PKC inhibitors GF109203x, Gö6983, and Ro-31-8220 and the MEK inhibitor UO126, suggesting a role for conventional PKC isoforms and MEK in the regulation of TRAIL receptor expression.

CONCLUSIONS

PKC stimulation in PANC-1 cells increases expression of the pro-apoptotic gene Bad and the TRAIL receptors, DR4 and DR5, through both conventional PKC- and MEK-dependent pathways. Agents that stimulate PKC may sensitize pancreatic cancer cells to apoptosis and provide a potential adjuvant therapy for the treatment of chemoresistant pancreatic cancers.

Adjuvant therapy for pancreatic adenocarcinoma: what have we learned since 1985?

To review developments relevant to pancreatic adjuvant therapy since the publication of the Gastrointestinal Tumor Study Group (GITSG) trial of adjuvant therapy for pancreatic cancer in 1985. Our understanding of the pathology, surgical management, clinical and pathologic prognostic factors, potential importance of adjuvant therapy, and optimal design of adjuvant therapies have all undergone major evolution. Available data suggest: (1) the morbidity of pancreaticoduodenectomy has been reduced substantially, especially in major referral centers; (2) physicians, patients, and families recognize the importance of clinical trials and substantial numbers of patients are available for such trials; (3) factors such as tumor size, margin status, nodal involvement, histologic differentiation, and blood loss at surgery have an impact on postoperative outcomes; (4) the use of gemcitabine and patient-specific, anatomic planning for conformal radiotherapy has the potential to radically alter the adjuvant paradigm; (5) vaccine therapies have completed Phase I testing and are being incorporated into Phase II trials; and (6) careful application of relevant statistical principles is necessary to avoid the execution of ambiguous or uninterpretable trials. The need for effective adjuvant therapy is undisputed, because surgery alone is inadequate. Increasing numbers of patients are undergoing and recovering from surgery who are willing to consider clinical trials. Major cooperative group and single-institution efforts recently completed, ongoing, or currently planned using improved stratification for prognostic subsets, translational approaches based on molecular biology and/or genetic engineering, and newer chemoradiotherapeutic regimens are rapidly changing the landscape of this clinical arena into one of promise and possibility.

Clinical research in pancreatic cancer: the Radiation Therapy Oncology Group trials

To summarize the clinical research activities of the Radiation Therapy Oncology Group program in the treatment of patients with locally advanced, as well as resected, pancreatic cancer. Phase II and III clinical trials are underway, examining novel cytotoxic and targeted agents with irradiation (RT) for patients with locally advanced and resected pancreatic cancer.A Phase II study incorporating concurrent paclitaxel with external beam radiotherapy in the locally advanced setting has been completed and recently analyzed. This experience has served as the foundation of a Phase II study using concurrent paclitaxel and gemcitabine with RT followed by R115777, a farnesyltransferase inhibitor, as maintenance therapy. In the adjuvant treatment of pancreatic cancer, an Intergroup Phase III trial has compared "conventional" postoperative chemoirradiation (5-fluorouracil before, after, and during RT) and gemcitabine before and after RT (with 5-fluorouracil during RT). This study has recently closed, meeting its accrual goal. The successor study will evaluate the use of gemcitabine given concurrently with RT, as well as in a maintenance schedule. This report summarizes current and future Radiation Therapy Oncology Group clinical trials in the treatment of patients with localized pancreatic cancer.

Management of the high-risk patient

Comprehensive breast cancer risk management is a practical tool that can now be regarded as a necessary clinical component of women's health. Risk assessment is the starting point for counseling women about risk, and it facilitates rational decision-making about prophylactic surgery, initiation of screening at an early age, and initiating preventive interventions. The availability of risk assessment models permit rapid risk calculation during routine clinical encounters, and risk profiles can be easily updated at subsequent clinical visits. Clinicians can now incorporate risk assessment and management into their routine screening and health maintenance appointments. Additional prospective clinical trials should be conducted to define the optimal use of existing management strategies, develop refined risk assessment instruments that incorporate additional risk-factor information, and evaluate populations for whom validated risk-assessment approaches do not yet exist.

Inhibition of pancreatic cancer cell growth and induction of apoptosis with novel therapies directed against protein kinase A

BACKGROUND

Pancreatic cancer is the most lethal abdominal malignancy. Expression of the RIalpha subunit of protein kinase A (PKA) has been associated with neoplastic transformation and mitogenic signaling. The effect of PKA inhibition on pancreatic cancer cell growth and apoptosis is unknown. In pancreatic cancer cells, we sought to determine (1) whether inhibition of PKA can inhibit growth or induce apoptosis, and (2) whether growth can be inhibited by silencing of RIalpha expression.

METHODS

Human pancreatic cancer cells (PANC-1, MIA PaCa-2, and SUIT-2) were treated with inhibitors of PKA (H89 or PKI) and cell growth, kinase activity, and induction of apoptosis measured. Small inhibitory RNA (siRNA) directed against the RIalpha subunit was synthesized and transfected into PANC-1 cells.

RESULTS

H89 decreased PKA activity and inhibited pancreatic cancer cell growth. Apoptosis was also induced by H89 in PANC-1 and MIA PaCa-2 cells. PANC-1 cells express high levels of the RIalpha subunit; transfection of siRNA decreased RIalpha protein expression and inhibited growth.

CONCLUSIONS

Inhibition of PKA in pancreatic cancer cells induces growth arrest and apoptosis; similar effects are noted in cells with siRNA used to block RIalpha expression. Inhibition of PKA may represent a novel therapeutic strategy for the adjuvant treatment of pancreatic cancer.

Survival benefits of portal vein resection for pancreatic cancer

BACKGROUND

The efficacy of portal vein resection for pancreatic cancer is controversial.

METHODS

Eighty-one consecutive patients with pancreatic cancer undergoing surgical resection were retrospectively analyzed. The clinicopathological findings and relationship between portal vein resection and survival were investigated.

RESULTS

Thirty-three patients with pancreatic cancer underwent pancreatic resection with portal vein resection. Histological examination revealed that 17 patients had definite invasion to the portal vein (group 1) and 16 patients had no invasion (group 2). Forty-eight patients with pancreatic cancer underwent pancreatic resection without portal vein resection (group 3). There were no significant differences in survival rates (P = 0.437) between patients with portal vein resection and patients without portal vein resection. However, patients in group 1 had a significantly (P = 0.021) worse prognosis as compared with those in group 2. Despite aggressive surgical resection, the surgical margin was positive in 35% of patients in group 1 as compared with 13% of patients in group 2 and 21% of patients in group 3.

CONCLUSIONS

Patients undergoing portal vein resection for pancreatic cancer had a prognosis similar to patients without portal vein resection. Negative microscopic invasion to the portal vein was significantly associated with improved survival.

Selective activation of PPARgamma inhibits pancreatic cancer invasion and decreases expression of tissue plasminogen activator

BACKGROUND

PPARgamma is a ligand-activated transcription factor with antitumor effects; its ability to inhibit pancreatic cancer invasion is unknown. The purpose of this study was to define the inhibitory effect of PPARgamma ligands on pancreatic cancer invasion and the expression of invasion-related genes.

METHODS

Western blotting was used to establish expression of PPARgamma in AsPC-1 and SUIT-2 cells. AsPC-1 cells were treated with nontoxic doses of PPARgamma ligands (15d-PGJ(2), troglitazone, or rosiglitazone) and Matrigel Invasion chambers were used to assess invasion in vitro. A microarray for genes that contribute to invasion was used to investigate the antiinvasive targets of PPARgamma. Gene array results were confirmed by use of ribonuclease protection assay or Northern blotting.

RESULTS

Rosiglitazone and 15d-PGJ(2) decreased AsPC-1 cell invasion; GW9662, which inhibits PPARgamma, reversed this effect. The expression of tissue plasminogen activator (tPA) was decreased by rosiglitazone treatment, which was confirmed by Northern blotting. Secreted levels of tPA in AsPC-1 conditioned media were also decreased.

CONCLUSIONS

We demonstrate, for the first time, that secretion of the invasive factor tPA was decreased by rosiglitazone treatment in AsPC-1 cells. PPARgamma ligands inhibit pancreatic cancer cell invasion, suggesting that these agents may represent novel strategies to treat pancreatic cancer.

[Chemoradiation in pancreatic carcinoma]

Prognosis of pancreatic carcinoma remains poor, with one-year and five-year overall survival rates of 20 and 5% respectively. Only 5 to 15% of patients present with tumors amenable to resection. Long-term (5 years) survival after curative resection is less than 20%, and the median survival is about 12 months. This paper updates recent trends about concomitant chemoradiation. At first, a review of the studies on adjuvant chemoradiation after surgery is proposed. Then, indications of preoperative chemoradiation for patients with localized resectable adenocarcinoma are discussed. The last part concerns the most important and recent studies about chemoradiation in locally advanced pancreatic cancer, either with 5-fluoro-uracile or based on new drugs like gemcitabine.