Clinical and radiologic characteristics of bone metastases in breast cancer

Effect of Bone Reading CT software on radiologist performance in detecting bone metastases from breast cancer

OBJECTIVE

To evaluate the effect of CT software that generates rib unfolding images and automatically numbers ribs and thoracic spines on radiologist performance in detecting thoracic bone metastases from breast cancer.

METHODS

A total of 126 patients with breast cancer who underwent chest CT and fludeoxyglucose (FDG)-positron emission tomography (PET)/CT and/or bone scans were retrospectively reviewed. One board-certified radiologist (R1) and one radiology resident (R2) independently assessed the original chest CT and rib unfolding images using a commercially available post-processing software (Bone Reading) application to evaluate metastasis in the ribs and thoracic spines. Results were compared with reference standard based on CT, FDG-PET/CT and/or bone scan with follow-up.

RESULTS

Based on reference standard, 78 metastatic bone lesions in 26 patients were identified. On per-patient-based analysis, Bone Reading assessed by R1/R2 had a sensitivity of 84.6%/80.8% and a specificity of 94.0%/94.0% with an accuracy of 92.1%/91.3%. The original CT reading yielded a sensitivity of 73.1%/57.7% and a specificity of 95.0%/94.0% with an accuracy of 90.5%/86.5%. The sensitivity and accuracy of Bone Reading were significantly higher than those of CT reading, as assessed by R2 (both p = 0.031). On per-lesion-based analysis, Bone Reading assessed by R1/R2 yielded a sensitivity of 84.6%/82.1% and a specificity of 99.7%/99.6% with an accuracy of 99.4%/99.3%, while the original CT reading yielded a sensitivity of 71.8%/62.8% and a specificity of 99.6%/99.5% with an accuracy of 99.2%/98.9%. The sensitivity and accuracy with Bone Reading application were significantly higher than those with CT reading by both readers (R1, p = 0.006 and p = 0.036, respectively; R2, both p < 0.001). The mean reading time needed for Bone Reading application was significantly shorter than that for original chest CT reading (p < 0.001). Bone Reading application helped readers find small and sclerotic lesions missed in original CT reading.

CONCLUSION

In patients with breast cancer, the use of Bone Reading application improved radiologist performance in bone metastasis detection compared with original chest CT reading with reduced reading time. This software will be more helpful to inexperienced radiologists for improving the reading performance. Advances in knowledge: Small and sclerotic lesions can be easily missed in original CT reading. Using Bone Reading CT software can enhance the performance of radiologists in detecting bone metastasis in breast cancer. False-negative rates can be significantly reduced in both inexperienced and experienced readers.

Circulating tumor cells at each follow-up time point during therapy of metastatic breast cancer patients predict progression-free and overall survival

PURPOSE

We reported previously that >or=5 circulating tumor cells (CTC) in 7.5 mL blood at baseline and at first follow-up in 177 patients with metastatic breast cancer (MBC) were associated with poor clinical outcome. In this study, additional follow-up data and CTC levels at subsequent follow-up visits were evaluated.

EXPERIMENTAL DESIGN

CTCs were enumerated in 177 MBC patients before the initiation of a new course of therapy (baseline) and 3 to 5, 6 to 8, 9 to 14, and 15 to 20 weeks after the initiation of therapy. Progression-free survival (PFS) and overall survival (OS) times were calculated from the dates of each follow-up blood draw. Kaplan-Meier plots and survival analyses were done using a threshold of >or=5 CTCs/7.5 mL at each blood draw.

RESULTS

Median PFS times for patients with <5 CTC from each of the five blood draw time points were 7.0, 6.1, 5.6, 7.0, and 6.0 months, respectively. For patients with >or=5 CTC, median PFS from these same time points was significantly shorter: 2.7, 1.3, 1.4, 3.0, and 3.6 months, respectively. Median OS for patients with <5 CTC from the five blood draw time points was all >18.5 months. For patients with >or=5 CTC, median OS from these same time points was significantly shorter: 10.9, 6.3, 6.3, 6.6, and 6.7 months, respectively. Median PFS and OS times at baseline and up to 9 to 14 weeks after the initiation of therapy were statistically significantly different.

CONCLUSIONS

Detection of elevated CTCs at any time during therapy is an accurate indication of subsequent rapid disease progression and mortality for MBC patients.

Role of 99mTc-hexakis-2-methoxyisobutylisonitrile for detecting marrow metastases in childhood solid tumours

AIM

To evaluate the role of 99mTc-hexakis-2-methoxyisobutylisonitrile (99mTc-MIBI) for detecting bone marrow metastases in childhood solid tumours, including lymphomas.

METHODS

Twenty-six children (18 males, eight females) were studied. They all had proven malignant solid tumours [Hodgkin's lymphoma (5), non-Hodgkin's lymphoma (3), neuroblastoma (9), Ewing's sarcoma (3), Langerhans cell histiocytosis (4), rhabdomyosarcoma (1) and germ cell tumour (1)] with suspected bone marrow metastases. All patients underwent computed tomography and/or magnetic resonance imaging, 99mTc-MIBI and Tc-methylene diphosphonate bone scans and bone marrow aspiration and/or biopsy. The scintigraphic evaluation of 99mTc-MIBI scans was performed according to the visual assessment of the extent and intensity of uptake. The scintigraphic score, which is the sum of the extent and intensity of uptake, was calculated for each patient. Scores of more than 2 were considered to be positive for bone marrow involvement.

RESULTS

Twenty-seven 99mTc-MIBI scans were studied for 26 patients. Twenty-two 99mTc-MIBI scans were accepted as normal bone marrow. Bone scans were also normal in these patients. Five of the 27 99mTc-MIBI scans had scores of more than 2. Bone marrow cytology revealed bone marrow metastases in these patients.

CONCLUSION

Abnormal 99mTc-MIBI uptake correlated extremely well with bone marrow aspiration/biopsy cytology results. Non-invasive 99mTc-MIBI imaging in children with malignant solid tumours appears to be promising for the evaluation of bone marrow metastases.

A pathologist's perspective on bone marrow aspiration and biopsy: I. Performing a bone marrow examination

The bone marrow aspirate and biopsy is an important medical procedure for the diagnosis of hematologic malignancies and other diseases, and for the follow-up evaluation of patients undergoing chemotherapy, bone marrow transplantation, and other forms of medical therapy. During the procedure, liquid bone marrow is aspirated from the posterior iliac crest or sternum with a special needle, smeared on glass microscope slides by one of several techniques, and stained by the Wright-Giemsa or other techniques for micro-scopic examination. The bone marrow core biopsy is obtained from the posterior iliac crest with a Jamshidi or similar needle and processed in the same manner as other surgical specimens. Flow cytometric examination, cytochemical stains, cytogenetic and molecular analysis, and other diagnostic procedures can be performed on bone marrow aspirate material, while sections prepared from the bone marrow biopsy can be stained by the immunoperoxidase or other techniques. The bone marrow procedure can be performed with a minimum of discomfort to the patient if adequate local anesthesia is utilized. Pain, bleeding, and infection are rare complications of the bone marrow procedure performed at the posterior iliac crest, while death from cardiac tamponade has rarely occurred from the sternal bone marrow aspiration. The recent development of bone marrow biopsy needles with specially sharpened cutting edges and core-securing devices has reduced the discomfort of the procedure and improved the quality of the specimens obtained.

Bone Metastases from Breast Cancer: Guidelines for Diagnosis

OBJECTIVE

To discuss the case of a 62-year-old woman with prior history of breast cancer who later sought chiropractic care, and to present an overview of appropriate imaging procedures in such cases.

CLINICAL FEATURES

The patient had a 6-month history of mild left-sided sacroiliac pain, which radiated into the left lateral thigh and leg. There was additional pain over the left upper ribs and left posterior arm, which had started insidiously. One year prior, she had undergone a lumpectomy. Current radiographs were negative for carcinoma.

INTERVENTION AND OUTCOME

Cautious spinal manipulation and soft tissue procedures were used to treat her sacroiliac joints. The thoracic pain was left untreated. The patient improved over the first 7 visits but had pain return after swimming. After ceasing therapy, she still suffered from similar pain.

CONCLUSIONS

It is important to assess patients who present with new bone pain after they already have a history of breast malignancy. Chiropractic physicians should take appropriate diagnostic steps to rule out suspected malignancy when there is no plain film evidence and biopsy is negative.

Clinical significance and outcome of one or two rib lesions on bone scans in breast cancer patients without known metastases

The presence of one or two rib lesions on bone scans of post-treatment breast cancer patients without known metastases often makes clinical decision making problematic. The aim of this study was to identify skeletal metastasis predictors that might help the management of these patients. We recruited post-treatment breast cancer patients without overt metastases whose bone scans showed (1) one or two rib hot spots, or (2) one rib lesion and a concurrent bone abnormality. Their clinical and serial scintigraphic data were collected, reviewed and evaluated for correlations. After their first abnormal bone scans, 23 patients (11 of the 77 patients initially with one rib lesion (incidence, 14.3%), three of the 27 patients with two rib lesions (incidence, 11.1%), and nine of the 11 patients with one rib lesion plus a concurrent bone abnormality (incidence, 81.8%)) developed multiple bone metastases within 2 years of the initial rib lesions in all but one case. Univariate analyses revealed that a concurrent bone lesion other than the rib, direct tumour invasion to the chest wall or skin, and 10 or more lymph nodes involved were associated with increased risks of bone metastases whereas longer persistence of the rib lesions was associated with a lower risk. Multivariate proportional hazard analyses indicated that patients with a concurrent bone lesion other than the rib (relative risk (RR)=39.65; 95% confidence interval (CI)=8.13-193.28), 10 or more lymph nodes involved (RR=13.49; 95% CI=2.09-86.91), and no radiotherapy (RR=7.59; 95% CI=2.11-27.39) were more likely to have bone metastases, while those with longer persistence of the rib lesions (RR=0.92; 95% CI=0.84-0.98) and longer time interval between surgery and the rib lesion detection (RR=0.96; 95% CI=0.94-0.99) were less likely. We have identified clinical features applicable to risk stratification. High incidence of bone metastases was noted in patients with one rib lesion and a concurrent bone abnormality. Regular follow-up for 2 years after detection of rib lesions is recommended, especially for those with risk factors.

The value of bone marrow scintigraphy using 99mTc monoclonal antigranulocyte antibodies in complement to bone scintigraphy in detecting bone metastases from primary breast cancer

This prospective study evaluates bone marrow scintigraphy (BMS) in detecting bone metastases from primary breast cancer when performed in complement to conventional bone scan (BS). Sixty women predominantly with low-stage disease underwent BS followed by BMS within 1-35 days using BW250/183 antigranulocyte antibodies. A receiver operating characteristic (ROC) analysis was performed to compare BS to BS+BMS on a patient-by-patient basis using a 'gold standard' composed of subsequent computed tomography, magnetic resonance imaging, X-ray or BS examinations and at least a 12 month follow-up. Metastases were present in eight out of 60 patients (13%). Specificity was improved by BS+BMS compared to BS alone (90%, 65%) as well as positive predictive value (62%, 27%), accuracy (87%, 72%), positive (10.4, 2.4) and negative (0.20, 0.00) likelihood ratios. Sensitivity (100%, 88%) and negative predictive value (100%, 97%) were similar for BMS+BS and BS alone. As a result of BMS, clinical management was modified in 15 patients (25%). In conclusion, BMS supplements BS by improving specificity, positive predictive value and accuracy in detecting breast cancer bone metastases. The ROC curves show improved specificity for BS+BMS at the same sensitivity compared to BS alone. Consequently, BMS may be useful in low-stage subjects with positive or equivocal BS for metastases.

Comparative diagnostic value and therapeutic relevance of magnetic resonance imaging and bone marrow scintigraphy in patients with metastatic solid tumors of the axial skeleton

PURPOSE

To evaluate the comparative impact of magnetic resonance imaging (MRI) and bone marrow scintigraphy (BMS) in bone marrow metastases of solid tumors.

METHODS

In 20 patients with solid tumors MRI of the axial skeleton and whole-body BMS were retrospectively reviewed. Detectability of metastases, extent of disease and therapeutic implications were assessed.

RESULTS

In 15/20 (75%) patients MRI and BMS concordantly revealed bone marrow metastases of the axial skeleton. In nine of these 15 patients (60%) MRI showed more metastases. Local radiotherapy or surgery was performed in seven of these cases (78%). BMS detected additional metastases of the appendicular skeleton in 8/15 (53%) patients. In 4/20 cases (20%) the imaging findings were discordant. In three patients with degenerative changes (n=2) or lipoma (n=1) BMS was false positive. In another patient BMS failed to detect metastases proven by MRI and clinical follow-up resulting in subsequent radiation therapy. One patient had normal bone marrow.

CONCLUSION

MRI appears to be more sensitive and specific in the detection of bone marrow metastases in the axial skeleton and is of clinical importance for subsequent local therapy.

Comparative detectability of bone metastases and impact on therapy of magnetic resonance imaging and bone scintigraphy in patients with breast cancer

OBJECTIVE

to evaluate the comparative impact of magnetic resonance imaging and bone scintigraphy in bone metastases of breast cancer.

METHODS AND PATIENTS

in 81 patients with histologically proven breast cancer magnetic resonance imaging of the axial skeleton and whole-body bone scintigraphy had been performed. Images were retrospectively reviewed and compared for detection of metastases, extent of metastatic disease and therapeutic implications according to the patients' records.

RESULTS

about 54/81 (67%) patients revealed bone metastases. In 7/54 (13%) patients with bone metastases, scintigraphy was false negative. In one patient a solitary sternal metastases was seen. In 26/53 [49%] patients with spinal metastases, magnetic resonance imaging showed more extensive disease. Local radiotherapy or surgery was indicated in ten patients with metastases not evident in bone scintigraphy, in 20 patients with positive results by both imaging modalities and in six patients with metastases of pelvis imaged by bone scintigraphy only.

CONCLUSION

magnetic resonance imaging of the axial skeleton and pelvis appears superior for staging as only one patient had metastases merely outside the axial skeleton and local therapy was indicated even in spinal regions negative in bone scintigraphy.

The usefulness of 99mTc-HMPAO-labeled leukocyte scintigraphy in the diagnosis of skeletal metastases of cancers

The usefulness of bone marrow scintigraphy with 99mTc-HMPAO-labeled leukocytes (leukocyte bone marrow scintigraphy) in the diagnosis of skeletal metastases of cancers was investigated in 70 lesions in 27 patients with various types of cancer. The final diagnosis of skeletal metastases was based on one or more criteria consisting of histological confirmation, typical findings of metastases by bone radiograph, CT and MRI, or progressive swellings of the lesions with severe pain due to nerve compression. Of the 70 lesions, 55 were finally diagnosed as metastases, and 15 as benign lesions. Leukocyte bone marrow scintigraphy showed photopenic defects in 52 of the 55 metastatic lesions (sensitivity 95%), and the remaining 3 negative lesions were found positive for metastases by MRI. In contrast, MRI could evaluate only 39 of the 55 lesions because 16 lesions in the ribs, scapula and sternum were not visualized. Of these 39 lesions, MRI showed positive findings for metastases in 33 (sensitivity 85%), and negative findings in 6 with photopenic defects found by leukocyte bone marrow scintigraphy. Of the 15 benign lesions, 3 were false positive for metastases on leukocyte bone marrow scintigraphy (specificity 80%). We conclude that 99mTc-HMPAO-labeled leukocyte bone marrow scintigraphy may be useful in the diagnosis of skeletal metastases of cancers, particularly when MRI fails to evaluate the lesions.

Metastatic breast cancer: clinical course, prognosis and therapy related to the first site of metastasis

Although metastasis is a frequent event in breast cancer patients, insight into the clinical course, prognosis and therapy with respect to the site of the first metastases has been poor and contradictory in former investigations. Follow-up data from 648 patients with metastatic breast cancer were statistically analyzed. Patients with bone metastases at first relapse had better overall survival (median 71 vs. 48 months; p < 0.001) and survival after first metastases (median 24 vs 12 months; p < 0.001) than patients with visceral metastases at first relapse. Bone was the site of first metastasis in 46%, and 71% of patients with metastatic breast cancer developed bone metastases. The localization of the second metastatic site was of prognostic relevance in patients with first visceral metastases, but not in patients with first bone metastases. The presence of osseous metastases correlated significantly with estrogen and progesterone receptor positivity, tumor grading I/II and S-phase fraction <5%. The better prognosis of patients with bone metastases is not determined exclusively by hormone receptor status. The disease is significantly more stable in patients with first bone metastases than in those with first visceral metastases.

Monitoring therapeutic response in skeletal metastases using dual-energy x-ray absorptiometry: a prospective feasibility study in breast cancer patients

Response to systemic therapy in breast cancer patients with lytic skeletal metastases manifests as a shift from increased bone resorption to new bone formation. We hypothesized that dual-energy x-ray absorptiometry (DXA) could be used to prospectively quantitate changes in bone mineral density (BMD) in metastatic skeletal lesions in breast cancer patients receiving systemic therapy. Nine metastatic breast cancer patients with one or more assessable lytic skeletal metastases receiving systemic therapy were prospectively evaluated with DXA, skeletal radiographs, computed tomography (CT), and radionuclide bone scans at baseline (t = 0 months, 2 months, and 6 months). The median (range) percentage change in BMD in skeletal lesions among patients responding to systemic therapy was 10.7% (0.1-21.85), 5.0% (-1.3-23.8), and 16.7% (-2.0-50.8) at 0-2, 2-6, and 0-6 months, respectively. Changes in BMD between 0-2, and 0-6 months were significant (Wilcoxin signed rank test; p = 0.013 and p = 0.017, respectively). The percentage change in BMD skeletal lesions between 0-2 and 2-6 months correlated with the changes imaged on skeletal x-rays (Spearman rank order correlation coefficient [Rs] = 0.511, p = 0.011) and CTs (Rs = 0.416, p = 0.046) but less so with bone scans (Rs = 0.293, p = 0.189). It is technically feasible to use DXA to prospectively monitor changes in lytic skeletal metastases in breast cancer patients receiving systemic therapy. The BMD of skeletal metastases increases in patients responding to treatment and was significantly correlated with the changes imaged on skeletal x-rays and CTs. Additional studies of DXA to evaluate response in skeletal metastasis are warranted.

Early detection and accurate description of extent of metastatic bone disease in breast cancer with fluoride ion and positron emission tomography

PURPOSE

Previous studies have shown that bone metastases are revealed by magnetic resonance imaging (MRI) or bone marrow scintigraphy several months before they are visible by conventional bone scintigraphy (BS). We present a new approach for detecting bone metastases in patients with breast cancer. We compared findings obtained with fluoride ion (F-18) and positron emission tomography (PET) with those obtained with conventional BS.

PATIENTS AND METHODS

Thirty-four breast cancer patients were prospectively examined using F-18-PET and conventional BS. F-18-PET and BS were performed within 3 weeks of each other. Metastatic bone disease was previously known to be present in six patients and was suspected (bone pain or increasing levels of tumor markers, Ca(2+), alkaline phosphatase) in 28 patients. Both imaging modalities were compared by patient-by-patient analysis and lesion-by-lesion analysis, using a five-point scale for receiver operating characteristic (ROC) curve analysis. A panel of reference methods was used, including MRI (28 patients), planar x-ray (17 patients), and spiral computed tomography (four patients).

RESULTS

With F-18-PET, 64 bone metastases were detected in 17 patients. Only 29 metastases were detected in 11 patients with BS. As a result of F-18-PET imaging, clinical management was changed in four patients (11.7%). For F-18-PET, the area under the ROC curve was 0.99 on a lesion basis (for BS, it was 0.74; P <.05) and 1.00 on a patient basis (for BS, it was 0.82; P <.05).

CONCLUSION

F-18-PET demonstrates a very early bone reaction when small bone marrow metastases are present, allowing accurate detection of breast cancer bone metastases. This accurate detection has a significant effect on clinical management, compared with the effect on management brought about by detection with conventional BS.

Human bone marrow-derived mitogenic stimulation selective for breast carcinoma and neuroblastoma cells

In patients with neuroblastoma (NB) or breast carcinoma (BC), metastatic disease in the bone marrow (BM) is observed more frequently than at any other site, and a high incidence of BM metastases in these patients is associated with advanced disease and poor prognosis. These observations suggest the presence of BM micro-environmental elements that are favorable for NB and BC tumor cell growth. The influence of normal human BM cell-derived conditioned medium (CM) on clonogenic growth of BC and NB cell lines was investigated in vitro. The effects obtained were compared with those on tumor cells with a lower potential for BM metastasis. CM from unstimulated cultures of normal, healthy, low-density BM cells reproducibly and markedly augmented clonogenic growth of 3 BC and 3 NB cell lines. In contrast, growth of cell lines established from human tumors with differing metastatic propensity was unaffected by BM CM. Initial characterization, using crude BM CM, indicated that mitogenic activity (i) is mediated by peptides released by the non-adherent fraction of low-density BM cells and (ii) is not abolished by neutralizing antibodies against various cytokines known to be produced by BM cells and to regulate hematopoietic cell growth. Our observations suggest that certain specific peptides in the BM micro-environment may be responsible for the preferential growth of NB and BC metastases in BM.

Radiologic features compared to clinical findings in a prospective study of 153 patients with metastatic spinal cord compression treated by radiotherapy

Plain radiography, myelography and post-myelographic CT-scan are described and related to clinical findings in a prospective study of 153 consecutive patients with myelographic signs of spinal cord compression. The majority of the metastatic tumours arise in the vertebral body or the pedicles. In 80% of the patients with total blockage to the contrast medium on myelography the post-myelographic-CT showed passage of the contrast medium. Ambulatory function at time of diagnosis was correlated to the degree and the localization of the epidural block. In 64 patients who underwent a second myelography, the post-treatment findings of sensory function were correlated to radiological regression.

Bone marrow metastases

This article discusses the clinical significance of bone marrow metastases and the current methods being used to detect tumor cells in marrow. The strategies being investigated for eradicating cancer cells from marrow in patients receiving hematopoietic cell autografts also are reviewed.

Second occurrence of symptomatic metastatic spinal cord compression and findings of multiple spinal epidural metastases

PURPOSE

To examine the frequency of initial multiple epidural metastases, and the occurrence of secondary spinal cord compression (SCC).

METHODS AND MATERIALS

To evaluate the frequency of a recurrent SCC after radiotherapy, and to compare among patients with single and multiple intraspinal metastases the risk of having a second SCC, we followed 107 patients with SCC from a histologically verified solid tumor prospectively with regular neurological examinations until death.

RESULTS

Multiple metastases were demonstrated in 37 (35%). Eight (7.5%) patients developed a second occurrence of SCC all in a new location within the spinal canal. The second occurrence of SCC was found with the same frequency in patients with single metastases (7.1%) compared to patients with multiple metastases (8.1%). The median survival time after the diagnosis of spinal cord compression was 3.4 months, while in the group of patients who developed a second occurrence of SCC the median survival time was 9.2 months.

CONCLUSION

Only symptomatic epidural metastases should be irradiated, and that all patients treated for SCC should be followed regularly and observed for development of a second SCC.

Serum YKL-40: a new potential marker of prognosis and location of metastases of patients with recurrent breast cancer

YKL-40 is a recently discovered glycoprotein which is related in amino acid sequence to the chitinase protein family, but has no chitinase activity. Although the function of YKL-40 is presently unknown, the pattern of its expression by some tissues suggests that YKL-40 could function in tissue remodelling. The diagnostic features and relation to survival of serum YKL-40 have not been examined previously in human malignancies. In the present study YKL-40 was measured in serum obtained from 60 patients at the time that breast cancer recurrence was suspected. The median serum YKL-40 in patients with visceral or bone metastases was 328 and 157 micrograms/l, respectively and significantly higher compared to controls (99 micrograms/l, P < 0.001). Kaplan-Meier survival curves demonstrated that survival rates after 18 months were 24% for patients with high serum YKL-40 (> 207 micrograms/l = the 95 percentile of controls) and 60% for patients with normal serum YKL-40. The significance of the difference between the shorter survival of patients with high serum YKL-40 and the longer survival of patients with normal serum YKL-40 was high (P < 0.0009). When evaluated with other prognostic factors of survival after recurrence of breast cancer, serum YKL-40 and serum lactate dehydrogenase (LDH) were the most significant independent factors. The results indicate that determination of serum YKL-40 can be used as a prognostic marker related to the extent of disease and survival of patients with recurrence of breast cancer. In addition, the serum YKL-40 level may be of value in the follow-up of patients with breast cancer and in evaluating potential metastatic spread.

Irradiation of bone metastases in breast cancer patients: a randomized study with 1 year follow-up

The results from a prospective randomized trial comparing two different radiation schedules for treatment of painful bone metastases in women with recurrent breast cancer are presented. A total of 217 patients with painful bone metastases were randomized to either 30 Grey (Gy) in ten fractions, five fractions a week (5F/W) or 15 Gy in three fractions 2F/W. The effect of treatment was evaluated by pain assessment, the radiological response and the degree of side-effects. The patients were rated at start of treatment and after 1, 3, 6 and 12 months. No difference between the two radiation regimes was found, neither in achieved pain relief, improvement in level of activity and medication, nor was there any difference in radiological response and side-effects from treatment. Both regimes resulted in a significant improvement in both pain score and level of activity 1 month after treatment, an improvement which persisted during the follow-up period. We conclude that 15 Gy given in three fractions 2F/W is as effective as 30 Gy in ten fractions 5F/W, but more convenient to the patient and of less cost to society.

The Urinary Excretion of Pyridinium Cross-links as Markers of Bone Meta stasisin Breast Cancer

The collagen cross-links, pyridinoline (Pyr) and deoxypyridinoline (D-Pyr) excreted in urine have recently been suggested as new markers of bone metastasis. In a pilot study we measured Pyr and D-Pyr in 61 patients with breast cancer, 16 with known bone metastasis and 45 with no recognized metastasis in bone. Twenty healthy female subjects were also measured as controls. The mean values (+/-SD) of Pyr and D-Pyr in the group with bone metastasis were significantly higher (Pyr: p<0.01, D-Pyr: p <0.05) than those in the group without bone metastasis and in the control group. The mean (+/-SD) values of postmenopausal women were significantly higher than those of premenopausal in the group without bone metastasis (p<0.05) and in the control group (p<0.01). Therefore, the effect of menopause should be taken into account in the diagnosis of bone metastasis by assays of Pyr and D-Pyr. Setting the cut-off values (mean + 2SD of the values of control) for pre and postmenopausal patients, the accuracy for Pyr was 71.4% in premenopausal and 75.8% in postmenopausal patients; and for D-Pyr it was 71.4% and 78.8% respectively. We consider that measurement of urinary collagen cross-links assays can contribute to the early detection of metastatic spread to bone in breast cancer.

Assessment of bone marrow involvement by magnetic resonance imaging in small cell lung cancer. No significant change of staging

STUDY OBJECTIVE

This prospective study was performed in an attempt to evaluate (1) the rate of magnetic resonance imaging (MRI) demonstrating bone marrow (BM) abnormalities, (2) the correlation of these abnormalities with a pathologic malignant BM involvement, and (3) the possible modification of patients' usual disease staging in the light of these abnormalities.

METHODS

After extensive staging investigations, patients' diseases were classified as limited or extensive. Dorsal and lumbar spine MRI was performed for second staging.

RESULTS

Thirty-two patients were eligible for this study. In ten patients (31.2 percent), MRI showed abnormalities; in four of them, the BM sample from the posterior iliac crest was free from malignancy. Three of these four patients had extensive disease. The last patient, because he had limited disease, had biopsy at the site of MRI abnormalities; the biopsy specimen revealed a malignant involvement and therefore this patient, initially classified as having limited disease, was classified in the extensive disease group. In only 1 of 32 patients, BM-MRI data modified initial staging.

CONCLUSIONS

The metastases disclosure yield of the MRI in the detection of medullar involvement is higher than BM biopsy but especially in patients with extensive disease. Therefore, MRI should not be considered in routine practice, in particular in patients with extensive disease.

Serum tumor markers for detection of bone metastasis in breast cancer patients

For the diagnosis of bone metastasis in breast cancer patients during systemic treatment serum tumor markers, including carbohydrate antigens 15-3 (CA 15-3) and 19-9 (CA 19-9), cancer antigen 125 (CA 125), alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), beta-2 microglobulin (BMG), ferritin, and tissue polypeptide antigen (determined by the M3 monoclonal antibody, TPS) were measured in 22 patients with known bone metastases and in 30 patients without documented metastases. The most useful single marker was CA 15-3. By stepwise discriminant analysis, it was found that 90% of the patients could be diagnosed truly by using the markers CA 15-3, BMG and ferritin. It is concluded that monitoring with combinations of tumor markers at regular intervals increases the diagnostic efficiency.

The diagnostic and prognostic value of serum bone Gla protein (osteocalcin) in patients with recurrent breast cancer

Serum bone Gla protein (S-BGP), a marker of bone metabolism, was measured in 60 patients included in a staging programme for recurrent breast cancer. Other diagnostic procedures comprised S-alkaline phosphatase (S-AP), bone scan (B-scan), bilateral iliac crest bone marrow biopsies, and radiological bone survey. The sites of recurrence were bone (61%), bone marrow (46%), soft tissue (52%), lung (13%), pleura (11%), liver (4%), and brain (2%). Radiology and bone biopsy served as key diagnoses as to the presence or absence of bone metastases. The diagnostic efficiency of B-scan and S-AP was greater than that of S-BGP, and the result of BGP measurement was associated with neither extent nor number of bone metastases. However, the BGP values were significantly lower in patients who had visceral metastases, and the median duration of survival after recurrence was 13 months for patients with low S-BGP levels (= < 2.0 nmol l-1), compared to 18 months for patients with medium S-BGP values (2.0-2.9 nmol l-1), and 25 months for patients with high values (> 3.0 nmol l-1) (p = 0.19). Analyses of the simultaneous effect of univariate prognostic factors were performed using the Cox proportional hazards model. S-alkaline phosphatase (S-AP) and S-BGP were the only significant, independent prognostic factors.

Patterns of metastatic breast cancer in relation to histological type

We have examined the clinical records fo 1238 patients with operable breast cancer to identify the sites of metastatic disease. Infiltrating ductal carcinoma (IDC) recurred more commonly in lung (P < 0.05), pleura (P < 0.05) and brain (P < 0.05), while infiltrating lobular carcinoma (ILC) more commonly metastasised to the bone marrow (P < 0.01) and peritoneum (P < 0.01). Bone involvement as the initial presentation of distant metastatic disease occurred in over 50% of women with ILC, significantly more commonly than in those with IDC (34%, P < 0.01). Survival was similar for the two groups, both from time of diagnosis and from time of development of distant metastases.

Multivariate analysis of serum tumor markers for diagnosis of skeletal metastases

Serum tumor markers, including carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), carbohydrate antigen 15-3 (CA 15-3), carbohydrate antigen 19-9 (CA 19-9), cancer antigen 125 (CA 125), and tissue polypeptide antigen (TPA), were measured in 26 patients with skeletal metastases and 11 patients with primary malignant bone tumors. TPA, which was elevated in 16 patients (61.5%), was the most sensitive marker for detection of skeletal metastases. Combined measurement of these markers was useful in detecting skeletal metastases from primary lesions, although tumor markers had little organ specificity. In addition, skeletal metastases could be completely differentiated from primary lesions by the use of multivariate discriminant analysis of markers. The most and least powerful discriminating factors were AFP and CA 19-9, respectively. On multidimensional scaling, the distance between AFP and CEA was longest, with the other markers scattered between them. Expression of individual markers can not be linked to that of other markers.

Prognostic indicators of metastatic bone disease in human breast cancer

The time to detection of metastatic bone disease (MBD) by radiographic examination was studied in 221 patients with advanced breast cancer. None of the patients had bone metastases by radiography or bone marrow carcinosis, evaluated by bilateral iliac crest biopsy. The period of follow-up after first recurrence was 46 months. Fifty-five patients (25%) had MBD; 89 patients died without MBD. The cumulated rate of MBD was 14% and 27% after 1 and 2 years, respectively. The actuarial time to MBD was associated significantly with the presence of positive regional lymph nodes at primary diagnosis, the occurrence of metastases in the mediastinum, and the presence of visceral metastases. Moreover, a positive bone scintigraphic scan at the time of first recurrence and abnormal biochemical analyses from serum also were associated significantly with a shortened time to MBD. Micrometastases in the bone marrow, as detected by monoclonal antibodies against epithelial markers (epithelial membrane antigen and cytokeratin), were present in 18% of the patients. The presence of such tumor cells was not associated with development of radiologic MBD. Cox analyses revealed that the result of bone scintigraphic scanning and the presence of visceral metastases were the most important and independent predictors of the time of MBD. Four distinct prognostic groups were identified based on the status of these two variables. The recognition of these prognostic groups has several implications for clinical and therapeutic management of patients with recurrent breast cancer.

Immunohistochemical detection of estrogen receptors in paraffin sections from primary and metastatic breast cancer

With the availability of monoclonal antibodies against the estrogen receptor (ER) it is possible to demonstrate the presence of ER immunohistochemically. Some of the antibodies are claimed to be reactive in formalin fixed, paraffin embedded tissue. We have evaluated the reactivity of one of these antibodies, D75 and found an acceptable reaction in routinely formalin fixed, paraffin embedded tissue. The antibody was applied to both primary and secondary tumors from a group of patients with recurrent breast cancer. The metastatic lesions consisted of lymph node metastases, bone marrow metastases, and liver metastases. While 41% of the primary tumors were ER-positive, this was only the case with 35%, 20%, and 17% of the lymph node, bone marrow, and liver metastases, respectively. The discordance between the ER-status of the primary tumor and the distant metastasis was 41% in cases of bone marrow metastases, and 44% in liver metastases. In most cases the shift was from an ER-positive primary tumor to an ER-negative metastasis. The results support the hypothesis that ER-negative tumor cells are probably more aggressive with a larger metastatic potential than the higher differentiated, ER-positive tumor cells.

Bone metastasis as a non-stochastic process

Bone metastasis may be considered a non-stochastic process, since the blood flow in bone is lower than that in other organs and most cancers do not have a tendency to metastasize to bone in in vivo experiments. Furthermore, the experimental model of bone metastasis, based on the ligation of major venous flow, can not explain the wide-spread bone metastasis which is commonly observed in clinical cases. These observations may be explained by the hypothesis that tumor cells have a phenotype for translocating to specific tissues and that tumor cell growth is controlled by the microenvironmental factors in situ.

Radioimmunoimaging for diagnosis of bone marrow involvement in breast cancer and malignant lymphoma

Granulopoietic bone-marrow was scintigraphically imaged in 15 patients with carcinoma of the breast and known skeletal metastases, 10 patients with malignant lymphomas, and 15 controls without suspected malignant disease, with a technetium-99m labelled murine monoclonal IgG1 antibody directed against nonspecific cross-reacting antigen (NCA-95) and carcinoembryonic antigen. Immunoscintigraphy revealed more lesions than did bone scanning in both patient groups. This method offers a sensitive, cost-effective, and easy-to-perform whole body technique for evaluating metastatic spread.

Metastatic pattern in recurrent breast cancer. Special reference to intrathoracic recurrences

The anatomical and temporal patterns of recurrence were studied in 401 patients with first recurrence of breast cancer. All patients underwent the same scheduled investigation program: history, physical examination, blood tests, bone scanning, bilateral iliac crest biopsy, radiologic bone survey, chest x-rays, and ultrasound scanning of the liver. The current article focuses on the diagnosis of intrathoracic (ITH) recurrence. Most patients recurred in a single site and 50% of the recurrences were diagnosed within the first 2 years from initial diagnosis. Chest x-ray revealed ITH recurrence in 27% (109 patients), and in 8% the lung, pleura, and/or mediastinum were the only signs of recurrence. Generally, the status of primary demographic, clinical, and pathoanatomical characteristics were not predictive as to the development of ITH recurrence, although patients with pleural recurrences often had centrally located primary tumors, locally advanced disease, and often received adjuvant radiotherapy. Clinical symptoms and signs of ITH recurrence were present in only one third of the patients, and the diagnostic specificity and sensitivity of serum lactate dehydrogenase were only 33% and 85%, respectively. Since ITH recurrences often are silent, and since recurrence in this site may have both prognostic and therapeutical implications, routine chest x-ray is indicated in all patients with first recurrence of breast cancer.

Adjuvant systemic treatment and the pattern of recurrences in patients with breast cancer

The aim was to analyze the impact of adjuvant systemic treatment (AST) on the anatomical distribution, the number, and the temporal relationship of the first metastases in 635 patients (pts) with breast cancer. These patients participated in the prospective studies of AST of the Danish Breast Cancer Cooperative Group (DBCG) 77-program. All patients had primary high-risk breast cancer (i.e. node positive or local invasion or tumor size greater than 5 cm). The initial treatment was mastectomy with axillary sampling, followed by postoperative radiotherapy. The types of AST and the number of patients with recurrence were: chemotherapy (CT), 134 pts; levamisole (LEV), 96 pts; tamoxifen (TAM), 154 pts. The pattern of recurrence in these patients was compared with the pattern of recurrence in 251 pts who did not receive AST (controls). Although CT reduced the total number of metastatic sites (P = 0.04), the incidence of liver metastases was increased compared to untreated controls (P = 0.02). The median number of metastatic sites was equal in TAM- and LEV-treated pts compared to controls. The incidence of lung metastases was increased in TAM-treated pts (P = 0.03), and LEV-treated pts had a decreased incidence of lymph node (P = 0.01) and pleural recurrences (P = 0.01) compared to controls. The results may suggest that mechanisms of clonal selection during the metastatic process involve differences in sensitivity to antineoplastic treatments of metastases at various anatomical locations.

The value of pre-scheduled bone scintigraphies in breast cancer

During the first 10 years of Danish Breast Cancer Cooperative Group (DBCG), the subcommittee on bone scintigraphy has focused on the value of bone scintigraphy at the time of operation in all patients and then yearly in those considered to be primarily operable (stage I and II). Out of 1175 patients examined at time of operation, bone metastases could be verified by x-ray or histology in only 16, of whom the majority had bone pain and/or spread to other organs. Similarly, around 2.5% per year for the first 3 postoperative years and about 1% per year during the next 4 postoperative years had bone metastases verified by x-ray or histology within 12 months after the latest scheduled bone scintigraphy. It is concluded that bone scintigraphy is of no value in primarily operable patients with breast cancer, and that the examination should be reserved for patients with symptoms and/or signs of bone metastases and for patients with relapse.