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

Fatty Acid Synthase (Fas) Predictive Strength in Poorly Differentiated Early Breast Carcinomas

Aims and background

Many normal and human cancer tissues express fatty acid synthase (FAS), the major enzyme required for endogenous fatty acid biosynthesis. Strong expression of FAS seems to be associated with a poor prognosis. This study examines the strength of FAS and other common markers of relapse in poorly differentiated breast carcinoma.

Materials and methods

Fifty-one patients with poorly differentiated ductal infiltrating breast carcinomas were followed up for more than 10 years. Immunohistochemical detection of FAS was associated with morphological features of the tumors, with immunohistochemical expression of c-erbB-2, cathepsin D, estrogen and progesterone receptor status and with DNA ploidy in order to detect a statistical correlation.

Results

The chi-square test revealed a correlation between FAS and peritumoral lymphatic vessel invasion (PLVI) (P = 0.001). Univariate analysis showed that FAS was correlated with disease-free survival (DFS) (P = 0.0001). Other prognosticators associated with DFS were PLVI (P = 0.002), estrogen (P = 0.008) and progesterone receptor status (P = 0.007). Bivariate analysis showed that FAS was a further prognostic discriminant of DFS within the ER, PgR and PLVI subsets.

Discussion

FAS is a reliable prognosticator of recurrence in poorly differentiated early breast carcinomas. Association of FAS with PLVI may be useful to plan a correct follow-up in patients with breast neoplasms.

Conventional and new emerging prognostic factors in breast cancer: an update

This article reviews the conventional clinicopathological, as well as the principal new emerging prognostic factors of breast cancer and proposes a tumor marker utility grading system for their use. In spite of the many advances in molecular biology toward better defining the biological aggressiveness of the primary malignancy, the conventional node-negative status, tumor size and grade are still the strongest predictors of relapse-free survival and/or overall survival. Microvessel count and bone-marrow micrometastases, among the more recently studied clinicopathological prognostic factors, and amplification and/or p53 mutation and S-phase fraction among the biological ones must be considered investigational, although, with enough documentation recommending their usefulness. Estrogen and/or progesterone expression, c-erbB-2 amplification and/or mutation are the prognostic factors currently included in the principal clinical guidelines. They also enable probable forecast of the response to endocrine treatment or chemotherapy. In particular, c-erbB-2 is used to define the different risk categories of node-negative operated breast cancer patients. In recent years, microarray and quantitative reverse-transcription PCR technologies have enabled the study of multiple genetic alterations and computer algorithms have been developed for visual recognition of tumors that share so-called ‘signatures’. So far, different gene-expression patterns with different prognoses have been identified but methodological problems remain to be solved prior to routine use.

Prognostic/Predictive Factors in Breast Cancer

This can be an exciting time for pathologists and cytopathologists as we refine or knowledge of prognostic/predictive factors in breast cancer. We can become more visible in our role as consultants to the other physicians, and more engaged in our role as re-searchers. Recent advances in computer science, coupled with the availability of new biological markers, now provide unique opportunities for us to expand our diagnostic abilities and also predict the biologic behavior of a given tumor. Thus, we must become more familiar with emerging concepts and technologies in different disciplines.

Proliferative markers as prognostic and predictive tools in early breast cancer: where are we now?

In the last few decades, proliferative markers have been broadly evaluated as prognostic and predictive factors for early stage breast cancer patients. Several papers evaluating one or more markers have been published, often with contradictory results. As a consequence, there is still uncertainty about the role of these proliferative markers. The present paper critically reviews the current knowledge about the following markers: thymidine labeling index, S phase fraction/flow cytometry, Ki 67, thymidine kinase (TK), cyclins E, cyclin D, the cyclin inhibitors p27 and p21, and topoisomerase IIalpha. For each marker, the prognostic and predictive role was separately analyzed. Only papers published in English in peer-reviewed journals before June 2004 that include at least 100 evaluable patients were selected. In addition, the prognostic and predictive role of the proliferative markers had to be assessed through multivariate analyses. One hundred and thirty-two papers fulfilled these criteria and 159 516 patients were analyzed. Unfortunately, several methodological problems in the research to date prevent us from including any one of these proliferative markers among the standard prognostic and predictive factors. Early incorporation of translational research and new technologies with clinical trials are needed to prospectively validate biological markers and allow their use in clinical practice.

Prognostic factors affecting the natural history of node-negative breast cancer

PURPOSE

We undertook a natural history investigation of a broad selection of prognostic factors in a cohort of women with node-negative breast cancer.

PATIENTS AND METHODS

The cohort consisted of 415 consecutive histologic node-negative (T1-3, M0) patients, operated on for primary breast cancer at Women's College Hospital, Toronto, Canada, between 1977 and 1986. Only 7% of these patients were given adjuvant systemic therapy; further, for the 48% of women who underwent lumpectomy, only 29% received adjuvant radiotherapy to the breast. Paraffin-embedded tumour tissue was available for the majority of patients. The following factors were examined for their univariate and multivariate effects on time to recurrence outside the breast (DFI) and survival from breast cancer (DSS): age, weight, tumour size, estrogen receptor, progesterone receptor, histologic type, tumour grade, nuclear grade, lymphovascular invasion, overexpression of neu oncoprotein, DNA ploidy, % cells in S-phase, and adjuvant therapy. Multivariate analyses utilized a Cox model with a step-wise factor selection for the 260 patients with complete information.

RESULTS

A worse prognosis was indicated when there was lymphovascular invasion (for DFI, p < 0.001; for DSS, p = 0.0046), high %S-phase (for DFI, p = 0.08; for DSS, p = 0.02), high tumour grade (for DFI, p = 0.02; for DSS, p = 0.03), and overexpression of neu oncoprotein (for DSS, p = 0.07).

CONCLUSIONS

In our natural history investigation, two factors, lymphovascular invasion and tumour grade, are of particular interest since they may be readily incorporated into clinical practice. Overexpression of neu oncoprotein may also play a role in determining prognosis for women administered adjuvant systemic therapy.

Evaluation of ER, PgR, HER-2 and Ki-67 as predictors of response to neoadjuvant anthracycline chemotherapy for operable breast cancer

Primary systemic therapy (PST) for operable breast cancer enables the identification of in vivo biological markers that predict response to treatment. A total of 118 patients with T2–4 N0–1 M0 primary breast cancer received six cycles of anthracycline-based PST. Clinical and radiological response was assessed before and after treatment using UICC criteria. A grading system to score pathological response was devised. Diagnostic biopsies and postchemotherapy surgical specimens were stained for oestrogen (ER) and progesterone (PgR) receptor, HER-2 and cell proliferation (Ki-67). Clinical, radiological and pathological response rates were 78, 72 and 38%, respectively. There was a strong correlation between ER and PgR staining (P<0.0001). Higher Ki-67 proliferation indices were associated with PgR− tumours (median 28.3%, PgR+ 22.9%; P=0.042). There was no relationship between HER-2 and other biological markers. No single pretreatment or postchemotherapy biological parameter predicted response by any modality of assessment. In all, 10 tumours changed hormone receptor classification after chemotherapy (three ER, seven PgR); HER-2 staining changed in nine cases. Median Ki-67 index was 24.9% before and 18.1% after treatment (P=0.02); the median reduction in Ki-67 index after treatment was 21.2%. Tumours displaying >75% reduction in Ki-67 after chemotherapy were more likely to achieve a pathological response (77.8 vs 26.7%, P=0.004).

Thymidine labeling index: prognostic role in breast cancer

The aim of this study is to evaluate the prognostic role of thymidine labeling index in patients with breast cancer. Cellular proliferation rates in 155 breast cancer specimens were investigated by 3H-thymidine labeling index (3H-TLI). Median age was 47 years (range: 23-76). At presentation, 11 patients (7.1%) had stage I disease, 76 (49%) had stage II, 64 (41.3%) had stage III disease, and 4 (2.6%) had metastatic involvement. Patients were placed in 2 groups based on their proliferative indices. The cut-off level was assigned as the median TLI value of the whole group. Correlations between proliferative activity of the tumors based on 3H-TLI levels and various previously established prognostic factors, as well as the influence of proliferative activity on survival as a clinical outcome, were analyzed. The mean and median TLI values for the whole group of patients were 4.36 +/- 4.96% and 2.76% (range: 0-23.6), respectively. There was a significant association of nuclear grade with TLI (P = 0.04). Patients who were alive with no sign of disease at the final follow-up examination had a significantly lower median TLI rate than those who were either alive with disease or those who had eventually died with disease progression (3.7% versus 1.9%, respectively; P = 0.04). Patients with locally advanced disease (N2 + N3 involvement) had a significantly higher median TLI rate than those with local nodal involvement (N1) (3.4% versus 1.7%, respectively, P = 0.026). Furthermore, TLI levels showed a significant association with overall survival in patients with node-negative disease (P = 0.02). Based on the results of this study, it can be concluded that TLI plays a significant prognostic role in a subset of patients with node-negative breast cancer. Furthermore, TLI appears to have a predictive value for the clinical outcome of patients with breast cancer. These findings may justify a more aggressive therapeutic approach in patients with high TLI levels. Further large-scale, prospective studies are required before a definite conclusion can be reached.reached.

Molecular evolutionary patterns in breast cancer

Geno-phenotypic patterns of pre-invasive and invasive lobular breast cancers and infiltrating ductal carcinomas of low, intermediate, and high grade are reviewed. One of the main differences between lobular breast cancers and ductal carcinomas is the presence of inactivating E-cadherin gene mutations in lobular breast cancers. In many other respects, lobular breast cancers and low-grade ductal carcinomas exhibit similar geno-phenotypic profiles. The development of p53 dysfunction may be a hallmark of infiltrating ductal cancers of intermediate and high grade. Sequential Her-2/neu and ras abnormalities define a subset of aggressive high-grade tumors, and the development of Rb dysfunction may define a separate subset of aggressive ductal cancers. Based on these observations, a branching molecular evolutionary model for the development and progression of breast cancer is proposed.

Positive surgical margins and ipsilateral breast tumor recurrence predict disease-specific survival after breast-conserving therapy

BACKGROUND

The current study identified determinants of systemic recurrence and disease-specific survival (DSS) in patients with early-stage breast carcinoma treated with breast-conserving surgery and radiation therapy (breast-conserving therapy, or BCT).

METHODS

The study population consisted of 1,043 consecutive women with Stages I or II breast carcinoma who underwent BCT between 1970 and 1994. Clinical and pathologic characteristics evaluated included age, tumor size, tumor grade, estrogen and progesterone receptor status, surgical margins, axillary lymph node involvement, and use of adjuvant therapy.

RESULTS

At a median follow-up time of 8.4 years, 127 patients (12%) had developed an ipsilateral breast tumor recurrence (IBTR), and 184 patients (18%) had developed a systemic recurrence. On multivariate logistic regression analysis, tumor size greater than 2 cm, positive lymph nodes, lack of adjuvant tamoxifen therapy, and positive margins (odds ratio [OR], 3.7; 95% confidence interval [CI], 1.1-12.3; P = 0.034) were predictors of systemic recurrence. When IBTR was added into the model, adjuvant therapy and surgical margins were not independent predictors; however, IBTR was an independent predictor of systemic recurrence (IBTR vs. no IBTR; OR, 6.2; 95% CI, 3.1-12.3; P < 0.001). The 10 year DSS rate after BCT was 87%. On multivariate Cox proportional hazards model analysis, the following factors were independent predictors of poor DSS: tumor size greater than 2 cm (vs. < or = 2 cm; relative risk [RR], 2.3; 95% CI, 1.2-4.3; P = 0.010), negative progesterone receptor status (vs. positive; RR, 2.7; 95% CI, 1.4-5.1; P = 0.003), positive margins (vs. negative; RR, 3.9; 95% CI, 1.4-11.5; P = 0.011), and IBTR (vs. no IBTR; RR, 5.5; 95% CI, 2.8-11.0; P < 0.001).

CONCLUSIONS

Positive surgical margins and IBTR are predictors of systemic recurrence and disease-specific survival after BCT. Aggressive local therapy is necessary to ensure adequate surgical margins and to minimize IBTR.

Prognostic and predictive role of proliferation indices in adjuvant therapy of breast cancer

In breast cancer, proliferative activity represents one of the biologic processes most thoroughly investigated for its association with tumor progression. In addition to the mitotic activity component of pathologic grading systems, several proliferation indices have provided independent information on prognosis and response to specific treatments in large retrospective studies. Recently, results from treatment protocols prospectively planned to test the clinical utility of proliferative activity have indicated that tumor cell proliferation markers identify two subsets among patients with lymph node-negative cancers: 1) those at a very low risk of relapse and 2) those who will benefit from regimens including antimetabolites. Future efforts should compare the prognostic accuracy of different proliferation markers, confirm preliminary evidence of a relationship between proliferation and response to specific systemic treatments, and standardize assay techniques to facilitate their transfer to general oncology practice.

Prognostic significance of tumor cell proliferation analyzed in fine needle aspirates from primary breast cancer

The objective of this study was to analyze the role of proliferating fraction (PF) measured with Ki-67/MIB-1 antibody in a large series of preoperative fine-needle aspirate (FNA) biopsies as a prognosticator of disease recurrence. The study comprised 732 patients who all had a conclusive cytological diagnosis of breast cancer. The follow-up time ranged from 1.2 to 10.2 years with a median of 5.7 years. In multivariate analysis Ki-67/MIB-1 value was a strong (p < 0.001) significant, prognosticator of disease recurrence free interval (DRFI) independent of lymph node status, progesterone receptor content, and tumor size. In the subgroup analysis of 430 node-negative patients the distant recurrence-free rate after 5 years was 94.4% in patients with Ki-67/MIB-1 value < 15% compared to 88.7% in patients with Ki-67/MIB-1 value > or = 15% (p = 0.03). Test of the interaction between tumor size and the value of PF revealed a p-value of 0.06. If the patients, in addition, had a tumor size >20 mm the distant recurrence-free rate after 5 years was 93.2% if Ki-67/MIB-1 < 15% compared to 80.7% in patients with Ki-67/MIB-1 value > or = 15%. This difference was statistically significant (p < 0.01). For patients with tumors <20mm Ki-67/MIB-1 value did not add any prognostic information. In the subgroup of 302 node-positive patients the distant recurrence-free rate after 5 years was 86.0% in patients with Ki-67/MIB-1 value < 15% compared to 70.6% in patients with Ki-67/MIB-1 value > or = 15% (p < 0.01). We conclude that PF assessed by Ki-67/MIB-1 antibodies in preoperative FNA biopsies has a significant prognostic value independent of lymph node status, PgR status and tumor size. To our knowledge, this is the first study demonstrating PF, which can contribute prognostic information when analyzed in preoperative smears.

Clinicopathologic analysis of breast carcinoma with chromosomal aneusomy detected by fluorescence in situ hybridization

BACKGROUND

The clinicopathologic characteristics of breast carcinoma with chromosomal aneusomy detected by fluorescence in situ hybridization (FISH) have yet to be clarified.

METHODS

Fine-needle aspiration biopsy (FNAB) samples were obtained from 113 breast tumors and were subjected to FISH analysis using centromeric probes for chromosomes 1, 11, and 17 to study a numerical aberration of these chromosomes and its correlation with various clinicopathologic features of breast tumors.

RESULTS

Polysomy was observed in 77.0%, 50.5%, and 37.2% of breast carcinoma samples for chromosomes 1, 11, and 17, respectively, and monosomy was observed in 1.8%, 8.8%, and 22.1% for chromosomes 1, 11, and 17, respectively. High histologic grade showed a significant correlation (P < 0.05) with polysomy of chromosome 11. Lymph node metastasis showed a significant correlation (P < 0.05) with polysomy of all three chromosomes, and positivity of lymph node metastasis increased as the number of polysomic chromosomes increased. In addition, estrogen receptor negativity was correlated significantly (P < 0.05) with monosomy of chromosome 17, and progesterone receptor negativity was correlated significantly (P < 0.05) with polysomy of chromosomes 11 and 17.

CONCLUSIONS

Aneusomy of chromosome 1, 11, or 17 detected by FISH is correlated significantly with various clinicopathologic features of breast carcinoma. Because FISH analysis of chromosomal aneusomy can be done using FNAB samples, this technique seems to have the potential to be used for a better, preoperative definition of the biologic characteristics of breast tumors.

Two-color, cytokeratin-labeled dna flow cytometric analysis of 332 breast cancers: lack of prognostic value with 12-year follow-up

CONTEXT

DNA flow cytometry of breast cancer is a proposed tumor marker of prognostic significance that is of controversial clinical utility because of lack of standardization and confirmatory studies.

OBJECTIVE

To evaluate the prognostic significance of the more informative technique of multiparametric 2-color DNA flow cytometry as recommended by the 1992 DNA Cytometry Consensus Conference.

DESIGN

Three hundred thirty-two breast carcinomas with 7 to 12 years of follow-up were prospectively analyzed as fresh tumors that were mechanically dissociated into whole cell suspensions. These suspensions were dual fluorescence-labeled with propidium iodide (DNA) and antibodies to cytokeratin (epithelium) and leukocyte common antigen (internal leukocyte control) for gated analysis of subpopulations. Multicycle software with histogram-dependent algorithms employing background, aggregate, and debris correction were used in DNA and cell-cycle quantitation. Data were analyzed according to the DNA Flow Cytometry Consensus Conference recommendations.

RESULTS

DNA ploidy and proliferation stratified into 3 categories were not predictive of overall or disease-free survival. Sixty-five percent of tumors were nondiploid, and 35.4% were diploid. Two hundred six tumors were able to be evaluated for synthesis-phase fraction (SPF) analysis, with 74 of 206 cases in the low range (<13.4%), 36.4% in the intermediate range (>13.5 to <25.4%), and 27.6% in the high SPF (>25.5%) category. Aneuploid tumors tended to have a higher SPF. Univariate survival analysis showed prognostic significance of the following: tumor size, stage, TNM components, vascular invasion, nuclear grade, and histologic grade. Only T classification, presence of positive axillary lymph nodes, and distant metastases were significant independent predictors of survival in multivariate Cox regression models. Age and hormone receptor status showed no prognostic significance. Synthesis-phase fraction was significantly correlated with tumor size, stage, T classification, nuclear and histologic grade, presence of estrogen or progesterone receptors, and axillary lymph node status. None of the histologic parameters showed any significant association with DNA aneuploidy, except for high nuclear and histologic grade and the absence of estrogen receptors.

CONCLUSIONS

Despite the use of state-of-the-art processing and flow cytometry analytic techniques, DNA ploidy and proliferation measurements were not predictive of survival in any stage of breast cancer. However, select histopathologic parameters and TNM stage were significant predictors of survival in univariate and multivariate analyses. We conclude that DNA ploidy and proliferation measurements do not provide significant prognostic information for clinicians to integrate into therapeutic decision making for patients with breast cancer.

Flow cytometric analysis of primary tumors and their corresponding metastatic nodes in breast cancer

Human breast carcinoma is biologically heterogeneous, and its clinical course may vary from one which is indolent to one which rapidly progresses. Although it is the metastasis rather than the primary tumor that ultimately overwhelms the patients, studies concerning the DNA pattern have focused on the primary tumors. This study was undertaken to identify heterogeneities between primary tumors and metastases, and to evaluate the prognostic significance of the ploidy pattern and the S-phase fraction (SPF) of metastatic nodes in axillary node positive patients. Seventy-four frozen specimens of the primary and corresponding metastatic nodes from 37 patients have been analyzed by flow cytometry and the SPF calculated. The results of ploidy pattern analysis in primaries revealed 25 diploidy (67.6%) and 12 aneuploidy (32.4%), while those in metastasis showed 17 diploidy (46.0%) and 20 aneuploidy (54.0%). The aneuploidy group in metastatic nodes had the poorer histological grade (85.0% vs. 15.0%, p = 0.02), and more mean metastatic nodes (5.75 +/- 2.10 vs. 3.05 +/- 1.56, p = 0.018), and more frequent lymphatic vessel invasion (65.0% vs. 11.8%, p = 0.031) than its counterpart. Decreased expression of ER (70.6% vs. 25.0% p = 0.006) and increased expression of c-erbB2 (65.0% vs. 23.5%, p = 0.012) were observed in the aneuploidy of metastatic nodes. The group with higher SPF in metastatic nodes had more metastatic nodes (5.47 +/- 2.31 vs. 4.00 +/- 1.78, p = 0.042), and the higher incidence of lymphatic vessel invasion (57.9% vs. 22.2%, p = 0.027), and poor histological grade (71.4% vs. 37.5%, p = 0.039). In conclusion, the cell populations in metastatic nodes revealed DNA pattern which differed from that of primary tumors. The ploidy pattern and SPF in metastatic nodes might be considered as discriminate measure for risk factors in breast cancer patients with positive axillary node.

In vitro DNA synthesis in freshly separated human breast cancer cells assessed by tritiated thymidine incorporation assay: relationship to the long-term outcome of patients

BACKGROUND

Tumour growth rate has a significant effect on the clinical course of various malignancies. The present study was designed to assess whether in vitro DNA synthesis in freshly separated breast cancer cells is a useful marker in evaluating growth rates and in predicting the clinical outcome of patients.

METHODS

From 1982 to 1992, DNA synthesis was assessed by [3H]thymidine incorporation in 97 samples of primary lesions from 94 patients with breast cancer. The patients were followed for 5-15 years and their outcome was surveyed in January 1998.

RESULTS

The level of DNA synthesis did not correlate with the patients' age, clinical stage or expression of oestrogen receptor. However, it correlated significantly with the histological grade. In 89 patients, whose outcome was reported, the survival rate in the group with a high rate of DNA synthesis (log10c.p.m. 3.0 or more) was significantly lower than that in the low-level group; the 5- and 10-year survival rates were 84 and 74 per cent for the low synthesis group (n = 46), and 60 and 46 per cent for the high synthesis group (n = 43) respectively. This was also noted in patients with stage 1 or 2 cancers, for whom the 5- and 10-year survival rates were 100 and 90 per cent for the low synthesis group (n = 25), and 75 and 70 per cent for the high synthesis group (n= 35). Multivariate analysis supported this significant correlation for DNA synthesis in the prognosis of patients after mastectomy. Furthermore, the level of DNA synthesis was significantly higher in 18 patients who died from a recurrence within 3 years after operation than in 56 survivors, and the level of DNA synthesis also correlated significantly with the survival period in the 33 patients who died.

CONCLUSION

The level of DNA synthesis in breast cancer was variable, and was independent of the clinical stage or oestrogen receptor status. However, a high level of DNA synthesis was a positive indicator of a high risk of recurrence after operation, especially for stage 1 or 2 breast cancer. In vitro DNA synthesis may account for some of the clinical characteristics of breast cancers.

S-phase fraction and breast cancer--a decade of experience

During the past decade, more than 300 articles, abstracts, and book chapters have been published about S-phase fraction (SPF) determined by DNA flow cytometry and its clinical utility for patients with breast cancer. However, the use of SPF for making treatment decisions for breast cancer patients remains controversial. After reviewing 273 published articles, we conclude: 1) Despite different techniques and cutpoints, correlations between SPF and other prognostic markers are relatively consistent across studies; higher SPF is generally associated with worse tumor grade, absence of steroid receptors, larger tumors, and positive axillary lymph nodes. 2) Higher SPF is generally associated with worse disease-free and overall survival in both univariate and multivariate analyses; SPF values from laboratories that have conducted validation studies can be used, in combination with other factors, to estimate the prognosis of patients with primary breast cancer. 3) There is considerable variability among laboratories regarding assay methodology, cell-cycle analysis techniques, and cutpoints for classifying and interpreting SPF; use of SPF values from different laboratories is problematic, and there remains a need for standardization of these processes and well-designed confirmation studies. We conclude that measurement of SPF does have clinical utility for patients with breast cancer, but standardization and quality control must be improved before it can be routinely used in community settings.

S-phase fraction combined with other patient and tumor characteristics for the prognosis of node-negative, estrogen-receptor-positive breast cancer

Women with estrogen-receptor (ER)-positive breast cancer and no axillary lymph-node involvement are considered to have excellent overall prognosis. However, this population is not homogeneous with regard to risk of recurrence; in fact, some of these patients have a prognosis no better than that of many women with ER-negative tumors or positive axillary nodes. Consequently, better tumor markers and better use of those currently available are needed to distinguish patients who would benefit from more aggressive therapy from those for whom such therapy is unnecessary. A well-defined cohort of over 4000 breast cancer patients from National Surgical Adjuvant Breast and Bowel Project (NSABP) Protocol B-14 who had ER-positive tumors and no axillary lymph-node involvement was analyzed to ascertain the usefulness of tumor cell S-phase fraction for prognosis. The significance of clinical tumor size, patient age at surgery, ER and progesterone receptor (PgR) expression, and nuclear grade was also explored. Statistical methods based on smoothing splines were used to relate treatment failure and mortality rates to patient and tumor characteristics. Models for 5- and 10-year disease-free survival (DFS) and overall survival were developed and summarized. The attenuation of the prognostic importance of covariates over time was investigated. After other characteristics were accounted for, a strong association was found between S-phase fraction and DFS, as well as survival. Tumor size, patient age at surgery, and PgR status were also significantly associated with outcome. The diversity of risk in the B-14 population was more extreme than is generally recognized. The prognostic capabilities of S-phase, tumor size, and PgR status were sharply attenuated as the time from surgery increased.

Breast stereotactic core biopsy washings: abundant cell samples from clinically occult lesions for flow cytometric DNA analysis

RATIONALE AND OBJECTIVES

The object of this study was to determine by flow cytometry the cellular and DNA content of the washings of core biopsy samples and needles obtained during stereotactic core biopsies of clinically occult suspicious lesions.

METHODS

Fourteen-gauge core multipass biopsy inner-needle saline washings obtained after dislodgment of the tissue core samples (n = 30) and 14-ga mammotomy core biopsy specimen washings (n = 30) were analyzed by flow cytometry.

RESULTS

Multipass core biopsy needle washings of 7 malignant and 23 benign lesions yielded a median of 10,584 cells per lesion (range 562-29,019 cells). Mammotomy core biopsy specimen washings of 10 malignant and 20 benign lesions yielded a median of 12,164 cells per lesion (range 1,295-115,150). Forty-four (73%) washings in each technique had more than 5000 cells. Flow cytometric DNA ploidy analysis was possible in 60 (100%) and the S phase percentage determination was possible in 59 (98%) of the washings. Aneuploidy was detected in 53% of malignant lesions and 2% of benign lesions.

CONCLUSIONS

Core biopsy specimen or needle washings provide abundant fresh cellular material from clinically occult lesions for DNA analysis by flow cytometry.

Prognostic implications of different cell cycle analysis models of flow cytometric DNA histograms of 1,301 breast cancer patients: results from the Multicenter Morphometric Mammary Carcinoma Project (MMMCP)

Conflicting prognostic results with regard to DNA flow cytometric cell cycle variables have been reported for breast cancer patients. An important reason for this may be related to differences in the interpretation of DNA histograms. Several computer programs based on different cell cycle fitting models are available resulting in significant variations in percent S-phase and other cell cycle variables. Our present study evaluated the prognostic value of percent S-phase cells obtained using 5 different cell cycle analysis models. Flow cytometric DNA histograms obtained from 1,301 fresh frozen breast cancer samples were interpreted with 5 different cell cycle analysis models using a commercially available computer program. Model 1 used the zero order S-phase calculation and "sliced nuclei" debris correction, model 2 added fixed G2/M- to G0/G1-phase ratio, and model 3 added correction for aggregates. Model 4 applied the first-order S-phase calculation and sliced debris correction. Model 5 fixed the coefficients of variation CVs of the G0/G1- and G2/M-phases in addition to applying the sliced nuclei debris correction and zero order S-phase calculation. The different models yielded clearly different prognostic results. The average percent S-phase cells of the aggregate correction model (model 3) provided the best prognostic value in all cases for overall survival (OS) as well as disease-free survival (DFS) (OS: p < 0.0001; DFS: p < 0.0001), in lymph node-positive cases (OS: p < 0.0001; DFS: p = 0.004) and in DNA-diploid subgroups (OS: p = 0.004; DFS: p = 0.001). For the lymph node negative and DNA-non-diploid subgroups, the percent S-phase of the second cell cycle reached slightly better prognostic significance than the average percent S-phase cells. In multivariate analysis, the average percent S-phase of the aggregate correction model had the best additional prognostic value to tumor size and lymph node status. In conclusion, different cell cycle analysis models yield clearly different prognostic results for invasive breast cancer patients. The most important prognostic percent S-phase variable was the average percent S-phase cells when aggregate correction was included in cell cycle analysis.

The influence of fixation delay on mitotic activity and flow cytometric cell cycle variables

Proliferation variables such as mitotic activity and the percentage of S-phase cells have been shown to be of prognostic value in many tumors, especially in breast cancer. However, some studies reported a decrease in mitotic activity caused by delay in fixation of the tissue. In contrast, other studies showed that the identifiability of mitotic figures decreases after fixation delay, but the total number of mitotic figures and also the percentage of S-phase cells remain unchanged. Most studies have been done on small numbers of experimental tumors, thus introducing the risk of selection bias. The aim of this study was to reinvestigate the influence of fixation delay on mitotic activity and cell cycle variables assessed by flow cytometry in an adequate number of resected human tissues to reach firmer conclusions. Resection specimens of 19 and 21 cases, respectively, for the mitotic activity estimate and the flow cytometric percentage of S-phase calculation were collected directly from the operating theater using lung, breast, and intestinal cancers and normal intestinal mucosa. The tissues were cut in pieces, and from each specimen, pieces were fixed in 4% buffered formaldehyde (for mitosis counting) as well as snap frozen (for flow cytometry) immediately after excision, as well as after a fixation delay of 1, 2, 4, 6, 8, 18, and 24 hours. Moreover, during the fixation delay, one series from each specimen was kept in the refrigerator and the second at room temperature. Thus, a total of 304 (19 X 16) and 336 (21 X 16) specimens were investigated for the mitotic activity estimate and the percentage of S-phase cells calculation, respectively. With regard to the estimation of the mitotic activity, both clear and doubtful mitotic figures were registered separately, obtaining an "uncorrected" and "corrected" (for doubtful mitotic figures) mitotic activity estimate. The percentage of S-phase cells was obtained by cell cycle analysis of flow cytometric DNA-histograms. The results showed that the quality of the material decreased during the fixation delay, as reflected by poorer cellular morphology in the hematoxylin-and-eosin-stained slides, resulting in more difficult identification of mitotic figures and a more time-consuming procedure with regard to the mitosis counts, but not in a worse intraobserver and interobserver reproducibility, which was acceptable. The reduction in quality of the tissues also was shown by the flow cytometric measurements because the coefficient of variation and percentage of debris increased after 4 hours or more of fixation delay. However, the mean values of the "uncorrected" mitotic activity and the "corrected" mitotic activity showed no decreasing trend; neither did the average percentage of S-phase cells. In conclusion, within the time investigated, fixation delay has no clear influence on the proliferation features studied. Because of the decreasing quality of the histological sections, resulting in more difficult identification of mitoses and interpretation of DNA histograms, fixation delay should be kept as short as possible, keeping the tissue at 4 degrees C until fixation.

Tumour heterogeneity of DNA cell cycle variables in breast cancer measured by flow cytometry

AIM/BACKGROUND

Conflicting results have been reported concerning the prognostic value of DNA flow cytometric variables (DNA ploidy, DNA index, %S phase fraction) in breast cancer. Selection bias and differences in treatment may have contributed to these conflicting prognostic results. Differences in tissue processing, the number of nuclei measured, DNA histogram/cell cycle analysis, and intra-tumour heterogeneity may also have played a role. The aim of the present study was to assess intra-tumour heterogeneity of DNA flow cytometric variables in breast cancer.

METHODS

Fresh frozen specimens (n = 274) (0.3 x 0.3 x 0.3 cm) of 17 breast cancers and 167 slices, 50 microns thick, of 58 paraffin wax embedded blocks of 21 breast cancers were studied. All samples were prepared individually for DNA flow cytometry. DNA histograms were interpreted by semi-automated cell cycle analysis (MultiCycle) by two observers to avoid biased interpretation. An artificial averaged DNA histogram of each case was composed to simulate a sample prepared from whole tumour tissue.

RESULTS

With regard to DNA ploidy, classified as diploid or aneuploid, the fresh frozen and paraffin wax embedded breast cancers showed intra-tumour heterogeneity in 53% and 38% of cases, respectively. For fresh frozen and paraffin wax embedded material, respectively, six samples had to be measured to detect the highest DNA ploidy class in 71% and 86% of cases. Averaged DNA histograms showed a loss of DNA aneuploidy in 36% and 6% of fresh frozen and paraffin wax embedded samples, respectively. High intra-tumour heterogeneity (wide ranges) was found for the %S phase fraction. Average %S phase fraction and average aneuploid %S phase fraction had the widest ranges at 9.5-31.6% and 0.0-62.7%, respectively. There was no correlation between the number of stemlines and intra-tumour %S phase variability on the one hand and tumour size and grade on the other.

CONCLUSIONS

High intra-tumour heterogeneity for breast cancer was found for DNA ploidy, the DNA index and %S phase fraction as measured by flow cytometry, which may explain the conflicting prognostic results reported in the literature. To detect aneuploid cells, six samples may have to be prepared and measured separately. Measurement of these variables may be more reliable in paraffin wax sections because the thick slices provide a more representative sample. Prospective studies are required to determine whether the highest %S phase fraction value or the average value is more useful in the clinical context.

Cellular proliferative activity of mammographic normal dense and fatty tissue determined by DNA S phase percentage

A prospective study was undertaken to evaluate associations among mammographic normal dense and fatty tissue, benign histologic findings, and cellular proliferative activity determined by DNA S phase percentages. Mammographic and histologic findings of benign, normal dense and fatty tissue contained in 100 excised specimens were cross-tabulated with flow cytometric DNA S phase percentages of needle aspirates obtained under radiographic guidance. Histologic evidence of atypia or hyperplasia was present in 21 (32%) of 66 fatty tissue samples and 11 (32%) of 34 dense tissue samples (p = NS). The median S phase percentages were identical for mammographic fatty and dense tissue (median % S phase = 5.35). The frequency of high S phase percentages (above the median) was not significantly different for tissue containing atypia or hyperplasia, 47% (15 of 32), as compared to tissue containing other benign histology, 52% (35 of 68) (p = NS). These frequencies were similar in women 49 and younger or 50 and older. These data show that mammographic normal dense and fatty tissues contain similar frequencies of histologic atypia or hyperplasia and low and high cellular proliferative activity determined by DNA S phase percentages in women aged 49 and younger and 50 and older.

S-phase fraction identifies high-risk subgroups among DNA-diploid breast cancers

The prognostic value of DNA content measured by means of flow cytometry was analyzed in formalin-fixed, paraffin-embedded samples from 231 breast cancer patients treated between 1984 and 1988, with a mean follow-up period of 55 months. We followed the guidelines of a Consensus Meeting held on this issue in Maine, USA, in 1992. DNA-diploid and -aneuploid tumors were evaluated separately for the fraction of cells in S-phase (SPF) contained in them, this being divided into three groups ('high', 'intermediate', and 'low'), defined by the 25th and 75th centile of the SPF-distribution corresponding to either DNA-diploid or DNA-aneuploid tumors. Unequivocally readable histograms were obtained from 174 samples (75.3%). A high SPF in diploid tumors was significantly associated with a higher recurrence rate (p = 0.015), a shorter disease-free survival (p = 0.014), advanced (IIIB) clinical stage (p = 0.034), and almost significantly with total survival (p = 0.055). In a multivariate Cox regression analysis, a high SPF in diploid tumors retained its independent prognostic power, being significantly associated with a shorter disease-free survival (p = 0.00049) and total survival (p = 0.0077). It also allowed to identify a subgroup with an ominous prognosis among patients < or = 50 years of age with early stage tumors. Our results fully validate the recommendations of the 1992 Maine Consensus Meeting.

DNA ploidy and p53 expression correlate with survival and cell proliferative activity in male breast carcinoma

DNA flow cytometry and the monoclonal antibody DO7 were applied in formalin-fixed, paraffin-embedded specimens from 34 primary male breast carcinomas to verify whether DNA ploidy and p53 expression were associated with survival and proliferative activity. They were compared with tumor clinicopathologic features, sex steroid hormone receptors and cell proliferative activity, assessed by the counts of the argyrophilic nucleolar organizer regions (AgNORs), the monoclonal antibody PC10 against the proliferating cell nuclear antigen and the monoclonal antibody MIB-1. A significant correlation was found between survival and tumor ploidy (median survival, 77 months for diploid but only 38 months for aneuploid cases; P = .03) and p53 expression (median survival, 95 months for cases with p53 scores < or = 14.06% versus 33 for cases with P53 scores > 14.06%; P = .0004; median survival, 99 months for p53 negative vs 39 for positive cases; P = .007). Tumor histological grade (P = .006), AgNOR counts (P = .0001), PC10 scores (P = .002), and MIB-1 scores (P = .001) were also associated with prognosis. In the multivariate analysis, only p53 scores (P = .001) or p53 immunopositivity (P = .003) and AgNOR counts (P = .022) retained an independent prognostic significance. Aneuploid tumors had higher AgNOR counts (P = .002), PC10 (P = .007), MIB-1 (P = .006), and p53 scores (P = .01) than diploid cases. A linear relationship was observed between p53 scores and AgNOR counts (r = .41; P = .014), PC10 (r = .46; P = .005), and MIB-1 scores (r = .44; P = .011). These results indicate that DNA ploidy and p53 expression are associated with survival and cell proliferative activity in male breast carcinoma. Quantitative parameters, such as DNA ploidy, p53 scores, AgNOR counts, PC10, and MIB-1 scores substantially improve the prognostic significance of the traditional parameters in male breast carcinoma.

Flow Cytometric Assay of c-erbB-2 Protein in Fine Needle Aspirates of Fresh and Frozen Human Breast Cancer Tissues

Using FCM (flow cytometry), we analyzed the ErbB-2 (c-erbB-2 protein) status of 61 breast cancer tissue samples obtained by FNAB (fine-needle aspiration biopsy). The number of cancer cells collected by FNAB from fresh samples was 1.7+/-0.7 x10&sup5;, 2.5 +/-0.6 x10&sup5;, and 4.0+/- 0.8x10 &sup5;, by single, double and triple aspirations, respectively. A mean of 3.0+/-0.6 x10&sup5;cells was collected on three aspirations from frozen samples. The number of cells collected on three aspirations was sufficient for the measurement of ErbB-2. Cells with higher ErbB-2 levels than those of normal human lymphocytes were designated ErbB-2 positive cells. The mean overall for ErbB-2 positive cell rates was 20.5 +/- 27.9 % (mean+/-SD). The rates were 27.9 +/- 31.6 % in patients with recurrence and 15.9 +/- 24.4% in patients without recurrence. When the cut-off value was set at 20% of the positive cell rate (P =0.008, generalized Wilcoxon test), patients with ErbB-2 negative tumors showed highly significantly longer survival without recurrence (P=0.008, generalized Wilcoxontest) and better overall survival rates (P=0.013) than patients with ErbB-2 positive tumors. Among 61 specimens, 16 (26.2%) scored positive for ErbB-2 by FCM. These finding indicated that the analysis of ErbB-2 status using FCM of samples obtained by FNAB should be useful for preoperatively evaluating the prognosis of patients with breast cancer.

Differential expression of the topoisomerase II alpha and beta genes in human breast cancers

Topoisomerase II is a key target for several anti-cancer drugs used for breast cancer therapy, including doxorubicin, epirubicin and mitoxantrone. Two isoforms of topoisomerase II (alpha and beta) have been described in human cells which differ in their subcellular localisation, biochemical properties and susceptibility to inhibition by anti-cancer drugs. The relative level of expression of the alpha and beta isoforms may contribute to the degree of tumour responsiveness to different chemotherapeutic agents. To assess the relationship between expression of topoisomerase II isoforms and established prognostic factors and pathological variables, 56 primary breast tumour samples were studied. The expression of the two topoisomerase II genes was apparently not co-ordinately regulated in these tissue samples. There was no relationship between any of the commonly used pathological variables [tumour size, lymph node status, S-phase fraction (SPF)] and the level of expression of topoisomerase II beta mRNA. However, high topoisomerase II alpha gene expression was significantly associated with a high SPF (sign-rank test; P = 0.01). Moreover, the ratio of mRNA levels for topoisomerase II alpha and beta showed a stronger relationship to SPF (median raito 0.62 for tumours with SPF < 10, and 1.64 for SPF > 10; P = 0.0021, sign-rank test). As expected from previous studies, an SPF > 10 was associated with poor overall survival (P = 0.01). Immunohistochemical analysis revealed that topoisomerase II beta was widely distributed ( > 90% positive tumour cells), but that topoisomerase II alpha expression was less widely expressed, with a pattern of expression similar to that of the proliferation-dependent antigen recognised by Ki67. Because topoisomerase II gene expression showed a log-normal distribution, log-transformed data were used in multivariate analysis of relapse-free survival. This showed that lymph node status and topoisomerase II beta mRNA expression were the only significant survival factors (P = 0.001 and 0.05, respectively, with relative risks of 1.3 and 1.8). These results indicate that topoisomerase II alpha, but not beta, expression is dependent upon cellular proliferation status, but that the more widely expressed topoisomerase II beta protein may play a significant role as a target for anti-tumour therapy.

Cell cycle analysis of 932 flow cytometric DNA histograms of fresh frozen breast carcinoma material. Correlations between flow cytometric, clinical, and pathologic variables. MMMCP Collaborative Group. Multicenter Morphometric Mammary Carcinoma Project Collaborative Group

BACKGROUND

Confusing data have been presented for breast cancer patients on correlations between DNA ploidy and the percentage of S-phase cells and other prognostic variables. The aim of this study was to compare DNA ploidy classification and cell cycle variables with clinical, classic, and quantitative pathologic variables and clinical variables in a large group of patients.

METHODS

DNA ploidy and cell cycle variables were extracted from MultiCycle (Phoenix Flow Systems, San Diego, CA) interpreted flow cytometric DNA histograms of fresh frozen material from 932 breast cancer patients and compared with clinical (age, hormonal status), classic pathology (lymph node status, tumor size and type), and quantitative pathologic variables (steroid receptor status, mitotic activity index [MAI], mean nuclear area [MNA]).

RESULTS

The DNA ploidy correlated significantly with MAI, MNA steroid receptor status, and tumor type. No significant correlations were found with tumor size, lymph node status, age, and hormonal status. The first DNA index correlated significantly with MAI, MNA, and steroid receptor status. The percentage of S-phase cells significantly correlated with MAI, MNA, steroid receptor status, and lymph mode status.

CONCLUSIONS

DNA index and DNA ploidy, as markers of genetic instability, correlated well with differentiation and proliferation markers and less well with lymph node status and tumor size as markers of metastatic potential and duration of disease. The percentage of S-phase cells was not independent of the percentage of differentiation markers and did not correlate strongly with mitotic activity. This indicates that the percentage of S-phase cells and the mitotic activity partially reflect different proliferative properties.

Invasive breast carcinoma: analysis of dynamic magnetic resonance imaging enhancement features and cell proliferative activity determined by DNA S-phase percentage

BACKGROUND

There is little information regarding associations between magnetic resonance imaging (MRI) enhancement and biologic parameters of breast carcinoma. A prospective study was undertaken to correlate MRI dynamic contrast enhancement features with cell proliferative activity, as determined by DNA S-phase percentage.

METHODS

Seventeen patients with invasive breast cancer underwent MRI at 1.5 tesla using a dynamic gadolinium-enhanced spoiled gradient recall echo technique. DNA analysis of samples of the excised lesions was then performed using flow cytometry.

RESULTS

Invasive carcinomas with high DNA S-phase percentages (> or = 6.9%, the median value in this study), a measure of increased cell proliferation, were associated with a peripheral MRI enhancement pattern in 4 of 6 (67%) lesions compared with 0 of 11 carcinomas with lower DNA S-phase percentages (< or = 6.9%) (P = 0.006). There was no significant association between a high DNA S-phase percentage and greater MRI enhancement amplitude, rate, or washout. There was no significant association between aneuploid DNA content and any MRI enhancement feature.

CONCLUSIONS

Increased cell proliferation in invasive breast carcinoma, as determined by high DNA S-phase percentage, is significantly associated with a peripheral MRI enhancement pattern but unrelated to greater MRI enhancement amplitude, rate, or washout.

Correlation of flow cytometry to clinical factors, hormone receptors, and histopathological grade in stage I and II invasive breast carcinoma

DNA index (ploidy) and S-phase fraction (SPF) were measured by flow cytometry in 131 invasive stage I and II breast carcinomas. Ploidy showed a strong correlation with SPF (p = 0.0001), with aneuploid tumors having a high SPF. Both cytometric parameters correlated with tumor size and hormonal receptor status. Smaller tumors tended to be diploid and have low SPF. Nodal status did not demonstrate an association with cytometric findings. There was a highly significant connection between tumor grade, especially nuclear grade, and SPF (p = 0.0001). The study demonstrates the relationship between conventional prognostic factors, DNA content, and proliferative activity of breast tumors.

Intratumoral heterogeneity of DNA ploidy in breast carcinomas: a flow cytometric assessment of sampling techniques

Intratumoral heterogeneity of DNA ploidy has been identified in breast carcinomas; however, optimal sampling methods have not been determined. In this study of 28 invasive breast carcinomas measuring more than 1.4 cm in greatest dimension, two different techniques for obtaining cells for flow cytometric DNA ploidy analysis were compared. Two solid pieces of tissue were taken from opposite halves of the tumor. A third sample was obtained by scraping multiple cut surfaces of the tumor. Heterogeneity of DNA ploidy was detected in 43% of cases. Most cases demonstrating heterogeneity contained multiple aneuploid populations. However, in five cases classification of the tumors as either DNA euploid or DNA aneuploid differed among samples. A total of 39 non-diploid populations were detected in 23 of the cases. Thirty-three (85%) were detected by scraping and 35 (90%) were detected in either one or both tissue pieces. Intratumoral DNA heterogeneity emphasizes the need for adequate sampling. The scraping technique was as effective in identifying aneuploid cell populations as the combined results of the two pieces of tissue and better than sampling a single piece of tissue. Scraping also offers the advantage of tissue conservation which may be critical when various analytic studies are performed.

Flow cytometry in node-positive breast cancer: cancer and leukemia group B protocol 8869

This report describes a companion flow cytometry study (Cancer and Leukemia Group B (CALGB)--8869) using tumors derived from patients enrolled in a large randomized clinical trial (CALGB-8541) performed on 1,572 patients with early stage, node-positive breast cancer. The CALGB initiated an adjuvant breast cancer trial in 1985 to determine if dose intensification (dose of drug per unit time) of chemotherapy was related to relapse-free and overall survival. Patients were randomized by pretreatment clinical variables to one of three different dosage regimens of chemotherapy. Using a tumor enrichment procedure, 442 paraffin-embedded blocks were analyzed by flow cytometry, and S-phase fraction (SPF) was analyzed by three different methods. Ploidy analysis was performed using standard procedures. Tissue from 90% of the patients was suitable for ploidy analysis, whereas only 68% could be assessed for SPF. With a median follow-up time of 80 months, our results show that ploidy status had no clinical utility, whereas high SPF predicted poorer overall survival. The rectangular fit model for SPF was more predictive of outcome than both the area fit model and a computer fit model (modfit) for SPF. In univariate analysis, patients with a low SPF (< 10%) had a better prognosis than those patients with a high SPF (> 10%), but they responded equally well to the different treatment regimens. Patients with high SPF (> 10%) had longer relapse-free and overall survival to high dose chemotherapy compared to low or standard dose chemotherapy. Multivariate analysis indicated that treatment intensity as well as the number of positive nodes, tumor size, steroid receptor status, and c-erb B-2 expression were significant in predicting overall and disease-free survival. The multivariate analysis, however, revealed that SPF was significant in predicting overall but not disease-free survival, but there was no longer any relationship among SPF, dose intensity, and outcome.

The prognostic value of DNA ploidy and S-phase estimate in primary breast cancer: a prospective study

In this prospective study, the independent prognostic value of DNA ploidy in combination with the major clinico-pathological characteristics (histological grade, nodal status, tumor size, estrogen and progesterone receptor status, number of tumors, multicentricity, lympho-vascular infiltration) was evaluated in a series of 399 breast-cancer patients. The mean follow-up time was 4.5 years. The DNA content was measured using image cytometry on fresh tumor samples. The overall survival of tetraploid and slowly proliferating diploid cases was significantly different compared with that of aneuploid and rapidly proliferating diploid cases (p = 0.0002). Thus, DNA ploidy combined with S-phase estimate (DNA histogram type) appeared to be good prognostic factors. In a multivariate survival analysis, DNA histogram type was not an independent prognostic factor unless the histological grade was excluded. This effect of DNA histogram type on survival was also observed among patients with grade-I or -II tumors and patients with small tumors. In conclusion, DNA histogram type was a valuable prognostic factor in univariate analysis, and provided independent complementary information for patients considered at low or intermediate risk by classical pathological findings.

The relationship between flow-cytometric and immunohistochemically detected c-erbB-2 expression, grade and DNA ploidy in breast cancer

Quantification of c-erbB-2 and its relationship with other prognostic markers using flow cytometry has been examined. In this study a level for c-erbB-2 expression above which tumours are classified as positive by flow cytometry has been determined by employment of positive cut-off threshold levels. c-erbB-2 expression by both flow cytometry and immunohistochemistry was studied using the monoclonal antibody NCL-CBII. The relationship of c-erbB-2 quantification by flow cytometry was then compared with ploidy, axillary node status, tumour size and grade. Increased c-erbB-2 expression was seen using flow cytometry. Correlation between immunohistochemistry and flow-cytometry methods just failed to reach significance (P = 0.06). Immunohistochemistry revealed a significant relationship between c-erbB-2 expression and aneuploidy (P = 0.04). Cytokeratin-positive cells from 110 samples obtained from patients with breast cancer were assayed for DNA content and c-erbB-2 expression by flow cytometry. No correlation was seen between these parameters upon application of Mann Whitney analysis. However, examination of fluorescence thresholds showed a positive correlation between grade and c-erbB-2 expression at a level of more than 3200 molecules (P < or = 0.03). At the level of 3600 molecules significance was increased (P = 0.004). These levels equated with between 15% and 19% of the samples being classified as c-erbB-2-positive. Application of these cut-off points showed no correlation between c-erbB-2 expression and ploidy, tumour size or axillary node status. Comparison of ploidy and grade showed a significant association (P = 0.0015), increased grade correlating with aneuploidy.

DNA flow cytometry of canine mammary tumours: the relationship of DNA ploidy and S-phase fraction to clinical and histological features

The DNA ploidy status and S-phase fraction (SPF) of benign proliferative lesions (BPL) and malignant tumours (MT) in the mammary glands of dogs were determined by flow cytometric analysis and the results were related to their clinical and histological features. Seven (14.3 per cent) of 49 BPL and 16 (48.5 per cent) of 33 primary MT had aneuploid G0,1 peaks (P < 0.001). Hypodiploid G0,1 peaks were found in one BPL and in five primary MT. The DNA ploidy status of primary MT was not found to be associated with their size, nodal status, grade of histological malignancy or nuclear grade. In several cases there was intra-tumour heterogeneity in ploidy status independent of histological heterogeneity. The SPF was significantly higher in 27 primary MT than in 45 BPL when diploid and aneploid cases were combined for comparison (P < 0.05), but not when only diploid cases were compared. Among the primary MT the SPF was higher in aneuploid than in diploid tumours (P < 0.05) and it was higher in five MT from five dogs with regional disease than in 22 MT from 19 dogs with local disease (P < 0.05). The SPF was positively correlated with the grade of histological malignancy (P < 0.05) but not with nuclear grade.

Relationship of the size of the invasive component of the primary breast carcinoma to axillary lymph node metastasis

BACKGROUND

Invasive ductal carcinomas of the breast frequently have an intraductal (in situ) component at the tumor periphery that, in some cases, is included in the measurement of the tumor and thereby increases the size of the tumor beyond that of the invasive component.

METHODS

Thirty-seven ductal carcinomas containing intraductal and invasive components were analyzed. The total tumor size, the size of the invasive component, the percentage of intraductal component, and the estimated tumor volume were assessed for each tumor.

RESULTS

The mean size of the invasive component was 6.5 mm in axillary lymph node negative patients and 14.3 mm in those with axillary lymph node metastasis (P = 0.0001). The mean total tumor size was 13.7 mm and 17.6 mm (P = 0.035) and the mean percent of intraductal component was 52% and 26% (P = 0.015) in patients with negative and positive axillary lymph nodes, respectively. Ninety-two and four tenths percent of the difference in mean estimated total tumor volume between patients with negative and positive axillary lymph nodes was attributable to the difference in the volume of the invasive component alone.

CONCLUSIONS

In small ductal carcinomas of the breast, the size of only the invasive component, as determined by microscopic measurement, is a better predictor of axillary lymph node status than is the total tumor size. The well established prognostic value of total tumor size largely is due to its reflection of the size of the invasive component.

Immunocytochemical staining of c-erb B-2 oncogene in fine-needle aspirates of breast carcinoma: a comparison with tissue sections and other breast cancer prognostic factors

The role of fine-needle aspiration (FNA) in breast cancer management is expanding to include prognostic in addition to diagnostic studies. This study was undertaken to compare the immunohistochemical staining of c-erbB-2, a breast cancer prognostic factor, on cytologic FNA smears of breast cancer with that on corresponding formalin-fixed, paraffin-embedded tissue sections of the same tumor and to correlate the c-erbB-2 expression with other known breast cancer prognostic factors. FNA smears (destained, alcohol-fixed, Pap-stained direct smears) and corresponding tissue sections (formalin-fixed, paraffin-embedded, unstained sections) from 36 primary breast carcinomas were stained immunohistochemically with c-erbB-2 antibody using an avidin-biotin procedure. Ten tumors (28%) showed strong positive staining for c-erbB-2 on the FNA smear and, of those ten, seven were positive on the corresponding tissue section and three were negative. In several of the cytology and tissue positive cases, staining on the tissue section was significantly weaker than on the FNA smear. Two cases involved treatment with preoperative chemotherapy; in one of those cases, tissue staining was weaker than cytologic staining, and, in the other case, both were negative. Correlation of c-erbB-2 staining with other prognostic factors showed an association between positive c-erbB-2 staining and high nuclear grade. Our results indicate that immunohistochemical staining for c-erbB-2 can be performed on destained FNA smears of breast carcinomas and may be more sensitive on the cytologic specimens than on formalin-fixed, paraffin-embedded tissue sections.

DNA ploidy and the percentage of cells in S-phase as prognostic factors for women with lymph node negative breast cancer

BACKGROUND

Previous cell kinetic studies have shown that the percentage of cells in S-phase (%S) of the tumor may be an important prognostic factor for relapse-free survival (RFS) and overall survival (OS) in patients with resected lymph node negative breast cancer.

METHODS

This study examined DNA ploidy and %S from the paraffin embedded primary tumors of 265 patients who had surgery between 1975 and 1981, had lymph node negative cancer, and had no adjuvant therapy. The %S and %G2M values were calculated using a debris and aggregate subtraction model.

RESULTS

The results of the DNA ploidy analysis revealed 130 (49%) DNA diploid tumors and 135 (51%) DNA nondiploid tumors. Ploidy was not significant for either RFS (P = 0.20) or OS (P = 0.13). The total %S (using a cutoff of 8%) was a statistically significant prognostic factor for RFS (P = 0.003) and borderline for OS (P = 0.08). The proliferation fraction (%S + %G2M), using a cutoff of 12.5, was a statistically significant prognostic factor for RFS (P = 0.01) and for OS (P = 0.01). In a Cox multivariate analysis for RFS, the total %S remained significant (P = 0.05) along with tumor size. In the analysis of OS, the proliferation fraction remained significant (P = 0.03) along with tumor size and age. DNA ploidy was not significant in any multivariate analysis.

CONCLUSIONS

This study suggests that tumor size and cell proliferation parameters are independent prognostic factors for patients with resected lymph node negative breast cancer. However, the clinical usefulness of the cell kinetic parameters appears limited.

Comparative study of interphase cytogenetics, flow cytometric analysis, and nuclear grade of fine-needle aspirates of breast carcinoma

The correlation between DNA ploidy and S-phase fraction (SPF) by flow cytometry (FCM) and the detection of numerical chromosomal abnormalities (NCA) by interphase cytogenetics (IC) involving chromosomes 8 and 12 was studied in 20 human breast lesions (17 breast carcinomas, 2 fibroadenomas, and 1 sclerosing adenosis). Initial diagnosis was performed on fine-needle aspiration biopsy (FNAB) material with subsequent histologic confirmation. FCM was performed on formalin-fixed paraffin-embedded tissue while IC by fluorescence in situ hybridization (FISH) was done on alcohol fixed FNAB materials. Sixteen (80%) cases showed concordance between FCM and IC with respect to the presence or absence of aneuploidy. The remainder of the cases (20%), which were all malignant neoplasms, showed discrepancies between the two methods, all four were DNA-diploid with low SPF by FCM but showed various NCA by IC. Nuclear grades (NG) of all the malignant samples were also evaluated and correlated with both FCM and IC studies. Although a good correlation was observed between NG and FCM, a better correlation was seen between NG and IC. This study shows that although IC by FISH correlated well with FCM analysis, it can detect NCA in DNA-diploid, low SPF tumors. It also correlates well with the NG of the tumor. The increased sensitivity provided by IC in detecting aneuploidy may be of great prognostic significance in low stage, DNA-diploid, low SPF breast carcinomas.

Prognostic factors in early breast carcinoma

Several investigators, the SEER data, and the ECOG/Intergroup study have shown that patients with small tumors (< 0.5 cm) have a recurrence rate of less than 2%, compared to 20-25% for large tumors (> or = 5 cm). Nuclear grade and tumor differentiation are established indicators; however, the interobserver lack of concordance has thwarted their use in clinical trials. The presence of peritumoral lymphatic and blood vessel invasion (PLBI) is associated with a relative risk of recurrence of 4.7. The predictive value of the presence of hormone receptors in tumors is associated with a favorable disease free and overall survival difference of 8-10%; however, this advantage is being eroded by the early appearance of other factors, such as the epidermal growth factor receptor (EGFR), proliferative capacity (S-phase), nuclear grade, and HER-2/neu oncogene. Concordance among the different methods of hormone-receptor assay (immunocytochemical, sucrose gradient, and dextran-coated charcoal) is essential to refine the true value of these factors. DNA flow cytometry measurements of ploidy (DNA content) and S-phase fraction are the most characterized of the prognostic factors. There are conflicting reports regarding the clinical significance of ploidy status, while measurements of S-phase fraction clearly indicate a robust association with disease free and overall survival. Our data continue to show that S-phase, but not ploidy, can predict time to recurrence significantly in untreated patients, even when data are stratified for tumor size. HER-2/neu oncogene is expressed in about 50% of ductal carcinoma in situ and 14% of invasive ductal carcinoma. The presence of this oncogene at high copy number may be a useful independent marker of poor prognosis and may be associated with drug resistance and correlated with tumor recurrence and shorter survival. EGFR could be measured in most breast tumors, and the level of its expression has inversely correlated with estrogen receptor protein expression. The value of EGFR as a predictor of prognosis remains controversial and is still being investigated. Cathepsin-D provides a provocative biologic rationale but is hindered by different and incongruent methods of analysis. The majority of large studies with more than 3-years' follow-up suggests that high cathepsin-D levels may be predictive of greater recurrence and lower survival. Angiogenesis has been implicated as a critical component of the metastatic process. Early studies show that tumor angiogenesis is an independent and highly significant prognostic indicator, and its presence may suggest the selection of "anti-angiogenic therapy."(ABSTRACT TRUNCATED AT 400 WORDS)

Prospective study correlating P120 antigen expression with established prognostic factors in breast cancer

P120 is a nucleolar proliferation antigen found in rapidly dividing cells and a variety of malignancies. Previous retrospective studies have demonstrated that, when detected in human breast cancer, P120 is associated with a poorer prognosis. To determine whether P120 expression correlates with other prognostic factors in breast cancer, we prospectively analysed pathologic and clinical data from 61 patients. P120 was detected in 40 of the 61 specimens (66%). No significant correlation existed between P120 expression and either tumour size or hormone receptors. A significant correlation was found between P120 expression and histological grade, degree of aneuploidy, S-phase fraction, degree of nodal involvement, and stage of disease. P120 is a biological marker indicative of tumour aggressiveness and may play an important role in determining which patients would most benefit from adjuvant therapy.