Prognostic factors. Stage and receptor status in breast cancer

Development of machine learning-based malignant pericardial effusion-related model in breast cancer: Implications for clinical significance, tumor immune and drug-therapy

Background

Malignant pericardial effusion (MPE) is a common complication of advanced breast cancer (BRCA) and plays an important role in BRCA. This study is aims to construct a prognostic model based on MPE-related genes for predicting the prognosis of breast cancer.

Methods

The BRCA samples are analyzed based on the expression of MPE-related genes by using an unsupervised cluster analysis method. This study processes the data by least absolute shrinkage and selection operator and multivariate Cox analysis, and uses machine learning algorithms to construct BRCA prognostic model and develop web tool.

Results

BRCA patients are classified into three clusters and a BRCA prognostic model is constructed containing 9 MPE-related genes. There are significant differences in signature pathways, immune infiltration, immunotherapy response and drug sensitivity testing between the high and low-risk groups. Of note, a web-based tool (http://wys.helyly.top/cox.html) is developed to predict overall survival as well as drug-therapy response of BRCA patients quickly and conveniently, which can provide a basis for clinicians to formulate individualized treatment plans.

Conclusion

The MPE-related prognostic model developed in this study can be used as an effective tool for predicting the prognosis of BRCA and provides new insights for the diagnosis and treatment of BRCA patients.

Treatment of axillary web syndrome using instrument assisted soft tissue mobilization and thoracic manipulation for associated thoracic rotation dysfunction

PURPOSE

There is a paucity of research that investigates physical therapy management for patients with axillary web syndrome (AWS) and thoracic rotation dysfunction. The purpose of this case report is to describe the management of a patient with AWS and thoracic rotation dysfunction using an impairment-based approach that includes instrument assisted soft tissue mobilization (IASTM), thoracic manipulation, and stretching.

CASE DESCRIPTION

The patient was a 48-year-old female with a past medical history of bilateral breast cancer with a bilateral latissimus dorsi flap reconstruction. The patient was referred to physical therapy with chief complaints of right shoulder pain with reaching and an inability to resume running due to right shoulder and scapula pain. The patient was seen in outpatient physical therapy for four visits over four weeks. Treatment consisted of IASTM, thoracic manipulation, stretching exercises, and home exercise program instruction.

OUTCOMES

Upon discharge, the patient had improved right shoulder and thoracic range of motion, decreased pain, and improved function on the patient specific functional scale (PSFS).

CONCLUSION

Utilization of an impairment-based physical therapy approach to treat a patient with AWS and thoracic dysfunction yielded positive outcomes. Further research on the efficacy of IASTM and physical therapy management of AWS is warranted.

A Nomogram for Predicting the Pathological Response of Axillary Lymph Node Metastasis in Breast Cancer Patients

The value of sentinel lymph node biopsy (SLNB) in post-neoadjuvant chemotherapy (NCT) patients is still controversial. We aimed to identify predictors and construct a nomogram for predicting the pathologically complete response (pCR) of axillary lymph nodes (ALNs) after NCT in node positive breast cancer patients. In total, 426 patients with pathologically proven ALN metastasis before NCT were enrolled, randomized 1:1 and divided into a training set and a validation set. We developed a nomogram based on independent predictors for ALN pCR identified by multivariate logistic regression as well as clinical significant predictors. The multivariate logistic regression analysis showed that hormone receptor (HR) status, human epidermal growth factor 2 (HER2) status and Ki67 index were independent predictors. The nomogram was thereby constructed by those independent predictors as well as tumor size and NCT regimens. The areas under the receiver operating characteristic curve of the training set and the validation set were 0.804 and 0.749, respectively. We constructed a nomogram for predicting ALN pCR in patients who received NCT. Our nomogram can improve risk stratification, accurately predict post-NCT ALN status and avoid unnecessary ALN dissection.

Prognostic value of nuclear hepatoma-derived growth factor (HDGF) localization in patients with breast cancer

Hepatoma-derived growth factor (HDGF) plays an important role in tumor progression. Highly expressed HDGF has been found to indicate poor prognosis in many cancers. However, no information is available regarding the prognostic value of nuclear or cytoplasmic HDGF staining level in breast cancer. In the present study, the nuclear or cytoplasmic HDGF staining level was investigated in 86 patients with primary breast cancer by immunohistochemistry; the relationship between nuclear or cytoplasmic HDGF staining level and clinicopathological parameters was examined by Two-tailed Mann-Whitney U-test or Krustal-Wallis. The prognostic value of nuclear or cytoplasmic HDGF staining level in disease-free survival and overall survival was analyzed by Kaplan-Meier methods and log-rank test. We found that the percentage of cases with strong nuclear HDGF staining level was significantly higher in the cases with high tumor grade, high stage, high proliferation index (Ki-67 index>20%), as well as in those with lymph node invasion and recurrence (p<0.05) compared to those without. No significant correlation was found between cytoplasmic HDGF expression and any clinicopathological variables. In addition, disease-free survival and overall survival were significantly lower in patients with high nuclear HDGF expression (level 2) than in those with low nuclear HDGF expression (level 0 and level 1). Further Cox multivariate analysis showed that high nuclear HDGF expression is an independent factor for indicating poor prognosis in breast cancer patients. No significant difference in disease-free survival rate and overall survival was found between different cytoplasmic HDGF staining levels. All these findings suggest that increased nuclear HDGF expression is involved in tumor progression and might be used as a new prognosticator for breast cancer.

Microspot immunoassay-based analysis of plasma protein profiles for biomarker discovery strategies

To expedite the development of personalized medicine, new and reliable biomarkers are required to facilitate early diagnosis, to determine prognosis, predict response or resistance to different therapies, and to monitor disease progression or recurrence. Human body fluids, such as blood, present a promising resource for biomarker discovery, in every sense. Microspot immunoassays allow the simultaneous quantification of multiple analytes from a minute amount of samples in a single measurement. The experimental design of microspot immunoassays is based on antibody pairs recognizing different epitopes of the analyte. The first antibody is used to capture the analyte from the complex sample, and the second antibody is used for detection. As with traditional enzyme-linked immunosorbent assays, highly reliable and reproducible results are obtained.

Immunohistochemistry compared to cytosol assays for determination of estrogen receptor and prediction of the long-term effect of adjuvant tamoxifen

The purpose of this study is to compare immunohistochemistry (IHC) and cytosol-based assays for determination of estrogen receptor (ER) and prediction of response to adjuvant tamoxifen treatment in postmenopausal women with early-stage invasive breast cancer. The Stockholm Breast Cancer Study Group conducted a randomized trial during 1976 through 1990 comparing adjuvant tamoxifen versus control. The patients were stratified according to tumor size and lymph node status in high-risk and low-risk groups. In this study we evaluated 683 patients with "low risk" breast cancer (size ≤30 mm, lymph node-negative) for whom ER status had been determined by both the cytosol assays and IHC at one pathology laboratory. The median follow-up was 17 years. Six hundred eighty-three patients had tumors with ER determined by both methods, 536 (78.5%) were ER-positive by cytosol assays using the cutoff level at ≥0.05 fmol/μg DNA and 539 patients were ER-positive (79%) by IHC using the cutoff level at ≥10% cell stained. Thirty-nine tumors (5.7%) were ER-positive by cytosol but not by IHC, whereas the opposite pattern was found for 42 cases (6.1%). Only seven tumors had stained cells between 0 and 9% by IHC. The concordance between IHC and cytosol assays was high (88%). The kappa statistic was 0.65, 95% CI 0.58-0.72. Among patients classified as ER-negative no therapeutic benefit from tamoxifen was observed. Among patients with ER-expressing tumors, tamoxifen resulted in significantly better recurrence-free survival irrespective of the method (IHC: HR, 0.53, P < 0.001; cytosol: HR, 0.53, P < 0.001). The effect on overall survival was not statistically significant probably due to the limited sample size. Both IHC and cytosol assay accurately predict long-term response to adjuvant tamoxifen.

Axillary web syndrome after axillary dissection in breast cancer: a prospective study

The axillary web syndrome is a self-limiting and frequently overlooked cause of significant morbidity in the early post-operative period after breast cancer axillary surgery, which is characterized by axillary pain that runs down the medial arm, limited shoulder range of motion affecting mainly shoulder abduction, and cords of subcutaneous tissue extending from axilla into the medial arm, made visible or palpable and painful by shoulder abduction. We evaluated the incidence of axillary web syndrome after axillary lymph-node dissection. Altogether 116 patients who underwent axillary lymph-node dissection were assessed for axillary web syndrome. Range of shoulder abduction, pain, and the subjective feeling of tightness along the arm were recorded. Axillary web syndrome was found in 56 patients, which means an incidence of 48.3% (CI95%: 38.9, 57.7). Axillary web syndrome is a significant self-limited cause of morbidity of axillary surgery ocurring not only in the early post-operative period.

Relationship between body mass index, waist circumference and waist to hip ratio and the steroid hormone receptor status in breast carcinoma of pre- and postmenopausal women

OBJECTIVE

To assess whether body mass index (BMI), waist circumference (WC) and waist to hip ratio (WRH) are associated to the steroid receptor status in breast carcinomas.

METHODS

Four hundred and seventy three women with breast malignancies stage I-III were included. Weight, height, the waist and hip circumferences (WC), body mass index (BMI), and the waist to hip ratio (WHR) were determined. The expression of estrogen (ER) and progesterone (PR) receptors was determined with immunohistochemistry.

RESULTS

Most women had central obesity (WC>or=88 and WHR>or=0.85 in 64.3 and 73.4%, respectively). The majority (78.1%) of the women had tumors that expressed at least one of the HR. BMI, WC and WHP were not related to the HR status in neither the pre- or postmenopausal women. Multivariate analysis confirmed these findings.

CONCLUSIONS

BMI, WC or WHR may not be good predictors of HR status in breast malignancies in either pre- or postmenopausal women.

Tumor metabolism and blood flow changes by positron emission tomography: relation to survival in patients treated with neoadjuvant chemotherapy for locally advanced breast cancer

PURPOSE

Patients with locally advanced breast carcinoma (LABC) receive preoperative chemotherapy to provide early systemic treatment and assess in vivo tumor response. Serial positron emission tomography (PET) has been shown to predict pathologic response in this setting. We evaluated serial quantitative PET tumor blood flow (BF) and metabolism as in vivo measurements to predict patient outcome.

PATIENTS AND METHODS

Fifty-three women with primary LABC underwent dynamic [(18)F]fluorodeoxyglucose (FDG) and [(15)O]water PET scans before and at midpoint of neoadjuvant chemotherapy. The FDG metabolic rate (MRFDG) and transport (FDG K(1)) parameters were calculated; BF was estimated from the [(15)O]water study. Associations between BF, MRFDG, FDG K(1), and standardized uptake value and disease-free survival (DFS) and overall survival (OS) were evaluated using the Cox proportional hazards model.

RESULTS

Patients with persistent or elevated BF and FDG K(1) from baseline to midtherapy had higher recurrence and mortality risks than patients with reductions. In multivariable analyses, BF and FDG K(1) changes remained independent prognosticators of DFS and OS. For example, in the association between BF and mortality, a patient with a 5% increase in tumor BF had a 67% higher mortality risk compared with a patient with a 5% decrease in tumor BF (hazard ratio = 1.67; 95% CI, 1.24 to 2.24; P < .001).

CONCLUSION

LABC patients with limited or no decline in BF and FDG K(1) experienced higher recurrence and mortality risks that were greater than the effects of clinical tumor characteristics. Tumor perfusion changes over the course of neoadjuvant chemotherapy measured directly by [(15)O]water or indirectly by dynamic FDG predict DFS and OS.

Progesterone receptor expression is a marker for early stage breast cancer: implications for progesterone receptor as a therapeutic tool and target

We determined the association of estrogen receptor (ER) and progesterone receptor (PR) expression in invasive breast cancer with stage at diagnosis. Univariate analyses indicated that although ER and PR expression were inversely associated with grade (P<0.0001), only PR expression (P<0.01) was inversely associated with stage. Multivariate analyses, adjusted for covariates, including HER-2/neu expression, indicated that PR (odds ratio (OR), 0.88; confidence interval (CI), 0.77-0.99; P=0.03) and not ER expression (OR, 1.04; CI, 0.94-1.16; P=0.45) was inversely associated with stage. PR and not ER expression is a marker for early stage breast cancer.

Hormone receptor status, tumor characteristics, and prognosis: a prospective cohort of breast cancer patients

Background

Breast cancer patients with tumors that are estrogen receptor (ER)-positive and/or progesterone receptor (PR)-positive have lower risks of mortality after their diagnosis compared to women with ER- and/or PR-negative disease. However, few studies have evaluated variations in the risks of breast cancer-specific mortality across ER/PR status by either demographic or clinical characteristics.

Methods

Using data from 11 population-based cancer registries that participate in the SEER (Surveillance, Epidemiology, and End Results) program, 155,175 women at least 30 years old with a primary diagnosis of invasive breast carcinoma from 1990 to 2001 were included in the study. Associations between joint hormone receptor status and breast cancer mortality risk within categories of diagnosis age, diagnosis year, race/ethnicity, histologic tumor type, stage, grade, size, and axillary lymph node status were evaluated using the Cox proportional hazards model.

Results

Compared to ER+/PR+ cases, elevations in risk of mortality were observed across all subcategories of age at diagnosis, ranging from 1.2- to 1.5-fold differences for ER+/PR- cases, 1.5- to 2.1-fold differences for ER-/PR+ cases, and 2.1- to 2.6-fold differences for ER-/PR- cases. Greater differences were observed in analyses stratified by grade; among women with low-grade lesions, ER-/PR- patients had a 2.6-fold (95% confidence interval [CI] 1.7 to 3.9) to 3.1-fold (95% CI 2.8 to 3.4) increased risk of mortality compared to ER+/PR+ patients, but among women with high-grade lesions, they had a 2.1-fold (95% CI 1.9 to 2.2) to 2.3-fold (95% CI 1.8 to 2.8) increased risk.

Conclusion

Compared to women with ER+/PR+ tumors, women with ER+/PR-, ER-/PR+, or ER-/PR- tumors experienced higher risks of mortality, which were largely independent of the various demographic and clinical tumor characteristics assessed in this study. The higher relative mortality risks identified among ER-/PR- patients with small or low-grade tumors raise the question of whether there may be a beneficial role for adjuvant chemotherapy in this population.

Association of physical activity with hormone receptor status: the Shanghai Breast Cancer Study

Evidence exists that breast tumors differing by estrogen receptor (ER) and progesterone receptor (PR) status may be phenotypically distinct diseases resulting from dissimilar etiologic processes. Few studies have attempted to examine the association of physical activity with breast cancer subtype. Such research may prove instructive into the biological mechanisms of activity. Consequently, this investigation was designed to assess the relationship between physical activity and hormone receptor-defined breast cancers in a population of Asian women in which the distribution of receptor types differed from traditional Western populations. Participants, ages 25 to 64 years, were recruited into this population-based, case-control study of breast cancer conducted in Shanghai, China from August 1996 to March 1998. Histologically confirmed breast cancer cases with available receptor status information (n = 1001) and age frequency-matched controls (n = 1,556) completed in-person interviews. Polytomous logistic regression was used to model the association between measures of activity with each breast cancer subtype (ER+/PR+, ER-/PR-, ER+/PR-, and ER-/PR+) using the control population as the reference group. Exercise in both adolescence and the last 10 years was associated with a decreased risk of both receptor-positive (ER+/PR+) and receptor-negative (ER-/PR-) breast cancers in both premenopausal and postmenopausal women (odds ratios, 0.44 and 0.51 and 0.43 and 0.21, respectively). Sweating during exercise within the last 10 years was also associated with decreased risk for receptor-positive and receptor-negative breast cancers among postmenopausal women (odds ratios, 0.58 and 0.28, respectively). These findings suggest that physical activity may reduce breast cancer risk through both hormonal and nonhormonal pathways.

Comparison of stage-specific outcome of breast cancer based on 5th and 6th AJCC staging system

BACKGROUND AND OBJECTIVES

To investigate the appropriateness of the new staging system (AJCC 6th edition) for breast carcinoma.

METHODS

We reviewed the clinicopathologic data of 1,768 breast cancer patients, and their disease stages were re-categorized by the new system. The overall survival (OS) and distant relapse free survival (DRFS) rates were compared between those patients whose stages by the old system (AJCC 5th edition) remained the same (the remainders) and those patients whose stages moved up (the upstaged cases) as well as between the subgroups in the new system.

RESULTS

The 10-year DRFS rates of the upstaged cases in each stage were poorer than those of the remainders, and statistical significance was demonstrated for stage IIB and stage IIIA. The 10-year OS rates were also poorer in the upstaged cases, and statistical significance was demonstrated for stage IIIA. Subgroup analysis within the new system between the node-negative versus node-positive subgroups in stages IIA and IIB showed a significant OS difference. The DRFS difference was also shown between the subgroups in stage IIA.

CONCLUSIONS

The new staging system seems to more accurately reflect disease outcome, however, a re-evaluation might be required to reflect the impact of nodal involvement upon the new staging system.

Long term treatment related upper limb morbidity and quality of life after sentinel lymph node biopsy for stage I or II breast cancer

BACKGROUND

In a prospective study, long term upper-limb morbidity, perceived disabilities in activities of daily life (ADL) and quality of life (QOL) were assessed before and 2 years after sentinel lymph node biopsy (SLNB) or axillary lymph node dissections (ALND) for breast cancer.

METHODS

Two hundred and four patients with stage I/II breast cancer, mean age 55.6 years (SD: 11.6) entered the study and 181 patients (89%) could be evaluated after 2 years. Fifty-seven patients underwent SLNB (31%) and 124 patients underwent an ALND (69%). Assessments included pain, shoulder range of motion, muscle strength, arm volume, perceived shoulder disability in ADL and QOL.

RESULTS

Significant (P<0.05) changes between before and 2 years after surgery were found in almost all assessments of shoulder function, ADL and several QOL subscales. Patients in the ALND group showed significant more changes in range of motion (ROM), grip strength, arm volume, ADL and QOL physical- and role functioning, pain and sleeplessness and arm symptoms compared to the SLNB group. Multivariate linear regression analysis showed that ALND could predict decrease of ROM, grip strength, ADL and physical functioning (QOL) and increase of arm volume, pain and arm symptoms score (QOL). Radiation on the axilla predicts an additional decrease in shoulder ROM and increase of arm volume.

CONCLUSION

Two years after surgery for breast cancer, patients show significantly less treatment related upper limb morbidity, perceived disability in ADL and worsening of QOL after SLNB compared with ALND.

Multicycle Dose-Intensive Chemotherapy for Women With High-Risk Primary Breast Cancer: Results of International Breast Cancer Study Group Trial 15-95

Purpose

To compare adjuvant dose-intensive epirubicin and cyclophosphamide chemotherapy administered with filgrastim and progenitor cell support (DI-EC) with standard-dose anthracycline-based chemotherapy (SD-CT) for patients with early-stage breast cancer and a high risk of relapse, defined as stage II disease with 10 or more positive axillary nodes; or an estrogen receptor–negative or stage III tumor with five or more positive axillary nodes.

Patients and Methods

Three hundred forty-four patients were randomized after surgery to receive seven cycles of SD-CT over 22 weeks, or three cycles of DI-EC (epirubicin 200 mg/m2 plus cyclophosphamide 4 gm/m2 with filgrastim and progenitor cell support) over 6 weeks. All patients were assigned tamoxifen at the completion of chemotherapy. The primary end point was disease-free survival (DFS).

Results

After a median follow-up of 5.8 years (range, 3 to 8.4 years), 188 DFS events had occurred (DI-EC, 86 events; SD-CT, 102 events). The 5-year DFS was 52% for DI-EC and 43% for SD-CT, with hazard ratio of DI-EC compared with SD-CT of 0.77 (95% CI, 0.58 to 1.02; P = .07). The 5-year overall survival was 70% for DI-EC and 61% for SD-CT, with a hazard ratio of 0.79 (95% CI, 0.56 to 1.11; P = .17). There were eight cases (5%) of anthracycline-induced cardiomyopathy (two fatal) among those who received DI-EC. Women with hormone receptor–positive tumors benefited significantly from DI-EC.

Conclusion

There was a trend in favor of DI-EC with respect to disease-free survival. A larger trial or meta-analysis will be required to reveal the true effect of dose-intensive therapy.

Angiogenesis and hypoxia in lymph node metastases is predicted by the angiogenesis and hypoxia in the primary tumour in patients with breast cancer

Hypoxia and angiogenesis are important factors in breast cancer progression. Little is known of hypoxia and angiogenesis in lymph node metastases of breast cancer. The aim of this study was to quantify hypoxia, by hypoxia-induced marker expression levels, and angiogenesis, by endothelial cell proliferation, comparing primary breast tumours and axillary lymph node metastases. Tissue sections of the primary tumour and a lymph node metastasis of 60 patients with breast cancer were immunohistochemically stained for the hypoxia-markers carbonic anhydrase 9 (CA9), hypoxia-inducible factor-1α (Hif-1α) and DEC-1 and for CD34/Ki-67. Endothelial cell proliferation fraction (ECP%) and tumour cell proliferation fraction (TCP%) were assessed. On haematoxylin–eosin stain, the growth pattern and the presence of a fibrotic focus were assessed. Hypoxia-marker expression, ECP% and TCP% in primary tumours and in lymph node metastases were correlated to each other and to clinico-pathological variables. Median ECP% and TCP% in primary tumours and lymph node metastases were comparable (primary tumours: ECP%=4.02, TCP%=19.54; lymph node metastases: ECP%=5.47, TCP%=21.26). ECP% correlated with TCP% (primary tumours: r=0.63, P<0.001; lymph node metastases: r=0.76, P<0.001). CA9 and Hif-1α expression were correlated (primary tumours P=0.005; lymph node metastases P<0.001). In primary tumours, CA9 and Hif-1α expression were correlated with DEC-1 expression (P=0.05), presence of a fibrotic focus (P<0.007) and mixed/expansive growth pattern (P<0.001). Primary tumours and lymph node metastases with CA9 or Hif-1α expression had a higher ECP% and TCP% (P<0.003); in primary tumours, mixed/expansive growth pattern and fibrotic focus were characterised by higher ECP% (P=0.03). Furthermore, between primary tumours and lymph node metastases a correlation was found for ECP%, TCP%, CA9 and Hif-1α expression (ECP% r=0.51, P<0.001; TCP r=0.77, P<0.001; CA9 and Hif-1α P<0.001). Our data demonstrate that the growth of breast cancer lymph node metastases is angiogenesis dependent and that angiogenesis and hypoxia in the primary tumour predict angiogenesis and hypoxia in the lymph node metastases. Together with previous findings in breast cancer liver metastases, which grow in 96% of cases angiogenesis independently, these data suggest that both the intrinsic growth characteristics and angiogenic potential of breast cancer cells and the site-specific tumour microenvironment determine angiogenesis and hypoxia in breast cancer.

The negative predictive value of electrical impedance scanning in BI-RADS category IV breast lesions

OBJECTIVES

We sought to prospectively assess the value of electrical impedance scanning (EIS) in discriminating benign from malignant lesions classified as BI-RADS category IV in mammography in comparison with ultrasound (US), with a special focus on negative prediction.

MATERIALS AND METHODS

EIS was performed on 128 BI-RADS category IV lesions in 121 women (mean, 51.8 years). The newly developed EIS software 2.67 calculates a BI-RADS-like level of suspicion (LOS) on a 5-grade scale. LOS 1, 2, and 3 were considered negative; LOS 4 and 5 were considered positive. Histopathologic results were obtained in all lesions.

RESULTS

Histology proved 37 lesions malignant, 91 benign. Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of EIS compared with US were 94.6%, 74.7%, 80.5%, 60.3%, 97.1% versus 90.5%, 33.8%, 47.2%, 29.7%, 92.0%, respectively. In 43 lesions sized < or = 10 mm, EIS demonstrated better sensitivity, specificity, accuracy, PPV, and NPV of 100%, 83.3%, 90.7%, 82.6%, and 100%, respectively. Although NPV was also high, US showed no sufficient results in 39 (30.5%) lesions because of microcalcifications. Receiver operating curve analysis revealed best results for a combined use of US and EIS.

CONCLUSIONS

With a NPV of 97.1% of EIS in BI-RADS category IV breast lesions, a negative result in these lesions could be firm indication to manage them as BI-RADS-category III and refer patients for a 6-month short-interval follow-up rather than performing a biopsy. The best adjunctive diagnostic performance can be achieved by a combination of US and EIS. Costs and patient morbidity could be minimized.

Incidence of male breast cancer in california, 1988-2000: racial/ethnic variation in 1759 men

Breast cancer among males is rare, accounting for less than 1% of all breast cancers in the United States. Although it is rare, it can cause significant morbidity and mortality. We analyzed data from 1759 California males whose diagnosis of breast cancer was made between 1988 and 2000 and reported to the population-based California Cancer Registry. Cases were primary, microscopically confirmed in situ and invasive breast cancer. Age-adjusted incidence rates per 100,000 men were highest in Blacks (1.65), intermediate in whites (1.31) and lowest in Hispanics and Asian/Pacific Islanders (0.68, 0.66, respectively). Age at diagnosis differed by race (p = 0.001) with blacks diagnosed at an earlier age than whites or Asians/Pacific Islanders. Stage at diagnosis also differed by race (p = 0.001) with blacks more likely to be diagnosed at distant stage. Further investigation showed that blacks and Hispanics were more likely to be diagnosed with tumors 5 cm in diameter or greater. The proportion of men having surgery following a diagnosis of breast cancer also varied by race/ethnicity (p = 0.001) with blacks least likely to have surgery following diagnosis. Understanding racial/ethnic variation in male breast cancer may provide clinical and etiologic implications for breast cancer in different populations.

Treatment-related upper limb morbidity 1 year after sentinel lymph node biopsy or axillary lymph node dissection for stage I or II breast cancer

BACKGROUND

In a prospective study, upper limb morbidity and perceived disability/activities of daily life (ADLs) were assessed before and 1 year after sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND).

METHODS

A total of 204 patients with stage I/II breast cancer (mean age, 55.6 years; SD, 11.6 years) entered the study, and 189 patients (93%) could be evaluated after 1 year. Fifty-eight patients (31%) underwent only SLNB, and 131 (69%) underwent ALND. Assessments performed before surgery (t(0)) and 1 year after surgery (t(1)), included pain, shoulder range of motion, muscle strength, upper arm/forearm circumference, and perceived shoulder disability/ADL.

RESULTS

Considerable treatment-related upper limb morbidity was observed. Significant (P < .05) changes between t(0) and t(1) were found in all assessments except strength of elbow flexors. Patients in the ALND group showed significantly more changes in the range of motion in forward flexion, abduction, and abduction/external rotation; grip strength and strength of shoulder abductors; circumference of upper arm and forearm; and perceived shoulder disability in ADLs compared with the SLNB group. Multivariate linear regression analysis showed that ALND could predict a decrease of range of motion in forward flexion, abduction, strength of shoulder abductors, grip strength, and shoulder-related ADLs and an increase in the circumference of the upper arm. Radiation of the axilla (19 patients) predicts an additional decrease in shoulder range of motion.

CONCLUSIONS

One year after treatment of breast cancer, there is significantly less upper limb morbidity after SLNB compared with ALND. ALND is a predictor for upper limb morbidity.

Short-term morbidity of the upper limb after sentinel lymph node biopsy or axillary lymph node dissection for Stage I or II breast carcinoma

BACKGROUND

The goals of sentinel lymph node biopsy (SLNB) are to improve axillary staging and reduce unnecessary axillary lymph node dissections (ALND), thereby reducing treatment-related upper-limb morbidity. In the current prospective study, short-term upper-limb morbidity was assessed after SLNB and/or ALND.

METHODS

The study comprised 204 patients with Stage I/II breast carcinoma. Mean patient age was 55.6 years (standard deviation, 11.6). Sixty-six patients (32%) underwent SLNB only, and 138 (68%) underwent a Level I-II ALND. Assessment (preoperative [t0] and 6 weeks postoperative [t1]) included evaluation of shoulder range of motion, muscle strength, grip strength, pain, upper/forearm circumference, shoulder disability, and activities of daily life (ADL).

RESULTS

Considerable treatment-related upper-limb morbidity was observed. Significant (P < 0.001) changes were found for pain, range of motion in forward flexion, abduction and abduction/external rotation, strength of shoulder abductors and elbow flexors, and in perceived disability in ADL. However, no significant difference in change of upper-limb function and ADL was found between the SLNB and ALND groups.

CONCLUSIONS

Significant short-term treatment-related upper-limb morbidity exists after SLNB or ALND. There is no significant difference in short-term treatment-related morbidity between SLNB and ALND.

Late morbidity after treatment of breast cancer in relation to daily activities and quality of life: a systematic review

AIMS

Breast cancer treatment may result in long-term upper limb morbidity: reduced range of motion of the shoulder, muscle weakness of the arm and hand, lymph edema, pain and numbness. Relationship of this late morbidity with activities of daily life (ADL) and quality of life (QOL) is infrequently described and the strength of this relationship is not clear.

METHODS

A systematic review was performed to evaluate the results of studies, analyzing late morbidity of breast cancer treatment in relationship with ADL and/or QOL. A literature search over the last 20 years (1980-2000) was performed in the databases MEDLINE, EMBASE, PSYCHLIT and CANCERLIT. Methodological quality of selected articles was assessed and additional, aspects of treatment related late morbidity and the relationship to ADL and/or QOL were summarized.

RESULTS

From the 1642 yielded articles 15 fulfilled our primary selection criteria. Only six articles could be selected due to the inappropriate methodological quality. There was high variation in prevalence of pain (12-51%), impairments in range of motion (2-51%), edema (6-43%) and decreased muscle strength (17-33%). Four articles reported significant relationships between late morbidity of the upper limb and perceived disabilities in ADL/QOL. The strength of these relationships was rather low.

CONCLUSIONS

Few studies investigated the relationship between late morbidity of the upper limb after treatment of early breast cancer and ADL/QOL. Significant relationship between late morbidity and restrictions of daily activities and poorer QOL was reported, however, the strength of this relationship was rather low.

Immunodetection of nmt55/p54nrb isoforms in human breast cancer

BACKGROUND

We previously identified and characterized a novel 55 kDa nuclear protein, termed nmt55/p54nrb, whose expression was decreased in a subset of human breast tumors. The objective of this study was to determine if this reduced expression in human breast tumors was attributed to the regulation of mRNA transcription or the presence of altered forms of this protein.

RESULTS

Northern blot analysis and ribonuclease protection assay indicated that nmt55/p54nrb mRNA is expressed at varying levels in estrogen receptor positive (ER+) and estrogen receptor negative (ER-) human breast tumors suggesting that reduced expression of nmt55/p54nrb protein in ER- tumors was not due to transcriptional regulation. To determine if multiple protein isoforms are expressed in breast cancer, we utilized Western blot and immunohistochemical analyses, which revealed the expression of an nmt55/p54nrb protein isoform in a subset of ER+ tumors. This subset of ER+ human breast tumors expressed an altered form of nmt55/p54nrb that was undetectable with an amino-terminal specific antibody suggesting that this isoform contains alterations or modifications within the amino terminal domain.

CONCLUSIONS

Our study indicates that nmt55/p54nrb protein is post-transcriptionally regulated in human breast tumors leading to reduced expression in ER- tumors and the expression of an amino terminal altered isoform in a subset of ER+ tumors. The potential involvement of nmt55/p54nrb in RNA binding and pre-mRNA splicing may be important for normal cell growth and function; thus, loss or alteration of protein structure may contribute to tumor growth and progression.

Postmenopausal obesity as a breast cancer risk factor according to estrogen and progesterone receptor status (Japan)

There have been inconsistent results on the association of postmenopausal obesity with breast cancer risk according to the estrogen (ER) and/or progesterone receptor (PR) status in the breast tissue, and this requires further evaluation. This study was designed to assess whether postmenopausal obesity differs according to receptor status. Information on risk factors was obtained from 1154 breast cancer cases and 21714 controls at Aichi Cancer Center Hospital, Nagoya, Japan between 1988 and 1992. The receptor status was known for 40% of cases. Obese postmenopausal women showed an increased risk of breast cancer (odds ratio (OR) for 5 kg of current weight=1.17, 95% confidence interval (CI)=1.10-1.25; OR for 1 kg/m(2) of body mass index (BMI)=1.07, 95% CI=1.04-1.10). The elevated OR was strongest for ER-positive, as well as with PR-positive, breast cancer among postmenopausal women who had a high BMI. The risk did not differ significantly according to ER status. However, obesity indices among postmenopausal women differed with borderline significance according to PR status. These results are consistent with the hypothesis that there is a gradient of risk for postmenopausal obesity according to hormonal receptor status, at least for PR status, although this was not statistically significant.

Estrogen receptor analysis in primary breast tumors by ligand-binding assay, immunocytochemical assay, and northern blot: a comparison

Estrogen receptor (ER) status is an important parameter in breast cancer management. In this study, ER protein contents established by two conventional techniques were confronted to ER mRNA level, to analyze whether the latter may be introduced in routine assay. Eighty-seven breast tumor samples were examined. ER amounts were determined by ligand-binding assay (LBA) and by computer-assisted immunocytochemical assay (ICA), ER mRNA was analysed and quantified by northern blot. Seventy-seven percent of tumor samples examined were positive for ER mRNA and they all expressed the 6.7-kb receptor signal. No trace of small-sized ER mRNA variants was detected in any sample. Following akaike information criterion (AIC) discriminant analysis, a simple linear correlation was found between ER mRNA levels and ER amounts provided by LBA. This was not observed when either mRNA or LBA values were compared to ICA values. These latter were found to rapidly reach a plateau at increasing mRNA or LBA values. In conclusion, our data points to the linear correlation between ER amounts determined in breast tumors at both protein and mRNA levels by quantitative methods; they also indicate that the semi-quantitative computer-associated ICA may complement rather than replace these quantitative methods.

Axillary web syndrome after axillary dissection

BACKGROUND

Some patients undergoing axillary lymph node dissection (ALND) experience postoperative pain and limited range of motion associated with a palpable web of tissue extending from the axilla into the ipsilateral arm. The purpose of this study is to characterize the previously undescribed axillary web syndrome (AWS).

METHODS

To identify patients with AWS, a retrospective review was performed of all invasive breast cancer patients treated by a single surgeon (REM) between 1980 and 1996. Records were also reviewed of 4 more recent patients who developed AWS after undergoing sentinel node lymph node dissection (SLND) without ALND.

RESULTS

Among 750 sequentially treated patients, 44 (6%) developed AWS between 1 and 8 weeks after their axillary procedure. The palpable subcutaneous cords extended from the axillary crease down the ipsilateral arm, across the antecubital space, and in severe cases down to the base of the thumb. The web was associated with pain and limited shoulder abduction (< or = 90 degrees in 74% of patients). AWS resolved in all cases within 2 to 3 months. AWS also occurred after SLND. Tissue sampling of webs in 4 patients showed occlusion in lymphatic and venous channels.

CONCLUSIONS

AWS is a self-limiting cause of morbidity in the early postoperative period. More limited axillary surgery, with less lymphovenous disruption, might reduce the severity and incidence of this syndrome, although SLND does not eliminate its occurrence.

Prognostic Variables in Male Breast Cancer

The prognostic role of ploidy status, S phase fraction, estrogen and progesterone receptor status, and the expression of p53 and erbB-2 protein in male breast carcinoma (MBC) remains controversial. The primary objective of this study was to determine which of the common prognostic factors for female breast cancer predict prognosis in MBC. A secondary objective was to assess the impact of comorbid illnesses on survival. A retrospective review of demographic data, surgical treatment, pathological staging, adjuvant treatment and follow-up was completed for 16 patients with MBC (1 intraductal and 15 invasive). Formalin-fixed, paraffin-embedded tissue was processed for ploidy, S phase fraction, and immunohistochemical detection of estrogen and progesterone receptors plus expression of p53 and erbB-2 protein. Six of 15 patients with infiltrating ductal carcinoma are currently alive without evidence of disease and a median survival of 61 months. Nine patients died after a median survival of 52 months, with 6 patients having no evidence of recurrent breast cancer. Two of 3 deaths secondary to advanced breast cancer occurred in patients who initially presented with T4 lesions and were staged IIIB. Two of 15 tumors were erbB-2 positive, whereas only 1 tested weakly positive for p53 protein. We observed that MBCs express erbB-2 and p53 proteins infrequently. Neither ploidy status, S phase fraction, nor erbB-2/ p53 status provided any apparent improvement in establishing prognosis beyond routine pathological staging. Advanced TNM stage was associated with diminished survival. The majority of MBCs express estrogen and progesterone receptors. Survivals in MBC were reduced in association with comorbid medical conditions.

Breast cancer metastatic to the uterine cervix: analysis of a rare event

A patient with cervical metastases leading to the diagnosis of a primary breast cancer is presented. To better define the frequency, symptoms, and characteristics of breast cancer metastasizing to the uterine cervix, all cases reported in the literature since 1950 are reviewed. This analysis reveals that in 21% of these cases, metastases were found before or at the same time as the primary tumor. The most common presenting symptom was abnormal vaginal bleeding (57%), but in 32% of the patients, no clinical sign was present. Because 41% of the reported cases were found only at autopsy, the characteristics of this kind of metastatic breast cancer, effectiveness of diagnostic procedures, and treatment options are critically discussed.

Estrogen replacement therapy and breast cancer survival in a large screening study

BACKGROUND

Hormone replacement therapy has been associated in some studies with reductions in breast cancer mortality among women who develop this disease. It is unclear whether this association reflects the biologic activity of the hormones or the earlier detection of tumors among hormone users. We examined breast cancer mortality among women who were diagnosed with axillary lymph node-negative and node-positive breast cancer according to the currency of estrogen use at diagnosis.

METHODS

Vital status through June 1995 was determined for 2614 patients with postmenopausal breast cancer diagnosed during the period from 1973 to January 1981. We estimated adjusted hazard-rate ratios (adjusting for tumor size, age, race, Quetelet [body mass] index, and number of positive lymph nodes in women with node-positive disease) and unadjusted cumulative probabilities of breast cancer death over time since diagnosis.

RESULTS

Among patients with node-negative disease, rate ratios for breast cancer mortality associated with current use compared with nonuse at diagnosis were 0.5 (95% confidence interval [CI] = 0.3-0.8) until 144 months after diagnosis and 2.2 (95% CI = 0.9-5.2) thereafter. Mortality was not statistically significantly lower in past users. The cumulative probabilities of breast cancer mortality at the end of follow-up were 0.14, 0.14, and 0.09 in nonusers, past users, and current users, respectively. Among women with node-positive disease, the rate ratios associated with current and past use were both 0.5 until 48 months after diagnosis (95% CI = 0.3-0.8 for current users; 95% CI = 0.3-0.9 for past users) and were 1.1 (95% CI = 0.7-1.7) and 1.8 (95% CI = 1.2-2.7), respectively, thereafter. The cumulative probabilities of breast cancer mortality were 0.32, 0.39, and 0.27 in nonusers, past users, and current users, respectively.

CONCLUSIONS

Patients with breast cancer who were using replacement estrogens at the time of diagnosis experienced reductions in breast cancer mortality, which waned with the time since diagnosis.

Physical and psychological morbidity after axillary lymph node dissection for breast cancer

PURPOSE

Alternatives to axillary lymph node dissection (ALND) are being developed amid controversy surrounding the therapeutic benefit and overall utility of this routine surgical procedure. Although potential negative side effects associated with ALND are known, we set out to examine whether these side effects contribute significantly to patient reports of quality of life and mental health.

PATIENTS AND METHODS

We surveyed 222 women who had received an ALND as part of breast cancer surgery. All women underwent a physical therapy assessment of range of arm/shoulder motion and completed the Modified Post-operative Pain Questionnaire, the Pain Disability Index, the McGill Pain Questionnaire (short form), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and the Mental Health Inventory.

RESULTS

Seventy-two percent of the women experienced arm/shoulder pain, weakness, or numbness in the week before the interview, and range of motion of the affected arm/shoulder was impaired in 73% of the women. Severity of pain was reported to be low to moderate, and younger patients experienced greater pain than older patients. Pain severity correlated positively with the number of lymph nodes removed and receipt of chemotherapy and was not significantly related to length of time since surgery or receipt of radiation therapy. Generally high levels of cancer-specific quality of life and mental health were reported. Quality of life was significantly predicted by the McGill Pain Questionnaire, and mental health was significantly predicted by the Pain Disability Index and the physical therapy assessment.

CONCLUSION

Surgery-related symptoms after ALND persist for a majority of women with breast cancer and are not significantly related to time since surgery or receipt of radiation therapy. These symptoms and associated disability are significantly predictive of cancer-specific quality of life and mental health.

Multicycle high-dose chemotherapy and filgrastim-mobilized peripheral-blood progenitor cells in women with high-risk stage II or III breast cancer: five-year follow-up

PURPOSE

To determine the safety and efficacy of multiple cycles of dose-intensive, nonablative chemotherapy in women with poor-prognosis breast cancer.

PATIENTS AND METHODS

Women with stage II breast cancer and 10 or more involved nodes or four or more involved nodes and estrogen receptor-negative tumors and women with stage III disease received three cycles of epirubicin 200 mg/m2 and cyclophosphamide 4 g/m2, with progenitor cell and filgrastim support every 28 days (n = 79) or 21 days (n = 20). Patients were reviewed at least twice yearly thereafter. Twenty-six patients had bone marrow and apheresis collections assessed for the presence of micrometastatic tumor cells.

RESULTS

Ninety-nine women (median age, 43 years; range, 24 to 60 years) were treated. Ninety-two completed all three cycles of chemotherapy. The major toxicity was severe, reversible myelosuppression that was more prolonged with successive cycles, and this did not differ between patients given treatment every 28 days and those treated every 21 days. Febrile neutropenia occurred in 176 (61%) of 287 cycles. Severe mucositis (grade 3 or 4) occurred in 23% of cycles but tended to be short-lived and was reversible. The cardiac ejection fraction fell by a median of 4% during treatment, and three patients developed evidence of cardiac failure after chemotherapy. Two patients (2%) died of acute toxicity. Three of 26 patients had evidence of circulating micrometastatic tumor cells. The actuarial distant disease-free and overall survival rates at 60-month follow-up were 64% (95% confidence interval [CI], 53% to 75%) and 67% (95% CI, 56% to 78%), respectively.

CONCLUSION

Multiple cycles of dose-intensive, nonablative chemotherapy is a feasible and safe approach. Disease control and survival are similar to those in other studies of myeloablative chemotherapy in poor-prognosis breast cancer. The regimen is being evaluated in a randomized trial of the International Breast Cancer Study Group.

Steroid Hormone Receptors Related to Parameters Characterizing the Biology of Human Breast Cancer

Steroid hormone receptors are important parameters to characterize breast tumors. Thus, it is important to evaluate their relationships with factors such as histological type and size of the tumor, axillary lymph node invasion and distant spread, age and menopausal status of the patients, and parameters of tumor differentiation.

The receptor levels observed vary within wide ranges. Therefore, statistically significant differences between different groups of parameters are seldom found. A significant dependence on receptor levels has been observed only for patient age and menopausal status. The parameters clinical stage, tumor size, tumor histology, metastatic involvement and histopathologic grading showed no statistically significant relation with receptor levels. Nevertheless, a relationship exists between all parameters mentioned and the frequency of a positive receptor status. Consequently, receptor status can contribute to define the biological behavior of the disease in specific groups of patients. In individual cases other parameters than the biochemical evidence of steroid receptor binding seem to be more important. We found that data derived from DNA flow cytometric measurements allowed a better recognition of tumor aggressiveness than ER status. In axillary lymph node metastases we usually observed higher receptor levels than in primary tumors, but we did not find an age dependency of ER levels in these metastases.

Accelerated onset of uterine tumors in transgenic mice with aberrant expression of the estrogen receptor after neonatal exposure to diethylstilbestrol

The role of estrogen and the estrogen receptor (ER) in the induction and promotion of tumors was investigated by using transgenic MT-mER mice, which overexpress the ER. It was hypothesized that because of this abnormal expression of the ER, the reproductive-tract tissues of the MT-mER mice may be more susceptible to tumors after neonatal exposure to the potent synthetic estrogen diethylstilbestrol (DES). Normally non-estrogen responsive tissues that may have expressed ER as a result of the transgene were also studied for DES-induced tumors. Wild-type and MT-mER littermates were treated with 2 micrograms/pup/d DES 1-5 d after birth and then killed at 4, 8, 12, and 18 mo of age. The DES-treated MT-mER mice demonstrated a significantly higher incidence of uterine adenocarcinoma at 8 mo (73%) than the DES-treated wild-type mice (46%). The tumors of the MT-mER mice were often more aggressive than those in the wild-type animals. These tumors were also preceeded at 4 mo by a significantly higher incidence of the preneoplastic lesion atypical hyperplasia in the MT-mER mice (26% compared with 0% in the wild-type mice). Other DES-induced abnormalities were observed at equal rates in the wild-type and MT-mER mice. Although no tumors were observed in untreated wild-type females, a single untreated MT-mER female had uterine adenocarcinoma at 18 mo. These data indicate that the level of ER present in a tissue may also be a determining factor in development of estrogen-responsive tumors.

Lack of relationship between the expression of Hsp27 heat shock estrogen receptor-associated protein and estrogen receptor or progesterone receptor status in male breast carcinoma

Estrogen, through estrogen receptors (ERs), may regulate the synthesis of progesterone receptors (PRs) and of a heat shock estrogen receptor-associated protein (hsp27). In female breast carcinoma (FBC) both proteins serve as surrogate indicators for the presence of functional ERs. In addition, the expression of these proteins was related to other prognostic indicators of value in female breast tumours. Endocrine disorders, hormone therapy and altered estrogen metabolism have been associated with the development of male breast cancer (MBC), suggesting that evaluation of the expression of ER, PR and hsp27 might improve our understanding of the biology of this tumour. ER and PR status and hsp27 expression were evaluated by immunohistochemistry in 16 primary MBC patients. The interrelationships between these parameters were established and compared with the clinicopathological data on the tumours. Ten (56%) MBC patients were ER-positive, 69% were PR-positive and all samples were hsp27-positive. Our series of MBC patients showed a positive correlation between ERs and PRs, however there was a lack of correlation between hsp27 and ERs or PRs. MBCs did not exhibit any correlation between the biomarkers studied and known prognostic indicators for females (e.g. Scarff-Bloom-Richardson (SBR) or modified SBR (MSBR) grade, T stage, lymph node status). This is the first published series reporting the incidence of hsp27 in MBC. The lack of association between the expression of ERs and hsp27 found in MBC differs from the results reported for FBC, moreover the expression of ERs, PRs or hsp27 did not correlate with the clinicopathological parameters that have prognostic value in females. Although the data were obtained from a relatively small sample population, our findings suggest that MBC and FBC are biologically different tumours with respect to the expression of the studied proteins.

The Z-isomer of 11 beta-methoxy-17 alpha-[123I]iodovinylestradiol is a promising radioligand for estrogen receptor imaging in human breast cancer

The potential of both stereoisomers of 11 beta-methoxy-17 alpha-[123I] iodovinylestradiol (E- and Z-[123I]MIVE) as suitable radioligands for imaging of estrogen receptor (ER)-positive human breast tumours was studied. The 17 alpha-[123I]iodovinylestradiol derivatives were prepared stereospecifically by oxidative radioiododestannylation of the corresponding 17 alpha-tri-n-butylstannylvinylestradiol precursors. Both isomers of MIVE showed high in vitro affinity for dimethylbenzanthracene-induced rat and fresh human mammary tumour ER, that of Z-MIVE however being manyfold higher than that of E-MIVE. In vivo distribution studies with E- and Z-[123I]MIVE in normal and tumour-bearing female rats showed ER-mediated uptake and retention in uterus, ovaries, pituitary, hypothalamus and mammary tumours, again the highest for Z-[123I]MIVE. The uterus- and tumour-to-nontarget tissue (far, muscle) uptake ratios were also highest for Z-[123I]MIVE. Additionally, planar whole body imaging of two breast cancer patients 1-2 h after injection of Z-[123I]MIVE showed increased focal uptake at known tumour sites. Therefore, we conclude that Z-[123I]MIVE is a promising radioligand for the diagnostic imaging of ER in human breast cancer.

A review of pathology reporting for breast cancer

BACKGROUND

A detailed pathology report is important in the determination of treatment options and prognosis in breast cancer. Australia's first National Cancer Consensus Conference, held in 1994, recommended guidelines for the standardization of the clinical information to be provided to the pathologist, the specifications relating to the handling of specimens, and the resultant pathology report.

METHODS

We examined the current status of pathology reporting in invasive breast cancer in three New South Wales hospitals from 1986 to 1994.

RESULTS

Histopathologic type was documented in 99% of reports, grade was documented in 47%, size in 46%, and lymph node status in 98%. Only 27% of pathology reports reviewed documented the status of all the above parameters in the one report. Other features such as lymphatic and vascular invasion were documented in only 21% and 9% of pathology reports, respectively, while sex steroid receptor status was reported in almost 90% of cases.

CONCLUSIONS

In view of the wide range in the percentage of features reported, we recommend the use of a standardized checklist for the pathological assessment of surgically resected invasive breast cancer specimens.

The stereoisomers of 17alpha-[123I]iodovinyloestradiol and its 11beta-methoxy derivative evaluated for their oestrogen receptor binding in human MCF-7 cells and rat uterus, and their distribution in immature rats

We studied the potential of both stereoisomers of 17alpha-[123I]iodovinyloestradiol (E- and Z-[123I]IVE) and of 11beta-methoxy-17alpha-[123I]iodovinyloestradiol (E- and Z-[123I]MIVE) as suitable radioligands for the imaging of oestrogen receptor(ER)-positive human breast tumours. The 17alpha-[123I]iodovinyloestradiols were prepared stereospecifically by oxidative radio-iododestannylation of the corresponding 17alpha-tri-n-butylstannylvinyloestradiol precursors. Competitive binding studies were performed in order to determine the relative binding affinity (RBA) of the unlabelled 17alpha-iodovinyloestradiols for the ER in both human MCF-7 breast tumour cells and rat uterine tissue, compared with that of diethylstilboestrol (DES). Target tissue uptake, retention and uptake selectivity of their 123I-labelled analogues were studied in immature female rats. All four 17alpha-iodovinyloestradiols showed high affinity for the ER in human MCF-7 cells, as well as rat uterus. Their RBA for the ER showed the following order of decreasing potency: RBA of DES >Z-IVE >Z-MIVE >E-MIVE > or =E-IVE. Neither of these 17alpha-iodovinyloestradiols showed any significant binding to the sex hormone binding globulin in human plasma. The biodistribution studies showed ER-mediated uptake in the uterus, ovaries and pituitary, that of E- and Z-[123I]MIVE being higher than that of E- and Z-[123I]IVE. High target-to-non-target tissue uptake ratios, especially at longer periods after injection (up to 24h), were exhibited by both isomers of [123I]MIVE. The uterus-to-blood uptake ratio was higher for E-[123I]MIVE. However, the uterus-to-fat uptake ratio appeared to be higher for the Z-isomer of [123I]MIVE, especially at 24h after injection. Metabolic properties and temperature effects, which play a more important role in vivo, probably cause the discrepancies seen between in vitro and in vivo binding results. On the basis of their in vitro binding properties and in vivo distribution characteristics we conclude that E- and Z-[123I]MIVE could be suitable radioligands for the diagnostic imaging of ER in human breast cancer. Therefore, further studies with these radioligands in mature normal and tumour-bearing rats are warranted.

Review of known prognostic variables

The prognosis of patients with primary breast cancer depends on prognostic factors per se and on treatment. In certain subgroups of patients, the overall treatment benefits of systemic adjuvant therapy are modest. Therefore, proper selection of patients and treatment modalities is absolutely necessary. Patients with primary breast cancer and a very good prognosis can be classified by known prognostic factors such as tumor size T < or = 1 cm, grade 1, hormone receptor positive tumors, and no other factors indicating poor prognosis. [table: see text] Patients with very poor prognosis are characterized by young age (< 35 years), large tumor size (T > 3 cm), grade 3, hormone receptor-negative tumors, and high S-phase fractions. Tumor size is the best prognostic factor for the decision to treat (breast conservation surgery, primary preoperative or adjuvant systemic therapy) or not to treat. Table 4 shows possible treatment decisions (type and timing of therapy) in primary breast cancer based on known prognostic and predictive variables. The decision to treat or not to treat outside clinical trials should be based on this kind of information. The type and aggressiveness of adjuvant systemic treatment should depend on the receptor status of the tumor and on the age and menopausal status of the patient, as classical predictive factors; however, prognosticators which can describe the metastatic potential of breast cancer cells have yet to be defined.

Sociodemographic factors associated with the diagnostic staging of breast cancer in southern Italy

BACKGROUND

There are marked regional differences in breast cancer mortality rates in Italy, probably linked to factors such as diagnostic delay, therapeutic strategies, and biologic and sociodemographic differences. To investigate a possible link between sociodemographic factors (e.g. age, education, and residence) and delay in the diagnosis of breast cancer, data were evaluated from all such patients from our Institute living in the Campania Region of Southern Italy for 1991-1993.

METHODS

Patients were grouped into Tis-T1/N0-N+ versus T2-4/N0-N+ and the variables examined were age (< 40, 41-50, 51-60, > 60 years), education (< or = 5 vs. > 5 school years) and residence (urban vs. rural). An analysis was made using the Pearson's Chi-square test and the multiple logistic regression.

RESULTS

Statistically significant differences were found for both residence (P = 0.04) and education level (P = 0.03) in the older than 60 years age group, but only for residence (P = 0.03) in the 51-60 years age group. The risks according to Mantel-Haenszel were 1.28 for education (P = 0.08) and 1.32 for residence in rural municipalities (P = 0.05). The odds ratio for residence in rural municipalities, adjusted by education and by the education-residence interaction, was 2.26 (95% confidence interval [CI], 1.12-4.54) in the 51-60 years age group and 1.74 (95% CI, 1.01-3.00) in the older than 60 years age group.

CONCLUSIONS

These data clearly indicate that residents of rural municipalities, as well as poorly educated subjects, are more likely than their respective counter-parts to have a delayed diagnosis of breast cancer.

Identification of structurally altered estrogen receptors in human breast cancer by site-directed monoclonal antibodies

We have developed and characterized site-directed monoclonal (MAb) and polyclonal antibodies to a specific domain in the N-terminal A/B region in order to assess estrogen receptor (ER) structural integrity in human breast tumor samples. The antibodies (Abs) reacted specifically with the native (undenatured) ER from various species. The synthetic peptides competed effectively for ER binding to the Abs, suggesting site-specificity. The Abs recognized the activated (4S) and transformed (5S) but not the unactivated, untransformed, molybdate-stabilized (8S) ER, suggesting that the epitope is inaccessible in the 8S form. Some of these Abs reacted with ER bound to its responsive elements, as determined by gel mobility shift assay. To evaluate the structural integrity of ER in breast cancer, we have utilized a) ligand binding analysis for the hormone binding domain; b) site-directed MAb to the DNA-binding domain; and c) site-directed MAb to the N-terminal transactivation domain. Analysis of ER from 29 human breast tumors revealed that 10 out of 29 tumors (35%) contained ER with intact hormone-, DNA-, and N-terminal domains. Thirteen out of 29 tumors (approximately 45%) contained ER with intact hormone binding and N-terminal domains but were defective only in the DNA-binding domain. Three out of 29 tumors (approximately 10%) contained ER defective only in the N-terminal domain. Another subgroup of tumors (3/29; approximately 10%) had ER with normal hormone binding domain but were defective in both the DNA-binding and the N-terminal activation domains.(ABSTRACT TRUNCATED AT 250 WORDS)

[Survival of women with breast cancer in a hospital-based registry (1979-1991)]

We analyzed the survival of 268 women diagnosed with breast cancer between 1979 and 1991, registered at the Tumour Registry of the Hospital S. Jaume i Sta. Magdalena, Mataró (Barcelona). Relative survival rates at two, five and ten years were 0.84, 0.69 and 0.49, respectively. The largest difference in survival was observed in relation to the stage at the time of diagnosis. The survival was worse in women aged between 30 and 39 years and between 80 and 89 years. No significant differences were observed in survival in relation to the interval from first symptoms to diagnosis. The survival at 5 years shows some trend towards improvement during the period between 1979 and 1986.

Estrogen receptors (ER) in human breast cancer. The significance of a new prognostic factor based on both ER protein and ER mRNA contents

BACKGROUND

The response to endocrine therapy is not entirely predictable from the estrogen receptor (ER) and progesterone receptor (PgR) status of primary breast tumors. The authors previously proposed a new prognostic factor, ER.R, which was based on both ER protein and mRNA levels. A previous analysis of 88 primary breast carcinomas showed that ER.R permits the identification of a subset of ER-positive women with a higher risk of early relapse. The purpose of the present study was to confirm the prognostic significance of ER.R.

METHODS

Estrogen receptor protein levels were determined for 171 patients with primary breast cancer either by radio-ligand binding assay (ER-LBA) or enzyme immunoassay (ER-EIA). Estrogen receptor, pS2, and c-erbB-2 mRNA were measured by Northern blot analysis.

RESULTS

ER.R factor is determined by calculating the ratio of the values (ER protein in fentomoles per milligram of total proteins) to (ER mRNA in picograms per 4 micrograms of total RNA). A cutoff value of 1.5 (protein levels measured by ER-LBA) or 3 (protein levels measured by ER-EIA) discriminate the two ER.R1 (lower ratio) and ER.R2 (higher ratio) subgroups, which present a significantly lower and higher risk of early relapse, respectively. No association was found between ER.R status and either PgR status or c-erbB-2 and pS2 expression. According to a Cox multivariate analysis for disease free survival, the two stronger factors in predicting a poor prognosis were c-erbB-2 overexpression and ER.R2. In the present analysis, ER.R2 was a stronger predictor of recurrence than was ER negativity.

CONCLUSIONS

In accordance with the authors' first published data, the analysis of a larger population with a longer follow-up showed that ER.R2 keeps its significance to predict a poorer outcome for a patient, regardless of which assay was used to quantify ER.

pTNM Stage Distribution in Breast Cancer: A Population-Based Survey in Northern Italy

Aims and background

The role of distribution by stage at diagnosis in breast cancer has been considered in many studies, with particular regard to evaluation of prognosis, impact of screening programs and quality of care. Nevertheless, international comparisons of descriptive data can be hampered by lack of homogeneity in staging methods. The TNM is presently the most common staging system used all over the world, although some criticism have been raised recently against its pragmatic value. The present study reports a population-based survey of pathologic TNM distribution in incident cases of female breast cancer in the Verona province, a geographical area of northern Italy covered by cancer registration.

Methods

All histologically proven incident cases of breast cancer were identified in the study period 1988-1990 and classified as for tumor size and nodal involvement according to the pathological TNM criteria. The type of surgical treatment was also registered for all cases diagnosed in 1990.

Results

one thousand two hundreds and fifty-four invasive and in situ breast cancers were observed and pT1 cases accounted for 44.4%. Nodal involvement was present in 41.5% of invasive cancers. A surgical treatment was performed in 1213 patients (96.7%). Axillary dissection was reported in 1080 cases, 820 of them (76.6%) having 10 or more lymph nodes examined. Radical mastectomy accounted for 74% of the 458 breast cancers diagnosed in 1990 and 31.6% of the eligible cases were conservatively treated.

Conclusions

Cancer registries should be encouraged to report data on stage distribution in breast cancer (and in other malignancies). This practice could improve international comparisons and give an essential contribution to studies on survival, screening programs and quality of care.

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.