Comparison of extent of disease and morphometric and DNA flow cytometric prognostic factors in invasive ductal breast cancer

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.

Screen-detected breast cancers have a lower mitotic activity index

We know that screening for breast cancer leads to detection of smaller tumours with less lymph node metastases. Could it be possible that the decrease in mortality after screening is not only caused by this earlier stage, but also by a different mitotic activity index (MAI) of the tumours that are detected by screening? Is MAI a prognostic factor for recurrence-free survival? A retrospective study was carried out of 387 patients with breast cancer, treated at the University Hospital Nijmegen between January 1992 and September 1997. Ninety patients had screen-detected breast cancer, 297 patients had breast cancers detected outside the screening programme. The MAI, other prognostic factors and recurrence-free survival were determined. In non-screen-detected tumours the MAI is twice as high as in screen-detected tumours, even after correction for age took place. The MAI correlated well with other tumour characteristics. The MAI in itself is a prognostic factor for recurrence-free survival. Favourable outcome in screen detected breast cancer is not entirely caused by detecting cancer in early stages: quantitative features such as the MAI indicate a less malignant character of screen detected breast cancer. The MAI is an independent prognostic factor for recurrence-free survival.

Interlaboratory reproducibility of semiautomated cell cycle analysis of flow cytometry DNA-histograms obtained from fresh material of 1,295 breast cancer cases

Conflicting prognostic results have been published as to the DNA variables, such as DNA ploidy, DNA index, and % S-phase cells for breast cancer patients. These variables can be obtained by interpreting DNA histograms by cell cycle analysis. Explanations for these conflicting results might be found on the level of the interpretation of the DNA histograms. In a previous study, the semi automated cell cycle analysis computer program MultiCycle (Phoenix Flow Systems, San Diego, CA) showed high intralaboratory reproducibility. However, what types of DNA histograms may cause disagreements was still unclear. The aim of this study was to determine the interlaboratory reproducibility of MultiCycle-based cell cycle analysis of 1,295 flow cytometric DNA histograms derived from fresh frozen breast cancer material and to clarify potential sources of interobserver variation when analyzing DNA histograms. DNA ploidy classification into diploid, hyperdiploid, tetraploid, hypertetraploid, and multiploid showed an interlaboratory agreement of 94% (kappa value = 0.92). The 6% discrepancies (n = 74) were caused by tetraploid peaks, as established in one laboratory, which shifted outside the tetraploid region on reanalysis by the other laboratory (37%), shoulders sometimes interpreted as peaks (24%), small peaks not always recognized as such (24%), fitting failures (10%), and overlooking of tetraploid peaks (5%). Furthermore, the cell cycle analysis variables showed variable reproducibility. The % S-phase cells of the first, second, and third cell cycle showed overall a moderate reproducibility (0.62 < or = R < or = 0.79), but the average % S-phase cells and the average aneuploid % S-phase cells were more reproducible with correlation coefficients of 0.89 and 0.81, respectively. The coefficient of variation of the G0/G1 peak of the first cell cycle, the DNA indices and the % diploid cells were highly reproducible (R > or = 0.94), and the % G2/M-phase cells of the first, second, and third cell cycle were poorly reproducible (0.22 < or = R < or = 0.68). When a cut-point was used at the mean value of 7% for the average % S-phase cells, the number of "threshold discrepancy cases" was 6%. Sources of variation for cell cycle analysis were variations in the debris correction procedures, disagreement about the modes of the aneuploid peaks, disagreement about small peaks, shoulders sometimes interpreted as peaks, and overlooking of tetraploid peaks.

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.

Comparison of the prognostic value of four methods to assess mitotic activity in 186 invasive breast cancer patients: classical and random mitotic activity assessments with correction for volume percentage of epithelium

Proliferation markers and especially the Mitotic Activity Index (MAI) are strong and reproducible prognosticators in invasive breast cancer. Traditionally, the MAI has been defined as the total number of mitoses counted in 10 consecutive high-power fields (objective, x40; numeric aperture, .75; field diameter, 450 microns), in the most cellular area at the periphery of the tumor, with the subjectively highest mitotic activity. No correction for epithelial percentage or cellularity was applied. This study investigates whether the prognostic value of mitotic activity could be improved by a random sampling procedure or correction for percentage of epithelium present. For this purpose the prognostic value of four methods used to assess mitotic activity in invasive breast cancer was compared in 4-microns-thick hematoxylin-eosin (H&E)-stained sections of 186 primary invasive breast cancer patients. These were the MAI, the random MAI (rMAI), the Mitosis per Volume (M/V) Index, and the random M/V Index (rM/V Index). The rMAI was defined as the total number of mitotic figures counted in 10 random fields through the whole outlined tumor at x400 magnification. A correction for the volume percentage of epithelium assessed with stereology yielded the M/V Index and the rM/V Index, respectively. The results of all four methods showed moderate to high correlations. Univariate survival analysis (Kaplan-Meier curves; Mantel-Cox test) confirmed that all four methods had a strong prognostic value (P < .001). The MAI, however, produced the best results (Mantel-Cox value, 17.1). Multivariate analysis showed that all four methods had additional prognostic value to tumor size and lymph node status. The M/V Index provided most additional prognostic information, followed by the MAI. Assessment of rMAI took 20 to 30 minutes on average, about two times longer than MAI. The correction for volume percentage of epithelium took about 10 minutes longer for both methods than the uncorrected methods. In conclusion, the rMAI gives an impression of the mitotic activity through the whole tumor, with almost similar prognostic value as the traditional MAI, especially when correcting for percentage of epithelium. Nevertheless, the MAI is still to be preferred, because the assessment is easy to apply and less time consuming.

At convenience and systematic random sampling: effects on the prognostic value of nuclear area assessments in breast cancer patients

This study compares the influence of two different nuclear sampling methods on the prognostic value of assessments of mean and standard deviation of nuclear area (MNA, SDNA) in 191 consecutive invasive breast cancer patients with long term follow up. The first sampling method used was 'at convenience' sampling (ACS); the second, systematic random sampling (SRS). Both sampling methods were tested with a sample size of 50 nuclei (ACS-50 and SRS-50). To determine whether, besides the sampling methods, sample size had impact on prognostic value as well, the SRS method was also tested using a sample size of 100 nuclei (SRS-100). SDNA values were systematically lower for ACS, obviously due to (unconsciously) not including small and large nuclei. Testing prognostic value of a series of cut off points, MNA and SDNA values assessed by the SRS method were prognostically significantly stronger than the values obtained by the ACS method. This was confirmed in Cox regression analysis. For the MNA, the Mantel-Cox p-values from SRS-50 and SRS-100 measurements were not significantly different. However, for the SDNA, SRS-100 yielded significantly lower p-values than SRS-50. In conclusion, compared with the 'at convenience' nuclear sampling method, systematic random sampling of nuclei is not only superior with respect to reproducibility of results, but also provides a better prognostic value in patients with invasive breast cancer.

Quantitative cellular and nuclear volumetric alterations in epithelium from lichen planus lesions of human buccal mucosa

Patients with oral lichen planus lesions may represent a relatively high risk population for subsequent development of oral cancer. Little is known of the relative effects of chronic inflammation and the process of malignant transformation itself on the histological structure of transforming epithelia. We have assessed cellular and nuclear volumes in defined basal and spinous cells from normal buccal mucosa epithelium, from epithelium associated with a non-specific chronic inflammatory infiltrate and from lichen planus lesions. Normal (N) tissues were obtained from the margins of non-neoplastic buccal mucosa lesions. Inflammatory (INF) lesions were from areas of the buccal mucosa diagnosed clinically as traumatic irritation without ulceration, and lichen planus (LI) lesions were biopsied from areas exhibiting Wickham's striae. Basal and spinous epithelial cells from normal and pathological human buccal mucosa were measured on haematoxylin and eosin-stained sections imaged through a video camera using a Zeiss VIDAS analyser and from these measurements, nuclear (VN) and cellular (VCELL) volumes were determined. VN and VCELL derived for both basal and spinous strata were similar in N and INF groups but were almost doubled in the LI group. Comparisons between LI and all other groups were significantly elevated. The effects of the inflammatory infiltrate on the oral epithelium in lichen planus and in non-specific inflammation thus differ significantly. VN and VCELL may serve as potential discriminators between benign lesions and premalignant lichen planus.

DNA ploidy, S-phase, and steroid receptors in more than 127,000 breast cancer patients

Several potential prognostic factors are available today for patients with breast cancer, and many more are being identified and studied. To evaluate the clinical utility of these factors, it will be necessary to measure them on a large number of patients, and then follow these patients so that multivariate survival analyses can be performed. The Oncology Research Network was established in 1986 by the University of Texas Health Science Center at San Antonio and Nichols Institute Reference Laboratories in order to evaluate the clinical utility of new prognostic factors for patients with primary breast cancer. The first generation of prognostic factors included steroid receptors, along with DNA ploidy and S-phase fraction determined by flow cytometry. Currently, laboratory results have been obtained from more than 127,000 patients, and follow-up information is available on a subset of more than 25,000 of these patients. S-phase fraction was related to the ploidy status of the tumor. An increased incidence of aneuploidy and higher S-phase fractions were found in estrogen and progesterone receptor negative tumors, tumors from patients with positive axillary lymph nodes, tumors greater than 2 cm in diameter, and patients younger than 35 years of age. Preliminary survival analyses suggest that S-phase fraction and DNA ploidy, in combination with other prognostic factors, are powerful predictors of early disease relapse. The Oncology Research Network provides an important resource for examining the clinical significance of new laboratory assays and for expediting improvements in existing laboratory techniques.

A retrospective study on the clinical and biological prediction of axillary lymph node metastasis in breast cancer

If axillary lymph node metastases were able to be accurately predicted, dissection could be avoided in some patients with breast cancer whose axillary nodes are clinically negative. In this study, we assessed the relationships between histological axillary lymph node metastases and clinical axillary nodal status, tumor size, DNA-ploidy, c-erbB-2 expression, and the score of the argyrophilic nucleolar organizer region. We then attempted to evaluate their predictive values for axillary lymph node metastasis in 173 patients with invasive breast cancer, retrospectively. The clinical and biological variables were significantly correlated with the presence and degree of axillary lymph node metastases. A metastatic index, calculated from the clinical and biological variables, proved especially useful for predicting axillary lymph node metastases in patients whose axillary nodes were clinically negative. However, the predictive abilities were still limited and thus it was concluded that as yet, only axillary dissection can provide accurate information on axillary lymph node metastases.

Risk of internal mammary lymph node metastases and its prognostic value in breast cancer patients

The risk of an internal mammary lymph node (IMN) metastasis and its prognostic value for patients with invasive breast cancer were assessed by evaluating 142 patients who had either a mastectomy with lymph node dissection or a biopsy of the IMN. By univariate analysis, overall survival significantly correlated with the patient's age, clinical axillary node status, tumor size, and DNA ploidy, as well as histologically confirmed axillary and IMN metastases. By multivariate analysis, however, only the presence of axillary and IMN metastases appeared to be an important independent factor affecting survival. However, the incidence of IMN metastases was associated significantly with age, clinical tumor and axillary node status, tumor size, axillary lymph node metastases, and DNA ploidy. Accordingly, the patient's age, tumor size, DNA ploidy, and axillary lymph node metastases proved to be effective variable for discrimination. Consequently, in predicting the presence of IMN metastases, a diagnostic accuracy of 82%, a sensitivity of 84%, and a specificity of 82% can be achieved by a discriminant function. We conclude that the discriminant function with these four variables is effective in assessing the risk of IMN metastases.

Clinical and biological prediction of axillary and internal mammary lymph node metastases in breast cancer

We assessed the relationships among histological axillary (AX) or internal mammary (IM) metastases and clinical and biological variables, and then attempted to evaluate their predictive values for AX and IM metastases in 128 patients with invasive breast cancer. As the results, these clinical and biological variables were significantly correlated with AX and IM metastases. However, a metastatic index calculated from clinical and biological variables was not much better in prediction of the AX metastases than axillary nodal status, whereas it was useful to predict the IM metastases. Thus, the predictive ability was still limited. Since accurate prediction of AX and IM metastases is critical to therapeutic choice, however, further study would be required.

DNA ploidy and helix pomatia lectin binding as predictors of regional lymph node metastases and prognostic factors in breast cancer

This study was designed to evaluate whether DNA ploidy and/or Helix pomatia lectin (HPA) staining would be useful for predicting regional lymph node metastases and patients' prognosis in 106 patients with invasive breast cancer. The combination of DNA ploidy and HPA staining correlated better with regional lymph node metastases than DNA aneuploidy or HPA staining alone. DNA ploidy and HPA staining in combination correlated strongly with overall and disease-free survival by univariate analysis. However, the prognostic significance of DNA ploidy and HPA staining in combination was lost in multivariate analysis when regional lymph node metastases were introduced into the models. This emphasized the relationship in survival between regional lymph node metastases and the combination of DNA ploidy and HPA staining. We therefore concluded that the combination of DNA ploidy and HPA staining might provide prognostic information for breast cancer patients in whom regional lymph node dissection has not been performed.

Grade and flow cytometric analysis of ploidy for infiltrating ductal carcinomas

Although many studies have found that ploidy as determined by flow cytometry correlates with grade for invasive mammary carcinomas, only a few groups of investigators have evaluated ploidy for infiltrating ductal carcinomas exclusively. In this study ploidy, as analyzed in fresh tumor specimens, was compared with grade (using the Bloom and Richardson grading scheme modified by Elston and Ellis) and each of its three components (tubule formation, nuclear pleomorphism, and mitotic rate) for 118 infiltrating ductal carcinomas. Two thirds of the neoplasms were DNA aneuploid, including 4% that were hypodiploid, 14% that were tetraploid, 8% that were hypertetraploid, and 12% that were multiploid. Ploidy correlated with nuclear pleomorphism (P = .004), mitotic rate (P = .001), and grade (P = .0007), but not with tubule formation (P = .09). Forty percent of grade I, 71% of grade II, and 83% of grade III neoplasms were DNA aneuploid. Ploidy was also compared with the results of combining nuclear pleomorphism with mitotic rate to form a five-part modified Bloom and Richardson scheme (MBRS grades I to V). The frequencies of DNA aneuploidy for tumors that were MBRS grades I, II, III, IV, and V were 25%, 65%, 66%, 73%, and 89%. This relationship was significant (P = .0006). When MBRS grades II, III, and IV neoplasms were combined and compared with MBRS grade I tumors and MBRS grade V carcinomas, the differences in frequency of DNA aneuploidy among these three groups also were significant (P = .00007). These results show that ploidy correlates with the grade of infiltrating ductal carcinoma and that nuclear pleomorphism and mitotic rate are more important than tubule formation for predicting the likelihood of DNA aneuploidy.

Cytogenetics, flow cytometry, cytophotometry and morphometry of 22 cases of primary breast carcinoma. A comparative study

Cytogenetic, flow cytometric, cytophotometric and morphometric analyses were performed on 22 previously untreated, primary solid breast carcinomas. Although the cell nuclei as the primary object of these studies were the same in all the tumors, distinct features were evaluated in each case to determine to what degree the results obtained by these techniques are comparable. From the cytogenetic viewpoint, six tumors had a modal number in the diploid range, seven were in the triploid range, and two in the tetraploid range; seven tumors had no modal number. These data correlate with the flow cytometry and cytophotometry results obtained, with DNA values slightly higher than their respective chromosomal modes. However, no correspondence between chromosomal modes and mean nuclear area was found. Chromosomal markers have been identified that particularly affect chromosomes 1 (p11, q21-qter), 11 and 16, although no common markers existed in all cases. Cytogenetics is the most sensitive technique, but the low yield (22 out of 140 tumors assayed) considerably restricts its value in any prospective breast cancer study.

The relationship between lymph node metastases and DNA-ploidy status as prognostic factors in invasive breast cancer

We evaluated the relationship between the regional lymph node metastases and the DNA ploidy status in 207 patients with invasive breast cancer, as well as their prognostic values in estimating the prognosis of breast cancer. A significantly higher incidence of aneuploidy was found in patients with a large T3 or T4 tumor, a positive axillary lymph node status, more than 4 positive axillary lymph nodes or positive internal mammary lymph nodes. In a univariate study, the overall survival was significantly correlated with tumor size, axillary lymph node status, axillary and internal mammary lymph node metastases, and DNA ploidy status. In the multivariate analysis, however, only axillary and internal mammary lymph node metastases were recognized as important independent prognostic factors on survival. In this series, the DNA ploidy status did not appear to be an independent prognostic factor either in the entire series or in negative axillary node patients, since it was closely correlated with the axillary or internal mammary lymph node metastases, and the axillary node negative patients had an extremely favorable prognosis.

Reappraisal of internal mammary node metastases as a prognostic factor in patients with breast cancer

Clinical, histologic, and biologic prognostic factors were examined in 144 patients with invasive breast cancer. It was determined whether variable prognostic factors, especially internal mammary lymph node metastases, would serve as a basis for the prognosis of breast cancer. In a univariate study, overall survival was significantly correlated with tumor size, axillary lymph node status, axillary and internal mammary lymph node metastases, and DNA ploidy status. Especially among patients with one to three positive axillary nodes, survival in case of internal mammary involvement were significantly lower than without internal mammary involvement. In a multivariate study, only axillary and internal mammary lymph node metastases were recognized as important, independent prognostic factors of survival, but neither axillary lymph node status nor DNA ploidy status appeared as important prognostic factors. It was concluded that internal mammary lymph node metastases is additional prognostic factor, especially in patients with one to three positive axillary nodes. Because axillary and internal mammary lymph node metastases could not be predicted from their clinical assessment, axillary lymph node dissection and biopsy of internal mammary nodes may be a useful staging procedure for these patients.

Should all patients with node-negative breast cancer receive adjuvant therapy? Identifying additional subsets of low-risk patients who are highly curable by surgery alone

This study, which used combined first-generation prognostic factors (tumor size, histologic differentiation, and age) on 408 patients with axillary node-negative (ANN) breast cancer treated by surgery alone without systemic adjuvant therapy between 1976 and 1987 at the Roswell Park Cancer Institute, discerned four subsets of low-risk patients with a 7-year relapse rate of 6% or better. The first subset consisted of 48 patients (12% of the population) with tumors 1 cm or less in diameter that were well or moderately differentiated. These patients had a disease-free rate (DFR) of 100% (95% confidence interval [CI], 94% to 100%). The second subset consisted of 35 patients (9% of the population) with tumors less than or equal to 1 cm that were poorly differentiated or anaplastic. These patients older than 50 years of age had a DFR of 97% (95% CI, 91% to 100%). The third subset consisted of 36 patients (9% of the population) with tumors 1.1 to 2 cm that were well or moderately differentiated. These patients were older than 50 years of age and had a DFR of 94% (95% CI, 85% to 100%). The fourth subset consisted of 36 patients with ductal carcinoma in situ with microscopic invasion. These patients had a DFR of 100% (95% CI, 87% to 100%). Twenty-two of these patients, not in the other subsets mentioned, comprised 5% of the total population. These patients at low risk of recurrence, who comprise one third of the entire node-negative population, are highly curable by local therapy alone and may be spared the risks and costs of routine adjuvant systemic therapy (AST). Patients with tumors larger than 2 cm (152 patients; 37% of the population) are at high risk of recurrence (26% with a DFR of 74% [95% CI, 64% to 84%]) and should routinely receive systemic adjuvant therapy. Patients with tumors up to 2 cm who are not in the low-risk groups fall in a gray area (recurrence, 15% to 21%; DFR, 79% to 85%). For these groups, combining second-generation prognostic factors such as DNA ploidy, S-phase fraction, or cathepsin D should give the physician additional information to aid in making decisions regarding adjuvant therapy.

Lymph node metastases versus DNA ploidy as prognostic factors for invasive ductal carcinoma of the breast

We evaluated the relationship between the DNA ploidy status and other variable prognostic factors, especially regional lymph node metastases, in 121 patients with invasive ductal carcinoma of breast, together with the value of these factors in estimating the prognostic of breast cancer. The ploidy status was diploid in 40% of the patients, and aneuploid in 60%. A significantly higher incidence of aneuploidy was found in patients with more than 4 positive axillary lymph nodes, positive internal mammary lymph nodes, or clinical stage 3 of malignancy. In a univariate study, overall survival and disease-free survival were significantly correlated with axillary and internal mammary lymph node metastases, tumor size, and clinical stage of malignancy. The disease-free survival rates for the diploid group tended to be somewhat higher than those for the aneuploid group of patients without axillary lymph node metastases. In the multivariate analysis, however, only axillary lymph node metastasis was significantly correlated with overall survival and disease-free survival. There was also a trend for the internal mammary lymph node metastases to be correlated with survival. As the DNA ploidy status was closely correlated with the axillary and internal mammary lymph node metastases, it did not appear to be an independent prognostic factor in this small series.

Prognostic value of proliferative activity in lymph node metastases of patients with breast cancer

Whether the proliferative activity of distant metastases could be predicted by the proliferation in axillary lymph node metastases was investigated in 304 lymph nodes metastases of 52 patients with breast cancer who had not received adjuvant treatment. The standard deviation of the mean mitotic index (MI)--the average number of mitoses per field in 10 high power fields--was of the best prognostic valve in univariate survival analysis. None of the classic (volume % epithelium and stroma) or morphometric features (nuclear area, nuclear axis ratio. shape factors) provided significant results. In Cox regression analysis a multivariate combination of the mean MI, the SD of the mean MI, and the maximum MI emerged, which provided a satisfying means of differentiating patients with a good (68% survival) and a poor (28% survival) prognosis. Proliferation variables derived from axillary lymph node metastases of patients with breast cancer can predict the clinical course of distant metastases.

The morphometric prognostic index is the strongest prognosticator in premenopausal lymph node-negative and lymph node-positive breast cancer patients

Earlier studies on breast cancer have shown the strong prognostic value of morphometric parameters (especially the morphometric prognostic index [MPI]) in comparison with clinical and classical pathologic parameters. It remained to be proven whether the prognostic value of the MPI holds for the subgroup of premenopausal patients. We have therefore investigated the value of different prognosticators in a group of 211 premenopausal breast cancer patients with long-term follow-up, 121 cases being lymph node-negative and 90 cases being lymph node-positive. The MPI, a multivariate combination of the mitotic activity index (MAI), lymph node status, and tumor size, was the best combined prognosticator (P less than .0001), exceeding the prognostic value of MAI, lymph node status, and tumor size as individual parameters and as indicators of histologic grade. Of all the features studied, the MPI had the best prognostic value in the lymph node-negative patients, while the MAI and MPI had the best prognostic value in the lymph node-positive patients. Since the MPI has been shown to be reproducible in intra- and interlaboratory studies and can be assessed with standard equipment in routine histologic sections, it is an attractive indicator for selecting high-risk lymph node-negative patients for systemic adjuvant therapy trials.

Is DNA ploidy an independent prognostic indicator in infiltrative node-negative breast adenocarcinoma?

To evaluate DNA content as an independent, long-term prognostic indicator in infiltrative, node-negative adenocarcinoma of the breast, flow cytometric DNA analyses were performed retrospectively in 165 patients. The exclusive use of paraffin-embedded tissue permitted the study of patients for whom 3 to 15 years' follow-up was available. Other investigators have shown a relationship between DNA nuclear content and well-known prognostic indicators of breast carcinoma, such as estrogen receptors, age, menopausal status, and stage of tumor. However, very few of these studies were based on patients with long-term clinical follow-up and investigated the independent prognostic value of DNA nuclear content. The frequency of aneuploidy in the patients in this study was 57%, with DNA indices ranging from 0.73 to 2.59. Survival in patients with localized breast carcinoma with DNA aneuploid tumors was 84.1% at 5 years and 75.5% at 10 years. Those with diploid tumors showed survival of 87.8% at 5 years and 73.4% at 10 years. These data show no independent prognostic value for DNA nuclear content. The relationship between DNA content, tumor histologic type, and age was also investigated. High-grade tumors were more often aneuploid. There was no association between DNA content and age. Of 165 patients, information regarding estrogen receptor status was available in only 77; 45% of those with aneuploid tumors and 35% with diploid tumors were estrogen receptor-negative. This difference was not significant. The authors conclude that simple determination of DNA ploidy fails to indicate prognosis for infiltrative, node-negative breast carcinoma.

Ploidy, proliferative activity and prognosis. DNA flow cytometry of solid tumors

Flow cytometric study has been used to measure the cellular DNA content of solid tumors for the last decade, and of paraffin-embedded tumor specimens for the last 5 years. Ploidy and proliferative activity are the two properties commonly measured by DNA content flow cytometric study. The ability to study archival, paraffin-embedded tumors has hastened an appreciation of the prognostic utility of this assay. Either abnormal ploidy or elevated proliferative activity predict a worsened disease-free or overall survival in most common adult malignancies. Both abnormalities are associated with poor outcome in locoregional breast, non-small cell lung, and colorectal cancers, and in all stages of ovarian cancer. Abnormal ploidy is also a dire prognostic indicator for cancers arising from the kidney, bladder, prostate, and endometrium. Clinical management of patients with these diseases may be aided by studying their tumors for these objective markers of biological aggressiveness.

The Multicenter Morphometric Mammary Carcinoma Project (MMMCP). A nationwide prospective study on reproducibility and prognostic power of routine quantitative assessments in The Netherlands

The Multicenter Morphometric Mammary Carcinoma Project (MMMCP) has been set up to investigate prospectively the prognostic value and reproducibility of routine assessments of the morphometric Multivariate Prognostic Index (MPI) and other quantitative parameters in comparison with classical prognosticators and steroid receptors in breast cancer patients. In this project, 34 hospitals participate, divided over six geographically different regions. Of each patient entering in the study, multiple clinical and classical pathological parameters (including tumor size and lymph node status) as well as several quantitative parameters such as mean nuclear area, DNA index and mitotic activity index will be evaluated. Of all patients, the MPI will be assessed with tumour size, lymph node status and mitotic activity index. The quantitative assessments are performed in all consecutive breast cancers which enter the participating pathology laboratories, and all measurements are controlled in Amsterdam. The patient intake time will be from January 1, 1988 until January 1, 1990. It is expected that 3000 patients will enter in this study. Follow up data will be gathered up to 10 years. However, two to five years after the initiation of the Project, a first evaluation of the reproducibility and prognostic significance of routine MPI and other assessments in breast cancer patients will be possible. A detailed description of this project is given.

Flow cytometric analysis of nuclear DNA content in esophageal cancer. Aneuploidy as an index for highly malignant potential

Flow cytometric analysis of nuclear DNA content was performed on excised malignant tissue of the esophagus. The DNA ploidy pattern was compared with a variety of histologic parameters and the subsequent clinical course to determine whether or not this pattern is associated with the mode of malignant potentiality. Of the 31 patients, eight had the diploidy DNA pattern and 23 the aneuploid DNA pattern. Tumors with the aneuploidy DNA pattern had a significantly higher frequency of lymph node metastasis than did those with the diploidy DNA pattern (P less than 0.01). Mitotic rates in the aneuploid tumors were significantly higher than was the case in diploid tumors (P less than 0.0005). The incidence of recurrence within 12 months after surgery was higher in patients with aneuploid tumors (83.3%) than in those with diploid ones (16.7%), with a statistical difference (P less than 0.05). Thus, the DNA aneuploidy based on flow cytometry closely correlates with the high frequency of nodal involvement and high mitotic rates, factors generally indicative of the aggressive behavior of the malignant tumors. DNA aneuploidy based on flow cytometric analysis is a pertinent index for determining the highly malignant potential in esophageal carcinoma.

The Multivariate Prognostic Index and nuclear DNA content are independent prognostic factors in primary breast cancer patients

The predictive value of a previously described Multivariate Prognostic Index (which incorporates weighted values of the mitotic activity index, tumor size, and the axillary lymph node status), and the nuclear DNA content (DNA) was evaluated in 156 patients with primary invasive ductal breast cancer, diagnosed between 1980 and 1983. The results were analysed with respect to the occurrence of distant recurrence and survival of the patients after at least 3 yr of follow-up (range 36-73 months; median 44 months). Known prognostic factors such as lymph node status, tumor size, and the mitotic activity index correlated independently with distant recurrence. Furthermore, in respect to survival, the investigated prognostic factors (except DNA content) were significantly correlated. The results indicate that the predictive value of the Multivariate Prognostic Index (MPI) is stronger (P less than 0.001) than of the nuclear DNA content (P less than 0.005) with respect to distant recurrence. In a Cox multivariate regression analysis DNA ploidy turned out to be an independent prognostic factor once the MPI was selected. Furthermore, in Cox's analysis, DNA ploidy was the fourth selected variable after lymph node status, mitotic activity index, and tumor size in individual parameter analysis. The results of this study indicate that, with respect to breast cancer screening programs, it seems worthwhile to integrate morphometric features, the MPI, and DNA ploidy in a new prognostic model.