A single N-terminal amino acid determines the distinct roles of histones H3 and H3.3 in the Drosophila male germline stem cell lineage

Adult stem cells undergo asymmetric cell divisions to produce 2 daughter cells with distinct cell fates: one capable of self-renewal and the other committed for differentiation. Misregulation of this delicate balance can lead to cancer and tissue degeneration. During asymmetric division of Drosophila male germline stem cells (GSCs), preexisting (old) and newly synthesized histone H3 are differentially segregated, whereas old and new histone variant H3.3 are more equally inherited. However, what underlies these distinct inheritance patterns remains unknown. Here, we report that the N-terminal tails of H3 and H3.3 are critical for their inheritance patterns, as well as GSC maintenance and proper differentiation. H3 and H3.3 differ at the 31st position in their N-termini with Alanine for H3 and Serine for H3.3. By swapping these 2 amino acids, we generated 2 mutant histones (i.e., H3A31S and H3.3S31A). Upon expressing them in the early-stage germline, we identified opposing phenotypes: overpopulation of early-stage germ cells in the H3A31S-expressing testes and significant germ cell loss in testes expressing the H3.3S31A. Asymmetric H3 inheritance is disrupted in the H3A31S-expressing GSCs, due to misincorporation of old histones between sister chromatids during DNA replication. Furthermore, H3.3S31A mutation accelerates old histone turnover in the GSCs. Finally, using a modified Chromatin Immunocleavage assay on early-stage germ cells, we found that H3A31S has enhanced occupancy at promoters and transcription starting sites compared with H3, while H3.3S31A is more enriched at transcriptionally silent intergenic regions compared to H3.3. Overall, these results suggest that the 31st amino acids for both H3 and H3.3 are critical for their proper genomic occupancy and function. Together, our findings indicate a critical role for the different amino acid composition of the N-terminal tails between H3 and H3.3 in an endogenous stem cell lineage and provide insights into the importance of proper histone inheritance in specifying cell fates and regulating cellular differentiation.

Asymmetric Histone Inheritance: Establishment, Recognition, and Execution

The discovery of biased histone inheritance in asymmetrically dividing Drosophila melanogaster male germline stem cells demonstrates one means to produce two distinct daughter cells with identical genetic material. This inspired further studies in different systems, which revealed that this phenomenon may be a widespread mechanism to introduce cellular diversity. While the extent of asymmetric histone inheritance could vary among systems, this phenomenon is proposed to occur in three steps: first, establishment of histone asymmetry between sister chromatids during DNA replication; second, recognition of sister chromatids carrying asymmetric histone information during mitosis; and third, execution of this asymmetry in the resulting daughter cells. By compiling the current knowledge from diverse eukaryotic systems, this review comprehensively details and compares known chromatin factors, mitotic machinery components, and cell cycle regulators that may contribute to each of these three steps. Also discussed are potential mechanisms that introduce and regulate variable histone inheritance modes and how these different modes may contribute to cell fate decisions in multicellular organisms.

Histone locus regulation by the Drosophila dosage compensation adaptor protein CLAMP

Rieder et al. report that conserved GA repeat cis elements within the bidirectional histone3–histone4 promoter direct histone locus body (HLB) formation in Drosophila. In addition, the CLAMP zinc finger protein binds these GA repeat motifs, increases chromatin accessibility, enhances histone gene transcription, and promotes HLB formation.

The conserved histone locus body (HLB) assembles prior to zygotic gene activation early during development and concentrates factors into a nuclear domain of coordinated histone gene regulation. Although HLBs form specifically at replication-dependent histone loci, the cis and trans factors that target HLB components to histone genes remained unknown. Here we report that conserved GA repeat cis elements within the bidirectional histone3–histone4 promoter direct HLB formation in Drosophila. In addition, the CLAMP (chromatin-linked adaptor for male-specific lethal [MSL] proteins) zinc finger protein binds these GA repeat motifs, increases chromatin accessibility, enhances histone gene transcription, and promotes HLB formation. We demonstrated previously that CLAMP also promotes the formation of another domain of coordinated gene regulation: the dosage-compensated male X chromosome. Therefore, CLAMP binding to GA repeat motifs promotes the formation of two distinct domains of coordinated gene activation located at different places in the genome.

The essential Drosophila CLAMP protein differentially regulates non-coding roX RNAs in male and females

Heterogametic species require chromosome-wide gene regulation to compensate for differences in sex chromosome gene dosage. In Drosophila melanogaster, transcriptional output from the single male X-chromosome is equalized to that of XX females by recruitment of the male-specific lethal (MSL) complex, which increases transcript levels of active genes 2-fold. The MSL complex contains several protein components and two non-coding RNA on the X ( roX) RNAs that are transcriptionally activated by the MSL complex. We previously discovered that targeting of the MSL complex to the X-chromosome is dependent on the chromatin-linked adapter for MSL proteins (CLAMP) zinc finger protein. To better understand CLAMP function, we used the CRISPR/Cas9 genome editing system to generate a frameshift mutation in the clamp gene that eliminates expression of the CLAMP protein. We found that clamp null females die at the third instar larval stage, while almost all clamp null males die at earlier developmental stages. Moreover, we found that in clamp null females roX gene expression is activated, whereas in clamp null males roX gene expression is reduced. Therefore, CLAMP regulates roX abundance in a sex-specific manner. Our results provide new insights into sex-specific gene regulation by an essential transcription factor.

Ceramic-on-polyethylene bearing surfaces in total hip arthroplasty. Seventeen to twenty-one-year results

BACKGROUND

Polyethylene wear debris, and the resulting inflammatory response leading to osteolysis and loosening, is the primary mode of failure limiting the longevity of total hip replacements. Alternative bearing surfaces, including ceramic-on-polyethylene, have been investigated in an effort to decrease the amount of polyethylene wear debris. The purpose of this study was to evaluate the seventeen to twenty-one-year results of the use of ceramic-on-polyethylene total hip prostheses.

METHODS

Sixty-four total hip prostheses were implanted with cement, by one surgeon, in fifty-six patients from 1978 to 1981. The average age at the index arthroplasty was sixty-nine years (range, fifty-one to eighty-four years). The components consisted of a cemented Charnley-Müller stem with a 32-mm modular alumina femoral head and a cemented all-polyethylene acetabular component. All patients who retained the index prosthesis were assessed clinically with use of Harris hip scores and were evaluated radiographically at the time of the latest follow-up.

RESULTS

At the time of this latest follow-up, of the original sixty-four implants, eighteen (28%) were still in place and five (8%) had been revised. The remaining forty-one implants were in patients who had died and were functioning well until the patient's death. No patient was lost to follow-up. Of the eighteen hips with an intact prosthesis in the surviving patients, seven had an excellent clinical result; nine, a good result; and two, a fair result. One asymptomatic hip had definite radiographic evidence of femoral loosening. No hip had definite signs of acetabular loosening or evidence of osteolysis. Survivorship analysis revealed that the probability of survival of the prostheses without revision was 95% at five years, 95% at ten years, 89% at fifteen years, and 79% at twenty years. The mean linear and volumetric polyethylene wear rates were 0.034 mm/yr and 28 mm(3)/yr, respectively. There were no fractures of the ceramic heads.

CONCLUSIONS

Outstanding long-term clinical and radiographic results were attained despite the use of what are now considered substandard techniques (an inferior stem design, a 32-mm head, and first-generation cementing techniques). The wear rates in this study are lower than previously reported metal-on-polyethylene wear rates and are consistent with the lowest reported in vivo ceramic-on-polyethylene wear rates. These findings support the consideration of ceramic-on-polyethylene bearing surfaces in total hip arthroplasty.

Emerging multiresistant strains: recommended precautions in the emergency room and surgical setting

The current success in treatment of surgical site infections may be jeopardized by the continued emergence of antibiotic resistance in bacteria common to these infections. The effectiveness of vancomycin against methicillin-resistant staphylococci may decrease as more cases of VISA emerge. No currently available antimicrobial is consistently effective against certain strains of VRE and the potential emergence of VRSA. Orthopaedic surgeons soon may be in the undesirable position of having to eradicate organisms resistant to all available antibiotics. Several new antibiotics show promising activity and may be useful against these multidrug-resistant bacteria. However, as the history of bacterial resistance has taught us, it likely only will be a matter of time until these organisms adapt mechanisms of resistance to these new drugs. The key then lies, as it always has, in preventive measures. Surgeons, and all physicians, must adhere to the precautionary guidelines recently set forth by the CDC and HICPAC. Chief among these guidelines is the elimination of inappropriate antibiotic usage, especially inappropriate vancomycin use.

Emerging antibiotic-resistant bacteria. Their treatment in total joint arthroplasty

Successful treatment of an infected total joint arthroplasty can be achieved in approximately 90% of cases. This outcome may be jeopardized by the emergence of antibiotic resistance in bacteria common to these infections. Staphylococci are the most frequently isolated bacteria in total joint infections, and the prevalence of antibiotic resistance in these organisms among all nosocomial and community-acquired infections has been increasing. As many as 46.7% of Staphylococcus aureus strains and 85.7% of coagulase-negative staphylococci strains are methicillin-resistant. Enterococci also are commonly isolated from infected total joint arthroplasties. The prevalence of vancomycin-resistant enterococci among all enterococci strains is estimated at 23%. As the prevalence of these resistant bacteria continues to increase among all infections, it is anticipated that they will be encountered more regularly in total joint infections. Knowledge of the mechanisms of resistance of these bacteria and currently available and newly developed antimicrobials is key to preventing the expansion of antimicrobial resistance and ensuring the future successful treatment of total joint infections.

Internal mammary node status: a major prognosticator in axillary node-negative breast cancer

BACKGROUND

The internal mammary lymph nodes (IMN) have received little attention in recent years, yet are a well-documented site of metastasis and a major prognostic factor in early-stage breast cancer.

METHODS/RESULTS

Ten-year follow-up of the final 195 patients treated by extended radical mastectomy (ERM) in this practice (selected largely on the basis of medial tumor location, and comprising 15% of all patients treated from 1965 to 1978) found IMN+ in 24% of all cases: 36% of AX+ versus 18% of AX- patients (p = 0.0023). In a multivariate analysis, the disease-free survival impact of IMN+ (p = 0.004) was second only to axillary node involvement (p < 0.0005), and surpassed tumor size (p = 0.077). IMN+ was equally frequent for tumors less than, or greater than, 2 cm (24%), and was not significantly related to patient age. Among AX- patients, there was a twofold greater risk of recurrence or death at 10 years for IMN+ than for IMN-. Among T1N0 patients, 19.6% were IMN+.

CONCLUSIONS

Failure to consider IMN status in the steadily enlarging cohort of T1N0 breast cancers may result in the undertreatment of a significant proportion of stage I patients. Systemic adjuvant therapy should be considered for T1N0 patients with central or medial tumors.

Have changing treatment patterns affected outcome for operable breast cancer? Ten-year follow-up in 1288 patients, 1965 to 1978

From 1965 to 1978, 1288 patients with primary operable breast cancer were treated by the senior author, using extended radical (ERM), radical (RM), and modified radical (MRM) mastectomy operations exclusively. Results were analyzed for trends in overall and disease-free survival, and patterns of local and distant relapse, the years 1965 to 1970 versus 1971 to 1974 versus 1975 to 1978. Significant changes (p less than 0.00001) from 1965 to 1978 included progressively earlier stage of disease, less frequent use of RM and ERM, a decline in the use of postoperative radiotherapy, and the introduction in 1975 of multidrug adjuvant chemotherapy. Ten-year disease-free survival rates improved significantly for all patients (by 11%, p = 0.00004) and for node-negative (by 12%, p = 0.0024), node-positive (by 8%, p = 0.012), clinical stage II (by 15%, p = 0.0022), and pathologic stage II (by 12%, p = 0.016) disease. Ten-year local recurrence for all patients was 3% (local only) and 2% (local with distant metastasis), and survival from date of recurrence for all patients failing treatment increased two times (p less than 0.0001) for patients treated most recently. As the primary surgical treatment of breast cancer continues to become more moderate, the promise of systemic adjuvant therapies can be realized only with continued emphasis on earlier diagnosis and maximal local control of disease.

Primary surgical treatment of breast cancer

An unexpected rise in breast cancer mortality has been reported for 1984 and 1985 in white women below 50 years of age in the United States. During the preceding 10 years, there had been a progressive drop of approximately 1% in breast cancer mortality for each successive year. This recent increase in mortality occurred despite the increased use of adjuvant chemotherapy; it is most likely a direct result of the current tendency to downgrade the need for adequate primary therapy. Several recent prospective randomized studies that evaluated the relative efficacy of mastectomies of varying extent have shown a direct relationship between local control and long-term survival. They also demonstrated that specific operative procedures were most effective for the appropriate clinicopathological stage of disease. Stage I cancers can be treated effectively by modified mastectomy, but radical mastectomy is superior for control of stage II and stage III disease. Inner-quadrant cancers are most effectively managed by extended radical mastectomy, which includes excision of the internal mammary nodes. Excellent surgical technique was employed in all studies, which included observed follow-up of 10-20 years. Optimal local control and long-term survival were achieved by the appropriate operative procedure.

Breast cancer 1985. What have we learned?

A popular misconception infers that all breast cancers are systemic from their inception, that variations of primary therapy will not affect prognosis, and that an effective systemic therapy is already available. This is not so. Moderate improvement in long-term survival of breast cancer patients has occurred during the last three decades, and particularly more recently, due to increased detection of "early" disease. More patients are being encountered with early Stage I lesions that are confined to the breast or with minimal axillary involvement. These patients have a minimal risk of occult systemic spread, and the majority can anticipate long-term disease-free survival through adequate primary therapy that achieves total local control. The great majority of our patients who are free of disease 15 years following aggressive primary therapy remain so thereafter. Although adjuvant multichemotherapy has prolonged disease-free survival, its effect on long-term patient survival has been marginal. Optimum control of breast cancer is achieved through early detection (most important) and aggressive primary therapy that aims to achieve total local control, plus the use of the best available systemic therapy for patients with high risk of occult systemic disease.

Rotter's node metastases. Therapeutic and prognostic considerations in early breast carcinoma

In 500 consecutive modified radical mastectomies (MRM) performed for clinically early (T1 N0) breast carcinomas between 1975 and 1982, the interpectoral lymph nodes (IPN) were separately sampled at the end of the operative procedure. Among the patients consistently sampled (1979-1982), lymph nodes were found in 73%. Interpectoral lymph node metastases were found in 2.6% of all patients, 3% of patients with infiltrating cancers, and 4% of patients sampled. A total of 8.2% of axillary node positive and 0.5% of axillary node negative patients had IPN disease. Among the 13 patients with positive IPN, there were no differences in tumor size or location from the entire group. The two patients whose only nodal metastases were to the IPN are currently disease-free without having received systemic adjuvant therapy. These data suggest that for early breast cancers treated by MRM, routine excision of the IPN is of potential therapeutic or prognostic benefit in very few cases. However, as MRM is increasingly applied to patients with more locally advanced disease (T2-3, N1b-N2), metastases in unexcised IPN may become a more significant source of local or systemic treatment failure.

Role of aspiration cytology in the diagnosis and management of mammary lesions in office practice

Sixteen hundred and eighty breast aspiration specimens obtained from 1410 patients seen in office practice were reviewed. The cytologic diagnosis was unsatisfactory in 230 cases, benign in 1019 cases, atypical in 198 cases, suspicious for malignancy in 102 cases, and malignant in 131 cases. All cases diagnosed as cytologically malignant had a subsequent tissue diagnosis of malignant neoplasm. Four percent of the cytologically benign cases and 17% of the cytologically atypical cases had malignant neoplasms. Clinical and cytologic examination detected more cancers (87%) than did clinical and mammographic examination (79%). Ninety-three percent of malignant neoplasms were detected by the combination of clinical, cytologic, and mammographic examination. Aspiration cytology significantly contributes to the clinical evaluation of mammary lesions in office practice, but it does not replace tissue biopsy or careful follow-up of mammary lesions of clinical concern. Proof of the presence of breast cancer by aspiration in the office may obviate the need for a two-stage procedure in the surgical management of breast cancer. Aspiration of minimally suspicious lesions often is helpful in initiating excisional biopsy in some occult, clinically unrecognized breast cancers.

Lobular carcinoma in situ of the breast: preliminary results of treatment by ipsilateral mastectomy and contralateral breast biopsy

This report describes the follow-up of 108 women who underwent ipsilateral mastectomy for lobular carcinoma in situ (LCIS). Twenty-four women found to have concurrent contralateral carcinoma underwent bilateral mastectomy. The contralateral breast was available for follow-up in the remaining 84 cases, including 33 patients who underwent contralateral biopsy and 51 others who did not have a biopsy of the opposite breast at the time of initial treatment. Five of these 84 patients later developed invasive cancer. Three had had a biopsy that revealed either atypia (two cases) or LCIS (one case). In the two other cases, there had not been a prior biopsy. Two of the 26 patients who had had a benign breast biopsy were found to have LCIS, but none subsequently had intraductal or invasive carcinoma, and none of the 26 women died of breast carcinoma. In this series, 64% of the women retained their contralateral breast; deaths due to contralateral breast carcinoma occurred with half the frequency that had been observed in a prior study of women with LCIS who did not have a contralateral biopsy. These results tend to support our current recommendation to treat LCIS by ipsilateral mastectomy and contralateral biopsy. However, it would be necessary to study these patients for approximately ten more years before results can be considered conclusive. Concurrently, prospective controlled investigations should be pursued to confirm these results, to identify patients most at risk in developing invasive carcinoma, and to determine whether nonsurgical therapy can modify the course of LCIS.

Surgical management of palpable breast cancer

The surgical treatment of primary breast cancer must cope with its multicentric origin, its occasional bilaterality, and its primary lymphatic drainage to the axillary and internal mammary nodes. The scope of the surgical procedure should correlate with the extent of disease in the individual patient with the primary aid of removing all disease present in these areas. We have used and continue to use three operative procedures--modified mastectomy (total mastectomy with thorough axillary dissection), radical mastectomy, and extended radical mastectomy. With this selected approach, we have attained a ten-year survival rate of 57% with a 4% local recurrence rate as the first sign of recurrent cancer--8.3% overall local recurrence rate--in a group of 515 patients with infiltrating cancer and 44% proven axillary nodal involvement treated between 1955 and 1964. This includes Stages I, II and III cases. These data are crude and uncorrected for age, intercurrent disease, and lost to follow-up. Forty-three percent of patients received adjuvant x-radiation therapy--4500 rads T.D. to the peripheral nodes. No chemotherapy was given. Similar local control and long term salvage has not been attained by conservative surgery with aggressive x-ray therapy. Long term follow-up--ten years at the minimum--with accurate information regarding extent of disease (nodal status), local recurrence, and survival rate is essential to evaluate the efficacy of a treatment regimen for primary breast cancer.

Mammography in symptomatic women 50 years of age and under, and those over 50

Our experience with the use of mammography as a diagnostic aid in symptomatic women with breast complaints has been presented. One-third of all cancers were found in women 50 years of age and under. The detection of cancer by mammography in the younger age group was similar to that experienced in the older age group. Radiation exposure by mammography has diminished markedly during the last 15 years--only one-third to one rad per exposure with modern technique. Recent hysterical criticism of the use of mammography in women under 50 years of age is unwarranted in the light of current findings. This diagnostic modality should be utilized when indicated in all age groups over 30. It is probable that screening clinics should include all women over 35 years of age.

The problem of carcinoma developing in a fibroadenoma: recent experience at Memorial Hospital

Fourteen new cases of unsuspected carcinoma developing in fibroadenomas are reported with a detailed analysis of their preoperative findings; histopathology, the results of varying surgical procedures and a three month to twenty-six year follow-up. The majority of lesions were lobular carcinoma in situ (71%) and 29% of all cases were found to have carcinoma of the contralateral breast. Our study suggests that for invasive carcinoma within a fibroadenoma complete mastectomy is warranted in virtually all instances while noninvasive disease treated by complete mastectomy is essentially curative. Contralateral breast biopsy at the time of diagnosis with a careful life-time follow-up are appropriate because of the high risk of contralateral invasive coarcinoma. There seemed to be no evidence of striking or unusual epithelial hyperplasia in the breast tissue adjacent to fibroadenomas that contained carcinoma suggesting that the carcinomas are not intrinsically different from those not related to fibroadenomas.

Management of operable breast cancer: the surgeon's view

There is no ideal single operation for breast cancer. In planning the choice of surgery for breast cancer, one must be aware of its multicentric origin, and of the regional spread from the breast to the axillary and internal mammary lymph nodes. The scope of the surgical attack should be correlated with the clinical pathologic extent of disease in the individual patient with the aim of removing all disease present, while preserving appearance and function to the utmost. The main goal remains removal of all disease from the breast and its regional nodes. Three distinct operative procedures have been utilized--modified radical mastectomy--total mastectomy with axillary dissection, radical mastectomy, and extended radical mastectomy. In all instances, the appropriate operation is applied to the individual, with the concept of removing most efficiently all disease present in the breast and regional nodes. With this plan of therapy, a 10 year survival rate of 61% with a local recurrence rat of 7.7% has been attained in a group of 565 patients with 40% axillary node involvement. These data are crude and uncorrected for age, intercurrent disease and for those lost to follow-up. The best salvage has been attained in the so-called "minimal" breast cancers--95% well 10 years following modified radical mastectomy. The extended radical mastectomy has been superior to the radical mastectomy when axillary node disease is present. In the more complete operation, 54% 10 year survival has been attained in patients with axillary node metastases, compared with only 33% attained in those treated by the conventional radical mastectomy. Adjuvant radiation therapy is applied to the adjacent regional nodes, when indicated. Adjuvant multi-chemotherapy is in its infancy and still to be evaluated. It should be used as a supplement to adequate primary surgical treatment, and should not be used as a crutch for inadequate primary surgery.

Barr body distribution and estrogen receptor protein in mammary carcinoma

The study was undertaken to investigate the relationship between Barr body distribution and estrogen receptor protein content of mammary carcinoma. The proportion of cells with one or more Barr body was determined in 105 specimens of mammary carcinoma from Guard stained imprints. Receptor protein content of the specimen was measured by the dextran charcoal method and compared with histopathologic features of the carcinomas. Primary carcinomas with Barr bodies in more than 10 percent of tumor cells were more likely to have higher levels of receptor protein than those with a lower proportion of Barr body containing cells (P less than 0.005). The results obtained for primary carcinoma may explain why patients with carcinomas that have a high proportion of Barr body positive cells are more likely to respond to hormonal therapy. Furthermore, these observations, when correlated with other available data about ERP suggest that an X-chromosome is involved in the synthesis of and/or carries the locus of action for estrogen receptor protein.

Estrogen receptor protein (ERP) in multiple tumor specimens from individual patients with breast cancer

We have studied 29 patients from whom two or more spatially and temporally separate samples of breast carcinoma were obtained for ERP analysis. Differences in ERP were obtained in 24% of all cases studied. The greatest degree of variation was found when comparing a primary tumor with a subsequent metastasis (38%). Among eight patients with ERP negative (-) primary tumors, six had ERP (-) and two ERP positive (+) metastases. Among 11 patients with ERP (+) primaries eight had ERP (+) and three ERP (-) metastases. Variations were found in 20% of multiple nonsimultaneous metastases from individual patients. The difference in average interval between cases that did not show variation (9.6 months) and those that did vary (19.3 months) suggests that variation may be more likely to occur with later metastases. However, there was considerable overlap in the range of intervals. These findings underscore the need to biopsy readily accessible recurrences rather than to rely on the results of prior specimens. There was no apparent consistent relationship of these variations to age, site of specimen, interval between specimens or the histologic features of the tissues submitted for analysis. Two patients with an ERP (+) primary tumor had ERP (-) metastases after interval therapy. Similar variations were observed in patients who did not have interval therapy. The data do not perimit any definite conclusions as to the effect of chemotherapy or radiation on the ERP properties of mammary carcinoma.

Prognostic significance of tumor emboli in intramammary lymphatics in patients with mammary carcinoma

Approximately 20% of patients with invasive mammary carcinoma who do not have axillary metastases develop recurrent carcinoma within 10 years of initial therapy. There is clearly a need to identify those patients most likely to develop recurrences in this group since they may benefit from adjuvant therapy. This study was undertaken to evaluate the prognostic significance of intramammary lymphatic tumror emboli in patients with invasive breast carcinoma who did not have lymph node metastases. Twenty-three such patients treated in 1974 and 15 from 1964 were compared with matched groups of control patients who did not have lymphatic emboli. About 43% of patients with lymphatic emboli and 4% of those without emboli followed for 5 or more years in the 1964 group developed distant metastases (p less than 0.001). Local recurrences were found in only one study patient and one control in the entire series of 1964 and 1974 patients. The results suggest that among patients without axillary metastases, the finding of tumor cells in lymphatic spaces within the breast is associated with a substantial risk of distant metastases but not local recurrence.

A comparative study of some pathologic features of mammary carcinoma in Tokyo, Japan and New York, USA

Epidemiologic and clinical studies conducted in the past 15 years have demonstrated striking differences in the biology of mammary carcinoma among Japanese and American women living in their native countries. These variations have, in part, been related to some differences in the characteristics of the primary tumors between the two groups. As part of a collaborative study we have had an opportunity to compare the stage of disease and to examine and compare histological sections of patients with breast carcinoma treated in 1973-74 at the National Cancer Center Hospital (NCH) in Tokyo and in 1974 at the Memorial Hospital (MH) in New York. The former group consisted of 216 and the latter of 555 carcinomas. Fewer patients in each group had axillary metastases than reported in a prior study of patients treated at MSKCC and in Tokyo 20 to 30 years earlier. Negative axillary nodes were now found in 58% of the MH patients and in 63% of women treated at the NCH. The magnitude of improvement in stage relative to the prior report was similar in both groups. However, it would appear that the change occurred mainly from the mid-1950s to the 1960s in New York and approximately 10 years later in Tokyo. Results of this study confirming prior reports were: (1) higher frequency of colloid and of medullary carcinoma with lymphoid stroma and lesser frequency of lobular carcinoma in the Japanese patients; (2) more intense lymphoid infiltrate in and around primary tumors in Japanese women; (3) higher frequency of rounded or circumscribed tumors in Japanese women; and (4) the more frequent occurrence of intralymphatic tumor emboli within the breast in American women. The difference in the frequency of lobular carcinoma was less striking when comparison was limited to patients with unilateral carcinoma.

Immunobiology of operable breast cancer: an assessment of biologic risk by immunoparameters

The concept of whether immune function was related to risk of recurrence was examined in patients with operable breast cancer in whom careful clinical and pathologic staging had been performed. Patients were classified according to the risk of recurrence. The "low risk" group included patients with minimal breast cancer, noninfiltrating cancer, or infiltrating cancer less than 1 cm with negative nodes. The "high ridk" group included patients with lesions greater than 1 cm or who had greater than or equal to 4 nodal metastases or who had macrometastases at Level II or III (apex). In the "intermediate risk" group were patients with infiltrating cancer less than 1 cm or with less than 4 nodal metastases at I only. Immune reactivity was assessed by skin tests, by measurement of absolute lymphocyte count, T and B cells, lymphocyte stimulation by mitogens and a battery of common antigens, serum immunoglobulins and complement levels. There were 134 patients with operable breast cancer and 63 patients with benign breast lesions. The breast cancer patients showed minimal or no impairment of DNCB skin test. Only patients with nodal metastases showed a slight but not significant impairment of DNCB responses (80% were DNCB positive compared to 90% in the controls.) The lymphocyte responses to mitogens were normal in the breast cancer patients, but there was a significant depression of lymphocyte responses to certain recall antigens such as Candida albicans and E coli. The absolute lymphocyte count and the T cell counts were normal, but B cells bearing complement receptors were decreased and B cells bearing sufface immunoglobulins were increased in the breast cancer patients. Analysis of immune function according to the pathologic stage of disease "risk of recurrence" categories showed no correlation with skin tests or lymphocyte levels. A striking and paradoxical finding was the demonstration that patients with "low risk" cancer overall had markedly lower responses to the battery of stimulating mitogens and antigens than found in patients with "high risk" or "intermediate risk" disease. Only the lymphocyte responses to PHA showed a significant linear correlation with increasing pathologic stage or "risk of recurrence." Current evidence from this study suggests that PHA response is markedly influenced by the primary tumor burdenand thus indirectly reflects the risk of recurrence.

Correlation between estrogen receptor protein and carcinoembryonic antigen in normal and carcinomatous human breast tissue

We determined estrogen receptor protein and carcinoembryonic antigen in cytosols prepared from 189 human breast carcinoma tissues, 85 benign or normal breast biopsies, and 101 tissue specimens metastatic from breast carcinoma. Carcinoembryonic antigen was observed in 70% of the primary carcinomatous tissues, 15% of the benign or normal specimens, and 51% of the metastases. Ninety-six of the 189 primary carcinomatous specimens with increased concentrations of carcinoembryonic antigen were also positive for estrogen receptor protein, whereas 67 of the 72 benign or normal biopsies with low concentrations of carcinoembryonic antigen were also negative for estrogen receptor protein. All five fenign specimens with positive estrogen receptor protein and normal carcinoembryonic antigen concentrations were from fibroadenomas. The concordance between estrogen receptor protein and carcinoembryonic antigen in the primary carcinomatous tissue was 66%, in metastatic carcinoma 51%, and in benign and normal tissue 85%.

Correlation between estrogen receptor protein and carcinoembryonic antigen in normal and carcinomatous human breast tissue

We determined estrogen receptor protein and carcinoembryonic antigen in cytosols prepared from 189 human breast carcinoma tissues, 85 benign or normal breast biopsies, and 101 tissue specimens metastatic from breast carcinoma. Carcinoembryonic antigen was observed in 70% of the primary carcinomatous tissues, 15% of the benign or normal specimens, and 51% of the metastases. Ninety-six of the 189 primary carcinomatous specimens with increased concentrations of carcinoembryonic antigen were also positive for estrogen receptor protein, whereas 67 of the 72 benign or normal biopsies with low concentrations of carcinoembryonic antigen were also negative for estrogen receptor protein. All five fenign specimens with positive estrogen receptor protein and normal carcinoembryonic antigen concentrations were from fibroadenomas. The concordance between estrogen receptor protein and carcinoembryonic antigen in the primary carcinomatous tissue was 66%, in metastatic carcinoma 51%, and in benign and normal tissue 85%.

Breast cancer presenting as an axillary mass

Experience with breast cancer presenting as an axillary mass in 42 patients has been reviewed according to initial clinical findings, treatment and survival. In the absence of an obvious inflammatory lesion, an axillary node may prove to be the first sign of breast cancer. It has been demonstrated that such a node should be biopsied and if positive for adenocarcinoma, a radical mastectomy performed presuming other primary sites have been ruled out. The survival rate after surgery in this group of patients is better than in those who present with a palpable breast mass and have axillary metastases.

Estrogen receptor protein in lesions of the male breast: a preliminary report

Eleven specimens of breast lesions obtained from 10 male patients were analyzed for estrogen receptor protein (ERP). Three patients (ages 49, 77, 82 years) had infiltrating duct carcinomas with no axillary metastases. ERP in each of these was positive. Eight specimens with gynecomastia, one of which was obtained from the 77-year-old patient with carcinoma in the same breast, were also analyzed. Of these ERP was positive in a 59-year-old man who had cirrhosis of the liver; two patients with borderline ERP had hepatitis and testicular seminoma, respectively. No relationship between histopathologic features of the lesions and ERP results was found and it is too early to relate these ERP studies to prognosis in these patients. Review of available literature, including our cases, reveals that six of eight male breast carcinomas were ERP-positive.

Changing patterns of breast cancer. Lucy Wortham James lecture (clinical)

At present, through public awareness and the use of improved diagnostic aids, increasing numbers of patients are being seen with localized "minimal" breast cancer. In our own experience, the average measured size of the primary tumor has diminished from 3.2 cm in 1955 to 2 cm in 1974. Although the incidence of axillary node metastases has diminished only from about 50% to 42% during this interval, the extent of involvement and the distribution of nodal disease has improved markedly with a marked decrease in apical node involvement. Mammography has been responsible for the detection of more than 50% of our "minimal" breast cancers. This improved patient material presents a great potential for improved control of this disease. In planning the choice of surgery for primary breast cancer, its multicentric origin, and regional nodal spread to axillary and internal mammary nodal areas must be considered. There is no single ideal operation for all breast cancers. The scope of surgery should be correlated with the clinical and pathologic extent of disease in the individual patient with the aim of removing all disease present while preserving appearance and function-the main goal being removal of disease. We have utilized three operative procedures: total mastectomy with axillary dissection, radical mastectomy, and extended radical mastectomy. With this approach a 10-year survival rate of 61% with a local recurrence rate of 7.7% has been attained in a group of 565 patients with 40% axillary node involvement. The best salvage obtained in patients with "minimal" breast cancers-noninfiltrating cancers and infiltrating cancers under 1 cm in diameter with clinically negative axillae-was 95% survival at 10 years following modified radical mastectomy (total mastectomy with axillary dissection). When disease has extended to the axillary nodes the more extensive procedures have proved more effective in achieving long term control-54% 10 year survival in patients with axillary node metastases treated by the extended radical mastectomy. An increasing number of patients are being seen who can be treated adequately by less than a radical mastectomy. Careful clinical judgment and close liason with a competent pathologist must be combined in selecting the proper operative procedure for each individual patient. Statistics concerning therapeutic effects based on current material, unless they are based on accurate data covering extent of disease, cannot be compared with previous data because of the improved patient material now being encountered. Adjuvant multiple chemotherapy appears promising as a supplement to surgical treatment of breast cancer. However, it should not be used to replace or minimize the role of primary surgery, but should be combined with the optimum procedure for each individual patient.

Pathological review of breast lesions analyzed for estrogen receptor protein

This report provides a detailed pathological review of 333 specimens analyzed for estrogen receptor protein (ERP) and correlates a series of morphological features with ERP results. Included were 147 primary breast carcinomas, 78 metastases, 27 fibroadenomas, and 81 nonneoplastic tissues, all from women. ERP in cytosols was assayed by incubation with [3H]estradiol in the presence and absence of "cold" estradiol followed by dextran-charcoal treatment. Results were summarized as positive (greater 60% inhibition by nontritiated estradiol, greater than 10 fmoles/mg protein), negative (less than 60% inhibition by nontritiated estradiol, less than 10 fmoles/mg protein), or intermediate borderline combinations. ERP in primary tumors ranged from 0.2 to 358 fmoles/mg protein (54.4% positive, 35.4% negative, 10.2% borderline). New findings are: (a) a high frequency of positive ERP in invasive lobular carcinoma (12 of 13, 92.3%) compared to typical ductal tumors (64 of 117, 54.7%); and (b) low frequency of positive ERP(5 of 21, 23.8%) in tumors with a prominent local lymphocyte reaction. Three ERP-positive noncarcinomatous specimens were fibroadenomas of high epithelial cellularity from patients under 30 years. No statistically significant relationship existed between ERP and any other morphological features that were examined.

"Residual" mammary carcinoma following simulated partial mastectomy

Treatment of mammary carcinoma by partial mastectomy rather than by total mastectomy and axillary dissection may diminish the chances of long-term cure by risking incomplete removal of all local carcinoma at the initial operation. This study was undertaken to determine by pathologic examination how often carcinoma might remain in the breast and axilla after partial mastectomy. The operation was simulated in 203 mastectomy specimens after operations for unilateral invasive carcinoma. In so far as could be determined on gross examination, the entire primary lesion was included in the quadrant which was excised in the simulated procedure. Among 100 women with primary lesions less than 2 cm in diameter, 26% had carcinoma in the breast which remained after simulated partial mastectomy. Six percent of them also had axillary node metastases. An additional 30% only had axillary node metastases. When the primary lesion was more than 2 cm in diameter, 38% of patients had carcinoma in the breast after simulated partial mastectomy, of whom 29% also had axillary metastases. After simulated partial mastectomy, carcinoma was found in 80% of breasts from patients with lesions in the subareolar area, in contrast with 25-35% of patients with a primary carcinoma in one of the four quadrants. None of the 9 patients with medullary and colloid carcinomas that measured under 2 cm had axillary metastases or carcinoma in the breast outside of the primary quadrant. The findings suggested that a familial history of breast carcinoma or a large primary lesion may be associated more often with multifocal disease, but factors such as age at diagnosis, axillary status, and the mammogram report did not have significant predictive value for distinguishing between patients who did or did not have carcinoma in breast tissue after the primary had been removed by a simulated partial mastectomy.

Full thickness chest wall resection for recurrent breast carcinoma involving the bony chest wall

Solitary recurrent breast cancer involving the bony chest wall (parasternal recurrence) is curable when no evidence of systemic spread is found. Radical full thickness chest wall resection is an effective mode of treatment; it remains the only available treatment for patients whose chest wall recurrence fails to respond to radiation therapy, and in those who develop complications due to heavy irradiation. This report covers a review of the records of 52 patients treated at Memorial Hospital by chest wall resection for recurrent breast cancer between 1950 and 1972. The technique of chest wall resection and immediate plastic reconstruction is described. The gross and determinate 5-year survival rates for patients who underwent chest wall resection as the initial mode of therapy for chest wall recurrence were 43% and 57%, respectively. On the other hand, when chest wall resection was performed on those patients whose chest wall recurrences failed to respond to radiation therapy, the gross and determinate 5-year survival rates dropped to 16% and 19%. Full thickness chest wall resection with immediate plastic reconstruction when employed as the first mode of therapy for chest wall recurrences provides a significant 5-year survival rate, and has a definite place in the management of recurrent breast cancer.

Therapy of primary breast cancer

Most breast cancers are multicentric in origin. They drain into two primary lymphatic depots-the axilla and internal mammary chain of nodes. The incidence of metastasis to the internal mammary nodes rises as the location of the primary tumor approaches to the sternal margin of the breast. One hundred and thirty-seven patients primarily with in situ and non-infiltrating intraductal carcinoma were treated adequately by simple mastectomy and axillary dissection with preservation of the pectoral muscles. All have remained free of disease. Infiltrating cancers arising in the lateral portion of the breast are best treated by radical mastectomy since they spread mainly to the axillary nodes. Medial and central infiltrating cancers have been treated by radical mastectomy with internal mammary resection, since they show a higher incidence of internal mammary metastasis. Seventy-two percent of 500 patients treated in this fashion survived at five years and 65 percent were clinically free of disease. A five-year salvage rate of 60 percent and a ten-year salvage rate of 50 percent were obtained in patients with only internal mammary node metastasis or in those with only axillary involvement. When both nodal areas were involved 43 percent remained free of disease at five years and 20 percent at ten years. Mammography and biopsy of the contralateral breast at the time of radical mastectomy contributed to the detection of early localized breast cancer.