Neoadjuvant endocrine therapy in women with operable breast cancer: A retrospective analysis of real-world use

BACKGROUND

A retrospective study of the real-world use of neoadjuvant endocrine therapy (NET) is important for standardizing its role in breast cancer care.

MATERIALS AND METHODS

In a consecutive series of women with operable breast cancer who received NET for ≥28 days, NET objectives, NET outcomes, adjuvant chemotherapy use after NET, and survivals, were examined for the correlation with clinicopathological factors.

RESULTS

NET objectives were for surgery extent reduction in 49 patients, surgery avoidance in 31, and treatment until scheduled surgery in 8. The mean duration of NET was 349.5 (range, 34-1923), 869.8 (range, 36-4859), and 55.8 (range, 39-113) days in the above cohorts (success: 79.6%, 64.5%, and 100%), respectively, with significant difference. In patients of the former two cohorts, better progression-free survival was significantly correlated with stage 0 or I, ductal carcinoma in situ or invasive ductal carcinoma, ≥71% estrogen receptor (ER) positivity, and the surgery extent reduction cohort than the other counterparts. Postoperative chemotherapy use was significantly correlated with lymph node metastasis, a high Ki67 labeling index, lymphovascular invasion, and a high Preoperative Endocrine Prognostic Index, at surgery after NET. Better recurrence-free survival after surgery was significantly correlated with high ER expression after NET and high PgR expression before and after NET.

CONCLUSIONS

NET can help to reduce the surgery extent or to avoid surgery in women with breast cancer of early-stage, ductal carcinoma, or high ER expression. NET may also contribute to appropriate decision of postoperative systemic therapy to improve survivals.

Optimal Treatment Duration of Neoadjuvant Endocrine Therapy for Women Aged 60 Years or Older with Estrogen Receptor-Positive, HER2-Negative Invasive Breast Cancer

BACKGROUND

Neoadjuvant endocrine therapy is not the standard of care for breast cancer, primarily because the optimal treatment duration remains unclear. This phase 2 prospective multicenter study analyzed time to progression, time to maximal response, and time to treatment failure for neoadjuvant exemestane.

METHODS

Inclusion criteria were women aged ≥60 years with Stage II or III breast cancer classified as estrogen receptor-positive/human epidermal growth factor receptor 2-negative. Response was defined as a ≥10% and minimum of 3 mm decrease in tumor size, as compared with the most recent or smallest value, and no new lesion. Progression was defined as a >10% and minimum of over 3 mm increase in tumor size, as compared with the most recent or smallest value, or a new lesion. Maximal response was defined as the final recorded response.

RESULTS

This study included 24 women, most of whom had T2 N0 tumors with high estrogen receptor expression. We initially observed a response in 23 patients (96%); however, 6 patients (25%) later experienced progression. Time to progression, time to maximal response, and time to treatment failure ranged from 7 to 22 months (estimated median, 35), 1 to 22 months (estimated median, 10), and 2 to 22 months (estimated median, 22), respectively. Treatment duration varied widely, but the estimated optimal duration of neoadjuvant exemestane therapy was 22 to 35 months in patients seeking to avoid surgery and 10 months in patients wishing to receive breast-conserving surgery.

CONCLUSIONS

Neoadjuvant exemestane therapy is long effective for older women with hormone-sensitive breast cancer.

Changing clinical and molecular characteristics of hepatitis E virus infection in Mie Prefecture, Japan: Disappearance of indigenous subtype 3e strains

AIM

To evaluate the clinical and molecular characteristics of hepatitis E virus (HEV) infection in Mie Prefecture, Japan, from 2004 through 2018.

METHODS

The clinical information of hepatitis E cases was collected from 21 medical institutions in Mie Prefecture. The nucleotide sequences of infecting HEV strains were determined for cases with available serum samples. The origins or transmission routes were inferred from phylogenetic analyses of the nucleotide sequences.

RESULTS

Fifty-three patients were diagnosed with HEV infection. The number of cases increased each year through 2012 and then decreased. Analyses of the clinical characteristics of the cases indicated that even mild cases were detected in the latter 10 years of the study. Nucleotide sequence analyses were undertaken on 38 of the 53 cases. The HEV subtype 3e (HEV-3e) strains identified for 13 cases were closely related to a swine HEV-3e strain that was isolated from the liver of a pig bred in Mie Prefecture. The number of cases infected with the indigenous Mie HEV-3e strains increased until 2012 but have not been reported since 2014. In the latter half of the study, cases involving various HEV strains of different genotypes and subtypes emerged.

CONCLUSIONS

The disappearance of indigenous Mie HEV-3e strains appeared to be the primary cause for the decrease in hepatitis E cases in Mie Prefecture. The disappearance might have been associated with improved hygienic conditions on pig farms or the closure of contaminated farms. The results suggest that indigenous HEV strains can be eradicated by appropriate management.

Correction to: Eribulin, trastuzumab, and pertuzumab as first-line therapy for patients with HER2-positive metastatic breast cancer: a phase II, multicenter, collaborative, open-label, single-arm clinical trial

The authors would like to note the replacement of Fig. 2b, for which Fig. 2a was placed erringly, with appropriate Fig. 2b.

Transudative chylothorax associated with alcoholic cirrhosis

We present the case of a 53-year-old man with decompensated alcoholic cirrhosis who was referred for right pleural effusion. After investigation, the patient was ultimately diagnosed with cirrhotic chylothorax. Chylothorax is a rare manifestation of cirrhosis, which results from the trans-diaphragmatic passage of chylous ascites. While chylothorax generally results in an exudative pleural effusion, cirrhotic chylothorax is always a transudative effusion. Biochemical characteristics are useful for diagnosis, avoiding potentially harmful diagnostic and therapeutic procedures.

Eribulin, trastuzumab, and pertuzumab as first-line therapy for patients with HER2-positive metastatic breast cancer: a phase II, multicenter, collaborative, open-label, single-arm clinical trial

Purpose To examine the efficacy and safety of triple therapy with eribulin, trastuzumab, and pertuzumab in patients with HER2-positive metastatic breast cancer (MBC) who never received any prior therapy in the first-line metastatic/advanced setting. Methods Eribulin 1.4 mg/m² (days 1 and 8), trastuzumab 8 mg/kg over 90 min and 6 mg/kg over 30 min, and pertuzumab 840 mg/body over 60 min and 420 mg/body over 30 min were administered intravenously in 21-day cycles. Results 25 women (median age, 57 years [range, 41–75 years]) received a median of 10 cycles (range, 0–34 cycles); 24 had performance status (PS) 0, 1 PS 1, 8 stage IV breast cancer, and 17 recurrence. Lung and liver metastases occurred in 9 and 9 patients, respectively. Median time to treatment failure with eribulin was 9.1 months (95% confidence interval [CI], 4.3–13.9 months), and median progression-free survival was 23.1 months (95% CI, 14.4–31.8 months). The overall response rate (complete response [CR] + partial response [PR]) was 80.0% (95% CI, 59.3–93.2%), and the clinical benefit rate (CR + PR + stable disease ≥24 weeks) was 84.0% (95% CI, 63.9–95.5%). The most common treatment-emergent adverse events (TEAEs) were alopecia (92.0%), fatigue (68.0%), and sensory peripheral neuropathy (60.0%). Grade 3/4 TEAEs occurred in 11 patients (44.0%). The only grade 4 TEAE was neutrophil count decreased (16.0%). Neither grade 4 peripheral neuropathy nor febrile neutropenia occurred. Conclusions ETP therapy showed acceptable efficacy and safety and is a potential first-line therapy for patients with HER2-positive MBC.

Abstract P6-17-14: Eribulin, trastuzumab, and pertuzumab as first-line therapy for patients with HER2-positive metastatic breast cancer: A multicenter, collaborative, open-label, phase II clinical trial for the SBCCSG-36 investigators

Background: Docetaxel, trastuzumab, and pertuzumab (DTP) therapy is established first-line therapy for patients with HER2-positive metastatic breast cancer (HER2 + MBC). However, the poor tolerability of docetaxel impedes its long-term administration. The safety of eribulin, trastuzumab, and pertuzumab (ETP) therapy for HER2 + MBC has been confirmed in Japan. We examined the primary endpoint—overall response rate, the secondary endpoints—time to treatment failure, progression-free survival, and overall survival, as well as adverse events (AEs) of ETP therapy. (University Hospital Medical Information Network identifier:000021585)

Methods: Eribulin 1.4 mg/m2/day iv (days 1 and 8), trastuzumab 8 mg/kg iv over 90 min (initial dose) and 6 mg/kg iv over 30 min (second and subsequent doses), and pertuzumab 840 mg/body over 60 min (initial dose) and 420 mg/body over 30 min (second and subsequent doses) were administered. Cycles consisting of 2 doses of eribulin and 1-week drug holiday were repeated. Patients were treated with trastuzumab and pertuzumab when AEs developed that did not allow medication continuation by reducing the dose of eribulin. Antitumor effect was assessed according to RECIST version 1.1. and toxicities to CTCAE Japanese version 4.0. All patients provided written informed consent before enrollment. The study protocol was approved by the Institutional or Central Ethics Committee, and the study was conducted in accordance with the Declaration of Helsinki, Good Clinical Practice, and local ethical and legal regulations.

Results: 25 female patients (median age: 57 years [41-75]) were enrolled from April 18, 2016, through November 22, 2017. Twenty-four had performance status (PS) 0, 1 PS 1, 8 stage 4 breast cancer, and 17 metastatic breast cancer. Anthracycline, taxane, and trastuzumab were administered as neoadjuvant and adjuvant pharmacotherapies to 13, 15, and 14 patients, respectively. Primary tumor was positive for estrogen and progesterone receptors in 12 and 6 patients, respectively. Lung, liver, and bone metastases occurred in 9, 9, and 6 patients, respectively. Three (12%), 17 (68%), 1 (4%), 1 (4%), and 2 (8%) patients showed complete response (CR), partial response (PR), long-term stable disease (LSD; stable disease ≥24 weeks), stable disease (SD; stable disease <24 weeks), and progression disease (PD), respectively; 1 (4%) was unassessable because ETP therapy could not be conducted due to the grade 3 infusion reaction of pertuzumab. Major AEs were neutropenia, anemia, fatigue, peripheral neuropathy, alopecia, and anorexia. The overall response rate (CR+PR) was 80.0% (95% confidence interval 59.3-93.2%). The median follow-up was 10.1 months [3.9-21.5]. Six and 3 patients showed tumor deterioration and died of breast cancer, respectively.

Conclusions: Similar to DTP, ETP showed high response rates and good safety as first-line therapy for HER2 + MBC.

Citation Format: Inoue K, Ninomiya J, Okubo K, Nakakuma T, Yamada H, Kimizuka K, Higuchi T, Saito T. Eribulin, trastuzumab, and pertuzumab as first-line therapy for patients with HER2-positive metastatic breast cancer: A multicenter, collaborative, open-label, phase II clinical trial for the SBCCSG-36 investigators [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-17-14.

Induction therapy with paclitaxel and bevacizumab followed by switch maintenance therapy with eribulin in Japanese patients with HER2-negative metastatic breast cancer: a multicenter, collaborative, open-label, phase II clinical study for the SBCCSG 35 investigators

BACKGROUND

To examine the efficacy and safety of induction therapy with paclitaxel and bevacizumab followed by switch maintenance therapy with eribulin (ISMT) in Japanese patients with HER2-negative metastatic breast cancer (MBC).

METHODS

Patients, who had previously undergone a maximum of 2 regimens of chemotherapy, received 3 cycles of induction therapy with paclitaxel (90 mg/m2 intravenously on days 1, 8, and 15 followed by 1-week drug holiday) and bevacizumab (10 mg/kg intravenously after the completion of paclitaxel administration on days 1 and 15). Patients who had complete response, partial response, or stable disease underwent switch maintenance therapy with eribulin (1.4 mg/m2 intravenously on days 1 and 8 followed by 1-week drug holiday). The primary endpoint was time to treatment failure (TTF) for ISMT.

RESULTS

Fifty-one eligible patients (median age: 66 years; range: 35-74) were enrolled: 19 (37.3%) and 32 (62.7%) had stage IV and recurrence, respectively, 42 (82.4%) had visceral metastases, and 45 (88.2%) received eribulin-38 of whom showed disease progression, and 40 (78.4%) underwent post therapy. Median TTF was 9.2 months (95% confidence interval [CI]: 7.3-11.1), median progression-free survival was 10.7 months (95% CI: 9.6-11.8), and median overall survival was 20.0 months (95% CI: 16.0-24.0). Relative dose intensity was 97.7% (range: 33.3-100.0) for induction therapy and was 83.3% (range: 49.3-100.6%) for eribulin maintenance therapy. The most common adverse event was alopecia (51 [100%]) in induction therapy and was peripheral sensory neuropathy (37 [82.2%]) in eribulin maintenance therapy. Eribulin was effective with manageable tolerability.

CONCLUSIONS

ISMT may be a promising therapeutic option for patients with MBC.

TRIAL REGISTRATION

UMIN000015971 . Registration date: January 1, 2015.

A Real-World Retrospective Cohort Study of Combined Therapy with Bevacizumab and Paclitaxel in Japanese Patients with Metastatic Breast Cancer

OBJECTIVE

Combined therapy with bevacizumab and paclitaxel (BP regimen) as a first-line treatment has proven highly effective with good tolerance for patients with metastatic breast cancer (MBC). The objective of this study was to examine the efficacy and safety of the BP regimen for Japanese patients with MBC in real-world clinical settings.

METHODS

From June 2012 through May 2014, we recruited 94 patients at 10 medical institutions. The primary endpoint was time to treatment failure (TTF), and the secondary endpoints were overall survival (OS) and safety. Objective response was assessed according to the Response Evaluation Criteria in Solid Tumors. Adverse events (AEs) were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0-Japan Clinical Oncology Group.

RESULTS

Nighty patients with MBC (mean 58 years, range: 34-80 years) were enrolled, and 60 (66.6%) and 52 (57.7%) had undergone prior chemotherapy as adjuvant treatment and treatment for MBC, respectively. Median TTF was 6.2 months (95% confidence interval [CI], 4.2-8.3 months), and median OS was 15.4 months (95% CI, 12.0-18.9 months). The overall response rate was 67.8% (95% CI: 57.1-77.2%). A total of 28 patients (31.1%) required a dose reduction of paclitaxel. Forty-five, 42, and 3 patients received the initial doses of 90, 80, and 60 mg/m², respectively. Among patients who received the initial doses of 90 mg/m², 13 patients (28.9%) unexpectedly required a dose reduction of ≥20 mg/m². The BP regimen was discontinued for 66 (73.3%) of the 90 patients, 52 (57.7%) of whom experienced "disease progression." Grade 3/4 hematologic AEs developed in 51 patients (56.6%), with leukopenia and neutropenia in 16 patients (17.8%) and 21 patients (23.3%), respectively. Grade 3 nonhematologic AEs developed in 8 patients (8.9%), with the most common nonhematologic AE of peripheral neuropathy in 4 patients (4.4%). No Grade 4 nonhematologic AEs developed. Peripheral neuropathy [56 patients (62.2%) ], nail discoloration [53 patients (58.9%) ], and fatigue [51 patients (56.7%) ] were the most predominant AEs-the known AEs of paclitaxel.

CONCLUSIONS

The BP regimen was active and well tolerated in the real-world clinical settings. As many as 28.9% of patients who received the initial dose of 90 mg/m² required a dose reduction of paclitaxel by 20 mg/m². Therefore, there is a need to find a therapeutic regimen that is less likely to result in dose reductions for patients with MBC who undergo a BP regimen using the initial paclitaxel dose of 90 mg/m².

Hepatotoxicity induced by trastuzumab used for breast cancer adjuvant therapy: a case report

Introduction

Trastuzumab is generally considered a highly safe drug, but there have been cases of infusion reaction and cardiotoxicity. This report will present a rare case of hepatotoxicity induced by trastuzumab used for adjuvant therapy of human epidermal growth factor receptor type 2-positive breast cancer.

Case presentation

The patient was a 60-year-old Japanese postmenopausal woman with a non-contributory past medical history. She presented for detailed examination of an abnormality in her left breast. She had left breast cancer (T2N1M0, stage IIB) that was positive for estrogen receptor and progesterone receptor and was human epidermal growth factor receptor type 2 3+. She began receiving epirubicin and cyclophosphamide therapy but developed hepatotoxicity (aspartate aminotransferase 43U/L, alanine aminotransferase 104U/L, alkaline phosphatase 634U/L, and γ-glutamyl transpeptidase 383U/L). Thus, the therapy was discontinued after two cycles, and a weekly paclitaxel therapy was begun. After the absence of an adverse event was confirmed, she also began receiving trastuzumab (4mg/kg) at the second cycle. However, hepatotoxicity (aspartate aminotransferase 267U/L, alanine aminotransferase 246U/L, alkaline phosphatase 553U/L, and γ-glutamyl transpeptidase 240U/L) developed again, and trastuzumab was discontinued. She received paclitaxel monotherapy for a total of four cycles and subsequently underwent partial mastectomy and axillary dissection. After completing adjuvant radiation therapy (breast, 50Gy), she received trastuzumab administration (4mg/kg) but hepatotoxicity (aspartate aminotransferase 47U/L, alanine aminotransferase 102U/L, alkaline phosphatase 377U/L, and γ-glutamyl transpeptidase 91U/L) recurred. Thus, it was discontinued again. There was no hepatitis B or C virus infection, and a drug-induced lymphocyte stimulation test revealed a positive reaction to trastuzumab (stimulation index: 227%). Thereafter she has used only oral letrozole (2.5mg/day) and no recurrent cancer has been observed.

Conclusions

Although trastuzumab is a highly safe drug, one must be mindful of its risk for hepatotoxicity. Periodic monitoring of liver functions is necessary during trastuzumab therapy.

Effectiveness and safety of tegafur-gimeracil-oteracil potassium (TS-1) for metastatic breast cancer: a single-center retrospective study

BACKGROUND

Tegafur-gimeracil-oteracil potassium (TS-1)is a drug that is used mainly as a third-line treatment or beyond for metastatic breast cancer(MBC). However, there is still insufficient evidence on its clinical effectiveness, and there are very few reports on clinical research using TS-1 up front. In this report, we examined the effectiveness and safety of TS-1 therapy for MBC.

PATIENTS AND METHODS

The subjects were 46 patients with MBC who were treated with TS-1 between January 2005 and January 2013. These patients were retrospectively examined.

RESULTS

The objective response rate to TS-1 therapy was 30.4%, clinical benefit rate (CBR)was 50.0%, and the median time to treatment failure was 10.7 months. When examined by site, the CBR was high locally (46.2%), in the lymph nodes (40.7%), in the bone (42.9%), and in the lungs and pleura (44.8%). However it was low in the liver(30.0%). The relationship was examined between clinicopathological factors and the effectiveness of TS-1 therapy. The objective response rate (ORR) was significantly higher for patients with disease-free interval (DFI) of 2 years or more (p=0.039), TS-1 therapy used as third-line treatment or earlier (p=0.022), negative HER2 status (p=0.020), and no history of capecitabine (CAP)therapy (p=0.049). The CBR was significantly higher for patients with no visceral metastasis (p=0.032), TS-1 used as third-line treatment or earlier (p=0.019), negative HER2 status (p= 0.045), no history of CAP therapy (p=0.006), and no history of tegafur-uracil/doxifluridine therapy (p=0.031). Multivariate analysis showed that DFI of 2 years or more (p=0.035, odds ratio:0.104)was an independent predictor of effectiveness assessed by ORR. There were only 4 patients in whom the treatment was discontinued due to adverse event, and TS-1 was generally well tolerated.

CONCLUSION

TS-1 was highly effective and well tolerated by patients with MBC. Its up-front use might enable the maintenance of satisfactory QOL and the enhancement of its clinical effectiveness.

Efficacy of high-dose toremifene therapy in postmenopausal patients with metastatic breast cancer resistant to aromatase inhibitors:a retrospective, single-institution study

BACKGROUND

Aromatase inhibitors(AI)have established efficacy as first-line therapy in postmenopausal patients with hormone-sensitive metastatic breast cancer(MBC). However,the use of endocrine therapy has not yet been established for second-line and later therapy. Our study examined the efficacy of high-dose toremifene therapy(HD-TOR)in patients with MBC resistant to AIs.

PATIENTS AND METHODS

A retrospective analysis was carried out to determine outcomes in 85 postmenopausal patients with MBC resistant to AIs who began HD-TOR between May 2001 and October 2011. The patients received toremifene 120 mg once daily on consecutive days.

RESULTS

The objective response rate(ORR)was 21.2%,the clinical benefit rate(CBR)was 41.2%,and the median time to treatment failure(TTF)was 7.3 months. The CBR was high in patients with ER-positive status(p=0.045),no visceral metastasis(p=0.037),HD -TOR as first- or second-line therapy(p=0.007),no history of tamoxifen(TAM)therapy(p=0.019),and no history of chemotherapy(p=0.017). Multivariate analysis showed that ER-positive status(p=0.005, odds ratio: 0.064)and no visceral metastasis(p=0.034, odds ratio: 0.323)were independent predictors of efficacy. The TTF was significantly longer in patients with ER-positive status(p=0.019)and no history of TAM therapy(p=0.015). Multivariate analysis showed that ER-positive status(p=0.025, hazard ratio: 0.377)and no history of TAM therapy(p=0.002, hazard ratio: 0.422)were independent predictors of efficacy. No patient discontinued HDTOR therapy due to adverse events.

CONCLUSION

HD-TOR is an effective endocrine therapy for patients with MBC who have failed AIs.

Locally advanced breast cancer with bleeding - two cases effectively treated with bevacizumab plus weekly paclitaxel

Bleeding is one of the serious adverse events of bevacizumab (BV). In our report, two patients had locally advanced breast cancer with bleeding. They received BV plus weekly paclitaxel (PTX), and good local control was observed. Case 1: The patient was a 50-year-old postmenopausal woman. She had left-sided breast cancer (T4cN2cM1 [bone]-stageIV) that was negative for estrogen receptor (ER), negative for progesterone receptor(PgR), and 1+for human epidermal growth factor receptor 2 (HER2). The patient began receiving different regimens of chemotherapy: 5-fluorouracil (5-FU), epirubicin (EPI), and cyclophosphamide(CPA), (FEC); PTX; docetaxel (DTX); and gemcitabine (GEM) plus PTX. Subsequently, she received BV plus PTX. The tumor was markedly reduced in size at the completion of 2 cycles. Bleeding and exudate were also reduced. The patient had a partial response until the sixth cycle, and good local control was obtained. However, the patient had progressive disease at the completion of 8 cycles. Therefore, therapy was changed to capecitabine(CAP)plus CPA, but the patient died one year after she began treatment with BV plus PTX. Case 2: The patient was a 76-year-old postmenopausal woman. She had right-sided breast cancer (T4bN3bM1[lung]-stageIV) that was negative for ER, negative for PgR, and 0 for HER2. The patient began receiving different regimens of chemotherapy: EPI and CPA (EC); and PTX. Subsequently, she received BV plus PTX. The tumor was markedly reduced in size at the completion of 2 cycles. Bleeding and exudate were also reduced. The patient had a partial response until the third cycle, and good local control was obtained. However, the patient had progressive disease at the completion of 4 cycles. Therefore, therapy was changed to CAP and DTX, but the patient died six months after she began treatment with BV plus PTX.

Paclitaxel-resistant advanced recurrent breast cancer: a case of partial response due to addition of bevacizumab to paclitaxel therapy: a case report

Background

Paclitaxel plus bevacizumab have shown a high response rate and prolonged progression-free survival in metastatic breast cancer patients. However, overall survival was not prolonged. Thus, no conclusion has been made on the effectiveness of bevacizumab. In our report, taxane plus bevacizumab were used to treat a metastatic breast cancer patient with taxane resistance, and a good therapeutic result was obtained.

Case presentation

The patient was a 68-year-old woman with a non-contributory history. In September 2004, she underwent a pectoral muscle-conserving mastectomy with axillary dissection for right-sided breast cancer (pT3N0M0-stage IIB, estrogen receptor positive, progesterone receptor negative, and human epidermal growth factor receptor type 2 negative). Adjuvant therapy consisted of 6 cycles of cyclophosphamide, epirubicin and fluorouracil, and subsequent oral anastrozole. In August 2007, the patient developed a recurrence in the left axillary lymph node. The chemotherapy was changed to high-dose toremifene, and radiation therapy was also performed. The patient achieved a complete response. In April 2009, CT showed left axillary lymph node enlargement once again and multiple lung metastases. Hormone therapy was changed to exemestane and long-term stable disease was achieved. In March 2011, the lung and left axillary lymph node metastases were enlarged and progressive disease was noted. Thus, the tumors were determined to be resistant to hormone therapy, and weekly paclitaxel was begun in May. Since partial response was achieved, this therapy was continued. In December, CT showed that lung and axillary lymph node metastases were enlarged and progressive disease was observed. Therefore, the tumors were determined to be resistant to paclitaxel. In January 2012, bevacizumab and weekly paclitaxel were begun. In April, lung and axillary lymph node metastases were reduced in size, and partial response was achieved. Thereafter the same treatment has been continued, and the patient has been followed up without clinical exacerbation as of January 2013.

Conclusion

Taxane plus bevacizumab were used to treat a metastatic breast cancer patient with taxane resistance, and a good therapeutic result was obtained. This result is considered important in increasing treatment options for patients with taxane resistance or patients using adjuvant taxane-based therapy and in examining the effectiveness of bevacizumab in metastatic breast cancer patients.

Abstract P1-14-06: Significance of examining biomarkers of residual tumors after neoadjuvant chemotherapy using trastuzumab in combination with anthracycline and taxane in patients with primary HER2-positive breast cancer

Background: Neoadjuvant chemotherapy (NAC) with taxane and FEC concurrently with trastuzumab is a potent regimen in women with HER2-positive breast cancer (BC), and several studies revealed high pCR rates in BC patients treated with this regimen. In the present study, we compared the status of biomarkers before and after NAC, and evaluated rates and patterns of discordant biomarker expression. We also evaluated differences of prognosis between patients with discordant biomarker expression and those with concordant expression.

Patients and Methods: We investigated 118 Japanese women with invasive HER2 positive BC. Patients received 12 cycles of paclitaxel or 4 cycles of docetaxel followed by 4 cycles of FEC-75 with concomitant trastuzumab for 24 weeks and were followed for ≥1 year after surgery. Of these, 27 patients with residual tumors 5 mm or larger were analyzed. HER2, ER, PgR, and Ki67 were examined in primary and residual tumors. Furthermore, recurrence-free survival (RFS) and overall survival (OS) were analyzed between patients classified based on these biomarkers.

Results: Patients with pCR after NAC (75/118; 63.5%) had significantly better RFS than non-pCR patients (median follow-up: 41 months). Residual tumors were obtained from 27 of 43 non-pCR patients and examined for immunohistochemical biomarker expression. In 14/27 non-pCR patients (51.9%), residual tumors were HER2 negative, despite being HER2 positive before NAC: HER2 score changed from 3+ to 0 or 1+ in 8/18 patients (44.4%) and from 2+ to 0 or 1+ in 6/9 (66.7%). ER expression changed in 2 patients (1 positive to negative and 1 negative to positive). Patterns of biomarker expression in residual tumors were HER2 (+)/ER (–), 6 patients (22.2%); HER2 (+)/ER (+), 7 (25.9%); HER2 (–)/ER (+), 11 (40.7%); and triple negative (TN), 3 (11.1%). Recurrence was observed in 8/27 (29.6%) non-pCR patients, and patterns of biomarker expression in residual tumors were HER2 (+)/ER (–), 3 patients; HER2 (+)/ER (+), 2; and HER2 (–)/ER (+), 3. In addition, 1 patient with a HER2 (+)/ER (+) tumor and 1 patient with a HER2 (−)/ER (+) tumor died. RFS and OS were not statistically different between patients classified based on ER and Ki67 expressions. However, in the 18 non-pCR patients with primary tumor HER2 score of 3+ (overexpression of HER2 protein), the 10 with HER2-positive residual tumors showed significantly lower RFS than the 8 with HER2-negative (p < 0.04).

Conclusions: Although this regimen achieved a high pCR rate in HER2-positive BC patients, about 40% still had residual tumors. In the present study, we found that positive HER2 expression seen in pre-NAC tumors became negative in 52% of residual tumors after NAC. Theses HER2-negative residual tumors might not respond well to trastuzumab therapy, and residual tumors remaining HER2 positive might show low or no response to trastuzumab therapy. Moreover, the prognosis seems worse for non-pCR patients with HER2-positive residual tumors. However, Ki67 was not a significant prognostic factor. Examining biomarker expression of residual tumors after NAC seems very important for deciding further adjuvant therapy.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-14-06.

Estrogen receptor (ER), Ki-67, p27Kip1, and histologic grade as predictors of pathologic complete response (pCR) in patients with HER2-positive breast cancer treated with neoadjuvant chemotherapy (NAC) using fluorouracil, epirubicin, and cyclophosphamide (FEC), taxanes, and trastuzumab

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Background: NAC with taxanes and FEC concurrently with trastuzumab is a potent regimen in patients with HER2-positive breast cancer (BC). Several studies revealed high pCR rates in BC patients treated with this regimen; however, predictive factors and a prognostic effect of pCR have been still unclear. In this study, we analyzed several factors including p27Kip1 (cyclin-dependent kinase inhibitor acting as tumor suppressor) for correlation with pCR. We also evaluated differences in recurrence-free survival (RFS) or overall survival (OS) between patients with pCR and non-pCR, and with positive and negative nodes after NAC. Methods: Our study included 129 Japanese women with invasive, HER2-positive BC who received 12 cycles of paclitaxel or 4 cycles of docetaxel followed by 4 cycles of FEC-75 with concomitant trastuzumab for 24 weeks. We analyzed the correlation of pCR (no invasive lesions in the breast) and nodal status after NAC with RFS and OS, and analyzed the baseline expressions of ER, Ki-67, and p27Kip1, and histological grade for correlation with pCR. Positive or high expression was defined by nuclear labeling index: ER ≥10%, p27Kip1 ≥75%, Ki-67 ≥30%. Results: In 129 patients, pCR was found in 85 (66%). Patients with pCR after NAC had significantly better RFS than those without pCR (median follow-up: 41 months). Furthermore, patients with pathologically negative nodes after NAC had significantly better OS than those with pathologically positive nodes. Negative ER (79% vs. 40%), high Ki-67 (72% vs. 47%), low p27Kip1 (71% vs. 50%), and histological grade 3 (70% vs. 39%) were significant predictors of pCR. Conclusions: In patients with HER2-positive BC, this regimen was effective achieving the high pCR rate. pCR and pathologically negative nodes after NAC were predictive of RFS and OS, respectively. The expressions of ER, Ki-67, and p27Kip1, and histological grade at baseline were predictive of pCR. p27Kip1, a new predictor of pCR after NAC needs to be further analyzed.

Sentinel lymph node biopsy after neoadjuvant chemotherapy predicts pathological axillary lymph node status in breast cancer patients with clinically positive axillary lymph nodes at presentation

BACKGROUND

It is still controversial whether axillary lymph node (ALN) dissection (ALND) can be omitted after negative sentinel lymph node (SLN) biopsy (SLNB) in breast cancer (BC) patients with clinically positive ALNs at presentation treated with neoadjuvant chemotherapy (NAC). The study aim was to analyze whether SLNB could be useful in these patients.

METHODS

In a retrospective study, eligible patients were women with invasive BC with clinically positive ALNs at presentation, treated with NAC then a total or partial mastectomy, with an intraoperative histological examination of SLNs and non-SLNs suspicious for metastasis followed by ALND. Non-SLNs suspicious for metastasis were defined as hard or large nodes located in the same level of the axilla where clinically positive ALNs had been initially identified. The results of SLNB and clinicopathological characteristics were analyzed for correlation with pathological ALN status.

RESULTS

In a consecutive series of 105 women with 107 BC cases, 81 (75.7 %) had at least 1 SLN, and the remaining 26 (24.3 %) had at least 1 non-SLN suspicious for metastasis. The intraoperative (or final) histological examination of these nodes revealed that the false-negative (FN) rate and accuracy were 8.2 (or 6.3) % and 95.1 (or 96.3) %, respectively. Estrogen receptor status at presentation, pathological tumor response, lymphovascular invasion after NAC, and NAC regimen were correlated with pathological ALN status.

CONCLUSION

The histological examination of SLNs and that of non-SLNs suspicious for metastasis are useful for predicting pathological ALN status in BC patients with clinically positive ALNs at presentation who are treated with NAC.

Axillary lymph node dissection can be avoided in women with breast cancer with intraoperative, false-negative sentinel lymph node biopsies

BACKGROUND

It is currently unclear which patients with breast cancer with sentinel lymph node (SLN) metastases do not need axillary lymph node dissection (ALND).

PATIENTS AND METHODS

A cohort of 1,132 women who had unilateral invasive breast cancer with clinically negative nodes or nodes suspicious for metastasis, were intraoperatively diagnosed as having negative SLNs, and did not undergo an immediate ALND. Our intraoperative histological investigation uses H&E staining of a frozen section from a maximum cut surface of each SLN. Of these 1,132 women, 132 (11.7%) were postoperatively diagnosed as having positive SLNs, which classifies them as having an intraoperative, false-negative SLN biopsy (SLNB). Patient and tumor characteristics, treatment methods, and the prognoses of these patients were investigated and compared with the remaining 1,000 patients who were negative for SLNB.

RESULTS

Of the 132 patients with intraoperative, false-negative SLNB, none underwent a further ALND. With a median follow-up period of 58.1 months, none of these patients exhibited recurrence in the axillary nodes. Their recurrence-free survival rates were not statistically different from those of patients with negative SLNB.

CONCLUSIONS

ALND can be avoided in most patients with breast cancer with intraoperative, false-negative SLNB.

Recurrence after sentinel lymph node biopsy with or without axillary lymph node dissection in patients with breast cancer

BACKGROUND

A regional nodal recurrence is a major concern after a sentinel lymph node biopsy (SLNB) alone in patients with breast cancer. In this study we investigated patterns and risk factors of regional nodal recurrence after SLNB alone.

PATIENTS AND METHODS

Between January 1999 and March 2005, a series of 1,704 consecutive breast cancer cases in 1,670 patients (34 bilateral breast cancer cases) with clinically negative nodes or suspicious nodes for metastasis who underwent SLNB at a single institute (Saitama Cancer Center) were studied. All 1,704 cases were classified based upon presence or absence of a metastatic lymph node, treated with or without axillary lymph node dissection (ALND). The site of first recurrence was classified as local, regional node, or distant. The regional node recurrences were subclassified as axillary, interpectoral, infraclavicular, supraclavicular, or parasternal.

RESULTS

After a median follow-up period of 34 months (range, 2-83 months), first recurrence occurred in local sites in 32 (1.9%) cases, regional nodes in 26 (1.5%) cases, and distant sites in 61 (3.6%) cases. In 1,062 cases with negative nodes treated without ALND and 459 cases with positive nodes treated with ALND, 11 (1.0%) and 15 (3.3%) recurred in regional nodes, respectively, and 4 (0.4%) and 2 (0.6%) recurred in axillary nodes, respectively. Of 822 cases of invasive breast cancer with negative nodes treated with SLNB alone, 10 (1.4%) recurred in regional nodes, and 4 (0.5%) recurred in axillary nodes. In the 10 patients with regional nodal failure, all of the tumors were negative for estrogen receptor (ER) and/or progesterone receptor (PR) and were nuclear grade (NG) 3.

CONCLUSIONS

The axillary recurrence rate was low in patients treated with SLNB alone. Omitting ALND is concluded to be safe after adequate SLNB. Risk factors for regional nodal failure after SLNB alone are negative hormone receptor status and high NG.

Immunohistochemical study of the relationship between Ki-67 labeling index of proliferating cells of gynecomastia, histological phase and duration of disease

Gynecomastia is a benign proliferative lesion caused by various etiological factors and may result from a relative imbalance between serum estrogen and androgen levels. The histological alterations are similar, and gynecomastia can progress from a florid type to a fibrous type. The Ki-67 labeling index (LI) of gynecomastia specimen was investigated and higher Ki-67 LI was observed in florid and intermediate than in fibrous gynecomastia (P = 0.017). A correlation was found between the duration of disease and Ki-67 LI (P = 0.041): the shorter the duration the higher the Ki-67 LI. Thus, Ki-67 LI seems a useful tool to examine proliferation activity of gynecomastia and can assist in determination of appropriate treatment of gynecomastia with hormonal therapy.

Sentinel Lymph Node Biopsy Alone Has No Adverse Impact on the Survival of Patients with Breast Cancer

We do not yet know the results from multicenter randomized trials comparing survival after sentinel lymph node biopsy (SLNB) alone and axillary lymph node dissection (ALND). Therefore, in this study, the prognostic significance of the type of axillary surgery is analyzed in combination with other known prognostic factors in patients with breast cancer. In a series of 1325 consecutive patients with unilateral breast cancer who underwent SLNB between January 1999 and June 2004 at a single institution, 884 underwent SLNB alone following an intraoperative negative histologic investigation and 441 underwent ALND. Disease-free survival (DFS) and overall survival (OS) were analyzed to correlate with clinicopathologic features and treatment methods using both univariate and multivariate analyses Cox proportional hazard regression models. With a median follow-up period of 31 months, 29 (3.3%) and 37 (8.4%) patients relapsed after SLNB alone and ALND, respectively. Tumor size (Tis, T1-2 versus T3-4), histologic nodal involvement (negative versus positive), nuclear grade (NG) (1, 2 versus 3), lymphatic vessel invasion (LVI) (absent, weak versus intense), estrogen receptor (ER) status (positive versus negative), type of axillary surgery (SLNB alone versus ALND), type of breast surgery (partial versus total mastectomy), and radiation therapy (yes versus no) significantly correlated with DFS by univariate analysis, demonstrating better DFS in the former category than the latter for each variable. The multivariate analysis revealed that NG, LVI, ER status, and radiation therapy significantly correlated with DFS, and ER and histologic nodal involvement correlated with OS. As the type of axillary surgery had no impact on the prognosis of patients with breast cancer, a SLNB alone is safe as determined by a negative histologic investigation.

Added value of the presence of blue nodes or hot nodes in sentinel lymph node biopsy of breast cancer

BACKGROUND

Combined use of blue dye and radiocolloid is considered to be useful for sentinel lymph node (SLN) biopsy of breast cancer. Whether both techniques together is superior to either alone was analyzed.

PATIENTS AND METHODS

A consecutive series of 308 cases of breast cancer who underwent SLN biopsy using the combination technique was used. The frequency of a blue node or hot node was analyzed in all cases and only node-positive cases. Furthermore, the frequency of a blue node and hot node together, or either alone, and the highest radiocount of the SLNs in each case were examined for correlation with 8 clinicopathologic features. Three types of SLN containing both blue dye and radioactivity (blue-hot node), blue dye alone (blue-only node) and radioactivity alone (hot-only node), and the SLN radiocounts were analyzed for correlation with metastatic tumor.

RESULTS

Of 308 cases, a blue node was present in 298 (97%), a hot node in 295 (96%), and either a blue or hot node in 306 (99%). The presence of a blue node or hot node was similarly affected by previous surgical biopsy and body mass index (BMI), and the presence of a hot node was also affected by age and tumor location. However, the presence of either a blue node or hot node was not affected by any of these characteristics. Of 77 node-positive cases, 8 (10%), 15 (19%) and 6 (8%) were considered to be node-negative based on blue node, hot node and either blue node or hot node positivity, respectively. The frequency of positivity for SLN metastasis decreased in order from blue-hot, blue-only to hot-only nodes. Of 62 cases with metastatic hot nodes, six (10%) were negative when the hottest node was examined, but the second-hottest node was positive.

CONCLUSIONS

The added value of the presence of blue node or hot node was confirmed in the SLN biopsy using the combination technique, which suggests that all blue nodes and hot nodes need to be harvested.

99mTc-phytate is better than 99mTc-human serum albumin as a radioactive tracer for sentinel lymph node biopsy in breast cancer

PURPOSE

Several radioactive agents are used for sentinel lymph node biopsy (SLNB) in breast cancer, but we are still unsure which of these is best. We retrospectively compared the effectiveness of two radioactive agents, 99mTc-phytate and 99mTc-human serum albumin (HSA), when used in combination with blue dye.

METHODS

A consecutive series of 533 clinically node-negative patients with a collective 539 breast carcinomas were divided into two groups for treatment with SLNB. The HSA-group consisted of 264 patients (with a collective 266 breast cancers) and the P-group consisted of 269 patients (with a collective 273 breast cancers) treated with 99mTc-HSA and 99mTc-phytate, respectively, in combination with blue dye. We analyzed the identification and radioactivity of SLNs in the two groups.

RESULTS

The identification rate of SLN was significantly higher in the P-group than in the HSA-group. The same results were produced by analysis using the radioactive agent alone, but not by using the blue dye alone. Most importantly, the highest radioactivity of SLNs per case was more than five times higher in the P-group than in the HSA-group, and this difference was significant.

CONCLUSION

Our historical analysis of the two radioactive agents used in different periods could not exclude the influence of the improved skill of the surgeons. However, because the specific accumulation of phytate in SLNs was greater than that of HSA, phytate might result in a higher SLN identification rate. Thus, 99mTc-phytate is better than 99mTc-HSA as a radioactive agent for SLNB in breast cancer.

Two case of breast cancer with cartilaginous and osseous metaplasia

Invasive breast cancer (IBC) with cartilaginous or osseous metaplasia is rare. Here we report two cases of this unusual variation. Case 1: The patient was a 33-year-old woman with a right breast tumor, 2.2 cm in size. Mammograms (MMG) presented no specific findings, but ultrasound (US) showed a cystic-like lesion. Excisional biopsy confirmed IBC with cartilaginous and osseous metaplasia. Biopsy was followed with a modified radical mastectomy. One lymph node was positive, and both estrogen receptor (ER) and progesterone receptor (PgR) were negative. Case 2: The patient was a 43-year-old woman with a left breast tumor, 4.2 cm in size. MMGs presented no findings but US showed an irregular shaped, low-echoic area, suggesting malignancy. Core needle biopsy confirmed IBC with cartilaginous metaplasia. A total adenectomy and lymph node dissection with breast reconstruction using a lattisimus dorsi muscle flap were performed. Two of 18 lymph nodes were positive for metastasis and both ER and PgR were negative. IBC with cartilaginous or osseus metaplasia seem to be divided into two types pathologically, with or without intervening spindle cells, which is related to the prognosis. Matrix producing carcinoma (MPC) has no intervening spindle cells and a better prognosis than other types, however, MPC has been reported to have the same prognosis as ordinary breast cancer after for adjusting its stage. Our two cases were MPC's and no recurrence has been detected 5 and 3 years from the initial therapy, respectively.

DPD activity and immunohistochemical DPD expression in human breast cancer

We investigated dihydropyrimidine dehydrogenase (DPD) activity and its expression in breast cancer cases, and evaluated the prognostic significance of DPD expression in invasive breast cancer. A total of 49 paired of breast cancer tissues and the adjacent normal breast tissues were evaluated in this study. DPD expression of 191 patients with invasive breast cancer was also evaluated immunohistochemically. DPD activity in breast cancer ranged from 13.4-360.0 pmol/mg/min (mean, 162.9 pmol/mg/min). DPD activity in breast cancer tissues was significantly (p<0.001) higher than in adjacent normal breast tissue. DPD activity was significantly higher in DPD expression-positive tumors than DPD expression-negative tumors. The level of DPD activity was correlated with DPD expression. Patients with DPD expression-positive tumors had a significantly (p<0.05) poorer prognosis in disease-free survival compared to those with DPD-negative tumors. When evaluated in patients treated with 5-FU or 5-FU derivatives, DPD expression was a significantly (p<0.05) poorer prognostic factor in disease-free and overall survival. Using a Cox proportional hazards model, nodal status, ER status, and DPD expression were independent prognostic factors for both disease-free and overall survival. In conclusion, DPD expression may function as a marker of DPD activity and may be a prognostic indicator for patients with breast cancer.

Long-term suppression of lymphangitic lung metastasis from breast cancer using biweekly docetaxel: a case report

A 45-year-old woman underwent a modified radical mastectomy for right breast cancer in July 1996. As lymph node metastases were quite advanced, chemotherapy was started with anthracyclines. Four years after surgery, cough and dyspnea appeared. Chest radiograph and CT showed reticular shadows bilaterally and slight pleural effusion, suggesting lymphangitic lung metastasis of breast cancer. Biweekly intravenous docetaxel (TXT,45 mg/m2) was initiated. Four courses of TXT ameliorated her complaints and radiographic findings. A total of 30 continuous courses of TXT suppressed disease exacerbation for 18 months until new lesions manifested in January 2002. The main side effects were grade 2 leukopenia and alopecia. This case report describes a patient with long-term suppression of lymphangitic lung metastasis of breast cancer using biweekly TXT without severe side effects or worsening quality of life.

Prognostic significance of scoring system based on histological heterogeneity of invasive ductal carcinoma for node-negative breast cancer patients

This study aimed to determine the prognostic significance of histological scoring system based on heterogeneity of invasive ductal carcinoma, for node-negative breast cancer patients. We studied 108 patients of node-negative invasive ductal carcinoma with invasive tumor >5 mm. Histological score of each patient was evaluated based on histological subtype of invasive ductal carcinoma and pattern of its heterogeneity. Score of each subtype was defined as follows; papillotubular carcinoma: score 1, solid-tubular carcinoma: score 2 and scirrhous carcinoma: score 3. The existence of histological heterogeneity was examined, and corresponding score was doubled in a pure case and scores of two dominant subtypes were summed in a composite case. Overall survival curves defined by sores were drawn by Kaplan-Meier method and the difference in survival rate was evaluated by log-rank test. The most significant difference of overall survival was recognized between low score group (scores 2, 3 and 4) and high score group (scores 5 and 6) (p<0.001). In addition, multivariate analysis confirmed that only histological score was an independent prognostic factor. These results suggested that assessment of histological heterogeneity of invasive ductal carcinoma could serve as independent potent prognostic factor for node-negative invasive ductal carcinoma of the breast, and this method might be useful to decide indication of postoperative adjuvant chemotherapy.

Sentinel lymph node biopsy without axillary dissection after an intraoperative negative histological investigation in 358 invasive breast cancer cases

BACKGROUND

Sentinel lymph node biopsy (SLNB) is an important treatment option for breast cancer patients, as it can accurately predict axillary status. Our previous study using dye with or without radioisotope showed the accuracy and sensitivity of SLNB to be 97% and 94%, respectively. Based on these results, axillary lymph node dissection (ALND) was eliminated starting in January, 1999 in patients with intraoperatively negative SLNB at our institution. The present study shows the results and outcomes of SLNB as a sole procedure for patients with invasive breast cancer.

PATIENTS AND METHODS

Three-hundred-fifty-four patients and 358 cases of invasive breast cancer (4 bilateral breast carcinoma) treated with SLNB alone after an intraoperative negative SLNB were studied prospectively from January 1999 to December 2001.

RESULTS

The number of the identified SLNs per case ranged from 1 to 8 (mean, 2.5). Of a total of 358 cases, 297 (83%) were treated with hormone therapy and/or chemotherapy, and 281 (78%) were treated with radiotherapy to the conserved breast (50 Gy+/-10 Gy boost), the axilla (50 Gy), or the both sites. After a median follow-up of 21 (range 6-42) months, no patient developed an axillary relapse. Four cases initially recurred in distant organs and one case in the conserved breast.

CONCLUSIONS

Our results indicate that an intraoperative negative SLNB without further ALND may be a safe procedure when strict SLNB is performed. To better assess the safety, however, may require longer follow-up.

Primary amenorrhea accompanied by adrenal adenoma: start of menarche soon after tumor resection

We report a patient with primary amenorrhea accompanied by adrenal adenoma. A 21-year-old woman was admitted to our hospital because of primary amenorrhea and hyperprogesteronemia without virilization. Venous sampling showed progesterone overproduction at the left adrenal gland. Computed tomography revealed a 7 cm mass in left adrenal gland. Serum pregnenorone, 17-hydroxypregnenorone, dehydroepiandrosterone, 17-hydroxyprogesterone, deoxycorticosterone, and 11-deoxycortisol were elevated. The diagnosis of steroid hormone producing tumor was made. Following tumor resection, serum progesterone normalized 4 days later, and menarche occurred 51 days after operation. The present case indicated that adrenal functioning tumor should not be overlooked in patients with primary amenorrhea.

Prognostic significance of dihydropyrimidine dehydrogenase expression in breast cancer

We have investigated dihydropyrimidine dehydrogenase expression as a prognostic marker in breast cancer. A total of 119 women with breast cancer undergoing surgery between 1985 and 1996 were included in this study. Eighty-seven patients were treated with postoperative chemotherapy including 5-fluorouracil or 5-fluorouracil derivatives. Fifty-nine (50%) of 119 patients were determined to be immunostaining-positive for dihydropyrimidine dehydrogenase. There was no significant difference between dihydropyrimidine dehydrogenase staining and tumour size, lymph node status, clinical stage, oestrogen receptor status, histologic grade, or 5-fluorouracil administration. When evaluated in patients treated with 5-fluorouracil or 5-fluorouracil derivatives, patients with dihydropyrimidine dehydrogenase-positive tumours had a significantly (P<0.05) poorer disease-free survival compared to those with dihydropyrimidine dehydrogenase-negative tumour. No conclusion can be drawn about the prognostic impact of dihydropyrimidine dehydrogenase status in patients who were not treated with 5-fluorouracil regimes due to the small number of such cases in this series. Lymph node and dihydropyrimidine dehydrogenase status were independent prognostic factors for disease-free survival, and lymph node status for overall survival using multivariate analysis. In conclusion, dihydropyrimidine dehydrogenase is a possible prognostic factor in patients with breast cancer treated with 5-fluorouracil or 5-fluorouracil derivatives.

[A case of lymphocutaneous sporotrichosis]

We report a case of lymphocutaneous sporotrichosis in a 69-year old man who had nodular-ulcerated lesions on the right hand and forearm. Small nodules remained on the right hand after 8 weeks of 0.5 g daily treatment with potassium iodide. Alternatively, terbinafine therapy (125 mg/day) resulted in healing with atrophic scars after 9 weeks without side effects. We reviewed 67 patients of cutaneous sporotrichosis in Japan from 1993 to 1999. Those cure rates (and mean durations of treatments in parentheses) are 90.9% (8.1 weeks) with potassium iodide, 86.6% (12.6 weeks) with itraconazole (100 mg/day) and 71.4% (12.8 weeks) with terbinafine (125 mg/day) treatments, respectively. These results lead us to consider a daily dose of 250 mg as more appropriate for terbinafine.

[Dermatophytosis of the external auditory meatus]

Dermatophytosis of the external auditory meatus is believed to be a fairly rare disease. In the past three and a half years we have had seven cases of dermatophytosis in the external auditory meatus. All cases except one were associated with tinea of other lesions. Case 1: A 44-year-old man had tinea of the auricle, tinea pedis and tinea unguium. Case 2: A 14-year-old boy, the son of case 1 had no tinea elsewhere on his body, including the auricle. He scratched the auditory meatus with an earpick which his father had used. Case 3: A 62-year-old man had tinea of the auricle, tinea pedis and tinea unguium. Case 4: A 50-year-old man had tinea of the auricle, tinea pedis and tinea unguium. Case 5: A 36-year-old man had tinea of the auricle, tinea pedis, tinea unguium and tinea cruris. Case 6: A 30-year-old woman had tinea of the auricle. Case 7: A 68-year-old man had tinea of the auricle, tinea pedis, tinea unguium and tinea manuum. Endoscopic examination (except for cases 4 and 7) revealed dry cerumen from cartilaginous to bony region of the external auditory meatus. Direct examination using KOH method of the cerumen in all cases demonstrated numerous fungal elements. Fungal cultures identified Trichophyton rubrum except for cases 3 and 6. All cases were successfully treated with oral itraconazole or terbinafine. We suggest that tinea of the external auditory meatus is frequently associated with that of the auricle.

A case of seborrhoeic blepharitis

A fifty five-year old woman suffered from itching and scaling of the edge of her eyelid. She had long used topical corticosteroid for this condition. Direct examination of the scale by Parker KOH showed numerous fungal elements of spores and hyphae of Malassezia furfur. She was treated with oral itraconazole (100 mg daily or twice a week) for 8 weeks and was cured clinically and mycologically. The result suggests the possibility of treatment with an anti-fungal drug for seborrhoeic blepharitis or seborrhoeic dermatitis.

Purification of protease from a mixture of exfoliative toxin and newborn-mouse epidermis

Although the role of exfoliative toxin in staphylococcal scalded-skin syndrome has been suggested to be that of a serine protease, it has not been demonstrated to show proteolytic activity. Our purpose was to purify a proteolytic enzyme from a mixture of exfoliative toxin and newborn-mouse epidermis. We used gel filtration and ion-exchange and hydroxyapatite chromatography with a high-pressure liquid chromatography system. A casein-hydrolyzing enzyme was isolated from the mixture. The molecular mass of the enzyme was confirmed to be 20 kDa by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Subcutaneous injection of the purified enzyme into newborn mice reproduced the epidermal splitting that is seen in staphylococcal scalded-skin syndrome. These results suggest that exfoliative toxin does not work as a protease itself but that some reaction between exfoliative toxin and an epidermal component(s) first produces a protease, after which epidermal splitting occurs.

[Effect of temperature, humidity and minor injury to the penetration of dermatophytes into human stratum corneum]

We evaluated the minimum period for penetration of Trichophyton mentagrophytes into human stratum corneum using an experimental model of tinea pedis. Fungal elements were applied to the surface of stratum corneum which were obtained from a healthy human heel, and samples were incubated under a designated condition of temperature and humidity. Thirty-five degrees, which is the approximate temperature of the surface of human skin, seemed more suitable for penetration than 27C. The result also indicated that humidity was a more significant factor than temperature. In the following examination using T. mentagrophytes and T. rubrum, the minimum period for penetration at 100% humidity was 1 day with the former and 1.5 days with the latter. At 95% humidity, T. mentagrophytes penetrated into human stratum corneum on day 1.5 and T. rubrum penetrated on day 4. Humidity of the 4th interdigital space in daily life was calculated to be below 95% using a hygro-thermometer. Therefore, to wash the feet daily can prevent development of tinea pedis. When we applied fungal elements to a cut side of stratum corneum, fungi penetrated within a day at 100% and 95% humidity. In addition, fungi were able to penetrate at below 85% humidity, which they were unable to do when applied them to the surface side. We stress that minor injury of stratum corneum is also a significant factor of the development of tinea pedis.

[Statistical surveillance of mucocutaneous candidiasis in Showa University Fujigaoka Hospital in the past 5 years]

We investigated the epidemiology of 618 patients of mucocutaneous candidiasis who visited our outpatient clinic between 1993 and 1997. Compared with previous reports in Japan, the incidence of candida intertrigo increased and that of erythema mycoticum infantile decreased. The incidence of "others", such as nail candidiasis and candidiasis developed under plaster increased. We identified the species of Candida from patients in 496 recent cases, and these species were cultured successfully in 79.2%. As reported by previous authors, a majority or our results were Candida albicans serotype A. We also investigated the risk factors such as diseases or conditions which might be related to immunodeficiency (neoplasm, AIDS) and that might force a patient to restrict himself to bed for a long period (neurological disease). The former was found in 22.7%, and the latter in 23.3% of patients.

Temporal and behavioral patterning of parturition in rabbits and rats

Although the rabbit (Oryctolagus cuniculus) continues to play an important role in the study of parturitional processes, a detailed behavioral description of birth in this species, necessary for accurately assessing the effects of experimental manipulation, is lacking. It is the aim of this report to provide such a description and to compare it with corresponding behavior in the better-studied rat. Ten pregnant chinchilla-breed rabbits and 10 pregnant Wistar rats were placed in glass-bottomed observation cages 2 days before term, and their behavior recorded on closed-circuit video, viewing the animals from below. All aspects of parturition were accomplished much faster in rabbits than rats; latency to birth of first pup, rate of delivery, duration of vaginal retention, time spent by mothers eating placentas, and in licking and nursing pups. In contrast to rat pups, rabbits were usually born separated from the placenta and already free from membranes. They were much more active, and well able to cast off any remaining membranes, suckle, and survive, whether directly attended to by the mother or not. We conclude that the tight temporal organization of events in the rabbit provides an unusually sensitive assay for investigating mechanisms underlying mammalian parturition.

[Experimental studies on the penetration into the human stratum corneum of the dermatophyte]

We present results on the experimental penetration of Trichophyton mentagrophytes and T. rubrum under designated condition of humidity into human stratum corneum obtained from a healthy human heelregion. When mycelia were applied to the surface side of stratum corneum and then incubated at 100 % humidity, T. mentagrophytes and T. rubrum were observed in the stratum corneum on day 1 and day 1.5, respectively. At 95% humidity, T. mentagrophytes and T. rubrum penetrated on day 1.5 and day 4, and at 90% humidity, they penetrated on day 3 and day 7, respectively. At less than 85% humidity, no fungal elements of either strain were observed in stratum corneum for up to 7 days. These datasuggest that at least 90% humidity is necessary for these two fungi to penetrate into stratum corneum within a few days. However, when T. mentagrophytes was applied to the cutting side of the stratum corneum and thenincubated at more than 70% humidity, the mycelia were able to penetrate within a day. The same results were obtained when T. rubrum was applied on the cutting side and incubated at 95 and 100% humidity. T. rubrum was also able to penetrate into the stratum corneum within several days at 70 and 80% humidity. These results may indicate that not only persistent moisture but also minor injuries of stratum corneum are the most important factors in the development of tinea pedis.

Induction of a critical elevation of povidone-iodine absorption in the treatment of a burn patient: report of a case

A critical elevation of povidone-iodine absorption which occurred in a burn patient who was topically treated with 10% povidone-iodine (PI) gel is herein reported. A 65-year-old man was admitted to our hospital for deep second- and third-degree burns covering 26% of his total body surface area. The intravenous administration with lactated Ringer's solution and topical treatment with silver sulfadiazine were applied in addition to such treatments as debridement and skin grafting. However, wound infection occurred due to Pseudomonas aeruginosa. Topical treatment with PI gel was effective for this condition. Persistent nodal bradycardia with hypotension, metabolic acidosis, and renal failure occurred 16 days after the start of PI gel treatment. Iodine toxicosis caused by PI gel was suspected with a serum iodine level of 20600 microg/dl (normal range 2-9 microg/dl). The PI gel treatment was therefore discontinued immediately, and hemodialysis was scheduled. However, the patient's family refused hemodialysis and he died 44 days after admission. To our knowledge, only eight patients with iodine toxicosis have been reported in burn patients treated with PI gel.

[Evaluation of the efficacy of small-dose itraconazole pulse therapy (200 mg/day) for tinea unguium]

Thirty-six patients with tinea unguium were treated with 200 mg of itraconazole daily for 7 days each month. We suggested that a patient who had a lesion in the thumbnail needed 5 months of treatment for mycologial cure, while in a patient without thumbnail lesion, 3 months of treatment was enough.

Experimental penetration of Trichophyton mentagrophytes into human stratum corneum

We present confirmation of the experimental penetration of Trichophyton mentagrophytes into human stratum corneum under designated conditions of temperature and humidity. When stratum corneum, obtained from healthy human heel region, was incubated at 100% humidity, mycelium was observed in the corneum layer on day 2 at 35 degrees C and 27 degrees C, and on day 4 at 15 degrees C. At 90% humidity, the hyphae penetrated into the stratum corneum on day 4 at 35 degrees C, and on day 6 at 27 degrees C. Whereas, at 80% humidity, no fungal elements were observed in the stratum corneum at both 27 degrees C and 35 degrees C for up to 7 days. These data suggested that humidity was a more important environmental factor for penetration than temperature, and that at least 90% humidity is necessary for dermatophytes to penetrate into the stratum corneum within a few days. Mean humidity in the interdigital space between the fourth and fifth toes was found to be approximately 98%.

Successful treatment of anomalous origin of the left coronary artery from the pulmonary artery in a 5-week-old male infant

A 5-week-old male infant who was referred to our hospital because of tachypnea and poor feeding. An electrocardiogram showed a deep Q wave in lead aVL, negative T waves in leads I, II, III, aVF and V6 and a positive T wave in VL. Echocardiography revealed severely impaired left ventricular function. Aortography confirmed with a diagnosis of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Takeuchi's procedure was performed and the patient maintained postoperatively on assisted circulation for 7 hours even though sternal closure delayed until 7 days post operatively. His left ventricular function showed and marked improvement gradually.