Paternal morphine exposure enhances morphine self-administration and induces region-specific neural adaptations in reward-related brain regions of male offspring

Background

A growing body of preclinical studies report that preconceptional experiences can have a profound and long-lasting impact on adult offspring behavior and physiology. However, less is known about paternal drug exposure and its effects on reward sensitivity in the next generation.

Methods

Adult male rats self-administered morphine for 65 days; controls received saline. Sires were bred to drug-naïve dams to produce first-generation (F1) offspring. Morphine, cocaine, and nicotine self-administration were measured in adult F1 progeny. Molecular correlates of addiction-like behaviors were measured in reward-related brain regions of drug naïve F1 offspring.

Results

Male, but not female offspring produced by morphine-exposed sires exhibited dose-dependent increased morphine self-administration and increased motivation to earn morphine infusions under a progressive ratio schedule of reinforcement. This phenotype was drug-specific as self-administration of cocaine, nicotine, and sucrose were not altered by paternal morphine history. The male offspring of morphine-exposed sires also had increased expression of mu-opioid receptors in the ventral tegmental area but not in the nucleus accumbens.

Conclusions

Paternal morphine exposure increased morphine addiction-like behavioral vulnerability in male but not female progeny. This phenotype is likely driven by long-lasting neural adaptations within the reward neural brain pathways.

A novel Oprm1-Cre mouse maintains endogenous expression, function and enables detailed molecular characterization of μ-opioid receptor cells

Key targets of both the therapeutic and abused properties of opioids are μ-opioid receptors (MORs). Despite years of research investigating the biochemistry and signal transduction pathways associated with MOR activation, we do not fully understand the cellular mechanisms underlying opioid addiction. Given that addictive opioids such as morphine, oxycodone, heroin, and fentanyl all activate MORs, and current therapies such as naloxone and buprenorphine block this activation, the availability of tools to mechanistically investigate opioid-mediated cellular and behavioral phenotypes are necessary. Therefore, we derived, validated, and applied a novel MOR-specific Cre mouse line, inserting a T2A cleavable peptide sequence and the Cre coding sequence into the MOR 3'UTR. Importantly, this line shows specificity and fidelity of MOR expression throughout the brain and with respect to function, there were no differences in behavioral responses to morphine when compared to wild type mice, nor are there any alterations in Oprm1 gene expression or receptor density. To assess Cre recombinase activity, MOR-Cre mice were crossed with the floxed GFP-reporters, RosaLSLSun1-sfGFP or RosaLSL-GFP-L10a. The latter allowed for cell type specific RNA sequencing via TRAP (Translating Ribosome Affinity Purification) of striatal MOR+ neurons following opioid withdrawal. The breadth of utility of this new tool will greatly facilitate the study of opioid biology under varying conditions.

Agonist-Promoted Phosphorylation and Internalization of the Kappa Opioid Receptor in Mouse Brains: Lack of Connection With Conditioned Place Aversion

Selective kappa opioid receptor (KOR) agonists are promising antipruritic agents and analgesics. However, clinical development of KOR agonists has been limited by side effects, including psychotomimetic effects, dysphoria, and sedation, except for nalfurafine, and recently. CR845 (difelikefalin). Activation of KOR elicits G protein- and β-arrestin-mediated signaling. KOR-induced analgesic and antipruritic effects are mediated by G protein signaling. However, different results have been reported as to whether conditioned place aversion (CPA) induced by KOR agonists is mediated by β-arrestin signaling. In this study, we examined in male mice if there was a connection between agonist-promoted CPA and KOR phosphorylation and internalization, proxies for β-arrestin recruitment in vivo using four KOR agonists. Herein, we demonstrated that at doses producing maximal effective analgesic and antiscratch effects, U50,488H, MOM-SalB, and 42B, but not nalfurafine, promoted KOR phosphorylation at T363 and S369 in mouse brains, as detected by immunoblotting with phospho-KOR-specific antibodies. In addition, at doses producing maximal effective analgesic and antiscratch effects, U50,488H, MOM-SalB, and 42B, but not nalfurafine, caused KOR internalization in the ventral tegmental area of a mutant mouse line expressing a fusion protein of KOR conjugated at the C-terminus with tdTomato (KtdT). We have reported previously that the KOR agonists U50,488H and methoxymethyl salvinorin B (MOM-SalB) cause CPA, whereas nalfurafine and 42B do not, at doses effective for analgesic and antiscratch effects. Taken together, these data reveal a lack of connection between agonist-promoted KOR-mediated CPA with agonist-induced KOR phosphorylation and internalization in male mice.

Abstract P3-03-03: A tri-modality imaging assessment algorithm to evaluate neoadjuvant therapy response in patients with operable breast cancer

Background: To determine the negative predictive value (NPV), positive predictive value (PPV), accuracy, sensitivity and specificity of a pre-surgical tri-modality imaging assessment algorithm to determine complete pathologic response (pCR) post neoadjuvant therapy in patients with operable breast cancer.

Methods: A retrospective analysis was performed on data collected from patients receiving neoadjuvant therapy and pre-surgical breast magnetic resonance imaging (MRI), ultrasound (US) and mammography between 2004 and 2010 at our institution. Tri-modality imaging was reviewed by a single blinded breast radiologist and evaluated for predetermined modality specific parameters as defined in Table 1. The NPV, PPV, accuracy, sensitivity, and specificity were calculated on the basis of the final surgical pathology report with a complete pathologic response in the breast defined as no residual invasive disease or in situ disease.

Results. Eighty-three tumors in 83 patients with a mean age of 50 (range 27–70) were evaluated. Twenty-three patients had a pCR. The NPV, PPV, sensitivity, specificity, and accuracy of tri-modality imaging algorithm for pCR were 0.87, 0.95, 0.95, 0.87 and 0.93 utilizing a cut-point of ≤ 5 for complete response by imaging. The mean score for patients with pCR was 4.61 (range 3–10) with 3 patients scoring above 5. The mean score for patients with residual disease was 7.73 (range 5–11).

Conclusions: A tri-modality imaging scoring algorithm is predictive of complete pathologic response. This algorithm will be tested in a developing prospective trial that will also assess the additive value of tumor bed biopsy in patients who achieve a score of 5 or less.

P3-14-26: The Effect of Biologic Subtype in Patients Treated with Neoadjuvant Chemotherapy: A UAB Experience

Purpose: Previous studies have suggested that the pre treatment clinical stage drives loco-regional recurrence (LRR), distant metastasis (DM) and survival in patients treated with neoadjuvant chemotherapy. This retrospective analysis was performed to look at the effect of biologic subtype on patient outcomes.

Methods: Between 1999 and 2005, 115 patients treated with neoadjuvant chemotherapy, surgery, and +/−radiation therapy at UAB were identified. Patient, tumor, and treatment characteristics were recorded. Pathologic complete response was defined as resolution of both invasive disease and DCIS in both the primary and nodal disease. Survival was measured using the Kaplan Meier statistics. Univariate and multivariate analyses of covariates associated with LRR, DM, progression-free (PFS) and overall survival (OS) were performed. Results: The mean age was 49 years, with a mean follow-up of 5.8 years. Subtype distribution was as follows: 52 luminal A, 17 luminal B, 36 triple negative, 9 Her2+ and one patient with an unknown biologic subtype. Distribution of clinical stage was as follows: 40 IIA, 34 IIB, 26 IIIA, 10 IIIB, and 5 IIIC. Tumors were down-staged following neoadjuvant therapy as follows: 18: pCR, 6: residual DCIS, 17: I, 38: IIA, 11: IIB, 13: IIIA, 5: IIIB, and 7: IIIC. Pre-treatment clinical stage did not significantly influence LRR, DM or progression free and overall survival; however, final pathologic T, N and group stage were associated with both progression free, p=0.003, 0.011, 0.005 and overall survival, p=0.02, 0.037, and 0.009. Complete resolution of tumor by mammographic or MR imaging to neoadjuvant chemotherapy, was associated with an increased overall survival, p=0.0025. Univariate analysis did not show a significant effect of biologic subtype, age, grade, use of radiation therapy or anti-hormonal therapy.

Discussion: In this retrospective series, response to chemotherapy and the final pathologic stage, representing the volume of residual disease, were important predictors of survival. Further study to determine factors predictive of chemotherapy response is needed.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-14-26.

P3-07-06: Prognostic Utility of Upfront Nodal Staging Prior to Neoadjuvant Chemotherapy: The UAB Experience

Purpose: Controversy exists regarding the prognostic utility of upfront lymph node staging in patients receiving neoadjuvant chemotherapy. This retrospective study explores whether upfront verses outback nodal staging influenced locoregional control and survival endpoints. Methods: Between 1999 and 2005 one hundred and fifteen patients treated with neoadjuvant chemotherapy at UAB were identified. Patient, tumor, and treatment variables were recorded. Timing of nodal assessment was based on either surgeon preference or stipulated upfront per several clinical protocols. Survival was measured using the Kaplan Meier statistics. Univariate and multivariate analyses of covariates associated with local-regional control (LRC), progressionfree (PFS) and overall survival (OS) were performed. Results: Mean age was 49 years and mean follow-up was 5.8 years. Stage distribution was as follows: 40 IIA, 34 IIB, 26 IIIA, 10 IIIB, and 5 IIIC. Definitive surgery included breast conservation in 49 patients, total mastectomy in 21 and modified radical mastectomy in 44. Seventy-two patients had upfront nodal sampling before neoadjuvant therapy, 36 by fine needle assessment and the remainder by sentinel node biopsy. Forty-three patients had their nodal assessment following neoadjuvant chemotherapy. Of those with upfront nodal staging: forty nine patients had a positive nodal result and 23 had negative findings. In those that were sampled at the time of definitive surgery: 21 had positive results, 21 had a negative result, and 1 patient did not have any nodes in the specimen. One hundred five patients had post-operative radiation therapy. Overall there was no difference in LRC, PFS or OS outcomes between patients that had an upfront nodal staging procedure and those that had their nodes sampled at the time of definitive surgery. Patients achieving pCR had a non-significant trend towards improved overall survival (p=0.12). Final pathologic T, N and group stage were statistically significant in determining the progression free, p=0.003, 0.011, 0.005 and overall survival, p=0.02, 0.037, and 0.009. Lymphovascular space invasion was associated with progression free survival on univariate analysis, p=0.0179, but not multivariate analysis. Other covariates including age, biologic subtype, grade, type of chemotherapy, use of radiation therapy, radiation volume, time to complete radiation therapy, and use of hormonal therapy did not affect outcomes. Discussion: Upfront as compared with outback lymph node staging did not influence locoregional control or survival endpoints. Final pathologic stage and not initial clinical stage remains the most important prognostic factor associated with survival.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-06.

Abstract P1-12-04: Long Term Follow-Up of a Pilot Trial of Pre-Operative (Neoadjuvant) Letrozole in Combination with Bevacizumab in Post-Menopausal Women with Newly Diagnosed Estrogen and/or Progesterone Receptor Positive Breast Cancer

Introduction: Overexpression of vascular endothelial growth factor (VEGF) in breast cancer tumors has been associated with resistance to anti-estrogen adjuvant therapy. We designed a pilot study of neoadjuvant letrozole and bevacizumab (anti-VEGF) to assess feasibility and short term efficacy in post-menopausal women with stage II/III, ER/PR positive breast cancer. Patients and Methods: Patients were treated with a neoadjuvant regimen of letrozole, 2.5 mg/day (PO) and bevacizumab 15 mg/kg every 3 weeks (IV) for a total of 24 weeks prior to surgical treatment of their breast cancer. Patients were followed for toxicity at three week intervals and tumor assessment (physical exam and tumor ultrasound) at six week intervals. Results: Twenty-five evaluable patients were treated. The regimen was well tolerated except for two patients who were taken off-study for difficult to control hypertension. Objective clinical response occurred in 17/25 patients (68%) including 16% CR and 52% PR. The four patients with clinical CR had pathologic CR in their breasts (16%) although one had residual tumor cells in axillary nodes. Two of the 17 responding patients were lost to follow-up; with a median follow-up of 50 months, no relapses have been seen in the 15 responsive patients, including 10 patients who received no adjuvant chemotherapy. Two patients with progressive disease at 9 and 16 weeks received neoadjuvant chemotherapy, surgery and radiation. One of these patients relapsed at 35 months and the other is NED at 44 months. Four patients had stable disease and all received adjuvant chemotherapy; one patient relapsed at 25 months, and the reminder are NED at 44-52 months. Overall, 2 out of 21 patients with adequate follow-up had disease reoccurrence (9.5%) at a median follow-up of 45 months. Conclusion: Combination neoadjuvant therapy with letrozole and bevacizumab was well tolerated and resulted in impressive clinical and pathologic responses. Data suggest that patients having an objective response to neoadjuvant therapy had excellent 4 year disease-free survival (100%) while relapsed occurred in 2 out of 6 patients who failed to have an objective response despite additional neoadjuvant or adjuvant chemotherapy. The Breast Cancer Translational Research Consortium has an ongoing randomized phase II trial of letrozole ± bevacizumab in this patient population.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-12-04.

Abstract P4-11-04: The Influence of Radiation on Survival in Patients with Triple Negative Stage II Breast Cancer

Background: Prospective trials of locally advanced breast cancer patients treated with adjuvant radiation (RT) have demonstrated a survival advantage; however, use of postmastectomy RT in stage II patients is controversial. This study explores the possibility that patients with aggressive variant molecular subtypes [triple receptor negative (TN)] treated with modern chemotherapy, may experience a survival benefit from adjuvant RT.

Methods: Billing codes for all breast cancer patients treated with chemotherapy between 1/1998 and 5/2005 at the University of Alabama at Birmingham were reviewed to comprehensively capture all Stage II and III patients with intact data. Patient, tumor, and treatment related variables were recorded and patients were divided into 3 molecular subtypes based on receptor status: hormone receptor (HR) positive, Her2 negative; HR+/− , Her2+; and TN. Kaplan Meier curves to assess survival were performed by dividing the TN group into 2 groups: those who did or did not receive adjuvant RT.

Results: 409 patients with stage II-III disease with were identified. Out of this group, 81 patients had TN breast cancer (60 Stage II and 21 Stage III). RT data was known in 79 of these patients. Median age was 49 years. Median follow-up was 72 months. Thirty-seven stage II and 18 stage III patients received adjuvant RT. Of the stage II patients who received radiation, 25 underwent lumpectomy and 11 underwent mastectomy. Stage II patients who received adjuvant RT had a statistically significant improvement in DFS (p=0.03), and had a trend towards improvement in OS (p=0.07) when compared with those who did not receive adjuvant RT. There was no significant difference in survival for the stage III patients with use of RT, however numbers in this group were small. Conclusion: Adjuvant RT was associated with an improvement in DFS and a trend towards improvement in OS in patients with Stage II, TN breast cancers treated with modern chemotherapy.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-04.

Abstract P5-10-19: The Influence of Time to Completion of Chemotherapy on Survival in Patients with Triple Negative Stage III Breast Cancer

Background: Neoadjuvant chemotherapy is increasingly delivered to facilitate breast conserving surgery through tumor downstaging. Prospective trials of neoadjuvant chemotherapy from the NSABP suggest no difference in survival outcomes in patients receiving neoadjuvant versus adjuvant therapy; however, subset analysis in 2 combined trials (B-18 and B-27) demonstrated a trend in DFS improvement in young patients (<50 yrs), who often have more aggressive variant tumors. This study explores the possibility that patients with aggressive variant molecular subtypes [triple receptor negative (TN)] treated with modern chemotherapy, may significantly benefit from earlier completion of drug delivery. Methods: Billing codes for all breast cancer patients treated with chemotherapy between 1/1998 and 5/2005 at the University of Alabama at Birmingham were reviewed to comprehensively capture all Stage II and III patients with intact data. Patient, tumor, and treatment related variables were recorded and patients were divided to 4 molecular subtypes based on receptor status: hormone receptor (HR) positive, Her2 negative; HR+/− , Her2+; and triple receptor negative (TN). Kaplan Meier curves to assess survival were performed by dividing the TN group into 2 groups: those completing chemotherapy ≥5 vs > 5 months from diagnosis. Results: 409 patients with Stage II-III disease with were identified: 124 received neoadjuvant and 285 received adjuvant chemotherapy. Out of this group, 81 patients had TN breast cancer (60 Stage II and 21 Stage III). Median age was 49 years. Median follow-up was 72 months. Chemotherapy consisted of adriamycin, taxol and cytoxan for a median of 9 cycles. Stage III patients who completed chemotherapy within 5 months had a statistically significant improvement in OS and DFS (p=0.03), and had a trend towards improvement in DMFS (p=0.10) when compared with those who took longer than 5 months to complete chemotherapy. Conclusion: Completion of chemotherapy in a shorter time interval in patients with Stage III, TN breast cancers was associated with an improvement in DFS and OS. Consideration of timing of chemotherapy warrants further study.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-10-19.

A Pilot Trial of Pre-Operative (Neoadjuvant) Letrozole in Combination with Bevacizumab in Post-Menopausal Women with Newly Diagnosed Estrogen and/or Progesterone Receptor Positive Breast Cancer

Purpose Tumor content or expression of vascular endothelial growth factor (VEGF) is associated with impaired efficacy of anti-estrogen adjuvant therapy. We designed a pilot study of neoadjuvant letrozole and bevacizumab (anti-VEGF) to assess feasibility and short term efficacy in post-menopausal women with stage II/III, ER/PR positive breast cancer. Patients and Methods Patients were treated with a neo-adjuvant regimen of letrozole, 2.5mg/day (P.O.) and bevacizumab 15mg/kg Q3 weeks (I.V.) for a total of 24 weeks prior to surgical treatment of their breast cancer. Patients were followed for toxicity at 3 week intervals and tumor assessment (physical exam and tumor ultrasound) at 6 week intervals. PET scans were carried out prior to therapy and 6 weeks after initiation of therapy. Surgery was done 4 weeks after the last dose of bevacizumab. Results Twenty five evaluable patients were treated. The regimen was well tolerated except for 2 patients who were taken off-study for difficult to control hypertension. Objective clinical response occurred in 17/25 patients (68%) including 16% CR and 52% PR. The 4 patients with clinical CR had pathologic CR in their breasts (16%) although one had residual tumor cells in axillary nodes. 8/25 patients (32%) attained stage 0 or 1 status. PET scan response at 6 weeks correlated with clinical CR and breast pathologic CR at 24 weeks (p < 0.0036). Conclusion Combination neo-adjuvant therapy with letrozole and bevacizumab was well tolerated and resulted in impressive clinical and pathologic responses. The Breast Cancer Translational Research Consortium has an ongoing randomized phase II trial of this regimen in this patient population.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1088.

The Accuracy of MRI in Predicting Pathologic Complete Response in Invasive Breast Cancer Patients Receiving Neoadjuvant Systemic Treatment

Background: Magnetic resonance imaging (MRI) has increased sensitivity to detect abnormalities in breast tissue as compared with mammography or ultrasound. Published reports of MRIs ability to predict pathologic response to neoadjuvant chemotherapy have shown conflicting results that vary depending on baseline molecular characteristics and chemotherapeutic regimens, with some studies suggesting higher predictive accuracy in Her2 positive patients receiving trastuzumab. This study examines both the ability of MRI to predict pathologic response and how tumor molecular profiles and treatment regimens influence MRI sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Sensitivity, specificity, PPV, and NPV for the combination of post-treatment mammogram, ultrasound, and MRI studies in predicting pathologic complete response (pCR) was also explored.Methods: Eighty-one patients with invasive breast cancer treated with neoadjuvant systemic therapy between 2002 to 2009 and imaged pre and post-treatment with breast MRI were reviewed. Patient, tumor, and treatment characteristics including tumor grade, histologic type, receptor status (ER, PR, and Her2), breast cancer subtype [luminal A, luminal B, Her2 positive, triple negative (TN)], correlative pre- and post-treatment mammographic and ultrasound imaging, drug regimen, and pathologic findings were recorded. Complete pathologic response was defined as no residual invasive or pre-invasive disease in the breast.Results: Patients had the following subtypes of breast cancer: 21/81 (26%) luminal A, 13/81 (16%) luminal B, 23/81 (28%) Her2 positive, and 24/81(30%) TN. Of the Her2 positive, only 12/23 (52%) treated after May 2005 received adjuvant trastuzumab. Twenty patients (25%) had a complete radiographic response (rCR) on post-treatment MRI and 23/81(28%) had a pCR. The sensitivity, specificity, PPV, and NPV of MRI for predicting pathologic response was 57%, 88%, 65%, and 84%, respectively. Analysis of breast cancer subtype did not demonstrate a predilection in any particular subtype for correlation of radiographic and pathologic response, although MRI sensitivity (100%) and NPV (100%) were highest in luminal A disease, and specificity and PPV were highest for patients with ER negative (96% and 90%) and triple negative (100% and 100%) disease, respectively. Mammographic and ultrasound post-treatment findings of residual disease did not significantly correlate with pathologic findings in the setting of a rCR on MRI. Multivariate analysis of factors potentially influencing MRIs sensitivity and specificity failed to show that tumor characteristics (ER status, PR status, HER2 status) or neoadjuvant treatment (ACT vs other or trastuzumab) had any effect on these parameters.Conclusions: MRI has the highest specificity and PPV in the setting of ER negative and TN breast cancer. Although treatment results and breast cancer subtype did not influence the sensitivity, specificity, PPV, or NPV of MRI in predicting pathologic response, only half of the Her2 positive subset received trastuzumab. Results from an ongoing large multi-institutional study will further clarify these results.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4022.

Safety and effectiveness of dose dense neoadjuvant chemotherapy in patients with stage II/III breast cancer

e11566

Background: NSABP B-18 randomized women with operable breast cancer to receive chemotherapy (AC) either pre- or postoperatively; in the study there was no significant difference in disease free survival (DFS) or overall survival (OS) among patients in either group. Pathologic complete response rate (pCR) was directly proportional to DFS and OS. Dose dense adjuvant chemotherapy (ATC) has shown a statistically significant improvement in DFS and OS. Methods: We performed a single institution review of pts enrolled in a neoadjuvant trial and who received dose dense neoadjuvant chemotherapy (doxorubicin 60 mg/m2 IV Q2wks x4, paclitaxel 175 mg/m2 IV Q2wks x4, and cyclophosphamide 600 mg/m2 IV Q2wks x4) to assess response rates, safety, and DFS. Women with newly diagnosed breast cancer, T ≥ 3cm, any N, M0 were enrolled. Results: Since 02/2003, 43 pts were enrolled (mean age 47.6, range 28–64) and received dose dense chemotherapy. 41.4% of the pts were triple negative and 14.6% were Her2+ by FISH or IHC. The median follow-up is 49 months (range 8–69). Two patients dropped out without finishing therapy. Forty one pts completed dose dense chemotherapy and proceeded to surgery. 17 pts (41.4%) achieved a pCR in the breast and of those 14 pts were also negative in the axillary lymph nodes (34.1% pCR in the breast and lymph nodes). 10 of the 17 pts with pCR in the breast (8 out of the 14 pts with pCR in breast and axillary lymph nodes) were triple negative. 18 pts (43.9%) achieved PR, 3 pts (7.31%) had SD and 3 pts (7.31%) had PD. Up to November 2008, 7 pts who did not have a pCR have relapsed (4 triple negative, 1 Her2+, 1 ER/PR positive and 1 ER negative, PR positive) with a relapsed free survival rate of 85%. Hematologic toxicity consisted of grade 3 anemia in 2 patients with no grade 4 anemia, no G4 thrombocytopenia and febrile neutropenia in 2 pts. Non-hematologic grade 3 or 4 toxicity consisted of mediport thrombosis in 2 pts, hyperglycemia in 2 pts, syncope in 1 pt, neuropathy in 1 pt, and varicella zoster in 1 pt. Conclusions: Our results show that dose dense neoadjuvant chemotherapy achieves a pCR (breast + node) in about 1/3 of patients (34%) with tolerable toxicity; although the number of patients is limited, our data suggest that triple negative breast cancer seems to be the most sensitive tumor to this regimen.

No significant financial relationships to disclose.

Is surgical management compromised in elderly patients with breast cancer?

OBJECTIVE

The suggestion that breast cancer management is compromised in elderly patients had prompted our review of the results of policies regarding screening and early detection of breast cancer and the adequacy of primary treatment in older women (> or = 65 years of age) compared to younger women (40 to 64 years of age).

SUMMARY BACKGROUND DATA

Although breast cancer in elderly patients is considered biologically less aggressive than similar staged cancer in younger counterparts, outcome still is a matter of stage and adequate treatment of primary cancer. For many reasons, physicians appear reluctant to treat elderly patients according to the same standards used for younger patients. There is even government-mandated alterations in early detection programs. Thus, since 1993, Medicare has mandated screening mammography on a biennial basis for women older than 65 year of age compared to the current accepted standard of yearly mammograms for women older than 50 years of age. Using State Health Department and tumor registry data, the authors reviewed screening practice and management of elderly patients with primary breast cancer to determine the effects of age on screening, detection policies (as reflected in stage at diagnosis), treatment strategies, and outcome.

METHODS

Data were analyzed from 5962 patients with breast cancer recorded in the state-wide Tumor Registry of the Hospital Association of Rhoda Island between 1987 and 1995. The focus of the data collection was nine institutions with established tumor registries using AJCC classified tumor data. Additional data were provided by the State Health Department on screening mammography practice in 2536 women during the years 1987, 1989, and 1995.

RESULTS

The frequency of mammographic screening for all averaged 40% in 1987, 52% in 1987, and 63% in 1995. In the 65-year-old and older patients, the frequency of screening was 34% in 1987, 45% in 1989, and 48% in 1995, whereas in the 40- to 49-year-old age group, the frequency of mammography was 47% in 1987, 61% in 1989, and 74% in 1995 (p < 0.001). There was a lower detection rate of preinvasive cancer in the 65-year-old and older patients, 8.8% versus 13.7% in patients within the 40- to 64-year-old age group (p < 0.001). There was a higher percentage of treatment by limited surgery among elderly patients with highly curable Stage IA and IB cancer with 26.6% having lumpectomy alone versus 9.4% in the younger patients. Five-year survival in that group was significantly worse (63%) than in patients treated by mastectomy (80%) or lumpectomy with axillary dissection and radiation (95%, < 0.001). A similar effect was seen in patients with Stage II cancer.

CONCLUSIONS

Breast cancer management appears compromised in elderly patients (older than 65 years of age). Frequency of mammography screening is significantly less in elderly women older than 65 years of age. Early detection of preinvasive (curative cancers) is significantly less than in younger patients. The recent requirement by Medicare of mammography every other year may further reduce the opportunity to detect potentially curable cancers. Approximately 20% of patients had inferior treatment of favorable stage early primary cancer with worsened survival. Detection and treatment strategy changes are needed to remedy these deficiencies.

Paclitaxel and concurrent radiation for locally advanced pancreatic and gastric cancer: a phase I study

PURPOSE

To determine the maximum-tolerated dose (MTD), dose-limiting toxicities, and potential antitumor activity of weekly paclitaxel with concurrent radiation (RT) for locally advanced pancreatic and gastric cancer.

PATIENTS AND METHODS

Thirty-four patients with locally advanced adenocarcinoma of the pancreas or stomach were studied. The initial dose of paclitaxel was 30 mg/m2 by 3-hour intravenous (I.V.) infusion repeated every week for 6 weeks with 50 Gy RT. Doses were escalated at 10-mg/m2 increments in successive cohorts of three new patients until dose-limiting toxicity was observed.

RESULTS

The dose-limiting toxicities at 60 mg/m2/wk were abdominal pain within the RT field, nausea, and anorexia. Of 23 patients with assessable disease, 11 (seven with gastric, four with pancreatic cancer) had objective responses for an overall response rate of 48%.

CONCLUSION

Concurrent paclitaxel with upper abdominal RT is well tolerated at dosages that have substantial activity. A phase II trial of neoadjuvant paclitaxel and RT at the MTD of 50 mg/m2/wk is underway.

Immunologic localization and kinetic characterization of a Na+/Ca2+ exchanger in neuronal and non-neuronal cells

The plasma membrane Na+/Ca2+ exchanger is believed to play a role in the regulation of Ca2+ fluxes in neurons, though the lack of specific inhibitors has limited the delineation of its precise contribution. We recently reported the development of antibodies against a 36-kDa brain synaptic membrane protein which immunoprecipitated exchanger activity from solubilized membranes. In the present study we examined the kinetics of the Na+/Ca2+ exchanger in primary neurons in culture, in a neuronal hybrid cell line (NCB-20), and in a fibroblast-like cell line (CV-1) to see whether the level of exchanger activity correlated with the degree of immunostaining produced by our antibodies. The Vmax was determined for each cell type and found to be highest in primary neurons. Exchanger activity increased in primary neurons between days 1 and 6 in culture, but no such time-dependent change occurred in either of the cell lines. Immunoblot analysis of the three cell types probed with the anti-36-kDa protein antibodies revealed significantly greater immunostaining in the primary neurons compared with the other two cell types. Intensity of staining of neurons also increased significantly between days 1 and 6 in culture. Immunocytochemistry showed significant labelling of the primary neurons on the neuritic processes and points of contact between cells. The NCB-20 and CV-1 cells showed considerably lower levels of immunoreactivity. The antibodies immunoextracted approximately 90% of the exchanger activity in the primary neurons and approximately 70 and 50% of the activity in NCB-20 and CV-1 cells respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention and early detection of melanoma: a surgeon's perspective

Americans are clearly losing the battle against malignant melanoma. In 1930, it was estimated that one in 1,500 people would develop melanoma sometime during their lifetimes, but by the year 2000, one in 75 people in the United States will develop the disease. Although the individual case prognosis is improving, the death rate has doubled in the last 35 years. The rising mortality rate has to be attributed to an escalating incidence that is not offset sufficiently by improved diagnosis and treatment. Malignant melanoma is a disease that lends itself to early detection and screening programs. Melanoma is highly prevalent and causes considerable morbidity and mortality. The natural history of the disease is known and it is well established that the earlier diagnosis of "thinner" lesions can reduce morbidity and mortality. There is also an acceptable, safe, inexpensive, and noninvasive screening test for melanoma, the skin examination. This work reviews the current evidence that melanoma screening may be effective, compares screening projects for this cutaneous tumor with other screening programs, and outlines a proposed project for melanoma screening.

Radioimmunoguided surgery using iodine 125 B72.3 in patients with colorectal cancer

Preliminary data using B72.3 murine monoclonal antibody labeled with iodine 125 suggested that both clinically apparent as well as occult sites of colorectal cancer could be identified intraoperatively using a hand-held gamma detecting probe. We report the preliminary data of a multicenter trial of this approach in patients with primary or recurrent colorectal cancer. One hundred four patients with primary, suspected, or known recurrent colorectal cancer received an intravenous infusion of 1 mg of B72.3 monoclonal antibody radiolabeled with 7.4 x 10 Bq of iodine 125. Twenty-six patients with primary colorectal cancer and 72 patients with recurrent colorectal cancer were examined. Using the gamma detecting probe, 78% of the patients had localization of the antibody in their tumor; this included 75% of primary tumor sites and 63% of all recurrent tumor sites; 9.2% of all tumor sites identified represented occult sites detected only with the gamma detecting probe. The overall sensitivity was 77% and a predictive value of a positive detection was 78%. A total of 30 occult sites in 26 patients were identified. In patients with recurrent cancer, the antibody study provided unique data that precluded resection in 10 patients, and in another eight patients it extended the potentially curative procedure.

Positive relationship of clinical and serologic responses to vaccinia melanoma oncolysate

In this phase Ia/Ib trial, vaccinia melanoma oncolysate (VMO) is a virus-augmented melanoma cell membrane vaccine that has been shown to be safe and to stimulate the production of antimelanoma antibodies in high-risk melanoma patients treated in a surgical adjuvant setting. One patient with stage I and 38 patients with stage II melanoma were entered in the study between December 1984 and October 1985, with a mean follow-up of approximately 17 months. Each patient received a smallpox booster injection followed one week later by the first of 13 weekly intradermal injections of 2.0 mg of VMO. At the end of 13 weeks, injections were given every other week for 12 months or until recurrence. Clinical results show that 25 of the 39 patients had no evidence of disease as of December 1986. Moreover and more importantly, statistical comparison of patients in this study with 39 matched controls shows a significant increase in disease-free survival for the patients treated with VMO. Serum obtained prior to treatment and at three-month intervals during treatment was tested in a Staphylococcus protein A rosette assay for reactivity with melanoma cell lines. All pretreatment samples (39/39) were negative, and 64% became positive by 12 months after appropriate dosage escalations. Moreover, enzyme-linked immunosorbent assay showed a positive correlation between anti-melanoma IgG antibody titer and disease-free survival.