The prognostic value of p53 and c-erb B-2 immunostaining is overrated for patients with lymph node negative breast carcinoma: a multivariate analysis of prognostic factors in 613 patients with a follow-up of 14-30 years

BACKGROUND

Approximately 30% of breast carcinoma patients with negative lymph nodes die of their disease. Biologic markers such p53 protein and c-erb B-2 have been related to tumor progression, but their prognostic value remains controversial.

METHODS

Two large series of a total of 613 lymph node negative breast carcinoma patients from a single institution were analyzed with respect to tumor size, histologic grade, and immunohistochemical staining for p53, c-erb B-2, estrogen receptor (ER), and progesterone receptor (PgR). Interobserver variation in histologic grading was evaluated by Kappa statistics. The two series had different treatment modalities: 228 patients (SACGS group) were treated surgically with mastectomy and given 1 perioperative chemotherapy course, and 385 patients (HOST group) were treated with mastectomy and ovarian radiation and further randomized to receive postoperative treatment with radiotherapy or no adjuvant treatment. The follow-up ranged from 14-30 years.

RESULTS

Immunoreactivities for p53, c-erb B-2, ER, and PgR did not differ significantly in the two series. p53 immunostaining was present in 187 of 613 tumors (29%), and c-erb B-2 immunoreactivity was present in 58 of the tumors (10%). Three hundred forty-eight tumors (57%) were positive for ER. Kappa statistics value of interobserver variation in the histologic grading of ductal carcinomas was 0.69, which is considered to be a substantial degree of agreement. No significant differences in survival were found when comparing p53, c-erb B-2, ER, and PgR positive and negative cases. However, both recurrence free survival rates and overall survival rates after 10 years were significantly better in the T1N0M0 group compared with the T2N0M0 group (81% vs. 67% [P < 0.0001] and 85% vs. 70% [P < 0.0001]). Ten-year recurrence free survival rates for patients with histologic Grade 1 versus Grades 2-3 (according to Elston and Ellis' modification of the Bloom and Richardson method) tumors were 90% and 70%, respectively (P < 0. 0001), and overall survival rates for the same groups were 94% and 81%, respectively (P=0.0002). After 30 years of follow-up, the overall survival rate for patients with tumors of histologic Grade 1 versus Grades 2-3 were 87% and 68%, respectively, and were 78% and 66%, respectively, for patients with tumors </= 2 mm versus those with tumors > 20-50 mm. Approximately 35% of the patients with tumors of histologic Grades 2-3 and measuring > 20 mm were dead after 10 years of follow-up, contrary to 6% of the patients with tumors of histologic Grade 1 measuring </= 20 mm. A significantly more favorable prognosis also was observed in patients in the HOST group treated with adjuvant radiotherapy.

CONCLUSIONS

Histologic grade and tumor size were found to be major prognostic factors for patients after 30 years of follow-up. c-erb B-2 and p53 immunostaining does not appear have any independent prognostic value. Adjuvant radiotherapy may be of value in the treatment of patients with localized tumors.

The prognostic value of p53 and c-erb B-2 immunostaining is overrated for patients with lymph node negative breast carcinoma: a multivariate analysis of prognostic factors in 613 patients with a follow-up of 14-30 years

BACKGROUND

Approximately 30% of breast carcinoma patients with negative lymph nodes die of their disease. Biologic markers such p53 protein and c-erb B-2 have been related to tumor progression, but their prognostic value remains controversial.

METHODS

Two large series of a total of 613 lymph node negative breast carcinoma patients from a single institution were analyzed with respect to tumor size, histologic grade, and immunohistochemical staining for p53, c-erb B-2, estrogen receptor (ER), and progesterone receptor (PgR). Interobserver variation in histologic grading was evaluated by Kappa statistics. The two series had different treatment modalities: 228 patients (SACGS group) were treated surgically with mastectomy and given 1 perioperative chemotherapy course, and 385 patients (HOST group) were treated with mastectomy and ovarian radiation and further randomized to receive postoperative treatment with radiotherapy or no adjuvant treatment. The follow-up ranged from 14-30 years.

RESULTS

Immunoreactivities for p53, c-erb B-2, ER, and PgR did not differ significantly in the two series. p53 immunostaining was present in 187 of 613 tumors (29%), and c-erb B-2 immunoreactivity was present in 58 of the tumors (10%). Three hundred forty-eight tumors (57%) were positive for ER. Kappa statistics value of interobserver variation in the histologic grading of ductal carcinomas was 0.69, which is considered to be a substantial degree of agreement. No significant differences in survival were found when comparing p53, c-erb B-2, ER, and PgR positive and negative cases. However, both recurrence free survival rates and overall survival rates after 10 years were significantly better in the T1N0M0 group compared with the T2N0M0 group (81% vs. 67% [P < 0.0001] and 85% vs. 70% [P < 0.0001]). Ten-year recurrence free survival rates for patients with histologic Grade 1 versus Grades 2-3 (according to Elston and Ellis' modification of the Bloom and Richardson method) tumors were 90% and 70%, respectively (P < 0. 0001), and overall survival rates for the same groups were 94% and 81%, respectively (P=0.0002). After 30 years of follow-up, the overall survival rate for patients with tumors of histologic Grade 1 versus Grades 2-3 were 87% and 68%, respectively, and were 78% and 66%, respectively, for patients with tumors </= 2 mm versus those with tumors > 20-50 mm. Approximately 35% of the patients with tumors of histologic Grades 2-3 and measuring > 20 mm were dead after 10 years of follow-up, contrary to 6% of the patients with tumors of histologic Grade 1 measuring </= 20 mm. A significantly more favorable prognosis also was observed in patients in the HOST group treated with adjuvant radiotherapy.

CONCLUSIONS

Histologic grade and tumor size were found to be major prognostic factors for patients after 30 years of follow-up. c-erb B-2 and p53 immunostaining does not appear have any independent prognostic value. Adjuvant radiotherapy may be of value in the treatment of patients with localized tumors.

Cause-specific mortality in long-term survivors of breast cancer who participated in trials of radiotherapy

PURPOSE

To examine long-term cause-specific mortality in patients irradiated for breast cancer as part of a randomized clinical trial.

PATIENTS AND METHODS

We studied all available information from randomized trials initiated before 1975 in which radiotherapy was the randomized option and surgery was the same for both treatment arms. Eight such trials were identified.

RESULTS

The increased all-cause mortality rate in 10-year survivors previously reported is no longer significant, although a numerical difference in favor of non-irradiated patients remains. This result was strongly influenced by the earliest trials, and more recent trials have found a nonsignificant net benefit in overall mortality associated with radiation therapy. An excess of cardiac deaths was apparent in both early and more recent trials (P < .001), but this was offset by a reduced number of deaths due to breast cancer, especially in more recent trials.

CONCLUSION

The reduction of breast cancer deaths suggests that radiation therapy may have a value beyond the clearly established improvements obtainable for local control. Use of techniques that minimize cardiac dose is important in reducing the risks of adjuvant radiotherapy, especially in good-prognosis patients.

Short perioperative versus long-term adjuvant chemotherapy

A single course of cyclophosphamide IV 5 mg/kg daily for 6 days was given immediately after mastectomy to 507 patients (519 randomized controls). The relapse-free rates were significantly increased, and after 16 years the difference was 12%. In a parallel series the same adjuvant course was given 2-4 weeks after mastectomy to 52 patients (58 randomized controls). No effect of this delayed course was found. In a second study a short multidrug course was given to all patients immediately after mastectomy. One-half of the axillary node-positive cases were randomized to continue with IV CMF for 1 year. The preliminary observations show that the prolonged treatment improved the relapse-free rates significantly during the first few years. One year after mastectomy the difference was 10%; after 2 years, 9%; after 3 years, 11%; and after 4 years, 9%. The side-effects of the short course were negligible, but the side-effects of prolonged treatment were considerable and increased with increasing treatment duration. More trials are needed to find the optimum duration of adjuvant chemotherapy.

Combination chemotherapy of germ cell tumors of the testis with vincristine, adriamycin, cyclophosphamide, actinomycin D and medroxyprogesterone acetate

Forty-three patients with disseminated germ cell cancer were treated with a combination of vincristine, Adriamycin, cyclophosphamide, actinomycin-D, and medroxyprogesterone acetate. All the 43 patients were considered evaluable for response. Thirty-one patients (72%) achieved a complete or partial remission and 14 (32.5%) achieved a complete remission. The patients who attained an objective response obtained a significant prolongation of life compared with the nonresponders (median survival 55 vs. 23 weeks). Responses were seen in all histologic categories and most frequently in patients with metastases confined to the lungs. The major side effects were leukopenia and stomatitis. There were no deaths related to toxicity of the chemotherapy.

Cerebrospinal irradiation of Burkitt's lymphoma. Failure in preventing central nervous system relapse

Twenty-two patients with Burkitt's lymphoma in complete remission induced by either cyclophosphamide or a combination of cyclophosphamide, oncovin and methotrexate were randomized to receive or not to receive prophylactic cerebrospinal irradiation. Six of 11 irradiated patients relapsed with tumour of the central nervous system as compared to 4 of 11 controls. Relapse frequency appeared to be related to stage of disease on admission. It is concluded that irradiation does not prevent relapse.

Combined surgery and radiation therapy versus surgery alone in primary mammary carcinoma. I. The effect of orthovoltage radiation

The effect of routine postoperative irradiation in the treatment of carcinoma of the breast has been evaluated. Postoperative irradiation had no effect on the proportion of patients free of disease nor on the survival rate, but the incidence of local recurrence and homolateral supraclavicular lymph node metastasis was reduced. In stage II patients homolateral axillary lymph node metastases were also encountered less frequently in the irradiated group. Distant metastases occurred either in stage II patients with postoperative irradiation as compared with controls.