A high neutrophil-lymphocyte ratio and platelet-lymphocyte ratio are associated with a worse outcome in inflammatory breast cancer

Introduction

Inflammatory breast cancer (IBC) is an uncommon, but aggressive form of breast cancer that accounts for a disproportionally high fraction of breast cancer related mortality. The aim of this study was to explore the peripheral immune response and the prognostic value of blood-based biomarkers, such as the neutrophil-to-lymphocyte ratio (NLR), in a large IBC cohort.

Patients & methods

We retrospectively identified 127 IBC patients and collected lab results from in-hospital medical records. The differential count of leukocytes was determined at the moment of diagnosis, before any therapeutic intervention. A cohort of early stage (n = 108), locally advanced (n = 74) and metastatic breast cancer patients (n = 41) served as a control population.

Results

The NLR was significantly higher in IBC compared to an early stage breast cancer cohort, but no difference between IBC patients and locally advanced breast cancer patients was noted. In the metastatic setting, there was also no significant difference between IBC and nIBC. However, a high NLR (>4.0) remained a significant predictor of worse outcome in IBC patients (HR: 0.49; 95% CI: 0.24–1.00; P = .05) and a lower platelet-lymphocyte ratio (PLR) (≤210) correlated with a better disease-free survival (DFS) (HR: 0.51; 95% CI: 0.28–0.93; P = .03).

Conclusion

Patients with a high NLR (>4.0) have a worse overall prognosis in IBC, while the PLR correlated with relapse free survival (RFS). Since NLR and PLR were not specifically associated with IBC disease, they can be seen as markers of more extensive disease.

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There is no association between NLR or PLR and inflammatory breast cancer (IBC).

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IBC and non-inflammatory breast cancer elicit a similar peripheral immune response.

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A high neutrophil-to-lymphocyte ratio (NLR) is associated with a worse overall survival in IBC.

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A high platelet-lymphocyte ratio (PLR) correlates with a worse disease-free survival in IBC.

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An elevated PLR or NLR should be seen as a marker of more extensive disease in IBC.

The rationale of opportunistic bilateral salpingectomies (OBS) during benign gynaecological and obstetric surgery: a consensus text of the Flemish Society of Obstetrics and Gynaecology (VVOG)

Ovarian cancer (OC), is a disease difficult to diagnose in an early stage implicating a poor prognosis. The 5-year overall survival in Belgium has not changed in the last 18 years and remains 44 %. There is no effective screening method (secondary prevention) to detect ovarian cancer at an early stage. Primary prevention of ovarian cancer came in the picture through the paradigm shift that the fallopian tube is often the origin of ovarian cancer and not the ovary itself. Opportunistic bilateral salpingectomy (OBS) during benign gynaecological and obstetric surgery might have the potential to reduce the risk of ovarian cancer by as much as 65 %. Bilateral risk-reducing salpingectomy during a benign procedure is feasible, safe, appears to have no impact on the ovarian function and seems to be cost effective. The key question is whether we should wait for a RCT or implement OBS directly in our daily practice. Guidelines regarding OBS within our societies are therefore urgently needed. Our recommendation is to inform all women without a child wish, undergoing a benign gynaecological or obstetrical surgical procedure about the pro's and the con's of OBS and advise a bilateral salpingectomy. Furthermore, there is an urgent need for a prospective registry of OBS. The present article is the consensus text of the Flemish Society of Obstetrics and Gynaecology (VVOG) regarding OBS.

Is there a role for urokinase-type plasminogen activator inhibitors as maintenance therapy in patients with ovarian cancer?

There is abundant evidence that the urokinase-type plasminogen activator (uPA), its inhibitors PAI-1 and PAI-2 (plasminogen activator inhibitor type-1 and type-2) and its cells surface receptor (uPA-R, CD87) play a fundamental role in tumor invasion and metastasis and are of significant prognostic significance for many tumor types. We performed a systematic Med-line search on uPA, PAI, uPA-R and (epithelial) ovarian cancer (EOC). The majority of malignant EOC specimens show moderate to strong immunostating of tumor and stromal cells. Overexpression of u-PA and PAI-1 can be found in more the 75% of primary ovarian carcinomas, in most metastatic EOC samples and all examined epithelial ovarian cancer cell lines. uPA overexpression in primary specimens was significantly associated with tumor stage, grade, residual disease status after cytoreductive surgery, and poor clinical outcome. This may be explained by increased chemoresistance, a lower resectability and more aggressive tumor biology and tumor dissemination in patients with high uPA and PAI-1. Several therapeutical approaches aimed at inhibiting the uPA/uPAR functions have shown to possess anti-tumor effects in vitro and in animal models. When treating a patient with advanced ovarian cancer it may to be assumed that inhibiting the progression of established (micro) metastases may be more therapeutically relevant than trying to destroy all tumor cells which is not possible in most cases with current systemic treatment modalities. Taking into account the role of uPA and PAI in cell detachment, formation of new stroma, tumor cell reimplantation and metastasis uPA inhibition should be further investigated as maintenance treatment in patients with advanced EOC.

Neoadjuvant endocrine treatment in early breast cancer: An overlooked alternative?

During the last decade neoadjuvant endocrine therapy (NET) has moved from being reserved for elderly and frail non-chemotherapy candidates to a primary systemic modality in selected patients with hormone sensitive breast cancer. Neoadjuvant hormonal treatment in patients with hormone receptor positive, HER-2 negative early breast cancer is proven to be an effective and safe option; it is associated with a higher rate of breast conserving surgery (BCS), may reduce the need for adjuvant chemotherapy and enables a delay of surgery for medical or practical reasons. Clinical responses range from 13% to 100% with at least 3 months of NET. Methods of assessing response should include MRI of the breast, particularly in lobular tumours. In studies comparing tamoxifen with aromatase inhibitors (AI), AI proved to be superior in terms of tumour response and rates of BCS. Change in Ki67 is accepted as a validated endpoint for comparing endocrine neoadjuvant agents. Levels of Ki67 during treatment are more closely related to long-term prognosis than pretreatment Ki67. Neoadjuvant endocrine therapy provides a unique opportunity for studies of endocrine responsiveness and the development of new experimental drugs combined with systemic hormonal treatment.

VEGF-A-independent and angiogenesis-dependent tumour growth in patients with metastatic breast cancer

BACKGROUND The mechanisms of tumour progression during anti-VEGF-A treatment are poorly understood. PATIENTS AND MATERIALS Two patients with metastatic breast cancer are described who developed new metastases while receiving anti-VEGF-A treatment. Angiogenic parameters were determined by CD34/Ki67 double staining, Chalkley counts (CC) and endothelial cell proliferation fractions (ECP). RT-PCR Taqman low-density arrays with a gene panel of 94 angiogenesis-related genes were performed on both metastases and compared to 10 unselected primary breast tumours. RESULTS Both lesions showed a high and intermediate CC of, respectively, 7.5±0.62 and 4.8±0.2. Both lesions had elevated ECP values of 14% and 8%. Low-density array screening showed that VEGFR1 mRNA was overexpressed in both samples (z-score=7.85 and 7.81) compared to control samples (out of range [min-max]). Additional analysis confirmed this finding at the protein level by immunohistochemistry. CONCLUSION These observations suggest that tumour progression under continuous anti-VEGF-A continues to be angiogenesis dependent. Further exploration is needed to identify the mechanisms of anti-VEGF-A resistance in order to design combination-targeted therapies.

The VEGF pathway and the AKT/mTOR/p70S6K1 signalling pathway in human epithelial ovarian cancer

Vascular endothelial growth factor (VEGF)-A inhibitors exhibit unseen high responses and toxicity in recurrent epithelial ovarian cancer suggesting an important role for the VEGF/VEGFR pathway. We studied the correlation of VEGF signalling and AKT/mTOR signalling. Using a tissue microarray of clinical samples (N=86), tumour cell immunohistochemical staining of AKT/mTOR downstream targets, pS6 and p4E-BP1, together with tumour cell staining of VEGF-A and pVEGFR2 were semi-quantified. A correlation was found between the marker for VEGFR2 activation (pVEGFR2) and a downstream target of AKT/mTOR signalling (pS6) (R=0.29; P=0.002). Additional gene expression analysis in an independent cDNA microarray dataset (N=24) showed a negative correlation (R=−0.73, P<0.0001) between the RPS6 and the VEGFR2 gene, which is consistent as the gene expression and phosphorylation of S6 is inversely regulated. An activated tumour cell VEGFR2/AKT/mTOR pathway was associated with increased incidence of ascites (χ², P=0.002) and reduced overall survival of cisplatin–taxane-based patients with serous histology (N=32, log-rank test, P=0.04). These data propose that VEGF-A signalling acts on tumour cells as a stimulator of the AKT/mTOR pathway. Although VEGF-A inhibitors are classified as anti-angiogenic drugs, these data suggest that the working mechanism has an important additional modality of targeting the tumour cells directly.

The correlation of the AKT/mTOR/p70S6K1 pathway and VEGF in human epithelial ovarian cancer

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Background: The Akt/mTOR/p70S6K1 (Amp) pathway is activated in a proportion of epithelial ovarian cancers. The ribosomal protein pS6 and p4EBP1 are downstream targets and presumed representative for the pathway's activity. VEGF and angiogenesis in ovarian cancer play an important role as bevacizumab induces high response rates and prolongs progression-free survival in women with relapsed ovarian cancer in two phase II trials. The Amp pathway has proven to be correlated with HIF1alfa and VEGF A expression in vitro. Material and Methods: Our primary objective was to evaluate correlation between this pathway in human subject tissues and angiogenesis using VEGF A and pVEGFR2. Our second objective was to evaluate if different metastatic abdominal (peritoneal and/or omental) lesions show the same pathway hyperactivity and/or angiogenesis as the primary tumour, because relapses usually involve metastatic abdominal lesions. Epithelial ovarian cancer paraffin imbedded material from 1999–2004 was collected. A tissue micro array was build with three samples per paraffin block. Immunohistochemical staining was performed using pS6, p4EBP1, pAKT, VEGF and pVEGFR2. Results: 89 patients were collected with a median age of 69.8y. Patients were FIGO stage I in 21%, stage II in 4%, stage III in 62% and 11% stage IV. Histological examination showed in 53% serous papillary tumours, 25.8% endometroid tumours, clear cell carcinoma in 11.2% and mucinous tumours in 4.5%. 65 patients had available tissue material of both primary tumour as well as other (multiple) metastatic abdominal disease tissue. The results of the immunohistochemical staining as well as the correlation analysis will be presented. Conclusion: Although anti-angiogenesis seems to be very active against human epithelial ovarian cancer, it is at present associated with unacceptable treatment induced toxicities. Inhibiting the Amp pathway with mTOR inhibitors could potentially also inhibit angiogenesis in ovarian cancer with the potential of more manageable side effects. This study will provide some evidence on the relationship between the Amp pathway and the VEGF pathway in human epithelial ovarian cancer.

No significant financial relationships to disclose.

The clinical value and the cost-effectiveness of follow-up in endometrial cancer patients

The aim of the present article was to evaluate the cost-effectiveness of follow-up in endometrial cancer patients. A literature review was performed regarding the studies that addressed routine follow-up of endometrial cancer. For each published study, the costs of the follow-up program were calculated according to Belgium standards. A mean total of 13% relapsed. Symptomatology and clinical examination detected over 83% of the recurrences. The follow-up cost in euro after 5 and 10 years ranged between 127.68 and 2,028.78 and between 207.48 and 2,353.48, respectively. Based on the available data, there is little evidence of routine follow-up improving survival rates. Multiple protocols are used in practice without an evidence base. There is an urgent need for prospective randomized studies to evaluate the value of the current so-called 'standard medical practice of follow-up.' It is to be expected that the cost of follow-up could be reduced considerably, for instance, by tailoring to low- and high-risk groups, or by abandoning routine follow-up. Symptomatic patients, however, should be evaluated immediately. A reduction in the number of visits and examinations would mean an enormous reduction in costs. This economic benefit would be warmly welcomed in the times of increased health costs and decreased budgets.

Intraoperative sentinel node identification with Technetium-99m-labeled nanocolloid in patients with cancer of the uterine cervix: a feasibility study

The objective of this study is to determine the feasibility of intraoperative lymphatic mapping in patients with cervical carcinoma. Patients with early-stage cervical cancer, scheduled to undergo a Wertheims radical hysterectomy and pelvic lymphadenectomy, were eligible for the study. Technetium-99-m-labeled nanocolloid was injected intracervically at two locations around the tumor 3-6 hours before the operation. Images were recorded immediately and 2.5 hours later using a gamma camera. During the operation sentinel nodes (SLN) were identified using a handheld or laparoscopic gamma-detection probe (Navigator, Auto-Suture). After resection of the SLNs a standard pelvic (and para-aortic) lymphadenectomy was performed. The results of the histopathology of SLNs and non-SLNs were compared. The procedure was well tolerated by 24 of 25 patients. One or more SLN could be identified in 21 out of 25 patients. In one patient who was preoperatively irradiated, in two patients who had had a cone biopsy, and in one patient without previous interventions, no SLN could be detected. The mean time for identification was 5 minutes. In 16 patients, pathologic examination showed no metastatic disease in both SLNs and non-SLNs, whereas metastases were found in the SLN in five patients (in one case only SLN involved, four cases SLN and respectively 3, 11, 22 and 31 other positive nodes). This study shows that identification of SLNs in cancer of the uterine cervix is feasible with preoperatively administered 99mTc-labeled nanocolloid. To date, no false negative SLNs have been found, but expansion of the study is necessary to determine possible clinical application of this new technique.

The importance of biological factors (bcl-2, bax, p53, PCNA, MI, HPV and angiogenesis) in invasive cervical cancer

OBJECTIVE

The present study was designed to analyse the relationship between apoptosis related proteins (bcl-2 and bax), tumour suppressor protein p53, proliferation markers (PCNA and mitotic index), human papillomavirus (HPV) and angiogenesis in cervical cancer and their impact on clinical outcome.

STUDY DESIGN

Tumours from 111 patients were assessed by immunohistochemistry for the expression of bcl-2, bax, p53 and PCNA, by PCR for the presence of HPV-DNA, for the quantification of the mitotic index and the microvessel density (CD 31). The results were correlated with various histopathologic characteristics and survival.

RESULTS

The multiple Cox's regression analysis for overall survival of all prognostic variables gave as best model: bcl-2 (P<0.001), lymphovascular permeation (P=0.004), mitotic index (P=0.019), tumour grade (P=0.048) and FIGO stage (P=0.070). Subanalysis was performed for the patients where the lymph node status was known (n=79). Adding the lymph node status gave as best model for overall survival bcl-2 (P=0.001), lymphovascular permeation (P=0.003) and mitotic index (P=0.044). However, they hardly influenced the association.

CONCLUSION

In the apoptotic pathway of cervical cancer, bcl-2 is one of most important proteins. It can probably not only mediate cell death but also regulate cell growth. A better understanding of their relations will probably provide the basis for more rational cancer therapies in the future.

Trocar implantation metastasis after laparoscopy in patients with advanced ovarian cancer: can the risk be reduced?

OBJECTIVE

The purpose of this study was to determine risk factors for trocar implantation metastasis after diagnostic laparoscopy in patients with primary or recurrent advanced ovarian cancer.

STUDY DESIGN

Eighty-three women with primary advanced ovarian cancer and 21 women with recurrent ovarian cancer undergoing a laparoscopy for a tissue diagnosis and for assessment of operability were included in the study. The occurrence of implantation metastasis at the trocar incision scars was analyzed according to clinicopathologic characteristics.

RESULTS

A recurrence developed at the trocar site in 7 (58%) of 12 patients undergoing a laparoscopy in which only the skin was closed at the end of the procedure and in 2 (2%) of 92 patients undergoing a laparoscopy with closure of all layers (odds ratio, 63; 95% confidence interval, 10.3-385; P <.001). The International Federation of Gynecology and Obstetrics stage at initial presentation, tumor histologic type, tumor differentiation, maximal tumor diameter at the time of diagnosis, estimated weight of the metastatic tumor, residual tumor after cytoreductive surgery, surgical characteristics, and type of chemotherapy were well balanced among both groups. Patients with implantation metastasis had significantly more ascites (median, 700 mL vs 300 mL; P =.032) and a longer interval between the start of platinum-based chemotherapy or cytoreductive surgery (median, 6 days vs 17 days; P <.01) compared with patients without abdominal wall recurrence. A palpable abdominal wall metastasis developed in none of the patients undergoing a laparoscopy with closure of all layers of the abdomen followed by cytoreductive surgery or chemotherapy within 1 week after the laparoscopy. Kaplan-Meier survival analysis showed that patients with abdominal wall implantation metastasis had a survival rate similar to that of the other patients.

CONCLUSIONS

Laparoscopy with careful closure of the peritoneum, rectus sheath, and skin followed by chemotherapy or cytoreductive surgery with excision of the trocar trajectories within 1 week is safe in patients with disseminated ovarian cancer.

Vaccination with HPV16 peptides of patients with advanced cervical carcinoma: clinical evaluation of a phase I-II trial

A phase I-II clinical trial was performed involving vaccination with HPV16 E7 peptides of patients suffering from HPV16 positive cervical carcinoma which was refractory to conventional treatment. Patients receiving the vaccine were HLA-A*0201 positive with HPV16 positive cervical carcinoma. The clinical trial was designed as a dose-escalation study, in which successive groups of patients received 100 micrograms, 300 micrograms or 1000 micrograms of each peptide, respectively. The vaccine consisted of two HPV16 E7 peptides and one helper peptide emulsified in Montanide ISA 51 adjuvant. 19 patients were included in the study, no adverse side-effects were observed. 2 patients showed stable disease for 1 year after vaccination; 15 patients showed progressive disease of whom 1 died during the vaccination treatment due to progressive disease; and 2 patients showed tumour-regression after chemotherapy following vaccination. A relative low count of lymphocytes before and after vaccination was present in 11/19 patients indicating that these patients were immunocompromised. This study shows that HPV16 E7 peptide vaccination is feasible, even in a group of patients with terminal disease. This paves the way for vaccinating patients with less advanced disease, whose immune system is less compromised by progressive disease.

Epithelioid sarcoma of the vulva

We report a case of a 23-year-old woman diagnosed as having an epithelioid sarcoma of the vulva. She was treated by a clitoris-sparing hemivulvectomy and lymph node sampling of the ipsilateral groin. Vulvar reconstruction was performed with a rectus abdominis myocutaneous flap. Four years after the operation there is no evidence of disease and the patient has a normal sex life. The English literature on this subject is reviewed with special attention to the biological behavior and therapeutic approach.

Ultraradical debulking of epithelial ovarian cancer with the ultrasonic surgical aspirator: a prospective randomized trial

OBJECTIVE

Our purpose was to evaluate the effectiveness, benefits, and potential side effects of the use of the cavitational ultrasonic surgical aspirator for cytoreduction of advanced ovarian cancer.

STUDY DESIGN

Forty patients with stage IIC to IV ovarian carcinoma were randomized to undergo ultraradical cytoreductive surgery with (group 1, 20 patients) or without (group 2, 20 patients) the use of the CUSA 200 cavitational ultrasonic surgical aspirator (Valleylab, Boulder, Colo). Preoperative and postoperative information and follow-up data were collected prospectively and compared between both groups.

RESULTS

The amount of residual tumor after debulking surgery, the duration of the operation, and the rate of perioperative complications were comparable in both study groups. The amount of perioperative blood loss was significantly lower (1450 ml vs 1650 ml, p=0.02) in group 1. These patients had less morbidity (p<0.05), and could be discharged from the hospital significantly sooner (14 days vs 16 days, p=0.031). CA 125 levels 1 and 2 months after surgery were significantly lower in the group with cavitational ultrasonic surgical aspirator (p<0.01 and p<0.01, respectively), suggesting more successful cytoreduction. However, this is not reflected in a better disease-free or overall survival.

CONCLUSION

Cavitational ultrasonic surgical aspirator-assisted cytoreductive surgery of advanced ovarian carcinoma is more effective in eradicating disease, reduces morbidity, and is cost beneficial.

Prognostic value of bcl-2 expression in invasive breast cancer

Expression of the bcl-2 proto-oncogene was studied immunohistochemically in 251 invasive ductal breast carcinomas (median follow-up time 91 months, range 24-186 months) and the results were correlated with clinicopathological data and prognostic variables. Sixty-three (25%) tumours were scored bcl-2 negative and 188 (75%) tumours were bcl-2 positive. No relationship could be observed between bcl-2 status and tumour grade, pTNM staging or menopausal status. A strong positive relationship was demonstrated between bcl-2 immunoreactivity and oestrogen receptor status (P < 0.001) and progesterone receptor status (P < 0.001). No prognostic value was demonstrated for bcl-2 expression on disease-free survival and overall survival in axillary node-negative breast cancer patients. However, in axillary node-positive breast cancer patients multivariate analysis demonstrated absence of bcl-2 expression to be independently related to shortened disease-free survival (P = 0.003) and shortened overall survival (P < 0.001). Our results suggest a potential important role for bcl-2 expression as a modulator of response to adjuvant therapy in breast cancer.

Primary extrauterine müllerian adenosarcoma of the peritoneum

A case of an extrauterine Müllerian adenosarcoma of the pelvic peritoneum is described. The patient, a 16-year-old girl, presented with abdominal distension and pain. At laparotomy, a tumor was found originating from the left pelvic side wall. Light microscopic examination revealed a Müllerian adenosarcoma. Postoperatively she was treated with polychemotherapy. Seventy months after initial presentation she is still free of tumor.

Immunohistochemical study of topoisomerase II-alpha expression in primary ductal carcinoma of the breast

AIMS

To study the patterns of expression of topoisomerase II-alpha in primary invasive ductal breast carcinomas; to correlate this expression with clinicopathological data and prognosis.

METHODS

Cryostat sections from 63 primary invasive ductal breast carcinomas were stained immunohistochemically for topoisomerase II-alpha. Nuclear immunoreactivity was quantified by counting at least 500 cells in different random fields and results were expressed as per cent of cells staining positively for topoisomerase II-alpha.

RESULTS

Topoisomerase II-alpha nuclear immunoreactivity (median 14% of nuclei; range 2-62%) was detected in all tumours with highly variable intertumour and intratumour nuclear reactivity. Higher levels of topoisomerase II-alpha expression were strongly related to higher tumour grade, larger tumour size, nodal status, and the presence of distant metastases at diagnosis. No correlation was found with menopausal status, steroid hormone receptor status, disease free survival, or overall survival.

CONCLUSIONS

Expression of topoisomerase II-alpha is related to the presence of poor prognostic factors. Immunohistochemical assessment of topoisomerase II-alpha expression in breast cancer could be potentially useful for tailoring chemotherapy with topoisomerase II inhibitors.

Expression of c-erbB-2, c-myc, and c-ras oncoproteins, insulin-like growth factor receptor I, and epidermal growth factor receptor in ovarian carcinoma

AIMS

To assess whether the overexpression of five dominant oncogene encoded proteins is crucial to the pathogenesis of ovarian carcinoma and whether this provides any useful prognostic information.

METHODS

The expression of the insulin-like growth factor 1 receptor (ILGFR 1), epidermal growth factor receptor (EGFR), and the c-erbB-2, c-ras, and c-myc products was studied by multiparameter flow cytometry in 80 patients with epithelial ovarian cancer for whom long term follow up was available.

RESULTS

Overexpression of ILGFR 1, EGFR, c-erbB-2, c-ras and c-myc was found in, respectively, nine of 80 (11%), 10 of 80 (12%), 19 of 80 (24%), 16 of 80 (20%) and 28 of 80 (35%) ovarian carcinomas. The levels of expression of ILGFR 1, EGFR, c-erbB-2 and c-ras were significantly higher in the tumours of patients with recurrent or persistent disease after chemotherapy than in the tumours of patients at initial presentation (p < 0.02). Multivariate analysis showed that residual tumour (p < 0.001), FIGO stage (p = 0.002), EGFR overexpression (p = 0.030) and previous chemotherapy (p = 0.034) were independent variables for predicting survival.

CONCLUSIONS

Overexpression of these oncoproteins only occurs in a small proportion of ovarian carcinomas but may have an important role in the progression of the disease.

Is there an increased risk for tumor dissemination using ultrasonic surgical aspiration in patients with vulvar carcinoma?

The ultrasonic surgical aspirator (USA) is a new surgical instrument that allows precise and selective tissue dissection. Ultrasonic cell destruction is combined with continuous irrigation causing a cloud of fine droplets, which sometimes contains viable tumor cells, hanging above the operative field. We present a patient who developed massive recurrent vulvar carcinoma in the subcutaneous tissue in the proximity of the incisions of the vulva and both groins 3.5 months after a USA-assisted radical vulvectomy and inguinal lymphadenectomy. The atypical pattern of recurrence in the entire operative field suggests that tumor cells might have been spread by the irrigation fluid of the USA. Further investigation is needed to assess the risk of tumor dissemination with USA before the instrument can be used safely in patients with early cancer.

Flow cytometric measurement of cell components other than DNA: virtues, limitations, and applications in gynecologic oncology

Flow cytometry is a high-precision technique for rapid analysis and sorting of cells and particles. In theory, it can be used to measure any cell constituent, provided that a fluorescent tracer is available that reacts specifically and stoichiometrically with that constituent. The technique provides statistical accuracy, reproducibility, and sensitivity and allows simultaneous measurement of several constituents on a cell-to-cell basis. The main drawback of flow cytometry is the lack of visual control and structural information in solid tissues. Careful sample preparation, quality control of all staining and instrumentation procedures, and the use of immunohistologic or cytologic controls are essential for high-quality flow cytometric analysis. The technique has been used successfully for simultaneous measurement of DNA and tumor-associated antigens, oncogene products, proliferation markers, and markers for multidrug resistance in cultured cell lines and in cell suspensions prepared from solid tumors and cervical smears. Flow cytometry has the potential to play an important role in the study of carcinogenesis. With an appropriate panel of monoclonal antibodies, the technique can be used for screening, "biochemical" diagnosis of neoplasia, and rapid drug, hormone, and radiotherapy sensitivity tests.

Comparative evaluation of fresh, fixed, and cryopreserved solid tumor cells for reliable flow cytometry of DNA and tumor associated antigen

Five different protocols for the short-term preservation of cells used for multiparameter flow cytometric assay of tumour associated antigens (TAA) and DNA were assessed in cell suspensions prepared by mechanical disaggregation of 15 gynecological tumors. The protocols at 4 degrees C were 1) storage in buffer, 2) storage in 50% methanol, and 3) storage in buffer after formalin fixation. Tissues were also cryopreserved as cell suspensions and tissue blocks. When the TAA expression and DNA histograms of the preserved cells were compared with those in fresh cell suspensions, cryopreservation was found to be the best method: TAA expression was well preserved and there was a good correlation between TAA expression and the quality of the DNA histograms, respectively, in fresh and cryopreserved cells (RS: 0.82-0.91, P less than 0.001 for all TAAs). The cell suspensions preserved at 4 degrees C all showed a significant increase in background fluorescence (P less than 0.05) and a reduction in the TAA specific fluorescence (P less than 0.011). Methanol fixation was better than buffered formalin for the proteins studied, though both gave significantly worse results than cryopreservation. The quality of these cell suspensions and the correlation with TAA measurements in fresh cell suspensions deteriorated progressively with time, particularly if they were stored more than a week.

Multiparameter flow-cytometric quantitation of epidermal growth factor receptor and c-erbB-2 oncoprotein in normal and neoplastic tissues of the female genital tract

A novel multiparameter flow-cytometric method was used to quantify the expression of epidermal growth factor receptor (EGFR) and c-erbB-2 oncoprotein on 85 cryopreserved normal tissues (30 ovary, 29 endometrium, 16 cervix) and 67 carcinomas (31 ovarian, 18 cervical, 15 endometrial, 3 vulvar). Overexpression of the EGFR and c-erbB-2 oncoproteins was found in respectively 3/31 (9%) and 10/31 (32%) ovarian carcinomas, 13/18 (72%) and 7/18 (38%) cervical carcinomas, and 2/15 (13%) and 2/15 (13%) endometrial carcinomas. Oncoprotein expression was significantly higher in the malignant tumors (for all tumor sites) than in the corresponding normal tissues (P less than 0.034 for all combinations). Aneuploid tumors expressed levels of EGFR and c-erbB-2 oncoprotein significantly higher than those of DNA diploid tumors (P = 0.042 and P = 0.048, respectively). Oncoprotein could be detected in nearly all normal tissues: expression was higher in premenopausal than in postmenopausal patients (EGFR, P = 0.07; c-erbB-2, P less than 0.001). The present study supports the idea that EGFR and c-erbB-2 may play an important role in the autocrine, paracrine, and/or endocrine growth control and differentiation of normal tissues. Alteration in the expression of these oncoproteins is probably involved in malignant transformation and tumorigenesis.

Multi-parameter flow cytometric quantitation of the expression of the tumor-associated antigen SM3 in normal and neoplastic ovarian tissues. A comparison with HMFG1 and HMFG2

SM3 is a monoclonal antibody that reacts with a peptide epitope in the core protein of polymorphic epithelial mucin. Multi-parameter flow cytometry was used to characterize the expression of SM3 and compare it with two related tumor-associated antigens, HMFG1 and HMFG2, in cell suspensions of 44 malignant ovarian tumors, 15 benign ovarian tumors, and 16 normal ovaries. Tumor-associated antigen expression was significantly higher in malignant ovarian neoplasms than in benign neoplasms (P less than 0.001 for all three antigens). SM3 was expressed more specifically in malignant than benign tumors but had a lower affinity than HMFG1 and HMFG2. Multi-parameter flow cytometric evaluation of a panel of monoclonal antibodies can be used to help in choosing the best antibody for immunohistochemistry, imaging, and eventually treatment of ovarian tumors.

DNA ploidy and the expression of tissue-carcinoembryonic antigen in grade III carcinoma of the breast

A series of 50 Stage I and II, Grade III ductal carcinomas of the breast was characterized by DNA flow cytometry and further analyzed with a monoclonal antibody for carcinoembryonic antigen (CEA). The antigen was detected with the indirect immunoperoxidase technique on paraffin sections and on cytologic smears of the cell suspensions that were used for flow cytometric DNA analysis. A significant higher incidence of CEA-positivity in cytologic smears and tissue sections was found in DNA-diploid tumors (13/18 and 12/18, respectively) than in DNA-aneuploid tumors (13/22 and 12/32, respectively) (P less than 0.05 and P less than 0.025, respectively).

Prostacyclin/thromboxane ratio in human breast cancer

In this prospective follow-up study the prognostic value of the tumor prostacyclin/thromboxane ratio in human breast carcinoma was investigated. The stable degradation products of prostacyclin and thromboxane (6-keto-PGF1 alpha and TXB2, respectively), were measured by radio-immunoassay in homogenized primary tumours from 29 patients with primary non-metastatic breast cancer. The median follow-up was 43 months (range 24-58 months). Patients with recurrent disease or patients who died of breast cancer had a significantly higher 6-keto-PGF1 alpha/TXB2 ratio than the disease-free survivors (p = 0.018 and p = 0.047, respectively). There was no significant difference in the 6-keto-PGF1 alpha and TXB2 levels. These data indicate that the prostacyclin/thromboxane balance in the tumour might be a prognostic factor in breast cancer. Prostanoid may contribute to metastasis in breast cancer, but the problem is complex because the different prostaglandins have numerous actions that may produce both undesirable and desirable effects.

Tissue preparation for simultaneous flow cytometric quantitation of tumour associated antigens and DNA in solid tumours

A multiparameter flow cytometric assay for the simultaneous study of tumour associated antigens (TAA) and DNA in fresh solid tumours was devised. Cell suspensions were prepared by disaggregating unfixed solid tumour samples mechanically over a stainless steel mesh. Indirect immunofluorescence was used to identify the TAA, and DNA was stained with propidium iodide. Cell morphology was well preserved, cell clumping was negligible, and high quality indirect immunofluorescence quality indirect immunofluorescence and DNA staining were obtained. The technique is simple, rapid, and reproducible. Multiparameter assays can be developed to study prognostic indicators such as membrane oncoproteins, receptors, and multidrug resistance in solid tumours. With a suitable panel of antibodies the technique might become an aid in the differential diagnosis and biochemical diagnosis of some solid tumours.

A logit model to evaluate the performance of diagnosis of solid palpable breast tumours

The applicability of log-linear (logit) analysis has been tested with preoperative data of 303 consecutive patients with a solid palpable breast tumour. The log-linear routine of the SPSS-package provides for the selection of appropriate diagnostic tests, which can be suitably judged in a given situation. The histologic diagnosis (benign or malignant) has been chosen as dependent variable. The independent variables are: (1) the patient's age (less than 50 years or greater than or equal to 50 years), (2) the size of the lesion (diameter less than 2 cm or greater than or equal to 2 cm) and the test results (benign or malignant) of (3) physical examination, (4) mammography, (5) ultrasound scanning and (6) thermography. Of the tested models with one independent variable, the best model uses ultrasonography test results (H = 0.35). Physical examination and mammography also have good predictive power (H, respectively: 0.23 and 0.25). The combination of two independent variables augments accuracy. Models combining ultrasonography with age, physical examination or mammography are shown to be most successful (H respectively: 0.41, 0.42 and 0.39).

Flow cytometric detection of multifocal DNA aneuploid cell populations in mastectomy specimens containing a primary breast carcinoma

DNA flow cytometry was used to study the presence of DNA aneuploid cell populations in macroscopically normal glandular tissue in mastectomy specimens from 30 patients with breast cancer. In the 13 patients with a DNA diploid primary tumor, no DNA aneuploidy could be found in any of the 39 distant specimens assessed. However, DNA aneuploid cell populations were demonstrated in four of the 17 (23%) patients with a primary DNA aneuploid carcinoma and in seven out of 54 (13%) distant tissue samples (P = 0.02). In all cases the DNA index of the DNA aneuploid cells found in the distant samples was identical to that of the primary tumor. The replicate aneuploid DNA indices and histologic controls taken in parallel very strongly suggest that these distant DNA aneuploid cell populations are metastases.

Prognostic value of prostaglandin F2 alpha concentrations in breast carcinoma

Prostaglandin F2 alpha (PGF2 alpha) concentrations were measured by radioimmunoassay in homogenised primary tumours from 57 patients with breast cancer. These patients were followed up from 60 to 78 months (median 63 months) after surgery and PGF2 alpha concentrations were related prospectively to metastatic spread and survival. The amounts of PGF2 alpha varied greatly in the different tumours (range 0-90 ng/mg protein), but no significant association was found between PGF2 alpha concentrations and disease free survival, time of relapse, site of recurrence, or overall survival. It therefore seems unlikely that measurement of PGF2 alpha in breast carcinoma is important in the prognosis of the disease.

Palpable solid breast masses: retrospective single- and multimodality evaluation of 201 lesions

The diagnostic virtues and limitations of single- and multimodality testing in the evaluation of solid palpable breast masses were studied. Two hundred one consecutive patients who had a solid palpable breast mass and who underwent biopsy between September 1982 and July 1986 were included for blinded retrospective analysis of their physical examination, mammographic, ultrasonographic (US), thermographic, and pathologic characteristics. Benign breast disease was diagnosed histologically in 106 women, while carcinoma was established in 95. The sensitivities of physical examination, mammography, US, and thermography were 0.88, 0.94, 0.78, and 0.49, respectively. US alone had the highest sensitivity in correct diagnosis of a benign solid breast mass and had the highest accuracy (0.84). Use of four modalities increased the preoperative diagnostic true-positive rate to 0.97, with some decline in specificity. Multimodality testing seems particularly beneficial in pre- and perimenopausal patients.