Abstract P4-16-13: Prospective study of scalp cooling for hair loss prevention in Japanese breast cancer women receiving (neo)adjuvant chemotherapy

Introduction

Recently scalp cooling during chemotherapy infusion has been reported to be quite effective to mitigate chemotherapy-induced alopecia. But data in Asian patients are quite limited.

Patients and methods

Japanese breast cancer female patients who planned to receive (neo)adjuvant chemotherapy were offered to participate in this prospective study of scalp cooling with Paxman Scalp Cooling System for alopecia prevention. The scalp cooling was done 30 minutes prior to and during and 90 minutes after each chemotherapy infusion. Photographs of the head of the participants were taken from 5 directions, namely front, back, both sides, and top, on the day of chemotherapy infusion and 1 month after the last infusion. Two investigators consisting of a physician and a nurse judged the grade of alopecia by looking at the photographs according to the WHO classification. The primary outcomes were the rates of patients with Grade 3 alopecia (defined as hair loss of > 50%) and the rates of patients who used a wig or hat to conceal the hair loss one month after the last infusion of chemotherapy. This paper reports on the former outcome mainly. They were asked to answer a brief questionnaire regarding headache, fatigue, chill etc. shortly after each cooling. They could use the cooling cap for free on the first cycle of chemotherapy. But they were required to purchase it (about 1,130 US$) for the scalp cooling of the following cycles.

Results

One hundred forty three patients participated in the study and actually used the cooling cap at least once. The mean and median age of them are 50.6 and 50, respectively (28 - 76). One hundred twenty nine patients completed the planned chemotherapy of 4 to 8 cycles (89 Pts 4 cycles, 1 Pt 6 cycles, 39 Pts 8 cycles). Among them (7 patients were not evaluable), 74 patients (60.7 %) had Grade 3 alopecia 1 month after chemotherapy. In 80 patients who used the scalp cooling system throughout the planned chemotherapy (1 patient was not evaluable), 36 patients (45.6 %) experienced Grade 3 alopecia. On the other hand, among 49 patients who discontinued the cooling mostly after the 1st cycle (6 were not evaluable), 38 (88.3 %) had Grade 3 alopecia. When we restrict them to 33 (5 were not evaluable) who decided to discontinue the cooling by day10 of the first cycle of chemotherapy to exclude the patients who discontinued it because of less effect on alopecia prevention than they expected, 25 (89.3 %) experienced Grade 3 alopecia. Comparing the results of those who completed the cooling and patients who decided to discontinue it by day10 of the first cycle, the rates of Grade 3 alopecia (45.6 % vs. 89.3 %) were statistically significantly different in favor of the former (P = 0.0001). Most patients complained of some headache, chill, and pain of the jaw.

Conclusion

Scalp cooling with Paxman Scalp Cooling System during chemotherapy infusion in Asian women seems as effective for hair loss mitigation as in Caucasian women.

Citation Format: Ohsumi S, Kiyoto S, Takahashi M, Hara F, Takashima S, Aogi K, Matsuda M, Yamamura N, Matsuda A, Yamauchi T, Doi M. Prospective study of scalp cooling for hair loss prevention in Japanese breast cancer women receiving (neo)adjuvant chemotherapy [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 P4-16-13.

Abstract P1-13-09: Long-term follow-up of two randomized controlled trials (N-SAS-BC01 trial and CUBC trial) comparing oral tegafur-uracil (UFT) versus classical cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) as adjuvant therapy in early breast cancer

Background: Two randomized controlled trials comparing the efficacy of oral tegafur-uracil (UFT) (2 years) with that of classical cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) (6 courses) were conducted in patients with resected early breast cancer. UFT is an oral fluoropyrimidine that combines tegafur, a prodrug of 5-fluorouracil, with uracil in a 1:4 molar ratio. One study was the N-SAS-BC01 trial (Watanabe et al, J Clin Oncol 2009), which was conducted in patients with high-risk node-negative breast cancer (n=733). The other was the CUBC trial (Park et al, Br J Cancer 2009), which was performed in patients with node-positive breast cancer (n=377). We reported the pooled analysis of these two randomized control trials using individual patient data (Ohashi et al, Breast Cancer Res Treat 2010). This pooled analysis showed that UFT was non-inferior to CMF in terms of inhibiting recurrence of estrogen receptor (ER)-positive early breast cancer. In addition, an exploratory subgroup analysis showed that UFT may be more effective in ER-positive patients who were 50 years or older. The present study was conducted to investigate the long-term efficacy of UFT or CMF in patients with early breast cancer.

Methods: Long-term follow-up data for disease recurrence and survival were collected. Hazard ratios (HR) were determined using the Cox model stratified by study and adjusted for clinical characteristics, namely age, tumor size, nodal status, histological type, ER, and progesterone receptor (PgR). Survival curves were estimated by the Kaplan-Meier method. Hochberg multiplicity adjustment was applied in the previous pooled analysis, and non-inferiority of UFT versus CMF was shown in terms of relapse-free survival (RFS) in the ER-positive patient group. We investigated the non-inferiority of UFT in the same patient group with updated data. Restricted mean survival time (RMST) was calculated to consider the relative efficacy of UFT. This study is registered with JapicCTI-163321.

Results: In total, 1,057 patients were analyzed (CMF, n=528; UFT n=529). The median follow-up time was 11.1 years (12.1 years in the N-SAS-BC 01 trial and 8.3 years in the CUBC trial). Table 1 shows the 10-year RFS and overall survival (OS) in all patients and ER-positive patients. The difference in RMST between arms at 20 years in terms of RFS was -2.7 months in all patients and 3.4 months in ER-positive patients. Table 2 shows the HR for RFS according to ER status and age.

 UFT (%)CMF (%)UFT to CMF; HR (95% CI)10-year RFSall patients74.477.11.02 (0.81–1.30)ER-positive patients75.075.10.91 (0.66–1.27)10-year OSall patients86.886.90.98 (0.72–1.34)ER-positive patients89.987.90.86 (0.54–1.37)

 Age <50 yearsAge ≥50 yearsER negative1.76 (0.95–3.26)0.93 (0.58–1.51)ER positive1.29 (0.74–2.23)0.76 (0.50–1.16)

Conclusion: This study shows that UFT was shown to be non-inferior to CMF in terms of RFS in ER-positive early breast cancer. This result is similar to that of the previous pooled analysis.

Sponsor: Taiho Pharmaceutical Co., LTD

Citation Format: Yonemori K, Ohsumi S, Takao S, Tokuda Y, Ito Y, Nakagami K, Takahashi M, Yoshidome K, Nakayama T, Yamaguchi Y, Ohashi Y, Inaji H, Watanabe T. Long-term follow-up of two randomized controlled trials (N-SAS-BC01 trial and CUBC trial) comparing oral tegafur-uracil (UFT) versus classical cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) as adjuvant therapy in early breast cancer [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 P1-13-09.

Abstract P4-14-07: Impact of preservation of the intercostobrachial nerve during axillary dissection on sensory change and health-related quality of life two years after breast cancer surgery

Background: Sensory loss or paresthesia due to division of the intercostobrachial nerve (ICBN) is a complication of axillary lymph node dissection (ALND). Preservation of the ICBN may be of value, but few prospective studies have shown an impact of preservation on sensory changes or health related quality of life (HRQOL) after breast cancer surgery.

Methods: Prospective study was performed to evaluate the association of ICBN preservation with sensory change and HRQOL at 1 (baseline), 6, 12 and 24 months after breast cancer surgery in 140 patients. The sensory examination included dysesthesia, paresthesia, abnormal touch and pain sensation in the upper arm.

Results: Division of the ICBN did not influence the frequency or severity of subjective dysesthesia and paresthesia. There was no marked difference in touch or pain sensation at baseline between patients with a preserved (group P) and divided (group D) ICBN. In group P, the percentage of patients aware of a sensory deficit or loss decreased with time, and that of patients aware of a hypersensitive sensation increased. These changes did not occur in group D, leading to a significant difference between the groups at 24 months. The main difference between the groups was the area with reduced touch or pain sensation. This area decreased with time in group P, but not in group D. ICBN preservation or division did not influence HRQOL.

Conclusion: ICBN preservation in ALND has a benefit of a reduced area with long-term axillary hypoesthesia, but has no influence on improvement of pain and HRQOL.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-07.

P1-16-01: A Randomized, Double-Blinded, Controlled Study of Exemestane vs. Anastrozole for the First-Line Treatment of Postmenopausal Japanese Women with Hormone Receptor Positive Advanced Breast Cancer

Background The steroidal irreversible aromatase inhibitor (AI) exemestane (E), the non-steroidal reversible AI anastrozole (A) and tamoxifen (T) are approved for the first-line treatment of the postmenopausal women with hormone receptor (HR) positive advanced breast cancer (ABC) in Japan. Although there are some studies which compare the efficacy and safety of AIs and T in the first-line disease setting, the number of studies that compare efficacy and safety of AIs is limited. We conducted this multicenter, randomized, double-blinded non-inferiority study, to evaluate the time to progression (TTP) in HR positive ABC randomized to therapy with E or A.

Methods Patients (pts) who were ≥20 years [yrs], postmenopausal, ECOG PS ≤1 and had HR positive ABC that recurred after the adjuvant therapy or metastatic disease settings were eligible and randomized (1:1) to 25 mg/day of E or to 1 mg/day of A. Data were evaluated for non-inferiority of E compared to A defined as the upper limit of a two-sided 95% confidence interval (CI) of the hazard ratio (HR) of TTP being less than or equal to 1.25. The primary endpoint was TTP assessed by the independent radiological images review committee (RIRC). Secondary endpoints included TTP by investigator, time to treatment failure, overall survival (OS), objective response rate (ORR), clinical benefit rate, and safety.

Results A total of 298 pts from 58 sites were randomized to E (n=149; mean age: 63.4 yrs) or A (n=149; mean age: 64.0 yrs). The mean BMI for the E and A arms were 23.0 kg/m2 and 23.6 kg/m2, respectively. Six pts (2 pts in E arm, 4 pts in A arm) were excluded from the full analysis set due to lack of evaluation for anti-tumor response after study medication started.

Median TTP (as per RIRC) was 13.8 months (M) vs. 11.1 M for E vs. A, respectively (HR 1.007; 95% CI: 0.771−1.317). Median TTP (Investigator) was 13.8 M vs. 13.7 M for E vs. A, respectively (HR 1.059; 95% CI: 0.816−1.374). The median OS for A treated pts was 60.1 M, OS for E was not reached (as of data cut-off: December 8, 2010). ORR for E was 43.9% (95% CI: 35.3−52.8) and 39.1% (95% CI: 30.6−18.1) for A. Other analyses, including sub-population analyses are ongoing.

The incidence of treatment related adverse events (AEs) in E arm was 71.1% (n=106) and in A arm 59.7% (n=89); the AEs were mostly grade 1 and 2 in 61.7% (n=92) and 53.7% (n=80) of pts respectively. They were expected and manageable. Treatment related SAEs were similar in both groups: 6 (4.0%) in E arm and 5 (3.4%) in A arm. The most common AEs for E were hot flushes (22.1%), arthralgias (16.8%), musculoskeletal stiffness (11.4%) and γ-GTP increased (10.1%); in A arm, hot flushes (14.8%) and arthralgia (16.8%) were observed in >10% pts.

Conclusions Although median TTP (RIRC) of E is slightly improved compared with that of A, the result of TTP did not meet the non-inferiority criteria. There were no significant differences found between E and A in ORR. Although AEs in E were numerically higher, the observed AE profiles were similar to those previously reported for E and A. This study shows that E is comparable to A in efficacy and safety.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-16-01.

P2-15-04: Clinical Significance of Resection with Curative Intent for Isolated Pulmonary Metastases from Breast Cancer. Multi-Institutional Study in Japan

OBJECTIVE: Although resection of isolated pulmonary metastases is a common treatment in other primaries such as colon cancer, the role of lung metastasectomy of breast cancer is still unclear. The objective of the present study was to investigate the clinical outcome of our operated patients with isolated pulmonary breast cancer metastases and discuss the clinical implication of resection with curative intent for them.

METHODS: We retrospectively analyzed 86 female patients with histologically proven isolated pulmonary metastases from breast cancer who were treated with surgery of curative intent between January 1980 and September 2010 at 7 Japanese hospitals. The mean age of them was 50 years, the median disease free interval (DFI) from the definitive surgery for the primary breast cancer was 4.6 years (range: 0.5−20.4 years) and the median follow-up after lung metastasectomy was 4.1 years (range: 0.3−30.9 years).

RESULTS: Lung metastasectomy was performed by thoracotomy in 22 patients and by video-assisted thoracoscopic surgical resection in 64 patients. The number of metastatic foci resected was one for 79 patients, two for 6, and unknown for 1. Lymph node resection was performed for 12 patients, was not done for 69, and unknown for 5. Five-year survival rates after lung metastasectomy were 68% in the patients. The main prognostic factor was the DFI. Five-year survival rates for patients with DFI of longer than 2 years (n = 72) and those with DFI of shorter than 2 years (n=14) were 74.5% and 33.8%, respectively (p = 0.0006). Five-year survival rates after lung metastasectomy were 68% in patients without macroscopic residual pulmonary tumor after lung metastasectomy (n = 69) and 34% in those with macroscopic residual tumor (n = 12) (p = 0.023). Five-year disease free survival after lung metastasectomy for patients without macroscopic residual tumor was 51 %. Five-year survival rates were 78% in patient with endocrine hormonal therapy following lung metastasectomy (n = 51) and 53% in those without endocrine hormonal therapy (n = 35) (p = 0.045). No prognostic influence could be demonstrated for age, number of initial axillary node metastases, primary tumor size.

CONCLUSION: The prognosis of the breast cancer patients with isolated pulmonary metastases who underwent metastasectomy with curative intent was good. It was affected by the biological aspects of the primary tumor, “curativity” of the resection, and systemic treatments after lung resection. It may be expected that some of those patients will be cured by surgery with curative intent.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-15-04.

P3-12-03: A Prognostic Index of Ipsilateral Breast Tumor Recurrence in Patients Treated with Breast-Conserving Surgery after Preoperative Chemotherapy: Validation of M.D. Anderson Prognostic Index

Background: Preoperative chemotherapy (PCT) is widely used to increase the possibility of breast-conserving treatment (BCT). However, the appropriate indication for BCT after PCT is controversial, because the rates of ipsilateral breast tumor recurrence (IBTR) may be higher than those reported for BCT when surgery is used first. We performed a multicenter retrospective study to evaluate factors that were associated with IBTR in patients with BCT after PCT, and validated M. D. Anderson Prognostic Index (MDAPI) (Cancer 2005;103:689–95) using our data set.

Patients and Methods: From eight Japanese hospitals, data were extracted on a total of 381 patients with invasive breast cancer (BC) who were treated with ≥3 cycles of PCT followed by breast-conserving surgery and irradiation. The rates of IBTR were evaluated by MDAPI including clinical N2 or N3 disease, pathologic residual tumor >2 cm, multifocal pattern of residual disease, and lymphovascular space invasion in the specimen. Kaplan-Meier method was used to estimate cumulative recurrence rates. Log-rank test and Cox's proportional hazard model were used for statistical analyses.

Results: Median age at diagnosis of the primary tumor was 48 years; median size of the primary tumor at diagnosis was 4.0 cm. One hundred and forty-six patients received postoperative chemotherapy and 211 received postoperative endocrine therapy. At a median follow-up period of 50 months, 18 of 381 patients developed IBTR, which resulted in 5-year IBTR-free rate of 94.1%. Univariate analyses revealed that estrogen receptor (ER) status both before and after PCT (positive vs. negative), pathological nodal status after PCT (≥4 vs. 0–3 positive nodes), and pathologically residual invasive tumor (≥1.8 vs. ≤1.7 cm) were significantly associated with IBTR (all P < 0.05). Pathological margin status did not affect IBTR rate (P=0.88). Multivariate analysis revealed that significant independent predictors of IBTR included ER status after PCT (Hazard Ratio [HR], 0.10; P<0.01), size of residual invasive tumor (HR, 5.29; P=0.03), and pathological nodal status after PCT (HR, 3.59; P=0.02). The rates of IBTR of patients with MDAPI 0–3 were 1.3%, 2.9%, 16.0%, and 3.6%, respectively. Based on the data of our multivariate analysis, ER status after PCT (ER positive;0 and ER negative; 1 was added to MDAPI. Total scores of the prognostic index including MDAPI and ER status after PCT ranged between 0 and 5. The rates of IBTR correlated well with this prognostic index. The 5-year IBTR-free survival rates were 0% for 23 patients in score 0, 3.4% for 89 in score 1, 3.9% for 51 in score 2, 21.2% for 33 in score 3, and 16.7% for 6 in score 4 (P < 0.01).

Conclusion: Our prognostic index (MDAPI plus ER status) would be useful for clinical decision making according to surgical procedures after PCT. BCT is an appropriate treatment option for patients with the low prognostic index (0 to 2). The high risk population with the high prognostic index (3 to 5) may benefit from mastectomy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-12-03.

P3-07-14: Sensory Disturbance of the Ipsilateral Upper Arm after Breast Cancer Surgery with Sentinel Node Biopsy Alone Compared with Axillary Dissection – A Prospective Study

Background

Axillary surgery for breast cancer causes several postoperative complications including edema of the ipsilateral arm and sensory disturbance of the ipsilateral upper arm. Although sentinel node biopsy has been considered as a standard procedure for node-negative patients, some complications bother patients even after it. Although data regarding the quality of life of patients and/or subjective and objective assessment of arm morbidity after axillary surgery have been reported, to our knowledge, quite a few data have been reported on actual examination of sensory disturbance of the ipsilateral upper arm after sentinel node biopsy alone. We report comparative data regarding the objective and subjective degrees of postoperative sensory disturbance of the ipsilateral upper arm examined prospectively between sentinel node biopsy alone and axillary dissection.

Patients and Methods

A total of 118 patients, who received breast cancer surgery with sentinel node biopsy alone (51 patients)(SN group) or axillary dissection (67 patients)(AD group) at NHO Shikoku Cancer Center, were prospectively evaluated sensory disturbance regarding the following: (a) dysesthesia, (b) paresthesia, (c) degree of disturbed tactile sensation, (d) degree of disturbed pain sensation, (e) ratio of disturbed area of tactile sensation (defined as (A) length of disturbed area/(B) total length of upper arm), and (f) ratio of disturbed area of pain sensation (defined as A/B). Patients were either asked about the above or examined for them at one month, 6 months and 1 year, respectively, after surgery. At surgery it was recorded whether or not the intercostobrachial nerve(s) were totally preserved in patients who underwent axillary dissection. Unpaired t-test, Mann-Whitney U-test and Wilcoxon signed rank test were used to test statistical significance.

Results: The mean ages at surgery were 54.7 and 53.7 years in the SN and AD groups, respectively (P = 0.66). The mean number of biopsied lymph nodes in the SN group was 2.4 (range: 1–5). In 22 patients of the AD group the intercostobrachial nerves were totally preserved. There was no difference in dysesthesia, paresthesia, and the level of disturbed pain sensation between the two groups throughout one year after surgery. However, the patients in the SN group showed milder disturbed tactile sensation at one and 6 months than those in the AD group (P = 0.04 and 0.03, respectively). Both the ratios of disturbed area of tactile and pain sensation were statistically significantly lower in the SN group than in the AD group throughout one year (P = 0.03 ∼ <0.0001). The mean ratios of disturbed area of those sensations were stable in the SN group over the year (0.03−0.05 for both tactile and pain sensations, P > 0.12 for any comparison). On the other hand, the mean ratios in the AD group became lower from 0.23 to 0.17 for tactile sensation and from 0.20 to 0.13 in pain sensation (P = 0.02, and 0.05 for tactile and pain sensations, respectively).

Conclusion: Sensory disturbance of the ipsilateral upper arm after sentinel node biopsy alone was much milder than after axillary dissection throughout the study period.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-14.

Effects of exemestane, anastrozole and tamoxifen on bone mineral density and bone turnover markers in postmenopausal early breast cancer patients: results of N-SAS BC 04, the TEAM Japan substudy

BACKGROUND

Use of aromatase inhibitors in women with postmenopausal breast cancer accompanies risks of bone loss. We evaluated changes in bone mineral density (BMD) and bone turnover markers in patients treated with exemestane, anastrozole or tamoxifen for hormone-sensitive postmenopausal early breast cancer.

PATIENTS AND METHODS

Sixty-eight patients enrolled in the Tamoxifen Exemestane Adjuvant Multinational Japan bone substudy were randomly assigned to receive tamoxifen, exemestane or anastrozole. During a 2-year study period, lumbar spine BMD was measured using dual-energy X-ray absorptiometry, and urinary type I collagen cross-linked N-telopeptide (NTX) and serum bone-specific alkaline phosphatase (BAP) were also measured.

RESULTS

BMD at 2 years of treatment was higher in tamoxifen patients compared with exemestane and anastrozole patients; however, the intergroup difference was not significant (p = 0.2521 and p = 0.0753, respectively). BMD was higher in exemestane patients compared with anastrozole patients; however, the intergroup difference was not significant (p = 0.7059 and p = 0.8134, respectively). NTX and BAP were significantly lower in tamoxifen patients compared with exemestane and anastrozole patients at 1 and 2 years of treatment (p < 0.05).

CONCLUSION

Tamoxifen may provide better bone protection compared with exemestane or anastrozole. The effect of exemestane and anastrozole on bone loss may be comparable in Japanese postmenopausal women.

Abstract P4-10-05: Factors Associated with Ipsilateral Breast Tumor Recurrence in Breast Cancer Patients Treated with Breast Conserving Surgery and Radiotherapy after Preoperative Chemotherapy

Background: Although preoperative chemotherapy (PCT) was originally used to make locally advanced breast cancers (BC) operable, it is now frequently utilized to make relatively large primary tumors small enough for breast conserving treatment (BCT). A large number of studies have been performed to identify risk factors of ipsilateral breast tumor recurrence (IBTR) after breast conserving treatment for originally small tumors. However, those studies for patients (Pts) who received BCT after PCT for relatively large tumors are limited. We have done a multicenter retrospective study to identify factors which were associated with IBTR in Pts treated with BCT after PCT.

Patients and methods: From 7 Japanese hospitals, data, which regard characteristics of tumors and Pts, and treatment, of Pts who fulfilled the following criteria; 1. Female BC Pts who started PCT before January 2007 2. Her tumor was invasive, clinically solitary, and 2 cm or largerby palpation at diagnosis 3. She received 3 or more cycles of PCT 4. She received breast conserving surgery as a definitive surgery after PCT including axillary dissection or sentinel node biopsy 5. She received radiotherapy at least to the conserved breast. Pts with inflammatory BC and BC Pts who received preoperative treatment(s) other than chemotherapy were excluded. Kaplan-Meier method was used to estimate cumulative recurrence rates. Log rank test and Cox's proportional hazard model were used for statistical analyses. Receiver Operating Characteristic (ROC) Curves and C statistics were used for evaluating the prediction ability of Cox's proportional hazard model about IBTR.

Results: A total of 324 Pts were registered. The median age at diagnosis of them was 48 years old. The median size of the primary tumors by palpation at diagnosis was 4 cm. For PCT anthracycline-based regimens were used for 83 Pts, taxane-based regimens were for 29, and anthracycline-taxane regimens were for 212. One hundred forty two Pts (43.8%) received postoperative chemotherapy, 180 (55.6%) had postoperative endocrine therapy, and only 7 had postoperative trastuzumab therapy. The median follow-up period was 45 months. Nineteen Pts (5.9%) developed IBTR. The cumulative 4-year IBTR rate was 5.5%. Univariate analyses revealed that estrogen receptor (ER) status both before and after PCT, pathological nodal status after PCT, and pathologically residual invasive tumor (solitary vs. multifocal, 1.7 cm or smaller vs. 1.8 cm or larger) were statistically significantly associated with IBTR (P &lt; 0.05 for all of them). Pathological margin status did not affect IBTR rate (P=0.73). ER status prior to PCT (positive vs. negative)(Hazard Ratio [HR], 6.76; P=0.012), size of the residual invasive tumor (1.7 cm or smaller vs. 1.8 cm or larger)(HR, 4.74; P=0.020), and pathological nodal status after PCT (0-3 positive nodes vs. 4 or more)(HR, 3.03; P=0.041) were associated with IBTR on multivariate analysis. C statistic was 78.3%.

Conclusion: Mastectomy may be a better choice for the Pts who have tumors with negative ER, pathologically large (1.8 cm or larger) residual invasive lesions after PCT, or 4 or more pathologically positive nodes after PCT in terms of local control.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-10-05.

Abstract P5-14-20: Clinical Features of Surgical Resection for Solitary Pulmonary Metastasis and the Discrepancy in Immunopathological Features between Primary and Metastatic Breast Cancer Lesions

Background: The treatment for metastatic breast cancer (MBC) is usually systemic therapy decided by the hormone and HER2 status of primary breast cancer lesion. There are some reports about the discrepancy in hormone and HER2 status between primary and metastatic lesion in these days. We have reported previously that the expression of ALDH-1 which considered the pathological markers of breast cancer stem cell in axillary lymph node matastases is a significant predictor of poor outcome in primary breast cancer patients (Figure 1). We evaluated the role of surgery in the diagnosis and treatment of a solitary pulmonary nodule (SPN) in breast cancer patients and demonstrated the significance of analyzing the immunopathological features in metastatic breast cancer lesion.

Methods: Between 1990 and 2006, 17 patients (PM) with SPN which were diagnosed breast cancer metastases underwent complete pulmonary resection and 36 MBC patients (AP) underwent autopsy after breast cancer related death in our hospitals. We retrospectively analyzed clinicopathological features and the expression of ER, HER2, Ki-67 and ALDH-1 in both primary and metastatic breast cancer lesions.

Results: The median age of PM patients was 53 (range 30-80). All PM patients had not other metastases and had undergone curative breast cancer operation. The pulmonary operation were partial pulmonary resection in 15(88%) and lobectomy in 2 (12%) patients. The median disease free survival (DFS) was 63 months (range 9-175). Median overall survival (OS) was 181 months and the median OS after pulmonary operation was 48 months. The median DFS and OS of AP patients were 21 and 43 months. All AP patients had multiple visceral metastases. We compared the immunohistlogical status between primary and metastatic lesion and evaluated the colletation with these status in metastatic lesion and prognosis in all patients. Conclusion: Pulmonary resection was effective to diagnose and the OS after resection was relatively long in PM patients. We report the value of the expression of ER, HER2, Ki67 and ALDH-1 in distant metastatic lesions.

Objective and Subjective Assessment of Edema during Adjuvant Chemotherapy Using Taxane-Containing Regimens in a Randomized Controlled Trial: National Surgical Adjuvant Study of Breast Cancer (NSAS-BC) 02

Background: Taxanes are frequently used in treatment of breast cancer (BC) patients. However, some patients treated with taxanes, especially docetaxel (DTX), experience severe edema during and following the treatment. We prospectively assessed body weight and health-related quality of life (HRQOL) related to edema in a randomized controlled trial (RCT) comparing four taxane-containing regimens in an adjuvant setting.Patients and Method: We conducted NSAS BC02 trial in which postoperative patients with node positive BC were randomly assigned to receive one of the following four adjuvant chemotherapeutic regimens; (1) ACP regimen: 4 cycles of doxorubicin 60mg/m2 plus cyclophosphamide 600mg/m2 q3weeks (AC) followed by 4 cycles of paclitaxel (PTX) 175 mg/m2 q3weeks, (2) ACD regimen: 4 cycles of AC followed by 4 cycles of DTX 75mg/m2 q3weeks, (3) PTX regimen: 8 cycles of PTX, (4) DTX regimen: 8 cycles of DTX. During the study we recorded body weight at baseline (at study entry), on day 1 of each cycle and at 8 months, and every 6 months thereafter. And we asked the patients to answer FACT-B, and -Taxane at baseline, on day 1 of cycle 3, 5, and 7, and at 8 and 12 months. We compared the change of weight and the scores of 4 items regarding edema in FACT-B (B8) (change in weight) and FACT-Taxane (Tax1 [anasarca], Tax2 [edema of hands], and Tax3 [edema of legs]) among the four regimens. Data were analyzed on an intent-to-treat basis. The statistical significance of the differences among the regimens was examined with analysis of covariance and t-test.Results: Of 1060 patients who entered N-SAS BC 02 trial, first 300 patients participated in this HRQOL study (ACP 74 patients, ACD 75, PTX 76, and DTX 75). The weight increased markedly and recovered by 8 months in the patients of DTX regimen, increased slightly in those of ACD regimen, and was almost stable in those of ACP and PTX regimens. The difference in the change of weight from the baseline to the 8th cycle between the patients of DTX plus ACD regimens and those of ACP plus PTX regimens was statistically significant (P&lt; .0001). The compliance of FACT-B, and -Taxane was high throughout the study period (&gt; 85 % at each point). The scores of B8, Tax1, Tax2, or Tax3 were relatively stable in ACP, ACD, and PTX regimens over the study period, but those of DTX regimen became lower (indicating worse HRQOL) up to 8 months, then recovered to the baseline except the scores of Tax2 which were still lower than those of other 3 regimens at 12 months. When the scores of the patients of DTX regimen were compared with those of other 3 regimens combined, the differences were statistically significant in all items of B8 (P= .0450), Tax1 (P= .0016), Tax2 (P&lt; .0001), and Tax3 (P&lt; .0001).Discussion: The patients who received 8 cycles of DTX were agonized by chemotherapy (CT)-related edema. However, the agony seemed to disappear by 6 months after the completion of CT except for that of edema of hands. The reason why only the scores of Tax2 did not recover at 12 months in the patients of DTX regimen is suspected to be the ipsilateral hand and arm edema affected by axillary dissection which might have lasted for a long time.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2090.

Detection of Isolated Regional Lymph Node Recurrences by PET-CT in Follow-Up of Postoperative Breast Cancer Patients

Background: It is not recommended to use imaging diagnostic methods in order to find small distant metastases in follow-up of postoperative breast cancer patients because of lack of improvement in survival with use of them in old randomized trials. However, use of new imaging modalities in follow-up of postoperative breast cancer patients may improve their survival due to detection of small regional lymph node recurrences without distant metastases which are potentially curable.Patients and methods: Between April 2006 and December 2008, we used PET-CT to find small recurrences in follow-up of 1908 postoperative breast cancer patients who received definitive surgery at the National Hospital Organization Shikoku Cancer Center. A total of 3283 times (1 to 4 times per a patient; median 1) of PET-CT imaging without contrast medium were performed during the period. A median age at the PET-CT imaging was 58 years (range, 22 to 91 years, mean 58.5 years). A median interval from the definitive surgery to the PET-CT imaging was 48 months (range, 3 to 385 months, mean 57.8 months). The results were analyzed retrospectively.Results: Seven patients were found to have isolated axillary node recurrence by PET-CT, and additional 3 patients were shown to have isolated subclavian node recurrence. Furthermore, only PET-CT showed that other 7 patients had isolated supraclavicular node recurrences and 6 patients had isolated parasternal node recurrences. All of those lymph node recurrences were missed by palpation or nonpalpable. A median interval from the definitive surgery to the diagnoses of the isolated regional node recurrences was 50 months (range, 19-167 months, mean 58.3 months). Those recurrences were found by the first examination with PET-CT in 14 patients and by the second examination in 9 patients. Fifteen asymptomatic other cancers including contralateral mammographically invisible breast cancers were found only by PET-CT (1 lung cancer, 2 gastric cancers, 1 colon cancer, 2 rectal cancers, 2 pancreatic cancers, 1 endometrial cancer, 4 thyroid cancers, and 2 contralateral breast cancers). The pathological lymph node status at the definitive surgery of 23 patients with the isolated regional lymph node recurrences was positive in 17 patients (number of positive nodes: 1 to 3 positive nodes in 7 patients, 4 to 9 in 8, 10 or more in 2), negative in 4, and unknown in 2. If the patients are limited to those who had the pathologically positive node(s) at the definitive surgery, the incidence of the patients with the isolated regional node recurrences found only by PET-CT will be 2.6% (17/663 patients).Conclusion: Early detection of isolated loco-regional recurrences of breast cancer is suggested to result in an improvement of survival. Therefore, the use of PET-CT in follow-up of postoperative node positive breast cancer patients may improve their survival because of early detection of isolated regional node recurrences which are still potentially curable and screening of other asymptomatic cancers.Reference: Lu WL et al. Impact on survival of early detection of isolated breast recurrences after the primary treatment for breast cancer. a meta-analysis. Breast Cancer Res Treat 114: 403-412, 2009

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4009.

Utility of Breast CT in the Management of Breast Cancer – Results from a Prospective Multi-Institutional Study

Background:In order to obtain negative margins after breast conserving surgery (BCS), even repeated surgery is widely accepted. Before surgery, it is important to conduct a precise assessment of the extent of the breast cancer so that each patient can receive individualized surgery. To evaluate the utility of breast computed tomography (CT) as a tool to manage BCS, a multi-institutional prospective study was conducted in Japan.Patients and Methods:Patients were eligible to participate in this study if they had histologically proven breast cancer and were determined to be BCS candidates based on palpation, mammography (MMG) and ultrasonography (US). Written informed consent was obtained from each patient. First, the surgeon marked the line of planned excision on the skin using information from the MMG and US. Next, an expired angiographic catheter was placed on the mark to show the original surgical margin on the CT image. Breast CT was scanned 60 seconds after the bolus injection of the contrast material in the supine surgical position. The surgeon determined the extent of surgery based on the breast CT results. Surgical specimens were serially sectioned in 5-mm slices.Results:Three hundred and two patients were enrolled in this study. The CT scanners used in this study varied from a single helical CT to a 64-row multidetector CT. The results of the breast CT changed the extent of resection in 14.7% of patients. Among the 5 patients who were recommended to undergo a mastectomy, 4 patients had multicentric tumors pathologically and 1 patient had a widely spread intraductal component. The other patients were recommended to have a quadrantectomy based on the extent of breast cancer that was visualized by CT. Three patients (1%) who required conversion from a lumpectomy to quadrantectomy resulted in overexcision. In short, breast CT correctly changed the extent of surgery in 13.7% of the examined patients.Conclusion:This prospective study suggested that breast CT is useful for hospitals equipped with any type of CT and can be used to provide patients with individualized surgery.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5021.

Health-related quality-of-life and psychological distress of postmenopausal breast cancer patients after surgery during the randomized trial, N-SAS BC 03, comparing further tamoxifen with switching to anastrozole after adjuvant tamoxifen for 1 to 4 years: the final results

Abstract #1136

Backgroud: Three years ago, we reported the interim results regarding heath-related quality of life (HRQOL) outcomes of the patients who switched their adjuvant endocrine therapy from several years of tamoxifen (TAM) to anastrozole (ANA) and those who had TAM for a total of 5 years in the randomized trial, National Surgical Adjuvant Study of Breast Cancer (NSAS BC) 03. We present the final results of HRQOL and psychological distress in the NSAS BC 03.&#x2028; Patients and Methods: Recurrence-free postmenopausal breast cancer patients who had received definitive surgery for hormone receptor positive breast cancer, and had been taking TAM for 1 to 4 years after the surgery were enrolled in the randomized trial: N-SAS BC 03. They were randomly assigned to continue TAM for the remaining periods of a total of 5 years or to switch from TAM to ANA and take the latter for the remaining periods. Primary endpoints of the N-SAS BC 03 trial were disease-free survival and adverse events. HRQOL and psychological distress were evaluated as secondary endpoints. They were asked to answer patient-administered instruments to assess HRQOL (FACT-B [breast cancer scale] and FACT-ES [endocrine symptom scale]) and psychological distress (CES-D: Center for Epidemiologic Studies Depression scale) at the randomization (baseline), 3 months, 1 and 2 years after the randomization. HRQOL and psychological distress scores during this period were compared using t-test and the general linear model with correlated errors.&#x2028; Results: There was no difference in demographic and medical characteristics between the two treatment groups. The response rates of the questionnaires were 98.6%, 97.2%, 90.9% and 78.5% at baseline, 3 months, 1 and 2 years after the randomization, respectively. At baseline 694 patients (346 in the TAM group and 348 in the ANA group) answered them. The total scores of FACT-G, and FACT-ES and the scores of FACT-G physical well-being (PWB) subscale were statistically significantly better in the TAM group than in the ANA group (P = 0.042, 0.038, and 0.005, respectively) after the randomization, while those of FACT-B in the former were marginally better than those in the latter (P= 0.066). However, there were no statistically significant differences between the two treatment groups for the scores of CES-D, and subscales other than PWB of FACT-G, FACT-B, and FACT-ES.&#x2028; Conclusions: Further TAM treatment after adjuvant TAM for 1 to 4 years may provide postmenopausal breast cancer patients with slightly better HRQOL comparing with switching to ANA.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1136.

Prospective assessment of chemotherapy-induced neurotoxicity in breast cancer (HOR 02) and questionnaire survey of physicians’ perspectives

6619

Background: Physician-based instruments (e.g., NCI-CTC) are widely used to assess chemotherapy-induced peripheral neuropathy (CIPN). However, current evidence suggests that physician-based assessments under-report the incidence and severity of CIPN. To overcome this limitation, a patient-based questionnaire, patient neurotoxicity questionnaire (PNQ) was developed, and a phase III randomized adjuvant trial of breast cancer (N-SAS BC 02; AC followed by PAC/DOC vs. PAC/DOC alone) has demonstrated that PNQ is reliable and sensitive and responsive instrument to assess CIPN (Shimozuma et al., SABCS 2004; #6037). We prospectively evaluated the reliability and sensitivity of PNQ in advanced or metastatic breast cancer treated by weekly administration of paclitaxel. Moreover, a questionnaire survey was conducted on physician perspectives regarding the assessment of CPIN in Japan. Methods: CIPN and QOL were prospectively assessed in thirty-five patients with advanced or metastatic breast cancer who received weekly paclitaxel (80–100 mg/m2/w). PNQ and FACT-Ntx subscale were compared to NCI-CTC. Assessments were conducted at baseline, 8 wk, 16 wk after starting treatments. A questionnaire was sent to physician who participated in N-SAS BC 02 to clarify their perspectives regarding the CPIN. Results: Average response rate of the instruments was 89%. Sensory PNQ scores correlated with sensory FACT-Ntx scores (r=0.51), and NCI-CTC scores (r=0.58). NCI-CTC scores mainly distributed between 0 and 1, while PNQ scores widely distributed. Follow-up study revealed that sensory CIPN assessed by PNQ appeared to be sensitive as compared to NCI-CTC. In clinician survey, 47 out of 61 physicians (77%) responded, and majority of them considered neurosensory symptoms as diagnostic hallmark for CIPN. However, for the justification for treatment delay, dose modification, or treatment cessation, most laid weight on functional impairment in patients with CIPN. Most (80%) rated PNQ is helpful in management of patients at risk for CIPN. Conclusions: This study confirmed that physicians tended to underestimate CIPN, and PNQ was a more reliable and valid instrument to assess CIPN with high acceptability in physicians.

[Table: see text]

Fertilizability and chromosomal integrity of frozen-thawed Bryde's whale (Balaenoptera edeni) spermatozoa intracytoplasmically injected into mouse oocytes

Prior to attempting the in vitro production of embryos in the Bryde's whale (Balaenoputera edeni), we investigated whether spermatozoa can retain the capacity for oocyte activation and pronucleus formation as well as chromosomal integrity under cryopreservation by using intracytoplasmic sperm injection (ICSI) into mouse oocytes. Regardless of motility and viability, whale spermatozoa efficiently led to the activation of mouse oocytes (90.3-97.4%), and sperm nuclei successfully transformed into male pronucleus within activated ooplasm (87.2-93.6%). Chromosome analysis at the first cleavage metaphase (M) of the hybrid zygotes revealed that a majority (95.2%) of motile spermatozoa had the normal chromosome complement, while the percentage of chromosomal normality was significantly reduced to 63.5% in immotile spermatozoa and 50.0% in dead spermatozoa due to the increase in structural chromosome aberrations. This is the first report showing that motile Bryde's whale spermatozoa are competent to support embryonic development.

381 FERTILIZABILITY AND CHROMOSOMAL INTEGRITY OF FROZEN - THAWED BRYDE's WHALE (BALAENOPTERA EDENI) SPERMATOZOA INTRACYTOPLASMICALLY INJECTED INTO MOUSE OOCYTES

In this study, we applied intracytoplasmic sperm injection (ICSI) to mouse oocytes to evaluate the fertilizability and chromosomal integrity of the three types of frozen–thawed Bryde's whale spermatozoa. B6D2F1 female mice (7–11 weeks of age) were superovulated by injections of PMSG followed by hCG 48 h later. The oocytes recovered from oviducts between 14 and 16 h after hCG injection were denuded of their cumulus cells. Sperm samples were obtained from a Bryde's whale (Balaenoptera edeni) captured under the Japanese Whale Research Program with Special Permit in the Western North Pacific between May and August 2003 (presumptive feeding season). The whale was killed by an explosive harpoon which has been recognized as the best humane method for whales by the International Whaling Commission (IWC) and stipulated by Schedule III (Capture) of the International Convention for the Regulation of Whaling. Spermatozoa collected from vasa deferentia were cryopreserved. Frozen Bryde's whale spermatozoa were thawed at 37�C and washed with HEPES-TYH by centrifugation at 500g for 5 min. Motile and immotile spermatozoa were obtained, and some spermatozoa in HEPES-TYH were refrozen without cryoprotectant at -20�C to be completely killed. Within 24 h, they were thawed at 37�C and prepared for ICSI. Comparison of group values was performed by either Fisher's exact probability test or chi-square test where necessary. Differences at P d 0.05 were considered significant. Chromosomal normality was determined by analyses of karyotyped haploid chromosomes (n = 22) of the whale sperm. Regardless of motility and viability, whale spermatozoa efficiently led to the activation of mouse oocytes (90.3–97.4%), and sperm nuclei successfully transformed into male pronuclei within activated ooplasm (87.2–93.6%). Chromosome analysis at the first cleavage metaphase of the hybrid zygotes revealed that a majority (95.2%) of motile spermatozoa had the normal chromosome complement, whereas the percentage of chromosomal normality was significantly (P ≤ 0.001) reduced to 63.5% in immotile spermatozoa and 50.0% in dead spermatozoa, due to the increase in structural chromosome aberrations such as chromosome fragments. This is the first report showing that motile Bryde's whale spermatozoa are competent to support embryonic development. Furthermore, we have shown that chromosomal analysis of whale spermatozoa is a useful technique for measuring the influences of marine pollution on reproduction in cetacean species that occupy the top niche in the marine ecosystem.

Assessment and quantification of taxane-induced neurotoxicity in a phase III randomized trial of breast cancer (AC followed by PAC/DOC vs. PAC/DOC alone): N-SAS BC 02

8523

Background: Chemotherapy-induced peripheral neuropathy (CIPN) commonly occurs during taxane chemotherapy (Tx). There is no standardized approach used in the assessment of CIPN. Physician-based instruments (e.g., NCI-CTC) are widely used for this purpose, but are associated with several important limitations. As current medical evidence suggests that physician-based assessments under-report the incidence and severity of subjective symptoms, they cannot reliably or accurately assess symptoms of CIPN. We prospectively assessed CIPN during Tx in a phase III randomized trial to evaluate the reliability and sensitivity of these different approaches. Methods: Three hundred breast cancer (BC) patients entered the National Surgical Adjuvant Study of Breast Cancer 02 (N-SAS BC 02), a phase III randomized trial comparing 4 cycles of AC followed by 4 cycles of Tx (paclitaxel [PAC] or docetaxel [DOC]) vs. 8 cycles of Tx alone in N+ BC patients after surgery. CIPN and QOL were secondary endpoints. Patient-based PNQ and FACT-Ntx were compared to the clinician-based NCI-CTC. Assessments were conducted at baseline, 3rd, 5th, 7th cycles, 8 months, and one year after starting adjuvant treatments. A linear mixed effect model was used to compare data in the two treatment groups across repeated cycles of treatment. Results: Average response rate of the instruments was > 90%. Sensory PNQ scores strongly correlated with sensory FACT-Ntx scores (r=0.70), while they weakly correlated (r=0.43) with NCI-CTC scores. NCI-CTC scores distributed between 0 and 2, while PNQ scores distributed between 0 and 4. Comparison of CIPN during the first 3 cycles showed that significantly higher overall incidence of sensory disturbance was observed in Tx compared with AC as assessed by both PNQ (PAC, P<0.0001; DOC, P=0.0007) and NCI-CTC (PAC, P<0.0001; DOC, P=0.0026). The PNQ appeared to detect more severe grades of sensory neuropathy compared to NCI-CTC. Conclusions: This study confirmed that physicians tended to underestimate CIPN, and patient-rated PNQ was a more reliable and valid instrument to assess CIPN. The development of new and reliable assessment methods would represent important medical advancements for cancer patients.

[Table: see text]

Breast biopsy for mammographically detected non-palpable lesions using a vacuum-assisted biopsy device (Mammotome) and an upright-type stereotactic mammography unit

BACKGROUND

It is planned to start screening mammography throughout Japan in the near future. However, a minimally invasive biopsy procedure for mammographically detected non-palpable breast lesions is not available in almost all Japanese hospitals. It is crucial to develop a useful minimally invasive biopsy method which can be applied without difficulty.

METHODS

Eighty-nine biopsies for 88 mammographically detected non-palpable breast lesions, consisting of 70 lesions with microcalcifications alone, eight masses without calcifications and 10 with both masses and microcalcifications, were performed using the combination of a vacuum-assisted biopsy device (Mammotome) and an upright-type stereotactic mammography unit.

RESULTS

Microcalcifications were confirmed radiographically in the tissue obtained from 78 biopsies among 81 biopsies for the lesions with microcalcifications (96.3%). All the lesions without calcifications were considered to be biopsied successfully. Five patients complained of nausea or fainted during the localization or biopsy procedure and an additional patient suffered from hyperventilation syndrome. Five cases experienced mild subcutaneous bleeding in the breasts.

CONCLUSIONS

The biopsy technique using the combination of a vacuum-assisted biopsy device and an upright-type stereotactic mammography unit is a cost-effective, safe and very useful method for mammographically detected non-palpable breast lesions. It is expected to be a standard method of biopsy for such lesions in many developed countries other than the USA. However, it is important to make the patients relaxed during the biopsy to prevent mental strain.

An attempt at intracytoplasmic sperm injection of frozen-thawed minke whale (Balaenoptera bonaerensis) oocytes

Little is known about the characteristics of fertilisation events in minke whales. Cryopreserved minke whale oocytes and spermatozoa do not fertilise in a standard IVF. This study was conducted to investigate the pronucleus formation ability of cryopreserved minke whale oocytes and their subsequent development following intracytoplasmic sperm injection (ICSI). In experiment 1, frozen-thawed minke whale immature oocytes were cultured for in vitro maturation (IVM) in a maturation medium (TCM199) supplemented with either porcine follicle stimulating hormone (pFSH)/estradiol-17beta (E2) or pregnant mare's serum gonadotropin (PMSG)/human chorionic gonadotropin (hCG). After 120 h of IVM, oocyte survival was examined before ICSI, and showed no significant difference in morphological normality (24-36%) between the two IVM media. Two-cell embryos (two oocytes from 21 sperm-injected oocytes) were obtained when the maturation medium was supplemented with pFSH/E2 or PMSG/hCG. In experiment 2, cryopreserved maturing oocytes were investigated for the effects of repeat-culture (2 h or 24 h) on survival before ICSI. Pronuclear formation and development were examined for the effects of sperm pretreatment with dithiothreitol (DTT) and oocyte activation with ethanol at ICSI. A frequency of 49-69% of frozen-thawed maturing oocytes was used for ICSI. Although oocyte activation did not produce a significant difference in survival, pronucleus formation and embryonic development, 2- and 4-cell cleaved oocytes were observed after injection of sperm pretreated with DTT.

Two cases of cholesterol granuloma of the breast

We report two cases of cholesterol granuloma of the breast clinically diagnosed as malignant and describe the features. The first patient was a 74-year-old woman who complained of a lump in the left breast. The mammography and ultrasonography suggested a malignant mass. Fine needle aspiration showed multinucleated giant cells. We suspected breast cancer, but cholesterol granuloma was diagnosed on excisional biopsy. The second case was a 51-year-old woman who was found to have a breast tumor on a screening mammography. The mammography and ultrasonography suggested carcinoma, but excisional biopsy revealed cholesterol granuloma. Reports of cholesterol granuloma of the breast are very rare. Cholesterol granuloma should be considered in the differential diagnosis of breast carcinoma.

Improvement on in vitro maturation, fertilization and development of minke whale (Balaenoptera acutorostrata) oocytes

The aims of the present study were to improve in vitro maturation, fertilization and subsequent development of minke whale oocytes. We investigated the effects of different concentrations (0, 10 and 20%) of fetal whale serum (FWS) in maturation medium on nuclear maturation, morphological grade (A or B) of cumulus-oocyte complexes (COC) obtained from prepubertal and adult minke whales. Grade A (> or = 5 layers of cumulus cells) COC collected from the adult whales and cultured in the medium with 20% FWS had a higher (P < 0.05) maturation rate (31.8%) than those in the medium without FWS (0%). Adding FWS to the maturation medium significantly (P < 0.01) improved the proportion of oocytes at Metaphase II (M-II): without FWS (7.9%), with 10% (19.4%) and 20% (21.4%) FWS. However, sexual maturity of whales and COC grades were not significantly affected by M-II oocytes. When in vitro fertilization of matured oocytes was performed in the presence of 20% FWS or 0.6% BSA in the fertilization medium, the proportions of sperm penetration and two-pronuclei formation in matured oocytes were not significantly different. Grade A COC cultured in a culture medium supplemented with 10% FWS cleaved at a higher rate (15.4%, P < 0.05) than did Grade A and B COCs cultured in the medium without FWS (0%). Neither Grade A nor B COCs cleaved when the medium was without FWS. The proportions of cleaved oocytes increased (P < 0.05) with FWS supplementation (6.9% and 8.1% for 1.0% FWS and 20% FWS, respectively). Grade A COC was significantly (P < 0.05) superior in its ability to cleave (14.5%) and develop to morula (4.2%) compared with that of the oocytes from Grade B COC (2.5% and 0%). Coculture with granulosa cells during in vitro culture did not significantly affect cleavage and development to the morula stage. These results indicate that FWS addition in the maturation medium improved the rate of in vitro maturation and cleavage after insemination of minke whale oocytes. The BSA supplementation in fertilization medium was as effective as FWS supplementation for in vitro fertilization of matured oocytes. In vitro embryo production beyond the morula stage of minke whale oocytes could be possible, if Grade A COC was selected and cultured in the maturation medium supplemented with 10% or 20% FWS.

Plasma and pituitary concentrations of gonadotropins (FSH and LH) in minke whales (Balaenoptera acutorostrata) during the feeding season

This study investigated plasma and pituitary concentrations of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) and steroid hormones (progesterone: P4, testosterone:T, estradiol-17beta: E2) by enzyme-immunoassay (EIA) in minke whales (Balaenoptera acutorostrata) captured during the feeding season (December to March) in the Antarctic Ocean. Plasma FSH and LH levels in female minke whales were higher (P <0.05) than in male whales. Although the pituitary weight was not significantly different between male and female whales, pituitary FSH and LH levels were higher in females than in males (P<0.01) and mature whales than immature whales (P<0.05). Plasma levels of FSH, T and E2 were not significantly different between immature and mature male whales, but plasma LH and pituitary FSH and LH levels were higher (P<0.05) in mature than in immature whales. In both immature and mature whales regardless of gender, pituitary FSH and LH levels were correlated significantly (r=0.69: P<0.01). In mature male whales, plasma T and E2 levels (r=0.60: P<0.01), and testis weight and plasma T levels (r=0.46: P <0.05) were correlated. In immature female whales, plasma FSH and LH levels were highly correlated (r=0.68: P<0.001), but were not for mature female whales. The results show that gender and maturity influence gonadal and pituitary function of minke whales during the feeding season.

Bronchiolitis obliterans organizing pneumonia syndrome in breast-conserving therapy for early breast cancer: radiation-induced lung toxicity

PURPOSE

Breast-conserving surgery and postoperative radiotherapy have played important roles in the treatment of early breast cancer. Bronchiolitis obliterans organizing pneumonia (BOOP) syndrome has recently been reported to be one of the complications of adjuvant radiotherapy. The purpose of this study was to determine the incidence of and risk factors for BOOP syndrome in breast cancer patients.

METHODS AND MATERIALS

Between January 1996 and December 1998, 157 patients with breast cancer underwent radiotherapy after breast-conserving surgery. The criteria used for the diagnosis of BOOP syndrome were as follows: 1) radiation therapy to the breast within 12 months, 2) general and/or respiratory symptoms lasting for at least 2 weeks, 3) radiographic lung infiltrates outside the radiation port, and 4) no evidence of a specific cause.

RESULTS

BOOP syndrome developed in 4 (2.5%) patients, who had fever and nonproductive cough, with patchy infiltrative shadows on chest roentgenograms which emerged between 5 and 6 months after radiotherapy. The symptoms and pulmonary infiltrates were rapidly improved by treatment with prednisone (40 mg/day), which was tapered over 2- to 5-month periods. However, BOOP syndrome relapsed in all cases during the tapering period or after withdrawal of prednisone. The eosinophil and neutrophil counts were increased and the ratios of CD4+ to CD8+ lymphocytes were elevated in bronchoalveolar lavage fluid in all four cases. There were no differences in proportions of patients by age, irradiated breast site, use of tamoxifen and/or chemotherapy, or radiation dose between those with and without BOOP syndrome.

CONCLUSIONS

BOOP syndrome is considered an intractable form of lung toxicity after radiotherapy to the breast. An immunologic reaction mediated by eosinophils, neutrophils, and lymphocytes may be responsible for the development of this syndrome. Methods of prevention of BOOP syndrome should be established.

Evaluation of the interobserver agreement in the number of mitotic figures of breast carcinoma as simulation of quality monitoring in the Japan National Surgical Adjuvant Study of Breast Cancer (NSAS-BC) protocol

In the National Surgical Adjuvant Study for Breast Cancer (NSAS-BC), node-negative breast cancers were divided into higher- and lower-risk groups according to the histopathological nuclear grade given at individual collaborating hospitals, and the higher-risk group was entered into a randomized protocol of adjuvant therapy. Because the nuclear grade was the composite of nuclear atypia and mitotic counts, maintenance of interobserver agreement in mitotic counts was indispensable for the success of the protocol study. Fourteen pathologists participating in the protocol judged whether or not 20 photomicrographs suspected of showing mitotic cancer-cell figures truly showed mitoses. After standardizing the counting method, these pathologists counted the number of mitotic figures per 10 high-power fields of hematoxylin-eosin-stained main-tissue sections of 20 tumors. Areas where mitotic counts were considered to be the most frequent by each pathologist were compared for these tumors. For the judgment of whether the photomicrograph indicated mitosis, the level of interobserver agreement was moderate (kappa = 0.569). In the observations of 20 tumors, interobserver agreement level of mitotic counts was moderate (kappa = 0.506), that of nuclear atypia scoring was fair (kappa = 0.265), and that of nuclear grading was substantial (kappa = 0.633). The counted area was almost the same among the observers in 9 tumors, split into two areas in 6, and dispersed in 5. Concordance in judgment was achieved in 7 of the first 9 and in all of the third 5, but only in one of the second 6. The cause of discordance was mostly derived from tumor heterogeneity and the difference in the site where mitoses were counted. Interobserver agreement level was considered to be satisfactory, and it was expected that the case entry would be performed appropriately in the protocol study. The selection of the counting area was confirmed to be important for the acquisition of high-level agreement level in mitotic counts.

In vitro maturation and ultrastructural observation of cryopreserved minke whale (Balaenoptera acutorostrata) follicular oocytes

Minke whale (Balaenoptera acutorostrata) follicular oocytes were cryopreserved by a slow-step freezing procedure using ethylene glycol. The morphologically viable proportion of postthawed minke whale follicular oocytes was 39.7%. The maturity of the animals (immature and mature whales) or the presence or absence of cumulus cells (CC) did not affect the proportion of morphologically viable oocytes. Postthawed oocytes were examined for nuclear status after in vitro maturation. The presence of CC (29.1%) significantly enhanced (P < 0.05) the proportion of oocytes at metaphase I/anaphase I/telophase I stages compared to results with the absence of CC (13.5%). A total of 4 of 194 postthawed oocytes matured to the second metaphase stage after culture for 5.5 days with or without CC. The cryopreserved immature oocytes obtained from immature and mature whales were processed to examine the ultrastructure by transmission electron microscopy. Varying ultrastructural damage to the cytoplasm was observed as a result of the cryopreservation procedures. These results show that 20-30% of cryopreserved minke whale follicular oocytes can resume meiosis in vitro, but damage induced by the freezing and thawing procedures was observed.

[Cancer chemotherapy based on evidence--metastatic breast cancer]

Breast cancer is relatively sensitive to chemotherapy. However, although response rate to chemotherapy is reported to be from 50 to 70% in metastatic breast cancer, it is incurable. Current standard chemotherapeutic regimens do not provide a large survival benefit according to the evidence obtained from clinical studies. Before developing a treatment program, we should therefore realize that the aims of chemotherapy for metastatic breast cancer are improvement of quality of life through relief of symptoms, and prolonging survival.

Breast-Concerving Surgery Following Preoperative Radiotherapy to the Primary Breast Cancer of 3 cm or Larger: Histological Analysis of Size Reduction of the Tumors by Radiotherapy

Fifteen women with primary breast cancer of 3 cm or larger were treated by radiotherapy of 5000 or 5100 cGy preoperatively for breast conservation. Among them, three responded completely to radiotherapy clinically, 6 did partially, and 6 showed minor response. Breast-concerving surgery was performed in all cases. Histologically one patient did not have cancer cells at surgery, while eight showed good response but had residual tumor, and the rest responded moderately. The histological margins were positive in six cases, of those three were positive due to an invasive component. Calculation of the size reduction of the primary tumor by radiotherapy at a histological level revealed that the invasive area of the tumors was 79.5% on average. There was a tendency, among well responding patients, to show a large reduction in size. However, the tumor cells tended to remain in the peripheral areas of the originally invasive areas. In summary, preoperative radiotherapy made the size of the primary tumors smaller in the majority of the cases clinically but the actual histological size reduction was relatively small in general. We conclude that preoperative radiotherapy is effective to extend the indications of conservative treatment in patients with a large primary breast cancer. However, care is required when we treat patients with a very large primary breast cancer conservatively.

Factors affecting in vitro maturation of minke whale (Balaenoptera acutorostrata) follicular oocytes

Factors affecting in vitro maturation (IVM) of minke whale (Balaenopetra acutorostrata) follicular oocytes were investigated. In experiment 1, recovery rates for oocytes from follicles of different sizes (small, 1-5 mm; medium, 6-10 mm; large, > or = 11 mm) were similar in both immature (54.7%) and mature (53.5%) females, and the follicular sizes did not affect recovery rate. Approximately half the oocytes recovered from small follicles in immature (55.5%) and mature (52.1%) whales were surrounded by at least a few layers of cumulus cells. Before culture, 71.7% and 61.2% of oocytes from immature and mature whales, respectively, were at the germinal vesicle stage. For IVM, effects of serum type, hormones, and additional cumulus cells (experiment 2) and effects of culture durations (24-120 h, experiment 3) were investigated. The three factors investigated in experiment 2 did not affect maturation rates. TCM199 supplemented with fetal whale serum, hormones, and additional cumulus cells showed the highest rate (21.6%) of matured oocytes and resulted in a significant difference from the rate in medium with only fetal calf serum added (6.6%). The first oocyte with an extruded polar body was observed after 84 h of culture. The maximum rate (27.3%) of matured oocytes was obtained by 96 h of culture, but there was no significant difference in the proportions of matured oocytes between 90 and 120 h in culture. These results indicate that in vitro nuclear maturation of immature follicular oocytes in minke whales can be induced.

[Granisetron versus granisetron plus methylprednisolone in the prevention of chemotherapy induced nausea and vomiting--in adjuvant chemotherapy, including CDDP against gastric cancer]

CDDP is one of the most effective drugs in chemotherapy for gastric cancer. We compared the antiemetic effect of a combination of granisetron and methylprednisolone with that of granisetron administered alone. Twenty postgastrectomy-patients who were to receive moderately emetogenic chemotherapy, including CDDP, were enrolled in randomized fashion to evaluate the efficacy and toxicity of two antiemetic regimens. The following antiemetic regimens were used: 3 mg of granisetron given intravenously before chemotherapy (11 patients) or a combination of granisetron and 250 mg of methylprednisolone in the same manner (9 patients). Granisetron combined with methylprednisolone tender to be more effective than granisetron alone. The adverse effects were very mild. Their efficacy against delayed emesis is still not entirely satisfactory.

Invasive Ductal Carcinoma of the Nipple: A Case Report

We report a very rare case of breast carcinoma which possibly arose from the duct of the nipple and formed a nipple mass. A 71-year-old woman presented with an elastically hard and enlarged right nipple, 3.5x 2.8 cm in size. Mammograms and ultrasonograms suggested a benign tumor of the nipple, but histological examination revealed invasive ductal carcinoma. No Paget's cells were found in the epidermis. Modified radical mastectomy was performed. Both estrogen and progesterone receptors were positive. One of the nine axillary nodes dissected had metastatic foci. To our knowledge, this case is only the second reported case of invasive ductal carcinoma originating from the nipple. Differential diagnosis and histogenesis are discussed.