Genetic risk of breast cancer

Several cutting-edge strategies are being used to evaluate candidate genetic risk factors for breast cancer. These include linkage analysis for mapping out BRCA1 and BRCA2, mutational screening of candidate risk genes like CHEK2, ATM, BRIP1 and PALB2, which are associated with an intermediate level of breast cancer risk. Genome-wide association studies have revealed several low-penetrance breast cancer risk alleles. The predisposition factors are associated with different levels of breast cancer risk. Relative to control population, the risk in patients harboring high-risk BRCA1 and 2 mutations is over 10-fold, with intermediate penetrance genes 2 to 4-fold and with low penetrance alleles less than 1.5-fold. Overall, these factors account for about 25% of the genetic risk for breast cancer. In the remainder, genetic factors to contribute to the risk of breast cancer remain unknown and are a subject of current investigation. With discovery and validation of newer and clinically relevant predisposition factors, additional breast cancer risk categories may be recognized. BRCA1 and BRCA2 mutation testing allows identification of individuals at increased risk of breast cancer who are offered risk-reducing interventions. Targeted therapies are being developed that may refine management of patients with BRCA1 and BRCA2 mutations. Further genome-wide studies are required to identify clinically relevant molecular factors that will allow more accurate and widely applicable genetic risk stratification. Current efforts in discovery, validation and qualification of molecular markers of breast cancer risk offer considerable promise in the future to develop more accurate breast cancer risk assessment along with development of more effective chemopreventive and therapeutic strategies.

HDAC inhibitors regulate claudin-1 expression in colon cancer cells through modulation of mRNA stability

Expression and cellular distribution of claudin-1, a tight junction protein, is dysregulated in colon cancer and its overexpression in colon cancer cells induced dedifferentiation and increased invasion. However, the molecular mechanism(s) underlying dysregulated claudin-1 expression in colon cancer remains poorly understood. Histone deacetylase (HDAC)-dependent histone acetylation is an important mechanism of the regulation of cancer-related genes and inhibition of HDACs induces epithelial differentiation and decreased invasion. Therefore, in this study, we examined the role of HDAC-dependent epigenetic regulation of claudin-1 in colon cancer. In this study, we show that sodium butyrate and Trichostatin A (TSA), two structurally different and widely used HDAC inhibitors, inhibited claudin-1 expression in multiple colon cancer cell lines. Further studies revealed modulation of claudin-1 mRNA stability by its 3'-UTR as the major mechanism underlying HDAC-dependent claudin-1 expression. In addition, overexpression of claudin-1 abrogated the TSA-induced inhibition of invasion in colon cancer cells suggesting functional crosstalk. Analysis of mRNA expression in colon cancer patients, showed a similar pattern of increase in claudin-1 and HDAC-2 mRNA expression throughout all stages of colon cancer. Inhibition of claudin-1 expression by HDAC-2-specific small interfering RNA further supported the role of HDAC-2 in this regulation. Taken together, we report a novel post-transcriptional regulation of claudin-1 expression in colon cancer cells and further show a functional correlation between claudin-1 expression and TSA-mediated regulation of invasion. As HDAC inhibitors are considered to be promising anticancer drugs, these new findings will have implications in both laboratory and clinical settings.

Osteopontin regulates multiple functions contributing to human colon cancer development and progression

Osteopontin (OPN) is a secreted phosphoglycoprotein known to interact with a number of integrin receptors. While increased OPN expression has been reported in a number of human cancers, and its cognate receptors (alphav-beta3, alphav-beta5, and alphav-beta1 integrins and CD44) have been identified, its role in colon cancer development and progression has not been extensively studied. We previously identified, using a combination of gene expression and tissue microarrays, that increased OPN expression is concordant with tumor stage. The current study examined the functional role of OPN in colon cancer progression and metastatic potential. The principal findings of this study were that both endogenous OPN expression (via stable transfection) as well as exogenous OPN (added to culture medium) enhanced the motility and invasive capacity of human colon cancer cells in vitro. OPN appeared to regulate motility though interaction with CD44. OPN expression also reduced intercellular (homotypic) adhesion, an important characteristic of metastatic cancer cells. Stable transfection of four poorly tumorigenic human colon cancer cell lines with OPN also resulted in enhanced tumorigenicity in vivo with increased proliferation and increased CD31 positive microvessel counts, concordant with the degree of OPN expression. Collectively, these results suggest that OPN may affect multiple functional components contributing to human colon cancer progression and solidifies its role in this process.

Search for epithelial-specific mRNAs in peripheral blood of patients with colon cancer by RT-PCR

Research has widely supported the efficacy of screening for colorectal cancer in reducing mortality. A blood-based assay potentially represents a more accessible early detection tool for the identification of solid tumor cells originating from a primary tumor site in the body. We demonstrate a relatively easy and highly reproducible technique for the detection of mRNA expression of genes as markers of malignancy in blood samples of patients with colon cancer. The present study aims to identify a set of specific mRNAs expressed in epithelial cells but not in blood cells, which may be useful as markers for early detection of circulating colon cancer cells by a simple, qualitative RT-PCR assay following semi-automated RNA extraction from peripheral blood samples. Our approach includes a systematic search for candidate markers using digital differential display, search on UniGene colon EST libraries and analysis of published data on colon cancer gene expression. A final list included the following genes: bone morphogenetic protein 4 (BMP4), cyclin D (CycD), family with sequence similarity 3, member D (FAM3D), gastrin (GAS), glycoprotein A33 transmembrane (GPA33), glutathione peroxidase 2 gastrointestinal (GPX2), galactoside-binding, soluble, 4 (galectin 4) (LGALS4), non-SMC, structural maintenance of chromosomes, element 1 protein (NSE1), tumor-associated calcium signal transducer 1 (TACSTD1), telomerase reverse transcriptase (hTERT), trefoil factor 3 intestinal (TFF3), transmembrane 4 superfamily member 3 (TM4SF3), UDP glycosyltransferase 1 family, polypeptide A9 (UGT1A9), villin 1 (VIL1), and the novel gene FLJ20127. The mRNA expression of these genes was evaluated in a pool of 16 samples from subjects diagnosed with colon cancer and from 16 normal-controls. We observed expression in 13 of the 15 investigated genes from the blood samples of the vast majority of patients considered, but also in a certain percentage of the controls (from 14.3 to 100%). This finding confirms that the extreme sensitivity of RT-PCR is able to detect minimal amounts of mRNA expressed in a non tissue-specific manner ('illegitimate transcription'). On the contrary, NSE1 and GAS mRNAs were not detected either in patient or in control blood samples; however, they were abundantly expressed in normal and cancerous colon mucosa, encouraging further search for useful markers able to detect epithelial cells in peripheral blood.

Identification of tumor markers in models of human colorectal cancer using a 19,200-element complementary DNA microarray

Metastasis represents a crucial transition in disease development and progression and has a profound impact on survival for a wide variety of cancers. Cell line models of metastasis have played an important role in developing our understanding of the metastatic process. We used a 19,200-element human cDNA microarray to profile transcription in three paired cell-line models of colorectal tumor metastasis. By correlating expression patterns across these cell lines, we have identified 176 genes that appear to be differentially expressed (greater than 2-fold) in all highly metastatic cell lines relative to their reference. An analysis of these genes reiterates much of our understanding of the metastatic process and suggests additional genes, many of previously uncharacterized function, that may be causatively involved in, or at least prognostic of, metastasis. Northern analysis of a limited number of these genes validates the observed pattern of expression and suggests that further investigation and functional characterization of the identified genes is warranted.

Local excision of T2 and T3 rectal cancers after downstaging chemoradiation

OBJECTIVE

To evaluate the safety and efficacy of local excision in patients with T2 and T3 distal rectal cancers that have been downstaged by preoperative chemoradiation.

SUMMARY BACKGROUND DATA

T2 and T3 cancers treated by local excision alone are associated with unacceptably high recurrence rates. The authors hypothesized that preoperative chemoradiation might downstage both T2 and T3 lesions and significantly expand the indications for local excision.

METHODS

Local excision was performed after preoperative chemoradiation on patients with a complete clinical response or on patients who were either ineligible for or refused to undergo abdominoperineal resection. Local excision was approached transanally by removing full-thickness rectal wall and the underlying mesorectum.

RESULTS

From 1994 to 2000, 95 patients with rectal cancers underwent preoperative chemoradiation and surgical resection for curative intent. Of these, 26 patients (28%), 19 men and 7 women, with a mean age of 63 years (range 44-90), underwent local excision. Pretreatment endoscopic ultrasound classifications included 5 T2N0, 13 T3N0, 7 T3N1, and 1 not done. Pathologic partial and complete responses were achieved in 9 of 26 (35%) and 17 of 26 (65%) patients, respectively. Two of nine partial responders underwent immediate abdominoperineal resection. The mean follow-up was 24 months (median 19, range 6-77). The only recurrence was in a patient who refused to undergo abdominoperineal resection after a partial response. There was one postoperative death from a stroke. This treatment was associated with a low rate of complications.

CONCLUSION

Local excision appears to be an effective alternative treatment to radical surgical resection for a highly select subset of patients with T2 and T3 adenocarcinomas of the distal rectum who show a complete pathologic response to preoperative chemoradiation.

v-Src transformation is mediated through farnesylated proteins

Src is an oncoprotein which has been implicated in a number of human malignancies in which it has been shown to be overexpressed and highly activated. The precise mechanism of Src transformation, however, is still poorly understood. We hypothesized that Ras and other farnesylated proteins may mediate Src transformation. To test this hypothesis, v-Src-transfected rat fibroblasts (3Y1) were treated every 72 h with a 15 microM concentration of a farnesyl-transferase inhibitor (FTI). At 2 weeks, a focus formation assay was performed to assess transformation potential. Untreated and FTI-treated v-Src-transfected 3Y1 cells formed a mean of 39 (+/-2.6) and 29.8 (+/-2.9) foci per well, respectively. This 24% decrease was judged to be statistically significant (P = 0.02). Moreover, foci (>90%) in the FTI-treated wells were also consistently smaller than foci in the untreated wells. Western blots with antibody directed toward H-Ras confirmed complete inhibition of Ras farnesylation in the treated cell lines. The specificity of this inhibition was verified by Western blot using antibody specific for Rap1A. The transforming potential of v-Src is inhibited, but not eliminated by FTI treatment. This suggests that v-Src transformation is mediated in part by farnesylated proteins, one of which may be Ras.

Role of Src expression and activation in human cancer

Since the original identification of a transmissible agent responsible for the development of tumors in chickens, now known to be a retrovirus encoding the v-src gene, significant progress has been made in defining the potential functions of its human homolog, SRC. The product of the human SRC gene, c-Src, is found to be over-expressed and highly activated in a wide variety of human cancers. The relationship between Src activation and cancer progression appears to be significant. Moreover, Src may have an influence on the development of the metastatic phenotype. This review discusses the data supporting a role for c-Src as a critical component of the signal transduction pathways that control cancer cell development and growth, and provides the rationale for targeting Src in drug discovery efforts.

NCCN Practice Guidelines for Colorectal Cancer

The NCCN Colorectal Cancer Guidelines panel believes that a multidisciplinary approach is necessary for the management of the patient with colorectal cancer. The panel endorses the concept that treatment of patients in a clinical trial has priority over standard or accepted therapy. The recommended surgical procedure for resectable colon cancer is an en bloc resection; laparoscopic surgery should be done only in the context of a clinical trial. For patients with stage III disease, 5-FU-based adjuvant therapy is recommended. A patient who has metastatic disease in the liver or lung should be considered for surgical resection if he or she is a candidate for surgery and if surgery can extend survival. Surgery should be followed by adjuvant chemotherapy. The panel advocates a conservative post-treatment surveillance program for colon and rectal carcinoma patients. Serial CEA determinations are appropriate if the patient is a candidate for aggressive surgical resection, should recurrence be detected. Abdominal and pelvic CT scans should be utilized only when there are clinical indications of possible recurrence. Patients whose disease progresses during 5-FU-based therapy should be treated with irinotecan or encouraged to participate in a phase I or phase II clinical trial.

Expression of insulin-like growth factor-1 receptor in human colorectal cancer

The activation of the insulinlike growth factor 1/IGF-1 receptor system (IGF1/IGF1-R) has recently emerged as critical event in transformation and tumorigenicity of several murine and human tumors. Expression of IGF1 and of IGF1-R has been demonstrated in normal and neoplastic intestinal cell lines of rats and humans. However, the modulation of IGF1-R expression during the progression from normal colonic mucosa to adenoma, to carcinoma, and to metastasis, has not been evaluated. In this retrospective study, we investigated the expression of IGF1-R in 12 colonic adenomas (AD), 36 primary colorectal adenocarcinomas (CA), and in 27 corresponding metastases (MT). Normal colonic mucosa (N) was adjacent to the CA in 34 cases. Formalin-fixed, paraffin-embedded tissues of each case were immunostained using the avidin-biotin-peroxidase method. We used an anti-IGF1-R rabbit polyclonal antibody (Santa Cruz Biotechnology, CA; dilution 1:100). Positive staining was quantitated by CAS-200. Moderate to strong cytoplasmic immunostaining was observed in 34 of 36 CA (96%), and in 25 of 27 MT (93%). In all of the positive MTs, the intensity of the staining was always strong. In 10 of 12 ADs (83%), only a faint cytoplasmic stain was identified. Normal mucosa when present was negative. Strong IGF1-R positivity correlated with higher grade and higher-stage tumors (P < .01). These data suggest a role of IGF1-R expression during the progression of colorectal adenoma to carcinoma. An increased number of IGF1-R receptors may favor the metastasis of colorectal cancer.

The significance of breast cancer lymph node micrometastases

The significance of breast cancer lymph node micrometastasis has been addressed by numerous studies. Although the results of these studies are mixed, most of the larger trials strongly suggest that the presence of a lymph node micrometastasis, in the absence of other nodal disease, will have a negative impact on disease free survival and on overall survival. The focus of this article is to analyze the biologic and therapeutic significance of micrometastatic disease in the axillary lymph nodes of patients with breast cancer.

Sentinel lymphadenectomy: a safe answer to less axillary surgery?

Lymphatic mapping techniques have the potential of changing the standard of surgical care of breast cancer patients. This paper reports a prospective study documenting the safety and efficacy of sentinel lymph node biopsy in 167 breast cancer patients and reviews the world literature on the procedure.

METHODS

One hundred sixty-seven patients with newly diagnosed breast cancers underwent a prospective trial of intra-operative lymphatic mapping using a combination of vital blue dye and filtered technetium-labeled sulfur colloid. A sentinel lymph node (SLN) was defined as a blue node and/or "hot" node with a 10/1 ex-vivo gamma-probe ratio of SLN to non-SLN. All SLN were bi-valved, step-sectioned, and examined with routine H&E stains and immunohistochemical stains for cytokeratin. Cytokeratin-positive SLN were defined as any SLN with a defined cluster of positive staining cells which could be confirmed histologically on H&E sections. Finally, a review of the worldwide data was undertaken using a uniform analytical method to compare the rates of sensitivity, diagnostic accuracy, and false negatives of SLN mapping.

RESULTS

In 167 patients, 337 SLN were harvested, for an average of 2.01 SLN/patient. Fifty-two (31.1%) of the patients had metastasis in the SLN. In the 115 patients with negative SLN, 1 was found to have tumor in higher axillary nodes, for a false negative rate of 0.88%. Fifty-nine (37.8%) of the patients were diagnosed by fine-needle aspiration, 89 (53.3%) by excisional biopsy, and 19 (11.4%) by core biopsy. Positive SLN were identified in 1/17 (5.9%) patients with DCIS. Metastasis was found in 33/115 (28.7%) of the patients with infiltrating ductal tumors and in 11/19 (57.9%) of the patients with infiltrating lobular tumors. Positive SLN were identified in 7/16 (43.7%) of the patients with mixed cellularity tumors. Metastasis in the SLN was detected in 7/55 (12.7%) of the 59 patients with T1a-T1b tumors and in 21/58 (36.2%) of the patients with T1c tumors. Positive SLN were found in 17/30 (56.7%) of the patients with T2 tumors and in 6/7 (85.7%) of the patients with T3 tumors. A literature review of 731 patients (including this study) demonstrates a sensitivity rate of 95% and a diagnostic accuracy rate of 98%. The overall false negative rate is 3.1%.

CONCLUSIONS

This study demonstrates that SLN biopsy is a highly sensitive and accurate method of predicting axillary nodal status. It is a reproducible technique that is easily learned. The future addition of more sensitive methods such as PCR evaluation of nodal involvement may reduce the need for widespread use of adjuvant chemotherapy with its high cost and attendant morbidity and mortality. We believe that this technique will eventually become the standard of care in the treatment of breast cancer, particularly for T1 and T2 lesions and perhaps also for high-grade DCIS tumors.

Activating SRC mutation in a subset of advanced human colon cancers

The discovery of Rous sarcoma virus (RSV) led to the identification of cellular Src (c-Src), a non-receptor tyrosine kinase, which has since been implicated in the development of numerous human cancers. c-Src has been found to be highly activated in colon cancers, particularly in those metastatic to the liver. Studies of the mechanism of c-Src regulation have suggested that c-Src kinase activity is downregulated by phosphorylation of a critical carboxy-terminal tyrosine (Tyr 530 in human c-Src, equivalent to Tyr 527 in chicken Src) and have implied the existence of activating mutations in this C-terminal regulatory region. We report here the identification of a truncating mutation in SRC at codon 531 in 12% of cases of advanced human colon cancer tested and demonstrate that the mutation is activating, transforming, tumorigenic and promotes metastasis. These results provide, for the first time, genetic evidence that activating SRC mutations may have a role in the malignant progression of human colon cancer.

Analysis of p53, p21WAF1, and TGF-beta1 in human ductal adenocarcinoma of the pancreas: TGF-beta1 protein expression predicts longer survival

Loss of p53 and p21WAF1 expression have previously been reported in pancreatic adenocarcinoma. Despite these findings in several reports of oncogene and tumor suppressor gene alterations in pancreatic cancer, the clinical significance of these changes is still poorly understood. In an attempt to detect molecular prognostic markers for pancreatic carcinoma, we studied the immunohistochemical expression of p53, p21WAF1, and TGF-beta1 proteins in 42 pancreatic adenocarcinomas of the ductal type. The results were correlated with clinicopathologic findings to identify the markers with prognostic significance. p53 nuclear immunoreactivity was seen in 20 (48%) of the cases, and it was strong to moderate in 14 (33%) of them. p21WAF1 cytoplasmic positivity was found in 16 (38%) of the tumors, with 72% staining strong to moderate. TGF-beta1 stained the cytoplasm of the tumor cells in 13 (31%). Of the p53-negative cases, 12 (54%) exhibited p21WAF1 expression. In 3 (30%) of cases, TGF-beta1 reactivity was seen in the absence of p53 and p21WAF1 p53 positivity identified tumors of higher grade, but did not correlate with stage or survival. TGF-beta1 expression, however, identified low-grade tumors and patients with longer survival. No correlation was found between the expression of any of these molecular markers and smoking history. We report a significant correlation between TGF-beta1 reactivity and low-grade tumors and between TGF-beta1 and better survival. This is a novel finding pointing to TGF-beta1 as a possible new stage-independent predictor of tumor survival in pancreatic ductal adenocarcinoma. In agreement with others, we also found p53 mutation in 20 (48%) of the tumors.

Analysis of colorectal cancer by comparative genomic hybridization: evidence for induction of the metastatic phenotype by loss of tumor suppressor genes

Current models suggest that colon cancer initiation and progression are secondary to both the activation of oncogenes and the deletion of tumor suppressor genes. The role of each, however, is still poorly understood, particularly with regard to the induction of metastasis. We hypothesized that genetic differences exist between tumors that metastasize distantly and those that do not, and that oncogenes and tumor suppressor genes participate equally in this process. To address this hypothesis, human tumor specimens from localized [tumor-node-metastasis (TNM) stage I-III] and primary colon cancers (n = 10) were directly compared with metastatic (TNM stage IV) lesions (n = 10) using comparative genomic hybridization analysis. Although several alterations were shared equally between primary tumors and metastases (+7q, +19q, and +20q), two patterns of distinguishing alterations were observed: (a) alterations that were more extensive in liver metastases than in primary tumors (+8q, +13q, -4p, -8p, -15q, -17p, -18q, -21q, and -22q); and (b) alterations that were unique to metastatic lesions (-9q, -11q, and -17q). Overall, genetic losses were more common than gains, and, more importantly, the number of losses/tumor was significantly higher for metastases than for primary tumors (9.3 + 1.3 versus 4.1 + 0.7; P = 0.00062, Wilcoxon's rank-sum test). The distinct predominance of genetic losses in the metastatic lesions when compared with the primary localized tumors provides evidence that the metastatic phenotype is induced by the deletion of tumor suppressor genes and permits the construction of physical maps targeting regions where novel tumor suppressor genes are likely to exist.

Activation of c-Src by receptor tyrosine kinases in human colon cancer cells with high metastatic potential

Recent data suggest that signal transduction may have a critical role in the development and regulation of the metastatic phenotype. Here, we investigated the role of c-Src activation in the process of human colon cancer metastasis to the liver. Our data, derived from two different sets of human colon cancer cell line metastatic variants, suggest that not only do highly-metastatic cells display constitutively elevated c-Src protein kinase activity when compared to poorly metastatic cells, but also that receptor tyrosine kinases participate in the ligand-activation of c-Src above basal levels. Specifically, the epidermal growth factor receptor (EGFR), p185HER2/Neu and the hepatocyte growth factor receptor (c-Met) appear to be linked to the process because they preferentially activate c-Src in highly-metastatic cells. EGFR was found to associate with c-Src in colon cancer cells and specific inhibitors of the EGFR resulted in a reduction of c-Src activity to basal levels. In addition, c-Src transfectants displayed partially-activated EGFRs, suggesting a feedback role for c-Src in the regulation of the EGFR. p185HER2/Neu was also identified in immunocomplexes of c-Src following ligand activation of the EGFR, but only in highly-metastatic cells. Collectively, these observations suggest a paradigm whereby c-Src interacts with multiple cell-surface growth factors in a catalytic fashion for the development of tumor cells with metastatic potential.

Overexpression of normal c-Src in poorly metastatic human colon cancer cells enhances primary tumor growth but not metastatic potential

Whereas genetic paradigms are now defined for the development of human colon cancer, little is known regarding the mechanisms that regulate development of the metastatic phenotype. Recent reports have indirectly linked the expression and activation of c-Src to the process of human colon cancer metastasis. Whereas v-Src, a highly activated mutational derivative of c-Src, has been shown to induce metastasis, normal c-Src has not been tested for this property. We hypothesized that c-Src overexpression in the milieu of a poorly metastatic cancer cell might permit the development of a highly metastatic cell. Two poorly metastatic human colon cancer cell lines were stably transfected with expression vectors encoding normal human c-Src. Clones producing 4-10-fold more c-Src than controls were injected s.c. and intrasplenically into the nude mouse to assess primary tumor growth and liver metastatic potential. Whereas metastatic potential was unaffected, primary tumor growth in vivo was significantly enhanced by c-Src overexpression. No effects on rates of tumor cell proliferation were seen in vitro. Our findings suggest that normal c-Src may be necessary but is insufficient for the induction of the metastatic phenotype.

Biliary glycoprotein is overexpressed in human colon cancer cells with high metastatic potential

Carcinoembryonic antigen (CEA) has been recently implicated in the process of human colon cancer liver metastasis by means of an adhesion mechanism. Based on the strong sequence and structural homology of biliary glycoprotein (BGP) to CEA, we hypothesized that BGP might be overexpressed at the RNA and protein level in tumor cells with high metastatic potential. We have found the BGP messenger RNA derived from highly metastatic colon cancer cells is constitutively overexpressed-nearly fourfold greater than poorly metastatic cells-and that BGP expression is induced by interferon-gamma. Similarly, we have demonstrated that BGP protein levels were constitutively elevated in highly metastatic human colon cancer cells when compared to poorly metastatic cells. Collectively these results suggest that the basal and interferon-stimulated expression of BGP transcripts may be regulated in a manner similar to CEA and that a potential role in the process of metastasis may be inferred.

Leptomeningeal carcinomatosis: a sequela of cholangiocarcinoma

Leptomeningeal carcinomatosis is a rare and deceptive presentation of systemic cancer. We report the treatment of a patient with a Klatskin's tumor by surgical resection. The patient presented with symptoms suggestive of liver failure in the early postoperative period. He rapidly developed progressive, multineuroaxis symptoms and died. Routine gastrointestinal evaluation failed to demonstrate any intraabdominal pathologic process that could be responsible for his decline. A MRI of the brain was also unremarkable. Serial lumbar punctures, however, documented leptomeningeal carcinomatosis consistent with a gastrointestinal primary. The clinical presentation of leptomeningeal carcinomatosis is subtle and may masquerade as another disease state. The hallmark of this lethal process is the finding of progressive neurologic deficits at more than one level of the neuroaxis. Serial cerebrospinal fluid examination is often diagnostic. This is the first known report of leptomeningeal carcinomatosis secondary to primary cholangiocarcinoma.

Bilaterality and recurrence rates for lobular breast cancer: considerations for treatment

BACKGROUND

The purpose of this study was to evaluate the tumor biology with respect to bilaterality and recurrence rates for bilateral infiltrating lobular (IL) breast carcinoma in comparison with other histological types.

METHODS

A prospectively accrued data base containing 1,548 breast cancer cases as well as H. Lee Moffitt Cancer Center's cancer registry compiled during the same period were queried for specific features relating to bilaterality and recurrence. The 116 patients in this study had been treated at the Comprehensive Breast Cancer Clinic and had documented bilateral breast cancer (invasive on situ).

RESULTS

Eighty-two of the patients (70.7%) had metachronous breast cancer, and 34 (29.3%) had synchronous cancer. Although median follow-up times were short, the risk of developing breast cancer in the contralateral breast after the diagnosis of cancer in the ipsilateral breast was estimated to be 0.7% per patient-year of follow-up. Recurrence rates for IL cancers were compared with those for invasive ductal (ID) and for ID + IL cancers. IL cancers recurred 8.1% of the time, whereas ID cancers recurred at a rate of 7.8%. Recurrences were equally divided between local and distant sites.

CONCLUSIONS

Although IL cancers have demonstrated insidious behavior, their incidence of bilaterality is only slightly higher than other histologies and their rates of recurrence are low when properly evaluated and treated. The risk to the opposite breast also appears to be low. These data do not support the routine use of blind contralateral biopsy or prophylactic mastectomy.

Role of computed tomographic arterial portography and intraoperative ultrasound in the evaluation of patients for resectability of hepatic lesions

Computed tomographic arterial portography (CTAP) has been shown to be the most sensitive preoperative test for determining resectability of hepatic lesions but we have shown it to have low specificity. Intraoperative ultrasound (IOUS) evaluation of the liver has also been proposed as an accurate means of assessing resectability. We sought to compare the effectiveness of the two modalities. Fifty-six patients who had been deemed candidates for liver resection based on CTAP findings underwent systematic exploration, liver mobilization, and IOUS examination. Ultrasound findings were compared with results of CTAP. In 46 patients the IOUS findings were in complete agreement with those of CTAP. In 10 patients CTAP lesions could not be verified by IOUS and these patients did not undergo resection. Follow-up of these 10 patients revealed eight who did not have progression of malignancy at the CTAP-predicted site (CTAP false positive). Two patients did have progression at a CTAP-positive IOUS-negative site (IOUS false negative). Sensitivity for CTAP and IOUS was 100% and 96%, respectively. Specificity for IOUS was 100%. These findings demonstrate the high sensitivity of CTAP and the high sensitivity and specificity of IOUS. CTAP may "overcall" hepatic lesions but IOUS can correctly identify these false positives in most instances. Because CTAP is useful for determining which patients might benefit from surgical exploration, we conclude that the two modalities are complementary for the assessment of resectability of hepatic lesions. The false positive rate for CTAP implies that caution must be used when declining to operate on patients on the basis of this test.

Identification of genetic alterations associated with the process of human experimental colon cancer liver metastasis in the nude mouse

Understanding the genetic elements controlling the process of tumor metastasis to distant organ sites such as the liver may be the key to improving survivorship from colon cancer. By using standard cytogenetic techniques in combination with comparative genomic hybridization, multiple genetic imbalances within three human colon cancer cell lines previously selected for differences in liver-metastatic behavior were identified. The entire genome of one poorly metastatic cell line (KM12C) was compared directly with that of two highly metastatic cell lines (KM12SM, KM12L4A) derived from it. A number of chromosomal gains (8q, 12q15, 20q11.2) and losses (5p13, 6p21.3, 18) were common to all three cell lines and are likely related to early tumor development rather than to the selection process used to generate cell lines of increased metastatic potential. Chromosomal imbalances detected only in the highly metastatic cell lines were also observed. KM12SM showed losses of portions of 2p22, 2q24.3--> 2q32.2, 4p15.3--> cen, 4q24 without the 13q and 15q22.3 gains noted for KM12C. Both gains (1p31.3--> 1p21, 2q22--> 2q33, 3cen--> 3q26.2, 5q14--> 5q23, 6cen--> 6q23) and losses (16p, 17p, 17q 19p, 19q 22q) were observed for KM12L4A but not for the other two cell lines. Identification of these alterations provides valuable insight into the process of experimental liver metastasis and is a first step towards mapping genes linked to the terminal phases of human colon cancer progression.

Avoiding Colostomy With Conservative Multimodality Management of Distal Rectal Cancer

While abdominoperineal resection with permanent colostomy has been the surgical benchmark in the treatment of distal rectal carcinoma, different approaches to treatment have been sought for decades to decrease the morbidity and mortality associated with radical surgical procedures for this disease. The advent of alternative methods of sphincter preservation that afford excellent functional results has led to a decline in the incidence of abdominoperineal resection. With appropriate patient selection, accurate preoperative staging data, and the selection of a surgical approach appropriate to the tumor stage, conservative surgical approaches now can be considered in the treatment of cancer at every level of the rectum.

Identification of a differentially-expressed message associated with colon cancer liver metastasis using an improved method of differential display

Images

Tumor biology of infiltrating lobular carcinoma. Implications for management

OBJECTIVE

The purpose of this study was to characterize the biologic determinants that affect the behavior and management of infiltrating lobular cancer.

METHODS

A prospectively accrued data base containing 1548 breast cancer cases was queried for specific pathologic and mammographic features. From this data base, 777 patients treated and followed-up at the H. Lee Moffitt Cancer Center were reviewed, and comparisons were made between the following three histologic subgroups: 661 infiltrating ductal (ID), 42 infiltrating ductal plus infiltrating lobular (ID + IL), and 74 infiltrating lobular (IL).

RESULTS

Comparisons of the three histologic forms of breast cancer demonstrated the following: 1. At diagnosis tumors with IL components were larger than those with ID components (p < 0.001); in addition, a greater percentage of IL cancers were T3 lesions (14.8%), compared with ID cancers (4.5%). 2. Sizes of IL tumors were underestimated frequently by mammographic examinations when compared with pathologic measurements (p < 0.001). 3. By comparison to ID tumors, increasing IL tumor size is less likely to be associated with an increased number of metastatic lymph nodes per patient (p = 0.09). 4. Infiltrating lobular cancers treated by lumpectomy with cytologic surgical margin analysis more often gave false-negative results than did ID cancers (p < 0.001). 5. Infiltrating lobular cancers treated by lumpectomy required conversion to mastectomy over 2 times more frequently than ID cancers treated by lumpectomy. 6. Mastectomy was performed more frequently than lumpectomy for the treatment of IL versus ID tumors (p = 0.039).

CONCLUSIONS

Infiltrating lobular cancers are biologically distinct from ID cancers. Although lumpectomy may be performed safely in selected patients, multiple difficulties exist in the management of IL cancer, particularly when breast conservation is chosen.

The natural history of locally advanced primary breast carcinoma and metastatic disease

Breast cancer is considered a chronic disease in most women. This belief is based on natural history data that suggest that some patients with untreated, advanced disease may survive for up to and beyond 20 years after diagnosis. These data are corroborated by studies of treated patients in whom breast cancer recurred up to 15 to 20 years postmastectomy. Conversely, there are also patients who die rapidly after presentation. These divergent observations suggest that there are at least two subpopulations of patients with breast cancer-one that co-exists with the disease and one that rapidly succumbs to it. This heterogeneous biologic behavior is likely related to divergent tumor cell growth rates that have been documented as well as to other unidentified factors. These two subsets of patients, unfortunately, are quite difficult to distinguish. With the promise of the ongoing genetic revolution, the hope is that genes associated with rapidly progressing disease states can be identified. It is important to be cognizant of the prolonged natural history of this disease whenever we attempt to draw conclusions regarding a promising new treatment and we must make every attempt to ensure that patients are improving because of, rather than despite, a therapeutic intervention. Patients entered into trials examining survival as an endpoint should make every attempt to follow patients for 20 to 30 years after treatment. These considerations will ensure that patients requiring therapy are treated to derive benefit, whereas those who would normally not benefit or fare just as well without treatment are not exposed to unnecessary morbidity and mortality. Finally, it must be concluded as Bloom et al have stated that "the value of treatment of primary breast cancer cannot be measured entirely by survival statistics." The quality of a patient's remaining life once the diagnosis of breast cancer has been made should be considered. From untreated natural history data, we know that patients may suffer a painful death without intervention, and we are aware as well that overtreatment may impart untoward symptomatic consequences in the final stages of life when quality is of paramount importance to both the patient and the family.

Augmentation of carcinoembryonic antigen release from intact, viable tumor cells by a factor in human serum

BACKGROUND

Measurement of carcinoembryonic antigen (CEA) levels in human serum is frequently used to detect tumor recurrence in patients with resected primary colorectal cancers. These levels are highly variable from patient to patient, and the mechanism that determines these levels is still poorly understood.

METHODS

Using a 6-h in vitro CEA-release assay, we determined that a factor in human and fetal bovine sera significantly augments the release of CEA from the tumor cell surface into cell culture supernatants.

RESULTS

As little as 1% serum admixed with tumor cells results in CEA release up to 200% greater than that of serum-free controls. It is not inhibited by 1,10-phenanthroline or heat inactivation (of serum) but is calcium dependent. The electrophoretic mobility and membrane linkage of CEA released by serum appear to be identical to those of CEA released by bacterial phospholipase C. Because bacterial phospholipase C is known specifically to cleave the phosphoinositol (PI) glycan moiety that anchors CEA to the tumor cell surface, a mechanism of action for serum cleaving this anchor is suggested.

CONCLUSIONS

The large range of CEA levels observed in patients with colorectal cancers may be related to differential sensitivity of the CEA membrane anchor to the CEA-releasing factor in serum.

Molecular basis for chemoprevention of colorectal carcinogenesis

Colorectal cancer is a common disease that frequently produces limited survival in afflicted patients. Recently a genetic model for tumorigenesis has been defined and has led to a better understanding of the interrelationships between environmental mutagens and genes. Epidemiologic studies have identified multiple chemopreventive agents that appear to reduce the risk of developing colorectal cancer. Their molecular mechanisms of action, as related to the genetic model for colorectal cancer, are discussed.

Phospholipase C-gamma 1 is present on the surface of human colorectal cancer cells

Using murine monoclonal antibodies, we have detected the novel signal transducing enzyme, phospholipase C-gamma 1, on the surface of cultured human colorectal cancer cells. We have also demonstrated the presence of this enzyme on the surface of fresh human tumor cells derived from primary and metastatic colorectal tumors. This enzyme has previously been described to be associated only with the inner face of the plasma membrane and the cell cytosol. The finding of an enzyme critical to the signal transduction pathway may have important implications for additional functions of this protein.

Molecular basis of tumor progression: mechanisms of organ-specific tumor metastasis

Tumor cell metastasis is an extremely complex process governed by many different classes of molecules with each class having a separate function. Metastasis is the result of multiple sequential steps and is a highly organized, nonrandom, and organ-selective process. Recent advances in tumor and molecular biology have permitted the identification of a variety of heterogeneous molecules governing invasion (degradative enzymes, motility factors), adhesion (integrins, selectins, cadherins, immunoglobulin-like superfamily, annexins), and growth (paracrine and autocrine growth factors) of tumor cells. This diverse group of biological molecules is collectively responsible for determining whether tumor cells can progress from a single malignant cell to a lethal, multiorgan, metastatic disease.

Expression of annexins on the surfaces of non-metastatic and metastatic human and rodent tumor cells

Annexins are a large group of calcium-dependent cytoskeletal- and membrane-associated proteins whose properties include cytoskeleton and phospholipid binding and mitotic signal transduction. Although annexin-like molecules have been reported on the external plasma membranes of certain cells, in general they are considered to be cytoplasmic proteins. We report here the heterogenous expression of certain annexins (I-VI) on the external cell surfaces of non-metastatic and metastatic murine (RAW117 large-cell lymphoma), rat (13762NF mammary adenocarcinoma) and some human (KM12 and HT29 colorectal carcinoma) cell lines but not on some other cell lines such as human (A375 and MeWo) and mouse (B16) melanoma. The implication of annexin cell surface expression in the metastatic process is discussed with respect to tumor cell adhesion.

Depletion of dietary arginine inhibits growth of metastatic tumor

The effects of dietary arginine on the growth of a murine colon tumor metastatic to the liver were examined in a model of advanced neoplastic disease. Tumor growth was influenced by arginine both in vivo and in vitro. An arginine-supplemented diet stimulated tumor growth by 55% compared with controls. Conversely, an arginine-depleted diet inhibited tumor growth by 78% compared with controls. In vitro culture of both murine and human colon tumor cells confirmed that arginine was necessary for cell growth. Flow-cytometric analysis using propidium iodide and bromodeoxyuridine suggested that colon tumor cells cultured without arginine enter a quiescent S phase and depend on arginine for further growth and cell cycle progression. The potential roles for selective dietary arginine modulation in patients with cancer with advanced disease are discussed.

Relationship between colorectal liver metastases and CEA levels in gallbladder bile

While computerized tomographic (CT) scanning and intraoperative exploration are both considered accurate measures of liver involvement with metastatic disease, 10% to 30% of colorectal liver metastases remain undetected. Attempting to improve current methods for detecting colorectal liver metastases, CEA levels in gallbladder bile and serum from patients with known liver metastases were determined. One hundred per cent of patients with single and multiple metastases of various dimensions were observed to have gallbladder bile CEA levels strikingly higher than serum values (4.7 to 259 times greater, p = 0.0009). Linear regression analysis of estimated tumor volume and surface area versus gallbladder bile CEA levels predicted that very small tumors (less than or equal to 1 cm3 in volume) might produce detectable levels (9 to 41 ng/mL) of biliary CEA. For this reason, patients who lack clinical and radiologic evidence of distant metastases at the time of primary colorectal resection but who do have elevated gallbladder bile CEA levels (greater than or equal to 10 ng/mL) are being followed for the appearance of occult hepatic metastases.

Tumor cell-surface galactose correlates with the degree of colorectal liver metastasis

The phenotypic heterogeneity of tumor cell-surface galactose expression within a cell population may dictate metastatic potential. The hepatic asialoglycoprotein receptor, whose known function is to bind to terminal galactose residues of desialylated glycoproteins and effete cells, may participate in the arrest and subsequent growth of subpopulations of tumor cells with high galactose expression. To test this hypothesis, murine colon carcinoma cells (CT-26) were sorted, using the galactose-specific lectin, soybean agglutinin (SBA), and fluorescence-activated cell-sorting (FACS) technology, into two subpopulations--one low in surface galactose and one high in surface galactose. After intrasplenic injection of tumor cell subpopulations, liver metastasis was found to be proportional to the degree of tumor cell-surface galactose expression. These data suggest that tumor galactose expression and hepatic recognition may be important components of a specific mechanism of colorectal liver metastasis.

Can susceptibility to carcinoid tumors be inherited?

Previously, all carcinoid tumors were considered to occur sporadically. We present an extremely rare series of three first-degree relatives in two generations with proximal duodenal carcinoid tumors and other family-associated neoplasms. This unusual circumstance, which has never been described previously, represents the sixth case of familial clustering of carcinoid tumors reported in the world's literature.

Sphincter-saving procedures for distal carcinoma of the rectum

Methods of sphincter preservation were developed more than a century ago. Combining these techniques with adequate anterior resection has permitted the resurrection of sphincter-saving procedures that are currently being applied in the therapy of cancer at every level of the rectum. Although Miles' abdominoperineal resection still remains the "gold standard" for the treatment of low rectal neoplasms, restorative resection may now be possible with equivalent oncologic disease control and survival. Further, current trends also suggest that the abdominoperineal resection is being used less frequently in the treatment of most rectal cancers and is being replaced with sphincter-preserving techniques that afford excellent functional results. In this review, the pertinent anorectal anatomy, current issues, and sphincter-saving surgical techniques presently available for the treatment of distal cancers of the rectum are presented.

A rare manifestation of metastatic adenocarcinoma

We report a very rare case of adenocarcinoma metastatic to the epiglottis and cervical lymph nodes that presented clinically with symptoms of dysphagia. The method of diagnosis, including recent advances in the evaluation of head and neck metastases, is discussed.

Emphysematous cholecystitis: an insidious variant of acute cholecystitis

Emphysematous cholecystitis is an insidious and rapidly progressing disease that requires prompt surgical intervention. As the majority of the patients contracting this disease initially present to the emergency department with complaints of abdominal pain and often mild constitutional symptoms, it is important for the emergency physician to be aware of this clinical entity. Didactic cases have been presented that, in many ways, illustrate classic examples of emphysematous cholecystitis, the diagnosis of which can often be made in the emergency department using an upright abdominal radiograph.

Multiple biological activities of homogeneous human alpha interferon

To identify the active molecule in human alpha interferon preparations, we performed several studies, using both partially purified interferon and homogeneous interferon. Our results indicated that there is little difference between the partially purified and the homogeneous interferon preparations in terms of antiviral activity, inhibition of deoxyribonucleic acid synthesis in human neoplastic cells, and enhancement of human natural killer cell activity.

ADCC analysis with the Coulter counter: a highly sensitive, ultramicro assay suitable for clinical and experimental application

Antibody-dependent cellular cytotoxicity (ADCC) is an in vitro immune mechanism implicated in several in vivo phenomena such as transplant rejection, tumor immunity and parasite elimination. We developed a method for detecting ADCC using the Coulter Counter and the Coulter Channelyzer that circumvents many of the disadvantages associated with existing assays for ADCC. Effector mononuclear cells were incubated with chicken red blood cell (CRBC) targets and anti-target antibody for 1-1, 5h. Killing was quantified by the Coulter Counter on the basis of size differences between effector and target cell nuclei. Using a 4 microliter total volume we were able to detect cytotoxic levels of 55% when as few as 5000 effector cells were incubated with an equal number of target cells. This method for the detection of ADCC may be suitable for clinical and research application.

Effect of the new immunosuppressive agent, cyclosporin-A, on natural killer cell and antibody-dependent cell-mediated cytotoxic activity

Athymic nude mouse homozygotes (nu/nu) and the heterozygote nu/nu+ were injected intraperitoneally with 2 mg of cyclosporin-A (CS-A) twice, 72 and 1 h prior to analysis. We have found that in vivo administration of CS-A results in a significant suppression of natural killer (NK) cell and antibody-dependent cell-mediated cytotoxic (ADCC) activity which probably play an important role in tumor and graft rejection. T cells were also suppressed, in contrast, B cells were found to be immunocompetent as determined by cell proliferation and antibody-forming capacity in response to mitogens and antigens. The identity of cells mediating NK cell and ADCC activity and its relationship to T lymphocytes are also discussed.

Differential effect of human interferon on normal and neoplastic T- and B-cell lymphocytes

The effect of human interferon (HIF) on the growth and function of normal and neoplastic proliferating human T and B cells was studied. Cell cycle analysis by flow-cytometry showed that up to 2000 units of HIF had little effect on the proliferating fraction (that is, the present S + G2 + M phases of the cell cycle) of normal T cells grown continuously wit growth-promoting factor from PHA-stimulated lymphocytes, while 500 units of HIF suppressed the percent S + G2 + M of the acute lymphocytic leukemia (ALL) T-cell line, MOLT, by 36%. Up to 2000 units of HIF had a moderate enhancing effect on the percent S + G2 + M of PWM-stimulated lymphocytes. In striking contrast, a single unit of HIF caused nearly 40% suppression of the percent S + G2 + M of Daudi, a Burkitt's lymphoma cell. One-thousand units of HIF did not decrease the number of antibody-forming normal cells, and up to 500 units of HIF did not inhibit the total Ig secreted by these cells. These results suggest that amounts of HIF affecting the proliferation of some neoplastic lymphoid cells has little effect on the proliferation of normal T and B cells. In addition, HIF does not appear to affect polyclonal induction of B-cell differentiation.

Antibody-dependent cell-mediated cytotoxicity: detection by automated flow cytometry with ultramicro techniques

Antibody-dependent cell-mediated cytotoxicity can be measured with as few as 1000 leukocytes with an automated flow cytometry technique.

Natural killer cells (NK) and antibody-dependent cell-mediated cytotoxicity (ADCC) components of Schistosoma mansoni infection

Schistosoma mansoni cercariae were used to infect CBA-J mice, a strain characterized by possessing a high level of NK cells. 4 days after infection with cercariae, the natural cytotoxic capacity of these mice, as measured by NK and ADCC, reached a peak level of enhancement significantly greater than that of uninfected controls. Infection by this parasite appears to activate natural cell-mediated immune defense systems. Further observation of the pattern of response of NK and ADCC effector cells to infection by cercariae may reveal important information regarding the inherent immunity to the schistosome infection.

Is DNA synthesis a requisite for the differentiation of B lymphocytes into immunoglobulin-secreting plasma cells?

A great amount of conflicting evidence has been reported concerning the relationship between DNA synthesis and the differentiation of immunoglobulin-secreting cells. With the development of flow cytometry, it has become possible to analyze lymphocyte populations by making rapid and accurate measurements of cellular DNA content, and by estimating the fraction of cells that synthesize DNA. Application of these techniques to an in vitro culture system stimulated by the T-dependent sheep red blood cell antigen has allowed us to investigate cell division in populations of antibody-forming cells. DNA synthesis is apparently not a requisite for the differentiation of immunoglobulin-secreting cells.