Second Malignancy Probabilities in Patients With Breast Cancer Treated With Conventional Versus Hypofractionated External Beam Radiation Therapy in the Adjuvant Setting.

AIMS: For women with breast cancer, seminal studies have shown that adjuvant hypofractionated external beam radiation therapy (hEBRT) maintains similar outcomes and may reduce overall costs compared with conventionally fractionated external beam radiation therapy (cEBRT). However, it is unclear whether hEBRT may be associated with differential risk of development of radiation-induced second malignancies compared with cEBRT. Because the occurrence of second malignancies is small, large databases may improve our understanding of the relative risk of second malignancies between hEBRT and cEBRT. MATERIALS AND METHODS: Using the National Cancer Database, we carried out a retrospective cohort analysis of women diagnosed with non-metastatic, stage 0-III breast cancer from 2004 to 2017. All patients had a lumpectomy or mastectomy and a follow-up time of at least 60 months after diagnosis. The probability of second malignancies in women receiving adjuvant cEBRT or hEBRT was compared using multivariable logistic regression adjusting for sociodemographic, geographical, clinical and treatment factors, allowing for relative (but not absolute) comparison of second malignancy risk. Temporal sensitivity analyses stratified by year of diagnosis and length of follow-up time were also conducted. RESULTS: Of the 125 228 women in our study, 115 576 (92.3%) received cEBRT and 9652 (7.71%) received hEBRT. The median age of the cohort was 60 (interquartile range 51-68) years at diagnosis and the median follow-up time was 99.61 (interquartile range 77.5-128.49) months. Upon adjusting for sociodemographic and clinical factors, patients who received hEBRT had no difference in relative risk than patients who received cEBRT (odds ratio 0.937, 95% confidence interval 0.869-1.010, P = 0.091). In analyses stratified by year of diagnosis, and stratified by length of follow-up, there was no difference in second malignancy probability between patients who completed hEBRT and patients who completed cEBRT. CONCLUSIONS: In this analysis of over 120 000 women with non-metastatic breast cancer, hEBRT was not associated with different odds of developing second malignancies compared with cEBRT. Our findings may inform patient counselling in the choice of radiation regimens for breast cancer and further support the safety of hypofractionated regimens for breast cancer.

Skin reaction to yellow fever vaccine after immunization with rabies vaccine of chick embryo cell culture origin.

Skin reaction to yellow fever vaccine was examined after immunization with rabies vaccine. The two vaccines contained substrates from chick embryo cells (rabies vaccine) and chick whole embryo (yellow fever attenuated vaccine), as well as gelatin. A prick test with gelatin showed negative results in all vaccinees examined. An intradermal skin test revealed that the yellow fever vaccine had reacted with an anti-egg protein antibody-like substance in a case with a history of egg allergy before rabies vaccination. A case inoculated two times with the rabies vaccine revealed a positive reaction to egg-white protein as well as the yellow fever vaccine. This case had no anamnesis of egg allergy. Thus, an antibody reactive to the egg-white protein and/or the yellow fever vaccine was inducible by the rabies vaccine. The reaction of this antibody was not systemic but local at the skin test by the yellow fever vaccine. The period of the rabies vaccine sensitization reactive to the yellow fever vaccine could be estimated as longer than 14.3 +/- 9.6 days (mean +/- SD), based on a follow-up examination of the positive skin reaction in 41 of 84 cases examined. We therefore conclude that the yellow fever vaccine can be safely administered at an interval of at least four weeks after a second rabies vaccination.

[Application of the limulus amebocyte lysate test to measurement of endotoxin in therapeutic human plasma protein fraction. Comparison with the rabbit pyrogen test].

We applied the limulus amebocyte lysate (LAL) test to the detection of bacterial endotoxins in therapeutic human plasma protein fraction (PPF) and compared the LAL-test with the rabbit pyrogen test. Two endotoxin-specific LAL-reagents were used for the colorimetric method and turbidimetric kinetic method. The amounts of added endotoxin to the PPF were correctly estimated by either method. The results of four independent assays for the 53 samples of PPF corresponded well with each other (correlation coefficient: 0.851-0.959, regression coefficient: 0.898-1.151). The amounts of endotoxin in the PPF estimated by the LAL-test significantly correlated with the rise of body temperature in rabbits (correlation coefficient: 0.547-0.642, and 0.911-0.934 for the endotoxin added samples). These results suggest that the LAL-test could be used as an alternative method for the rabbit pyrogen test to PPF.

[Application of the Limulus test for practical quality control on endotoxin content in commercial human serum albumin (HSA) products. In comparison with the rabbit pyrogen test].

The bacterial endotoxin content in human serum albumin (HSA) products measured by two different Limulus amebocyte lysate (LAL) test methods, colorimetric and kinetic turbidimetric methods, were compared. So far as endotoxin-specific LAL reagents which do not show a false-positive reaction with (1-->3)-beta-D-glucan are used, a definite correlation was found between the results with the two LAL test methods. Endotoxin added to HSA products was recovered in a quantitative manner showing neither inhibition nor enhancement by HSA to the both LAL test methods. Results of the LAL tests showed a significant correlation with that of the rabbit pyrogen test. The correlation was much improved with endotoxin-added HSA. The present results indicate the practical applicability of the LAL test as an alternative method for the rabbit pyrogen test.

Experimental transmission of Creutzfeldt-Jakob disease to guinea pigs.

Brain material used in this experiment was from a 47-year-old woman autopsied 5 hours after death. The brain was markedly atrophic weighing 750 g. Histopathologically, a spongy state was extensive from cortex to medulla with fibrous astrocytosis and neuronal loss. This brain tissue was aseptically removed at autopsy and a 20% emulsion was prepared. Intracranially 0.1 ml and intraperitoneally 0.2 ml of the emulsion were inoculated into each guinea pig. Five and three of them were killed 10 and 22 months later, respectively, nevertheless showing no clinical signs. The brains from these guinea pigs did not reveal any changes as seen in the human autopsy brain both macroscopically and microscopically. However, all the brains indicated ultrastructural changes characterized by vacuolation with curled membranes in dendrites and free membranes with cellular debris in extracellular space. These changes were not found in guinea pigs inoculated with material from normal guinea pig brain or uninoculated guinea pigs, but similar to those observed in the human autopsy brain used as inoculum. Therefore, it could be considered that Creutzfeldt-Jakob disease was transmitted from man to guinea pig to present an early stage of the lesion. Several organs were observed ultrastructurally after whole bleeding in monkeys. Curled membranes were generated only on the vacuoles of dendrite from 2 1/2 hours after bleeding and not in those of other organs. This may explain at least a part of the pathogenesis of spongiform changes restricted in the central nervous system.

The views and policy of the Japanese control authorities on the three Rs.

NIH Japan has tested and regulated the three Rs of animal experiments in the development and control of biological products in a stepwise manner. (1) The number of monkeys was reduced from 108 to 72 for the neurovirulence test of OPV in each type, since paralysed monkeys inoculated intraspinally revealed a linear relationship between average scores of the lumbar lesion and cumulated paralysis occurrence ratio (%). (2) Rabbits for the pyrogen test were replaced by the endotoxin test for PPF, albumin and interferon products. The endotoxin is measured by the parallel line assay method using both turbidimetric kinetic and colorimetric methods. (3) Histopathological examination was introduced to the abnormal toxicity test as a refinement. Mean body weight loss of two guinea pigs inoculated with five ml. of an albumin product in each was far below the mean weight of pooled guinea pigs used (P < or = 0.01) and appeared repeatedly. The histopathological examination showed focal necrosis in the liver. This finding was suggestive of the presence of endotoxin in the product. The product contained 0.1 EU/ml of endotoxin. The same amount of the reference endotoxin produced a similar change in guinea pigs. The mechanism of the liver cell damage by endotoxin has been investigated by an in vitro method.

Character of the tumors developing in young hamsters by the mixed cell transplantation of para-adeno-virus 12 and SV40 tumors-the similarity to the tumors induced by para-adenovirus 7.

Two mixtures of either allogeneic PARA-adenovirus 12 tumor cells or adenovirus (Adeno) 12 tumor cells and SV40 tumor cells in an equal number of 1 multiplied by 10(7) cells were transplanted subcutaneously at two sites of 10 young hamsters. The former two tumor cells were transplantable in nearly half of the transplants and the latter tumor cells in all of the transplants. By the mixture of PARA-Adeno 12 and SV40 tumor cells, 10 tumors were grown, 7 of which were mixed with Adeno and SV40 types and 3 were solely SV40 type. The other 10 tumors produced by the mixture of Adeno 12 and SV40 tumor cells revealed SV40 type only. Morphologically, Adeno type resembled the tumor induced by Adeno, and SV40 type by SV40. The results suggest that the existence of SV40 genetic information in Adeno type tumor cells is indispensable to the formation of mixed tumor in allogeneic tumor cell system. The similarity between the tumors developed by the mixed cell transplantation and those induced by PARA-adeno 7 was discussed both viro-immunologically and morphologically.

Passive transfer of experimental allergic encephalomyelitis with lymphocytes collected from brains of immunized guinea pigs.

Lymphocytes were collected from the brains of guinea pigs immunized with syngeneic spinal cord emulsified in complete Freund's adjuvant. Sixteen to 32 X 10(6) lymphocytes were inoculated into the vein of each inbred guinea pig (NIH 13). Recipient animals without clinical signs of experimental allergic encephalomyelitis (EAE) were sacrificed 20 days later. Some of the recipients had perivascular infiltrates of a large number of mononuclear cells mostly in choroid plexus and meninges of the brain and spinal cord. Demyelination, which was not so intense, was also observed in the vicinity of the perivascular infiltrates. Thus, the lymphocytes from the brain as well as lymph node and spleen were clear to have the ability to transfer EAE.

Experimental infection of young rabbits with rabbit parvovirus.

A newly isolated parvovirus of rabbits (F-7-9 strain) was inoculated into young female rabbits by the oral or intravenous route. Virus was recovered from the feces 3 to 13 days after inoculation. Viremia was demonstrated in orally inoculated rabbits. The virus was also isolated from tissue extracts of liver, pancreas, spleen, small intestine, appendix and mesenteric lymph node on days 10 and/or 14, and from the small intestine on day 30 after inoculation. Hemagglutination inhibiting antibody appeared in the serum after 8 days and neutralizing antibody was detected later. An 11S neutralizing antibody was demonstrated in fecal extracts between 15 and 30 days after inoculation. Infected rabbits showed very mild clinical signs of listlessness and inappetence lasting for a few days. Histologically, mild to moderate catarrhal enteritis was observed in the small intestine.

Growth and spread of causative agent of Creutzfeldt-Jakob disease in intraperitoneally infected mice.

The progression of Creutzfeldt-Jakob disease (CJD) was studied in ddY mice infected intraperitoneally with the Fukuoka-1 strain, a transmissible agent isolated from a CJD patient in Japan. Infectivity became detectable simultaneously in the brain, the spleen and the liver, i.e. 19 weeks after inoculation. Infectivity titer ranged from 10(2) to 10(3) LD50/g in all three organs up to 35 weeks, in contrast to intracerebrally infected mice in which the content of infectious CJD agent is higher in the brain than in the liver and the spleen. Cuffs appeared in the brain roughly four times in the period from 3 to 37 weeks after inoculation. The observed infectivity was discussed in relation to the appearance of cuffs in the brain.

Skin reactions to vaccinia virus infection in the rabbits immunized with vaccinia-soluble early antigen.

Rabbits were immunized with vaccinia-soluble early antigen (Es antigen) in Freund's complete adjuvant (FCA). Circulating neutralizing antibody was not induced, but CF antibody against the soluble antigens of vaccinia-infected cells was induced. By intradermal inoculation of vaccinia virus, erythema developed early at the site of inoculation and enlarged up to 3 days post infection (p.i.). No multiplication of the viruses in the erythematous areas was indicated on day 3 p.i. The erythematous areas showed histologically severe changes involving infiltration of numerous cells accompanied with necrotic and hemorrhagic lesions in a part of the dermis. Eosinophilic leukocytes were dominant and there were also some lymphocytes in the cell infiltration. The role of these kinds of cells was discussed in connection with cell-mediated immunity in the mechanism of excluding vaccinia virus from the immune rabbits.

Retrovirus particles in spontaneously occurring and radiation-induced tumors in ddY mice.

Among spontaneously occurring tumors, pulmonary tumor, malignant lymphoma, mammary tumor, and ovarian tumor were the major ones in 232 ddY female mice. The former three tumors appeared significantly earlier and the latter one increased in incidence in 229 mice given 600 R whole or 800 R partial body (tunk) x-irradiation at the age of 10 weeks. Five tumors were examined electronmicroscopically from each tumor type of both the spontaneously occurring and radiation-induced tumors. C type virus particles were present only in the malignant lymphoma and B particles in the mammary, ovarian and pulmonary tumors, which are all of epithelial character. Thus, as far as we were concerned in this mouse strain, B particles were produced preferentially in epithelial cells and C particles in non-epithelial cells. The retrovirus particles were found in the same frequency, namely, 10 of 20 tumors examined in both the tumor groups. From our results, the intervention of virus in radiation carcinogenesis still remains in question.

Studies on recovery mechanism from rinderpest virus infection in rabbits. I. Effect of anti-thymocyte serum and thymectomy.

The role of cell-mediated immunity in recovery from rinderpest virus infection in rabbits was investigated by application of immunosuppressive procedures, i.e., treatment with anti-thymocyte serum and combined treatment with thymectomy and anti-thymocyte serum, both of which were confirmed to depress significantly cell-mediated immunity in rabbits. The immunosuppressed animals recovered in almost the normal fashion in terms of clinical signs, of virus clearance from the blood and lymphoid tissues and of repair of the lesions. It was suggested that the thymus-dependent cell-mediated immunity may not be essential in recovery from rinderpest virus infection. Possibility of participation of other recovery mechanisms was discussed.

Evaluation of the neurovirulence test of oral poliovaccines in Japan during the period 1963-1982.

The present study showed that the neurovirulence test for the lesion-inducing virus dose in the spinal cord in 50% of monkeys inoculated with oral polio-vaccine (Sabin) (LID50) reflected to a large extent safety and efficacy of the vaccine upon administration to children. The degree of attenuation of the vaccine in terms of LID50 appeared to be related to the decrease in the vaccine-associated cases as well as the seroconversion rate. An exceptional case, however, was noted in which lot No. 301 was not classified into less attenuated vaccine by the neurovirulence test. This fact suggests that the method we have employed awaits further improvement.

Alterations of the thymus and peripheral lymphoid tissues in fatal measles. A review of 14 autopsy cases.

As a result of re-examining 14 autopsy cases of fatal measles, neither aplastic nor hypoplastic thymuses were found even in a case with giant cell pneumonia, but there were degenerative and/or necrotic changes with giant cells mostly in the thymus and less in the peripheral lymphoid organs such as spleen, lymph nodes, Peyer's patches and tonsils. This damage of the lymphoid system was associated with the occurrence of complications, particularly of giant cell pneumonia and encephalitis. The lymphoid cell damage, which might be primarily due to virulence of the infected measles virus, seemed to prolong the viremia. Involvement of viremia in the process of complication is discussed.

Immunotherapeutic trials of murine and guinea-pig solid tumors by oral administration of BCG.

Efficacy of oral administration of BCG on the growth of various tumors in mice and guinea pigs was studied. The growth-inhibitory effect varied depending on the tumor systems and the experimental conditions. Weekly oral administrations with 5-mg doses of BCG to mice or 80-mg doses of BCG to guinea pigs were ineffective on syngeneic mouse melanoma B16 or syngeneic guinea pig hepatocarcinoma line-10 but effective on syngeneic mouse carcinoma IMC and syngeneic guinea-pig fibrosarcoma H9A. Oral BCG seemed effective also on allogeneic mouse carcinoma Ehrlich, developed with a relatively small size of tumor cell inoculum, and on guinea-pig syngeneic liposarcoma H10. On Ehrlich tumors, oral BCG given once a week seemed to have better effects than did oral BCG given twice a week or subcutaneously once or repeatedly; heat-killed BCG given orally showed no effect. However, it seems premature to draw a definite conclusion on the efficacy of oral BCG on Ehrlich and H10 tumors, because some of these tumors regressed spontaneously even in nontreated control animals. The host responses to oral BCG were studied with the following results. Weekly oral administration with 80-mg doses of BCG to guinea pigs elicited positive skin reactions to 25 TU PPD in about 65 days after the first BCG, while a single sc injection of 8 mg of BCG did so within 10 days. Orally administered BCG organisms were recovered largely from Peyer's patches, a little from the mesenteric lymph nodes, and very little from the liver and the spleen. The BCG distributive pattern was in reverse order when BCG was given subcutaneously. Histologic examinations of Peyer's patches indicated enlargement of germinal centers, in which primitive reticular cells proliferated prominently and the macrophages with tingible bodies scattered frequently.

Late effects of whole or partial body x-irradiation on mice: life shortening.

Life table data were obtained on 2400 ddY/SLC female mice exposed at 10 weeks of age to a single dose of X-rays. Doses given to the whole body were 95, 190, 380 and 570 rad, and to head, trunk or lower body, 190, 380, 570 and 760 rad. The mean survival time of unirradiated controls was 73 weeks. The mean survival times after whole body exposure decreased linearly with increasing dose. The estimate of life shortening per 100 rad was 7.2 per cent for whole body exposure. The life shortening after head or lower body exposure to a dose of 190 rad was 6.2 and 7.1 weeks respectively, and almost no further life shortening up to 760 rad. After trunk irradiation with 190 rad, life shortening was 10.4 weeks and beyond that dose life shortening was 1.1 per cent per 100 rad.

Nonbacterial thrombotic endocarditis in a Japanese autopsy sample. A review of eighty cases.

A study of nonbacterial thrombotic endocarditis has been carried out in a series of 3,404 autopsies performed upon atomic bomb survivors in Hiroshima in the period 1953-1970. The prevalence of the lesion was 2.4 per cent, with a greater frequency among the elderly and among females, and with a significant relationship to malignant neoplasms. In contrast to other reported series, there was a greater prevalence among cancers of the colon, rectum, and female genitourinary tract. No relationship was noted between the presence of NBTE and exposure to ionizing radiation. Histologic findings in the heart-valve leaflets in close proximity to the verrucae, like experimental studies reported by others, suggest that in association with severe systemic disease there appears a process consisting of degenerative changes in valve collagen and ground substance, with subsequent denudation of endothelium, localized almost entirely to the apposing leaflet surfaces of the left-heart valves. The verrucae of nonbacterial thrombotic endocarditis are then formed upon this abnormal leaflet surface. While the relationship between systemic disease and the pathologic changes observed in cardiac valve tissue is unclear, and although it is not known whether a "hypercoagulable state" may accentuate the tendency for thrombi to form upon these abnormal valves, there is no doubt that this lesion represents a clinically important complication of severe systemic disease. It also seems likely that in some cases NBTE may complicate an illness which may otherwise be curable. Increasing awareness of this pathologic entity among clinicians, coupled with appropriate laboratory techniques, most likely echocardiography, will permit more frequent diagnosis in living patients.