Delphi-panel analysis of appropriateness of high-dose chemotherapy and blood cell or bone marrow autotransplants in women with breast cancer.

BACKGROUND: There is controversy whether high-dose chemotherapy and a blood cell or bone marrow autotransplant is a better treatment than conventional-dose chemotherapy for women with local/regional or metastatic breast cancer. Subject selection and time-to-treatment biases make definitive comparison impossible. Recent results of randomized trials are contradictory. OBJECTIVE: Determine appropriateness of high-dose chemotherapy and a blood cell or bone marrow autotransplant in women with breast cancer. PANELISTS: Nine breast cancer experts from diverse geographic sites and practice settings. EVIDENCE: Boolean MEDLINE searches of 'breast cancer' and 'chemotherapy' and/or 'blood cell' or 'bone marrow transplants'. PROCESS: We used a modified Delphi-panel group judgement process. Clinical variables were permuted to define 2058 clinical settings. Each panelist rated appropriateness of high-dose therapy and an autotransplant versus conventional therapy on a 9-point ordinal scale (1: most inappropriate, 9: most appropriate). An appropriateness index was developed based on median rating and amount of disagreement. The relationship of appropriateness indices to the permuted clinical variables was considered by analysis of variance and recursive partitioning. CONCLUSIONS: In women with local/regional breast cancer autotransplants were rated: 1) appropriate in those with > or = 10 cancer-involved lymph nodes; 2) uncertain in those with 4-9 cancer-involved nodes; and 3) inappropriate in women with < or = 3 cancer-involved lymph nodes. In women with metastatic breast cancer autotransplants were rated: 1) appropriate in those with metastases to 'favorable' sites (skin, lymph node, pleura) and a complete or partial response to chemotherapy; 2) uncertain in women with metastases to 'unfavorable' sites (lung, liver, or central nervous system) and a complete response to chemotherapy or those with bone metastases and a complete or partial response or stable disease after chemotherapy; and 3) inappropriate in other settings.

Novel pattern of p53 gene mutations in an American black cohort with high mortality from breast cancer.

The pattern of acquired mutations in the p53 gene can be used to study differences in factors contributing to carcinogenesis. We investigated mutations in exons 5-9 and adjacent intronic regions in 47 breast cancers of black women from Michigan, a population with the highest breast-cancer mortality in the US. The 16 mutations detected differed from those of other populations. In particular, the black women had an excess of A:T-->G:C transitions compared with rural white US midwest women. While the causes of the different pattern of acquired mutation remain to be determined, this molecular epidemiological approach detects the consequences of mutagenic processes in specific populations. Mutation patterns will constrain hypotheses to mechanisms consistent with the observed biochemical alterations.

Participation in clinical trials: is it state-of-the-art treatment for African Americans and other people of color?

We have attempted to initiate a much needed constructive dialogue regarding the participation of African-American patients in clinical cancer research trials. It was our intent to provide a greater understanding of the historical context and evolving nature of clinical research trials pertaining to cancer. Some of the same challenges hold true for acquired immunodeficiency syndrome (AIDS)-related clinical research. Physicians interested in becoming a member of SOCRATES should contact Dr Roach at the University of California San Francisco.

Multiple forms of cytoplasmic ER and PgR characterized by polyacrylamide gel electrophoresis.

The multiple forms of cytoplasmic ER and PgR were electrophoretically characterized by PAGE under non-denatured conditions and SDS PAGE under denatured conditions. The ordinary PAGE and SDS PAGE were modified in such a way as to reveal the authentic multiple forms of the hormone receptors studied. The experimental conditions were well-defined. The standard protein criteria for evaluation of molecular weights were established. The high polymers containing main activity can be revealed by 3% PAGE under non-denatured conditions and all the multiple forms can be revealed by 3% SDS PAGE under milder SDS coupling reaction. The multiple forms commonly occurring are monomer, dimer, tetramer and hexamer for both ER and PgR. For PgR, there are two monomer components A and B, dimer AB. Tetramer 2AB and hexamer 3 AB. Octamer 4 AB is observed sometimes.

Hypothetical multiple forms of cytoplasmic ER and PgR and commentary remarks.

Based on the generalization from previous studies the hypothetical multiple forms of cytoplasmic ER and PgR are proposed. Eight forms of ER and 10 forms of PrR have been observed as a whole. However, only four forms of ER, monomer, dimer, tetramer and hexamer, and five forms of PrR, monomer A or B, dimer AB, tetramer AB . AB and hexamer 3(AB) of PgR commonly occur. In conclusion, comments on our results and on those of others are made. Previous studies (1,2) have demonstrated that the high polymeric forms of cytoplasmic ER and PrR from rabbit uteri contain major activity. In continuous studies (3,4) the solubilized nuclear ER and PgR from rabbit uteri demonstrated the similarity of multiple forms to the cytoplasmic receptors. Further, by analyses of human breast tumors (5) similar multiple forms in both cytoplasmic and nuclear ER and PrR have been revealed. In order to generalize what we have observed with our rational experimental approaches we are proposing hypothetical multiple forms of cytoplasmic ER and PrR in this communication.

Molecular sieve of cytoplasmic ER and PgR.

Cytosol from immature rabbit uteri was classified into six groups according to range of molecular weights. The molecular sieve can be achieved by AMICON ultrafiltration using membranes of different pore sizes. The results revealed that almost 50% of the total activity of ER and PgR was confined to the largest fraction with a molecular weight greater than 300,000. A detailed study by electrophoretic characterization in later experiments demonstrated that the cytoplasmic ER and PgR exist mainly in high polymer forms.

Phase II evaluation of esorubicin (4'deoxydoxorubicin) in pancreatic adenocarcinoma: a Southwest Oncology Group study.

Esorubicin (4' deoxydoxorubicin) is a new analogue of the anthracycline, doxorubicin. This compound lacks the hydroxyl group at 4' position on the amino sugar of the anthracycline. Phase II study was designed to determine the clinical response rate and to define the qualitative and quantitative toxicities of esorubicin in patients with adenocarcinoma of the pancreas. Fifty-eight patients with inoperable adenocarcinoma of the pancreas were entered on the study, 47 were evaluable for response, and 57 were evaluable for toxicity. The dose of esorubicin was 30 mg/m2 for good risk patients and 25 mg/m2 for poor risk patients every 21 days and administered IV push through a side arm of a running IV. Diphenhydramine, 50 mg is administered IM prior to the administration of the drug to block local venous reaction. Subsequent doses of esorubicin were modified according to granulocyte and platelet nadirs and the drug was not administered until recovery of platelets (greater than 100,000/microliters) and wbc (greater than 3000/microliters). Three partial responses, 20 stable, and 31 with increased disease were observed. Forty-seven had severe granulocytopenia (less than 250), and two patients had severe thrombocytopenia (less than 25,000). One patient experienced a decrease in left ventricular ejection fraction with a total dose of 180 mg/m2. The dose of esorubicin in this study demonstrated that the drug has minimal activity in adenocarcinoma of the pancreas but the toxicity is tolerable. Search should continue for single agents with activity in this disease.

Tissue ferritin concentration and prognosis in carcinoma of the breast.

Seven year follow-up data were available on 36 of 40 breast carcinoma patients in whom breast tissue ferritin concentrations at the time of surgery were known. 18 patients were alive and free of recurrence or second tumor (Group 1) and 11 died with breast cancer (Group 2). Patients with lower tissue ferritin concentrations defined as less than 319 ng/mcp (nanograms of ferritin/milligram of cytosol protein) were at reduced risk: 86% of patients with low tissue ferritin concentration survived free of recurrence or second tumor vs. 40% of patients with high tissue ferritin concentration (P = 0.0056). Mean breast carcinoma tissue ferritin concentration was 295 +/- 52 ng/mcp in Group 1 and 444 +/- 55 ng/mcp in Group 2 (P = 0.036). Lymph node involvement was predictive of mortality from breast carcinoma (P = 0.0003), but did not correlate with mean tissue ferritin concentration (P = 0.082). 10/10 (100%) patients who had both low tissue ferritin concentration and absence of lymph node involvement were in Group 1. The correlation of breast tissue ferritin concentration with histopathologic dedifferentiation and with prognosis suggests tumor tissue ferritin as a marker of malignant potential.

Production and characterization of a monoclonal antibody to partially purified estrogen receptor from human breast tumor.

A hybridoma cell line that secretes monoclonal antibody, MAb-ER-Br-1-15-4-18 is established. The MAb is highly specific for estrogen receptor (ER) from human breast tumor cells. In order to raise the antibody, the ER was first isolated from human breast tumor. Mice were immunized with the partially purified ER and the fusion of the spleen cells from the mouse, showing the highest serum titer, with the cells of the NS-1 mouse myeloma line, produced hybrid cells which continuously secreted antibodies specific for ER. Three of the hybridoma cultures which tested strongly positive were cloned using limiting dilution method and one of the cell lines was selected for further study. The recovery of the MAb from the cell culture was done by ammonium sulfate precipitation followed by dialysis and then hydroxylapatite liquid chromatography using linear gradients. The purity of the antibody was checked by polyacrylamide gel electrophoresis. The MAb was isotyped and found to be IgG1. When checked against other antigens the MAb showed a minimal cross-reactivity to ER from rabbit uterus and none to ovalbumin or rat liver ferritin. Further experiments showed that the MAb recognized the ER bound to the hormone and ER in the nucleus of breast tumor cells.

Ammonium sulfate fractionation and assay of hormone receptors.

Ammonium sulfate (AS) precipitation by consecutive steps at 10% to 50% saturation has been utilized for fractionation of cytoplasmic estrogen receptor (ER) and progesterone receptor (PgR). The highest percentage of both receptor activities are confined mainly in two fractions at AS saturation from 20% to 30% and 30% to 40%. The total percentages of activity of the cytoplasmic ER and PgR salted out at 50% saturation are 77% and 53%, respectively. Precipitation of hormone-receptor complexes at 50% saturation for assay of ER and PgR can be achieved, but needs improvement for efficient salting out of the receptors. ER and PgR salted out in the AS pellet are much more stable for storage than in the cytosol.

Locally advanced adenocarcinoma of the breast without distant metastasis treated with multimodal therapies.

Locally advanced breast cancer has been treated with a variety of primary treatments with or without adjuvant therapies. This study combines radiation, chemotherapy, and surgery as a multimodal program for Stage III breast cancer. Radiation was started on day 1: 4600 rad were administered to the breast and 4500 rad were administered to the axilla and supraclavicular areas. Chemotherapy was started on day 1 with weekly intravenous injections of 5-fluorouracil (5FU) (300 mg/m2), methotrexate (15 mg/m2), vincristine (0.625 mg/m2), oral cytoxan (60 mg/m2), and prednisone (30 mg/m2 for two weeks, then 20 mg/m2 for two weeks, then 10 mg/m2 for two weeks). The 5FU, methotrexate, and cytoxan were given for 10 months postsurgery. This combination of modalities produced a complete remission in all 13 patients with Stage III breast cancer after two months of therapy. The median disease-free period was two years. The median survival was 44 months. This approach to the management of Stage III breast cancer is worthy of further investigation.

VP-16 + adriamycin vs. adriamycin alone in advanced adenocarcinoma of the breast, phase II, a randomized trial: a Southwest Oncology Group Study.

One hundred twenty-two patients with advanced adenocarcinoma of the breast were randomized to receive adriamycin (AD) alone or a combination of VP-16 plus lower dose adriamycin (VAD). The patients were stratified to good and poor risk. The starting dose (day 1) of AD was 60 mg/m2 for good risk and 45 mg/m2 for poor risk. The starting dose of the VAD combination for the good-risk patient was VP-16, 75 mg/m2 daily x 5 plus adriamycin 35 mg/m2. The poor-risk dose for VAD was VP-16, 50 mg/m2 daily x 5 plus adriamycin, 30 mg/m2 on day 1. The total dose of AD was 450 mg/m2 on both arms. The patients who were on the VAD arm continued on VP-16 maintenance. Both arms were repeated every 21 days. There were 54 evaluable patients on the adriamycin arm and 52 evaluable patients on the VAD arm. Both arms were similar with regard to age, menopausal status, performance status, and prior hormonal therapy. More hematologic toxicity was seen in the adriamycin arm. Complete responses were observed on both arms, three (5%) with adriamycin and three (5%) with combination. Eleven (19%) and ten (18%) partial responses were observed with the adriamycin and VP-16 plus adriamycin, respectively. AD produced more stable disease than VAD (41% vs. 29%). Complete responses were seen only in the good-risk patients. Time to progression was delayed on the combination arm (P = 0.02). The survival in both arms was similar. The addition of VP-16 to adriamycin does not offer an important clinical advantage.

Anatomic distribution of ER and PgR in rabbit and dog uteri.

Similar ER activities were observed in the different sections and in both branches of rabbit uterus, while PgR activities varied greatly from branch to branch and from section to section in the left branch of the uterus. The total ER activity was much higher than the total PgR activity in both branches. In the dog uterus, both ER and PgR showed higher activity in the right branch, but both appeared to be equally distributed in the sections and in each branch. The total ER and PgR activities were equally distributed in both branches.

Extraction of ER and PgR with molybdate.

Extraction of ER and PgR with 10 mM molybdate in TEDG buffer greatly facilitated their solubilization and a much higher receptor value was observed. However, since molybdate also affects the hormone receptor binding reaction, the apparent receptor activity assayed with molybdate is different from the actual receptor activity normally assayed without molybdate. A correction factor obtained by assaying cytosol with and without adding molybdate can be used to convert the apparent value into the actual value. The mathematical evaluation involving two separate effects of molybdate on receptors is illustrated.

Ferritin content in human cancerous and noncancerous colonic tissue.

Tumor tissue samples from 25 patients with adenocarcinoma of the colon, twelve related samples of normal colons as well as five serum specimens from the same patients were analyzed for ferritin. The average ferritin content of the tumor tissue was 788 ng/mcp with a range of 47-1,745 ng/mcp. The average ferritin content of normal colon mucosa was 115 ng/mcp with a range of 32-230 ng/mcp. Two specimens of metastatic colon cancer taken from the retroperitoneal space and liver, respectively, contained 3,867 and 2,827 ng/mcp of ferritin. The ferritin content of the tumor tissue was higher than that of the normal colon in 8 of 9 patients who had specimens obtained from both sites. The amount of ferritin found in tumor tissue was independent of sex, age, and the site of the original tumor. This study shows that the ferritin content of colon neoplasms is elevated and indicates that the tumor tissue may be the direct source of elevated serum levels of ferritin previously observed in cancer patients.

Efficacy of extraction and incubation of ER and PgR with different solvent systems from rabbit uterus.

Methods for improving the estrogen receptor (ER) and progestin receptor (PgR) assay were studied. Using DCC procedure as the basis, the extraction and incubation of ER and PgR is more efficiently achieved by phosphate buffer as compared with water, tris and veronal buffers. The multiple extractions of hormone receptors by any solvent system used is more complete than a single operation of homogenization and centrifugation. The utilization of combined extraction first with water and then phosphate buffer, followed by incubation of the cytosol in phosphate buffer with hormone is also an efficient procedure for the assay of both ER and PgR.

The efficacy of 5-fluorouracil, mitomycin C, and methyl CCNU in advanced colorectal cancer.

Sixty-six patients with advanced colorectal cancer were treated with 5-fluorouracil, Mitomycin C, and 1-(2-chloroethyl)-3-(4-methylcyclohexyl)-1-nitrosourea. Fifty-seven patients were evaluable by completing 2 months of therapy. Nine patients (16.0%) achieved a complete remission (CR) with the above combination. A partial remission (PR) was seen in 9 patients. The response rate (CR + PR) was 32%. The average duration of response was 8.5 months. Mucositis, leukopenia, and thrombocytopenia were the significant toxicities experienced in this study.

Multiple extractions of hormone receptor from rabbit uteri and human breast tumors.

The cytosol hormone receptors were extracted from rabbit uteri and human tumors with tris buffer systems for three consecutive homogenization and centrifugation processes to obtain three cytosols C-1, C-2, and C-3. The assay results evaluated revealed that minimal to tremendous amounts of receptor activities were present in C-2 and/or C-3 fractions. The essential experimental conditions and some speculative mechanisms have been discussed in detail.