Axillary recurrence rate 5 years after negative sentinel node biopsy for breast cancer.

BACKGROUND: Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) as the standard axillary staging procedure in breast cancer. Follow-up studies in SLN-negative women treated without ALND report low rates of axillary recurrence, but most studies have short follow-up, and few are multicentre studies. METHODS: Between September 2000 and January 2004, patients who were SLN-negative and did not have ALND were included in a prospective cohort. Kaplan-Meier estimates were used to analyse the rates of axillary recurrence and survival. The risk of axillary recurrence was also compared in centres with high and low experience with the SLN biopsy (SLNB) technique. RESULTS: A total of 2195 patients with 2216 breast tumours were followed for a median of 65 months. Isolated axillary recurrence was diagnosed in 1·0 per cent of patients. The event-free 5-year survival rate was 88·8 per cent and the overall 5-year survival rate 93·1 per cent. There was no difference in recurrence rates between centres contributing fewer than 150 SLNB procedures to the cohort and centres contributing 150 or more procedures. CONCLUSION: This study confirmed the low risk of axillary recurrence 5 years after SLNB for breast cancer without ALND.

CYP2C8 and CYP2C9 polymorphisms in relation to tumour characteristics and early breast cancer related events among 652 breast cancer patients.

BACKGROUND: CYP2C8/9 polymorphisms may influence breast cancer-free survival after diagnosis due to their role in the metabolism of tamoxifen, paclitaxel, and other chemotherapy. cytochrome P450 (CYP)2C8/9 metabolise arachidonic acid to epoxyeicosatrienoic acids, which enhance migration and invasion in vitro and promote angiogenesis in vivo. We aimed to investigate the frequency of CYP2C8/9 polymorphisms in relation to breast tumour characteristics and disease-free survival. METHODS: A prospective series of 652 breast cancer patients from southern Sweden was genotyped for CYP2C8*3, CYP2C8*4, CYP2C9*2, and CYP2C9*3. Blood samples and questionnaires were obtained pre- and postoperatively. Clinical information and tumour characteristics were obtained from patients' charts and pathology reports. RESULTS: Frequencies of CYP2C8/9 polymorphisms were similar to healthy European populations. Significantly less node involvement (P=0.002) and fewer PR+ tumours (P=0.012) were associated with CYP2C8*4. Median follow-up was 25 months and 52 breast cancer-related events were reported. In a multivariate model, CYP2C8/9*3/*1*/*2/*1 was the only factor associated with increased risk for early events in 297 tamoxifen-treated, ER-positive patients, adjusted HR 2.54 (95%CI 1.11-5.79). The effect appeared to be driven by CYP2C8*3, adjusted HR 8.56 (95%CI 1.53-51.1). CONCLUSION: Polymorphic variants of CYP2C8/9 may influence breast tumour characteristics and disease-free survival in tamoxifen-treated patients.

Determination of sentinel lymph node (SLN) status in primary breast cancer by prospective use of immunohistochemistry increases the rate of micrometastases and isolated tumour cells: analysis of 174 patients after SLN biopsy.

AIM: The objective of the present study was to evaluate the prospective use of immunohistochemistry (IHC) for histopathological diagnosis of sentinel lymph node(s) (SLN) in primary breast cancer using stage migration and non-SLN metastases as endpoints in relation to metastatic involvement. METHOD: Serial sectioning and prospective use of IHC were applied to SLN examination in addition to routine haematoxylin-eosin staining in 174 consecutive patients with unifocal T1-T2 breast cancer included in a National Sentinel Node Study. Axillary lymph node dissection (ALND) was performed in all cases with macrometastases, micrometastases and isolated tumour cells (ITC). RESULTS: The SLN was found in 173/174 patients and a metastatic foci was found in 50 patients including 28/50 with macrometastases, 16/50 with micrometastases and 6/50 with ITC. IHC detected 3/16 of the micrometastases and 4/6 of ITC. Stage migration from N0 to N1mi was encountered in 3/132 patients by use of IHC. Non-SLN metastases were noted in 15/28 of patients with macrometastases and in 3/16 of patients with micrometastases, whereas no patient with ITC had additional metastases (p=0.007). CONCLUSION: The prospective use of IHC and serial sectioning for histopathological diagnosis of SLNs increased the detection rate of N1mi and ITC, but only 3/132 patients were stage-migrated by use of IHC. Patients with ITC did not have any risk of non-SLN metastases, supporting that ALND can safely be omitted in this group of patients.

Regional hyperthermic perfusion with melphalan after surgery for recurrent malignant melanoma of the extremities. Swedish Melanoma Study Group.

A prospective randomized trial testing regional hyperthermic perfusion with melphalan has been conducted. Sixty-nine patients with recurrent malignant melanoma of the extremities were randomly allocated to surgery (36 patients) or surgery plus regional perfusion (33 patients). Prognostic variables concerning primary tumor as well as the recurrent disease were evenly distributed in the groups, excluding any bias in the randomization. Median tumor-free survival after randomization was 17 months in the perfusion group and 10 months in the control group. There were 15 locoregional recurrences in the perfusion group and 24 in the control group. The tumor-free survival curve was significantly (P = .044) better for the perfusion group than for the control group. Median survival time after randomization was 57 months in the perfusion group and 35 months in the control group. This difference was not significant. One patient died within 1 month after perfusion of pulmonary embolism. Regional hyperthermic perfusion after surgery of recurrent malignant melanoma should only be recommended in prospective and controlled trials, until its value has been proven in several randomized studies.

Pathology parameters and adjuvant tamoxifen response in a randomised premenopausal breast cancer trial.

BACKGROUND: Subgroups of breast cancer that have an impaired response to endocrine treatment, despite hormone receptor positivity, are still poorly defined. Breast cancer can be subdivided according to standard pathological parameters including histological type, grade, and assessment of proliferation. These parameters are the net result of combinations of genetic alterations effecting tumour behaviour and could potentially reflect subtypes that respond differently to endocrine treatment. AIMS: To investigate the usefulness of these parameters as predictors of the response to tamoxifen in premenopausal women with breast cancer. MATERIALS/METHODS: Clinically established pathological parameters were assessed and related to the tamoxifen response in 500 available tumour specimens from 564 premenopausal patients with breast cancer randomised to either two years of tamoxifen or no treatment with 14 years of follow up. Proliferation was further evaluated by immunohistochemical Ki-67 expression. RESULTS: Oestrogen receptor positive ductal carcinomas responded as expected to tamoxifen, whereas the difference in recurrence free survival between control and tamoxifen treated patients was less apparent in the relatively few lobular carcinomas. For histological grade, there was no obvious difference in treatment response between the groups. The relation between proliferation and tamoxifen response seemed to be more complex, with a clear response in tumours with high and low proliferation, whereas tumours with intermediate proliferation defined by Ki-67 responded more poorly. CONCLUSIONS: Clinically established pathology parameters seem to mirror the endocrine treatment response and could potentially be valuable in future treatment decisions for patients with breast cancer.

Preoperative assessment of small tumours in women with breast cancer.

BACKGROUND AND OBJECTIVES: In patients with breast cancer, planning of the surgical strategy may rely on preoperative tumour size. The optimal method for assessment of small tumours has not been established. We compared findings from preoperative mammography and ultrasonography with histopathological tumour size in patients treated with breast-conserving surgery. MATERIAL AND METHODS: The study was retrospective and the setting a single institution clinic with free referral of patients. The patients were examined before the operation with mammography, ultrasonography, and findings were compared with postoperative histopathological tumour size. RESULTS: The study included 131 patients (median age was 59) years with grade I, II, and III cancers in 47, 71 and in 13 patients, respectively. The medium histological tumour size was 14 mm, range 4-45 mm. A wide 95% confidence interval between histopathological tumour size and preoperative mammography (standard deviation 4.8 mm) and ultrasonography (standard deviation 4.8 mm) was found. The combination of mammography and ultrasonography did not improve the results (standard deviation 4.3 mm). Preoperative mammography tended to over estimate the tumour size compared with histological tumour size whereas preoperative ultrasonography tended to underestimate the tumour size. CONCLUSION: In this retrospective study with preoperative evaluation of small breast cancers by mammography and ultrasonography, wide 95% confidence intervals for the methods were found and they should therefore be used with caution in the planning of the surgical strategy.

Breast conservation surgery, with and without radiotherapy, in women with lymph node-negative breast cancer: a randomised clinical trial in a population with access to public mammography screening.

The effect of postoperative radiotherapy after sector resection for stage I-II lymph node-negative breast cancer was evaluated in a patient population with access to public mammographical screening. 1187 women were randomised to no further treatment or postoperative radiotherapy following a standardised sector resection and axillary dissection. Radiation was administered to a dose of 48-54 Gy. Median age was 60 years, and median size of the detected tumours was 12 mm. Of the women 65% had their tumours detected by mammographical screening. The relative risk (RR) of ipsilateral breast recurrence was significantly higher in the non-irradiated patients compared with the irradiated patients, RR=3.33 (95% Confidence Interval (CI) 2.13-5.19, P<0.001). The corresponding cumulative incidence at 5 years was 14% versus 4%, respectively. Overall survival (OS) was similar, RR=1.16 (95% CI 0.81-1.65, P=0.41), with 5 year probabilities of 93 and 94%, respectively. Recurrence-free survival (RFS) at 5 years was significantly lower in the non-irradiated women, 77% versus 88% (P<0.001). Although women above 49 years of age, whose tumours were detected with mammographical screening, had the lowest rate of ipsilateral breast recurrence in this study, the cumulative incidence of such event amounted to 10% at 5 years if radiotherapy was not given. Such a recurrence rate has been considered as unacceptably high, but is, however, in the same range as that reported after lumpectomy and postoperative radiotherapy in published series.

Dosimetry in lymphoscintigraphy of Tc-99m antimony sulfide colloid.

A quantitative kinetic technique using a scintillation camera has been developed for investigating lymph drainage and the uptake in the lymph nodes of 99mTcSb2S3 colloid injected subcutaneously. Twenty-two patients with primary malignant melanoma were examined. Lymph-node dissection was performed and 185 lymph nodes were individually measured for radioactivity. The kinetics of colloid uptake in individual nodes can be expressed by a simple two-compartment model. The outflow of colloid from the injection site was found to be monoexponential, and the tissue volume containing the injected colloid at the injection site increased asymptotically with time. A model has been developed for calculating absorbed doses at the injection site and in organs with colloid uptake. The following absorbed doses were estimated (muGy/MBq): whole body 0.7-4.5, gonads 0-22, liver 1.0-3.9, lymph nodes up to 1000 and injection site about 10,000. Possible biological effects in the skin and effective dose equivalents have been estimated when using other lymphoscintigraphic agents.

Biokinetics of radiolabeled monoclonal antibodies in heterotransplanted nude rats: evaluation of corrected specific tissue uptake.

A tumor model is presented to study the biokinetics and localization of radiolabeled monoclonal antibodies (MAb) in the nude rat (Rowett RNu/RNu) heterotransplanted with human melanoma metastases. The nude rat is larger, less sensitive, and lives longer than the nude mouse. It is, therefore, well suited for in vivo studies of tumor localization with radiolabeled monoclonal antibodies. The tumor-to-host weight ratio was closer to the human situation for the nude rat than for the mouse, and quantitative imaging could be performed with a parallel hole collimator. We followed the antibody biokinetics for as long as 8 days, with repeated blood sampling and imaging. Specific uptake of MAb was higher in tumor tissue than in all other tissues except blood. Initial high uptake was also recorded in the bone marrow. The lymph glands showed a slow uptake of specific and control antibody. A simple in vitro correction procedure is described to calculate the corrected specific tissue uptake (STUcorr) that takes the blood activity into account. Thus it was shown that 80% of the tissue uptake in the dissected liver at 30 hr was due to labeled antibodies circulating in the blood. The specific tissue uptake ratio of antibodies 96.5 and OKT3 (nonspecific control) was unity for all other organs except for tumor tissue, where the ratio was greater than two and even higher when correction for blood content of labeled antibody was made.

Blockage of the hepatic-artery blood flow by biodegradable microspheres (Spherex) combined with local hyperthermia in the treatment of experimental liver tumors in rats.

The effect of local hyperthermia and a simultaneous blockage of the hepatic-artery blood flow by degradable starch microspheres (Spherex) was studied in a model of liver cancer in Wistar rats. Six days after each rat was inoculated with a cell suspension (NGW) in the central liver lobe, the rats were randomly allocated into four groups. The first group served as control, the second was treated with hyperthermia, the third by degradable starch microspheres (DSM) intraarterially, and the fourth with a combination of hyperthermia and DSM intraarterially. Tumor volumes were measured at laparotomy on days 0, 7, and 14. Temperature fluctuations in the tumor correlated well with those in the liver tissue, but were 2 degrees-4 degrees higher. The infusion of DSM did not change the pattern significantly. The tumor volumes were homogeneous between the groups at the start of treatment. The tumor growth was significantly reduced compared with the control group at day 7 in group III (P less than 0.05) and group IV (P less than 0.01) but only in group IV at day 14 (P less than 0.05). No differences in survival were found. Local hyperthermia concurrent with a blockage of the nutritional tumor blood flow seems to offer a more prominent and lasting tumor-growth inhibition.

Incorporation of pyrimidines and 5-fluoropyrimidines into normal tissues and an adenocarcinoma transplanted into the liver in rat.

In a model of secondary liver cancer in Wistar rats, the incorporation of tracer doses of pyrimidines and 5-fluoropyrimidines into the acid-soluble fraction, RNA and DNA of several normal tissues and of an experimental adenocarcinoma of the colon transplanted to the liver of rat was determined 90 min after infusion of the substances via the gastroduodenal artery. There was a higher incorporation after injection of FUra than after uracil into tumor RNA. There was very little labeling of DNA by FdUrd but a greater labeling of RNA following injection of this substance than following deoxyuridine in all tissues including tumor except in liver, where it was of the same magnitude. All fluoro compounds gave high labeling of the acid-soluble fraction of the kidney and liver. The experiments will be continued with therapeutic doses of the fluoro compounds.

Postoperative acute acalculous cholecystitis.

Two patients with acute acalculous cholecystitis after major surgical operations (cystectomy ad modum Bricker because of carcinoma of the urinary bladder, and proctocolectomy because of ulcerative colitis) are described. Various possible causes of acalculous cholecystitis after operation or after trauma are discussed. Postoperative acute acalculous cholecystitis has a more fulminant course than ordinary calculous cholecystitis. Treatment consists of immediate cholecystectomy.

Effect of hepatic artery ligation on the incorporation of 3H-orotic acid into an adenocarcinoma transplanted to rat liver.

In the model of secondary liver cancer in Wistar rats a study was made of the influence of hepatic artery ligation (HAL) on the amount of nucleotides and RNA in tumor and liver tissue and on the uptake of 3H-orotic acid into these compounds and DNA after labelling for 90 minutes. Ten days after inoculation with tumor cells into the central liver lobe, a catheter was placed into the portal vein in all rats and in half of them the hepatic artery was ligated. On days one, three, five or ten, rats were given 3H-orotic acid through the catheter. On day ten 3H-orotic acid was also infused via the femoral vein or intraperitoneally. After HAL there was a decrease in the nucleotide and RNA content of the tumor cells after one, three and five days. There was no such decrease in the liver cells. In all HAL rats there was an increase in the nucleotide and RNA content of the tumor cells at day ten compared to day five. The ratio of RNA to acid soluble fraction labelling in tumors was also increased on day ten in all groups compared to HAL rats at day five. The increased uptake of 3H-orotic acid into tumour RNA at day ten after HAL strongly suggests rearterialization. There was no support for an increased vascularization of the tumor from the portal vein on day three or five. In the liver tissue, HAL had no influence. This experimental study gives no support for the use of hepatic dearterialization followed by intraportal infusion av cytostatic agents in clinical settings.

Tourniquet infusion chemotherapy of the lower extremities--clinical and pharmacokinetic results.

A prospective analysis of tourniquet infusion chemotherapy is reported. Twelve patients with recurrent malignant melanoma and one patient with Kaposi's sarcoma on the lower extremities were treated. An objective tumor response (CR + PR) was noted in 4/8 patients with DTIC and in 1/5 with Adriamycin. Stable disease was registered in 2/8 and 2/5 when respective drugs were used. No major side effects were observed. Pharmacolkinetical analysis of Adriamycin were performed in five patients after two to three treatments. The plasma concentration time-curves of Adriamycin were in most cases described by an open three-compartment model. The AUC (area under the curve) values for Adriamycin were 3.4 (median value 95% CI 2.9-5.1) times higher than for Adriamycinol. The reproducibility of the intra-arterial techniques was established by the repeated pharmacokinetic analysis. This technique seems to give lower AUC (mg/m2) when compared with earlier published intravenous data. The results indicate that tourniquet infusion chemotherapy produces a reasonable response, and that further evaluation with other drugs and comparison with isolation hyperthermic drug perfusion will be of interest.

Palliative surgery for brain metastases of malignant melanoma.

Forty patients with melanoma brain metastases were treated by surgery. Single brain metastases were found in 32 cases and multiple in eight. The most frequent tumor location was the frontal and frontoparietal lobes. Neurological improvement was observed in 25 patients and surgical mortality rate was less than 5%. The median survival time for all patients was 8 months. When patients with multiple cerebral metastases were excluded the median survival time was 13 months. The 3- and 5-year survival was 25% and 15%, respectively. Seventeen patients with extracerebral metastases received treatment and were without known extracerebral tumor at the time of brain metastases diagnosis. These patients had a median survival time that did not significantly differ from those without occurrence of extracerebral metastases. Quality of life as judged by Karnofsky index was improved after surgery and maintained on an acceptable level for the remaining time of survival.

Influence of degradable starch microspheres (Spherex) on the retention of pertechnetate in a solitary rat liver tumor.

In a model of secondary liver cancer in the rat an evaluation was made of the influence of degradable starch microspheres (Spherex) on the drug retention in tumor and liver tissue. Sodium pertechnetate was used as a drug model substance and was injected into the hepatic artery alone or with degradable starch microspheres (DSM) in a dose of 6 or 12 mg. The distribution of pertechnetate was measured by a gamma-camera equipped with a high resolution collimator. In rats with liver tumor the total elimination of pertechnetate from the liver was delayed when compared to rats without tumor. The tumor concentration of pertechnetate was higher than that of the surrounding liver tissue, irrespective of the presence of DSM. With a DSM dose of 12 mg there was a significantly higher retention of pertechnetate in the tumor during the whole observation period compared to pertechnetate only. The results of this study indicates that DSM can be of value in regional liver chemotherapy to increase liver tumor drug exposure and to reduce systemic toxicity.

Potentiation by dipyridamole of 5-fluorouridine antitumor activity against a rat adenocarcinoma in vivo.

Rats were inoculated subcutaneously into both flanks with a transplantable adenocarcinoma of the colon. They were treated intravenously with either 5-FUrd (5-fluorouridine) or 5-FdUrd (5-fluoro-2'-deoxyuridine) with or without addition of dipyridamole 20 and 30 min later, respectively, for 3 consecutive days. Dipyridamole improved the antitumor activity of 5-FUrd but decreased that of 5-FdUrd.

Estrogen receptor and binding site for estramustine in metastatic malignant melanoma.

Enzyme immuno assay (EIA) of estrogen receptor (ER) has confirmed the results of earlier investigations using steroid binding techniques, namely that ER is present at very low concentrations in samples from metastatic melanoma. Thirty-four of 61 samples (56%) were ER positive with EIA. The corresponding figures using isoelectric focusing (IF) for the steroid binding assay were 16 of these 61 samples (26%). The difference between the methods may be due to difficulties in the interpretation of analytical results for IF at low ER concentration levels or to interference from other 3H-estradiol binding components. Estramustine binding site (EMBS) has been found in samples from 15 of 77 patients (20%) with IF in polyacrylamide gels. Estramustine is, together with estramustine, the cytotoxic metabolite of estramustine phosphate (Estracyt). In analogy to the previously suggested therapeutic significance of estramustine binding protein in the treatment of prostatic cancer, the clinical importance of estramustine phosphate should also be studied in metastatic malignant melanoma in correlation with EMBS status.

Weekly dose adriamycin as first line chemotherapy in advanced breast cancer.

Weekly dose Adriamycin was given prospectively as first line chemotherapy in a phase II study including 76 patients with evaluable advanced breast cancer. The response rate (CR+PR) was 24 percent (18/76) and a further 41 per cent (31/76) of the patients achieved stable disease (NC). Mean time to progression for responders was 17 months and for those with stabilized disease 10 months. Mean time to progression for all patients was 8.8 months and overall mean survival time 16 months (2-55+). Side effects were well tolerable; myelosuppression was registered in 27 percent and alopecia requiring a wig in 24 percent. In three patients cardiotoxicity was registered after 1,190 mg, 1,480 mg and 1,780 mg respectively. This low dose regimen seems effective and well comparable regarding time to progression with multidrug regimens, including doxorubicin.

Estrogen and progesterone receptors in melanoma metastases with special reference to analytical methods and prognosis.

Fifty-one tumor biopsies from 33 patients with metastatic melanoma were assessed for estrogen receptor (ER) content, and 46 of these for progesterone receptor (PgR) content in the cytoplasm. ER posivity (above 0.2 fmol/mg protein), as measured with isoelectric focusing on polyacrylamide gels, was found in 23 (70%) of the patients (range 0.2 - 14 fmol/mg protein). With a reference limit of 2 fmol ER/mg protein, 12 patients were positive (36%). PgR was analysed with the dextran coated charcoal technique and no sample demonstrated any positivity with certainty. The ER content was related to clinical prognostic factors without any significant correlation independent of reference limit used. A correlation to survival can not be excluded with ER values above 2 fmol/mg. Pertinent data are given regarding the technique used in comparison with others.