Factor In Node-negative Breast Cancer Research Articles

Positive estrogen receptor status is a poor prognostic factor in node-negative breast cancer: An observational study in Asian patients.

This study evaluated the outcomes and prognostic factors for breast cancer according to initial lymph node (LN) status. Among patients with LN-negative breast cancer, we also focused on the prognostic value of estrogen receptor (ER) status.Medical records were retrospectively reviewed for 715 patients who underwent curative surgery for breast cancer between January 2005 and December 2015 at a single Korean institution. We evaluated factors that were associated with metastasis-free survival (MFS) according to LN status.Among the 715 patients (age: 28–87 years), 458 patients (64.1%) did not have axillary LN metastasis. Relative to patients without LN metastasis, patients with LN metastasis had larger tumor sizes and higher histological grades. Among patients with no LN metastasis, ER positivity was associated with non-significantly poorer MFS than ER negativity (mean survival: 138.90 months vs. 146.99 months, p = .17), and patients with LN-negative ER-positive disease had MFS rates of 91.7% at 5 years and 74.5% at 10 years. Among patients with LN-negative ER-positive disease, a poor prognosis was significantly associated with larger tumor size (≥2 cm, P = .03) and older age (≥50 years, P = .03).These results indicate that the risk of metastasis increases over time for patients with LN-negative ER-positive breast cancer, and especially for older patients or patients with larger tumors.

Abstract 4561: Dissecting mechanisms of CART signalling through the estrogen receptor in ER+ breast cancer

Abstract The cocaine- and amphetamine-regulated transcript (CART) was first discovered as a peptide up-regulated by the administration of cocaine and amphetamine to rats. CART peptides are involved in regulating physiological processes, such as feeding, reward and neuro-protection. However, recent studies have associated high CART expression with worse overall survival in patients with small-bowel carcinoid tumours [1] and estrogen receptor-positive (ER+), lymph node-negative breast cancer [2]. Interestingly, in ER+ breast cancer, CART was also shown to be associated with poor patient response to tamoxifen, suggesting CART may play a role in conferring tamoxifen resistance [2]. The aim of this study was to elucidate the mechanism(s) by which CART signals in ER+ breast cancer. In order to test whether CART could mediate the ligand-independent activation of ER-alpha, MAP-Kinase pathway activation and levels of downstream gene-targets of ER-alpha were assessed post CART stimulation. Additionally, the ability of CART to activate ER-alpha using three LXD motifs (nuclear receptor co-activator recognition motifs) present within the CART sequence was also assessed. This was achieved through selectively mutating these motifs and testing whether CART still possessed the ability to activate ER-alpha using an ERE-Dual luciferase reporter assay. Treatment of cells with CART demonstrated an increase in MAP-Kinase activity through the detection of increasing phosphorylated ERK levels. An increase in the phosphorylation of ER-alpha at serine 118 (a phosphorylation site thought to be involved in tamoxifen resistance) was also evident following CART stimulation. CART stimulation also resulted in an increase in levels of the progesterone receptor, a known ER-alpha gene target. Mutagenesis of each LXD motif within CART resulted in significant decreases in ER-alpha activity, suggesting a potential structure-function relationship between CART and ER-alpha. In conclusion, we suggest that CART can activate ER-alpha in a ligand-independent manner through the MAP-Kinase pathway, and also potentially through specific LXD motifs within its sequence. Further investigation into the relationship between CART and ER-alpha will help us gain a better understanding of, not only the potential structure-function relationship between CART and ER-alpha, but also the role CART plays with regards to tamoxifen resistance in ER+ breast cancer. [1] Landerholm K et al., Expression of cocaine- and amphetamine-regulated transcript is associated with worse survival in small bowel carcinoid tumors. Clin Cancer Res. 2012 Jul 1;18(13):3668-76 [2] DJ Brennan, DP O’Connor et al., The cocaine- and amphetamine-regulated transcript mediates ligand-independent activation of ERα, and is an independent prognostic factor in node-negative breast cancer. Oncogene 2011 Dec 5. Doi: 10.1038/onc.2011.519 Citation Format: Brian Mooney, Sudipto Das, Rut Klinger, William Gallagher, Darran O’Connor. Dissecting mechanisms of CART signalling through the estrogen receptor in ER+ breast cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4561.

Prognostic Influence of Pre-Operative C-Reactive Protein in Node-Negative Breast Cancer Patients

The importance of inflammation is increasingly noticed in cancer. The aim of this study was to analyze the prognostic influence of pre-operative serum C-reactive protein (CRP) in a cohort of 148 lymph node-negative breast cancer patients. The prognostic significance of CRP level for disease-free survival (DFS), metastasis-free survival (MFS) and overall survival (OS) was evaluated using univariate and multivariate Cox regression, also including information on age at diagnosis, tumor size, tumor grade, estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status, proliferation index (Ki67) and molecular subtype, as well as an assessment of the presence of necrosis and inflammation in the tumor tissue. Univariate analysis showed that CRP, as a continuous variable, was significantly associated with DFS (P = 0.002, hazard ratio [HR] = 1.04, 95% confidence interval [CI] = 1.02–1.07) and OS (P = 0.036, HR = 1.03, 95% CI = 1.00–1.06), whereas a trend was observed for MFS (P = 0.111). In the multivariate analysis, CRP retained its significance for DFS (P = 0.033, HR = 1.01, 95% CI = 1.00–1.07) as well as OS (P = 0.023, HR = 1.03, 95% CI = 1.00–1.06), independent of established prognostic factors. Furthermore, large-scale gene expression analysis by Affymetrix HG-U133A arrays was performed for 72 (48.6%) patients. The correlations between serum CRP and gene expression levels in the corresponding carcinoma of the breast were assessed using Spearman's rank correlation, controlled for false-discovery rate. No significant correlation was observed between CRP level and gene expression indicative of an ongoing local inflammatory process. In summary, pre-operatively elevated CRP levels at the time of diagnosis were associated with shorter DFS and OS independent of established prognostic factors in node-negative breast cancer, supporting a possible link between inflammation and prognosis in breast cancer.

Expression of the hypoxia-inducible monocarboxylate transporter MCT4 is increased in triple negative breast cancer and correlates independently with clinical outcome

Background18Fluor-deoxy-glucose PET-scanning of glycolytic metabolism is being used for staging in many tumors however its impact on prognosis has never been studied in breast cancer. MethodsGlycolytic and hypoxic markers: glucose transporter (GLUT1), carbonic anhydrase IX (CAIX), monocarboxylate transporter 1 and 4 (MCT1, 4), MCT accessory protein basigin and lactate-dehydrogenase A (LDH-A) were assessed by immunohistochemistry in two cohorts of breast cancer comprising 643 node-negative and 127 triple negative breast cancers (TNBC) respectively. ResultsIn the 643 node-negative breast tumor cohort with a median follow-up of 124months, TNBC were the most glycolytic (≈70%), followed by Her-2 (≈50%) and RH-positive cancers (≈30%). Tumoral MCT4 staining (without stromal staining) was a strong independent prognostic factor for metastasis-free survival (HR=0.47, P=0.02) and overall-survival (HR=0.38, P=0.002). These results were confirmed in the independent cohort of 127 cancer patients. ConclusionGlycolytic markers are expressed in all breast tumors with highest expression occurring in TNBC. MCT4, the hypoxia-inducible lactate/H+ symporter demonstrated the strongest deleterious impact on survival. We propose that MCT4 serves as a new prognostic factor in node-negative breast cancer and can perhaps act soon as a theranostic factor considering the current pharmacological development of MCT4 inhibitors.

The cocaine- and amphetamine-regulated transcript mediates ligand-independent activation of ERα and is an independent prognostic factor in node-negative breast cancer

The cocaine- and amphetamine-regulated transcript mediates ligand-independent activation of ERα and is an independent prognostic factor in node-negative breast cancer

The cocaine- and amphetamine-regulated transcript mediates ligand-independent activation of ERα, and is an independent prognostic factor in node-negative breast cancer

Personalized medicine requires the identification of unambiguous prognostic and predictive biomarkers to inform therapeutic decisions. Within this context, the management of lymph node-negative breast cancer is the subject of much debate with particular emphasis on the requirement for adjuvant chemotherapy. The identification of prognostic and predictive biomarkers in this group of patients is crucial. Here, we demonstrate by tissue microarray and automated image analysis that the cocaine- and amphetamine-regulated transcript (CART) is expressed in primary and metastatic breast cancer and is an independent poor prognostic factor in estrogen receptor (ER)-positive, lymph node-negative tumors in two separate breast cancer cohorts (n=690; P=0.002, 0.013). We also show that CART increases the transcriptional activity of ERα in a ligand-independent manner via the mitogen-activated protein kinase pathway and that CART stimulates an autocrine/paracrine loop within tumor cells to amplify the CART signal. Additionally, we demonstrate that CART expression in ER-positive breast cancer cell lines protects against tamoxifen-mediated cell death and that high CART expression predicts disease outcome in tamoxifen-treated patients in vivo in three independent breast cancer cohorts. We believe that CART profiling will help facilitate stratification of lymph node-negative breast cancer patients into high- and low-risk categories and allow for the personalization of therapy.

A New Look at Node-Negative Breast Cancer

Node-negative breast cancer is a prevalent form of the disease worldwide, particularly in regions with rigorous screening and disease awareness efforts. Although there is a common biology between node-negative and node-positive breast tumors, it is still important to specifically address risk assessment and predictive factors in node-negative breast cancer. The relative risks and benefits are more pronounced in these patients, but there is no single prognostic factor available for deciding whether to administer chemotherapy and selecting the best adjuvant chemotherapy regimen. In the absence of universal predictive factors, the trend is to give chemotherapy to all patients to ensure the highest possibility for cure. Tumor grade is important in that it is predictive of risk over time, but lacks standardization. Adjuvant! Online, a web-based algorithm, is also used to guide treatment decisions. Recently, the urokinase-type plasminogen activator (uPA) and plasminogen activator inhibitor type 1 (PAI-1) biomarkers have been used to determine disease risk and, consequently, determine whether or not chemotherapy is needed. However, the assay requires a fresh-frozen tissue sample, which is not always feasible. The oncotype DX® genomic assay has also been used to help prognosis estimation and treatment decisions. It is currently under evaluation in conjunction with the uPA/PAI-1 assay in the Plan B trial. The question that remains in adjuvant chemotherapy today for patients with node-negative disease is proper patient selection. Node-negative breast cancer does not automatically suggest a good prognosis, or the preclusion of chemotherapy benefits, and additional biomarkers are needed to help identify patients who do benefit from chemotherapy.

A New Look at Node-Negative Breast Cancer

Node-negative breast cancer is a prevalent form of the disease worldwide, particularly in regions with rigorous screening and disease awareness efforts. Although there is a common biology between node-negative and node-positive breast tumors, it is still important to specifically address risk assessment and predictive factors in node-negative breast cancer. The relative risks and benefits are more pronounced in these patients, but there is no single prognostic factor available for deciding whether to administer chemotherapy and selecting the best adjuvant chemotherapy regimen. In the absence of universal predictive factors, the trend is to give chemotherapy to all patients to ensure the highest possibility for cure. Tumor grade is important in that it is predictive of risk over time, but lacks standardization. Adjuvant! Online, a web-based algorithm, is also used to guide treatment decisions. Recently, the urokinase-type plasminogen activator (uPA) and plasminogen activator inhibitor type 1 (PAI-1) biomarkers have been used to determine disease risk and, consequently, determine whether or not chemotherapy is needed. However, the assay requires a fresh-frozen tissue sample, which is not always feasible. The oncotype DX® genomic assay has also been used to help prognosis estimation and treatment decisions. It is currently under evaluation in conjunction with the uPA/PAI-1 assay in the Plan B trial. The question that remains in adjuvant chemotherapy today for patients with node-negative disease is proper patient selection. Node-negative breast cancer does not automatically suggest a good prognosis, or the preclusion of chemotherapy benefits, and additional biomarkers are needed to help identify patients who do benefit from chemotherapy.

The prognostic value of Ki67 is dependent on estrogen receptor status and histological grade in premenopausal patients with node-negative breast cancer

The aim of this study was to evaluate the prognostic value of Ki67 in relation to established prognostic factors in lymph node-negative breast cancer, and furthermore, whether the prognostic impact was dependent on estrogen receptor (ER) status and histological grade. In 200 premenopausal patients, with 5 years of follow-up, Ki67 was determined on tissue microarrays. In univariate analysis, Ki67 (≤20 vs >20%) was a prognostic factor for distant disease-free survival (hazard ratio: 2.7, 95% confidence interval: 1.3–5.4, P=0.005) and overall survival (hazard ratio: 4.9, 95% confidence interval: 1.7–14, P=0.003). When stratifying for ER status and histological grade, Ki67 was a significant prognostic factor for distant disease-free survival and overall survival only in the ER-positive group, and only in patients with histological grade 2, respectively. In multivariate analysis, human epidermal growth factor receptor 2 and age were independent prognostic factors for distant disease-free survival, whereas Ki67, histological grade, and tumor size were not. Ki67 was, however, an independent prognostic factor in the 87% of the patients who had not received adjuvant medical treatment. Agreement between the three readers was very good (κ-values: 0.83–0.88). Furthermore, Ki67 was a significant prognostic factor for all three investigators (hazard ratio: 2.7–3.2). This study shows that Ki67 is a prognostic factor in node-negative breast cancer. It is noteworthy that the prognostic information of Ki67 is restricted to ER-positive patients, and to patients with histological grade 2. Taken together, Ki67, as an easily assessed and reproducible proliferation factor, may be an alternative or complement to histological grade as a prognostic tool and for selection of adjuvant treatment.

Low number of examined lymph nodes in node-negative breast cancer patients is an adverse prognostic factor

The aim of the study was to determine whether the number of lymph nodes removed at axillary dissection is associated with recurrence and survival in node-negative breast cancer (NNBC) patients. We retrospectively reviewed the medical records of 1606 women with pathologically node-negative T1-T3 invasive breast cancer. Median follow-up was 61 months (range 2-251). Potential prognostic factors assessed included: number of axillary lymph nodes examined, age, menopausal status, tumor size, histological type, tumor grade, estrogen receptor(ER), progesterone receptor (PR) and HER2. At 5 years, relapse-free survival (RFS) rate was 85% and breast cancer-specific survival (BCSS) rate was 94%. In univariate analysis, factors significantly associated with lower RFS and BCSS were: fewer than six lymph nodes examined (RFS, P = 0.01; BCSS, P = 0.007), tumor size >2 cm, grade III, negative ER or PR. Statistically significant factors for lower RFS and BCSS in multivariate analysis were: fewer than six lymph nodes examined [RFS, hazard ratio (HR) 1.36, P = 0.029; BCSS, HR 1.87, P = 0.005], tumor size >2 cm, tumor grade III and negative PR. Examination of fewer than six lymph nodes is an adverse prognostic factor in NNBC because it could lead to understaging. Six or more nodes need to be examined at axillary dissection to be confident of a node-negative status. This may be useful, in conjunction with other prognostic factors, in the assessment of NNBC patients for adjuvant systemic therapy.

Prognostic value of lymphovascular invasion in women with lymph node negative invasive breast carcinoma

This study aimed to test the hypothesis that lymphovascular invasion adds prognostic information to histological grade and tumour size in node-negative invasive carcinoma of the breast. Lymphovascular invasion was assessed in haematoxylin and eosin tumour sections from 2760 patients with node-negative invasive breast carcinoma treated with definitive surgery. Patients were divided into two groups: 990 in the no adjuvant therapy series (diagnosed in 1974-1988) with median follow-up of 13 years; and 1765 in the selective adjuvant therapy series (1988-2000) with median follow-up of 6.8 years. Lymphovascular invasion was identified in 19% of tumours and was associated with larger tumour size, higher histological grade and younger age. Overall, survival was associated on multivariate analysis with lymphovascular invasion, histological grade and tumour size in both patient series, and with histological type in the no adjuvant therapy series. In conclusion, lymphovascular invasion is an independent prognostic factor in node-negative breast cancer and should be considered in decisions about adjuvant treatment in this group of women.

Natural history of node-negative breast cancer: are conventional prognostic factors predictors of time to relapse?

The purpose of this study was to determine a subpopulation of node-negative breast cancer patients at high risk of metastases and to analyse the relationship between conventional prognostic factors and the onset of metastatic disease. Patients with node-negative breast cancer, who were not receiving systemic adjuvant therapy, were prospectively enrolled into a multicentre study. We studied the onset of metastatic disease in relation to family history, age, and tumour characteristics of 2683 registered patients, 2213 were available for analysis. Median follow-up was 100 months. Metastatic disease-free survival was 88% at 5 years and 80% at 10 years. The two strongest prognostic factors in a multivariate analysis tumour Scraff, Bloom and Richardson (SBR) grade ( P<0.0001) and size ( P<0.02), were used to classify patients into three groups with different risks of relapse at 10 years: (1) lowest (8.4%) risk: SBR I and ≤1 cm; (2) intermediate (20%) risk: SBR I and >1 cm or SBR II or SBR III and ≤2 cm; (3) highest (32%) risk: SBR II or SBR III and >2 cm. A peak in the incidence of metastases was noted between 2 and 4 years, and a nadir between 6 and 8 years, after surgery. SBR grade is a highly predictive factor in node-negative breast cancer. The time course of the appearance of metastases is not linear. Prognostic factors are related to the height of an early peak in the occurrence of metastases rather than to the timing of this peak.

P53 determination alongside classical prognostic factors in node-negative breast cancer: An evaluation at more than 10-year follow-up

There is heterogeneity of methods and conflicting results concerning the prognostic value of p53 in node-negative breast cancer. The clinical value of a quantitative method for measuring tumoralp53 content still needs to be evaluated. A long-term retrospective study was conducted on 297 node-negative patients with a median follow-up greater than 10 years (11 years, 101-172 months). Classic prognostic factors were considered including age, tumor size, histoprognostic grade and estradiol (ER) and progesterone receptors (PR). In addition, the value of p53 determination (immunoluminometric assay in tumor cytosol) was assessed for this long follow-up period. p53 concentrations were significantly linked to the histological grade (P = 0.001), to tumor size (P = 0.02) and ER status (P = 0.01). Higher p53 tumoral concentrations were found in tumors with large size, pejorative histological grade and negative ER status. In contrast, p53 tumoral concentrations were not influenced by menopausal or PR status. Multivariate Cox analysis demonstrates that tumor size was the only significant predictor of disease-free survival (P = 0.049) with a risk factor at 1.38. As regards specific survival, univariate Cox analysis indicates that p53 taken as a continuous variable is a significant predictor (P = 0.024) together with histological grade, tumor size and ER status. In a multivariate Cox analysis there were two significant and independent variables for predicting overall survival: tumor size (P = 0.031) and, ER status (P = 0.015) with the highest risk factor (RR = 2.14). The present investigation points out that the prognostic power of p53 tumor determination evaluated at more than 10 years median survival is not higher than the well-recognized classic prognostic factors in node-negative breast cancer. The present data highlight the need to assess the prognostic value of potentially new biological factors in node-negative breast cancer on cohorts of patients followed over periods in excess of 10 years.

Do we need better prognostic factors in node-negative breast cancer?: Pro:

Do we need better prognostic factors in node-negative breast cancer?: Pro:

Co-determination of the angiogenic factors thymidine phosphorylase and vascular endothelial growth factor in node-negative breast cancer: prognostic implications.

Experimental and clinical studies have shown that human breast cancer is an angiogenesis-dependent neoplasm. In fact, several authors have demonstrated that the determination in primary tumors of the degree of vascularization (microvessel counts) as well as of some angiogenic peptides is of prognostic value. However, which are the most important mediators of angiogenesis and their relationship with other relevant biological markers needs further investigation. In the series of 260 women with node-negative breast cancer (NNBC) on which we previously assessed vascular endothelial growth factor (VEGF), we have now also determined thymidine phosphorylase (TP) protein as well as p53 protein and Cathepsin-D cytosolic levels using immunometric methods. The median concentrations of TP, p53 and Cathepsin-D were 105.4U/mg (range 1.2-843.1), 0.22 ng/mg (range 0.0-41.65) and 33.80nmol/mg (range 4.20-216.0), respectively. We found that TP concentrations were associated with Cathepsin-D and p53, but not with VEGF. VEGF (p<0.0001) and p53 (p = 0.03 and p = 0.012, respectively) were found to be statistically significant prognostic variables for both relapse-free survival (RFS) and overall survival in univariate analysis. Conversely, TP and Cathepsin-D levels did not correlate with prognosis. In multivariate analysis for RFS, VEGF levels (p<0.0001), TP levels (p = 0.050) and their first-order interaction terms (p = 0.027) were statistically significant prognostic indicators. Cathepsin-D and p53 protein levels did not retain significance in the model inclusive of all the above variables. The predictive capability of the complete model was satisfactory (Harrell c statistic = 0.72). Moreover, these results suggest a possible potentiation of the capability of predicting the likelihood of recurrence by the co-determination of TP and VEGF. The probability of recurrence was particularly high in the patients with primary tumors characterized by elevated levels of both angiogenic factors. This is the first study showing in vivo that two different angiogenic peptides concur in the progression of human breast cancer. The biology and possible therapeutic implications of this observation are discussed.

Prognostic significance of microvessel density in lymph node negative breast carcinoma

We evaluated the prognostic value of tumor angiogenesis in node negative breast cancer (NNBC). Paraffin-embedded tissues from 87 patients with NNBC were immunostained for factor VIII-related antigen, using one tissue block representative of the invasive edge of the tumor. Sections were scanned at low power to identify “hotspots” of angiogenesis. Microvessel (MV) counts were performed at X200 magnification, using a grid eyepiece graticule. Within each hot spot, three fields (area of field = 0.22 mm 2) were counted and averaged. The highest average for a hot spot and the highest single field value was recorded for each case. Patients were stratified into low and high MV groups and their survival compared. There were no differences in disease-free or overall survival between the two groups whether the highest average or the highest single value was used. Microvessel counts did not correlate with other prognostic features, ie, grade, size, estrogen receptor status, c-erb B-2 or accumulated P53 status. Because of the difficulty in assessing angiogenesis that is heterogenous throughout tumors, MV counting may not be suitable for clinical use as a prognostic factor in NNBC. This problem could be addressed in a prospective study involving more extensive tumor sampling.

664 Flow cytometrically determined S-phase fraction is a stronger prognostic factor in node-negative breast cancer than immunohistochemically detected MIB1 (KI-67)

The proliferation markers, S-phase fraction (SPF) and MIB1, were evaluated in 90 primary node-negative breast carcinomas. SPF was determined flow cytometrically using an improved Hedley protocol for release of pure nuclei from formalin-fixed, paraffin-embedded sections. SPF analysis was performed using the ModFit software program (Verity, Maine, U.S.A.). MIB1 immunostaining (Dianova, Hamburg, Germany) was performed on adjacent paraffin sections using APAAP. The percentage of MIB1 positive cells was calculated in 500 randomly chosen tumor cells. Median follow-up was 34 (9–72) months. An optimal cutoff of 8% SPF was found using isotonic regression analysis: 61 (68%) tumors had low (≤ 8%) and 29 (32%) high (> 8%) SPF. The optimal cutoff for MIB1 was 25%: 75 (83%) tumors had a low (≤ 25%) and 15 (17%) a high (> 25%) MIB1 staining percentage. MIB1 was significantly correlated to grading (P = 0.018) and medullary histological tumor type (P

Defining a high mortality risk group among women with primary breast cancer

Increasing interest has been focused on DNA ploidy, hormone receptor status and tumour size as prognostic factors in node-negative breast cancer. We analysed these factors in patients operated on for primary invasive breast cancer between January 1981 and December 1987 in a prospective study of 248 women with no involved axillary nodes and 188 women with positive nodes followed until 15 April 1989. Oestrogen or progesterone receptor negativity, aneuploidy and tumour diameter exceeding 20 mm were studied as negative prognostic signs in life table analyses and Cox proportional hazards models of corrected survival. Corrected survival decreased with increasing number of negative signs. Three to four signs yielded a statistically significant, two- to threefold higher risk than the others. Survival estimates by life table analyses differed by 20% at 5 years. In the whole group, women with three or four negative factors had a relative risk of dying from their disease more than twice that of the others. Women with no involved nodes and with three or four negative factors had a risk of dying from breast cancer similar to that of node-positive women with fewer than three.

Urokinase (uPA) and its inhibitor PAI-1 are strong and independent prognostic factors in node-negative breast cancer.

Evidence has accumulated that invasion and metastasis in solid tumors require the action of tumor-associated proteases, which promote the dissolution of the surrounding tumor matrix and the basement membranes. The serine protease urokinase-type plasminogen activator (uPA), which is elevated in solid tumors, appears to play a key role in these processes. We used enzyme-linked immunoassays (ELISA) to test for uPA antigen and its inhibitor PAI-1 in tumor tissue extracts of 247 breast cancer patients who were enrolled in a prospective study. The relation of these data to known prognostic factors and to other variables such as DNA analysis and cathepsin D was studied. Disease-free and overall survival were analyzed according to Cox's proportional hazard model. The major new finding is that breast cancer patients with either high uPA (> 2.97 ng/mg protein) or high content of the uPA inhibitor PAI-1 (> 2.18 ng/mg protein) in their primary tumors have an increased risk of relapse and death. Multivariate analyses revealed uPA to be an independent and strong prognostic factor. The impact of uPA is as high as that of the lymph node status. In node-negative patients the impact of uPA is closely followed by that of PAI-1. Since uPA and PAI-1 are independent prognostic factors, the node-negative patients could be subdivided further by combining these two variables. In this refined analysis, patients whose primary tumors have lower levels of both antigens evidently have a very low risk of relapse (93% disease-free survival at three years) in contrast to patients with high uPA and high PAI-1 (55% disease-free survival at three years). The combination of uPA and PAI-1 in our group of patients with axillary node-negative breast cancer allows us to identify the 45 percent of patients having an increased risk of relapse. Consequently, more than half of the patients had less than a 10% probability of relapse and thus would possibly be candidates for being spared the necessity of adjuvant therapy.

Prognostic Factors in Node-Negative Breast Cancer

One hundred patients with node-negative breast cancer were examined to analyze the influence of tumor size, nuclear grade, and DNA content determined by flow cytometry on overall survival. Patients with diploid cancers lived significantly longer than those with aneuploid cancers (126 +/- 8 vs 80 +/- 11 months). Patients with an S-phase fraction less than 10% lived significantly longer than those with S-phase fractions 10% or greater (122 +/- 8 vs 85 +/- 10 months). Tumor size had the major impact on survival, and multivariate analysis of variance by the Cox proportional hazards model showed the greatest effect on prognosis. Tumor grade did not significantly influence overall survival.