Node-positive Breast Carcinoma Research Articles

Bcl‐2 and apoptosis in lymph node positive breast carcinoma

bcl‐2 and apoptosis in lymph node positive breast carcinoma

A prospective study of the significance of gene and chromosome alterations as prognostic indicators of breast cancer patients with lymph node metastases

In 150 surgically resected primary breast carcinomas that had axillary lymph-node metastases, we examined the incidence of loss of heterozygosity on chromosomes 16p, 16q, 17p, 17q, and 18q, point mutation of the p53 tumor-suppressor gene, nuclear immunoreaction of p53 protein, and amplifications of the c-erbB-2 and int-2 oncogenes by Southern blotting, single-strand conformation polymorphism analysis, and immunohistochemistry. We analyzed the association of these factors and conventional prognostic parameters with outcome of the patients, using Cox's univariate and multivariate analyses. The univariate analysis revealed that nuclear p53 immunoreaction, p53 mutation, and c-erbB-2 amplification as well as the number of metastatic lymph nodes, histological grade, and hormone-receptor statuses were significant prognostic indicators for both recurrence and cancer death. p53 immunoreaction was correlated more strongly with a poor prognosis than p53 mutations. The combination of p53 and c-erbB-2 effectively identified the high-risk patient group, and even among Grade 3 cases the subgroup with these alterations tended to have poorer clinical outcomes. The multivariate analysis including p53, c-erbB-2, and conventional factors. Lymph node status, grade, and p53 had independent impacts on the survival of patients. Under identical adjuvant systemic therapies, prognoses differed between the patient groups with and without alterations of p53 or c-erbB-2. Appropriate combinations of conventional factors with nuclear p53 immunoreaction and c-erbB-2 amplification would help to identify highly aggressive node-positive breast carcinomas and would aid stratification of patient groups in randomized clinical trials of adjuvant systemic therapies.

Relationship of elevated tumour thymidine phosphorylase in node-positive breast carcinomas to the effects of adjuvant CMF

Thymidine phosphorylase (TP) catalyses the reversible phosphorylation of thymidine to thymine and 2-deoxyribose-1-phosphate. High expression of TP in cell lines potentiates the effects of the cytotoxic drugs 5-fluorouracil and methotrexate, both of which are used in the cyclophosphamide, 5-fluorouracil and methotrexate (CMF) treatment regimen of breast cancer. We therefore examined the expression of this enzyme in 328 invasive breast carcinomas using immunohistochemistry and assessed whether the expression of this enzyme by the tumour predicts patients response to CMF in node-positive patients. Whereas no significant difference in either relapse-free survival (RFS) (P = 0.2) or overall survival (OS) (P = 0.07) was observed between TP-negative and -positive tumours in non-treated patients, there was a significant increase in both RFS (P = 0.02) and OS (P = 0.02) in patients treated with CMF in TP-positive compared with TP-negative tumours. A multivariate analysis of the 134 node-positive patients demonstrated that in ductal carcinomas, TP was an independent variable for OS. This pilot study suggests that patients with TP-positive tumours have a significant survival benefit when treated with CMF and supports the hypothesis that TP enhances tumour sensitivity to the anti-metabolites 5-fluorouracil and methotrexate.

Infiltrating Ductal Carcinoma of the Vulva

The eleventh case of primary infiltrating ductal carcinoma of the vulva is reported with a review of the literature. The infiltrating tumor is associated with an intraductal component as well as noninvolved mammary-like glandular tissue (ectopic breast tissue) and metastases to inguinal lymph nodes. Estrogen receptor and progesterone receptor immunohistochemical staining is negative utilizing the HSCORE method. The treatment regimen is patterned after approach to node-positive breast carcinoma.

Clinical significance of cyclin D1 expression in patients with node-positive breast carcinoma treated with adjuvant therapy

Experimental and clinical studies suggest that cyclin D1 is involved in transformation and tumour progression. However, there is little and contradictory data on the clinical significance of cyclin D1 in human invasive breast carcinoma. We investigated whether the determination of cyclin D1 has prognostic value in a series of 180 patients with node-positive breast carcinoma and treated with adjuvant therapy with a median follow-up exceeding 6 years. We assessed cyclin D1 expression using the CDS-6 monoclonal antibody and a highly sensitive immunohistochemical technique. We found that most of the evaluable tumours (117 of 167; 70.1%) presented nuclear cyclin D1 staining and that its expression was significantly associated with both the hormone receptors (P = 0.009 and P = 0.005 for ER and PgR, respectively). Furthermore, 29 (17%) of 167 tumours had a weak (15 cases) or strong (9 cases) cytoplasmic cyclin D1 staining. In a subgroup of cases we also studied the amplification of the cyclin D1 gene and a moderate agreement between cyclin D1 nuclear overexpression assessed immunohistochemically and the gene amplification was found. In univariate analysis, cyclin D1 nuclear positivity was significantly associated with improved 6-year relapse-free survival (RFS) (P = 0.004), but not with overall survival (OS) (P = 0.12). The results of the Cox multivariate analysis (final model) indicate that cyclin D1 expression (P = 0.0049) as well as the number of involved nodes (P < 0.001) and tumour size (P = 0.036) are significant prognostic indicators for RFS. Only the number of involved nodes retained significance (P < 0.001) for OS in our series. The joint assessment of the variables considered in the final model of the multivariate analyses had a moderate prognostic capability as determined using the Harrell c statistic (c = 0.66 and 0.64 for RFS and OS, respectively). The patients with node-positive breast cancer who have a higher likelihood of gaining benefit from adjuvant therapy are those with tumours with cyclin D1 nuclear expression, small size and less than 3 metastatic nodes. Further studies are needed to verify the prognostic value of cyclin D1 in relation to different adjuvant treatments and to deepen the biological pathways that regulate its activation/ suppression in human breast carcinoma.

Comparison of estrogen receptor determinations by a biochemical ligand‐binding assay and immunohistochemical staining with monoclonal antibody ER1D5 in females with lymph node positive breast carcinoma entered on two prospective clinical trials

BACKGROUND The measurement of estrogen receptors (ER) in breast cancer specimens has traditionally been assessed with a dextran-coated charcoal assay (DCCA). More recently the immunohistochemical staining (IHC) method has gained increasing popularity because of its ability to use fixed tissue, assess needle biopsies, and reduce cost. Controversy exists over the accuracy of IHC compared with that of DCCA in determining ER. We compared these two techniques using tumor tissue obtained from a large group of females with lymph node positive breast carcinoma with long term follow-up. METHODS Breast carcinoma tissue was obtained from a large group of females with node positive breast carcinoma participating in two adjuvant chemotherapy trials. ER was determined by the traditional DCCA method and by IHC using the ER1D5 antibody. Disease free survival (DFS) and overall survival (OS) were assessed by each of these methods. RESULTS ER status was determined by DCCA and IHC in tumor tissue obtained from 316 females. A concordance of 79% was observed for the determination of ER-positive tumors. Of the discordant results, the majority of DCCA-negative, IHC-positive tumors could be explained by a low level of DCCA positivity (<10 fmol) or IHC staining of nonmalignant cells. A much higher rate of discordant results was observed in premenopausal females. Of the DCCA-negative, IHC-positive patients 97% were premenopausal and of the DCCA-positive, IHC-negative patients 79% were premenopausal. ER by DCC appears to perform better than ER by IHC as a prognostic factor in terms of DFS and OS. CONCLUSIONS When compared with DCCA, IHC with monoclonal antibody ER1D5 appears to be a reasonable substitute for the determination of ER. Although DCCA appeared to perform better as a determinant of prognosis, ER detection is used primarily for deciding on hormonal therapy. Review of discordant cases indicates IHC may more accurately reflect the ER status of malignant cells in some patients. Attention must be paid to quality control considerations in performance of IHC staining. Cancer 1996;78:764-72.

Disease-free Survival of Node-positive Breast Cancer Patients: Improved Prognostication by Cytometrical Parameters

Feulgen stained cytologic samples from 225 node-positive breast cancers were investigated by means of an image analysis system. From each tumor sample, 100 cells were scanned and several DNA, morphometrical and textural parameters were evaluated. The meaning of the cytometric parameters for prediction of distant metastases within five years was investigated by the stepwise Cox regression analysis. Most of the investigated DNA- and morphometrical parameters, as well as one textural feature, showed a significant univariate correlation with the clinical course. In the multivariate approach, the lymph node status (pN) was the strongest prognostic factor, followed by the histogram type, the tumor size (pT) and a textural parameter (heterochromatin area). By the linear combination of these selected variables a multivariate prognostic factor was calculated for each individual patient. Using this factor, the patients could be splitted into four groups according to their risk for distant metastases. For this, the continuous range of the multivariate factor was subdivided so that about 35% of the patients were in the middle groups and about 15% of the patients in each of the border groups with highest and lowest factors, respectively. Thus a low risk group (lowest factors) of node-positive patients could be identified with a 5-year distant recurrence-rate of only 6.5%, as well as a group of patients with a considerably worse prognosis (highest factors) and a distant recurrence-rate of 67%. Therefore, DNA, morphometrical and textural parameters can provide powerful prognostic information in node-positive breast carcinomas. Using the multivariate combination of clinical and relevant cytometrical parameters may allow a more appropriate selection of patients for adjuvant therapy.

Apoptosis suppressing protein bcl-2 is expressed in well-differentiated breast carcinomas with favourable prognosis.

The expression of bcl-2 protein was analysed immunohistochemically in 202 female breast carcinomas. The intensity of bcl-2 expression was inversely related to tumour grade (P < 0.0001), tumor necrosis (P < 0.0001), mitotic index (P < 0.0001), oestrogen receptor content (P < 0.0001), progesterone receptor content (P = 0.0007), S-phase fraction (P = 0.00047), and apoptotic index (P = 0.087). A high fraction of bcl-2-positive cells was related to ductal or lobular type (P = 0.03) and slight nuclear pleomorphism (P = 0.03). Heterogeneous expression of bcl-2 protein was associated with high grade (P = 0.02), severe nuclear pleomorphism (P = 0.02), DNA aneuploidy (P = 0.018), high S-phase fraction (P = 0.05), and early metastasis (P = 0.03). Intense expression of bcl-2 protein was significantly related to favourable outcome in the entire cohort (P = 0.0013), as well as in axillary lymph node-negative (ANN) tumours (P = 0.0124). Long recurrence-free periods in the entire cohort (P = 0.037) and in ANN tumours (P = 0.08) were confined to cases with intense expression of bcl-2 protein. In multivariate analysis, bcl-2 expression had no independent prognostic value in the entire cohort or in axillary lymph node-negative breast carcinomas, whereas it was a weak independent prognostic factor in axillary lymph node-positive breast carcinomas.

Prognostic significance of heat-shock protein-27 in node-positive breast carcinoma: an immunohistochemical study

Immunostaining for heat-shock protein-27 (HSP-27) was performed on formalin fixed-paraffin embedded sections of 890 node-positive breast carcinomas resected between 1980 and 1986. The follow-up ranged from 2.5 to 10.5 years. A polyclonal antibody (Hu27, dilution: 1/200) was used. A positive cytoplasmic staining was obtained in 383 cases (43%). No difference in distant metastasis-free survival (DMFS) or overall survival (OS) was noted between cases with positive or negative immunostaining. This study suggests that HSP-27 expression is not predictive of the outcome in node-positive breast cancer.

Audit of Cancer and Leukemia Group B Data

To the Editor: One of the cases reported in our paper “Dose and Dose Intensity of Adjuvant Chemotherapy for Stage II, Node-Positive Breast Carcinoma” (May 5 issue)1 came from St. Mary's Hospital in Montreal, an institution that is reported to have provided false information to the National Surgical Adjuvant Breast and Bowel Project. The Cancer and Leukemia Group B (CALGB) audited data from this hospital on April 13 and 14, 1994. As part of this audit, the primary data on the case reported in the CALGB 8541 trial were carefully reviewed and compared with the research record. Although we are . . .

Dose and Dose Intensity of Adjuvant Chemotherapy for Stage II, Node-Positive Breast Carcinoma

Dose and Dose Intensity of Adjuvant Chemotherapy for Stage II, Node-Positive Breast Carcinoma

Prognostic significance of cathepsin-D expression in node-positive breast carcinoma: an immunohistochemical study.

The prognostic significance of cathepsin-D expression was evaluated by immunohistochemistry in 638 node-positive breast carcinomas diagnosed between 1980 and 1986. A minimum of 2.5 years of follow-up was available for each patient (maximum: 9.5 years). Cathepsin-D expression was assessed separately both in cancer and in stromal cells using a commercially available polyclonal antibody. While cancer-cell immunostaining was not associated with prognosis, positive staining of stromal elements was related to shorter metastasis-free survival. The difference in distant metastasis-free survival between positive and negative expressors was greatest in the sub-group of patients submitted to adjuvant chemotherapy, with a hazard ratio for occurrence of distant metastasis of 1.76 by multivariate analysis, but was lowest for those receiving hormone therapy. Cathepsin-D expression by stromal cells was related to HER-2/neu oncoprotein expression, HSP-27 expression, poor nuclear grade, aneuploidy, and absence of estrogen and progesterone receptors. No association was found with the number of involved lymph nodes, tumor size, age, histologic grade, S-phase fraction, or vascular invasion. Our study suggests that cathepsin-D expression by stromal cells (and not by cancer cells) affects the prognosis of breast cancer, that stromal cells probably play a key role in local invasion and metastatic dissemination of the tumor, and that the prognostic significance of cathepsin-D expression may vary according to the type of adjuvant therapy.

Pathologic correlates of prognosis in lymph node-positive breast carcinomas

Many pathologic features of breast carcinomas have been proposed as prognostic correlates; their interrelationships and their relative value as prognostic indicators were studied. A series of 399 axillary lymph node-positive infiltrating ductal breast carcinomas was studied histologically and compared with the patient prognosis. Many pathologic findings fit into two groups of closely related features--those related to the extent of local spread and those related to histologic anaplasia and mitotic count. Both groups correlated with the primary tumor size. The best predictors of long-term survival were measures of the extent of axillary metastasis (the number of axillary metastases, the size of the largest metastasis, and lymph node capsular invasion), which are components of the pathologic node stage. The mitotic count, tumor grade, primary tumor stage, smooth tumor border, tumor necrosis, and multifocal primary tumors were weaker but significant survival correlates. The mitotic count and Bloom-Richardson grade best predicted the survival time of patients with node-positive disease who died. Four years after diagnosis, less than 25% of the patients who would die of breast carcinoma in the low mitotic count and Bloom-Richardson Grade 1 (well differentiated) groups already had died; more than 75% of those in the high mitotic count and Bloom-Richardson Grade 3 (poorly differentiated) groups already had died. Among patients with small tumors (< 1.8 cm in diameter), those with one micrometastasis (1-2 mm) had a worse prognosis than those with uninvolved lymph nodes of similar size. The extent of axillary metastasis best predicted the long-term prognosis of patients with infiltrating ductal carcinoma and axillary metastases. The mitotic count and tumor grade best predicted the survival time of those who died.

Ploidy Analysis and S-Phase Fraction Determination by Flow Cytometry of Invasive Adenocarcinomas of the Breast

The results of flow cytometric analysis of ploidy and S-phase fraction for invasive breast cancers have been compared with various clinical and pathologic parameters by many investigators. Ploidy usually has been found to be associated with histologic type, tumor grade, and S-phase fraction values, but not with patient age, menopausal status, tumor size, axillary nodal status, estrogen receptor status, or progesterone receptor status. S-phase fraction values have correlated with histologic type, grade, estrogen receptor status, and progesterone receptor status, but not with menopausal status or axillary nodal status. Although in several studies ploidy and S-phase fraction have been compared with patient outcome, only a few of these reports have stratified data according to the histologic types and grades of the neoplasms. There is conflicting information regarding the value of ploidy analysis for women with either node-negative or node-positive breast carcinoma. Data from a few studies seem to indicate that S-phase fraction alone or in combination with ploidy may be more important prognostically than ploidy alone, although the results have not been uniform. More studies that examine ploidy, S-phase fraction, various important clinical and pathologic variables, and outcome for patients with invasive mammary cancer must be performed before the clinical importance of DNA analysis by flow cytometry becomes known.

Adjuvant chemohormonal therapy with cyclophosphamide, methotrexate, 5-fluorouracil, and prednisone (CMFP) or CMFP plus tamoxifen compared with CMF for premenopausal breast cancer patients. An eastern cooperative oncology group trial

The current trial was designed to assess whether the addition of prednisone or prednisone + tamoxifen would enhance the therapeutic effectiveness of 1 year of adjuvant CMF therapy. Premenopausal women with ipsilateral axillary node-positive breast carcinoma and known estrogen receptor (ER) status were randomized to receive 1 year of postoperative treatment with 12 28-day cycles of cyclophosphamide, methotrexate, 5-fluorouracil (CMF), CMF plus prednisone (CMFP), or CMFP plus tamoxifen (CMFPT). There were 553 analyzed cases with 188 receiving CMF, 183 CMFP, and 182 CMFPT. The overall time to relapse (TTR) and survival comparisons between the regimens are not statistically different at a median follow-up time of 7.7 years. The major subgroups currently with a suggestive TTR difference are greater than 3N+ (CMFPT greater than CMF, P = 0.07) and estrogen receptor-negative (ER-) greater than 3N+ (CMFPT greater than CMF, P = 0.03). Patients receiving CMFPT appeared to have a superior survival to CMF in the ER- greater than 3N+ cohort (P = 0.02). The following patient characteristics were associated with a significantly longer TTR: decreasing nodal involvement or tumor size, positive ER status, age greater than or equal to 40 years, and decreasing obesity. The favorable effects of decreasing nodal involvement, positive ER status, age 40 years or greater, and decreasing obesity carried over to survival. Development of amenorrhea was also significantly associated with improved survival (P = 0.001). Toxicity was increased by the addition of prednisone to CMF and by the addition of tamoxifen to CMFP. Overall relapse patterns were similar among the three regimens. The results of the current trial do not currently suggest an overall therapeutic benefit for adding prednisone or only 1 year of tamoxifen to CMF adjuvant treatment.

Significance of plasma retinol binding protein levels in recurrence of breast tumors in women.

Plasma retinol-binding protein (RBP), prealbumin, vitamin A (total) and beta-carotene levels were studied in premenopausal women with node-positive breast carcinoma receiving adjuvant chemotherapy. Plasma levels were measured prior to chemotherapy and at monthly intervals during the chemotherapy course. The results showed that significantly lower RBP levels during the course of the study were associated with early tumor recurrence. Patients who maintained a disease-free status for 24 months or longer had significantly higher plasma RBP levels than those who had tumor metastasis at distant sites within 24 months after beginning chemotherapy. RBP levels were not associated with adjuvant chemotherapy (CMF)-induced hormonal changes (amenorrhea vs. no amenorrhea), or family history of breast cancer. In contrast, breast cancer patients with a prior history of benign breast disease had significantly lower RBP levels than did healthy, premenopausal women. Reduced RBP levels in these patients are due to neither an inadequate dietary intake of beta-carotene, nor to severe protein malnutrition.

The changing pattern of recurrence in oestrogen positive and negative breast cancer with nodal spread, related to efferent vascular invasion.

In a series of 50 cases of node-positive breast carcinoma, 11 of 26 of those with efferent vascular invasion (EVI) in the axillary nodes at the time of operation were dead 3 years later, in contrast to 1 of 24 EVI-negative. Recurrence within the 1st year was more common in the cases with an oestrogen receptor (ER) negative primary, but by the 3rd year this trend had reversed, and there were more recurrences in the ER-positive. While recurrence and death came earlier in EVI + ER - cases, the EVI + ER + followed soon after. Next came recurrence and death in the EVI - ER +, while there have been no deaths to date in the EVI - ER -. A model is proposed to explain the timing of recurrence in these different groups.