British Association of Surgical Oncology 49th Scientific Meeting of BASO, held at The Royal College of Surgeons of England, London on 24 November 1994

European Journal of Suryical Oncoloyy 1995; 2 1 : 1 1 1 - 1 2 1

British Association of Surgical Oncology 49th Scientific Meeting of BASO, held at The Royal College of Surgeons of England, London on 24 November 1994 Abstracts of members' papers Editorial Note. The Editors would like to remind readers that authors whose papers have been accepted for presentation at the British Association of Surgical Oncology are invited to submit a full manuscript of their presentation for consideration of publication in the European Journal ofSuryical OncolotTy. The Editors have arranged a fast-track system by which papers which have passed the standard review procedure will be published within three months of submission. We hope our readers take full advantage of this so that early publication of important information presented at BASO meetings can be made available. The same offer applies to publication of full manuscripts from ESSO meetings. Any author wishing to avail themselves of this early publication offer should ensure that the manuscripts are submitted to the Editor within one week of the BASO meeting.

Tumours developing on HRT have a better grade Claudia Harding, Fiona Knox,* A. D. Baildam, N. J. Bundred

Department of Suryery and *Patholoyy, University Hospital of South Manchester, Nell Lane, Didsbury, Manchester, M20 8LR, UK Hormone Replacement Therapy (HRT) increases the risk of breast cancer. Gambrell et al. have suggested that cancers detected in women on HRT have a better prognosis. The aim of this study was to determine the effect of H RT on the histological grade, size and node status of screen detected breast cancers. Lymph node status, tumour grade, size, steroid receptor status and proliferation index were compared in all cancers detected at screening over the last 30 months in one centre. 83 women were taking HRT at diagnosis compared to 125 who were not.

HRT (n = 83) No HRT (n = 125)

% node positive

Grade I

Size < 2 cm

ER positive

26% 42%

38 (45%) 37 (30%)

67 (80%) 102 (81%)

50% 72%

X2 = 4.986 P = 0.026

P = NS

P = NS

Tumour size and steroid receptor status did not differ between women on or off H R T but women on H R T had better differentiated tumours (P ~< 0.03) and less frequent axillary node metastases associated with their tumours. We conclude that women taking H R T at the time of diagnosis of their breast cancer have significantly better grade cancers. HRT, hormone replacement therapy. ER, oestrogen receptor.

Japanese and British gastric cancer - - the same biological entity? J. I. Livingstone, W. Yasui,* E. Tahara,* C. Wasteil

Department of Academic Surgery, Chelsea and Westminster Hospital, London and * 1st Department of Patholoyy, University School of Medicine, Hiroshima, Japan We performed a comparative immunohistochemical study of 40 Japanese and 33 age, sex and stage-matched British gastric cancers using eight markers representing different aspects of tumour activity. Paraffin sections were subjected to immunohistochemistry using the modified enzyme-bridge (ABC) technique. Where staining was successful, the presence or absence of immunopositivity to the following markers was recorded: EGF, EGFR, TGF~,, cripto (a novel member o f t b e E G F family), c-erbB2, p53 and nm23 (an anti-metastasis factor). The proliferation index of each tumour was calculated by monoclonal antibody labelling for PCNA. The greater expression o f c-erbB2, lesser expression of nm23 and higher PCNA index of the British tumours suggests they may have greater malignant potential. 0748-7983/95/010111 + 11 $08.00/0

© 1995 W.B. Saunders Company Limited

Abstracts

112 The results were:

PCNA index

Number (percentage) of positive cases

Japanese British p (~2)

EGF

EGFR

TGFa

p53

c-erbB2

cripto

nm23

mean (sd)

22/40 (55%) 15/26 (58%) n.s.

28/39 (72%) 20/33 (61%) n.s.

21/39 (54%) 23/32 (72%) n.s.

17/40 (42%) 14/33 (42%) n.s.

8/39 (21%) 14/26 (54%) 0.01

18/40 (45%) 15/33 (45%) n.s.

35/38 (92%) 21/33 (64%) <0.01

36,7 47,7 0.001

EGF, epidermal growth factor; EGFR, epidermal growth factor receptor; TGFct, transforming growth factor alpha; PCNA, proliferating cell nuclear antigen; X-', Chi square; n.s., not significant; sd, standard deviation.

Laparoscopic surgery for colorectal carcinoma - - a t e s t of the surgeon not the equipment J . H a r t l e y , A. Q u r e s h i , G . D u t h i e , P . W . R . L e e , J . R. T . Monson

University of Hull, Academic Suryical Unit, Castle Hill Hospital, Cottinyham, North Humberside, HU16 5JQ, UK It has been suggested that the potential for surgical cure of colon cancer may be jeopardized by the adoption of a laparoscopic surgical approach. All patients undergoing elective laparoscopic resection for colorectal cancer in this unit from November 1993 have been studied prospectively. The study was non-randomized, one surgeon performing laparoscopic surgery and another surgeon only conventional resection. Operations performed laparoscopically comprised (no. of open cases in parentheses): anterior Resection with full mesorectal excision 12 (17). right hemicolectomy 4 (2), left hemicolectomy 2 (1), sigmoid colectomy 2 (3) and abdominoperineal resection 2 (I). Parameters measured were excision margin, lymph node yield, length of postoperative stay and in-patient morbidity and mortality.

Group (n)

Age (yrs)

Excision margin (cm) (Rectum only)

No. of positive margins

Node yield

Hospital stay (days)

OPN (24) LAP (22)

68.5+ 17.3 66 + 38.3

1.5+3.4 3.5 + 4.0

0 0

8.5+5.5 8.0 +_5.0

10+5.5 11 _ 5

The distribution (median _+interquartile range) of age and sex and median Dukes stage of the two groups were comparable. There was no perioperative mortality. These preliminary data suggest that immediate cancer clearance is not compromised by a laparoscopic approach. However, laparoscopic colorectal resection conferred no benefit over conventional open surgery in either major morbidity or hospital stay. Improved cosmesis may prove to be the only benefit proferred by the technique. Although long-term cancer follow up is awaited we suggest that, as with open surgery, clearance of colorectal cancer by the laparoscopic approach is a surgeon dependant variable and not a failure of technology. OPN, open; LAP, laparoscopic.

Enhancement of t u m o u r i n f i l t r a t i n g lymphocytes in human tumours by dietary supplementation with L-arginine D. M. Bruce, A. Segar, S. D. Heys, S. Payne,* N. M. Kernohan,* O. Eremin

Departments of Suryery and *Patholoyy, University of Aberdeen Medical School, Foresterhill, Aberdeen, UK The presence of a lymphoreticular infiltrate in human colorectal cancers is well recognized. However, most of the tumour infiltrating lymphocytes (TILs) are T helper cells; no or low levels of natural killer (NK) and B lymphocytes are found. Current interest in immunotherapy has focused on the administration of TILs, isolated from tumours and stimulated with interleukin 2 (IL2) in vio'oto enhance the numbers and activity of NK and lymphokine activated killer (LAK) cells. However, this form of therapy is expensive and labour intensive and alternative approaches increasing functional activity of TILs in the tumour microenvironment are required. We have shown previously that dietary supplementation with L-arginine can enhance natural cytotoxicity in peripheral blood lymphocytes. This study, therefore, has evaluated the effects of dietary supplementation with L-arginine on TILs in patients with colorectal cancer. Sixteen patients with colorectal cancer were allocated to receive either a standard hospital diet (n = 8) or a standard hospital diet supplemented with 30 g/day of L-arginine (n = 8) for three days prior to surgery. Tumour biopsies were taken at the time of surgery, snap frozen in liquid nitrogen and stored at - 7 0 C . Standard immunohistochemical techniques and panel of monoclonal antibodies against defined CD antigens were performed to determine the lymphocyte subsets in the T1Ls. The tumours from patients receiving dietary supplementation with L-arginine had increased expression of the following within the tumour: CD 16, P < 0.0004 (NK cells and macrophages); CD 19, P = 0.009 (B lymphoytes); CD 56, P = 0.0023 (NK and LAK cells) (Wilcoxon rank sum test), when compared with turnouts from patients receiving the standard hospital diet alone. This study has demonstrated, for the first time in man, in vivo, that dietary supplementation with a normal nutrient, albeit in pharmacological amounts, can result in an enhancement of the lymhoreticular infiltrate and may have important implications in the treatment of patients with cancer.

Suicide gene therapy: the 'bystander effect' has a definite immunologic component S. Gagandeep, G. J. Poston, A. R. Kinsella

University Departments of Suryery, Royal Liverpool University Hospital, Liverpool, UK This study provides evidence that the 'bystander effect' has a definite immunogenic component and is not entirely a function of metabolic co-operation. Subcutaneous tumours were created using a colon carcinoma cell line MC-26. All control mice were injected with a NB-16 packaging cells

Abstracts

113

expressing the nls-Lacz gene, and all study mice were injected with pLJ-TK packaging cells, expressing the HSVt-TK gene (Herpes Simplex Virus-thymidine kinase). Mice were divided into four groups, nude balb-c mice into a control and test group (Group 1 and Group 2, respectively), normal balb-c mice into a control and test group (Group 3 and Group 4 respectively). All mice received simultaneous injections of I x 106 cells of the tumour and the packaging cell lines. Seven days later, the mice were treated with a nucleoside analogue ganciclovir for five days at the end of which time they were sacrificed. A significant tumour regression was observed in the test groups vs the control groups. The mean tumour volume was 42. I mm J in the control groups (Groups I + 3) as against 3.3 mm 3 in the test group (Group 4) (P<0.01). The test mice in the nude group (Group 2) however did not respond with the same efficacy reaching a mean tumour volume of 20.5 mm 3 (P>0.05). The data demonstrate a near complete regression of established tumour after successful transduction of HSV,-TK suicide gene, however the same is not true for nude mice pointing towards the fact that the immune system has a definite role to play in the bystander effect.

Clinicopathological features of gastric carcinoid and their relationship to serum gastrin D. B. Gough, G. B. Thompson,* J. H. Donohue,* L. V. Donohue,* L. V. Kvolls,* J. A. Carney,* C. S. Grant,* D. M. Nagorney* (Introduced by O. Eremin)

University of Aberdeen, UK, and *Mayo Clinic, Rochester, MN, USA The prognosis and management of patients with primary gastric carcinoid is controversial. Records of 36 consecutive patients ([mean age 58.4 years] [range 24-82]) presenting between 1975 and 1990 with gastric careinoid were reviewed. Follow-up was complete in 97% of patients. Clinical presentation included anaemia (72%), pain (69%) and carcinoid syndrome (1 I%). Immune and endocrine abnormalities were common (67%). Lesions were non-antral in 78%, multiple in 42%, > 2 cm in 28% and associated with liver metastases in 33%. Urinary 5-hydroxy-indole-acetic acid (5HIAA) and serum gastrin levels were elevated in 17% and 50%, respectively. Overall survival was 58% at 5 years. The presence of metastases, atypical histology, serosal involvement and size >2 cm were adverse prognostic factors. In patients without hypergastrinaemia, 66% developed metastases, 60% had elevated 5HIAA and 50% died ofcarcinoid turnout. In contrast, in those with typical histology, and hypergastrinaemia, metastases and death did not occur (P<0.003 and <0.005, respectively compared to eugastrinaemic patients), solitary lesions or serosal penetration were seen less often (33% vs 100%, P<0.005 and 0% vs 33%, P<0.05), no lesion measured >2 cm, no patients had raised 5HIAA levels and survival was 80% at 5 years. Gastric carcinoids which are histologically atypical, or present without elevated gastrin should be regarded as having a very poor prognosis, while gastric carcinoids with typical histology and hypergastrinaemia are rarely fatal.

Comparison of DPI & I O U S in d i a g n o s i n g occult colorectai liver metastases: follow-up r e s u l t s E . L e e n , W . J . A n g e r s o n , * H . W o t h e r s p o o n , * B. M o u l e , T. G. C o o k e , * C . S. M c A r d l e *

Department of Radiology, and * University Department of Surgery, Royal Infirmary, Glasgow, UK Previous studies using duplex/colour Doppler sonography have shown that the measurement of the Doppler perfusion index (DPI: hepatic arterial to total liver blood flow ratio) can detect the presence of "occult' colorectal liver metastases. In this study we compared the accuracy of intraoperative ultrasound (IOUS) with DPI in the detection of occult liver metastases. IOUS and DPI were evaluated in 90 colorectal cancer patients with an apparently disease-free liver on the basis of CT scans and laparotomy. IOUS detected liver metastases in four of the 23 patients who subsequently developed overt liver metastases during one year follow-up. However DP! predicted the development of hepatic metastases in all 23 cases. The results suggest that DPI is more sensitive than IOUS in the early detection of occult colorectal liver metastases. The routine use of IOUS in screening for occult colorectal liver metastases is not recommended.

Effects of immediate vs delayed communication of biopsy results on anxiety in patients with breast disease S. Ubhi, S. Wright, Susan Black, Lucy Clarke, P. Shaw, Anne Stotter, R. Windle

Departments of Surgery, Ps.vcholo#y and Pathology, Glenfield General Hospital, Leicester, LE3 9QP, UK Immediate reporting of FNAB specimens has been introduced into many breast clinics. While in others, women return to a later clinic to receive the results. This delay in communication of results may lead to elevated anxiety. This study compared the psychological states in two groups having FNAB. One group received results at the initial clinic visit (immediate; n -- 53), the other having delayed communication (Delayed, n = 69). Anxiety was measured using the HADS (administered at the first clinic visit and after one week) and the six-item short-form of the STAI (administered before and after each consultation). Initial anxiety was high in both groups with nearly half displaying "case' levels on the HADS. Women with malignant results had higher post-communication anxiety compared to women with benign results. However, within the group with benign results (the vast majority), immediate communication was associated with a significantly greater fall in STAI scores from before to after the first consultation (U = 587.0; P < 0.02). There was no difference between the immediate and delayed communication amongst women with a malignant diagnosis (U = 26.0; n.s.). These results provide support for the more widespread introduction of a Cytologist into breast clinics to allow immediate communication of results. FNAB, fine needle aspiration biopsy; HADS, Hospital Anxiety and Depression Scale; STAI, Spielberger State-Trait Anxiety Inventory.

Selective radiotherapy following wide local excision of breast cancer; early results of a randomized trial R. P. F. Lee, A. Vincenti, R. Buchanan, R. M. Rainsbury

Breast Unit, Royal Hampshire County Hospital, Winchester, UK Wholesale use of radiotherapy (RT) following wide local excision (WLE) is questionable as most patients gain no benefit and some are harmed. We have evaluated a method of selective radiotherapy following WLE. From 1990, 104 patients < 70 yr with T0-T2, N0-N1 primary breast cancers underwent WLE. Four bed biopsies (BB) were taken, followed by a ring-doughnut shaped re-excision specimen (RS) of the entire cavity wall and level I axillary dissection. Specimens were inked and tumours classified according to size, type, grade, in-situ disease, lymphatic and vascular invasion. Margin and nodal involvement were recorded. Patients with invasive cancer (IC) in BB or RS received adjuvant breast RT (Gp I). Those without IC in BB and RS were randomized to RT (Gp 2) or no RT (Gp 3). None of 20 patients in Gp I have developed local recurrence (LR) (mean foUow-up 26 months). Of 84 patients with clear BB and RS, one of 39 (2.6%) randomized to Gp 2 and five of 45 (11.1%) randomized to Gp 3 have developed LR. As three in Gp 2 declined RT and three in Gp 3 requested RT; LR occurred in 5.1% of irradiated and 8.9% of non-irradiated patients, respectively. All were in premenopausal patients with Grade 2/3 T2 ductal carcinomas. Four out of six had lymphatic or vascular invasion, or both.

Abstracts

114

Early LR of 'high risk' cancers following WLE was neither predicted by margin analysis, nor prevented by RT. Omitting RT in more favourable tumours with clear BB/RS has not increased early local relapse.,

A randomized trial to assess the addition of interferon-a2a (IFNa) to 5-fluorouracil (5FU) and ieucovorin (LV) in advanced coiorectal cancer M. T. Seymour, M. Slevin, D. Cunningham, D. Kerr, R. James, J. Ledermann, T. Perren, W. McAdam, Alison Duffy, S a l l y S t e n n i n g , I. Taylor Colorectal Cancer Workin# Party, Medical Research Council, UK In order to test the hypothesis that IFNa enhances the anticancer efficacy of 5FU and LV, 260 chemonaive patients with advanced colorectal adenocarcinoma were randomized, at 21 UK centres, to receive either 'FU/LV' (LV 200 mg/m: i/v over 2 hours, then 5FU 400 mg/m2 i/v bolus, then 5FU 400 mg/m 2 by i/v infusion over 22 hours, all repeated on day 2, on a fortnightly cycle), or 'FU/LV/IFNa' (the same schedule of 5FU/LV, plus IFNa 6 x 106 units s/c every 48 hours throughout). Treatment was for up to 6 months. Toxicity and quality of life (QoL) were assessed at each cycle, and response was assessed objectively by serial radiology. At preliminary analysis, response data are available in 165 pts. FU/LV: CR = 4%, PR = 26%, SD = 31%. FU/LV/1FNa: CR = 4%, PR = 26%, SD = 22% (95% c.i. for difference in CR = PR, -- 12 to + 12%). Projected median survival is: FU/LV = 10.8 months; FUILVllFNa = I0.0 months. Toxicity was generally mild: alopecia was commoner in the FU/LV[IFNagroup (28% vs 7% grade I> 2), as was mild neutropenia, but gastrointestinal toxicity was not. One treatment-related death occurred in each group. The IFNa dose was reduced, usually for persistent lethargy, in 42% of patients. QoL analysis shows a steady overall improvement in physical and psychological state during 5FU/LV treatment, but little improvement during 5FU/LV[IFNa. We conclude that IFNa affects neither the activity nor the dose-limiting toxicity of 5FU/LV treatment, but impedes its palliative effects. We cannot recommend the inclusion of IFNa in regimens for colorectal cancer.

Increased proliferation in infected and adjacent mucosa in experimental Helicobacter gastritis D. J. Corless, R. Mulla, S. Kaur, C. W a s t e l l Academic Surgery, Chelsea and Westminster Hospital, 369 Fulham Road, London, SWIO 9NH, UK Helicobacterpyloriis linked to gastric cancer. The aim of this study was to examine the hypothesis that experimental gastritis could increase mueosal proliferation and thereby act as a potential promotor of gastric cancer. Method: Twenty four nude PVG rats were colonized with Helicobacterfelis. Animals were killed at 1, 2, 4 and 8 weeks and sections of the stomach stained by the monoclonal antibody PC I0 to PCNA. The proportion of stained cells in 40 randomly selected glands in the antrum and in the body of the glandular part of the stomach was calculated and compared to 10 control animals. Results: Helicobacterfelisspecifically colonized the antrum and not the rest of the stomach. It caused a gastritis which increased in severity with time and began to regress by 8 weeks.

Control median

1 week median

2 weeks median

4 weeks median

8 weeks median

Antrum P value

9.6%

21.7% P < 0.02

23.5% P < 0.02

15.8% P = 0.12

16% P = 0.12

Body P value

13.5%

30.0% P < 0.004

35.3% P < 0~003

25.4% P < 0.003

24.2% P < 0.004

PCNA

The increased proliferation occurred at the colonized site and declined as the gastritis became quiescent. However, in the adjacent, noncolonized mucosa the increased proliferation persisted. Conclusion: These results support the hypothesis that organisms of the Helicobactergenus can act as potential promotors of gastric cancer by increasing proliferation and rendering the mucosa more susceptible to other genotoxic agents. PCNA, Proliferating cell nuclear antigen

Results from the EURONUT-European Cancer Prevention Organization (ECP) intestinal metaplasia (IM) study P. I. Reed for the EURONUT-ECP Intestinal Metaplasia Study Group, UK Subgroup Lady Sobell Gastrointestinal Unit, Wexham Park Hospital, Slou#h, Berks, SL2 4HL, UK A multi-national European study of IM set up to examine factors involved in the early stages of development of intestinal type gastric adenoearcinoma was carried out in six European countries. In the four United Kingdom centres in addition to the core diet study plasma ascorbic acid, ~-carotene, ~-tocopherol and ~-tocopherol:cholesterol levels and serum anti-Helicobacterpylori (HP) antibody levels were measured. Three groups of patients matched for age (+3 years) and sex were studied: IM, patients with histologically proven IM; EC, patients with near normal gastric mucosa; and NC, non-endoscoped controls with no history of upper gastrointestinal disease. Full HP serology data were available on 116 sets of matched patients and 136 sets for vitamin levels. The prevalence of HP was significantly higher in the IM cases than in either set of controls (IM 85.3%, EC 24.3%, NC 37.1%). Ascorbic acid levels were significantly lower in IM patients than in control groups with lower levels seen in areas at greater risk of gastric cancer in all three patient groups. No other significant changes in vitamin levels were demonstrated: These study results were used in planning a large multi-national HP eradication, vitamin C supplementation European Intervention Study in IM. I n c r e a s e d TGFac e x p r e s s i o n in e x p e r i m e n t a l Helicobacter gastritis D. J . Corless, R. MuHa, S. Kaur, C. W a s t e l l Academic Surgery, Chelsea and Westminster Hospital, 369 Fulham Road, London, SWlO 9NH, UK TGF~ expression is increased during rat carcinogenesis with MNNG. This study has examined TGF~ expression in an animal model of Helicobactergastritis. Method: Eighteen nude PVG rats were colonized with Helicobacterfelis and groups of six killed at each interval of 2, 4 and 8 weeks. The

Abstracts

115

antrum and glandular stomach (GS) were examined with the monoclonal antibody Ab-2 to TGF~t, grading immunoreactivity 0-III, using a, previously described semi-quantitative method. TGF= expression was also examined in 10 control animals Results: Gastritis was specific to the antrum and gradually increased in severity but was regressing by 8 weeks. TGFa was expressed in the normal rat stomach, (median = 0.5 in the antrum and 0.4 in the GS) maximally in the outer differentiated region (median = 0.9 in the antrum and 1.2 in the GS). No change in TGFa expression could be detected in the first 4 weeks but at 8 weeks increased expression was found in the antrum (median = 0.9; P < 0.003) and the GS (median = 1.2; P < 0.003). This wasmost markedin the outerdifferentiatedregion (antrum = 1.2; P<0.005 and GS = 1.8; P<0.00006). Conclusion: These results support a role for Helicobacterpylori infection in gastric carcinogenesis. MNNG, N-Methyl-N'-Nitro-N-Nitrosoguanidine. TGF~t, transforming growth factor ct. M y e l o t o x i c i t y w i t h a d j u v a n t m i t o m y c i n C f o l l o w i n g s u r g e r y f o r g a s t r i c cancer J. May, J. P. Griffith, S. Young, S. Richards, D. Johnston, H. M. S u e - - L i n g Academic Unit of Surgery and Centre for Digestive diseases, The General Infirmary, Leeds, UK Mitomycin C (MMC) in six weekly cycles at a dose of 20 rag/m-" is reported to prolong survival after potentially 'curative' resection (PCR) for gastric cancer with relatively few side effects. We have treated 12 patients with MMC following PCR for gastric cancer. Absolute numbers of platelets, neutrophils and lymphocytes were measured in order to monitor myelosuppression and to assess whether any recovery occurred with this cyclical regimen. MMC (20 mg]m 2) was commenced 14-28 days after radical (R2) gastrectomy for stage IlI disease. Absolute numbers of platelets, neutrophils and lymphocytes were measured before and after operation and before (post-operative days 14, 56, 98, 140) and after (postoperative days 28, 70, 112, 154) each dose of chemotherapy. We compared the results with a matched group of patients who underwent PCR alone. There was a sustained depression in absolute numbers of platelets in the MMC treated group and five patients developed thrombocytopenia (platelets < 50 x 109/1). Lymphocyte count in the MMC treated group was al~io significantly depressed compared to the control group. Three patients developed leucopenia (leucocyte < 2 x 109/I), one of whom developed a bronchopneumonia.

Results

Day 0

14

28

70

112

154

Platelets (MMC) x 109/I Platelets (Controls) Lymphocytes (MMC) x 109]1 Lymphocytes (Controls)

450 460 1.7 1.7

536 510 1.3 1.4

151 520 1.3 2

133 552 1.2 1.8

183 616 0.9 1.8

117" 605* 0.8"1" 2.7"1"

* P < 0.05. t P < 0.05. Adjuvant MMC resulted in significant myelotoxicity in 50% of patients and treatment had to be delayed in 5 patients. There was no evidence of recovery in absolute numbers of platelets or leucocytes between doses of MMC. MMC, Mitomycin C; PCR, potentially curative surgery.

Investigation of anthracycline uptake and action in sensitive and resistant bladder cancer cells S. S. Mudan,* Claire L. Davies, Marilena C. Loizidou, A. J. MacRobert, A. J. Cooper, I. Taylor Departments of Surgery, University College London Medical School and *St George's Hospital, London, UK Drug resistance is a recurrent problem in solid tumour management. Unravelling of the mechanisms and prediction of resistance are important goals. We have investigated the uptake, intracellular concentration and cytotoxicity of naturally fluorescent anthracyclines in sensitive and resistant tumour cells. The human bladder cancer cell line (MGHUI) and its drug resistant variant (MGHU1R) were grown in vitro and incubated (1 h) with Epirubicin (2-20/~g/ml). Cultures were (i) washed, trypsinized and read by flow cytometry and (ii) washed and at 0 h and 1 h analysed by high resolution fluorescent image analysis. Cytotoxicity was determined by methylene blue uptake, after 24h epirubicin incubation. Flow cytometry dose response studies showed higher drug affinity in sensitive compared to resistant cells (gradient y = 7.8, y = 0.4, P < 0.001 by regression analysis, saturation at 10 iLg]ml, 4 mg/ml, respectively). Fluorescent image analysis revealed a predominantly nuclear drug localization for MGHU1, but not for M G H U I R cells (nucleus: cytoplasm 2.4: 1, 1.4: 1, respectively). At 1 h post wash, M G H U I R lost approximately 50% of drug. Cytotoxicity studies showed an Ic~ of 25 pg/ml and 2 pg]ml Epirubicin for M G H U I R and MGHU1 cells, respectively. We demonstrated significant differences in drug uptake and localization between sensitive and resistant cancer cells and that drug uptake correlates with cell killing. Combining flow cytometry and image analysis is a useful means of investigating drug resistance mechanisms. h, hour; lc~, 50% inhibitory concentration.

Expression of Matrilysin (MMP-7) is increased in gastric cancer and lymph node metastases N. J. Keeling, M. Mnkai, Sonja Jonas, C. Wastell Department of Academic Suryery, Chelsea & Westminster Hospital, Fulham Road, London, SWIO 9NH, UK Why some gastric cancers behave more aggressively than others is poorly understood. Invasion and metastasis may be related to increased expression of enzymes which degrade the basement membrane and extra-cellular matrix. The expression of MMP-7 was examined in a series of 15 gastric cancers, I 1 lymph node metastases, 30 uninvolved resection margins and seven non-neoplastic lymph nodes. Ten control samples were taken from patients undergoing surgery for morbid obesity. Messenger RNA expression was detected by Reverse Transcriptase - - Polymerase Chain Reaction using oligonucleotide primers after eDNA synthesis of extracted RNA. Products were seen as a predicted 365 base pair band on agarose gel electrophoresis; this was confirmed as MMP-7 aftei,"

116

Abstracts

Southern blotting using a specific oligonucleotide probe and autoradiography. Human fl-actin was used as a positive control and sterile water as a negative control.

Tissue

+ ve

- ve

Fisher's exact test

Metastatic tumour Non-metastatic tumour Non-malignant gastric/oesophageal tissue Lymph node with metastsis Lymph node without metastasis Control stomach

9 3 1

3 0 29

P < 0.4

I1 1 0

0 6 I0

P < 0.0001

P < 0.0001

Increased expression of MMP-7 is a characteristic of primary gastric cancer and metastatic gastric cancer which may account for its invasive behaviour. Further research is required to identify the mechanism by which increased expression occurs.

Does a negative H a e m o c c u l t t e s t delay symptomatic p r e s e n t a t i o n ? D. H. Bennett, C. M. Mangham, M. W. Lang, J. Chamberlain,* J. D. Hardcastle Department of Surgery, University Hospital, Nottingham & *Cancer Screening Evaluation Unit, Sutton, UK One criticism of screening programmes is that a negative test may be falsely reassuring and lead to delayed presentation following the development of symptoms. Interval cancers, defined as cancers presenting in the screened group that were not detected by the screening test, were analyzed to look for evidence that this was occurring in a prospective, randomized trial of Haemoccult screening for colorectal cancer. The mean duration of follow up of the population examined was 6.95 years. The interval cancer presentation rate, 4.9110 000 screened, was the same for both the first and second year post-screening. A comparison of tumour stage and grade with cancers presenting in the control group is shown below.

Dukes" stage

lnt I Int 2 lnt U Control

Differentiation

A

B

C

D

Well

Mod.

Poor

14 10 5 82

13 15 15 226

16 18 12 219

16 16 6 149

1 6 0 45

40 40 24 409

9 4 7 123

lnt 1, interval cancer 1-12 months post screening. lnt 2, interval cancer 13-24 months post screening. lnt U, interval cancer > 24 months post screening. The interval cancer presentation rate represents a specificity of 99.9% for Haemoccult. The results demonstrate that there is no statistical difference in either the grade or stage of tumour presenting as an interval cancer when compared to the control group. This suggests that a negative Haemoccult test does not delay presentation following the development of symptoms and that a false-negative screening test does not adversely affect prognosis.

Vaginography in the diagnosis and evaluation of vaginal fistulae P. J. Drew, P. Giordano, D. Taylor,* G. Duthie, P. W. R. Lee, J. R. T. Monson Academic Surgical Unit, and *Department of Radiology, University of Hull, Castle Hill Hospital, Hull, HUI 6

5SQ, uK The anatomical delineation of vaginal fistulae is a radiological dilemma. Current literature suggests poor sensitivities for barium enema examinations (34%) and CT scanning (60%). Vaginography represents an alternative imaging modality. Vaginography was performed on 27 patients presenting with symptoms suggestive ofvaginal fistulae. Four patients were subsequently shown on clinical 01 = 3) and operative (n = I) grounds not to have vaginal fistulae. In total there were 20 simple and four complex vaginal fistulae. One patient presented on two occasions with different fistulae. The underlying aetiology was malignant in 12 patients, benign in nine patients, pseudomyxoma peritonei in one patient and iatrogenic in two patients. Six (50%) of the patients with malignant aetiologies had received pelvic radiotherapy. Eight (88.9%) of the patients with benign aetiologies had undergone previous hysterectomy. The results of the radiological investigations are shown below.

Examination

Performed

True + ve

Fals~ - ve

Sensitivity

Barium enema Vaginography

Il 24

I 19

l0 5

7.7% 79.2%

In this, the largest series to date, vaginography is shown to have a sensitivity o f 79.2%. This is superior to the barium examinations in this series and also to the barium and CT examinations in previous series. In conclusion, vaginography represents the most sensitive, informative and economical investigation for patients with suspected vaginal fistulae and should be the initial radiological investigation of choice in this group. CT, computed tomography; + ve, positive; - v e , negative.

Abstracts

I 17

Mesenteric arterio-venous differences in cytokines in patients with colorectal cancer D. J. Deehan, S. D. Heys, O. Eremin

Department of Surgery, University of Aberdeen, Medical School Buildings, Foresterhill, Aberdeen AB9 2ZD, UK Introduction: The presence of malignancy may induce host immunosuppression through disrupted cellular and humoral activity. The macrophage-derived eicosanoid prostaglandin E2, PGE2 has been shown, in vitro, to inhibit mononuclear cell function. This study has examined the in-vivorelease of this and other key mediators from the tumour-draining site of patients with colorectal cancer. Methods: At laparotomy, blood samples were taken from the inferior mesenteric artery and vein, prior to resection in 22 patients (I 1 with colorectal cancer and I I with benign colorectal disease, diverticular or inflammatory). Stored sera was analysed for soluble interleukin-2 receptor (slL-2R), interleukin-6 (IL-6) and PGE2. Results: Significantly increased concentrations of slL-2R and PGE2 were found in the venous blood draining tumour bearing sites (results in Table). No significant arteriovenous differences were identified in those patients undergoing resection for benign disease.

Table Malignant Arterial PGE2 (pg/ml) slL-2R (pg/ml)

Venous

Arterial Venous 35(12--46) 84(57-112)* 465(350-610) 1350(970-1530)*

Benign Arterial

Venous

Arterial 42(32-54) 520(345-720)

Venous 25(16--42) 630(390-810)

Conclusions: Increased circulating concentrations of PGE., and slL-2R from the tumour site draining into the portal system may contribute to impaired host immune response in patients with cancer. Results: median (95% confidence intervals). * P<0.05, Mann-Whitney U-test.

Gastrin receptor expression in azoxymethane-induced colorectal neoplasms T. A. Justin, Susan Watson, Theresa Morris, G. Robinson,* J. D. Hardcastle

Departments of Surgery & *Pathology, University Hospital, Queen's Medical Centre, Nottingham NG7 2 UH, UK The role of gastrin and particularly the significance of gastrin receptor (GR) expression in gastrointestinal tumour progression is unknown. To investigate this further we studied GR expression using a monoclonal antibody, 2C1, in chemically induced colonic neoplasms. This model involves the induction of tumours by the administration of azoxymethane and the full range of progressive events, i.e. hyperplasia, adenomas and adenocarcinomas are seen. Male and female Wistar rats were treated with azoxymethane 15mg/kg weekly for six weeks. The animals were weighted and inspected weekly for a period of 34 weeks prior to termination. Samples of colonic neoplasms were taken for histological verification and 2C1 staining. Sections were stained with 2CI at a 1 : 1000 dilution, overnight, at 4 C and the antibody binding detected using the avidin-biotin complex technique with diaminobenzidene as the substrate. Sections were obtained of all stages of tumourogenesis. Markedly increased staining with 2CI occurred in the transitional epithelium surrounding these neoplasms as well as both adenomas and carcinomas. It appears that GR's are associated with highly proliferating cells and progression to adenomas and carcinomas. These findings add further weight to the theory that colorectal carcinogenesis involves abnormal gastrin metabolism in the colonic mucosa. UKCCCR guidelines were followed during this experiment.

Blood vessels in colorectal liver metastases are not innervated S. Ashraf, Rahima Crowe,* Marilena C. Loizidou, M. Turmaine,* I. Taylor, G. Burnstock*

Department of Surgery, University College Medical School and *Department of Anatomy and Developmental Biology, University College, London, UK The management of colorectal liver metastases by hepatic arterial cytotoxic infusion might be enhanced by manipulating the blood supply to the tumours. There is a predominant arterial flow to metastases, but the underlying control of tumour blood vessels is unknown. Therefore, the peptidergic/aminergic perivascular innervation of normal human liver and associated colorectal liver metastases was investigated to determine vascular control. Normal liver and colorectal metastases from 13 patients were studied immunohistochemically for the presence of protein gene product 9.5 (PGP), neuropeptides and tyrosine hydroxylase (TH). The ultrastructure of blood vessels and perivascular innervation were investigated by transmission electron microscopy. In normal human liver, the greatest density of nerves contained PGP, followed by neuropeptide Y and TH along the interlobular blood vessels, the sinusoids and central vein of the hepatic Iobule. Vasoactive intestinal peptide, substance P and calcitonin gene-related peptide immunoreactivity was observed in nerve bundles associated with interlobular blood vessels. Unlike normal liver, no perivascular immunoreactive nerves were observed in colorectal liver metastases. Transmission electron microscopy confirmed the absence of perivascular nerves and demonstrated that these vessels lacked a continuous muscle coat. In man, vessels supplying colorectal liver metastases are devoid of normal neuronal regulation; whether there is a role for endothelial control mechanisms of blood flow in these vessels is unknown. PGP, protein gene product 9.5: TH, tyrosine hydroxylase.

Prognostic power of Doppler perfusion index in colorectal cancer: correlation with survival E. Leen,* W. J. Angerson, H. Wotherspoon, B. Moule,* T. G. Cooke, C. S. McArdle

*Department of Radiology, University Department of Surgery, Royal Infirmary, Glasgow, UK The measurementof Doppler perfusion index (DPI: ratio of hepatic arterial to total liver blood flow) using Doppler sonography may detect the presence of occult liver metastases. In this study we assessed its prognostic value.

Abstracts

1 18

Eighty patients undergoing apparently curative surgery for eolorectal cancer were studied. All patients had preoperative DPI measurements and were staged using Dukes classification. Two years after presentation, of the 49 patients with abnormal DPI, 27 patients developed overt liver metastases, of whom 21 died; eight of the nine patients who subsequently developed local recurrence also died; another two patients died at home. Of the 31 patients with normal DPI, 30 are still alive and remain disease free. Dukes' classification failed, to define clearly those patients who died or developed recurrent disease. In contrast DPI clearly identified two groups; only 22% of patients with an abnormally elevated DPI survived and remain disease-frce compared with 97% of patients with normal DPI. This technique can identify patients at high risk, who would be suitable for adjuvant therapy. P r o g e s t e r o n e r e c e p t o r s t a t u s in D C I S C. Murphy, D. M. Sibbering, I. O . E l l i s ,

S. Pinder, R. W. Blamey, J. F. R. Robertson

Nottingham City Hospital, UK The use of tamoxifen in the control of DCIS is currently the subject of a number of studies. Prediction for response of invasive cancer to tamoxifen has been based on knowledge of oestrogen receptor (ER) and progesterone receptor (PR) status, there has been little work on DCIS. The ER status of DCIS has been described. PR status has not, hence 123 cases of pure DCIS were examined and PR status documented with an immunocytoi:hemical assay with a monoclonal antibody. PR-ve

PR+ve

62 8 21 30 28 20 36 47 29

32 16 26 10 8 29 7 33 5

ER negative ER positive Small cell cribriform Large cell Pure comedo CERB2 negative CERB2 positive p53 negative p53 positive

"~ P < 0.001 3 "] I P < 0.05 P < 0.05 P < 0.05

No inferences can be made on clinical outcome as even at median follow up 126 months the number of events is so small. These results show that over 50% of DCIS appear hormone independent (ER negative, PR negative) and emphasize that tamoxifen is unlikely to benefit over 50% of patients with DCIS.

With a clear margin of excision, radiotherapy may be unnecessary after local excision of DCIS D. M. Sibbering, J. F. R. Robertson, R. W. Blamey, C. W. Elston, I. O . Ellis, A. R. M. Wilson, A. J. Evans

Nottingham City Hospital, UK Data from the NSABP B-I 7 study suggests that radiotherapy may significantly reduce LR after local excision of DCIS. However, although clear histological excision margins were required for entry into the study, no stated minimum margin of normal breast tissue was required. Residual DCIS was probably present in a significant proportion of patients after surgical excision and this could account for the higher LR in the 'no radiotherapy' group. The policy for treatment of DCIS at our unit is as follows: patients with tumours/>4 cm are advised mastectomy; if the tumour is < 4 cm patients are offered WLE. WLE is not quadrantectomy but a minimum I cm clear histological excision margin is required. Post-operative radiotherapy is not given. Of 130 cases of DCIS treated since 1988, 48 were suitable for and chose WLE. At a median follow up of 38 months no patient had developed LR. This contrasts with the 16% LR in NSABP B-17 at 43 months. Conclusion: If local excision of DCIS is ensured (with a measured margin of I cm), post-operative radiotherapy appears to be unnecessary. LR, local recurrence; WLE, wide local excision; DCIS, ductal carcinoma in situ.

Lobular carcinoma of the breast can be managed by breast conserving therapy P. A. Holland, A. Shah, A. Howell,* A. D. Baildam, N. J. Bundred

Department of Suryery and *Medical Oncoloyy, Withinyton Hospital, Nell Lane, West Didsbury, Manchester, M 2 0 8LR, UK Duetal carcinoma of the breast can be managed by breast conservation techniques or by mastectomy, with similar rates of local control. The high incidence of multifocal disease in lobular carcinoma has led to claims that mastectomy is the treatment of choice for patients with Iobular carcinoma. We have reviewed the patients with Iobular carcinoma presenting to our unit, to determine whether breast conservation is associated with a higher incidence of local relapse compared to mastectomy. Between December 1973 and December 1991, 226 patients with lobular carcinoma 4 4 cm in size, underwent either mastectomy (77%) or breast conservation (23%). Patients with involved pathological margins underwent re-excision or mastectomy. Twelve contralateral breast cancers occurred, four (1.8%) synchronous and seven (3. I%) metachronous.

Mastectomy n = 174 Breast conservation n=52

Local recurrence

Median follow-up

Median tumour size

21 (12.0%)

60 months

2.0 cm

4 (7.7%)

55 months

1.5 cm

Abstracts

119

Multi-focal cancers were present in 48 (27.6%) of mastectomy patients and seven (13.5 %) of patients undergoing breast conservation. No recurrences in the conservation group were associated with multifocal cancer. Breast conservation achieves similar rates of loco-regional control as mastectomy in patients with lobular carcinoma of the breast.

Tumour bed biopsy predicts the presence of multifocai disease in patients undergoing breast conservation therapy for breast carcinoma P. Rubin, D. M. O'Hanlon, K. Callanan, C. D. M. Griffith, D. Scott,* J. Shrimanker,* V. Wadehra

Breast Screening Unit, Department of Surgery & *Pathology, Newcastle General Hospital, Newcastle Upon Tyne, UK The introduction of screening mammography has resulted in detection of more, early carcinomas and an increase in the number of patients undergoing breast conservation. This may be associated with an elevated risk of local recurrence, due to the presence of residual disease, multifocal disease or true turnout recurrence. This study prospectively examined tumour bed biopsies in 135 patients with no evidence of marginal involvement (four biopsies, initial specimen immersed in india ink to accurately assess margins) to determine the presence of multifocal disease and to examine what factors predicted its presence. Twelve (8.9%) patients had positive tumour bed biopsies and the inferior margin was the commonest site (eight patients). Patients were significantly more likely to have ductal carcinoma in situ (DCIS) and the presence of lymph node involvement and vascular invasion were also predictive of positive bed biopsy. Results are summarized in the Tables. Biopsy negative

Biopsy positive

Significance

57.2 (0.6) 3.0 (0.3) 0.1 (0.05) 12.9 (0.5) 67.7 (5.3)

55.4 (1.8) 1.8 (0.5) 0.7 (0.4) 16.7 (3.2) 55.0 (10.7)

ns ns P < 0.01 ns ns

Age (yrs) Clearance (ram) LN involvement (number) Size (mm) Size of specimen (g)

'

Results given as mean (SEM). Stats used: Mann-Whitney U, Pearson's correlation, Fisher exact and Chi square test with significance assumed at the P < 0.05 level, ns, non significant.

Number (%) with tumour bed biopsy positive Menopausal status Ca other breast FNAC AC Needle localized Histology Grade Vascular invasion

Pre 3/18 (17%) no 12/125 (10%) '5" 3/60 (5%) no 3/49 (6%) ductal 6/107 (6%) '3' 2/12 (17%) no 9/130 (7%)

Post 9/117 (8%) yes 0/10 (0%) '0" 6/15 (40%) yes 9/86 (10%) DCIS 5/20 (25%) '1' 3/66 (4%) yes 3/5 (60%)

Signifcance ns ns P < 0.01 ns P < 0.01 ns P < 0.0t

This study confirms the existence of multifocal disease. It is associated with lymph node involvement, vascular invasion and the presence of DCIS. As it may be a factor in recurrent disease and may dictate changes in therapy we recommend routine tumour bed biopsy in all patients undergoing breast conservation therapy.

In-vitro modulation of human breast cancer cell adhesion and invasion

G. P. H. Gui, J. R. Puddefoot, G. P. Vinson, C. A. Wells, R. Carpenter The Breast Unit, St Bartholomew's Hospital and Queen Mary & Westfield College, London, UK Fibronectin is a major contituent of the interstitial extracellular matrix. Malignant cell interaction With the substratum is a recognized prerquisite of tumour metastasis. The cell adhesion molecules provide a possible mechanism for this interaction between cancer cells and fibronectin via the ct3/31 and ~tv//5 integrin receptors. Four breast cancer cell lines that we have shown to express both ct3fll and av//5 by immunocytoehemistry were used. Integrin mediated cell adhesion and invasion were assayed in 96 well plates and eight micron porous filtres respectively, each coated with I00 #g/mL of fibronectin. Experiments were conducted in the presence of monoclonal antibodies (75/~g/mL) directed against the//1 or//5 integrin snbunits. Control experiments were run in the absence of inhibitors. The adhesion index was defined as the percentage of adherent cells compared to the control. Invasion was expressed as the percentage of cells that had penetrated through the fibronectin matrix, in the presence or absence of inhibitory monoclonal antibodies. Cells were quantified by absorbance following tetrazolium uptake.

Adhesion index % invasive cells

MCF7

MDAMB231

ZR75-1

Hs578T

//1 0.09t /35 0.48? C 0.09 //1 0.06 f15 0.07

0.29* 0.01 t 0.03 0.03 0.02

0.29t 0.09"]" 0.02 0.01 0.01

0.291" 0.39* 0.44 0.14" 0.11"

* P < 0.01; t P < 0.001 Student's t-test; C, control.

Abstracts

120

Invasion in the aggressive Hs578T cell line is integrin-dependent, but is of less importance in non-aggressive cells. Assessment of integrin expression and function may thus be a marker of invasive potential in human breast cancer. This may be of future value in the targetting of systemic therapy against metastasis.

Development of a flow cytometric assay for patient-specific adjuvant chemotherapy in human solid tumours J. Featherstone, A. Cooper, D. Rew

University Surgical Unit, Southampton General Hospital, Southampton, UK Adjuvant chemotherapy o f colorectal and other adenocarcinomas has been handicapped by the lack of reproducible assays of drug efficacy. Anthracycline and related cytotoxic drugs such as doxorubicin (DOX), epirubicin and mitozantrone exhibit specific fluoresce under blue light excitation. Their uptake into tumour cells and its pharmacological modification by cellular mechanisms such as the p-glycoprotein efflux pump can be detected and quantified by flow cytometry. This study was undertaken to develop a flow cytometric assay of drug uptake in normal epithelial and adenocarcinoma cells using colorectal cancer and mucosa as a model. Drug uptake was initially assessed in M G U H - I . COL-320 and HT-29 cell lines. Cell viability studies using fluorescein diacetate (FDA) allowed living and dead cells to be distinguished simultaneously with drug uptake measurements. Samples were collected from 17 fresh colorectal resections and incubated with DOX. Tumour disaggregation was optimized. DOX fluorescence was readily quantifiable at 530nm with similar characteristics in cells from both tumours and cell lines over a 100-fold range of light emission intensity. Drug uptake was concentration-dependent and identified two or more discrete functional populations in tumour and mucosa. Flow cytometric assays for the characterization of cytotoxic drug uptake h~l,itro into individual tumours are feasible. Side effects remain a serious problem with these agents. However, the practicality of patient specific assays may herald a less empirical approach to adjuvant cancer chemotherapy based on the selective use of drugs which can be shown to concentrate in tumour cells, and whose cellular uptake may be enhanced by p-glycoprotein blockade.

BCL2 expression in breast cancer identifies patients who should not receive endocrine therapy J. F. R. Robertson, J. M. W. Gee,* R. A. McClelland,* 1. O . Ellis, P. Willsher, R. W. Blamey, R. I. Nicholson*

Department of Surgery, City Hospital, Nottingham, and * Tenovus Institute, Card([..'[] UK BCL2 a putative GTP-binding protein mediating signal transduction pathways, has been reported to increase cell survival by blocking programmed cell death (apoptosis). We have compared BCL2 expression in 42 primary breast cancers with a series of other known prognostic markers. BCL2 showed a significant correlation with oestrogen receptor (ER) (P<0.005) and progesterone receptor (PgR) (P<0.005) status suggesting BCL2 is oestrogen regulated. There was no correlation with the proliferation antigen, Ki67. All 42 patients had received endocrine therapy either for a locally advanced primary or systemically advanced breast cancer. BCL2 and ER status correlated strongly with therapeutic response.

Non progression Response

Static

Progression

BCL2+

9

10

13

14.2 I df

-

0

0

14

[P < 0.0001)

8 1

9 1

I1 16

I1.11df (P < 0.0009)

ER+ -

X-"

While ER is statistically a good predictor of progression it failed to do so in 12% of cases. BCL2 negativity predicted for progression in 100% of cases - - these patients should not receive endocrine therapy.

Population effectiveness of adjuvant systemic therapy for breast cancer K. Albuquerque, R. A. Badwe, I. Mittra

Department of Surgical Oncolo#y, Tata Memorial Hospital, Bombay - - 4 0 0 0 1 2 , India There is indirect evidence to suggest that the modest benefits from adjuvant systemic therapy (AST) in breast cancer reported in the world overview of trials may not be translated into reality in clinical practice. To investigate the population effectiveness of AST, we undertook a study of all axillary node positive patients with operable breast cancer residing in Bombay and treated at Tata Memorial Hospital (TMH) from 1974 to 1988. The end point of the study was death. There were a total of 678 patients, 303 were premenopausal and 371 were post menopausal. Of the 303 premenopausal women, 135 had received chemotherapy (CT), five had received tamoxifen (T), 12 had received T + CT; 151 patients were untreated. Of the 371 postmenopausal women, 117 had received CT, 58 had received T, 29 had received T + CT and 167 were untreated. Cox proportional hazard model was used to control for the imbalances in prognostic factors, such as tumour size and the number of metastatic lymph nodes (LNM) which had influenced the clinicians" decision to use AST. When all patients were considered together, the analysis revealed that AST was an independent prognostic variable (P <0.003) together with LNM, tumour grade and menopausal status. For premenopausal women, AST was again found to be a significant variable (P<0.019) as was LNM. For post menopausal women, AST did not emerge as a significant variable, while LNM, tumour grade and registration year (cut off year 1980) proved to be significant determinants of survival. The use of AST, as practiced at TMH, was found to have beneficial effect overall, but difference in treatment outcome was observed with respect to menopausal subgroups. Randomized study of radiotherapy vs tamoxifen in locally advanced primary breast cancer - - long-term follow up P. Willsher, N. C. Armitage, R. I. Nicholson, I. O . Ellis, D. A. L. Morgan, J. F. R. Robertson, R. W. Blarney

Department of Surgery, City Hospital, Nottingham, UK We have previously reported a randomized crossover study of radical radiotherapy vs tamoxifen in patients with locally advanced primary breast cancer (LAPC). This study recruited 143 patients with a maximum of 10 years follow up.

Abstracts

12i

There was no difference between the two treatment groups in terms of size, oestrogen receptor (ER) status or skin ulceration of the tumours. None of these factors predicted therapeutic response for either treatment. Response and static disease categories were combined. There was no difference between radiotherapy and tamoxifen as initial treatment. When patients from one treatment group crossed-over to the other treatment again the rate of response and static disease to the second line treatment was similar between the groups. There was no difference between patients who crossed over R T / T a m or T a m / R T in terms of time to first progression (test statistic = 0. l I I, I dr, P = 0.73), time to progression after 2nd line treatment (test statistic = 0.094, l dr, P = 0.758) and survival (test statistic = 0.79, I d f, P = 0.38). The time to diagnosing metastases was almost significant (test statistic = 3.1, l df, P = 0.08) in favour of tamoxifen as initial therapy.

Conclusions I. There is no significant difference between these two therapies for the initial treatment of patients with LAPC. 2. Most LAPC patients have micromets which may explain the difference in time to metastases between the two treatment groups.

Positron Emission Tomography of locally advanced breast cancers using D. M. Bruce, N. T. S. Evans,* S. D. Heys, G. Needham,~

F. W . S m i t h , t

2-deoxy-2-[~SFl-fluorodeoxy-o-glncose P . F . S h a r p , * O . Eremin

Depts of Surgery, *Biomedical Physics, t Radiology, and ~.Nuclear Medicine, University of Aberdeen, Foresterhill AB9 2ZD, UK Positron Emission T o m o g r a p h y (PET) allows an in-l,iro assessment of t u m o u r metabolism to be made by measuring the uptake of isotopically labelled metabolic substrates. Glucose metabolism in tumours can be assessed by uptake of its analogue, 2-deoxy-[J~F]-fluoro-o-glucose (FDG). which is preferentially accumulated in t u m o u r tissue. The aim of this study, therefore, was to evaluate F D G uptake by locally advanced breast cancers (LABC) and to determine if the subsequent response to neo-adjuvant chemotherapy could be predicted from early changes in t u m o u r metabolism as assessed by F D G uptake. Prior to treatment, the turnouts of 15 patients with LABC (mean turnout diameter 5.9cm; range 3-10cm) were imaged in five planes 12ram apart, using an E C A T II PET scanner. Up to 5mCi ~SF-labelled F D G was injected intravenously 40 minutes before the scan was performed. F D G uptake was measured in the t u m o u r and in a corresponding area in the other breast. The ratio of maximal pixel counts in these two regions was determined. In 14 of the 15 turnouts, PET demonstrated an increased F D G uptake at the site corresponding to the position of the tumour. Standard m a m m o g r a p h y was conclusively malignant in seven patients. M a m m o g r a m s were reported as being suspicious of malignancy in six, and failed to demonstrate the tumours in two patients. However, PET successfully imaged all these turnouts. In five patients who underwent a second scan after chemotherapy there was a reduction in the F D G uptake ratio to a median of 37% (range 12%-70%) of pre-treatment values. In three of these patients, this reduction preceded the partial response (clinical) of their turnouts, whilst the other two patients" tumours had stasis of disease. This study, therefore, has demonstrated a preferential uptake of F D G by breast cancers. Sequential uptake patterns may give an early indication of beneficial responses to neoadjuvant chemotherapy.

Endogenous I L 2 m a y i n f l u e n c e T N F production and metabolism in patients with advanced cancer D. B. Gough, K. C. H. Fearon,* D. C. Carter,* (Introduced by O. Eremin) Departments of Surgery, University of Aberdeen, and *Royal h!firmary of Edinburgh, UK Sepsis associated with a prolonged A P P R frequently results in death of cancer patients and may be mediated by T N F . IL2 production is reduced in certain cancer patients and we have reported that exogenous in-ritro IL2 reduces h u m a n peripheral blood mononuclear cell T N F production in response to endotoxin. To investigate the relationships between IL2 production, endotoxin sensitivy, T N F secretion and prolonged APPR, 14 patients with metastatic cancer (aged [mean +- SEMI 59.8 +__2.7 years, weight loss [10_+ 2%]), and young healthy volunteers (n = 7) were studied, hi-vitro peripheral blood mononuclear cell T N F secretion in response to endotoxin (I.25 ug/ml), P H A (62.5ug/ml) induced IL2 production and bleiro prolonged A P P R (CRP/albumin ratios) were investigated. WEHI-164 clone-13 and CTLL-2 bioassays were used respectively to assess T N F (% change) and [L2 (units) production. Patient IL2 production was less (0.5+0.1 v 0.9+_0.3 units/ml, P < 0 . 0 1 * ) and A P P R greater (2.6+_0.6 v 0.2-1-0.02, P<0.001*) than in the healthy volunteers. Endotoxin (in vitro) stimulated T N F secretion in 9/14 patients but only in 1/7 normals (P<0.01*). Patient IL2 production was inversely correlated with T N F section (r ~ = 0.624, P<0.003), C R P (r ~ = - 0 . 6 0 5 , P<0.005) and prolonged A P P R (r ~ = - 0 . 5 5 , P<0.0012). These correlations and our previous findings (IL2 reduces T N F production in response to endotoxin) suggest that reduced IL2 production may influence T N F secretion and associated sequelae in cancer patients. APPR, acute phase protein synthesis; T N F, t u m o u r necrosis factor; IL2, interleukin-2; SEM, standard error; PHA, phyto-haemagglutinin; CRP, C-reactive protein; ~ , Spearman correlation; * M a n n Whitney. M a l e b r e a s t c a n c e r - - a study of clinico-pathologicai and multiple immunohistochemical P . C . W i l l s h e r , I. L e a c h , J . B e l l , R . W . B l a m e y , J . F . R . R o b e r t s o n

features

Nottingham City Hospital, UK Male breast cancer (MBC) patients presenting in our region during the 20 years ending June 1994 have been studied. Two patients with DCIS and 41 with invasive cancer were identified. Mean age was 63 years and mean duration of symptoms was 6 months. Of the invasive cancers one was locally adwmced and treated with radiotherapy, the remaining 40 underwent surgery. Ten patients received adjuvant local radiotherapy and four adjuvant tamoxifen. Local recurrence occurred in nine patients, regional node recurrence in 16 and 14 patients developed metastases. For operable cancers the mean size was 20 ram, the majority were ductal NST (36/40) and high grade (29/40). Multiple immunohistochemical factors were assessed (see Table). Comparison with an age- and stage-matched control group of female breast cancer patients (n = 123) showed no difference from M B C with respect to DFI (P = 0.90) or survival (P = 0.27).

Conclusions: (1) The high ER with PgR positivity suggests that M B C would likely be endocrine responsive. (2) Contrary to c o m m o n perception we have shown no difference in clinical outcome between M B C and a matched female group.

Percent positive

ER

PR

c-erbB-2

EGFR

p53

MiBI

NCRCI I

93%

73%

45%

10%

58%

40%

78%